DRAFT VERSION 19
27 January 2016
VALUE PROPOSITION – ENCOMPASS MCP (FORMALLY WHITSTABLE, FAVERSHAM AND
CANTERBURY COMMUNITY MCP) – BID FOR FUNDING IN 2016/17.
1.
Introduction
The encompass MCP seeks to deliver an integrated health and social care model that focuses on
delivering high quality, outcome focused, person centred, coordinated care that is easy to access and
that enables people to stay well and live independently for as long as possible in their home setting.
More than that, it seeks to transform local services so that we deliver proactive care and support focused
on promoting health and wellness, rather than care and support that is solely reactive to ill health. Core
to the model of care is the philosophy of health and care services working together to promote and
support independence, utilising statutory, voluntary and where appropriate independent sector services
to deliver the right care, in the right place at the right time.
The Value Proposition also sets out an ambitious vision for whole system redesign at an organisational
level, seeking to work in collaboration across the health and care landscape to build and implement an
innovative workforce redesign model that will enable the local economy to develop and deploy a
workforce fit for the future of integrated health and care delivery across current professional boundaries.
The MCP will be looking to draw on support from the National Team, as well as local education and
evaluation leaders as it progresses with this programme.
The MCP core team has engaged with its delivery partners and with service users (via the local
Community Network infrastructure) in developing its work programme and in development of the Value
Proposition. This process of engagement and co-design will continue as the work programme is
developed and as services become operational.
2.
Scope of the MCP
When the MCP was awarded vanguard status in April it represented a population base of approximately
53,000. The NHS England New Models of Care Team recommended that the MCP should look to scale
up its size, as set out in the feedback from the site visit on 5th and 6th May. Subsequently the vanguard
clinical leads have held bilateral meetings with a number of neighbouring practices, and have also held a
GP briefing session with all CCG practices. This resulted in a further 13 practices formally signing up to
the MCP Memorandum of Understanding. The MCP now represents a population base of 169,806
patients across Whitstable, Canterbury, Faversham, Sandwich, Ash and the surrounding rural locations.
3.
Local case for change
In line with the national trend, the MCP population faces challenges in respect of its ageing population
profile. It also faces challenges in terms of meeting the complex needs of people living with long term
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conditions. To help inform the MCP’s future planning, the MCP has requested that the Kent County
Council’s Public Health Team develops an MCP specific Needs Assessment that focuses on the 16 GP
practices that incorporate the MCP. In addition to this very localised Needs Assessment, we have drawn
on the Canterbury and Coastal CCG wide Demographic Profile.
4.
Developing Impactful Opportunities for Change
The MCP will draw on both the methodology and learning from the CCG’s Commissioning for Value
programme, and Kent County Council’s methodology for identifying impactful change. The MCP’s Value
Proposition and associated model of care seeks to support health and social care commissioning
priorities across the locality.
The MCP will utilise the methodology and learning from the Commissioning for Value work programme
which originated during 2013/14 in response to requests from clinical commissioning groups (CCGs) that
they would like support to help them identify the most impactful opportunities for change. It is a
partnership between NHS England, Public Health England and NHS Right Care and the initial work was
an integral part of the planning approach for CCGs.
Commissioning for Value is about identifying priority programmes which offer the best opportunities to
improve healthcare for populations; improving the value that patients receive from their healthcare and
improving the value that populations receive from investment in their local health system. By providing
the commissioning system with data, evidence, tools and practical support around spend, outcomes and
quality, the Commissioning for Value programme can help clinicians and commissioners transform the
way care is delivered for their patients and populations. The MCP will support delivery of future CCG
priorities as these develop for 16/17.
5.
How the MCP programme will generate value
The following table outlines encompass MCP’s Value Generation Hypothesis Tree. This seeks to
describe the key elements of the programme, the outcomes it will deliver, metrics and targets that will
measure its success, the resource investment required and the resource sustainability evidence. The
Value Generation Hypothesis Tree is backed up with a full set of Value Generation Assessments,
detailing the assertions and evidence base that supports the assertions. The full set of Assessments,
can be found at Annex A of this paper.
Overarching MCP programme objectives During 2016/17
Encompass MCP will seek to build Community Hub Operating Centres (CHOCs) that represent a fully
integrated health and social care team, offering hub-level services, inclusive of primary, community and
social care provision over the period until 2017/18. It is planned that the integration of services at a hub
level, coupled with the continuation of the alignment of paramedic practitioners at a practice level to
support home visiting, will:


Contribute to a reduction in A&E demand and onward admission in the short term.
Reduce pressure on acute services and long term care home placements in the longer term.
Once proven, the MCP will negotiate for funding to be removed from the acute contract to support these
schemes on a recurrent basis. It is expected that this would occur during the 17/18 contracting period.
Proving that the MCP has the ability to deliver these schemes will be key to building the trust between
parties that will enable the closure of existing bed capacity in 17/18.
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By building integrated community teams we will endeavour to increase effectiveness within the current
system and release capacity through enabling an integrated workforce to operate more efficiently. We
will monitor the impact on the existing services and also monitor the potential for the creation of new
demand that is often missed from the evaluation of projects.
Value generation hypothesis tree
1
Drivers
2
Evidence
3
Metrics
To develop a new model of care that that delivers high quality, outcome focused, person centred, coordinated care that is easy to access
and that promotes wellness and enables people to live independently for as long as possible
Clinical outcomes will be
improved via integrated care
hubs and specialist
treatment in the community
Developing
Primary Care :
- Scope GP
extended
provision
Develop GPSIs
Increase PP
utilisation
•
Shift activity from secondary
to primary and community
setting resulting in:
•
Reduction in secondary care
activity
Quicker diagnosis and
treatment for routine care
Integration of
practice,
community and
mental health
workers with
services beyond
health including
social care and
the voluntary
sector
•
•
•
•
•
•
•
•
Transforming
the Workforce
6.
•
•
•
Developing
Estate
Infrastructure
Patient experience will be
improved through a focus on
self-care & increased access
to earlier community-based
care
•
Integrated teams delivering
reduction in overall caseload
time per patient and
optimum patient outcomes.
Reduction in conditions
linked to social isolation (e.g.
MH)
Reduced sec. care activity.
Decrease in delayed
discharge
•
•
•
•
Create local hubs and deliver
patient care closer to home
Co-location of services
Reduction in the use of
secondary beds for patients
who can be treated in the
community
•
Ensure patients receive the
best level of care by the right
professional.
Develop a flexible and
responsive workforce who
want to deliver patient
centred care
•
Safety/quality of the
service will be safeguarded
through an IT system that
integrates records across the
community
Scope extended access to GP
services, drawing on Year 1
learning.
Allow patients to be seen in
the right environment for
their condition closer to
home.
Reduce waiting times
•
Reduce hand offs between
organisations.
More consistent care
delivered by fewer
professionals
Social prescribing will
improve patients’ health and
wellbeing through improved
access to self care and self
management
•
•
Ensure patients are treated
in the right care setting at
the right time.
•
Ensure a motivated
workforce to deliver high
quality care and support
•
Allow patient records to be
shared with other health
professionals improving both
the quality and safety of care
whilst a single patient record
is developed.
Consistent quality of care
delivered by professionals in
different workforce areas.
Coordinated planning and
reduction in handoffs result
in better quality care.
Deliver high quality, custom
designed, energy efficient
and fit for purpose estate
Resource requirement of
£1.6M is reasonable and the
required workforce can be
put in place
•
•
•
•
•
Allow the scoping and
development of an extended
primary care service,
integrated health and social
care community services
delivered through operational
hubs, supported by
integrated IT co-located on 4
sites at a cost of £3.7m. In
16/17
Resource input from the
existing health and social
care economy of £13.7m in
16/17.
Require investment of £150k
in 16/17 to further develop
the case for change in
respect of bed utilisation –
both health and social care.
Likely requirement
significant funding to double
run services. In 17/18
Create a workforce willing
and able to deliver
sustainable efficiencies for
the above level of
investment
Resource sustainability
will be driven through
increased efficiency and
improved staff retention
•
•
•
•
•
Reduced attendance,
admissions and outpatient
activity equating to £900k
delivered in 17/18.
Shifting mind-sets to
embrace 7 day services and
closer interaction between
professionals .
Use of linked care dataset to
cohort match patients
comparing patient journey
now to patient journey in
17/18.
Will allow co-location of
services and efficiency gain
through seamless transfer of
patients through the system
Create a sustainable
workforce
Build a workforce that will
have the capability to deliver
high quality care in a
sustainable way
Encompass MCP’s progress to date – a brief outline of year one work programme
The MCP commenced building capacity and capability within primary and community services in Year 1
of its Work Programme. It operationalised extended GP services and paramedic practitioner services in
November 2015, as soon as funding was secured via the NHS England Investment Committee. The
Social Prescribing programme has also commenced, to enable the voluntary sector umbrella
organisation Red Zebra to commence work to build an MCP wide database of voluntary and community
services that service users and practitioners will be able to access via the social prescribing service
team. An audit of community and practice nursing services has been undertaken to secure a robust
evidence base from which to build the new model of care. This has provided critical baseline activity
data, a solid understanding of current practice and a robust picture of the relationship challenges that
must be addressed as we progress to building the integrated model of care.
In addition, we have commenced work to integrate community and practice nursing services across
specific service pathways related to continence care and wound care – these were identified as service
pathways that offered clear opportunities to commence joined up delivery across primary and community
nursing teams, through the utilisation of existing services and establishment within the health economy,
ensuring that front line services to patients remain stable whilst the new model of care is developed.
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As set out in the MCP’s original Value Proposition, we are focused on utilising the additional community
capacity to reduce demand in secondary care. We continue to work closely with our partners in the
Community and Acute Trusts to model the planned shift in activity and to mitigate the risk of destabilising
elements of the health economy.
As set out in the Year 1 Value Proposition, the MCP has commenced the development of modelling
services around hub localities based in Whitstable, Canterbury and Faversham, with a further hub in
Sandwich to support the Sandwich and Ash practices. The hubs will deliver a broad range of integrated
community services ranging from primary care GP and practice nurse services, specialist nursing
services, community nursing services, paramedic practitioner services, health prevention and promotion
services and voluntary and community services. The MCP is working with colleagues in Kent County
Council to also integrate social care services at a hub level. The MCP Executive Team and The Leader
of the Council meet regularly and work is in train to commence alignment at a single hub site within the
MCP, to function as a test bed for further integration of health and social care services in 2016/17.
Further down the line we intend to link these services via a single electronic patient record to broaden
the effective use of IT across the Vanguard to support joined up high quality patient care, although
recognise the challenges that this presents in terms of current contractual arrangements within partner
organisations, information governance challenges and system inter-operability challenges.
The MCP team has fully utilised the £150k management allowance received for set up. For the 15/16
transformation funding received the MCP team has established finance and governance procedures
within the existing CCG SBS system that will be in place until the organisational form for the MCP is
established.
7.
Year 2 – Investment and sustainability overview
The table below shows the summary request for further transformation funding in 16/17 and beyond
alongside existing resource within the local health and social care economy that will be invested in MCP
programmes going forward.
16/17 Bid Summary
Q1- 16/17
Developing Primary Care
Extended Primary Care and Community Services
Paramedic Practitioners
GPwSI Services
Palliative Care Clinics
Developing Nursing Integration and the Integration of Services Beyond Health
Continuation of Yr 1 Nursing Projects
Community Hub Operational Centres
Waitless App
Developing Estate Infrastructure and Community Bed Development
Corporate Funding
Net Investment Requested from Transformation Fund
Total Investment to be Aligned from Existing Resources
Total Net Investment to MCP Programme
Q2- 16/17
Q3- 16/17
Q4- 16/17
£12,590
£87,750
£5,876
£30,767
£12,590
£87,750
£28,893
£30,767
£12,590
£87,750
£28,893
£30,767
£12,590
£87,750
£28,893
£30,767
£46,023
£325,728
£40,000
£37,500
£441,407
£17,347
£325,455
£40,000
£37,500
£441,407
£17,347
£152,955
£0
£37,500
£441,407
£17,347
£152,955
£0
£37,500
£441,407
£1,027,639 £1,021,709 £809,209
£1,691,273
£1,691,273
£5,151,767
2016/17
£50,359
£351,000
£92,556
£123,067
2017/2018 2018/2019 2019/2020 2020/2021
£0
-£130,632
-£7,633
£123,067
£0
-£317,119
-£7,633
£123,067
£0
-£329,814
-£7,633
£123,067
£98,065
-£20,914
-£20,914
-£20,914
-£20,914
£957,093
-£736,468
-£736,468
-£736,468
-£736,468
£80,000
£0
£0
£0
£0
£150,000 TBC
TBC
TBC
TBC
£1,765,627
£1,765,627
£1,765,627
£1,765,627
£1,765,627
£809,209 £3,667,766 £993,047
£5,151,767
£0
-£140,264
-£7,633
£123,067
£13,686,080
£13,686,080
£983,415
£13,686,080
£806,559
£13,686,080
£793,865
£13,686,080
£2,718,912 £2,712,982 £5,960,976 £5,960,976 £17,353,846 £14,679,127 £14,669,495 £14,492,640 £14,479,945
In line with expectation, this bid sets out the expected impacts on both activity and finance as a result of
the development of the new model of care. For the main projects a “Do Nothing” option is considered
and shows the expected increases in activity and cost as set out by “A Call to Action” over the 5 years
until 2020/2021.
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5 Year Activity Projections of New Care Model Impact
60,000
A&E attendances
55,000
Do nothing
50,000
Less Paramedic Practitioners
Less Integrated Care
45,000
40,000
2014/15
2015/16
2016/17
23,000
2017/18
2018/19
2019/20
2020/21
Unscheduled admissions
21,000
Do nothing
19,000
Less Paramedic Practitioners
Less Integrated Care
17,000
15,000
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Although the request for transformation funding in 2016/17 is accompanied by robust workings, there will
remain some ambiguity with regard to cost in future years and estimated potential savings. However, this
will be continuously reviewed throughout the development of the MCP. The MCP development team
have been careful to consider the financial landscape across the health economy and how recurrent
funding will be generated within existing commissioning resource in future years. However, some of this
cannot be defined until the projects have had the opportunity to run for a period of time and whilst some
may release savings to allow investment, others may need to be reviewed and cease if found to be
ineffective, either in terms of financial efficiency or service improvement in respect of patient pathways.
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As financial efficiency is one of a number of key success factors in the delivery of the new model of care,
the success of projects will be measured alongside other clinical/service effectiveness, patient
experience and quality outcomes. This is articulated within the Value Generation Hypothesis Tree (see
Section 6 above) and associated Value Generation Assessments set out in Annex A of the paper.
Traditionally, it has been challenging to demonstrate the success of innovative projects through activity
and finance reductions due to the number of influencing variables and concurrent projects. The MCP will
not be exempt from this issue but will strive to collate data in a way that enables robust measurement of
outcomes and the creation of an evidence base, where one doesn’t already exist. The MCP will seek to
draw on the robust and measurable evidence base that exists within partner organisations, including
Kent County Council to support this. Section 11 of this paper outlines the evaluation strategy that the
MCP will operate.
The MCP has already demonstrated its ability to achieve this through the delivery of a community and
practice nursing audit that has provided an activity baseline, and quantitative and qualitative evidence
about the activities of nursing staff and evidence of the issues in respect of both service delivery and
relationships, that the MCP will need to address in order to make real and long-term efficiencies within
the health economy.
As a GP led team, the ability to access primary care data is felt to be of particular value. Similarly, the
involvement of partners across the provider landscape will enable the MCP to access and collate data
across the whole system, in a way that has proved difficult to date. Kent has been a Year of Care
Pioneer site for a number of years and the MCP is working closely with the relevant programme team to
develop capitated budgets from the starter linked care datasets that are in place. The MCP will provide
both technical support and leadership as the programme moves further towards capitated payment
working with both Clinical Commissioning Groups and providers. As the national lead for developing new
contracting models, the MCP programme team feels that there is an intrinsic link between payment and
contracting, and therefore development of these should run concurrently.
Furthermore, the MCP is committed not only to developing innovative service models but also innovative
evaluation. The linked care dataset will enable the MCP to set targets and evaluate projects in a way that
hasn’t been achieved previously and it is expected that some cohort case matching will occur prior and
post project implementation for relevant projects. Additionally, the MCP will be working with the
University of Kent’s Centre for Health Service Studies to develop a robust evaluation arm to its
programme, which encompasses research, education and evaluation. This will enable the MCP to work
closely with Professor Jenny Billings, who is supporting the NHS England evaluation programme
nationally, in addition to linking into the Nuffield Trust which is looking at MCP models as a research
basis for portfolio research.
The Research Director is Dr Vanessa Short who is a GP in one of the Vanguard practices and has a
part-time appointment as clinical research fellow in CHSS. She will direct the research office and line
manage the staff as well as chairing the Vanguard Research Committee made up of representatives
from the Vanguard, constituent practices and senior researchers from CHSS. Some support for the
central research costs have been agreed with the kent Surrey and Sussex CRN.
As set out in the Year One Value Proposition, a Logic Model has been developed (see below). The
MCP programme team will be producing a separate model for each service area and will use these as
part of the package of communication resources that set out the MCP’s vision for the outcomes that its
model of care seeks to deliver. This will be of particular value in supporting organisational and
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27 January 2016
behavioural change management with key groups of staff aligned to the integrated health and social care
model.
Logic Model
Develop a new model of care that that delivers high quality, outcome focused, person centred, coordinated care that is easy to access and
that promotes wellness and enables people to live independently for as long as possible
Challenges:
• Ageing population profile
• Meeting complex needs of people living with LTCs
• Financial challenges faced by local health economy
• Traditional divide between primary, secondary and social care
Inputs
Financial:
• Initial ‘start-up’
input of £150k
received
• Allocation of
£1.636m for
2015/16 now
received
• Value Proposition
for 2016/17 to be
submitted by 8
February 2016
Non-financial:
• MCP core team
• Partnership
Steering Board and
sub-groups
• CCG support
• National CSU
support
• NHSE support
Activities
Opportunities :
• To improve identification and management of disease specific conditions
• Health professionals to work in a proactive and coordinated way
• Integration with social care to improve discharge processes
• To be able to develop a more sustainable model for health and care
• Efficiencies and savings
Short-term outcomes
Medium-term outcomes
Developing Primary Care:
• Extended access to
primary care through
extended working 8-8
seven days a week
• GPwSI and outpatient
development
• Paramedic Practitioners
• Shift of unscheduled
activity from secondary
to primary care
• Quicker diagnostics and
treatment for routine
care
• Increased GP capacity
• Access to patient records
• Medium to long-term
improvement in
population health
• Larger step-change in
short-term outcomes
• Improved patient
satisfaction with access
to primary care
Integration of practice,
community and mental
health workers with services
beyond health such as social
care and the voluntary
sector
• Maximise use of existing
nursing capacity
• Reduction in admissions
and length of stay
• Less delayed discharges
• Reduction in care home
admission
• Improved management of
patients
• Improved quality of
referral
• Larger reduction in
secondary care activity
Developing Estate
Infrastructure:
• Creation of local hubs
• Co-location of services
• Bedded capacity
• East Kent wide bed
modelling work to aid
programme of change
• Develop business case
• Increased step up
capacity
• Faster discharge from
acute setting
• Reduction in LOS
Transforming the Workforce
• GPwSI training and
education
• Workforce redesign across
nursing, social care and
domiciliary care
• Maximise use of specialist
clinical staff
• Effective referral demand
management
• High quality triage
• Stable and committed
local workforce
Impacts
To deliver an
integrated health and
social care model of
care that focuses on
delivering high
quality, outcome
focused, person
centred, coordinated
care that is easy to
access and that
enables people to
stay well and live
independently for as
long as possible in
their home setting
To transform local
services so that we
deliver proactive care
and support focused
on promoting health
and wellness, rather
than care and support
that is solely reactive
to ill health
In both the short and longer term the MCP will contribute to support the wider health and social care
economy in reaching financial balance. As the economy approaches the end of the 15/16 financial year,
the local acute trust is expected to have a deficit in the region of £37m. Although both the local CCG and
community trust are intending to reach planned surplus targets in 15/16, going forward all organisations
will face significant financial challenge.
During 2016/17 encompass MCP will seek to build a fully integrated health and social care team, offering
hub-level services, inclusive of primary, community and social care provision over the period until
2017/18. It is planned that the integration of services at a hub level, coupled with the continuation of the
alignment of paramedic practitioners at a practice level to support home visiting, will contribute to a
reduction in A&E demand and onward admission in the short term. In the longer term, it will seek to
reduce pressure on acute services and long term care home placements. These schemes are still in
their early stages and will continue to be evaluated. Once proven, the MCP will negotiate for funding to
be removed from the acute contract to support these schemes on a recurrent basis. It is expected that
this would occur during the 17/18 contracting period.
By building integrated teams in the community, admission avoidance (to hospital and long term care)
and more rapid discharge will also relieve pressure on the acute Trust in the longer-term. Proving that
the MCP has the ability to deliver these schemes will be key to building the trust between parties that will
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enable the closure of existing bed capacity in 17/18. By building integrated community teams we will
endeavour to increase effectiveness within the current system and release capacity through enabling an
integrated workforce to operate more efficiently. We will monitor the impact on the existing services and
also monitor the potential for the creation of new demand that is often missed from the evaluation of
projects.
Longer term the MCP wishes to develop and utilise new community hospital facilities and further
encourage treatment of patients within their own homes. Dependant on future demand growth this may
enable the acute trust to reduce their bed base, leading to large-scale cost reductions. The plans for the
MCP are consistent with the East Kent University Hospitals FT (EKUHFT) clinical strategy. System wide
bed modelling has already begun, to enable further development of this work. The MCP is directly
represented on the East Kent Strategy Board, established in early September to tackle the whole system
challenges facing the health and social care economy.
Encompass MCP’s Aim, vision and values
8.
8.1 Aim
Encompass MCP is developing services that will operate from Community Hub Operating Centres
(CHOCs) in Whitstable, Canterbury, Faversham and Sandwich. It seeks to deliver services that:










Provide “wrapped around care” to meet the full needs of people accessing services, delivered
locally.
Improved quality of care for service users and carers and improved health outcomes following
treatment.
Proactively support people to maintain their health and wellbeing and independence for as long as
possible, receiving the right care in the right place and at the right time. This will be underpinned by
provision of good quality patient and carer information.
Support people to enable them to access high quality information.
Reduce duplication of assessments, records and services.
Provide linked data sets enabling tracking of the care of individuals with complex needs.
Enable easy and effective referral pathways for health practitioners to enable access to multidisciplinary skilled staff that support the care planning and delivery of care for the patient.
Support the development of self-care strategies.
Utilise Telehealth and Telecare effectively and efficiently.
Provide a Single Point of Access for Social Prescribing.
8.2 Vision
8.2.1
MCP vision is to develop a new model of care that that delivers:
“High quality, outcome focused, person centred, coordinated care that is easy to
access and that promotes wellness and enables people to live independently for as
long as possible”.
8.2.2
MCP Vision and alignment to the Canterbury and Coastal CCG Strategy
Canterbury and Coastal CCG – Strategy:
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“Improve the health and wellbeing of local people by working in partnership with
local communities to create a sustainable health care system, integrating
hospitals, GPs, social care and community services including the voluntary
sector”.
CCG wide Community Networks programme
Community Networks have been established across the CCG and offer the potential to offer accessible
and responsive services that extend well beyond what is currently available in general practices.
Community Networks aim to:



Make sure health and social care services are meeting the needs of our population.
Function as advisory groups focusing on the needs of their communities.
Inform and drive commissioning priorities through engagement in the CCG’s Commissioning for
Value programme. The diagram below illustrates this:
Next steps:
Encompass MCP regards the Community Networks as an integral component of effective stakeholder
engagement to underpin the co-design of the MCP new model of care.
8.2.3
MCP Vision and alignment to National Voices Narrative
The National Voices Narrative statement of co-ordinated care encapsulates what
service users say that they want from integrated care across the Vanguard area:
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Overarching summary – service user perspective
Care Planning
Information
Communication
“I can plan my care with people
who
work together to understand me
and my
carer(s), allow me control,
and bring together services
to achieve the outcomes important
to me”
My
Goals/outcome
es
Transitions
Decision
Making
8.2.4 Alignment to the “Six Principles”: A new model of partnership with people and
communities:
Encompass MCP is fully committed to developing its model of care in alignment with the People and
Communities Board’s six principles for changing the way that health and care relate to people and
communities. The ‘six principles’ set out the basis of good person centred, community focused health
and care. This is illustrated throughout the Value Proposition.
Social
prescribing
will be
embedded in
model
CHOCs will
deliver
coordinated
person
centrrtere
care
Working with
all sectors to
support model
Co-design via
engagement
with
Networks
Health
promotion
and
prevention
embedded at
practice level
Carers will be
supported in
line with
Vision and
values via
CHOCs
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8.3
27 January 2016
Values
The MCP vanguard values underpin the proposed new model of integrated care:







Patient and Primary Care at its heart - pro-active care and prevention through early identification,
coordinated care planning and delivery in primary and community care setting.
Care should be patient-focused, easy to access, and well-co-ordinated via “care navigation”
enabling clear transition through services based around clearly identified and agreed “care decision
points”.
People are supported to stay well and maintain their health and independence for as long as
possible, living in the place of their choice, supported by appropriate integrated multi-agency
community service provision;
Self-care and self-management is promoted and supported;
Carers are effectively supported; and
Care should take place in the most appropriate setting, based on what is clinically appropriate, safe
and effective – shifting unnecessary activity out of the acute setting and into the community.
Services are underpinned by integrated IT across the whole system (including community IT
solutions for all community staff)
9.
Encompass MCP’s transformation programme
Encompass MCP is seeking to deliver a transformational change programme across the health and
social care landscape. The Logic Model and associated Value Generation Hypothesis Tree illustrate the
change programme in the following bands:





Developing Primary Care
Developing Nursing Integration
Beyond Health
Developing Estate Infrastructure
Transforming the Workforce.
The scale of the change programme is broad, encompassing prevention, early intervention, primary and
community health services, social care, home care, residential and nursing care and in reach to acute
health care. It also seeks to deliver an ambitious workforce development programme, that will facilitate
Encompass MCP to deliver a fully integrated model of care supported by a flexible and responsive
workforce that is able to deliver the right care and services, delivered by the most appropriate
professional, in an appropriate setting, and within the optimal timeframe.
9.1
Developing Primary Care
In 2015/16 Encompass MCP sought to commence building capacity in primary care by extending GP
services to operate from 8am to 8pm six days’ a week. The service commenced on 7 November but it
has proved operationally challenging to identify the GP workforce to cover clinics across all three hub
localities and take up of appointments has also been patchy. In line with the New Care Model’s
Vanguard Programme ethos of testing, evaluating and where appropriate adjusting projects based on
early evidence, we propose re-visiting the operating model for developing primary care in 2016/17. In
2016/17 we will focus on scoping demand, review the workforce capacity to deliver extended services,
explore options to operate a skills mix workforce model to deliver primary care services (inclusive of
GPs, Nurse Practitioners and other professionals) and map the interface with out of hours services,
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which are currently subject to re-procurement. Scoping and service development will be undertaken
from March to September with a view to procuring (if necessary) and implementing the new service from
April 2017. This will also enable the MCP to explore how the extended primary care team will interface
operationally at a hub level with the Community Hub Operating Centres. It should also be noted that by
taking this approach, the MCP will be well-placed to respond to the developing national contract work.
The Paramedic Practitioner Home Visiting service became fully operational across the MCP in
December. The scheme continues to prove successful in terms of quality, patient experience and impact
on the wider health system. Early evaluation indicates a 10 per cent reduction in conveyances to
hospital for the areas supported by the PP teams. Furthermore, GPs are reporting that the additional
time available to them within practice is enabling them to focus clinic time on those patients who require
longer appointment slots, such as complex LTC and end of life patients. In 2016/17 the MCP seeks to
continue the PP service and explore how this is embedded within the primary care team and the
CHOCs.
Encompass MCP is also developing GP with a Special Interest services in the specialities of ENT,
neurology, cardiology, ophthalmology and colorectal. The MCP’s GPSI programme is aligned to the
CCG’s priorities in respect GPSI provision, as well as the acute Trust’s strategy to reduce outpatient
activity in the acute setting across a range of specialities. This system wide, coordinated approach to
managing outpatient demand in a range of specialties will ensure that all parties are working towards the
same purpose to deliver high quality, patient focused specialist care that is cost effective and supports
planning at a Trust and CCG wide level.
Encompass will also be utilising outpatient clincis focused on End of Life care, delivered in hub based
outpatient clinics, in the first instance this will be in Estuary View. The clinics will enable services
traditionally delivered in secondary care to be accessed in the community, closer to home. An advanced
nurse practitioner, community nurse and consultant will work together, offering care in clinics and in
patient’s homes.
The proposed integrated model
The MCP integrated model of care will deliver holistic health and social care services through
Community Hub Operating Centres (CHOCs) located in Whitstable, Canterbury, Faversham and
Sandwich. Each CHOC will support clusters of GP practices. Although there will be room for local
variation in each CHOC, to enable services to be tailored to meet specific population needs, each CHOC
will include as a core:



Integrated nursing and social care services
Health prevention and health promotion services
Access to voluntary and community services via social prescribing
We are working to confirm the CHOC sites, with a view to collocating them with existing community
health facilities. For example, the Whitstable CHOC is likely to operate from Estuary View Medical
Centre, which already houses a range of outpatient and diagnostic services and an MIU. Sites for the
other CHOCs are being finalised.
Sections 9.2 and 9.3 below describe in detail the two elements of the programme that form the
integrated model.
Schematic of the Model of Care
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Community Hub Operating Centres (CHOCs)
The development of a fully integrated health and care service with the MCP will require an extensive
change management and organisational design programme to support its delivery. Whilst we will seek
to build on existing integrated services where appropriate, the ambition across both the health and social
care system is to develop a transformational model of care, supported by a skilled, stable and integrated
nursing and care workforce that is fit for the future and offers both career progression, professional
development and high levels of job satisfaction.
Each hub will incorporate:





General Practice
Integrated nursing and social care (including domiciliary care)
Functional therapy services
Access to voluntary and community service via social prescribing
Health promotion and prevention services
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
9.2
27 January 2016
Integrated mental health services
Developing Nursing Integration
Integrating practice and community nursing will maximise use of existing nursing capacity. In November
the MCP commissioned Impower Consulting Ltd to undertake an audit of nursing services across the
MCP locality. The MCP has shared the audit report with the NCM Team, as well as with partners locally.
It provides an excellent baseline from which to develop the integrated service in 2016/17. In 2015/16
the MCP has focused on integrating nursing services to support two specific pathways – catheter
services and wound care. The new integrated pathways will function from hub localities, currently based
in surgeries in Faversham, Whitstable and Canterbury and will release capacity within community teams
to enable staff to support those patients more likely to end up in acute care. It will address unnecessary
admission, delayed discharge and reduce length of stay. They will function as a single integrated clinical
team built around the patient pathway.
In 2016/17 the MCP will commence the change management programme to bring together the
community nursing and social care services across the locality to start buildingING the new Community
Hub Operating Centres (CHOCs). The change programme will see all nursing services re-aligning to the
CHOCs from April 2016, with a phased integration of social care resources, commencing with Whitstable
CHOC in April. The CHOCs will operate appropriate and comprehensive assessment of patients’ holistic
health and care needs, drawing on a full integrated team workforce, as set out in the following section
“Beyond Health”. Mental health nursing will also be integrated at a hub level, offering improved
community mental health provision resulting in appropriate triage of referrals to deliver clinically
appropriate care.
9.3
Beyond Health
The integrated health and social care model that Encompass MCP seeks to deliver incorporates a broad
range of interventions, encompassing prevention, early intervention, primary and community health
services, social care, home care, residential and nursing care and in reach to acute health care.
Promoting Wellbeing – community based
The MCP offers an opportunity to network the local voluntary sector so that there is no wrong door
providing information advice and guidance. The CHOCs will enable people to access a range of jointly
commissioned services that prevent inappropriate admissions to hospital and care homes (and also
unnecessary primary care appointments). The Hub Teams will also be able to signpost people to
community activities / services via the social prescribing programme.
Promoting Independence
The MCP will utilise the Health Foundation’s “Practical Guide to Self-Management Support” to ensure
that self-management is embedded within the new model of care. In particular it will ensure that the
following four principles of person-centred care are delivered throughout its services:



Affording people dignity, compassion and respect.
Offering coordinated care, support or treatment.
Offering personalised care, support or treatment.
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
27 January 2016
Supporting people to recognise and develop their own strengths and abilities to enable them to
live an independent and fulfilling life.
The CHOCs will include therapy services that will utilise functional assessments, and which will offer
people access to a wide range of equipment and assistive technologies. There is also an opportunity to
integrate OT services provided by KCC and Kent Community Trust as well as NRS (the jointly
commissioned community equipment provider) to optimise services, and to remove the risk of duplication
and variation in assessment and provision.
The integration programme also offers the opportunity to develop an Occupational Therapy led
integrated re-ablement service (bringing together KCC enablement service and Community Trust
intermediate care services). The breadth of service would be extended to include people who require
double handed care as well as people with dementia. The service would respond rapidly to support
people to stay out of hospital and through the CHOCs will be aligned to the paramedic service.
Supporting Independence
A nurse led integrated homecare service (bringing together KCC commissioned homecare services and
Community Trust nurses) providing outcome focussed specialist services to those people living at home.
This offers a real opportunity to develop a workforce model that is fit for the future, and which explores
the opportunities to train and develop carers and health care assistants and nurses to deliver holistic
care focused on patient need. For example, this may include training domiciliary care workers and
carers to carry out insulin injections for insulin dependent people in receipt of home care, and who would
otherwise require daily nursing visits. Integrated re-ablement and homecare services will also provide
peripatetic support to care homes in the area. Again, the teams will work with care homes to develop and
train staff as appropriate. An integrated workforce strategy will ensure that there is a genuine career
pathway across an integrated health and social care system.
Intelligence Led Model of Health Prevention
Kent County Council Public Health Team will utilise the MCP be trail-blaze a transformed Health Trainer
model, testing how a county wide service should be changed to become more effective at reducing
future demand in an intelligence led model of health prevention. The Council is already out to public
consultation to transform the approach to health improvement services. The trailblazer in the MCP
provides an approach which enables learning of lessons for replicability and implementation across Kent.
The transformed model will bring closer integration with General Practice and the hub model, including
through better patient targeting by analysing GP lists and identifying those patients at high risk of CVD
and diabetes. The impact of the intervention will be monitored through the reduction in visits to GPs,
demand on CVD and diabetes services and through improvements in key metrics relating to clinical
conditions in particular obesity. We will work closely with leading experts to develop a systematic
process to identify high risk patients. There will be a particular focus around the obesity pathway and the
range of interventions to tackle this through the development of a whole system pathway.
This development will require specific software development to aid integration of patient notes and
records, allowing GPs and Health trainer to jointly monitor progress and track a patient’s journey. This
will be clearly linked with the social prescribing programme of work underway to ensure a holistic
alternative to particularly those people who are frequent fliers to General Practice for issues better
served through social and community resource, than a medically prescribed response.
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A behavioural insights study will also be undertaken to understand how people will best respond to
challenges around improving their health through engagement with integrated services in new settings,
and what kind of community support will be most effective. This will focus on studying how best to
engage the target group, and what kind of service would best respond to their needs, with support to
step down from a service and utilise the community resource rather than a service.
For patients, the learning from the behavioural insights work will be applied to inform the design of the
right messages, whilst it will be essential to ensure that the GPs are aware of the opportunities of the
preventative programme and understand how best to access it for the benefit of their patients, therefore
guidance will be developed for both patients and GPs.
This will build on a programme of insight work already underway to get to the heart of the approaches
that deliver real behavioural change. There is a programme of behaviour insights work underway
commissioned by KCC and this investment will bolster this specifically focused in the Vanguard area to
build the understanding into the new health trainer model and into the Health Social Prescribing
programme.
Social Prescribing
A key element of Encompass MCP’s model relates to the establishment and roll out of a social
prescribing programme across the MCP locality. Social prescribing seeks to use the People Powered
Health model of building generational resilience for improved health and well-being through:




Building strong social networks
Exercising more
Eating more healthily
Feeling more supported and in control of lives.
It is underpinned by a clear referral management process, and clear evaluation model. The MCP is
working with Red Zebra, a local voluntary sector umbrella organisation to develop and embed the social
prescribing model within the MCP’s community hub-based services. In 2016 social prescribing will
become one of the core services to which practitioners are able to refer, and also that people will be able
to access directly. By embedding social prescribing within the community integrated team, it will become
a standard offer to people, for the first time systematically promoting health and wellbeing and selfmanagement as a matter of course.
9.4 Developing estate infrastructure
Encompass MCP is working with the CCG, KCC, primary care, the Acute Trust and the Community Trust
to develop the estate infrastructure to ensure bedded capacity is appropriate across the MCP locality.
Furthermore, the bed modelling that will underpin this is based on local need and demand and is
embedded in the East Kent Strategy to ensure that the whole system is able to meet demand in the
future. The MCP will seek to develop health and wellbeing services to meet local demand, increase
education and training resource as well as consulting space.
This will result in:



People having access to high quality services delivered in appropriate settings.
Co-location of services to support integrated working in the community.
GP direct community bed management in MCP locality.
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
27 January 2016
Reduction in admissions and LOS to acute as patients managed in bedded community provision
under care of GP.
Whitstable

The model includes community hospital provision that facilitates direct GP admissions; nursing
home provision and extra care provision, inclusive of a day centre. This will be delivered in a
range of new settings co-located on the Estuary View site, and in line with the Kent County
Council’s nursing home and extra care strategies. It should be noted that this will come on
stream in the second phase of the MCP’s programme, with a target of the new facilities being
operational from April 2017.
Canterbury


Northgate
In Canterbury, Northgate Medical Practice successfully bid for GP Infrastructure Funding to
support the development of the Northgate Health and Wellbeing Centre which will be linked to
Northgate Medical Practice, enabling the Practice to expand the services it provides in primary
care. The Health and Wellbeing Centre will add consulting rooms, health education space and
therapy rooms as well as consultant led clinics and possible additional diagnostic facilities. The
Northgate patient participation group was involved in the co-design of the funding bid and have
added their full support to it.
The Wellbeing Centre will support a reduction in routine outpatient appointments and
attendances in secondary care, improvements in patient outcome and reduction in hospital
admissions as well as improving rapid diagnoses for treatable conditions such as diabetes and
cancers.
Canterbury Medical Centre



Canterbury Medical Centre has developed a GP Premises Development Business in respect of
re-modelling of practice infrastructure across the Canterbury West locality. An important
component of this is addressing transformational change in Primary and Out of Hospital Care. It
is part of an ongoing process of delivering the strategic challenges most recently outlined in the
Five Year Forward View, breaking down the barriers in how care is provided between family
doctors and hospitals and health and social care. As such it is very much aligned to the delivering
both the MCP’s integrated health and care model and the Canterbury and Coastal CCG Strategy.
It would see two red rated time-limited premises replaced with a new purpose built Primary Care
facility, co-located on the Kent and Canterbury Hospital site.
Canterbury Medical Practice and Cossington House Surgery, working collaboratively with other
stakeholders that include EKHUFT, KCHFT, NHS England, their patient groups and other local
practices, have pursued a model of care that aims to break down the barriers of care provision.
Most recently these plans have become aligned with the Canterbury and surrounding areas
Vanguard programme.
Faversham
The MCP will explore the options for providing community inpatient facilities in Faversham.
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
9.5
27 January 2016
Sandwich and Ash
The MCP will explore the options for providing community facilities in Sandwich and Ash.
Workforce redesign including education and training
As referenced in 9.1, 9.2 and 9.3 above, key to the success of the MCP’s integrated model of care will
be its ambitious programme of workforce redesign. Education, Training and Workforce planning is key
element of Encompass MCP’s modelling. The proposals made within this Vanguard Value proposition
are underpinned by a Primary Care East Kent wide strategy for Education, Training, and Research that
supports the current and future needs of a multi-professional and interdisciplinary collaborative
workforce. Such strategic aims are vital and integral to the wider workforce planning agenda that takes
into account both local and national priorities.
In order to deliver the clinical service aims described within this Value Proposition, the MCP has aligned
with other providers within East Kent for the purpose of developing an Integrated multi-professional
education strategy through the East Kent Community Educator Provider Network ( EK CEPN). The
Community Education Provider Network is tasked with increasing capacity for future workforce training in
the community and the development of the current and future workforce around the needs of a
geographically defined population.
Correct and best use of any service model is dependent upon the appropriate education and training of
its users. Within the implementation of the Five Year Forward View this requires a coherent and rapid
change to the way individuals and teams within Health and Social Care currently train, learn and
maintain their scope of practice. Moreover, a change in the traditional hierarchies and professional
cultures across health and social care is essential in order to enable integration and real-time
collaboration with shared NHS values. Within East Kent this challenge is being addressed through the
evolution of the EK CEPN (Training Hub ) of which Vanguard is part. Thus the overarching educational
and training aims within Vanguard are co-terminus with the East Kent CEPN.
Through workforce redesign across nursing, social care and domiciliary care we will develop a flexible
local workforce that has the optimum skills mix and profile to support MCP population cohort. This will
result in:






Workforce that is delivering excellent clinical and social care
People will get right care, from the right professional, in the right setting and at the right time.
Workforce that is delivering excellent clinical and social care
Maximising use of specialist clinical staff, through to voluntary sector support workers.
Safe, transparent professional pathways of care
Maximising opportunities to train and retain staff at a local level, offering career progression
within and across professional staffing groups.
Through GPwSI training and education the MCP will build a skilled and competent GP workforce that will
result in:



Effective referral demand management.
High quality triage
Stable and committed local workforce.
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10.
27 January 2016
Innovation and IT Enablers - using technology to make informed decisions on accessing
health care
The MCP is looking to utilise technology to support both clinicians and service users to interface
effectively with the system. We are working with an external provider to develop SHREWD, a realtime
escalation tool that will be used within the CHOCs to support patient flow around the urgent care system.
The MCP will also be investing in the development of Wait Less, a public facing APP that enables
service users to identify in real time what services are accessible to them and what wait times they might
experience, and travel times to location. This will be designed at a local level, built on feedback from
people who will be using the APP. It offers improved:



Clinical Benefits – improved time to assessment, improved diagnosis, better outcomes (fewer
admissions)
Patient Experience- – quicker access to care, improved expectation, more convenience
Quality - APP to improve time to assessment, access and diagnosis. Reduced pressure on busy
A&E departments
The proof of concept and development costs will be in the region of £80k and will require sign off by all
providers and sign off through the East Kent Surge and Resilience Board.
11.
Research and Evaluation
The Centre for Health Service Studies (CHSS) at the University of Kent has been working with
Encompass to establish research capacity and a research support office within the Vanguard. This work
has been in collaboration with the Kent Surrey Sussex Clinical Research Network to pool resources and
ensure that high quality national studies can be delivered in the Vanguard. The aim is to facilitate and
generate research activity within the Vanguard and member practices with the goal of making research
part of the normal activities of the Vanguard and its constituent practices. Research will contribute to the
Vanguard’s development and activities by:
•
•
•
•
generating new knowledge
improving the quality of patient care
providing education opportunities for staff in practices and the Vanguard
improving staff recruitment
CHSS will undertake two initial evaluation projects within the Vanguard. The first involves evaluating the
impact integrated nursing approach within the Vanguard. This research will be led by Professor Jenny
Billings (CHSS) Director of the Centres’ Integrated Care Research Unit. The aim will be to assess the
impact on patient care and workforce. The second project will examine the role of paramedic
practitioners and evaluate their impact on the provision of primary care.
The above programme of research and evaluation will complement the internal evaluation being
undertaken by the MCP analysts. Furthermore, the MCP will seek to engage Public Health colleagues
from KCC in the research and evaluation programme to ensure that all elements of the MCP model are
evaluated in a comprehensive and coordinated manner. The table below seeks to illustrate the MCP’s
evaluation strategy:
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Evaluation Strategy
encompass
aim
Develop a new model of care that that delivers high quality, outcome focused, person centred,
coordinated care that is easy to access and that promotes wellness and enables people to live
independently for as long as possible
Evaluation
aim
Evaluation to understand whether the elements of the new model of care have worked, also how and
why – enabling us to learn lessons for spreading successful interventions and developing new ones
Evaluation
phases
During planning and set up
• Logic model
Evaluation
tools
• Value generation
hypothesis trees
• Evidence and best practice
During implementation and
model development
• Rapid cycle evaluation
• NCM national metrics
dashboard
• Encompass national and
local metrics dashboard
• Contract and activity
performance reports
After implementation /
ongoing
• Cohort case matching using
linked care dataset
• University of Kent Centre
for Health and Services
Studies research and
evaluation
Monitoring of impacts using cohort case matching and counterfactuals
Evaluation
activities
Monitoring of progress against local and national outcome, output and enabler / process metrics
Interviews, qualitative and quantitative research to establish the ‘how’ and ‘why’
12.
Activity, Finance and Evaluation Detailed Profile
(i)
Developing Primary Care
Extended Working Investment
As set out in 9.1 above, Encompass MCP will focus on scoping and developing the extended primary
care model in 2016/17. This will require a resource investment of £50k to fund a project manager to
focus on development of primary care. This investment will be non-recurrent transformational
development funding, it will not support direct service delivery.
Paramedic Practitioners Investment, Resource Sustainability and Evaluation
Building on the successful community paramedic practitioner pilot undertaken in Whitstable prior to the
formation of the MCP, paramedic practitioners have now been implemented across the MCP. The
number of visits that can be undertaken per week equates to 150 per week and in the short term it has
been agreed that this will require an investment of £45 per visit. On average paramedics are spending
45 minutes within the patients home.
The paramedic practitioners are undertaking GP home visit requests on behalf of GPs and the pilot
evidenced a clear reduction in the total number of 999 conveyances to hospital. The outcome of the
Whistable pilot shows that there has been a reduction of approximately 15% in conveyance level. Early
indications show that since the pilot has been rolled out across the whole MCP, conveyance levels have
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begun to reduce (by up to 10% in the first month of operation). Paramedic teams are now aligned to hub
areas within the MCP and rotate between dedicated paramedic practitioner and emergency vehicles.
The reductions in conveyances are being generated through the building relationships with both patients
and GPs within hub areas. Alongside releasing financial efficiency savings this scheme is enabling GPs
to undertake further work such as visiting palliative care patients with the capacity that is being released.
Patients are reporting increased satisfaction and demonstrating how alternative use of and development
of existing workforce can have significant impacts on the local economy. The MCP is working with the
University to undertake a detailed evaluation of this project in terms of the wider impact within primary
care.
Paramedic practitioner investment and savings table
2015/16
Investment
SECamb Saving
A&E Saving
UC Saving
Total Investment Required / Saving Achieved
2016/2017
2017/2018
2018/2019
2019/2020
2020/2021
£100,241
£0
£0
£0
£351,000
£0
£0
£0
£351,000
£0
£160,544
£321,088
£351,000
£0
£163,755
£327,510
£351,000
£0
£222,706
£445,413
£351,000
£0
£226,938
£453,876
£100,241
£351,000
£130,632
£140,264
£317,119
£329,814
A&E and Unscheduled care activity and finance over 5 years table EKHUFT A&E Activity
2014/15
Activity
Expected Reduction in A&E Attendances
Finance
Expected Reduction in A&E Cost
Resultant Finance
EKHUFT Unscheduled Care Activity (Short Stay Only)
Resultant Activity
Finance
Expected Reduction in UC Cost
Resultant Finance
2016/2017
12,834
-
Resultant Activity
Activity
Expected Reduction in UC Attendances
2015/16
12,570
2017/2018
13,103
1,310 -
2018/2019
13,379
2,007 -
13,646
2,047 -
2019/2020
13,919
2,784 -
2020/2021
14,184
2,837
12,570
12,834
11,793
11,372
11,599
11,135
11,347
£1,164,748
1,189,208
£0
1,214,181
£0
1,239,679
£160,544
1,264,472
£163,755
1,289,762
£222,706
1,314,267
£226,938
£1,164,748
£1,189,208
£1,214,181
£1,079,135
£1,100,718
£1,067,055
£1,087,329
2014/15
2015/16
11,329
2016/2017
11,567
-
2017/2018
11,810
262 -
2018/2019
12,058
401 -
12,311
409 -
2019/2020
12,570
557 -
2020/2021
12,834
567
11,329
11,567
11,548
11,656
11,902
12,013
12,266
£6,914,081
7,059,277
£0
7,207,522
£0
7,358,879
£321,088
7,513,416
£327,510
7,671,198
£445,413
7,832,293
£453,876
£6,914,081
£7,059,277
£7,207,522
£7,037,792
£7,185,906
£7,225,785
£7,378,417
GPwSI Services Investment, Resource Sustainability and Evaluation
The MCP programme includes a range of GPSI services that clinicians are keen to expand. Some
services are already well established, whilst others will require work up. It is anticipated that the MCP
will work alongside the CCG to explore how best to develop services, based on population needs and in
line with the MCP principles. Initial analysis of service pathways indicates that the current GPSI services
related to ENT, ophthalmology, cardiology, colorectal and neurology require development. Within ENT
and Neurology there is significant variation in referrals to secondary care, the MCP intends to capitalise
on examples of good practice across the locality and will invest £69k in existing GPSI contracts to shift
activity from the Acute. It is likely that these changes will be implemented in Q2 of 16/17. Full investment
will be requested as anticipated savings will not be negotiated into the contract during the 16/17 financial
year. Due to the need to undertake baseline work and ensure that new clinics do not generate
unnecessary demand the proposals for other areas will be worked up during 16/17. Furthermore, the
MCP will be looking to develop GPSI services that offer sustainability linked to accreditation and reaccreditation. The MCP is requesting £24k of funding to invest in project management time. We
anticipate having further detailed analysis of GPSI services set out in future bids. The cost of treating
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patients in the community is less for these services and therefore will be sustainable from 17/18 onward.
Anticipated financial efficiencies are small and can be easily eroded by generating additional demand for
these services. However, the MCP will work to mitigate against this and are working with the acute trust
to ensure that new services can help to relieve the pressures within secondary care.
End of Life Clinics Investment, Resource Sustainability and Evaluation
Development of the community based clinics referred to in section 9.1 above will require an investment
of £125k. It is likely that in addition to improving patient experience and quality, the delivery of these
clinics will likely result in a reduction in EoL admissions. The MCP will be looking at how this can be
evaluated, both in terms of financial impact but more importantly quality for patients and families.
(ii) Developing Nursing Integration and the Integration of Services Beyond Health
Integration Investment and Savings Table
2016/2017 2017/2018 2018/2019 2019/2020 2020/2021
Investment Required
Expected Admissions Savings
Expected Excess Bed Day Savings
Total Investment Required / Saving Achieved
£957,093
£0
£0
£957,093
-£1,374,808
-£318,753
£957,093
-£1,374,808
-£318,753
£957,093
-£1,374,808
-£318,753
£957,093
-£1,374,808
-£318,753
£957,093
-£736,468
-£736,468
-£736,468
-£736,468
Developing Nursing Integration and the Integration of Services Beyond Health Investment
The MCPs intention to create Integrated teams across hub sites, clearly requires significant shifts to
where resources are currently aligned and will be phased across 16/17 with the hope of fully aligned
team by September 2016.
Table 1 below sets out the current investment from the health and social care economy that is aligned to
the development of the MCP integrated model of care across a number of organisations. This
demonstrates that whilst we are seeking additional investment to facilitate service transformation,
partners across the health economy are also aligning existing resource to the MCP programme.
Partner Organisation
Kent Community Foundation Trust
Kent County Council
Total
£
6,765,092
6,920,998
13,686,080
The MCP is seeking additional investment to facilitate integration and is requesting funding of £x which
consists of the following:









£200k for workforce development
£124k for operational managers to oversee hub development and delivery
£300k for premises
£145k for I.T. integration of records and hardware for “control rooms”
£18k for local Shrewd specification
£98k for the continuation of year 1 nursing projects
£x for additional mental health nursing
£122k for the extension of social prescribing services
£48k to support the development of the health trainer programme
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Investment in more detail
Practice and Community Nursing Integration Investment
The MCP has used funding received through the 15/16 transformation funding to undertake an audit of
practice and community nursing consisting of a number of elements. These were:
1. A desktop review of activity and staffing numbers
2. A survey designed to understand relationships between GPs, practice nurses, community nurses
and HCAs.
3. A diary card exercise to gain detailed understanding of nursing activities, time spent with patients,
travel time etc.
4. Interviews with to clarify and add depth to diary card findings.
5. A good practice review.
The audit has produced extensive analysis that will be the foundation for making improvements to the
nursing service and measuring those improvements going. The main findings suggest a number of
issues including poor relationships between GPs and nurses, poor referrals to community teams, I.T.
barriers and non housebound patients being treated in their home.
Work undertaken to date to develop catheter clinics in primary care and improve healing rates through
better wound care will continue in 16/17 and further investment will be required.
Skill mix is currently being reviewed within primary care and the alignment of community teams to hubs
has been worked through and has informed the investment from existing resource calculations above. It
is envisaged that the MCP will procure expert consultancy services to undertake the organisational
development required and feel that this work is imperative to the successful integration of teams due to
the strength of feeling with regard to communications between professionals. In the short term the MCP
will seek to employ a two operational managers for each hub to aid their development. As the MCP will
be gathering evidence and adapting working practices as it develops it is felt that this role is required in
the short term.
The co-location of teams within hubs and for some staffing groups at a practice level will require changes
to the use of existing estate as well as I.T. investment to provide practical infrastructure. The need for
integration of records to minimise duplication and administration, a key finding from the audit, will require
short-term investment whilst a suitable solution is found for the longer term.
Mental Health Nursing Integration Investment
An investment of £x will be required to add mental health workers into the Integrated teams. Expected
costs have been taken from the primary care mental health worker pilots that have been undertaken in
Ashford and Canterbury CCGs. Where possible the MCP will try to use existing nursing resource but as
there are currently significant issues with mental health nursing recruitment this value has been included
as a working figure.
Social Care Integration Investment
The MCP has worked with Social Care to understand the number of social workers and associated care
staff (inclusive of those outsourced) that is available to integrate into hubs. This work remains in its early
stages and provides an estimate of the number of staff, skill mix and potential alignment to hubs but is
still subject to change. Social care information and finance is not as detailed and not held in the same
geographical regions as health data but is being developed to better align to the MCP and local Clinical
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Commissioning group requirements. In the longer term it is hoped that these budgets could be pooled as
per national direction and this represents a significant step toward the true integration of health and
social care.
Single Patient Access for Social Prescribing Investment
The Social Prescribing scheme is now being developed across the MCP area following a successful pilot
during 14/15 in the Whitstable area. The Vanguard is committed to enhancing the role of the voluntary
organisations within the new model of care and is requesting a small amount of transformation funding to
enable this to continue and expand resources to enable a greater number of assessments to be
undertaken. This will equate to £122k and would be expected to be fully absorbed into the
commissioning budget from 2017/18. No additional investment will be required for the integration of Age
UK into hubs.
Health Trainer Investment
£48k will be required to fund change management expertise on the GP list approach to health trainer
delivery. It will also support additional health trainer capacity whilst the new approach embeds,
management capacity to implement the new health trainer model and associated software costs, and will
support additional behaviour insights work specific to the vanguard.
Developing Nursing Integration and the Integration of Services Beyond Health Resource Sustainability
and Evaluation
In contrast to a traditional approach to re-designing services where a pathway or a particular element of
a pathway is reviewed, the MCP will integrate services without a prescriptive expectation of how activity
will shift. This approach is being taken for two reasons. Firstly the audit identified that 264 patients
account for 43.6% of the overall patient contacts. These are complex patients with multiple conditions
and as such they need to be reviewed as individual cases. Secondly, a lack of good quality data does
not enable a detailed financial model to be developed.
The overall expectation is that by integrating nursing services activity undertaken in a community setting
will be carried out in the right place and by the right professional. For example ensuring non-housebound
patients are treated by practice nurses will result in an increase in capacity within the community nursing
workload. In turn, community nurses will be able to focus on areas such as blocked catheters and
catheter replacements therefore reducing unnecessary admissions. It is likely that there will many areas
identified which will release capacity between teams and reduce duplication allowing a targeted effort to
reduce unnecessary admissions, reduced the number of delayed discharges, ensure patients are placed
out of hospital in the right place and reduce length of stay.
The MCP is going to target a reduction of circa 2,500 zero and one day length of stay admissions where
the patient received no procedure during their stay. This equates to 27% (similar to findings of the
nationally recognised MCap tool) of all short stay admissions and will release £1.4m of financial savings.
In addition the MCP anticipates a reduction in length of stay and so a conservative estimate of £318k
has been included reflecting a 50% reduction in excess bed days and 4% against overall bed days.
Using the baseline activity and areas for improvement identified through the nursing audit, both process
and outcome targets will be measured and are in the process of being defined for the short term.
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For mental health, social care services and health trainers the expected activity changes will be more
clearly defined and existing organisations targets and measures will need to remain in place where the
change doesn’t impact the majority of the service.
One of the key datasets that the MCP will use to the evaluate this programme is the locally developed
linked care dataset. This currently encompasses acute, community, GP, social care and mental health
data as well as a number of smaller providers so a patient’s journey can be followed and the
interventions leading to and post admissions can be identified. The MCP is committed to reviewing this
data and using it to produce cohorts that will be compared against in future years. Ideally the 264
patients that account for 43.6% of the workload will be put into a cohort to see how they their contacts
change once integration is fully implemented. However, governance issues will have to be resolved in
order for this to happen.
In addition the MCP will work with the University of Kent to explore alternative ways of evaluating the
programmes. An area of particular interest is robustly proving the impact of the voluntary sector within
integrated teams. The MCP is currently developing and investing in an academic programme of work
with a view to evaluations beginning as soon as is possible.
(iii) Developing Estate Infrastructure
Investment for infrastructure
The MCP will be bidding for further transformation funding in 17/18 to develop estate and further
capacity in the community. This will consist of a number of areas:




Developing a community hospital at the Estuary View site. Funding will be required to double run
services whilst the existing community inpatient beds are closed. This is estimated to be circa
£4m.
Developing community beds at the Kent and Canterbury site. Funding will be required to
transform existing estate and manage transition costs. As part of this work, an existing practice in
the Canterbury area is intending to develop new estate on this site and is bidding through the
primary care infrastructure fund. This has clear alignment to the MCP vision of developing a hub
at this site.
Developing community beds in the Faversham locality. This is yet to be explored but it is likely
that funding will be required.
Developing a Health and Wellbeing centre at Northgate Medical Practice, with capital funding
requirements expected to be in the region of £1m. This will be bid for through the primary care
infrastructure fund and has clear alignment to the MCP vision of developing preventative services
within the hub area.
In the short-term the MCP is requesting £150k funding to procure project resource to prepare the full
investment case for developing estate. It is expected that these cases will be worked up in full by
September 2016. The procurement processes that will follow will likely mean that double running will not
occur until Q2 of 17/18.
This work is being underpinned by the system wide work on bed modelling lead by the East Kent
Strategy Board. This sophisticated modelling will help to build the case for investment and meet the
needs of the local acute provider to reduce the acute bed base.
It is expected that significant savings will be derived from shorter lengths of stay, more cost effective
estate and a “pull” approach from the acute setting. In the longer term, the commissioning of a new
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community hospital and nursing home will be sustainable and deliver savings through the decommissioning of acute hospital wards, and the closure of existing estate.
Corporate Costs
There is an additional funding request of £1.76m to support the further development of the MCP for
2016/17. In future years and as an organisational form is developed this will change significantly.
Staffing costs are primarily comprised of funds to support GP backfill during the development of the
clinical model and GP at scale proposals. These GPs will be representative of total target population. A
payment mechanism has been developed in which a flat rate is paid to practices for their engagement
that is carefully monitored. In addition external resource has been purchased to support the project. This
is reflective of the fact that GP led MCPs do not have the same ability as larger organisations to absorb
additional project work into normal business.
The development team for the MCP has acquired some premises to work from both for management
and clinical staff as the model of care is developed.
Additionally, there are costs included for communications and engagement, costs for potential data
platforms to support the development of capitated payment and costs for consultancy as there is an
intention to undertake MCP organisational development work. Also included in the corporate costs is an
allocation to support the research and evaluation programme that the MCP has commissioned from
Centre for Health Services Studies at the University of Kent.
As is prudent, there is a contingency allowance for corporate spend given that the MCP has grown in
population size rapidly.
13.
Programme Management and Governance
The MCP established a Partnership Steering Group that includes senior representation across the health
and social care commissioner and provider landscape. It has been operational since February 2015.
The Group operates under a clearly defined terms of reference, and is establishing its sub group
structure, that will focus on operational design and delivery of the full MCP work programme.
The MCP has now decided to form a General Practice Leadership Board that will ensure that all 16
practices who are members of the MCP have a strategic and decision making role. This will become
increasingly important as the MCP develop its organisational and contractual form in 2016/17.
14.
Communications and Engagement Strategy for the MCP
Effective communications and engagement is essential for the development of Encompass’s plans to
develop our new model of care. Our patients, their carers and our stakeholders, the people who rely on
local health services, are uniquely placed to help us develop the services we will provide, and advise us
on what works best for them and the areas that could be improved on. As the way health services are
provided and used changes, we want to make sure our patients, carers and stakeholders feel fully
informed and involved in the decisions we make. We also want to make sure that we do this in a way
that meets NHS standards and statutory duties.
An effective communications and engagement strategy will help us to raise awareness of the services
available to patients, provide information on common conditions to support self-management and
diagnosis of care as well as encouraging healthy lifestyles.
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We want to involve patients and members of the public in discussions and decisions about how their
healthcare will be provided in the future and to be given information to enable help them to do this. This
includes informing patients and the public about the healthcare services available to them locally and
nationally and offering easily accessible, reliable and relevant information to enable them to participate
fully in their own healthcare decisions and choices. To do this, we will deliver high quality
communications and engagement.
We will take a planned and sustained approach to communications and engagement to fulfil our vision
for our residents to have access to the best healthcare available, the opportunity to improve their
physical, mental and social wellbeing and to be involved in decisions about their own health and
healthcare.
We will engage and communicate so that:












People know who we are and what we do.
People know what services we provide and how to access them.
People can make informed choices about their health and lifestyle.
We can equip people with the skills and knowledge to be able to self-care and self-manage their
conditions.
Health services are used effectively.
People can publicly hold us to account.
Our strategic objectives and the delivery of our plans are supported through engaging people,
partners and stakeholders.
Our care model develops through better involvement and engagement of the people who use
services.
Service provision is joined up.
Quality of care improves.
The reputation of, and confidence in, the local NHS is upheld.
Other parts of the NHS can learn from our development.
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Annex A
Value Hypothesis Generation Assessments
Currently being updated
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Annex B
Canterbury and Coastal CCG HEALTH Needs Assessment
ONLY TO BE INCLUDED IF IT IS RE-WORKED TO COVER ALL 16 PRACTICES – THE CURRENT
HNA COVERS THE 3 FOUNDER PRACTICES ONLY
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Annex C
MCP Partnership Steering Group
(Whitstable, Faversham and Canterbury Community Multi-Speciality Community Provider Vanguard Site)
Terms of Reference
1
Purpose of the Steering Group
1.1 The Steering Group will oversee the MCP Vanguard Site work programme, as endorsed by NHS England
National Five Year Forward View New Models of Care Programme Team. The practices jointly submitted a bid
to NHS England, and it has been selected as one of 29 sites to prototype new approaches for care design and
delivery that have been developed to meet the needs of local populations.
1.2 The National Programme will work through coordinated national and regional support to help the Steering
Group accelerate the implementation of these locally-owned community-focused models. This support will
facilitate clinical innovation and more coordinated person-centred care, as well as learning and benefiting
from greater and more responsive citizen and community engagement. These forerunners will be evaluated
thoroughly, with a view to being replicated elsewhere across the country, and provide real-life examples and
learning for how current barriers to transformational change may be overcome.
1.3 The Steering Group will comprise representation from the multi-agency bodies that will oversee, enable and
facilitate the development and implementation of the MCP’s work programme. Accountability for the sites is
yet to be determined by the National New Models of Care Team. Whilst the CCG remains the statutory
authority responsible for commissioning health services for its local population, it will work with the MCP to
explore how the MCP can be supported to take on delegated commissioning responsibility for its MCP patient
cohort.
2
Scope of the MCP Work Programme
2.1 The MCP programme strategy is to transform the quality and cost effectiveness of health and social care for
the local population serviced by its 16 member practices, which represent a patient population of 169,806.
The implementation of the strategy will build on the achievements and experiences to date of the Whitstable
Integrated Health and Social Care pilot. To date the pilot has focused on developing:

An integrated community long term conditions management service;
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

27 January 2016
A community urgent care service;
A community elective care service.
The MCP programme will focus on developing:
 An integrated health and social care model of care that focuses on delivering high quality, outcome
focused, person centred, coordinated care that is easy to access and that enables people to stay well and
live independently for as long as possible in their home setting. The model will include community
hospital provision that facilitates direct GP admissions; nursing home provision and extra care provision,
inclusive of day centre provision.
2.2 The aim of the MCP model of care is to secure:
High quality, outcome focused, person centred, coordinated care that is easy to access and that promotes
physical and mental health and wellbeing, and which enables people to stay well and live independently
for as long as possible.
2.3 The objectives from this model of care are to:
 Develop high quality, outcome focused and community based person centred physical and mental health
care and wellbeing services. Services will be coordinated, and where practicable, co-located within hubs
located in Whitstable, Faversham and Canterbury. This will improve diagnosis and treatments outside
hospital and create a more patient centred model of care.
 Work towards setting up extended Primary Care and Community Services, starting with a Saturday service
to cover what is seen as the weekend time of most demand. The effectiveness of this new service can
then be evaluated, and the service modified as appropriate. This will maximise access to primary care –
this will be inclusive of GP, nursing, mental health and paramedic practitioner services.
 Enable better step up and step down, with less delayed transfers of care. This will also enable faster and
more successful discharge to a patient’s home.
• Enhance the use of IT to facilitate both streamlined communication between patients, clinicians and
carers; and to maximise the use of tele care and telemedicine to maintain support self-care and selfmanagement to promote independence.
• Create a more cost effective service. By treating patients in the local community setting we will reduce the
cost of some outpatient procedures and outpatient appointments through expanding the use of GPs with
special interest to triage referrals. We will reduce the number of OPD follow up appointments, making
these one stop where possible. Increased educational and communication opportunities will improve GP
case management, rationalise investigations and make referrals to secondary care easier.
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• Focus on prevention to ensure that as a whole health and social care system we are working seamlessly to
support people to stay well and to live independently, with appropriate support where it is necessary. By
focusing on prevention we will seek to manage both admissions to hospital and admissions to nursing
homes.
• Explore a new contracting mechanism based on capitated budget. This will allow us to have the control
over how to deploy resources available in a way to achieve best outcomes for our population.
• Meet the aims of the Kent Accommodation Strategy. The bid supports the strategy of KCC, the CCG and
Kent’s district councils to support people, including those with dementia, to maintain independence as
long as possible.
 Work with voluntary groups and charities to ensure that the Vanguard is making best use of opportunities
that exist to utilise these services locally.
3
Role of the MCP Partnership Steering Group
3.1 The Steering Group will oversee, enable and facilitate the development and implementation of the MCP
work programme. In particular, it will oversee individual outcome focused work streams focused on:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Service user and carer pathway, service and workforce modelling;
Financial and activity analysis;
Contractual modelling and governance;
Human Resources and Organisational Development;
Information Management and Technology;
Communications and engagement;
Developing General Practice at Scale;
Estates and Infrastructure.
3.2 Key deliverables for the Steering Group will include:






Agreeing the scope of the MCP model’s coverage in respect of the population and range of services
included within it.
Agreeing the commissioning model to support its implementation.
Agreeing the key outcomes that the MCP model will deliver, and the metrics by which it will be measured.
Developing the estates plan that will support the model.
Ensuring that strategies across the partner organisations are in place to enable delivery of the work plan.
Developing wider partnerships with the voluntary sector and community through the Community
Networks.
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

4.
27 January 2016
Ensuring that community equipment services provision and transport provision, which facilitate and
enable effective community service delivery, are in line with the MCP work programme.
Ensuring that the IT infrastructure required to support the MCP is in place, inclusive of telemedicine and
telehealth.
Timescale
4.1 The timescale for the work programme is yet to be confirmed but an outline timeline of key milestones is
attached to this Terms of Reference.
4.
Membership of the Steering Group
4.1 The Steering Group membership has been proposed to ensure that all partners are appropriately
represented in terms of managerial, clinical, financial and estates expertise.
4.2 The current membership list is:
John Ribchester – Chair
Ann Judges – Programme Manager
Dr Richard Brice, Whitstable Medical Practice
Dr Peter Biggs – Northgate Medical Practice (Vice Chair)
Dr Sakel, Saddleton Road Practice
Dr Jacky Buchanan, Whitstable Medical Practice
Dr Anne Weatherly, The Butchery, Sandwich
Dr Sarah Phillips, Newton Place Medical Practice
Dr Guarav Gupta, Faversham Medical Centre
Dr Kim Gardener, Canterbury Medical Centre
Dr Dan Horton-Szar, Northgate Medical Practice
Dr Alison Bowhay, University Medical Centre
Lorraine Goodsell – Transformation Programme Director – Canterbury &Coastal CCG (CCCCG)
Mark Lobban – Director of Strategic Commissioning – Kent County Council (KCC)
Mags Harrison – Transformation and Pioneer Programme Manager, KCC
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Christy Holden – Head of Strategic Commissioning - Accommodation Solutions
Lesley Strong, Director of Operations, Kent Community Health Foundation Trust (KCHFT)
Liz Shutler – Director of Strategic Development, East Kent University Health Foundation Trust (EKUHFT)
Ivan McConnell - Executive Director of Commercial Development and Transformation, Kent and Medway
Partnership Trust (KMPT)
Ivor Duffy, Finance Director, CCCCG
Carolyn Nelson, Practice Manager, Whitstable Medical Practice
Kaye Blanford, Clinical Services Manager, Whitstable Medical Practice
Dr Faiza Khan, Public Health Consultant, KCC
Karen Sharp Head of Commissioning, KCC
Amy Dibban, MCP Finance Consultant
Paul Sutton, CEO South East Coast Ambulance Service (SECamb) NHS Foundation Trust
David Muir, Communications Lead, South East Commissioning Support Unit (SECSU) (Associate Member to
attend as apropriate)
Dr Robert Stewart, KCC (Associate Member to attend as appropriate)
Christy Holden – Head of Strategic Commissioning - Accommodation Solutions
4.3 In addition to the core Steering Group membership, the Group may seek to co-opt additional partner
representatives to attend Steering Group meetings as required.
5 Governance
5.1 Accountability for the new model of care will rest with the Partnership Steering Group. All organisations
represented on the Steering Group should therefore ensure that the relevant nominated representative is of
sufficient seniority to have delegated decision making powers to ensure that the MCP is able to progress
swiftly with developing the new model of care. 5.2 The Steering Group will determine its sub-group
structure. It is proposed that work is progressed in seven work streams as follows:
i) Service user and carer pathway, service and workforce modelling;
ii) Financial and activity analysis;
iii) Contractual modelling and governance;
iv) Human Resources and Organisational Development
v) Information Management and Technology
vi) Communications and engagement;
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vii) Estates and Infrastructure.
5.2 The charts below illustrate the organisational structure (Fig 1) and interdependencies (Fig2) for the MCP
work programme’s Steering Group and seven work stream groups:
Service user and
carer pathway &
workforce modelling
Financial and activity
analysis
NHS England New
Models of Care
Programme
MCP GP Partner
Practice Boards
Contractual
modelling and
governance
MCP Partner
Steering Group
HR and OD
IM&T
Commissioners
(CCH, NHS England
AT)
Comms and
engagement
MCP Provider
Partners
Estates and
Infrastructure
Service user and
carer pathway &
workforce modelling
Financial and activity
analysis
NHS England New
Models of Care
Programme
MCP GP Partner
Practice Boards
Contractual
modelling and
governance
MCP Partner
Steering Group
HR and OD
IM&T
Commissioners
(CCH, NHS England
AT)
Comms and
engagement
MCP Provider
Partners
Estates and
Infrastructure
Fig 1
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Service user and
carer pathway &
workforce
modelling
Estates and
Infrastructure
Financial and
activity analysis
MCP
Partnership
Steering
Group
Communications
and engagement
Contractual
modelling and
governance
Human
Resources and
Organisational
Development
Information
Management
and Technology
Service user and
carer pathway &
workforce
modelling
Estates and
Infrastructure
Financial and
activity analysis
MCP
Partnership
Steering
Group
Communications
and engagement
Information
Management
and Technology
Contractual
modelling and
governance
Human
Resources and
Organisational
Development
Fig 2
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6
27 January 2016
Meetings
6.1 The Steering Group will meet on a monthly basis. Dates will be established after to first meeting.
6.2 The Group will be quorate provided that the following are in attendance:
Chair or Deputy Chair
1 x CCCCG representative
1 x Representative (chair or nominated deputy) of each working group (as working groups are established
and come on stream, if dictated by the agenda)
1 x MCP member practice representative
1 x KCC representative
1 x representative (or nominated deputy) of lead partner organisations
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Outline Time Plan
MCP Implementation Timeline - Outline
Plan
Action
1. MCP Partnership Steering Group
Description
1.4 Sign off OPP
1.3 Produce Outline project plan (OPP)
Risk register to be signed off post site visit
Risk Register sets out key programme risks and
issues. It is a "live" document and will be
reviewed regulary. Execption reporting to
Steering Group
Sign off by Steering Group post site visit
Draft ToR discussed and amended following 18/3.
Revised ToR to be agreed 23/4. Work Stream
Descriptors circulated and membership for each
group sought for 23/4.
OPP sets out key deliverables and milstones for
programme (to be finalised after site visit).
Group established 18/3. Agreed to meet monthly
during start up and until work streams are
established. NMC Site Visit 5/6 May
1.5 Produce risk register
Ma
r15
r-1
5
Ap
◊
23
April
Ma
y-1
5
◊
5/6
May
-1 5
Jul
-15
Jun
16
July
◊
◊
11
June
16
July
Au
Group focused on defining scope/cohort to be
supported through MCP. Also to define staging of
services coming on stream if whole population
approach taken (e.g. initial focus on 65+ and LTC,
moving to roll out across all ages/whole
population/all services)
g-1
5
-15
Se
p
◊
17
Sept
Oc
t -1
5
No
v-1
5
De
c-1
5
-16
Ja n
Fe
b-1
6
Ma
r-1
6
r-1
6
Ap
ENCOMPASS MCP - Working together for better health and care
1.1 Establish Steering Group monthly/bi-monthly meetings
1.6 Sign of risk register
Propose commencing Clinical Pathway Modelling,
Financial and Analytical Modelling and Comms &
Engagement work streams initially. Planned
launch workshop on 16 July (will replace Steering
Group meeting)
1.2 Produce ToRs and Work stream descriptors
1.7 Agree membership and commence work stream groups
2. Programme Work Stream Groups
1.Service user and carer pathway, service and workforce
modelling
Focus on collecting and analysing financial and
activity data that underpins the business model.
This will support potential capitation budget. Will
also inform financial and activity envelope for
contracting purposes.
Steering Group agreed 7 work streams focused on
key elements of the programme. Desriptors
circulated and Steering Group members requested
to nominate members for Grps
2. Analytical and financial modelling
Oversee governance of MCP and explore options
to develop its independent status, inc. working
with CCG on commissioning responsibility for the
MCP’s services. Explore contractual implications of
the MCP, and contractual models that might
support it.
2.1 Establish work stream groups:
3. Contractual modelling and governance
To map the Human Resources and Organisational
Development implications of the MCP, in
particular to focus on the employment
implications of the MCP’s new model .
Groups to be established after 11 June.
Anticipated staggered approach to groups coming
on stream.
4. Human resources and Organisational Development
To oversee the IM&T elements of the MCP,
including addressing interoperability of systems
across partner organisations. Focus on utilisation
of telehealth and telemedicine and PDAs. Manage
and mitigate IG issues, explore digital solutions to
community-based working across multiple
specialities.
Launch 16/7
2.2 Groups to meet monthly (virtual or face to face)
5. Information Management and Technology
Launch 16/7
38
27 January 2016
DRAFT VERSION 19
6. Communications and Engagement
7. Estates and Infrastructure
Develop comms and engagement strategy to
support the MCP’s development, design and roll
out, inc. include utilisation of the Community
Networks structure. Also managing HOSC and
formal consultation as required. Will also oversee
coordinated comms across partners.
Full business case for vanguard programme being
developed alongside accelerated Year 1 bid to NHS
Ensure the estates and infrastructure that will
underpin the MCP are in place and operational.
Ensure the MCP plans are consistent with and
aligned to the wider health and social care
housing/accommodation and bed modelling
strategies across the locality.
3.1 Building the business case (Year1, Year 2 and Year3)
Submission to go to NHS E NMC Team by 19/6
setting out Year 1 bid for Transformation Fund
monies to support Vanguard development.
3. Developing the Vanguard Bid
3.2 Submit business case Inc. value proposition to NHS E NMC
Team in June. Project lines outlined below.
(Note projects are colour coded - Green indicates commenced
and/or fully worked up proposal. Amber indicates not
commenced or requires additional work up).
Increasing capacity in primary care through
additon of 1xGP at whitstable, Northgate and
Faversham (subject to confirmed scaling up).
Aliognment of distric and community nursing
services including MH nursing services to ensure
coordinated care. Possible to commence from
Aug, subject to funding release. Additional access
to routine care, delivering more flexible access to
patients. Access to full multi-professional team
will ensure better continuity of care, seamless
3.2.1 Build capacity in primary care (7 day working across Vanguard transition and improved patient experience.
locality)
Paramedic home visiting to support patients to be
triaged at home in timely manner (inside 2 hours),
enabling correct treatment, referral and
signposting as required.Building multiprofessional workforce capacity in the community
to deliver optimum patient care in home setting
(right care, right time, right setting, right
workforce).
3.2.4 Over 75 care co-ordinator and pharmacist project.
Care home project enhancement.
3.2.3 Social Prescribing Service
Marketing, comms materials and venue hire to
support model development and roll out inclusive
of full patient and carer engagement in co-design.
Also allows for potential formal consultation
which may be required in respect of local service
re-design.
Care coordinator in place across Whitstable and
Northgate to support proactive care planning for
over 75 risk strast patients. Includes proactive
pulling of patients from secondary care. Subject to
vanguard expansion, may require expansion to
service. Community pharmacist wokring across
Whitstable and Northgate to review drug
programmes for patients, including those in care
homes.
Improved user and carer access to voluntary sector
services. Build resilience, improve health and
wellbeing, improved mental wellbeing.
Evaluation of the impact/benefits of social
prescribing. Pilot in place - will continue subject
to funding release. This is currently Whitstable
only - will need to be scaled up across full
Vanguard.
3.2.2 Paramedic Practitioner continuation at Whitstable and roll
out to Northgate and Faversham.
3.2.5 Comms and engagement programme to support vanguard
development and delievery
Launch 16/7
ENCOMPASS MCP - Working together for better health and care
39
27 January 2016
DRAFT VERSION 19
4. Developing year 2 programme including building
programme, capitation funding and new contractual model
CCG to be aware of potential need to serve notice to current
providers (12 month) if applicable or 6 months' notice in Sept 15
to release funding from secondary care system from April 16
Link to Year of Care EK Project Group to inform capitation budget
AJ sitting in EK YoC Commissioning Group. Also EK
YoC Grp to visit EVMP to brief on project to date.
Develop comms and engagement strategy to
support the MCP’s development, design and roll
◊
10
April
◊
26
June
21
July
ENCOMPASS MCP - Working together for better health and care
Outcome of outline building planning application
Outcome of full planning application (subject to outline plan)
Building work commences (Mar 16)
First building operational (community hospital)Dec 16
6. Communications and Engagement
Laun
ch
16/8
40
DRAFT VERSION 19
27 January 2016
41
ENCOMPASS MCP - Working together for better health and care
27 January 2016
DRAFT VERSION 19
Outline Time Plan
MCP Implementation Timeline - Outline
Plan
Action
1. MCP Partnership Steering Group
Description
1.4 Sign off OPP
1.3 Produce Outline project plan (OPP)
Risk register to be signed off post site visit
Risk Register sets out key programme risks and
issues. It is a "live" document and will be
reviewed regulary. Execption reporting to
Steering Group
Sign off by Steering Group post site visit
Draft ToR discussed and amended following 18/3.
Revised ToR to be agreed 23/4. Work Stream
Descriptors circulated and membership for each
group sought for 23/4.
OPP sets out key deliverables and milstones for
programme (to be finalised after site visit).
Group established 18/3. Agreed to meet monthly
during start up and until work streams are
established. NMC Site Visit 5/6 May
1.5 Produce risk register
Ma
r15
r-1
5
Ap
◊
23
April
Ma
y-1
5
◊
5/6
May
-1 5
Jul
-15
Jun
16
July
◊
◊
11
June
16
July
Au
Group focused on defining scope/cohort to be
supported through MCP. Also to define staging of
services coming on stream if whole population
approach taken (e.g. initial focus on 65+ and LTC,
moving to roll out across all ages/whole
population/all services)
g-1
5
-15
Se
p
◊
17
Sept
Oc
t -1
5
No
v-1
5
De
c-1
5
-16
Ja n
Fe
b-1
6
Ma
r-1
6
r-1
6
Ap
ENCOMPASS MCP - Working together for better health and care
1.1 Establish Steering Group monthly/bi-monthly meetings
1.6 Sign of risk register
Propose commencing Clinical Pathway Modelling,
Financial and Analytical Modelling and Comms &
Engagement work streams initially. Planned
launch workshop on 16 July (will replace Steering
Group meeting)
1.2 Produce ToRs and Work stream descriptors
1.7 Agree membership and commence work stream groups
2. Programme Work Stream Groups
1.Service user and carer pathway, service and workforce
modelling
Focus on collecting and analysing financial and
activity data that underpins the business model.
This will support potential capitation budget. Will
also inform financial and activity envelope for
contracting purposes.
Steering Group agreed 7 work streams focused on
key elements of the programme. Desriptors
circulated and Steering Group members requested
to nominate members for Grps
2. Analytical and financial modelling
Oversee governance of MCP and explore options
to develop its independent status, inc. working
with CCG on commissioning responsibility for the
MCP’s services. Explore contractual implications of
the MCP, and contractual models that might
support it.
2.1 Establish work stream groups:
3. Contractual modelling and governance
To map the Human Resources and Organisational
Development implications of the MCP, in
particular to focus on the employment
implications of the MCP’s new model .
Groups to be established after 11 June.
Anticipated staggered approach to groups coming
on stream.
4. Human resources and Organisational Development
To oversee the IM&T elements of the MCP,
including addressing interoperability of systems
across partner organisations. Focus on utilisation
of telehealth and telemedicine and PDAs. Manage
and mitigate IG issues, explore digital solutions to
community-based working across multiple
specialities.
Launch 16/7
2.2 Groups to meet monthly (virtual or face to face)
5. Information Management and Technology
Launch 16/7
42
27 January 2016
DRAFT VERSION 19
6. Communications and Engagement
7. Estates and Infrastructure
Develop comms and engagement strategy to
support the MCP’s development, design and roll
out, inc. include utilisation of the Community
Networks structure. Also managing HOSC and
formal consultation as required. Will also oversee
coordinated comms across partners.
Full business case for vanguard programme being
developed alongside accelerated Year 1 bid to NHS
Ensure the estates and infrastructure that will
underpin the MCP are in place and operational.
Ensure the MCP plans are consistent with and
aligned to the wider health and social care
housing/accommodation and bed modelling
strategies across the locality.
3.1 Building the business case (Year1, Year 2 and Year3)
Submission to go to NHS E NMC Team by 19/6
setting out Year 1 bid for Transformation Fund
monies to support Vanguard development.
3. Developing the Vanguard Bid
3.2 Submit business case Inc. value proposition to NHS E NMC
Team in June. Project lines outlined below.
(Note projects are colour coded - Green indicates commenced
and/or fully worked up proposal. Amber indicates not
commenced or requires additional work up).
Increasing capacity in primary care through
additon of 1xGP at whitstable, Northgate and
Faversham (subject to confirmed scaling up).
Aliognment of distric and community nursing
services including MH nursing services to ensure
coordinated care. Possible to commence from
Aug, subject to funding release. Additional access
to routine care, delivering more flexible access to
patients. Access to full multi-professional team
will ensure better continuity of care, seamless
3.2.1 Build capacity in primary care (7 day working across Vanguard transition and improved patient experience.
locality)
Paramedic home visiting to support patients to be
triaged at home in timely manner (inside 2 hours),
enabling correct treatment, referral and
signposting as required.Building multiprofessional workforce capacity in the community
to deliver optimum patient care in home setting
(right care, right time, right setting, right
workforce).
3.2.4 Over 75 care co-ordinator and pharmacist project.
Care home project enhancement.
3.2.3 Social Prescribing Service
Marketing, comms materials and venue hire to
support model development and roll out inclusive
of full patient and carer engagement in co-design.
Also allows for potential formal consultation
which may be required in respect of local service
re-design.
Care coordinator in place across Whitstable and
Northgate to support proactive care planning for
over 75 risk strast patients. Includes proactive
pulling of patients from secondary care. Subject to
vanguard expansion, may require expansion to
service. Community pharmacist wokring across
Whitstable and Northgate to review drug
programmes for patients, including those in care
homes.
Improved user and carer access to voluntary sector
services. Build resilience, improve health and
wellbeing, improved mental wellbeing.
Evaluation of the impact/benefits of social
prescribing. Pilot in place - will continue subject
to funding release. This is currently Whitstable
only - will need to be scaled up across full
Vanguard.
3.2.2 Paramedic Practitioner continuation at Whitstable and roll
out to Northgate and Faversham.
3.2.5 Comms and engagement programme to support vanguard
development and delievery
Launch 16/7
ENCOMPASS MCP - Working together for better health and care
43
27 January 2016
DRAFT VERSION 19
4. Developing year 2 programme including building
programme, capitation funding and new contractual model
CCG to be aware of potential need to serve notice to current
providers (12 month) if applicable or 6 months' notice in Sept 15
to release funding from secondary care system from April 16
Link to Year of Care EK Project Group to inform capitation budget
AJ sitting in EK YoC Commissioning Group. Also EK
YoC Grp to visit EVMP to brief on project to date.
Develop comms and engagement strategy to
support the MCP’s development, design and roll
◊
10
April
◊
26
June
21
July
ENCOMPASS MCP - Working together for better health and care
Outcome of outline building planning application
Outcome of full planning application (subject to outline plan)
Building work commences (Mar 16)
First building operational (community hospital)Dec 16
6. Communications and Engagement
Laun
ch
16/8
44
DRAFT VERSION 19
27 January 2016
45
ENCOMPASS MCP - Working together for better health and care