PUBLIC BOARD MEETING 29th March 2017

Details of the Paper Title Buckinghamshire Integrated Health and Care Update

Responsible Director David Williams, Director of Strategy and Business Development

Purpose of the paper To update the Board on how we are working with our partners to transform services for our

patients and initiatives to accelerate new models of integrated care

Action / decision required (e.g., approve, support, endorse)

The Board are asked to note:-

• The Buckinghamshire Joint Health and Well-Being Strategy 2016-2021 • The intent of partners to accelerate integrated health and care in Buckinghamshire • Progress on new models of integrated care • Governance arrangements for how the new system of integrated care will be

managed will be provided for future Board discussion

IMPLICATIONS AND ISSUES TO WHICH THE PAPER RELATES (PLEASE MARK IN BOLD) Patient Quality Financial

Performance Operational Performance

Strategy Workforce performance

New or elevated risk

Legal Regulatory/ Compliance

Public Engagement /Reputation

Equality & Diversity

Partnership Working

Information Technology / Property Services

ANNUAL OBJECTIVE Integrated Care Enhance partnerships between community services, primary health, social care, voluntary sector partners and patients to better support care in people's homes and in other community settings.

Please summarise the potential benefit or value arising from this paper: RISK Are there any the specific risks associated with this paper? If so, please summarise here.

Non-Financial Risk: BAF 5.1a There is a risk that if we do not enhance partnerships between various stakeholders that we will not deliver the best support to patients in their homes and other community settings. BAF 5.1c If we do not lead and drive an integrated primary acute care system (PACS) in Buckinghamshire we will not optimise the benefits from joined up working e.g. reducing fragmentation and duplication of services for patients. BAF 7a If we do not redesign our musculo-skeletal services with our partners there is a risk the that service will be competitively tendered. If this happens and we are not successful in bidding for the tender it is possible that we would lose control of the provision of secondary care MSK services (risk to recruitment, patient care and finance)

Financial Risk:

LINK TO CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF SAFETY AND QUALITY Which CQC standard/s does this paper relate to?

Well-Led Domain

Author of paper: David Williams, Director of Strategy and Business Development Presenter of Paper: David Williams, Director of Strategy and Business Development Other committees / groups where this paper / item has been considered: Executive Management Committee Date of Paper: 15th March 2017

BUCKINGHAMSHIRE HEALTH AND CARE INTEGRATION UPDATE

1. Introduction

This paper updates the Board on initiatives linked to our vision to be one of the safest healthcare systems in the country leading the way on joining up health and care across Buckinghamshire.

It describes how we are working with our partners to transform services for our patients as well as development initiatives between providers and commissioners to accelerate new models of integrated care.

2. Health and Well-Being Strategy

The Buckinghamshire Joint Health and Well-Being Strategy 2016-2021 has been approved by the Health and Well-Being Board at its March meeting after an extensive consultation exercise across the county. The Board assessed the priorities against our own Strategy in the September 2017 as part of this process.

The Board is aware that Local authorities and clinical commissioning groups have equal and joint duties to prepare Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies, through the Health and Wellbeing Board which Buckinghamshire Healthcare NHS Trust is a member.

The 2016 – 2021 strategy aims to create the best conditions in Buckinghamshire for people to live healthy, happy and fulfilling lives and achieve their full potential. The vision is to improve outcomes for the whole population as well as having a greater impact on improving the health and wellbeing of those people in Buckinghamshire who have poorer health and wellbeing.

The strategy aims to make an impact on the five key priority areas:-

• Give every child the best start in life • Keep people healthier for longer and reduce the impact of long term conditions • Promote good mental health and wellbeing for everyone • Protect residents from harm • Support communities to enable people to achieve their potential and ensure

Buckinghamshire is a great place to live

The full strategy can be found here:- https://democracy.buckscc.gov.uk/documents/s94925/JHWS2017Feb27web.pdf

An annual report will be produced to show the impact that the Board and its partners have made over the year to improving the county’s health and wellbeing.

The Health and Wellbeing Board will develop a set of performance indicators to monitor progress throughout each year to demonstrate how the strategy is making a difference in Buckinghamshire.

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3. Creating an Integrated Health and Care System in Buckinghamshire

The Trust has been working closely with local providers and commissioners to create the environment for integrated care. The Buckinghamshire Health and Well-Being Board discussed a Health and Social Integration Roadmap to 2020 as a clear statement of intent for all statutory organisations in this regard. The roadmap focusses on:-

• Joint Commissioning • Integrated Provision • Back office (One Public Estate, Communications and Business intelligence) • Governance

https://democracy.buckscc.gov.uk/documents/s94866/Health%20and%20Social%20Care%20integration%20report%20for%209%20March%20HWB.pdf In terms of integrated provision, the Trust has been continuing its work with Oxford Health and Fed Bucks (an organisation supporting 85% of GP practices in Buckinghamshire) to develop a Primary and Acute Care System (PACS) with learning from the national vanguard programme. A memorandum of understanding is being developed between the partners. Our ambition as providers is to co-design and implement new models of care to address the challenges facing our health and social care system. Proposals focus on the following priority areas:

• Preventing diabetic ill health, by shifting focus from treatment to prevention • Improving access to the highest quality primary, community and urgent care

services. • Improving the health outcomes of patients using mental health services, ensuring

services are operating efficiently. • Increasing our ability to care closer to home for frail older people, avoiding an • emergency admission to hospital.

Proposals for how the new system of integrated care will be governed will be provided for discussion by a future Board. These will include changing contracting and commissioning arrangements as well as mechanisms to support providers to work in Alliances to share resources, management and joint programmes of delivery.

4. New Models of Care – Progress

4.1 Care Closer to Patient’s Homes

From April 2017, the Trust will start to introduce new developments to the way care is delivered in the community as the first stage of its Care Closer to Home Strategy. These changes will be introduced following engagement on our community hubs programme undertaken in 2016/17.

We will double the number of outpatient appointments offered at some community hospitals, provide short term support packages to bridge the gap between home and hospital to over 3000 people and reduce hospital admissions, seeing 350 people through a new frailty assessment service as part of the changes.

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Specific changes include:-

• The launch of community hubs at Marlow and Thame Hospitals • Frailty assessment clinics to help frail older patients avoid a visit to Accident

and Emergency or a hospital admission. • Locality integrated teams including nurses, therapists and social workers

linking with GPs and practice nurses, will provide 24/7 cover to manage those patients identified as needing the greatest health and care support.

• Rapid response intermediate care. Therapists, care staff and community nurses will provide short-term packages of support in people’s own homes of up to six weeks to those who would benefit from a ‘jump start’ back to independence to those in need

• Community care coordinator. This will provide GPs, hospital clinicians and other health and social care staff with 24/7 phone and email ‘single point of access’ to organise specialist community services for their patients.

The service will be closely monitored over the next six months to assess the impact on patients and services and will inform the development of the wider community hub programme across Buckinghamshire. More details on the community hub pilots can be found at Appendix 1.

4.2 Urgent Care

The Board are aware that the Trust entered into a partnership arrangement with South Central Ambulance Services (SCAS) and neighbouring community providers to redesign NHS 111 and urgent care services in the community. All providers have been engaged in a redesign phase with commissioners to design the new service due to be operational from September 2017. The key elements of this redesign include:-

• Linking our community services to single points of access across Thames Valley to create synergies with other community providers and ease of access for patients into community services.

• An extended Directory of local services to manage demand into our A&E and wider system – improving access times and quality of care

• Providing more telephony and support for clinical triage from our clinicians as part of any new service - ensuring right care at the right time

• Link the skills of paramedics with our community services to avoid admission – reducing reliance on hospital care

The process culminated in a joint presentation to Commissioners, patients and stakeholders in March on the new model of care which the Trust were actively involved. The next stage will be to agree the resources and support required to deliver the model by with South Central Ambulance Service before contract agreement in May 2017 and mobilisation of the new service by September 2017. The Trust is working closely with FedBucks to remodel urgent care services in Wycombe linked to the Minor Injuries Unit and will develop proposals with primary care colleagues linked to the recent Government announcement of GPs in A&E for winter 2017.

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4.3 Diabetes

The Trust have been working with Commissioners and GPs in Buckinghamshire to remodel the way Diabetic care is managed. The focus has been to support GPs to manage more type 2 diabetic patients in the community to avoid unnecessary hospital appointments and reviews. A new pathway of care has been approved that includes:-

• Type 2 patients to be cared for in primary care • Complex Type 1 patients to be cared for in secondary care • Patients in ‘super 6’ category to remain in secondary care (antenatal, pump, foot,

young diabetic, renal, inpatient) Joint outcomes for diabetic patients have been defined including reductions in HbA1c, blood pressure and cholesterol, increased patient access to education and decreased referrals to hospital care. The service includes tailored education programmes and virtual (telephone) clinics to support primary care. The Trust have identified patient cohorts for 12 practices and virtual clinics in these practices have been initiated. Work will progress in 2017/18 on the contracting and commissioning model to support the new pathway so that more patients can be seen closer to home and resources are allocated to support the new model of care.

4.4 Musculo-skeletal services The Trust has been working to redesign musculo-skletal pathways with Care UK (who manage a MSK triage programme across Buckinghamshire) and other local providers to deliver a wholly integrated service. The aim of the work has been to reduce the number of appointments which patients have to attend, support demand management with GPs and reduce duplication and delays for patients by accessing the right service at the right time.

A patient engagement event has been held, and the proposal has also been presented to the GP’s Protected Learning Time (PLT) in both CCG areas. The service was well received by both groups and has provided valuable feedback to inform the design of the new service.

The service will begin to trial some new multi-disciplinary clinics as proof of concept, which can then be part a phased roll out of the new service. Other features of the service will include a care navigator, shared decision making tools and direct self-referral access for patients with long term conditions.

The Trust are working with Commissioners and providers on a commercial and revised contractual model to support the remodelled service which will be presented to the July Board.

5. Recommendations

The Board are asked to note:-

• The Buckinghamshire Joint Health and Well-Being Strategy 2016-2021

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• The intent of partners to accelerate integrated health and care in Buckinghamshire • Progress on new models of integrated care • Governance arrangements for how the new system of integrated care will be

managed will be provided for future Board discussion

David Williams Director of Strategy and Business Development March 2017

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Our vision for developing care closer to home:piloting community hubs

developing Buckinghamshire together

Every year, we make over 600,000 contacts of care outside of hospital. We are working with other parts of the NHS, Buckinghamshire County Council and local organisations to make health and care services safe, sustainable and able to meet the future needs of our local population. We want to do more to improve the care people receive and how they receive it. We have consistently heard from patients, GPs and community groups that people want their care delivered out of hospital and in local communities, and we have exciting plans to make this a reality. This booklet explains what we are doing and why.

Supporting you to stay well Through prevention and early-intervention we want to:

• Helpyoutotakegreatercontroloveryourcareandtreatment

• Ensurewemeetyourlong-termneedstohelpyoutostayindependent

• MakeiteasiertoaccesstherightservicesbyworkingmorecloselywithyourGP andotherproviderstojoin-upcareandsupport,reducingduplicationand makingbetteruseofnewtechnologies

Over the next year we will be investing over £1m to expand our community services, with an emphasis on older people and those with long-term conditions.

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What is happening now?We have joined up some services already so that it is easier for you to get the right care when you need it. For example:

• Our community nurses and therapists are available round the clock to help you stay at home or get home again quickly if you have been admitted to hospital. They can provide intravenous antibiotics (via a drip) or wound care at home and, when they visit, they have the technology to monitor your improvements, access the right support for you (such as ordering equipment) and review your clinical notes.

• If you have a long term condition (such as COPD or diabetes) our specialist nurses can support you to manage your own condition. They work closely with hospital consultants to keep you independent and at home should your condition worsen.

• If you need specialist stroke care our early supported discharge team will work to provide your therapy and nursing care at home so that you don’t need to stay in hospital for a long time.

• Rapidaccesstotesting

• Easiersignpostingtohealthandcare services–asinglepointofaccess

• Joinedupteamsacrossthesystem

• Fullrangeoftherapyservices

• Healthandwellbeingfunction, enhancingself-managementand providingeducation

• Asociablespacewithacafé

• Abasefromwhichskilledstaffcan workinthecommunity

• Moreoutpatientclinicslocally

• Virtualnetworksproviding informationforpatientssupported bytechnology

• Moreinformationsharedbetween organisationstoimprovepatient care

What you have told usOver the past year we have been talking to GPs, staff, patients, other health and social care organisations, voluntary organisations and local communities to understand what you want. You have told us that you want to avoid unnecessary travel, improve coordination between organisations and be given the support to manage your own health and wellbeing, and we have been developing plans to make this happen. We believe that community hubs – a focal point for health and wellbeing in local communities – could be part the solution. Some of the services you told us you would like to see include:

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Why do we need to change?There are three main influences that challenge the way health and care services are provided across the country. These have been outlined in local NHS plans and are supported in the Buckinghamshire, Oxfordshire and West Berkshire Sustainability and Transformation Plan published in late 2016:

1.Clinicalevidence: for many patients, there are better health outcomes if they can be treated at or close to home. For example, evidence shows that a healthy older person’s mobility could age by up to 10 years if they are bed bound for just 10 days

2. Patientfeedback: we have heard patients want to stay in their own homes, remain independent and part of the community, not be a burden to others, and continue with activities that give them meaning

3.Nationaldirection:the NHS Five Year Forward View outlines the long term future of the NHS. It seeks to close the:

• health and wellbeing gap, focusing on prevention

• care and quality gap, shifting the way care is delivered, reducing variation and making better use of technology

• finance and efficiency, closing the first two gaps will have a positive impact on this, but the NHS is also looking at investing in new ways of working to join-up care and help it become more productive.

Making this a reality: our plans for expanding out of hospital careTo best understand what will work for our communities, our clinicians want to test some of the ideas we heard before we finalise our plans. Some can be implemented now but others will take longer to develop.

From April 2017, we will start to introduce the following:

• Localityintegratedteams: we will bring together community and specialist nurses, therapists, social workers, GPs and relevant voluntary organisations. They will provide 24/7 cover to manage those patients identified as needing the greatest health and care support, typically those who have long term conditions. As a result patients will receive better, more coordinated care in their homes.

• Rapidresponseintermediatecare: therapists, care staff and community nurses, working as part of a locality integrated team, will provide short-term (up to six weeks) packages of support to those who would benefit from a ‘jump start’ back to independence. Available 8am – 9pm, seven days a week, these teams will support people to stay at home and avoid a hospital admission, and get people home more quickly from hospital to avoid transfer to a hospital bed. The team will visit as often as required and provide a range of support including rehabilitation or help with tasks such as washing, cooking or visiting the shops.

• Communitycarecoordinator: this will provide GPs, hospital clinicians and other health and social care staff with 24/7 phone and email ‘single point of access’ to organise specialist community services for their patients (including the rapid response intermediate care service). Making it easier to access community services will help to prevent admissions to hospital and avoid the delays to discharge that keep people in hospital for longer than they need to be.

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• Communityhubs: The hubs will provide a local base for community staff and will help patients to access prevention services (Live Well, Stay Well), primary care services (as appropriate) and hospital services (such as outpatient appointments, wound care or diagnostic testing) that people may have previously had to travel to.

Commencing first in Marlow and Thame, where we already have strong community health bases, we will be working closely with staff and local GPs to test these ideas for six months. We are planning to provide the following services in these hubs:

Frailtyassessmentclinics:GPs can refer patients to specialist clinics in the community to help frail older people to stay at home and avoid an A&E visit or hospital admission. The new one-stop same-day or next-day clinic, will be available 9am – 5pm, five days a week across Marlow and Thame. A multi-professional team of elderly care consultants, nurses, therapists, paramedics and GPs will provide expert assessments, undertake tests and agree a treatment plan with patients. If required they can refer patients to the right community or hospital team to provide on-going support or treatment. These clinics are already available at Stoke Mandeville and Wycombe hospitals, and their introduction in Thame and Marlow will reduce the need for patients to travel for support.

Outpatientclinics: Five more clinical specialties – palliative care, orthopaedics, care of the elderly, falls and oral surgery - will offer outpatient clinics in the community. We aim to further increase the number of outpatient clinics and specialities over the pilot period, with a focus on supporting people with long term conditions.

Voluntarysectorandsignposting: We are working with Prevention Matters, Carers Bucks and the Citizen Advice Bureau to offer a range of advice, support and signposting services in the first step of creating a single point of access to health and care services for the public. Carers Bucks will help carers access additional support such as benefits advice, practical and emotional learning, and emergency planning. Prevention Matters will support people to regain confidence and independence by finding suitable social activities and community services in their area.

GPisconcernedthatMrJacksisbecomingmorefrailandseemslessabletocope

Previously – the GP is concerned but can’t pinpoint anything specific that needs treating. He’s worried that Mr Jacks might need longer term care, possibly in a home and so sends him to hospital where he stays several weeks before transferring to a care home.

Now – the GP calls the community care coordinator and talks to the community matron, part of the locally integrated team. The nurse will visit and assess Mr Jacks, as well as talk to him about his life. She will then be able to talk to other members of the team, including social care, frailty assessment, intermediate care etc to put in place a variety of support that enables him to maintain his independence maybe some help with meals, someone to help with cleaning and some companionship.

Outcome– Mr Jacks’ health does not deteriorate. His care is organised and structured around his needs and he remains at home.

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Our clinicians believe that significantly expanding the support available to people in the community will help to maintain a person’s health and independence, which would otherwise deteriorate if admitted to hospital for a length of time. In particular, by introducing a rapid response service and specialist frailty assessment clinics in the community, we will reduce the need for bedded care in hospital. During the pilot our clinicians will not use the inpatient wards at Marlow and Thame hospitals, as these are our smallest inpatient units (12 and 8 beds respectively). Instead the space will be used to run the new frailty assessment clinics. On the rare occasion that a patient may need additional overnight support, which cannot be provided by the locality integrated teams, local transitional care home beds and overnight packages of care (night-sitting support for people in their own homes) will be available to our clinicians.

Over the next six months we will:

- double the number of outpatient appointments offered at Marlow and Thame

- see 350 patients through the one-stop frailty assessment clinic

- provide intermediate care to over 3000 people

- avoid almost 300 hospital admissions

- manage almost 20,000 referrals through the community care coordinator

MrsSmithisnotfeelingwellandhasbecomemoreforgetfulthannormal

Previously - Mrs Smith attends A&E and is admitted to hospital where she has a raft of tests and gets progressively more forgetful and weak.

Now– her GP sends her to thecommunityhub for a frailtyassessment. The geri-atrician, nurse and therapist do a full assessment as well as taking bloods (and use their point of care testing machine to get the result immediately). They diagnose a urine infection and so give Mrs S some antibiotics into a vein over six hours.

Outcome– Mrs Smith does not go to A&E. She is treated at the community hub and is able to go home later. She has follow-up visits at her house for a couple of days.

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How will we monitor the pilot?We are piloting these ideas to give us a better understanding of what works for these two communities. We will monitor how well things work - responding and adapting quickly if we are not demonstrating improvements for our patients and communities – and use our learning to inform our final plans.

We will look at how well things are working on a daily basis including how many people we have helped to stay independent and not admitted to hospital, and the patient experience of the new services. Our medical director and chief nurse will oversee this pilot to make sure the quality and safety of our care to patients and staff is maintained.

During the six month pilot we will also continue discussions with our staff, GPs, social care, other health and care providers, patients and the public in order to learn from their experiences of these new services and to further develop care in the community.

We will take this learning and have similar discussions in other communities across the county so that by the end of the pilot we have a clear proposal about how we wish to provide more care in the community in the future.

MrsJohnsonhasafallandistakenbyambulancetoA&E

Previously– Mrs Johnson is admitted to hospital, spends several days as in inpa tient and loses her confidence to be at home by herself. Social care is involved and it takes several weeks to arrange suitable alternative care accommodation.

Now– the rapid response intermediate care team have staff in A&E so Mrs Johnson can go home. They arrange for a member of the team to visit her at home later that day to organise her care whilst she gets over the fall and gets her confidence back.

Outcome– Mrs Johnson is able to return home and recover much more quickly. With a short-term package of support in place she maintains her confidence and independence.

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Where can I find out more?Visitwww.buckshealthcare.nhs.uk/communityhubs

If you want to get involved, have any questions or wish to feedback on these plans you can contact us on:

Email: community.hubs@buckshealthcare.nhs.uk Phone: 01494 734959

developing Buckinghamshire together