Progress to date and next steps…

1. Progress to date and next steps…

2. Growth in demand for care has to be served without growth in resources • The CCG budget for 2012/13 is balanced and the CCG has received its share of the surplus from the Kent and Medway PCTs • The future picture looks very different • Nuffield Trust is forecasting a ‘Decade of Austerity’ and there is speculation that NHS funding may not be ‘ring-fenced’ • CCG funding gap will increase every year, becoming ~£60m in 2018/19 • A majority of the savings are expected to come out of the acute setting • Our health care providers are already planning to make significant savings every year for next few years • MTW needs to do even more to account for the gradual withdrawal of Cluster support for Pembury PFI • West Kent has historically under-invested in community services and received a larger share of those services than it has paid for

3. If we do not change our health services there will be a widening gap between our income and spend Commissioner’s funding gap is £62m in 2018/19 CAGR 2013/14-2018/19: 2.5% £62m is nearly double the mental health spend this year! • These are nominal figures, i.e., inflation has not been excluded • Providers have to make further efficiencies to cover pay and prices Source: Nuffield Trust, 2012; CCG budget estimate from Reg Middleton, Feb 2013; NHS, Kent County Council population estimates Note: England population estimate 53m in 2012/13 growing to 55m in 2017/18; West Kent population estimate 0.466m in 2012/13 growing to 0.49m in 2017/18

4. Mapping the Future will describe what the future could look like to help us make consistent decisions Without an agreed vision of the future, decisions about individual services may be in conflict Mapping the Future develops a Blueprint that guides strategies of individual services

5. The Mapping the Future programme- 1 • There have been four events for patient representatives, clinicians, health and care professionals and managers covering around four clinical topics as exemplars for how systems could be reorganised • Falls and mobility • Dementia and cognitive impairment • Urgent and emergency care • Respiratory diseases • Participants considered why services need to change and evidence about what types of services have been developed elsewhere • They used this and their experience and judgement to describe the characteristics of the future health and care system • They looked at the whole spectrum of health from prevention through to recovery and at where services and support might be best provided • The outputs from the four workshops were analysed individually – there were many common themesand these were crafted into a generalised ‘Blueprint’ for the way services should be organised in the future.

6. The Mapping the Future programme - 2 • The emerging Blueprint was discussed at a fifth workshop on the 24thJune attended by participants from the four initial events. • The emerging blueprint was then tested at a two day patients panel event on 9th and 10th September • The Governing Body formally signed off the Blueprint on 27thSeptember. • The Blueprint has been discussed with local providers in Governing Body to Board meetings and with the local HWB in September and October. • The Blueprint has been shared and discussed at the CCG Annual General Meeting for all West Kent GPs on 23rd October • Delivery of Mapping the future is the West Kent integration work plan included in the successful Kent wide Integration Pioneer bid.

7. 4% annual growth in demand for care • No additional funds to cover increase in demand – very likely additional pressures on available funds (e.g., social care budget) • Many other “boxes to tick” for provider organisations (e.g., FT applications) • Failure of securing viability would result in take-overs, rationing and worse quality Mapping the Future: underlying principles Pressures on West Kent Foundation for our sustainable West Kent • West Kent will have a clear and credible plan of services that is shared and supported by commissioners and all providers and brings the best outcomes for local people • The whole approach to health and care has to change – piecemeal changes focusing on individual services and conditions will not be sufficient • Changes must be clinician-led and involve patients and the wider public • West Kent can learn from evidence of what was tried and what worked from elsewhere and develop our own solution to fit our population and geography • Instead of small pilots, West Kent will take some risk, accept that some things may not and be adept at learning and adapting quickly

8. The outcomes we should aim for • Consistent, high quality health and social care services that are interconnected and available round the clock • A system that offers the most effective and efficient care so that people get the right care in the right place by professionals with the right skills the first time • Proactive care which aims to prevent people from developing illnesses and limiting the severity of their conditions • Individuals and carers are active partners in their care, receiving personalised and coordinated services and support • Care is organised in a way that enables people to be as independent as possible and to only visit hospital when it is absolutely essential • Health and care services that are efficient in the way they use resources

9. The Blueprint • Whole system approach with campaigns on alcohol, smoking and obesity • Communities and individuals with capacity to support themselves and each other • All levers used to tackle health determinants – e.g Health education, environmental health, housing eligibility and maintenance, trading standards, standards and specifications of health and social care contracts Health and Wellbeing • People are supported to take responsibility for their health and care • People fully informed and take part in discussions about future plans • People are supported to stay independent and at home for as long as possible • Local communities and voluntary organisations are encouraged to provide support Self and Informal Care • GP practices, community services, OOH, social work and mental health as integrated team that can respond round the clock, easily accessible, seamless service • Some services brought into community (e.g., diagnostics) • Pro-active care and prevention New Primary Care • Helpline for advice to patients and carers, supported by GPs and well supervised , aware of all available services real-time • Paramedics provide care to people at the point where they become ill, as part of integrated team with same similar pathways and protocols and access to information Mobile Clinical Services • Transfer patients with urgent care needs to best setting, not necessarily only to A%E • Provide a range of treatments and diagnostic tests to patients on the way • More use is made of transport services by voluntary and community organisations Urgent Transfer • Urgent and planned care are managed as separate entities for optimum efficiency • Some services concentrated in larger centres • Urgent care as part of a total system connected with NPC and Mobile Services • Clear agreements between NPC and specialists about their responsibilities and risks New Secondary Care • Access to shared medical records and care plans for all care professionals anywhere • Improved communications and relationships between all care professionals • Risk management across the system contribute to more efficient and effective care (financial risk and clinical governance) • Financial and contractual levers aligned System Enablers

10. System Enablers Health and Wellbeing System • New Secondary Care Tertiary Services • Urgent Transfer Service • Mobile Clinical Service • New Primary Care • GP Practices • Community services • OOH • Self and Informal Care • MENTAL HEALTH CARE • Social care • Pharmacies Expert patients • Patient information • System capacity and performance information

11. In parallel, we are working up how the draft Blueprint could be applied to activity and resource patterns The Blueprint will contain • More detailed description of what services would need to be provided and their processes • More detail about the new primary and new secondary care systems • Specification of what resources would be needed for such services with comparison to available resources (workforce and infrastructure) • Outline of what productivity levels services would need to achieve to remain financially viable • Options for how providers could engage in the delivery, how commissioners could procure and contract these services, and how to transition from now to future The Blueprint will NOT contain • Detailed financial and operational plans for implementation of specified services for providers • Narrow definition of which provider should provide what services

12. We check that the Blueprint is financially viable Will the bottom line work?

13. Projected 2018/19 West Kent CCG spend by weighted LTC and service –The share of resources for people with LTCs will increase 2018/19 West Kent CCG forecast spend broken down by service type and weighted LTC band in £k Spend projection modulated based on ONS population growth forecast by age band Note: Figures are an amalgamation of 11/12 activity data and 12/13 budgets. Several assumptions have been made to apportion mental health, community, prescribing, and ‘other’ cost LTCs have been identified using hospital recorded ICD codes for 14 conditions (Asthma, Cancer, CHD, CKD, COPD, Dementia, Diabetes, Epilepsy, HT, Hypothyroidism, HF, MH, Obesity, Stroke) Source: 11/12 acute spend from West Kent integrated dataset, 12/13 budgets from West Kent CCG Financial Framework, ONS population projections Assumptions (spend distributions): Ambulance spend based on A&E and emer. admissions; high cost drugs and other acute based on acute; MH on MH activity; community on community activity; prescribing based on outpatient spend; continuing care based on emer. admission spend for >65 year olds; ‘other’ based on spend distribution of all other services

14. The greatest savings are likely to come from reducing emergency admissions, esp. of patients with LTCsWorking assumptions – currently being tested ICO gross target savings in 2018/19 for West Kent CCG broken down by service type and wLTC band in £k Note: Cost base figures are an amalgamation of 11/12 activity data and 12/13 budgets. Several assumptions have been made to apportion mental health, community, prescribing, and ‘other’ cost LTCs have been identified using hospital recorded ICD codes for 14 conditions (Asthma, Cancer, CHD, CKD, COPD, Dementia, Diabetes, Epilepsy, HT, Hypothyroidism, HF, MH, Obesity, Stroke) Source: 11/12 acute spend from West Kent integrated dataset, 12/13 budgets from West Kent CCG Financial Framework, ONS population projections Assumptions (spend distributions): Ambulance spend based on A&E and emer. admissions; high cost drugs and other acute based on acute; MH on MH activity; community on community activity; prescribing based on outpatient spend; continuing care based on emer. admission spend for >65 year olds; ‘other’ based on spend distribution of all other services

15. Sources of savings by system-wide changes • Better care is cheaper – avoiding delays in diagnosis and treatment to reduce deteriorations that drive care costs up (pro-active care, early recognition of deteriorations and faster response, faster pathways for new problems) • Greater independence for patients and carers – through better information and education for guided self-care, reducing the demand for formal, professional care • Staying in the community – providing more enhanced care at patients’ homes with less need for expanding expensive infrastructure • Hospital without walls – making specialist expertise accessible in the community • Supported by enablers (e.g., information systems, workforce development) and aligned incentives Sources of savings

16. The Blueprint leads towards Integrated Care – Therefore, ICO Key Success Factors are also valid for Creating the Future Creating the Future needs to cover clearly defined Success Factors Kaiser’s Key Success Factors King’s Fund/Nuffield Trust Key Success Factors • An engaged clinician and healthcare professional workforce (Leadership) • Exploitation of an integrated model (Team) • Harness Information Technology (IT) • Performance measurement to support and guide improvement activities (Measurement) • Compelling narrative for integrated care • Allow innovations to embed • Align financial incentives and allow commissioners funding flexibility • New contracts with providers • Allow providers to take risk and innovate • Governance and accountability frameworks based on single outcomes • Clarity on competition/integration rules • Nuanced interpretation of patient Choice • Leadership and organisational development • Evaluate impact

17. Next Steps • CCG clinicians and managers are working up a plan for how the changes that need to be made can be sequenced over 5 years – ‘Mapping the Journey’ • Once a draft transition plan (Mapping the Journey) is produced it will be tested with local people, stakeholders and HWB. • When agreed the blueprint and the transition plan will be included in the 5 and 2 year Commissioning Plan being produced for the CCG. • The CCGs internal governance structures and operating processes are being revised to align with the Blueprint described by Mapping the Future and the transition plan set out in Mapping the Journey. • Joint arrangements are being planned with local providers and the local authority to ensure the changes are progressed as an integrated partnership