Right first time 24/7

1. Right first time 24/7 Our evolving clinical and quality strategy Stakeholder meeting 6 February 2014

2. 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

3. 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

4. National context: affordability

5. Local context: resources 2014/2016

6. Local context: Better Care Fund 2015/16

7. Right first time 24/7

8. Our vision Right person Right place Right time First time 24/7

9. 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

10. “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.”

11. “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.”

12. “Services will be organised so that consultant review, clinical staff and diagnostic and support services are readily available on a 7-day basis.”

13. “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.”

14. “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.”

15. “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.”

16. “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.”

17. “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.”

18. “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.”

19. 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

20. 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?

21. Views of commissioners and local authorities

22. A CCG View- Planning priorities and commissioning intentions • Right First Time • Stakeholder Engagement Event • Thursday 6 February 2014

23. HIGH QUALITY CARE FOR ALL, NOW AND FOR FUTURE GENERATIONS

24. 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

25. 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

26. 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

27. 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

28. County Durham & Darlington Clinical Programme Board • Key Agreed Priorities • Elderly/frail elderly • Urgent Care • Mental Health and Dementia • Long Term Conditions

29. 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

30. 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

31. 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

32. 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

33. 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.

34. 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.

35. BCF for Darlington Darlington’s allocation of the fund totals £7.8m made up of the following for 2015/16:-

36. £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.

37. 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

38. 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

39. Views of commissioners and local authorities

40. 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?

41. 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

42. 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”

43. 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?

44. 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 -

45. 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?

46. 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”

47. 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

48. 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

49. 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.

50. 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)