TheErewashMul-specialty
CommunityProvider
ValueProposi-on
Refreshedfor2016/17
February 2016
Wellbeing Erewash, Your Life Your Way
The Erewash Multidisciplinary Community Provider (MCP)
1
Value Proposition – Refreshed for 2016/17
Contents
1. Introduction
2. Our vision
3. The over arching case for change
4. Summary of our new care model
5. Making it happen – what we have achieved in 2015/16
5.1 Building resilient communities
5.2 Personal resilience
5.3 Integrated services
4. IM&T
5. Workforce and OD
6. Governance
5.7 Communications
5.8 Engagement
5.9 Activity for the year to date
2. Replicability
3. Making it happen – what we will do on 2016/17 and beyond
4. Resource plan to deliver our ambition
4.4.Overview
4.5.Historic activity and finance
4.6.Planning assumptions
4.7.Projected plan
4.7.1. No change
4.7.2. Worst care
4.7.3. Likely case
4.7.4. Best case
4.8.Contracting arrangements
4.9.Governance of the financial plan
5. Governance issues
6. Evaluation
7. Risk
2
8. Summary
1. Introduction
A Value Proposition was submitted by the Erewash MCP in July 2015. This is a refresh of
that document providing an update on progress to date and greater detail on the plans for
delivery in 2016/17 and the anticipated benefits.
2. Our Vision
Our vision remains unchanged:
Our vision is for thriving communities within Erewash, where you feel confident and
supported to choose a healthier lifestyle, stay well, and know how to get help and support
when you need it.
Our mission is to develop Thriving, Capable, and Healthier Communities
In 2020 Erewash will be characterised by:
•
Strong inclusive communities
•
Shared ethos between the people in the community and their trusted
professional staff of self-care and shared decision making
•
Responsive and accessible support services
•
Integrated services that wrap around people and their family and carers
reducing the need for bed-based care
Our model is based on the principle of shifting care into the lower tiers of care thereby better
meeting the needs of people. There is emphasis on prevention and early intervention which
puts individuals at the centre of decisions about their care, and truly transforming community
and primary care services with integrated local provision of services. We are determined to
make a reality our aspiration that all patients are fully involved in decisions about their own
care and treatment so that the principle of shared decision-making - “no decision about me,
without me”- becomes the norm.
3
The logic model on the next page describes our ambition, the high level interventions we will
take to deliver this as well as the expected outcomes and longer term impacts.
4
LOGIC MODEL FOR EREWASH MCP
VISION: Our vision is for thriving communities within Erewash, where people feel confident and supported to choose a healthier lifestyle, stay well, and know how to
Our mission is to develop Thriving, Capable, and Healthier Communities
ACTIVITES
Key activities are centred around three pillars:
INPUTS:
1.
Workforce across all
organisations
to MCP.
2. Staff assigned
3. Patient and public
engagement, voice and
feedback.
4. Additional community based
staff with the required skill
mix to deliver the new care
model.
5. Transformation funding to
enable double running of
services and backfill of staff
whilst new ways of working
become embedded.
6. Engaged volunteers &
Community members.
7. MCP year on Year funding
1. Building resilient communities
•
Granular analysis of the social determinants within the localities of
Erewash
•
Map current and planned work in communities by partners
•
Identify the community assets and key leaders
•
Agree initial priorities with communities and education establishments with
an annual summit.
•
Priorities for action published annually, and fed back to local people.
2. Personal resilience
•
Training of staff on self-care and shared decision making
•
Development of decision aids and information.
•
Delivery of a consistent comms & engagement plan promoting services
and information on life style changes raising awareness of health/
wellbeing factors.
•
Marketing of approach, services and changes.
3.Integrated community and primary care
•
Definition and implementation of integrated MDT teams for the two
localities
•
Further develop the model of proactive care with effective risk
stratification.
•
Access to shared patient information
•
Development of on day urgent care services
•
Redesigning the delivery of services for Primary & Integrated Community
Care.
These activities will be enabled by:
•
Estates solution to support the delivery of new models of care.
•
IM&T solutions to support the efficient delivery of care model
•
Training and OD for all working within the Erewash system
•
Capitation model enabling alignment of incentives
OUTCOMES:
Building resilient communities
•
Educated and informed public
•
Increases community resilience
•
Increased prevention measures
•
Reduced intervention frequency
•
A coherent single service provide
communities improving patient su
Personal resilience
•
Provision of more support and ca
home or close to home Improving
Centralised approach to shared p
planning.
Improved patient adherence in se
All providers are aware of what is
support people
•
Increased personal resilience
Integrated Primary Care and Commu
•
Improved patient outcomes throu
appropriate care/support.
•
Improved access to same day pr
community services including urg
•
Reduced use of secondary care
total cost of care (including socia
weighted population.
•
Aligned understanding of what In
means to everyone who provides
care.
•
Care delivered closer to home w
on secondary care giving.
•
Changing the delivery of services
Integrated community care.
•
•
•
EnablingFactorsandassump-ons
•
The positive impact of Community Development will be direct, through the participation of an individual, and indirect through the influence that community parti
developing communities)
•
Social integration increases resilience against physical and mental health problems (RCGP Working with communities, developing communities)
•
If long term conditions are better managed through self-care, this results in decreased medical consultation and hospital attendances (NICE 29520; Self-care s
•
There is some evidence of improved clinical outcomes for patients being treated in community based settings. This is particularly the case for older patients: co
to reduce the number of hospital admissions, falls and moves into long term healthcare (Beswick et al, 2008)
•
Person-centred care delivered by GP led multi-disciplinary community teams.
•
Estates strategy across all organizations
5
The underlying ethos of all we do is encompassed by the triple aim of improving the health of
the people of Erewash, improving their experience of care, improving efficiency and reducing
costs
Focusonpreven,on,reducedhealth
inequali,es;workingwithpartners
toaddressthewiderdeterminants
ofhealth
Safe,effec,ve,,mely,pa,ent
centred,equitable
Improvedefficiency;reduced
duplica,onandwaste;capita,on
3. The overarching case for change
Our original Value Proposition contained the detailed information which shows Erewash as an
area with inequity across the area, and pressure on services as demonstrated by waiting times
in A&E as well as for planned care. Patient satisfaction with access to GPs is lower than in
comparable areas with significant variation across the patch. Whilst progress has been made in
addressing some health issues there are still a number of areas where people in Erewash have
a lower health status than in comparable areas. These factors alone paint a compelling
argument for change, but when the worsening financial position is factored in it is inconceivable
that things can remain the same.
Tinkering with small changes will not deliver the transformation required - we are ambitious and
want to:
•
Transform the health and well-being of local people
•
Make the Erewash pound stretch further so that the health and wellbeing system is
sustainable
•
Deliver excellence in the services that are provided
Wellbeing Erewash fits within a wider transformation programme across the South of
Derbyshire which is now being developed in the Derbyshire wide Sustainability and
Transformation Plan (covering both the Derbyshire County and Derby City Local Authority
6
areas). Our plans are seen as key to transforming community services, and it is intended that
lessons learnt and new models of care will be replicated across the unit of planning and
Derbyshire at scale and pace.
Within Erewash and across the wider unit of planning, plans for transforming care and services
are in place, but with the support available to Vanguards we can accelerate our progress in
delivery.
4. Summary of our new care model
Our new care model looks to build on our unique selling point of excellent clinical leadership to
remove organisational boundaries and shape an integrated person-centred community, where
people feel empowered to support themselves and reduce their reliance on costly statutory
services. Where care is needed, services will be wrapped around the patient.
Specifically, the new models will result in:
•
Resilient local supportive communities promoting education/information
•
Encouraging / empowering patients to self-care and training staff to share decisionmaking
•
Integrated care services with multi-disciplinary teams spanning primary and
community services which target at risk patients
•
A new care model for delivering 7 day on-day services for local people including
those with urgent care needs
•
Accessible primary care through appropriate GP coverage and use of triage systems
•
An electronic patient record enabling single point access for providers & patients
•
Sufficient out-of-hour care coverage
Together GPs and the integrated community services will become a Multi-speciality Community
Provider with a devolved capitation budget, working with the County and Borough Councils,
voluntary sector and local communities to meet the needs of the local population efficiently and
effectively.
Our vision can only be truly delivered when all workstreams have delivered their programmes.
There are some fundamental principles in our new care model that are addressed in all
projects:
•
A relentless focus on empowering people, promoting wellbeing and taking every
opportunity to equip people to make lifestyle changes;
•
A passion to deliver holistic care ensuring that mental, physical and social needs of a
person and their family are recognised and addressed to improve the overall wellbeing of
the residents of Erewash.
The care model described above is entirely consistent with the plans within the Joined Up Care
transformation programme across the South of Derbyshire and the wider Derbyshire footprint.
5. Making it happen – what we have achieved in 2015/16
We know our vision is ambitious. From day one we have been determined not just to ‘talk the
talk’; we are driven to transform the experience of people in Erewash and to turn our high level
7
plans as described in the original Value Proposition into action. However, we also know that in
order to deliver sustainable change, we need to co-design changes with local residents,
stakeholders and staff – and this takes time. In 2015/16 we have established the foundations on
which we can deliver the MCP ambitions.
Our delivery vehicles are three service-focussed workstreams (Community Resilience; Personal
Resilience and Integrated Primary and Community Services) and groups focussed on the key
enablers of workforce and OD, finance and contracting, communications and engagement,
IM&T and estates. Each group has an executive sponsor from the Board, an operational lead
and project resource.
The context and vision for these workstreams remains as previously described. Each of our
workstreams has reviewed the logic models, which were included in our original Value
Proposition – the current draft workstream logic models are attached in Appendix A. We know
that these need further development – feedback from the consultant at ICF International who is
supporting us with our logic models has commented that the original models needed a more
succinct diagrammatic form that showed the links between the interventions and outcomes
more clearly. We had a workshop in January to begin this work and will have fully developed
models by the end of February 2016.
The following sections give more detailed descriptions of their workstream activity and
achievements to date.
5.1
Community Resilience
We know that this workstream probably has the biggest potential to transform Erewash but, as
described in the Five Year Forward View, this will be slow burn, high impact.
A conceptual framework for this work has been developed:
BuildingCommunity
MakingShared
Peoplewithhealthanxiety
Resilience- Schools,
DecisionMaking
Towns&Villages
Minorandself-limiSngcondiSons
LongTermcondiSons
“WhenIbecomesWe,IllnessbecomesWellness”
8
Two task and finish groups have been formed to take this work forward:
•
Voluntary sector
•
Towns and villages
•
Schools
We are passionate to ensure our work is effective, and have wanted to learn from experience
elsewhere. Work to date has largely been to identify models in operation elsewhere, and
sourcing expertise to support our work locally. We have specifically:
•
visited Calderdale to understand their voluntary sector model;
•
visited the Bromley by Bow centre;
•
participated in teleconferences on building community resilience;
•
requested support from the King’s Fund for our work with schools;
•
contacted a university tutor at Derby University who has studied resilience in schools;
•
contacted Birmingham Jubilee Centre regarding resilience in schools.
The key learning to come out of these so far is the identification of the three faceted needs of all
people - namely jobs, houses and friends. These three things support individuals to have
confidence and purpose which leads to personal resilience, and at a community level, assets
for others to use creatively creating community resilience.
This work has provided a strong base for us to move forward in 2016/17 as described in section
7 of this document.
5.2
Personal Resilience (previously known as making self-care and shared decision
making a reality)
This workstream is seeking to transform the way care is delivered to ‘give time back to patients’,
rather than expecting them to come to see the ‘professional care giver’. The mantra of the
workstream is ‘We need a revolution, not an adjustment, to current practice”.
The bed rock of this change will be to embed shared decision making into everyday
practice. We know we need to change the mind set of health professionals; we will have
achieved success when the first question patients are asked is not “What’s the matter with
you?” to “What matters to you?”
Truly shared decision making will empower patients to self-care confidently, with the
knowledge that if required there is additional help for them to access.
In relation to self-care, three priority cohorts of people have been identified:
1. Self-care for people with health anxiety who do not need medical treatment, but who
visit the doctor to be reassured, or with social/emotional problems
2. Self-care for people with minor or self-limiting conditions who don’t know any different
than utilising GP or A&E services
3. Self-care for people with long term conditions
When considering the appropriate interventions for these target groups, the workstream has
developed a benefits realisation which also reflects the work being undertaken by the Building
Community resilience workstream.
9
Self-Care Benefits Realisation
People with health
anxiety who do not
need medical
treatment, but who
visit the doctor to be
reassured, or with
social/emotional
problems
People with minor or
self limiting conditions
People with long term
who don’t know any
conditions/issue
different than utilising
GP or A&E services
Building community
resilience
✓
✓
Self-care promotional
materials, roadshows,
displays
✓
✓
✓
Self-care targeted
material and displays
✓
✓
✓
Personalised care/
wellness planning
✓
Having explored different training packages for staff in relation to shared decision making and
self-care, we are rolling out sessions on person centred approaches to all staff working within
Erewash.
The community and personal resilience workstreams complement each other. Appendix B
demonstrates how the work is aligned to the six principles for new models of care
5.3 Integrated Primary and Community services
In our original Value Proposition, we had identified two workstreams – integrated service
delivery, and responsive and accessible primary care. However, once these groups began work
it was clear that the interdependencies were such that the groups came together to form a
single workstream.
A key achievement to date has been the agreement of the principles that will underpin our
integrated care model. These have been co-designed by front line community staff and
general practice and provide us with the clarity as to how to develop the new care model:
10 •
The GP-led population based multi-disciplinary teams working in the two localities are
the bedrock of our integrated care system and will be able to deliver the majority of the
care required by people and their families, thereby reducing the burden on secondary
care;
•
Care will be delivered in a seamless way reducing the number of visits and
professionals working with a person and their family thereby reducing time wasted by
the person repeating their story, attending appointments which add little value, etc; we
will work with the existing teams and staff to identify where there is current duplication
so that we can be sure this is eliminated in our new teams;
•
The teams will encompass health, social care and voluntary sector organisations with all
working to meet the needs of individuals rather than being hamstrung by organisational
boundaries;
•
The teams will identify and meet both physical and mental health needs and will bring
together the current plethora of functional teams;
•
The teams will ensure that decisions are made with the person, focusing on what is
important to them, and will encourage and support self-help activities and education;
•
Staff with specialist skills will be available to support the integrated teams to work
holistically with people;
•
We will preserve the jewel of the current primary care system – continuity of care and
the knowledge and relationships with people and their families;
•
We will respect each other’s skills and professional backgrounds but also challenge
each other to ensure care is based on people’s needs not our professional and
organisational needs;
•
Care and services for a person and their family will be provided by the person most able
to deliver this with the appropriate level of training;
•
We will have on-day, multi-disciplinary population based services where needs are met
on the day, as well as teams working proactively with people who have existing
conditions to prevent, as far as possible, exacerbations and where these do occur
ensure that there is a clear management plan in place.
The model for the integrated service is shown below:
!
* This model is uses the World Health Organisation definition of Primary Care:
‘Primary care is more than just the level of care or gate keeping; it is a key process in
the health system. It is first-contact, accessible, continued, comprehensive and
coordinated care. First-contact care is accessible at the time of need; ongoing care
11 focuses on the long-term health of a person rather than the short duration of the
disease; comprehensive care is a range of services appropriate to the common
problems in the respective population and coordination is the role by which primary care
acts to coordinate other specialists that the patient may need’.
In moving towards our new model we have:
•
Mapped the existing community services into hot (urgent) and cold (planned) responses
•
Held engagement events with community matrons, community nurses and GPs to
discuss the case of change, new emergent model for integrated teams and design
features for the new services
•
Identified a need for additional input into the teams in relation to mental health and
older person’s medicine
•
Developed a model for on-day primary care delivery at a locality level
During 2015 we have enhanced services on the ground for patients:
An acute home visiting pilot has been launched running from Monday 23 November 2015
until Friday 1 April 2016. The overall aim of the service is to provide additional capacity within
primary care via this home visiting service.
The pilot, which is based on the evidence from a Health Foundation report in 2000, will test
whether a same-day acute visit will benefit patients by reducing A&E attendances, potentially
avoidable admissions and reducing pressure on primary care.
Services have been put in place to support Care Homes:
•
Care Home Support Service (CHSS) – this was an initiative under the Prime Minister’s
Challenge Fund to enable care to be provided within the care home setting reducing the
need for residents to be admitted to hospital for avoidable conditions. During 2015/16
the MCP has been working to:
-
•
establish full coverage of homes by the CHSS;
improve integration with aligned primary care practice;
align, where possible, with the Airedale Telehealth pilot (pending evaluation
of Airedale pilot impact).
The Airedale Telehealth pilot has been set up to use Telehealth equipment (HD camera
and laptop) with 24/7 access to Airedale call centre. The intent is to safely prevent A&E
attendances and emergency admissions. It was established in the period June-August
but due to some data difficulties there is little information as yet to judge the impact of
the service.
Although there is more to do in our work with care homes the early results are promising. The
care homes admissions dashboard shows a 14% reduction of admissions from care homes in
Erewash covered by the CHSS service compared to the similar period in 2014/15. This service
is now funded from mainstream funds due to its high return on investment (4.16)
We have delivered 7 day access to GP services; primary care capacity has been increased
by the continuation of the primary care hubs that were begun under the Prime Ministers
Challenge Fund. These have operated from 18.00 – 20.00 hours on weekdays, and 09.00 –
14.00 hours at weekends, in Long Eaton and Ilkeston providing 15 minute appointments with
either an ANP or GP. Between November 2014 and November 2015, 5,760 patients were seen
in the hubs; children aged between 0 and 4 years are consistently the highest users of these
services (16.7% of all contacts).
12 The graph below shows the reduction in A&E attendances where there was no intervention, no
treatment (HRG VB11Z); this does not infer direct causal impact of the hubs, but is rather for
information as part of an overall picture in respect of the primary care hubs.
Profile of A&E attendances (not MIU) for VB11Z HRG (no intervention, no treatment)
!
There have been enhancements to the community team. Care co-ordinators have been in
place in Erewash for a number of years. They play a pivotal prole as the interface between
service users, carers, primary care, secondary care, community care, social care, mental
health, out of hours and voluntary organisations. We have agreed to extend this service so that
there will be 1WTE per 10,000 patients. This additional capacity allows us to progress our new
care model by:
•
•
•
•
Operating across the two localities of Long Eaton and Ilkeston which both have a
population of 50k allowing continuity of care at a population level;
Daily identification of ‘at risk’ patients and detailed immediate action taken;
Further monitoring of discharges and liaison with the enhanced service, GP practice and
the wider community teams;
Supporting the clinical navigator based at the Single Point of Access (SPA) by liaising
with both Derby and Nottingham acute hospitals as well as Ilkeston Community Hospital
on a daily basis to monitor in-patient progress and liaise with family, carers / agency and
community services regarding expected discharge dates and plans, and supporting the
coordination of services on discharge.
We are piloting having dedicated clinical health psychology support to work with patients who
are frequent users of health and social care services and whom have a physical health issue.
These would typically be patients that the current health services are struggling to progress with
and therefore have an increased inappropriate utilisation of community services, primary and
secondary care (including ED attendances and emergency admissions), and ambulance
services. Initially the input will be nine hours per week supporting the Long Eaton Integrated
Care Team; subject to evaluation this will be increased across the area.
We are developing a new patient facing role for pharmacists within the on-day service.
These roles will provide direct acute care for patients, promote proactive wellness planning and
self-care, as well as working to reduce polypharmacy and give medication advice as required,
thereby supporting effective medicines management for older people.
A community GP has been appointed. She provides medical support and cover to our SPA,
care homes service, acute home visiting service, and community matron service. We will review
how this role is working regularly as we adapt and develop our system to ensure that we use
this valuable resource to best meet the needs of our population and support our new model of
care.
13 Following several engagement events with Practices that have been led by Erewash Health, an
at scale model for primary care is developing. Individual Practices will continue to provide
primary medical services but with many services being offered at a locality, rather than practice
level. The immediate focus is on the delivery of primary on-day services in the two localities in
Erewash. The development of a super-partnership is being actively explored to support the
delivery of primary care at scale delivering population health services, and allowing sharing of
back office functions. The super-partnership model has grown out of engagement events held
with GPs to support their organisational response to the delivery of the MCP.
5.4
IM&T
IM&T is a key enabler for the changes we want to deliver. We are building from a strong IM&T
platform as in Erewash all Practices and DCHS use SystmOne. During 2015 we have made
further significant progress:
•
The Summary Care Record (SCR) has been enhanced to include more data which, as
all providers can see the SCR, helps ensure continuity of care
•
The TPP Hub has been commissioned and is being put in place to deliver a full
integrated record within the Primary Care Hubs and Home Visiting scheme; this will also
allow tasking between clinicians, but, perhaps more importantly, the full notes of any
visit/actions taken by any of these services can be seen by GPs, primary care team and
community/OOH services.
•
The Medical Inter-operability Gateway product (MIG) has been procured and will be
uploaded with information to provide GP record information to our urgent care providers.
In addition, data from the local acute hospitals will be provided to GP and community
systems.
•
Information Governance protocols have been completed to allow implied consent to
share, and explicit consent to view, across health and social care organisations within
Derbyshire. These protocols are currently going through all organisations’ Boards for
approval.
•
Shared decision making toolkits have been tested and a shortlist is being reviewed by
clinicians to take this forward in January 2016. Training will be between February - May
2016.
5.5
Workforce and OD
We know that delivering our vision will require very different skills and ways of working.
Working with Whole Systems Partnership, we have refreshed our workforce model, SWIPE (the
Strategic Workforce Planning and Evaluation approach). This model connects changes in
underlying population health needs with proposed service transformation in order to identify the
necessary future workforce at an aggregate level. The approach uses broad skill levels rather
than professional groupings, i.e. Foundation, Core, Specialist and Advanced. The ‘future vision’
for the workforce, reflecting underlying need, service transformation and skill mix changes, is
then compared with the ‘as is’ workforce in a dynamic modelling tool that enables different
future scenarios to be explored
14 Our initial work has focused on the workforce we will need to meet the needs of older people
with frailty – both physical and mental health frailty – as we know this is the population segment
who make highest use of secondary care services and where we will see significant
demographic change. The work undertaken has considered the workforce implications of our
new model for health, social care and independent home care staff, considering the types of
functions that will be required, and what level of staff will be delivering that care.
. Compared to our baseline staffing, the modelling suggests that by 2020 the need, driven by
underlying demographics and a shift from hospital to community settings, would equate to an
increase of 50wte – and would continue to grow by circa 7wte each year thereafter. However,
the skill mix would also be changing in response to increased capacity to deal effectively with
transitions and crisis events. Table 1 shows the relevant comparisons between 2015 and 2020.
2015
2020
c.315 wte
c.365 wte
% foundation skill level
48%
53%
% core skill level
30%
23%
% specialist skill level
14%
13%
% advanced skill level
7%
11%
Total community workforce
Table 1 - Comparison of workforce in number and skills mix between 2015 and 2020
The profile of change over time is shown in Figure 1, reflecting a broadly level requirement for
core and specialist staff from the existing baseline in Erewash but with significant increases
for foundation and advanced level staff. Examples of staff groups with advanced skills are
medical consultants, GPs and/or Advanced Nurse / Clinical Specialists), and foundation staff
(this level of skill requires staff to have an understanding and awareness of work procedures
which staff would be expected to have after induction and on the job training. Examples of staff
groups with foundation skills are health care assistants, care workers or generic support
workers).
The shape of the workforce, aggregated to skill level for the frail elderly population of Erewash,
is shown in Figure 1.
15 Figure 1:
Change in skill mix over time (1 = foundation skills; 2 = core skills; 3 = specialist;
4 = advanced)
The total increase in community workforce is c.32wte up to 2020 (an increase from 315 to 347
wte), with increases in Foundation and Advanced level staff. Core and Specialist skill level
requirements do fall slightly in the short term but increase again in the medium to long term.
Using average unit costs for each skill level the modelling tool suggests an increase in the cost
of community staff from c.£8.8M to c.10.2M across all agencies and including the independent
sector workforce captured in the baseline.
The changing shape of the community workforce will only result from a pro-active set of
workforce actions to recruit, up-skill and, where appropriate, transfer staff between sectors. The
balance of these three actions, by skill level, is provided by the model. This is shown, under the
current baseline scenario, in the following table. It should be noted that there is a default
assumption that staff are ‘upskilled’ rather than recruited directly to specialist or advanced level
posts, whilst core and professional level staff would be recruited directly, although alternative
approaches may be necessary in practice. The table below takes into account the impact of
upskilling to higher levels on the lower skill level capacity. For example, the 3.6 wte upskilling of
core to specialist in 2017 does not necessarily reflect an increase in total specialist workforce
because of the need to replace those being upskilled from specialist to advanced. The current
assumptions do not suggest the possibility of transfers from the hospital sector assuming this
would need to be co-ordinated across a larger geographic area.
2016
2017
2018
2019
7.5 wte
9.1 wte
10.6 wte
8.3 wte
-
-
-
4.9 wte
Upskill core to specialist
1.6 wte
3.6 wte
5.9 wte
6.0 wte
Upskill specialist to advanced
2.9 wte
4.6 wte
4.6 wte
3.6 wte
New foundation staff
New core staff
Table 2: Workforce actions necessary to support reshaping of the community workforce (over
and above turnover/replacement factor or actions to address vacancy levels or similar)
The full report is available in the Appendix C, but it should be noted that the current modelling
does not take into account the productivity gains from working as an integrated system;
these changes will be added into the more detailed workforce plan.
The SWIPE workforce model is a tool which we will continue to use throughout the MCP
programme to inform our more detailed workforce plans and to monitor progress. Work has
begun to run this workforce model in relation to the childrens’ workforce and are discussing with
the national workforce workstream how this model could also be applied to adults
We know our new care model will require all parts of the health and social care community to
change. This level of transformation will require a significant shift in culture. Therefore, we
commissioned, as part of the Joined Up Care programme across the South of Derbyshire unit
of planning, a detailed diagnostic exercise to clearly identify what OD activities are
required to support our ambitious programme of change.
This has identified the following themes.
•
Support and development for people leading the MCP and the workstreams eg 1:1
coaching and identification of development needs, facilitation of development for the
Leadership Team and the emerging organisation.
•
Support to promote the development of general practice, ranging from interventions to
help practices understand the reality of the context and environment and the
opportunities and challenges this has for established ways of doing things, through to
supporting practices to consider and adopt models of collaborative working.
16 •
Working with individuals and groups of staff who are key to delivering new service
models such as Community Matrons and District Nurses, to explore what the new
arrangements mean for them, understanding other peoples’ roles and to involve them in
designing new processes and systems.
•
Working with patients, carers, and the general public to develop understanding of what
services will look like and what this will mean for them, and building capacity in the
community to take on things that were previously done by statutory services.
•
Better awareness across workstreams of what others are doing and where there may be
common interests and linkages
•
Ensuing that Commissioning and contracts teams are aware of the direction of travel
and potential changes to services so that these inform the 16/17 contracting round
We are commissioning a Leading across Boundaries programme from the East Midlands
Leadership Academy and are in the process of designing our full OD programme to address
these themes.
5.6
Governance
We know that system transformation is complex. To be successful there has to be strong
system leadership built on good relationship and trust. The MCP Partners Delivery Board which
meets monthly has agreed a comprehensive accountability and governance framework
(Appendix D) which clearly articulates roles and responsibilities as well as principles for dealing
with conflict.
The core members of the MCP are unchanged :
•
•
•
•
•
NHS Erewash Clinical Commissioning Group
Derbyshire Community Health Services Foundation Trust
Derbyshire Healthcare Foundation Trust
Derbyshire Health United
Erewash Health (GP Federation)
While each organisation continues to have its own governance arrangements and is a statutory
organisation in its own right, these partners have come together to form a MCP Partners
Delivery Board. This Board, which has a membership of Chief Officers and senior clinicians,
leads the development of the MCP for Erewash, working across boundaries to drive forward the
five year vision. This is the decision-making group for the MCP. As each organisation is a
statutory organisation in its own right, members ensure that their boards are kept informed and
that there is compliance with their SFI/SOs .
The Board meets monthly with a standing invitation to associates of the MCP, the voluntary
sector, Healthwatch and adult social care, to join the meeting. Terms of Reference can be
supplied upon request.
The Board is supported by the MCP Project Team which meets monthly and acts as the PMO
for the programme.
This team undertakes the following functions:
17 •
•
•
•
monitoring and co-ordinating the work streams and projects to ensure successful
delivery of the MCP Value Proposition;
promoting project and programme management best practices in key control areas eg
programme scoping, planning, progress tracking, change control, financial
management, risk and issue management, benefits realisation and stakeholder
management and communications;
monitoring and managing the inter dependencies between the projects and themes;
holding the key programme management and change management resources required
to deliver the MCP.
The governance structure is shown below.
!
At present the OD agenda sits within the workforce enabler group but given the seismic shift in
culture that we are seeking, the MCP Board is considering establishing a separate workstream
focused solely on OD.
Any major transformation programme needs to manage risks effectively. Each workstream has
a risk register which is updated on a monthly basis. In addition, there is register of MCP wide
risks which is also reviewed monthly. At each meeting the Board receives a report on risks
which have a risk score of 15 or above. As the MCP Board has no statutory standing, individual
organisations feed risks relating to the MCP programme into their own risk management
processes.
Delivering large scale change requires strong programme management. A programme team is
being recruited to drive the delivery of the programme. Until the full team is in place, an interim
programme manager and senior analyst have been secured.
5.7
Communications
18 MCP partners have robust communications and engagement processes in place and we have
gained support for our direction of travel from the local Health and Wellbeing Board, Overview
and Scrutiny Committee, acute providers, stakeholder groups and voluntary sector colleagues.
Our vision has been informed by messages we have heard from the public over the years – that
care is too fragmented, people want to tell their story once, the system is confusing, and there
are problems in accessing some services.
Our key message is encapsulated by our vision for thriving communities within Erewash, where
people feel confident and supported to choose a healthier lifestyle, stay well, and know how to
get help and support when needed. The MCP will develop new care models, with the aim of:
•
•
•
Developing community support, rather than health and social care services;
Building resilience in our services and in communities;
Changing how we work together, what we deliver for people and what people deliver for
themselves.
To date the following activity regarding MCP has been completed:
•
•
•
•
•
•
Media releases announcing the successful bid for the MCP Vanguard and progress
updates
Video explaining the MCP Vanguard featuring partners and patients. This was shown at
the CCG's AGM in September
MCP page on Erewash CCG website with a link from the homepage
Articles in the last two Erewash CCG newsletters (July and October)
Self-Care Campaign to support the specific workstreams of self-care and community
resilience.
Presentations to numerous groups including Joined Up Care Board for the South of
Derbyshire, voluntary sector groups, community staff groups, GP groups, Overview and
Scrutiny. In addition, the MCP was presented during an engagement event for the
Joined Up Care programme which was attended by over 70 key stakeholders including
local FT governors, and Councillors
In addition, a brand has been developed for the MCP. A number of suggestions had been put
forward from different engagement events and from the Board itself. In order to determine the
final brand for our work, partner organisations cascaded this list within their staff group and
patient and public engagement groups, reminding them of the vision for Erewash, and asking
them to vote for which name they thought would best represent this ambition. The clear
‘winning’ name was ‘Wellbeing Erewash’ followed by ‘Your Life, Your Way’. The Board decided
to adopt both with Wellbeing Erewash as the name, supported by the strap line ‘Your Life, Your
Way’. We are now working on branding so that a full suite of materials and templates will be
available to promote the concept of our MCP.
The lead for MCP Communications and Engagement sits on the project team and the Delivery
Board, ensuring links can be made with the different workstreams, as well as being a member
of the Personal Resilience workstream. Communications leads from the MCP partners meet as
the MCP Communications and Engagement Enabling Group and there is a standing item on
communications and engagement on the MCP Board agenda.
5.8
Pubic engagement
We have established mechanism for talking with our local residents. The Foundation Trusts
have local membership, whilst the CCG has an extensive communications and engagement
programme in place, including regular online and media activity, printed materials, face to face
meetings and events, a stakeholder forum and a network of PPGs which meet bi-monthly.
The CCG has carried out a public engagement exercise on urgent and out of hours care, and a
19 touch screen survey has been used to gather patient feedback on the two primary care hubs
which have formed part of a pilot scheme under the Prime Minister’s Challenge Fund to
improve primary care.
Building on these activities there has been considerable communication and engagement work
during 2015. This includes presentations to PPGs and the CCG Annual General Meeting, as
well as presentations and discussions about the MCP vision at many partnership groups within
Erewash - for example Erewash Partnership Group, youth forum, market stalls, Erewash
Healthy Voices, Dementia Alliance Group, library sessions, patient and carer stories and
consultation with the voluntary and community sector Derby College. The detailed record of
engagement events and outcomes is in Appendix E.
A recent exciting development has been the supermarkets in Erewash identifying community
engagement officers which will really open up opportunities for joint work on promoting healthy
lifestyles, as well as opening new opportunities to engage with segments of the population who
may not normally hear these type of messages.
5.9
Activity for the year to date
The MCP builds on work which has been underway for several years, and therefore, with the
energy and enthusiasm generated by the MCP vision, we have seen a reduction in secondary
care activity.
Readmissions
Ac-vity&Cost
(Apr-Sep2014
and2015)
NEL Ac'vity &
Cost (Apr-Sep
2014and
AcSvity
Cost
2015)
12780
£17,100,000
12765
£17,025,000
12750
£16,950,000
12735
£16,875,000
12720
12772
12723
£16,800,000
1100
£2,400,000
1050
£2,325,000
1000
£2,250,000
950
900
£2,175,000
1100
AcSvity
981
£2,100,000
Cost
6. Replicability
As a Vanguard we are in a privileged position with access to the national support offer and early
learning from other Vanguards. Therefore, we take every opportunity to share our experience.
In particular:
•
We provide a monthly report to the South of Derbyshire Transformation Programme
highlighting learning;
20 •
Some of the early initiatives in Erewash are being adopted by the Community Support
Delivery Group in Southern Derbyshire e.g. the SPA arrangements;
•
Detailed presentations have been made to a number of the Delivery Groups within the
South of Derbyshire Transformation Programme;
•
We participate in the East Midlands Vanguards’ Network that is facilitated by the
Academic Health Sciences Network, where learning is shared and discussions take
place focussed on ‘thorny issues’, such as local evaluation metrics;
•
We have contacted other Vanguards to learn from their experiences eg the Mid
Nottinghamshire PACS has shared their approach to developing a capitation budget, the
Isle of Wight shared their care model and approach to delivery
•
We presented our approach to workforce modelling on the national MCP leads’ webinar
•
We have recently been selected to be a local partner for the Health as a Social
Movement programme.
•
A team of clinicians recently participated in the study tour to Buurtzorg. The key learning
from the visit is guiding the design of our new care model. In addition, we are sharing
the learning wider within Derbyshire, the East Midlands via the AHSN network and will
work with the New Care Models team to identify how the key messages can be spread
throughout the Vanguard network.
•
As we sit on the Nottingham/Derbyshire border, we have links into the South
Nottinghamshire Transformation programme. This gives further opportunities to both
share our learning with and to benefit from the experience of the South Nottinghamshire
health and social care system.
Specific schemes which we think could be of interest to other areas are:
•
Care Home Support Service which is a ANP led service working with Care Homes to
reduce avoidable admissions to hospital for their residents. The scheme has a full year
cost of £295k and has delivered in this year (to M7) £715,882 savings with a forecast full
year value of £1,227k
•
Use of the LEAN methodology to release time within general practice. This has
highlighted a number of priority areas that practices have agreed to address within their
own services and some that will be addressed across the Vanguard area. A softer
benefit has been the working together and sharing of information across practices.
•
The workforce model enables the system to model the impact of new care models for
specific population cohorts. It uses four skill levels that can be applied across health and
social care staff groups, and beyond to the independent sector, voluntary organisations
and service users and carers themselves where appropriate. This grouping therefore
makes it possible to think creatively about future roles and the overlap between
professional groups, carers and voluntary sector providers.
7. Making it happen – What we will do in 2016/17
The current year (2015/16) has enabled us to lay solid foundations so that we can deliver our
vision at scale and pace from 2016 onwards delivering real service and cultural changes that
will transform the delivery of services to the people of Erewash.
The work with Bain has enabled us to critically appraise our plans. The value generation
hypothesis tree below demonstrates the clinical outcomes, improved patient experience and
improvements to safety and quality that will be delivered by our new care model. The more
detailed value generations assessments can be seen in Appendix F.
21 !
22 7.1 What innovative changes are we making in 2016/17
During 2016/17 we will implement key elements of our new care models including:
•
Delivering primary care at scale by integrating our existing services into two GP led
multi-disciplinary integrated community teams focused on the populations in Ilkeston
and Long Eaton
•
Implementing a new model of on-day services for local people including urgent care
•
Enhancing the skill mix within the integrated teams to include primary care mental
health workers, pharmacists providing direct acute patient care, and build on the
existing links with the voluntary sector
•
Developing hot and cold service responses so that there is dedicated resource within
the integrated teams to ensure urgent needs are met on the day, and teams work
proactively with patients with existing conditions to prevent, as far as possible,
exacerbations and, where these do occur, ensure that there is a clear management
plan in place.
•
Introducing the comprehensive geriatric assessment approach into the community
setting
•
Ensuring staff have received awareness raising sessions on person centred
approaches
•
Launching a MCP app for people which provides signposting, self-care information
and public health/ill health prevention messages
•
Capacity building with the voluntary sector, including working with at least 20
organisations on the Quality for Health assurance programme
•
Co-production of Time Swap with local residents, and introducing Spice Time credits
supporting an increase in community resilience through volunteering and peer
support
In addition, our enabling workstreams will:
•
Develop the workforce model for children and the adult population
•
Develop a strategy for use of telehealth within our new care model
•
Review the approach to risk stratification used by the integrated care teams
•
Rollout of the shared record viewing via the MIG
•
Implement and monitor the shadow capitated budget
•
Review the current Governance and Organisational structure to ensure appropriate
arrangements are in place for the transition year 2016/17, as well clarity on the
required arrangements for 2017/18 onwards
7.2 Why are we making the change?
•
The key to sustainable change in any health and social care economy is changing
our relationship with local residents so that they become active partners in looking
after the health and well-being. Social support and strong social capital are
particularly important in increasing resilience and promoting recovery from illness
(Kings Fund, 2003, 2008)
•
In line with the 5-year forward view, our aim is to shift care and treatment to
prevention and early intervention agendas. Improving our ability to prevent illness,
diagnose, and intervene early before conditions become serious has the potential to
23 improve outcomes and reduce the long-term costs for health and social care
services.
•
The GP led integrated team addresses feedback from patients that care is not
currently joined up and that they need to repeat their story several times.
•
The on-day service, plus targeted pro-active work with at risk patients will reduce
reliance on secondary care services
•
Enhancing the skill mix in the teams, especially with the introduction of primary care
mental health workers, will enable more holistic care to be provided
•
Clinicians identify that lack of access to a single care record is the biggest barrier to
providing integrated care
As described in the hypothesis tree there is a clear evidence base for our proposed
interventions
7.3 How is this replicable?
Our plans for 2016/17 include many elements which will be of interest to the wider NHS, and
the lessons we learn will enable these interventions to be replicated at scale
•
Our integrated teams will focus on service provision to populations of 50k which is
the unit of delivery that many areas are also considering for place based planning
•
The GP led integrated teams and the on-day delivery model define a new model of
primary care working at a population rather than focusing solely on Practice
populations
•
The approach to working with staff on person-centred approaches would be directly
replicable into other areas
•
Many areas have already expressed interest in the workforce modelling tool used in
Erewash; the extension of its use to other age groups will be of equal interest
•
Whilst all areas have IAPT services, few have a wider primary care mental health
service although the need is well recognised by clinicians
Our learning will be shared with our local system transformation programme via the existing
reporting processes we have established. In addition, we regularly share learning and
updates on our progress with the other Vanguards within the East Midlands at the network
that is facilitated by the AHSN. Being a local partner in the Health as a Social Movement
programme, gives another opportunity to share our experiences and learning, and to feed
information from this programme to Vanguards.
7.4 When will the change happen?
The high level project plan for 2016/17 is shown below and will be monitored on a monthly
basis, with recovery plans required if delivery is not in line with this plan
24 !
25 !
Each workstream is developing a detailed project plan which will also be monitored, so that any
early indications of slippage can be recognised and acted upon. We are all passionate about
delivering our vision and there is clear commitment between all partners that barriers to progress
will be managed swiftly and effectively. There are clear processes in place to escalate difficulties
as they are encountered.
26 8. Resource plan to deliver our ambition
8.1
Overview
This section identifies how the plans described in this Value Proposition will enable our
service ambitions to be delivered within a resilient financial position.
Erewash is a financially stable CCG which has met its financial targets consistently, but we
recognise that there are a number of challenges going forward which will make ‘balancing
the books’ more difficult. There are similar pressures in social care.
For the modelling of the impact of the MCP we have looked at the health system costs i.e.
the total impact across the health system combining the CCG and local MCP health
providers’ figures. The do nothing deficit in the Erewash system in 2018/19 would be in the
order of £3.9m. Therefore, it is clear that that doing nothing is not a viable option.
The new models of care described in this Value Proposition are key to closing the financial
gap as described in the hypothesis tree - in particular they will:
•
•
•
•
increase productivity through the development of integrated teams and the greater
use of technology
reduce the use of hospital based care as communities become more resilient and
people are enabled to increase self care and self management
reduce the number of hospital bed days through integrated care services with
multi-disciplinary teams which target high-risk patients
Encourage and empower patients to self care, change care culture and train staff to
share decision-making which will reduce intervention frequency.
Erewash has a plan for transforming the provision of health and social care within its locality.
However, for successful change of the size described it is essential that time is given for staff
to adapt to new ways of working and time is allowed for changes to be truly embedded into
practice to deliver the maximum benefit. This requires double running investment
Looking across the 5 year modelling period in the do nothing scenario the health system has
growing deficit with a deficit of £14.8m in 2020/21 whereas with the new care models that
are summarised above in place the system is in recurrent surplus.
27 !
We have worked with the Central Southern Commissioning Support Unit (CSU) to develop a
high level financial and activity model for the MCP which we will use as our ongoing planning
tool. The full financial model plus summary activity and finance sheets generated by the
model are shown in Appendix G.
8.2
Historic Activity and Finances
As mentioned in section 8.1, Erewash CCG has a strong record of financial control. From
this strong financial base, services will be transformed.
8.2.1
Historic Activity
The historic activity levels across key service lines are provided below:
!
28 Activity across the four service areas rose by 5.3% over the 3 years analysed for this
document. Acute admissions and attendances rose by 2.4% (4328); Mental Health
admissions and contacts fell by 1.1% (450); and Primary Care appointments increased by
2.5% (13995). The only outlier was Community Health with an increase in admissions and
contacts of 21.8% (31270). 5.2% of this increase results from the addition of the Care Home
Support Service during 2014/15 and the majority, 52.3%, are additional contacts made by
Community and Specialist Nursing teams when the Community Delivery teams and Single
Point of Access were put in place. These early indicators are wholly in line with the aims of
the proposals laid out elsewhere in this paper.
8.2.2
Historic Finances
The historic finance profiles are detailed in the table below:
!
Analysis of these high level financial profiles shows that if adjustments are made, for tariff
and inflation the cost increase is in line with the activity changes described at 5.2.1 above.
Erewash CCG took on delegated responsibility for the primary care budget in 2015/16
resulting in the increased primary care spend in this year.
8.3
Planning Assumptions
The Vanguard has been working with Central Southern CSU to develop a financial model
which is able to forecast the impact of the changes we are planning to make. The financial
model is driven by a set of planning assumptions. This section explains the key planning
assumptions that are driving the outputs from the model.
8.3.1
Activity Assumptions
Our new care model looks to change the local care culture and remove organisational
boundaries, by building an integrated person-centred community where people feel
empowered to support themselves and reduce their reliance on costly secondary care
services.
29 We believe that our new models of care will enable us to achieve a step change in
performance for key indicators such as A&E attendances, rate of non-elective admissions,
as well as improving the patient experience.
To support the financial modelling, a group of clinicians have been working to review the
projected impact of the transformation we are attempting to deliver. For example, if we are
able to avoid an emergency admission, what support would this patient need (if any) from
other parts of the health, social care or voluntary sector. From this work, a number of broad
assumptions have been made to understand the impact of our proposed interventions. In
addition, we have reviewed our current baseline position, the evidence of impact of similar
interventions elsewhere and current top decile performance. There is no one single method
to forecast the impact with complete confidence, so we have brought together our evidence
review, clinical opinion and current benchmarked performance to develop the assumptions
for our base case (the realistic scenario).
The table below shows how these assumptions regarding the impact of our new care model
are supported by evidence and triangulate with best practice performance.
!
The activity model includes the impact of demographic change before these assumptions
are applied.
8.3.2
Allocation / Income Assumptions
Our modelling has used the latest information on CCG allocations over the planning period,
as well as inflation and efficiency as shown in the table below:
30 !
National guidance for 2016/17 states commissioners are required to plan to spend 1% of
their allocations non-recurrently, consistent with previous years. In order to provide funds
to insulate the health economy from financial risks, we have been told that this should be
uncommitted at the start of 2016/17, to enable progressive release in agreement with
NHS England as evidence emerges of risks not arising or being effectively mitigated
through other means. This financial plan complies with this requirement. However, from
2017/18 onwards we have used this 1% to non- recurrently support the transformation
programme each year. Throughout the period of this financial plan the CCG maintains
reserves in excess of 1% which includes the required contingency reserve, to off-set
against in-year risks.
We have not included the tariff deflator as our model operates at a system level. The deflator
would show as changes in the price of activity charged by the providers to the
commissioners, and as such are part of the commissioner costs and the provider income,
factoring into the split of the overall gap between the two. However, for the system view
these net off and do not show any affect.
We know there will be considerable productivity gains as teams integrate and adopt new
ways of working. They will be able to absorb some of the additional demands that will arise
from demographic changes within their current establishments. In addition, we expect to see
less use of non-acute secondary care services - for example secondary mental health
services. The changes will also support people for longer in their own homes reducing the
admissions into long term care. Whilst it is much harder to quantify these productivity gains,
we know they will materialise as we go on our journey to develop thriving, capable and
healthier communities. Therefore, the model has included a further 2% productivity gain
each year from 2017/18 in recognition of increased efficiency each year from service
changes. This will be delivered through reducing the investment required, rather than taking
posts out, and has been applied to community services and primary care lines (excluding
prescribing and out of hours) only.
The intention is that in 2017/18 the MCP will become a live organisation with an outcomes
based capitation contract. The working assumption is that by 2018/19 the structural changes
within commissioning will release a further £400k for investment into front line services.
8.4.The realistic scenario
Our historic analysis has shown community, mental health and primary care spend
separately but our new care model is predicated on integrated services within the
community. Therefore, we show our modelling for the future shows spend and activity in a
single line entitled ‘integrated community services’.
8.4.1 Activity changes
31 In our realistic scenario once the forecast population changes, and assumptions regarding
the impact of the programme are applied we see a downwards trend in acute activity with a
corresponding increase in community based activity as demonstrated in the table below:
!
8.4.2
Expenditure Assumptions
The diagram below shows how this cost profile over the planning period has resulted in the
system surplus by the end of the planning period
!
The ‘other spend’ line includes continuing care spend, prescribing spend, CCG corporate
reserves, specific costs associated with the Vanguard as well as investments in non NHS
services to support the resilience agenda.
8.4.4
Investment Assumptions
Our ambition is to change the pattern of care within Erewash so that people feel more
32 equipped to look after themselves, their families, and people within their community, and that
when care is required, the majority of it is delivered in a community setting. As demonstrated
above our activity and financial model shows this shift from acute based care to care in
community based settings.
We know from local experience, as well as published evidence, that achieving such change
does not happen overnight - it takes strong sustained leadership and commitment to see
through the change process, a system wide development programme so that all staff at all
levels understand the changes and commit to playing their part, as well as a substantial
training and development programme so that staff are equipped with the necessary skills for
a very different way of working.
Delivering an ambitious change programme requires investment - double running whilst the
new systems become embedded, robust programme management and investment in
enablers to change such as IM&T and OD and training programmes. We have demonstrated
above that the health system is financially sustainable but non recurrent transformation
funding is required to support the scale of change we are determined to deliver.
The activity and finance model constructed by the CSU includes assumptions on the level of
community based activity and associated cost that is required to support a shift of work from
secondary care. These additional costs are included within the cost profile shown above. In
addition to these activity related costs we know we need investment to:
-
ensure we have the enablers in place to deliver our vision – IM&T systems that can talk
to each other, shared access to patient records, joint training for staff, engagement
events with our local residents, OD programmes that will support the cultural change to
deliver our ambition
-
develop community resilience by working through initiatives and organisations who are
embedded in local communities – for example capacity building with the voluntary
sector, developing evidence based schemes such as Time Swap, warm housing, work
with schools etc
-
ensure robust programme and project management is in place to deliver the change at
the scale and pace we require
-
enable double running of services whilst new services ‘bed in’. Evaluations of new
schemes repeatedly demonstrate that during mobilisation and the early days of new
services, performance is not as high as once the schemes become established. This is
not recognized in the model which assumes the community based schemes are
immediately effective
We describe these costs as system enablers as without investment in these areas we will
not able to deliver the scale of change required.
The table below shows the evolution of provider costs (i.e. the decrease in investment in
secondary care and increased investment in community based services) plus other
investment requirements compared with the do noting option.
33 There is a lower rate of return on investment in 2016/17 and 2017/18 as the investment
includes non-recurrent spend on the system enabling activities described above (£1m in
each of these years).
!
This section demonstrates cost increases of £5.4m in 2016/17 and 2017/18 to deliver the
34 system change. In order to support the double running requirements and programme
costs (which are not fully reflected in the model) we require £2.8m of transformation
money in 2016/17 and 2017/18. The investments within the Better Care Fund (BCF)
support the MCP vision; in 2016/17 Erewash CCG are investing £6.6m within the BCF with
specific new recurrent investments into dementia support, 7 day working and further
development of intermediate care and community teams.
8.5
Scenario Analysis
Our base financial plan is based on the assumptions outlined in section 8.3. However, within
the financial modelling, we have run a number of scenarios to understand the impact on both
activity and finance of different assumptions. For the purpose of the Value Proposition we
have narrowed this into three cases, in addition to the realistic case that is described in
detail above.
Do Nothing - this scenario assumes that no action is taken as described in the
overview at 8.1. Activity is increased in line with demographic change but no other changes
are made. In this scenario the system remains in deficit in 2020 with the acute cost base
continuing to rise.
Worst case - this scenario assumes that the new care models have some impact but
that the impact on secondary care activity is 5% lower than in the realistic case. In addition,
it is assumed there is no productivity gain over and above inflation. In this scenario the
system remains in deficit in 2020.
Best case - this scenario assumes that the new care models have a greater impact
with the impact on secondary care activity being 5% higher than in the realistic case. In
addition, it is assumed there is an additional 1% productivity gain over and above inflation (ie
3% pa). In this case the system achieves a surplus position from 2018/19
The graph below shows the system wide position under each of the scenarios described
above.
!
6. Contracting Arrangements
35 The Vanguard is planning to move towards a capitation funded contract for the MCP. The
Board has discussed and agreed the development the capitated payment approach. The
intention is to shadow a place based capitated budget in 2016/17, and move to a real place
based capitated budget in 2017/18.
Our approach is based upon joint guidance from Monitor and NHS England - Capitation: a
potential new payment model to develop integrated care. This is a significant change to the
current arrangements and will require due diligence, support from the current organisations’
boards, legal advice etc. We look forward to working with the national team to progress
these discussions
The work is being driven and overseen by the MCP Finance Group.
7. Governance of the Financial Plan
The Financial Plan for the Vanguard has been approved by the MCP Partners Delivery
Board. This was approved on 4 February 2016. The plan is consistent with the one year
operational plans being submitted by individual organisations and provide a clear direction
for the five-year Sustainability and Transformation Plan that is being developed across
Derbyshire (including the City of Derby).
8.7.1
Review of Plan
The delivery of the finance plan will be overseen by the Finance Group. The Finance Group
will report to the MCP Board on a monthly basis, and will identify any issues which the MCP
Partners Delivery Board needs to debate and make a decision on.
The delivery of the plan will be challenged by the New Care Models team at the quarterly
review meetings.
8.7.2
Financial Risk Management
As part of the governance arrangements for the MCP, a risk sharing agreement is being
developed which will set out how financial risk will be managed across partners should the
need arise.
The Finance Group will oversee the management of the MCP finances, and will draw issues
to the attention of the Board for debate and decision.
Where financial risk is identified, Board approved mitigation plans will be agreed and
implemented.
8.7.3
Transition
The Value Proposition asks for national support for a significant allocation of additional
resources over 2016/17 and 2017/18. The Finance Group will prepare plans to ensure that
there is a clear plan to transition from this additional non-recurrent funding to business as
usual. 9. Governance issues
Whilst our existing governance structure is appropriate for programme delivery, we have
agreed that we want to explore the longer term options for new integrated organisational
forms.
As described in the previous section there is agreement to move towards a capitation funded
contract for the MCP – with an intention to develop a shadow place based capitated budget
36 during 2016/17 and a move to a real place based capitated contract in 2017/18. This has
significant implications for current provider and commissioner landscape.
The providers within Wellbeing Erewash recognise that there are a range of organisational
governance options available to them to come together more formally to hold this contract
and deliver the outcomes associated with it. They are currently commissioning a supplier to
work with them to develop and evaluate a comprehensive range of options for delivering
integrated care that can form the basis of consideration and consultation with the MCP
Board, constituent member’s Boards/ governing bodies and wider stakeholders during
2016/17.
Erewash CCG recognise that they also have choices open to them regarding future
commissioning structures, and are seeking a partner to help produce an outcomes
framework that can be used as the basis of creating a future Payor function. The output will
include identifying options as to which current aspects of the CCG function could move into
the MCP Provider organisation with clear reasons, population segmentation into disease
areas and pathways and other related divisions to support outcomes management, and
suggested pace of change from current commissioning, contracts, specifications and
evaluations to Payor, outcomes, and a population health improvement focus. The CCG are
working with the New Care Models team and NHS England on this development of the
commissioning function.
Both of the above pieces of work will be completed by the end of March 2016 to enable
agreement on future form to be reached, and processes put in place to enact the preferred
option during 2016/17.
We clear that we are not looking to make major organisational governance change in either
provider or commissioning organisations as an end in itself, but rather to maximise our ability
to deliver the vision for the people of Erewash that we have developed, and ensure a
resilient and sustainable local care service is in place within the current challenging financial
climate. It is therefore vital that we have a shared understanding of the respective benefits
and risks from a clinical service delivery, financial, legal, regulatory/accountability and quality
governance perspective in order to inform the next stage of delivery of our vision.
10. Evaluation
We want to improve the health and wellbeing of people in Erewash. We will only know if we
are achieving making that difference if we monitor and evaluate the changes that we make.
Our logic models embed evaluation into our approach by describing our starting point and
identifying the outcomes and benefits we want to achieve. The hypothesis tree builds on this
by identifying the metrics we will use to measure success and identifying where we need to
develop further measures.
The metrics we will be tracking are shown in the table below.
Domain
Metrics
37 Clinical
•
•
•
•
•
•
•
•
•
•
Patient experience
•
•
•
•
•
•
•
•
Quality and safety
•
•
•
•
•
Life expectancy
% population that can explain how to access care
services
% population at risk immunised
% of obese patients looking for support to reduce
weight
No. of care home non elective admissions
No. of hospital admissions
Non-elective admissions
Adherence levels
Variation between Practice referral rates for planned
care
% of electronic health record take up
Quality of life score for patients with LTC
Length of rehabilitation
% of patients going through structured education
programs
Number of patients referred to diabetes prevention
programme
% deaths in preferred place
% of patients on Practice palliative care registers
Patient family and friends survey score
100% of population to have access to same day GP
appointments including evenings and weekends
Reduction in medication errors
Staff family and friends score
% of re-admissions
Number of A&E attendances
Number of hospital bed days
Some of the metrics are covered within the national evaluation dashboard which enables us
to monitor our performance against other MCP and non MCP areas.
In addition to this national evaluation dashboard we are:
•
developing a dashboard for our local metrics as identified above
•
working with local clinicians to develop metrics that are meaningful to them rather
than just focusing on activity related data
•
working with the Health as a Social Movement programme to develop an
understanding of ‘what works’ in terms of community resilience using rigorous
evaluation methodologies
•
working with the Vanguards across the East Midlands and the AHSN to compare
performance and changes with other Vanguards and also non Vanguard areas
across the East Midlands footprint;
•
looking to use the additional resource that has been discussed for local evaluation to
strengthen our approach to evaluation; we are discussing with the AHSN Vanguard
network an approach which would put additional capacity into the AHSN as a group
to enable dedicated support per vanguard but with a central coordination function to
maximise early shared learning opportunities.
38 11. Risks
Any major transformation programmes need to manage risks effectively. We have a robust
approach to risk management which recognises that risk management is a dynamic
process.
Each workstream holds their own risk register which is reviewed monthly. Risks that have a
risk score of more than 15 (using the 5 x5, impact x likelihood matrix) are reported to the
Board. The Board is also made aware of the total number of risks being managed across
the programme.
As the MCP Board has no statutory standing individual organisations ensure they
arrangements in place to feed risks relating to the MCP programme into their own risk
management processes.
The South of Derbyshire unit of planning transformation programme is also made aware of
any risks or issues which may impact across the wider footprint.
Current high risk areas have been identified:
•
The MCP vision will require significant organisational development to deliver the
required changes in cross boundary working; multi-disciplinary working and cultural
change
Mitigations: Workforce work stream includes OD; OD diagnostic exercise
completed; the MCP financial plan includes significant resource for OD
•
The MCP vision will require new ways of working with staff undertaking new roles
which may require different skill sets. In order to achieve the shift from acute care
into the community, there will need to be additional capacity in the community
workforce
Mitigations: Workforce modelling begun to determine the required profile of the
workforce in the future; close working with HEE and the Joined Up Care
processes to ensure maximum leverage is utilised to obtain increased access to
training places; MCP financial plan includes significant non recurrent
transformation money to allow double running of services
•
Clinicians are unable to access the records of a patient when they are receiving care
from another organisation – this results in patients needing to tell their story multiple
times, reduces continuity of care and reduces ability to manage patient in a
community setting when all clinical information is not available for example at the
time of a crisis
Mitigations: Executive leadership of IM&T enabling work; MIG procured with
agreement to 'opt out' approach to patient consent; national programme support as
this is an issue facing all Vanguard sites
• Transformation money does not meet the full identified costs of investment into
enabling activities and double running costs to enable the transformation to take
place at scale and pace
Mitigations: Bid for transformational money to National programme; priorities being
identified within the financial plan and risks of non-investment in other areas being
identified
39 •
Transformation money is not available beyond 2016/17
Mitigations: Priorities being identified within year 2 of the financial plan and risks of
non-investment in other areas being identified. MCP plans fit within wider
transformation plan for the unit of planning and as such will still have access to the
system transformation fund
• Health and social care organisations face considerable financial challenges in both
the short and longer term. There is a risk that individual organisations take actions
which impact on the ability of the MCP to deliver the vision
Mitigations: MCP vision is clearly articulated and supported by all organisations;
Confirm and Challenge event in January confirmed alignment across organisations;
agreement to move to new way of contracting in Erewash
•
Insufficient capacity to deliver the ambition
Mitigations: Interim capacity secured whilst substantive appointments made to
project posts; Regularly report back to the project team and Board on any slippage in
the project timeline
•
Engagement with the Voluntary sector across Erewash is key to the project outcomes
as they are an essential element to building community resilience and delivery of the
overall vision; this is within the context of a significantly reducing financial envelope
for these organisations
to operate within.
Mitigations: Project team members are well engaged with members of the voluntary
sector in Erewash; voluntary sector is also funded by other sources; voluntary sector
are represented on the programme; investment in voluntary services included within
the financial plan
The implementation of the Wellbeing Erewash, and particularly the work of the
Community resilience workstream, need to be accepted and successful within the
communities. If communication with the different communities is not included in the
project development key required outcomes may be overlooked.
•
Mitigations: Mapping out an engagement and stakeholder approach including the
development of a reference group model; local partner within the Health as a Social
Movement programme
12. Summary
We are excited by the opportunities in Erewash to transform the care available to local
people. We have a track record of successful partnership working, excellent clinical
leadership and delivery of innovative projects, and have already made significant cultural
shifts and service changes in 2015/16 which are reducing our use of secondary care.
This refresh of our Value Proposition provides the detail of how we are meeting the triple aim
by developing true partnerships with local people and communities, and delivering services
that meet patient needs so that care is wrapped around a person and their family rather than
being delivered in organisational silos. Our Value Generation Hypothesis Tree demonstrates
that these changes will be financially sustainable in the long term with a funding strategy that
shifts money from secondary care services into primary and community services. The new
service model will deliver improved outcomes for patients and a better patient experience, as
well as further productivity savings through reduced duplication, and increased use of
technology.
40 We demonstrate within this document that our care model incorporates the components
within the emergent MCP framework that is shown below.
!
However perhaps the last word should go to our lead clinician:
‘As a local GP I am passionate about improving care for my patients. Wellbeing
Erewash provides a fantastic opportunity to do just that, by being innovative and truly
involving patients in their care and in the way services are delivered. I’m looking
forward to using a wide range of the resources we have at our disposal – from our
staff to developments in IT – to make our vision a reality.’
Dr Duncan Gooch, Clinical Lead, Wellbeing Erewash
41