Changing health and care in West Cheshire The West Cheshire Way

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1 Changing health and care in West Cheshire The West Cheshire Way

2 Why does the NHS need to change? The NHS is a hugely important service to patients and is highly regarded by the public. It does however need to change: To meet the needs of people who are living longer with complex health and care needs To respond to the global financial crisis in order to achieve high quality services within more limited resources To provide joined up care that crosses the boundaries of primary, community, hospital and social care To reduce variation in the quality of care which at times has meant that the NHS has failed to live up to the high expectations we all have To ensure we grasp the opportunity afforded by new technologies. What is the West Cheshire way? The West Cheshire Way describes how our local health and care system will work together in Chester, Ellesmere Port and the surrounding rural areas. It is a partnership between the West Cheshire Clinical Commissioning Group, Countess of Chester Hospital NHS Trust, Cheshire and Wirral Partnership NHS Trust and Cheshire West and Chester Council to respond to the challenges outlined. This document has been written as the result of extensive work by our senior clinicians to describe this commitment to working together. Emergency admissions yrs 85 yrs> Demand for high intensity hospital acute services is increasingly higher than demographic growth in the over 85s Increases in the number of older people yrs 85 yrs> 2011/12 26% 2021/ / /22 44% If NHS funding is held flat in real terms, the NHS in England could experience a 44 & 54 funding gap worth between Whilst the number of people in council funded long term care is falling, billion unless we change the way we fund healthcare the complexity of need and the length of time people are staying in long term care is increasing (especially in the over 85s). 13,600 April % healthcare related apps from Apple adults have mobile broadband 75% adults own or use a mobile phone 1 2

3 What will the West Cheshire Way do? The West Cheshire Way has four overall goals, based on an holistic approach where services are designed around the needs of the whole person, rather than around individual diagnoses or procedures: It will improve self-care All services should help people to take more responsibility for their health and wellbeing. Our staff will offer advice and support in person, by text, phone, through , dedicated web sites and social media. It will support people in the community As much as possible people will be supported to stay well in their own home, in their own community. People will only go into hospital as a last resort. Wherever needed, community services will operate seven days a week and 24 hours a day. It will work across boundaries By joining up primary care, community services and hospital based care it will be easier for people to be looked after in a coordinated way. This will result in the right care, being given in the right place by the right person at the right time. It will improve the management of long-term conditions We will place more emphasis and investment on anticipating problems. We will identify and keep in close contact with people at high risk of hospital admission. When admitted to hospital, there will be a stronger emphasis on minimising stays. Discharge will be planned on admission, with the emphasis on early rehabilitation. Overall, this will mean we need fewer beds in hospital. 3 4

4 What changes will we see? The health of our population will continue to improve by people being supported to stay well and take responsibility for their own well-being We will provide joined up care making it possible to navigate through the health and care system simply We will look after more people appropriately at home including delivering services locally which have traditionally been provided within hospital Fewer people will be admitted to hospital in an unplanned way. When people are admitted we will treat them well and get them home safely and quickly We will reduce the times people spend waiting, whether that is waiting for a GP or a hospital appointment, waiting for test results or waiting for an operation. Values and Principles We have agreed a set of values that will hold our system together. We will be: Compassionate about patients Empowering of staff and patients Accountable for all decisions What this will mean for staff? Our work will be clinically led with a social model of prevention and early intervention at its core. This will be enabled by using some of our resources to invest in leadership training and development of health and social care staff in whatever setting. We will empower staff to work alongside patients to reach shared outcomes in their care. We will integrate our workforce planning so that we do it on a system wide rather than individual organisation basis. We will attract and develop the best people to work in our services. In our clinical practice we will narrow the gap that has emerged in recent years between the specialists and the generalists (e.g. Consultants and GPs; specialist nurses and practice nurses). This will be underpinned by integrated education and learning. We will continue to identify best practice from elsewhere in the UK and internationally, looking to innovate and improve our models of care, practice and productivity. Clinicians and managers will work together to deliver this vision. Outcomes for services will be driven by clinical knowledge and expertise. Managers will support the delivery of this vision by reaching agreements across organisations and ensuring the appropriate use of resources. Collaborative always involve partners Mutually respectful to different opinions and perspectives Trusting of others motives and beliefs Flexible in our thinking Transparent and open about our decisions Innovative and creative in our models of care 5 6

5 We have agreed eight principles that will underpin our work: 1. Patients are at the heart of the West Cheshire Way 2. The West Cheshire Way is clinically led (and managerially supported) 3. The West Cheshire Way incorporates health, social care and the voluntary sector 4. Everybody recognises the need to work across organisational boundaries 5. We recognise the importance of general practice and its relationship with a defined group of patients 6. We will use a population health based approach that has a prevention focus and is holistic 7. Integrated care will be delivered by groups of health and social care professionals, both generalists and specialists, working alongside each other 8. We will learn from others, including best practice in the UK and internationally; where this does not exist we will seek to establish it locally. How will the West Cheshire Way work? We have developed a series of blueprints that illustrate how the West Cheshire Way will work in practice. These have been written by local clinicians and can be found at: This list of blueprints is not exhaustive, it is a start of an iterative process to steer our work into action. These will be built on over time as we embed this work into our continuous improvement of services. We want teams to take the spirit of the West Cheshire Way and build it into their own work. 7 8

6 Next Steps Our clinical senate agreed a set of actions to move us forward, these include concrete outcomes (the products) and wider pieces of work which need to be addressed (the enablers). Work has already started on some of the products: A simple and clear narrative, supported by a clear action plan: A process that ensures significant public, patient and carer engagement, at all levels Integrated clinical communication, including sharing medical records, to enable the identification of risk: Pathway improvements, led by clinicians, to deliver improvements and reduce variation: A system wide approach to quality improvement: A 5-year financial model (health/social/residential care) which models the shift in activity from beds to community based services: An approach to wellbeing and self care at scale There may be more good work going on as part of people s day jobs as people seek to improve the integration of their own services. Enablers A plan that incorporates better use of our facilities (recognising that this might include other resources) A training and development strategy (plan) for our system A communication and engagement plan A governance model that is clinically led and recognised by all organisations A risk framework that is updated and contains clear mitigation A process of measurement and evaluation 9 10

7 In memory of Pat Holmes, who worked as a District Nurse and then a Team Leader in Ellesmere Port from the mid-1980s until She sadly died in NHS West Cheshire Clinical Commissioning Group working in partnership with Countess of Cheshire NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust and Cheshire West and Chester Council. Design by Medical Illustration, Countess of Chester Hospital NHS Foundation Trust.