North Lincolnshire CCG Strategy 2019 - 2024

1. North Lincolnshire CCG Strategy2019 - 2024

2. Contents Executive Summary Our Plan on a Page Introduction Our Vision and Case for Change Where we are today – the current position, challenges and opportunities ahead What do we want to achieve? Our Strategy Enablers of our Strategy Appendix: Our 2 Year Plan - The improvements we will make

3. Executive Summary If we are to meet people’s health and care needs in a safe and sustainable way then incremental change won’t get us there. Our health and care system faces significant challenges, we can only resolve this by working together; as a single system, at greater scale, and in a more integrated way. Our Strategy sets out a blueprint for how we will deliver a healthy future for our population through high quality, proactive care; which is more joined up, improves outcomes, safety and experience; and increases value for the North Lincolnshire pound. It will act as a guiding framework for our commissioning intentions and for our partner health and care organisations, community partners, professionals, service users, and our population. At its heart is a new approach based on the principles of population health management - targeting our resources where they will have the greatest impact on health and wellbeing outcomes, care quality, and sustainability. In doing so we recognise that our population is made up of people who live in our local communities, and we must wrap services around people rather than their conditions or diseases. Whilst there are a number of changes outlined in this strategy covering all parts of our system the significant features are: Shifting our focus from ‘in hospital’ services to increasing investment in ‘out of hospital’ services to manage demand in a different way. This means integrated, person centred models of care designed around the needs of our population, delivered closer to home in local Primary Care Networks. Care will be less fragmented, more proactive, and enable individuals to do more and not less Effective and efficient interventions are available when they are needed, delivered in the right place, by the right person, at the right time, in a way which adds the most value. This will result in a shift from reactive to preventative care, and consistent pathways which reduce unwarranted variation in outcomes Cultural and organisational behavioural change. The changes described in this document will only be delivered through cultural and organisational behavioural change. Care professionals, service users, families, and carers will play an active role in the delivery of our strategy and will be empowered to drive change throughout the system. People will be enabled to take a greater responsibility for their own health and wellbeing Demonstrating that we place equal value on mental and physical health throughout all we do. People’s psychological and emotional wellbeing will be supported alongside their physical health and care needs. Mental Health will be a core component within our new model of care. In delivering our strategy we will implement changes at pace and scale, adopting best practice across our system to make rapid improvements to people’s care and support a healthier, more sustainable future for North Lincolnshire.

4. Our plan on a page Outcomes Key Results Delivery Programmes Population Enablers Vision Objectives • Constitutional targets delivered • Funding and efficiency gap closed • Demand for hospital services reduced • More planned and anticipatory care closer to home delivered • Services will be safe and sustainable Prevention • Children have a healthy start in life (first 1000 days) • Increased healthy life expectancy • Reduced health inequalities • Increased levels of healthy weight • Reduced harm from tobacco, alcohol & substance misuse • Reduced prevalence of preventable long term conditions • Healthy Communities which enable and support people to look after their health and wellbeing We will commission high quality and safe services Helping you build a healthy future Culture & Leadership; Digital Health; Quality (experience, outcomes and safety); Communications & Engagement; Workforce; Contracting & Payment Mechanisms; Governance, Performance, Population Health Management Generally well Primary Care • Increased access to routine primary care services over 7 days • Patient choice in how and when to access services including self-care advice, maximising digital options • Improvements to recruitment and retention rates through improved job satisfaction • Investment in the formation and development of Primary Care Networks and robust clinical leadership • Improved patient satisfaction with access to primary care • Minimised the risk of developing long term conditions (especially cancer, cardiovascular disease, respiratory disease, and diabetes) • Healthy communities which enable and support people to look after their health and wellbeing We will be responsive to the health and care needs of the population Out of Hospital Care • People take responsibility for their own health and wellbeing • Services are simplified • Support in the community will be the default • Care is co-ordinated & holistic needs are understood • Care will be planned and crisis will be the exception • Person should return to their own bed that night (following an episode of community support) People with a Diagnosed Long Term Conditions Children & Maternity • Reduction in perinatal and infant mortality and morbidity • Children received proactive healthcare in the least restrictive environment • Increased number of children and young people accessing evidence based mental health support • Families experience an integrated approach to support across health, education and social care • Healthy life expectancy increased • Proportion of people who have confidence in managing their own health increased • People supported to proactively manage long term conditions (LTC) • Our communities will be strengthened • Support in the community will be the default We will work together with patients, partners and the public to stay healthier and independent for longer Mental Health & Learning Disabilities • More people accessing psychological therapies including pathways for people with long term conditions • Improved community based secondary care services including psychological therapies • Increased access to mental health crisis care • Better physical health outcomes for people with mental health problems and learning disabilities • Proportion of people who are cared for at home or in their local community increased • Number of people who die in their place of choice, according to their wishes, free from avoidable distress and suffering increased • Range of options to support people to improve their health (incl. digital) increased We will make health and care services available when and where our population need them People with Complex Needs Hospital Care • Safe, sustainable hospital services • Constitutional targets delivered • Improved quality, safety and clinical outcomes • Greater access to care to keep people out of hospital when in crisis • Reduced occupied bed days and length of stay • Reduced Healthcare Associated Infections (HCAI)

5. Introduction What issues are we facing? This strategy will…. • More people are living longer with more years of ill health, increasing the pressure on hospital services • Our current services are fragmented and are not set up to meet this level of demand • Health outcomes in some areas are not as good as we would like them to be • We need to strengthen primary care leadership in our Care Networks • Contracting and payment mechanisms do not always support us to deliver transformational change in services we commission • We don’t always make the best use of technology as a system • The need to better integrate across the system to enable change, such as, ambition, leadership, care delivery, workforce, digital health and finances • articulate our future health & wellbeing ambitions for people in North Lincolnshire • demonstrate our commitment to working together with our partners to achieve common goals • build on current areas of good practice and integration already in place • provide a blue print for the future model of integrated care; and how this will deliver improved outcomes for our population, high quality services, and ensure sustainable health and care services • act as a framework that our employees, partner organisations, clinicians / practitioners, and wider heath and care professionals can understand to help them to perform their role • set out the changes required to deliver the transformation we seek • ensure full and effective professional engagement in the design, development & delivery of future health and care services Our health and care system faces significant challenges. We can only resolve this by working together as a single system; with partners, at greater scale, and in a more integrated way. This Strategy sets out a blueprint for integration and sustainable, high quality health and care within North Lincolnshire. It will act as a guiding framework for health and care organisations, professionals, and service users.

6. Our vision and case for change What’s needs to change What will be different Our vision: ‘Helping you build a healthy future’ We will work with our population to engage and empower them to help prevent illness and support resilient communities We focus on what people can’t do rather than what they can We will implement population health management - based on use of evidence to target our use of resources Resources are not targeted where they will have the most impact We will develop an integrated, person centred model of care, delivered closer to home via Primary Care Networks Care is sometimes fragmented and built around providers or diseases rather than individuals We will focus on out of hospital care and preventative interventions; with high quality, sustainable, hospital care when needed We have an overreliance on secondary care hospital provision Care will be personalised, proactive and better co-ordinated Care is often too reactive and episodic We will place equal value on mental and physical health throughout all that we do • Mental and physical health inequalities are not reducing We will develop care pathways which reduce variation in outcomes and scale best practice There is too much variation in professional practice, pathways, and outcomes Our partners will have a shared understanding of our strategy which is aligned to the Place Plan Organisations and staff do not see a common vision or strategy

7. Where we are today

8. Where we are today There are more than 28,000 adult smokers (>1 in 5 adults smoke) =5.5% NHS spend, 300 deaths a year in North Lincolnshire, significantly above average 26% 4-5yr olds, 36.6% 10-11yr olds and 70% adults are overweight or obese 17% high blood pressure Our Population & their Needs: • The number of patients registered with GP practices is 178,861. This figure includes 9,464 patients who live just over the North Lincolnshire local authority border. • Between now and 2025 the population is projected to rise by 2% (4,000) by natural population growth alone. • Scunthorpe is home to just under half of North Lincolnshire’s resident population. • More than half of our residents, 52%, live in our rural market towns and villages, where much of the recent growth in our older population has occurred. • About 18% (5,400) of children live in low income families (England 16.8%) • Our population is increasingly diverse. Levels of breastfeeding and smoking in pregnancy areboth worse than the England average Physical inactivity levels higher than average Worklessness in long term sick 6,000 Employment Support Allowance claimants – 41% with mental illness, 50% aged 50+ 80% of 5 year olds free of dental decay, compared with 75% nationally 12% of adults have prediabetes & 8% have diabetes <1% of births are to teenage mums 11.7% adults diagnosed with depression (England: 9.9%) 2% working days lost to sickness absence Growth in 85+ with multiple complex needs Higher use of urgent care by adults (all ages) Source: Public Health

10. Where we are today Morbidity by age group and top 8 broad causes Mortality & life expectancy: • Each year an average of 1750 people die in North Lincolnshire, the majority in their late 70s and 80s. A third of thesedie prematurely (i.e. under 75 years). Two thirds of these early deaths are men. • The rate of deaths from preventable causes is significantly higher in North Lincolnshire (201.4) than across England (182.8). • Premature death rates from respiratory disease such as chronic lung disease, from cancer (mainly cancers of the lung, and oesophagus) and for smoking related deaths are in the worst 25% in the country for these deaths. • Life expectancy in North Lincolnshire is lower than average: Male 79 (79.6 England) Female 82.6 (83.1 England) • The life expectancy gap: 9.8yrs lower for men and 8.3yrs lower for women in the most deprived areas than in the least deprived areas Morbidity & healthy life expectancy: • Healthy life expectancy in North Lincolnshire is 61.2 years for women (63.8 England) and 60.4 years for men, (63.4 England) • The healthy life expectancy gap is wider than for life expectancy, with a 12 year difference in the number of years of good health lived between the least and most deprived areas in North Lincolnshire • The 4 greatest behavioural risk factors for poor health in North Lincolnshire are smoking, dietary risks, high blood pressure and high BMI • Musculoskeletal conditions account for a significant proportion of years of life lived with disability (YLD), from middle age onwards • Mental illness and substance misuse account for the largest burden of disease of YLD in young adulthood. Amongst women, depressive disorders account for the second largest burden of disease • In older age, the bulk of the disability burden of disease comes from 4 specific causes: neurological diseases associated with dementia, musculoskeletal disease, mainly due to ‘back and neck’ pain rather than arthritis, falls, and Sensory loss

11. Where we are todayEngagement • Patient and Community Advisory Group (PCAG) • CCG priorities 2018/19 • Patient Transport Services; Humber Acute Services Review; • Community Services • Urgent Treatment Centre • Mental Health Services In 2018/19 the CCG identified an increase in the number of queries and requests for information submitted to the CCG by the Parliamentary Briefings Team at NHS England Making Time for Everyone Engagement Report Easier-to-access routine family health services for the future. Findings related to access A Clearer View: Transforming Ophthalmology Services in North and North East Lincolnshire Implementation of extended GP hours – feedback on difficulty securing appointments – uptake is 90% • Improved Communications • Facebook page: 19 to 1,040 likes • Twitter page: 9,250 followers – now the largest in Humber, Coast and Vale region • One of the first CCGs to launch Instagram and better communicate with the younger generation – 150 followers • Launched monthly staff news bulletin, Snapshot – your news your views • Relaunched Practice Dispatches as Spotlight – and widened to other partners • Launched first patient magazine, Your Health

12. Where we are todayHumber Acute Services Review Challenges • The Humber Acute Service Review (HASR) was established to consider services that are currently being delivered across the Humber area, in the two acute hospital Trusts – Northern Lincolnshire and Goole NHS Foundation Trust (NLG)and Hull University Teaching Hospitals NHS Trust – who provide a variety of hospital-based services from five different hospital sites: • Hull Royal Infirmary • Castle Hill Hospital • Diana Princess of Wales Hospital, Grimsby • Scunthorpe General Hospital • Goole Hospital • It is focused on meeting the needs of the population of the Humber area and providing the best possible care for local people who need acute hospital services within the resources (money, staffing and buildings) that are available to the system. It is looking to achieve improved levels of service quality and strengthen both operational and financial sustainability. • The review builds on the well-established collaborations between NLaG and Hull in the provision of acute hospital services and is developing opportunities to develop additional collaborations with other acute providers. Further arrangements are being made for a specific group of services (e.g. Pathology) to be reviewed on a regional or multi-regional basis. • The review is taking into account existing and planned developments in prevention, supported self-care and out of hospital care as set out in place-based plans. The review has engaged staff, clinicians and the public. Performance • Priority Specialities • Initially three priority individual specialties were identified as ‘fragile’ and being under immediate patient safety concerns, these were: Clinical Haematology, ENT and Urology. • In July 2018 the Steering Group identified six further specialities to be reviewed as a Wave 2 of priority services to be assessed through the review, these are: • Cardiology • Critical care • Specialist rehabilitation • Stroke • Neurology • Oncology and Haematology

13. Where we are today 2019/20 Planned Spend Finance: • Within the NHS Long Term Plan, investment in Mental Heath, Community and Primary Care Services is recommended locally • Health resource growth at an average of 3.4% over the next 5 years • Local population growth estimates (approximately 2% overall growth) • Overall healthcare system gap for providers and commissioners in region of £26m for 2019/20 • CCG £1m deficit control total for 2019/20 with QIPP requirement of £6.9m Healthcare

14. What do we want to achieve? Strategy Overview

15. Services for the people of North Lincolnshire will be commissioned at different levels Tiers of Commissioning Level Pop. Size Purpose • Strengthen primary care • Develop Primary Care Networks • Proactive & integrated models for defined population Each level performs specific functions under the following common headings Leadership, engagement and workforce Care redesign Accountability and performance management Strategy and planning Managing collective resources Neighbourhood Primary Care Networks Approx. 50k • Local and NL-wide commissioning • Broader commissioning with NE Lincs, East Riding, Hull, etc. • Collaborative commissioning with North Lincolnshire Council Place North Lincolnshire Approx. 250-500k System Humber, Coast and Vale H&C Partnership • Large scale change e.g. HASR • Collaborate on Digital, Estates, and Workforce • Deliver specialist services Approx. 1+m • Agree system ‘mandate’ • Hold systems to account • System development • Intervention and improvement Region North East and Yorkshire Approx. 5-10m 15

16. What do we want to achieve? Our staff Our objectives Our key results • Constitutional Targets met • Healthy life expectancy increased • Gap in health inequalities reduced • Proportion of people who have confidence in managing their own health increased • Risk of people developing long term conditions (especially cancer, cardiovascular disease, respiratory disease, and diabetes) reduced • Proportion of people who are cared for at home or in their local community increased • More planned and anticipatory care closer to home delivered • Hospital demand reduced • Number of people who die in their place of choice, according to their wishes, free from avoidable distress and suffering increased • Better value for money for the North Lincolnshire pound secured • Funding and efficiency gap closed • We will commission high quality and safe services • We will be responsive to the health and care needs of the population • We will work together with patients, partners and the public to stay healthier and independent for longer • We will make health and care services available when and where our population need them • We will increase the proportion of staff who feel they are motivated, have the right skills and knowledge, and are empowered and supported to use them , now and for the future • All staff understand our vision and their role in delivering it • We will attract and retain the required number of staff with the right skills • We will enable people to be resilient • We will increase the wellbeing of staff • We will develop an Organisational Development Plan that supports the needs of our organisation Generally well People with a Diagnosed LTC People with Complex Needs We will continue to further refine and quantify these outcomes as we develop detailed plans for the delivery of our strategy

17. Strategy Overview Population Health Management: We have grouped our population into three groups (which can be further segmented by age) and developed our Strategy around their needs: 3) People with complex needs 2) People living with a diagnosed long term condition (LTC) 1) People who are generally well We will prioritise resources where they will: • have the biggest impact on outcomes, quality and cost; and • where people will benefit most from an integrated approach

18. Strategy Overview Our Model of Care: • Our integrated Service Model will be most successful when enabling mechanisms for delivering tangible transformation are integrated at Primary Care Network and Place level. • Our integrated and seamless model of care will remove traditional boundaries between individual services and is designed around the needs of our population and delivered closer to home in local Primary Care Networks. • Effective and efficient interventions where needed, are delivered in the right place, by the right person, at the right time. This shifts activity from reactive to proactive. • Consideration of our key partners, ensuring they are sustainable, resilient, and can play the role we need them to in delivering integrated care. • The key enablers are the foundation to drive transformation and deliver integrate care. • We will work collaboratively with partners accountable for delivering the wider determinants of health in line with our strategy.

19. Improvement Interventions Overview We will implement our integrated and seamless model of care which will remove traditional boundaries between individual services and is designed around the needs of our population, delivered closer to home in local Primary Care Networks. As part of this we plan to redesign Frailty services that are grounded in early intervention and integrated across all tiers of need. Generally Well People with a Diagnosed Long Term Condition People with Complex Needs • When our population need to access routine or planned care services, we are committed to ensuring that these are high quality, cost effective, and sustainable. An Integrated Care Partnership will: • Deliver planned care interventions in the most cost effective setting, shift planned care activity closer to home, and use our highly skilled workforce in a way which delivers the most value to the population and the system • Redesign planned care services using evidence based improvement methodologies, and scale up best practice across the system. Develop a broader range of services in the community such as, cardiology, ENT • Manage demand by reducing referrals through the application of evidence based thresholds, better use of self-care (community assets based approach), Virtual Ward, Gateway to Care, value based commissioning • Improve productivity by streamlining services, reducing waiting times, removing delays, and providing choice and information on services and outcomes • Review the current usage of our estate and develop a plan to re-configure services that support the delivery of our model of care • We will secure sustainable hospital services by reviewing services that can be improved through greater collaboration and new clinical / delivery models. Humber Acute Services Review priorities include: ENT, Urology, Haematology, Cardiology, Critical care, Stroke, Complex Rehab, Neurology, Oncology • People with urgent but non-life threatening physical, mental health or social needs will receive responsive, effective and personalised services outside of hospital, delivered in or as close to their homes as possible • People with more serious or life-threatening emergency physical or mental health needs will be treated in centres with the very best expertise, delivering safe, high quality services to optimise patient outcomes and enable as many people as possible to safely return to their own homes • This will enable us to improve outcomes, lower mortality rates, avoid unnecessary hospital attendances or admissions, and improve flow through the system, in turn supporting discharge and reducing length of stay • We will review how we provide care for people with the most complex mental health and learning disability needs to achieve the best outcomes and provide care as close to home as possible • Our goal is to support our population to be as healthy as possible, targeting prevention and wellbeing interventions at high impact risk factors – thereby improving the overall health and wellbeing of our population and reducing the demand on the health and care system. • We will prevent, reduce, or delay need before it escalates; and prevent people with complex needs from reaching crisis points in their care. This includes: • Making Every Contact Count and use it as an opportunity to promote healthy behaviours at every interaction a person has with health and care professionals • Understanding what support people need for good self-care • Embedding prevention and an asset based approach to community health and wellbeing • Risk stratification and ongoing identification of people at the greatest risk of developing LTCs • Targeting population prevention interventions and addressing risk factors we have identified

20. Enablers of our Strategy

21. Enablers of our Strategy (1) Culture and Leadership Quality Information/ Technology/ Digital Health • Quality is at the heart of all we do as a CCG. We will continue to improve the quality (experience, outcomes and safety) of the care and services we commission for the people of North Lincolnshire. We will: • Use a population health management approach to help us improve quality by targeting improvement around populations of people of all ages who are generally well, people who have a diagnosed long term condition and people with complex needs • Work with partners and patients in North Lincolnshire and beyond to secure improvement in quality at scale and pace • Develop a Quality Strategy which sets out our approach to improving and assuring quality in the delivery of our strategic goals and the services we commission. This will include: • Ensuring that the use of a Quality Impact Assessment is embedded in all of our key delivery programmes • Using intelligence and data to identify priorities for Quality Improvement that will have the greatest positive impact for the people of North Lincolnshire • Developing our approach to Quality Assurance where care is delivered through new and different models of care delivery e.g. alliances of providers • The changes described in this document will only be delivered through cultural and behavioural change, which is a foundation of our strategy. • Care professionals, service users, families and carers will be empowered to drive the change throughout the system • We will commit to the ongoing Out of Hospital Transformation Board and developing an Integrated Care Partnership to enable continued engagement in the development and delivery of the strategy (incl. provider network) and break down barriers that exist within the system • Senior leaders need to empower professionals to follow through on their actions, whilst supporting them when we get it wrong • Information and technology will play a vital role in enabling our population health management approach and delivering the new models of care we have set out in this document. • It will also underpin the efficiency, effectiveness, and resilience of the key pillars of our system. Our priorities include: • Improving Community Services activity and performance reporting and monitoring • Patients will be provided with options for how they access advice and care (online consultations, Skype and face to face) • Enabling a collaborative and integrated working environment • Roll out of RAIDR to enable the CCG to take a population health management approach and improve risk stratification • Explore alternatives to outpatients, such as, virtual consultations • Support uptake of the NHS App • Shared clinical records

22. Enablers of our Strategy (2) Workforce Communications and Engagement • Securing a sustainable workforce in the right numbers with the right skills in North Lincolnshire is a key enabler to the delivery of our strategic objectives as a CCG. New and different roles will work alongside existing ones. The health and care workforce will need to work in different ways with more care being delivered in community settings and closer to people’s own homes. Our workforce will be able to provide a personalised approach to support people. As a CCG we will: • Work with partners in North Lincolnshire to develop and deliver a comprehensive workforce development plan utilising the comprehensive new workforce implementation plan arising out of the NHS Long Term Plan as a framework. This includes: • Expanding the number of nurses, AHP’s, Midwives and other staff • Growing the medical workforce • International recruitment • Supporting our current staff • Enabling productive working • Leadership and talent management • Recognising the value and contribution of volunteers • Actively contribute to workforce development initiatives at a Northern Lincolnshire, Humber and ICS level to support the development of a sustainable health and care workforce in North Lincolnshire, working with the local Health Academy • Actively support our Primary Care Networks in delivering workforce improvement including new roles and new ways of working, recruitment and retention, including working with local universities to increase GP numbers through GP graduate training • Deliver improvement against the workforce priorities set out in the General Practice Nursing (GPN) ten point plan • The CCG’s Engagement and Involvement Strategy has a key role to play in helping to deliver our vision. Here are some of our key priorities: • Our patient network Embrace provides us with an opportunity to reach out to a wider group of people than those who might otherwise choose to be involved. Embrace allows us to call on people to be directly involved in topics that interest them, and provides us with a network for sharing key messages and engagement opportunities. • We hold informal Café Conversation drop in sessions to ensure that the CCG is regularly listening to people’s experiences of the services we commission. We vary the location of these sessions to give all areas of North Lincolnshire an opportunity to join us in their local community. Feedback from people at these events is relayed back to our Quality and Commissioning teams to inform service planning. • We seek the views of the public and their representatives on our approach to public involvement through our Patient and Community Assurance Group (PCAG). This helps us review our involvement activity and ensure we refine our plans before engagement and feedback takes place.

23. Enablers of our Strategy (3) Contracting and payment mechanisms Medicines Optimisation • Commissioners now have greater opportunity to think differently and to experiment with alternative approaches to commissioning and contracting as a way of driving integrated care. We will need to carefully consider different contractual solutions ensuring that they are appropriate and proportionate for addressing new ways of commissioning to ensure delivery of high quality, cost-effective care.  • With the NHS long term plan clearly articulating a goal of care being delivered outside of hospital wherever possible, we will develop local solutions for payment of services that sit outside of Payment by Results (PbR) wherever appropriate. These will be developed to support an integrated approach to delivery of services and boost out of hospital care. • We will ensure high quality and safe prescribing in primary care. We will support the identification of risk patterns and improve efficiency; ensure there is enough clinical input into the development of new pathways; reduce unwarranted variation in prescribing; standardise the use of medicines; and ensure smoother transitions to avoid medicines-related delayed transfers of care. • As part of our Medicine Optimisation programme we will: • Support self-care by exploring access to services available from community pharmacies • Undertake Care Home Medication Reviews • Increase Shared Care between Primary & Secondary/Tertiary Care • Focus on STOMP (Stopping over medication of people with a learning disability, autism or both) and STAMP (Supporting Treatment and Appropriate Medication in Paediatrics)

24. Appendix Our 2 Year Plan The improvements we will make

25. Improvement Interventions Prevention Expected Outcomes • Reduced inequalities in ‘best start’ (breastfeeding, smoking in pregnancy, healthy weight, resilience in vulnerable groups) • Increased the number of Healthy Life Years people have • Reduced the gap in health inequalities • Reduced harm from tobacco, alcohol & substance misuse • Reduced prevalence of preventable long term conditions • Healthy Communities which enable and support people to look after their health and wellbeing Overview Our goal is to support our population to be as healthy as possible, targeting prevention and wellbeing interventions at high impact risk factors – thereby improving the health and wellbeing of our population and reducing the demand on the health and care system. We will work with partners to understand the wider determinants of health and develop joint plans to reduce inequalities. We will promote healthy behaviours and an active lifestyle. The Difference to our Residents “Taken together, my care and support help me live the life I want to the best of my ability” Interventions Generally Well People with a Diagnosed LTC People with Complex Needs • Work with place partners to develop overarching Prevention Strategy • Develop plan to address health inequalities • Develop community asset based Social Prescribing model for North Lincolnshire • Work with partners to tackle causes of ill health (smoking, obesity and alcohol, wider determinants) • Improve uptake of Health Checks • Develop framework for community asset based support with North Lincolnshire Council • Develop online portal for access to care and support • Continue to roll out national diabetes prevention programme and other LTC programmes • Greater range of care services in the community, such as cardiology • Develop Mental Health Strategy which will support the mental health of those with a diagnosed LTC and the physical health of those with a diagnosed mental illness • Roll out targeted approach for Cardio Vascular Disease (CVD) prevention including management of atrial fibrillation, hypertension and hyperlipidaemia • Develop care pathways which reduce variation in outcomes and scale best practice • Implement My COPD (Chronic obstructive pulmonary disease) • Improve the effectiveness and consistency of complex care planning

26. Improvement Interventions Primary Care Overview Through the investment in Primary Care Networks (PCNs) and development of strong clinical leadership within each we will work to secure 7 day access to primary care services and maximise our use of digital options for helping patients help themselves and have a choice in how they interact with services. PCN will lead the development of multi-disciplinary team working to ensure services are planned and delivered within the PCN where appropriate Expected Outcomes • Routine primary care services accessed over 7 days • Patient choice in how and when to access services including self-care advice, maximising digital options. • Improvements to recruitment and retention rates through improved job satisfaction • Investment in the formation and development of PCNs and robust clinical leadership within each • Improved patient satisfaction with access to primary care The Difference to our Residents “I understand how to access services and have a choice of how and when I do so. I am supported to make the right choices to help me achieve the best outcomes for my condition” When I do have to travel to receive care I know it is in my best interest” Interventions People with a Diagnosed LTC People with Complex Needs Generally Well • Improve access to primary care services over 7 days • Patients will be provided with options for how they access advice and care (online consultations, Skype and face-to-face) • Work with the PCNs to address recruitment and retention and develop new roles with primary care teams • All patients will have to local services commissioned through the PCNs • Develop multi-disciplinary approach within PCNs to ensure patients outcomes are maximised • Work with patients and carers to ensure suitable care plans are in place and understood by clinicians and families alike • Work with the PCNs to maximise the use of digital technology in monitoring and diagnosis as close to the patients home as possible • Ensure that through the development of PCNs we maximise all opportunities to provide services closer to home (within the PCNs) when appropriate, shifting the delivery of care from a hospital setting

27. Improvement Interventions Out of Hospital Care Overview We will implement our integrated and seamless model of care which will remove traditional boundaries between individual services, is designed around the needs of our population and is delivered closer to home in local Primary Care Networks; shifting our focus from ‘in hospital’ services to increasing investment in ‘out of hospital’ services to manage demand in a different way. • Expected Outcomes • People take responsibility for their own health and wellbeing • Services are simplified • Support in the community will be the default • Our communities are strengthened • Care is co-ordinated & holistic needs are understood • Care will be planned and crisis will be the exception • Person should return to their own bed that night (following an episode of community support) The Difference to our Residents “My care is planned with people who work together to understand me and my carers, put me in control, co-ordinate and deliver services to achieve my best outcomes.” Interventions Generally Well People with a Diagnosed LTC People with Complex Needs • Review Gateway to Care (single point of access) to transform it’s functions to improve service user satisfaction and improve signposting to broader health and care services (incl. voluntary sector) • Develop and implement approach to risk stratification and ongoing identification of people at the greatest risk of developing LTCs (map Frailty Index across system partners) • Develop greater range of services in the community • Review current usage of the Ironstone Centre and develop plan to reconfigure services that support the delivery of our model of care • Implement service (such as a Virtual Ward) which provides enhanced packages of health and care within peoples homes to enhance reablement • Enabled and proactive approach to management of high risk individuals • Increase use of Personal Health Budgets • Develop integrated approach to services in the community to prevent admission and reduce length of stay • Improve stroke pathway • Make improvements in end of life care • Develop Enhanced Care Home model • Develop Care Home Support Action Plan • Improve Discharge to Assess and Trusted Assessors Deliver a new out of hospital model of care - Deliver a new Frailty pathway

28. Improvement Interventions Children and Maternity Overview As a CCG we are committed to ensuring children and young people receive the best start in life, from conception to adulthood, in well-supported families. We will ensure that families are offered choice and receive locally delivered high quality care. When children and young people do become ill (either physically or mentally) we will deliver services at the right time, in the right place and intervene at the earliest possibility to manage conditions proactively to prevent escalation. Expected Outcomes • Reduction in perinatal and infant mortality and morbidity • Children receive proactive healthcare in the least restrictive environment • Increased number of children and young people accessing evidence based mental health support • Families experience an integrated approach to support across health, education and social care The Difference to our Residents “When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place before change happens.” Interventions Generally Well People with a Diagnosed LTC People with Complex Needs • Deliver Better Births, including continuity of carer and contributing to key public health targets including reducing smoking in pregnancy • Increase integration of midwifery and health visiting in networks • Improve support for vulnerable mothers for example through drop-in type facilities • Improve emotional health and wellbeing support in schools and colleges across the area • Provide robust and evidence based primary and secondary community pathways for children with physical and mental health problems • Work across health, education and social care to ensure families receive seamless support • Work with our partners across the HCV footprint to build resilience and high quality provision • Improve local transition pathways for young people moving from children’s to adult services • Where specialist children’s mental health services are required, improve access and waiting times • Work with partners to further develop Special Education Needs and Disabilities (SEND) provision • Proactively support the Transforming Care Programme (TCP) outcomes • Work with partners to implement the forthcoming children’s CHC framework • Review paediatric clinics Deliver a new children’s model of care

29. Improvement Interventions Mental Health and Learning Disabilities Expected Outcomes • More people accessing Improving Access to Psychological Therapies (IAPT), including IAPT pathways for people with long term conditions • Improved community based secondary care services including psychological therapies • Increased access to mental health crisis care • Better physical health outcomes for people with mental health problems and learning disabilities Overview Our all-age Mental Health and Learning Disabilities programme supports people with conditions to live well and self manage, alongside ensuring that people with acute or complex treatment or care needs have timely access to evidence based and person-centred support. The Difference to our Residents “I have the support I need to live well on a day-to-day basis, and know how to get help in a crisis” Interventions Generally Well People with a Diagnosed LTC People with Complex Needs • Work with our partners to embed a focus on mental well-being across North Lincolnshire • Increase access to social prescribing for people who may be vulnerable to mental health problems • Expand the Recovery College and peer support models to promote mental wellbeing and maintain recovery for people who have experienced mental ill-health • Ensure mental health is given the same priority as physical health across the health and care system • Provide robust and evidence based primary and secondary community support for people with mental health problems • Improve the physical healthcare of people with a mental health problem or learning disability • Improve mental health support for people with other long term conditions • Increase the proportion of people with dementia receiving a diagnosis and post-diagnostic support, and promote dementia friendly communities • Focus on STOMP (Stopping over medication of people with a learning disability, autism or both) • Improve access to mental health crisis services, including expanding alternatives to admission to a mental health inpatient unit • Minimise out of area acute mental health admissions • Work with our partners including ambulance and police services to ensure that people experiencing a mental health crisis receive appropriate support across the system • Improve specialist pathways and services for people with mental health problems or learning disabilities with the most complex needs

30. Improvement Interventions Hospital Care Overview We want to commission the best care possible for our population. We have identified pathways that will benefit from transformation and reduction in variation. Pathways will be outcome-focused and include prevention, self-care, medicines management and mental health. They will consider the whole person, not just an isolated long term condition. We will consider scale to ensure efficiency, effectiveness, and a reduction in clinical variation. • Expected Outcomes • Safe, sustainable hospital services • Constitutional targets delivered • Quality, safety and clinical outcomes improved • Greater access to care to keep people out of hospital when in crisis • Reduced occupied bed days and length of stay • Reduced Healthcare Associated Infections (HCAI) The Difference to our Residents “I will only attend hospital when absolutely necessary.” “I will be able to get rapid access and an appropriate response when I have an urgent need.” Interventions Generally Well People with a Diagnosed LTC People with Complex Needs • Hospital care partners are engaged in system-wide discussions on prevention • Timeliness of, and access to care • Achievement of national standards • Develop services out of hospital and closer to home, such as, MSK, Ophthalmology and ENT • Reduce hospital demand by embedding a different approach to elective and non-elective care • Work with hospital providers to ensure same day emergency discharges optimised • Integrate Local Clinical Advice Services with NHS111 • We will work with partners to secure safe, secure and sustainable hospital services (HASR) by reviewing services that can be improved through greater collaboration and new clinical / delivery models. Initial priorities include: ENT, Urology, Haematology, Cardiology, Critical care, Stroke, Complex rehab, Neurology, Oncology • Deliver an Urgent Treatment Centre • Develop pathways to avoid unnecessary hospital admissions