Agenda Item: 9.1 Subject: Presented by: Progress on the System Sustainability Programme Dr Sue Crossman, Chief Officer Submitted to: NHS West Norfolk CCG Governing Body, 31 July 2014 Purpose of Paper: For information Executive Summary: This paper outlines progress made in the last month by the System Sustainability Programme. KEY RISKS Clinical: Failure to deliver a robust approach to informing future local services commissioned from The Queen Elizabeth Hospital King s Lynn NHS Trust (QEHKL) would have an impact on local health needs being met. Finance and Performance: A robust financial plan is necessary to underpin the delivery of the CCG s operational and strategic plan against its funding allocation and to ensure that the CCG has prioritised resources appropriately to deliver the service changes to meet the needs of the local population informed by the strategic vision and future service requirements. Impact Assessment (environmental and equalities): N/a Reputation: Failure to develop a sound commissioning plan that addresses the sustainability issues will be damaging to the CCG reputation. Legal: N/a Patient focus (if appropriate): Failure to involve and engage our patients and the local population in the development of these plans will not support the delivery of care that responds to the needs of patients and the public. Reference to relevant Governing Body Assurance Framework: 2.1; 2.5; 2.6; 2.7; 3.1; 6.3. RECOMMENDATION: The Governing Body is asked to note the progress made with the Programme. A full report will be presented to the August meeting detailing the findings to be presented to the Monitor Contingency Planning Team. 1
1. Introduction This paper provides an update on the System Sustainability Programme, a complex piece of work focussing on developing locally derived, clinically driven, long term solutions to the challenge we face as a Local Health Economy (LHE). This challenge can be summarised as the following: We know that if we continue to provide services in the way that we currently do, it will be unaffordable in the future; and Patients tell us that services are often fragmented and poorly coordinated and they are not sure where to go for help. The West Norfolk Alliance is addressing this challenge through a number of working groups with the aim of using integration to provide sustainable co-ordinated care with patients in control. Alongside this programme of work, the hospital regulator Monitor is sending a Contingency Planning Team (CPT) into The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust (QEHKL) to develop options for ensuring a sustainable District General Hospital configuration. The CPT and the Clinical Commissioning Group (CCG) will work closely together drawing on the results of the System Sustainability Programme workstreams to develop local solutions for the acute trust and the LHE. This approach is quite different from previous CPT interventions where Monitor has directed the programme in a linear fashion, without addressing the wider LHE context. West Norfolk CCG has managed to achieve a more collaborative approach on this occasion, assisting Monitor to select the CPT and ensuring that the work completed by the System Sustainability Programme provides a starting point informed by locally developed intelligence. 2. Alliance and Pioneer Progress The Alliance Chief Executives Steering Group met in June to explore potential innovative contracting models that could support the integration of services across all health and social care partners. This is an important enabler to support implementation of emerging recommendations for service improvements from the clinical pathway workstreams. The Integration Pioneer Programme continues to provide some resources to support integration including an integration and transformation training programme for front-line staff, which six staff from across the Alliance have signed-up to. 3. Workstreams Previous Governing Body papers have described the workstreams and reporting structure which are illustrated at Appendix 1 for reference. Progress over the last month is summarised below. 3.1 IM&T Group The group has undertaken an assessment of current IM&T projects, programmes, strategies and local priorities. The group has also developed a digital care fund bid to deliver the requirements of the Alliance workstreams once these have been reported. The IM&T group will then move onto assessing any gaps, developing objectives and designing a work programme to meet the needs, which will hopefully be supported by the technology fund bid. The project lead will conduct an IM&T workforce assessment in the next month to assist in assessing and planning workforce requirements. From these pieces of work a draft Alliance IM&T Plan will be developed to support the programme in the short, medium and long term. The group has established an Information Governance sub-group which is developing an Alliance information sharing protocol and data sharing agreement for the information requirements in the bid. The project lead aims to complete drafting these by 8 August so that they can come to Governing Body for approval. 2
3.2 Workforce The Workforce group has conducted a system-wide review of the West Norfolk Alliance workforce and its key challenges. Organisations reviewed included: The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust Norfolk Community and Care NHS Trust (NCH&C) Norfolk and Suffolk NHS Foundation Trust (NSFT) Primary care services. Information sources included Trust five year workforce plans submitted to the East of England to commission education and training; reports produced on productivity challenges and actions to address them; a monitoring report placed on a Trust website; a ledger showing establishment and staff-in-post by cost centre, which enables a detailed analysis of services. In addition, a few interviews were conducted with key informants to explore issues concerning leadership and clinical culture. Key areas explored were: Staff vacancies, recruitment and retention issues; Trust five year plans; Productivity. It is clear from the work to date that the locality has significant workforce challenges including the effects of frequent change on organisational culture, the financial costs of ensuring adequate staffing levels to deliver high quality care, and the challenges around improving productivity, recruitment and retention of staff. Workforce initiatives Major initiatives are taking place to improve productivity. The QEH is undertaking a detailed review of medical costs and staffing, by specialty. NCH&C is carrying out a service and workforce redesign, which includes improving productivity through rationalising patient assessment, skill mix changes, and remote working. This includes rationalising work locations, using a hub and spoke service model. NSFT is seeking to integrate its dementia team with that of the Community Trust s frail and elderly team. This will be of particular benefit where considerable travel as one member of staff would be visiting the patient, not two travelling separately. West Norfolk Alliance future opportunity to inform integration of health and care services The development of an Alliance-wide honorary contract is being explored in order to enable staff from the existing Alliance organisations to work more closely together. 3.3 Integration and the Better Care Fund Work has progressed in the following schemes, establishing terms of reference and project plans: Establishing a consistent Integrated Care Organisation Model across the CCG; Establishing a more integrated reablement service; Hospital discharge social care 7 day working; Supporting independence and well-being creating a community care navigator network; Dementia care improving community support and diagnosis; Intermediate care beds. The links between some of the integration sub-workstreams and the clinical pathway work has been acknowledged and will be captured in the Programme Plan to highlight areas of alignment and ensure a consistent approach avoiding duplication. 3
3.4 Clinical Pathways The three clinical pathway sub-workstreams to the Clinical Reference Group (CRG), namely frail elderly, paediatrics, and maternity, have been conducting an in-depth analysis of the current pathways, evidence of best practice and proposals for future improvements, to inform future commissioning plans for the locality. This work has produced some common findings which are helping the CRG to form a view about the future shape of some core services. These emerging results also provide insight into the potential workforce, IT and infrastructure requirements to deliver redesigned services, which in turn are picked up by the appropriate workstreams designed to address these. The finance and contracting workstream has not yet been established as the work required by this group is relevant at a later stage, when proposed changes are more fully formed. Crucial to the approach used in this phase of the CRG work was that it started with a patient-centred pathway analysis via our envelopes of care model. This involved considering the patient s needs at each stage of the pathway, from home, through referrals, treatment and back to home again, noting at each stage what services were required and the type of personnel needed to deliver them. An inherent part of this exercise was consideration of ceilings of care that should be delivered locally, depending on travel time, local expertise and clinical guidance. 3.4.1 Early Findings What has the CRG told us about how the future hospital should look? It should be a centre of excellence for the West Norfolk patients, ie elderly care (hips, knees, eyes) and maternity; It should have senior clinical triage at the front door providing 24/7 emergency assessment in medicine, surgery and injuries; Minors in A&E could possibly be treated in an alternative setting; There should be a MDT (multi-disciplinary team) approach to care, both in hospital and across all settings; There should be a frail elderly urgent care pathway with effective proactive discharge planning; There should be some elective care, the scope of which should be determined by: o What can be done to a high standard locally; o What could be done locally supported by a clinical network/secondary care partnership with clinical rotation with a specialist centre; and o What should definitely only be done in a specialist centre. Maternity: Maintenance of normality for all women where safe, with efficient escalation within the model of care, a flexible service to enable choice throughout a user s journey. An accessible maternity service, greater performance and quality outcomes from the service, options for care are essential and currently do not exist, consistency of care and information throughout the patient journey. Paediatrics: Maintain the good quality leadership provided by consultants and lead nurses, protect the cross centre consultant lead, improve assessment within primary care setting, efficient acute pathway and appropriate setting for patients self-presenting to A&E, transitions between secondary and tertiary centres, and the process to discharge is clarified, development of key pathways are developed locally, parents and carers are sufficiently supported to keep their children well and are enabled to care for their children when unwell. This helps us to articulate what type of consultants should be available, define their job plan and PAs, the medical and non-medical team they need to support them, and therefore the shape of the workforce. What sort of personnel do we need to deliver the above? Elderly care consultants, working across community and secondary care; Excellent stroke care physicians; Acute general physicians, skilled in front door assessment and stabilisation across a wide range of clinical presentations; 4
Comprehensive surgical support, competent surgical opinion available at front door to determine what goes and what stays for treatment; Effect rapid assessment MDT (possibly including GP) to turnaround at front door ; Staff should rotate between community and acute care setting, so that they appreciate what can be provided where and they are flexible and adaptable; Trusts should operate a nursing and therapy bank, where staff have honorary contracts to work across different settings and organisations within the Alliance, where capacity and skills are most needed. Obstetricians and Midwifes confident to deliver models of care with direct leadership within each, sufficient establishment of midwives and supervisors of midwives, anaesthetist, service leadership and accountability. Local training for supervisors of midwives Paediatrics: Greater relationships between primary and secondary care with the provision of clear pathways. Paediatric Nurses across the centre are professionally supported by the Lead Paediatric Nurse. Paediatric nurses are rotated across the system including community. accessible paediatric nurse training. What does this team need access to in order to provide the care we require? Urgent care; Full stroke service; Maternity service; Inpatient short stay care, elderly patients treated by specialist consultant in dedicated unit; Diagnostics MRI, CT, echo-cardiogram, ultrasound; Operating theatre, ITU; Shared information (High Impact Intervention) to support remote triage for care home patients as well as appropriate turnaround at the front door ; Maternity: electronic records accessible within both communities through to hospital setting, anaesthetics; Paediatrics: Co-locations of A&E and PAU, electronic records across care system, paediatric diagnostic equipment within primary care, Health Visitor interventions appropriate for local needs and demands. How do we further test our early findings? The early findings above about key core elements are to be tested at clinical workshops, using clinical scenarios. For example, patients presenting with acute abdomen, acute asthma attack etc to test what other services might need to be layered on top of the core, to ensure that patients in West Norfolk will receive safe care in the right place. The next phase of the CRG work will be to examine urgent care and an elective specialty, again to come to a consensus about additional essential local core services. This process is an iterative one, whereby early hypotheses about the services required to provide essential local care are tested and further refined until we have a firm, comprehensive view. 4. Next Steps The Alliance Operating Group has tasked each workstream to develop clear outcomes and timeframes for further work, and to populate a programme management template for implementation. Stakeholder and public involvement will commence at the beginning of September with public meetings to discuss the emerging views amongst clinicians about essential local services and to gather user and carer feedback about what is important to them. This will then be incorporated into a report to be shared with the CPT, expected to commence early September, to provide them with sound locally debated evidence about key core services. 5. Recommendation The Governing Body is asked to note the progress made by the System Sustainability Programme, which has involved most clinical members working alongside CCG management staff. A report will be presented to the August meeting providing fuller information on the conclusions. 5
Appendix 1 West Norfolk System Sustainability Review Group and CCG Clinical Action Team (CAT) Reporting Lines NHS England, Monitor and CCG Oversight Group CHC CAT* LTC & Urgent Care CAT *Clinical Action Team CCG Governing Body CCG Executive Team (ET) Prescribing CAT Elective Care CAT Alliance Partners Boards Frail Older People Pathway Review Group Paediatric Urgent Care Pathway Review Group Maternity Pathway Review Group Alliance Steering Group CCG internal CRS* Working Group *commissioner requested services Clinical Reference Group (CRG) Alliance Operating Group Workforce Planning Finance and Contracts Integration Pioneer Working Group (incorporating Better Care Fund) Infrastructure IM&T Primary Care Communications and Engagement 6