A collaboration to develop and deliver a blueprint

A collaboration to develop and deliver a blueprint for a sustainable health care system for West Kent The Blueprint September 2013

About this Blueprint • This Blueprint provides an outline of how comprehensive healthcare services for physical and mental health for all age groups and its interactions with social care could be configured in West Kent in the future to maintain and improve patient experience and clinical outcomes while demand for care increases despite increasingly tight budgetary constraints • This Blueprint is a model for how services should be configured regardless of the organisations involved of its delivery • This Blueprint has been designed based on input by a broad base of stakeholders that included representatives of all local providers, commissioners, patients and the general public of West Kent 2

Contents • The Challenge • The Mapping the Future Process • Blueprint Principles 3

Hi Annie, A letter from the present . Sorry I missed our lunch yesterday. I had yet another doctors appointment. Between my epilepsy, diabetes and depression, I have endless numbers of appointments at different places. And usually I have to go through my whole story again and again – and it seems that the doctors and nurses in the different clinics do not talk with each other. I have to update the one doctor about what was said and done at the other’s clinic. Especially for my depression, it seems the mental health team and other doctors do not connect well. You would need a degree to figure out my medicines – which ones to take and when. And then one doctor prescribes something new, which then could cause problems with other pills. My GP is reluctant to change any medication because she is worried it may somehow interfere with my epilepsy medications. Ah, I am so frustrated. It seems all I do in my life is to look after my illnesses. Sometimes I wonder if all of these appointments are really necessary. There must be a better way. I feel overwhelmed and out of control of what is going on with me. Two weeks ago, I had another one of my chest infections and I found it hard to breathe at times. So I called the NHS when I felt poorly – and before you know it, I found myself in A&E (which was totally packed with people) and after several hours there, I got admitted. Could I not have been looked after at home? I don’t know – all the doctors and nurses and everyone are nice, seem interested in my problems, and all are very obviously working very hard, all are in a rush – and yet, it seems my care is getting worse, ever more fragmented, ever more rushed. I am less and less confident that I really get all the care that I need. How do I know? I am not a doctor. Will this get worse? The papers are full of stories about poor NHS care and government is running out of money. So will they have to shut down some services? Will fewer staff get ever more run off their feet? I live in West Kent and I heard that the people who are responsible for making sure we all get the care we need (They are called CCG) have started to really look in detail how to do things differently. The programme is called Mapping the Future. I was invited to one of their events. Really curious. . Fingers crossed they will get it right. Take care and see you soon 4

Demand keeps rising – resources stay flat West Kent CCG budget, £M, Nominal figures, Flat cash scenario 550 545 CAGR 2013/14 -2018/19: 2. 3% 530 Commissioner’s funding gap is £ 58 m in 2018/19 520 510 500 490 487 480 470 460 450 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 CCG estimate for West Kent Income (allocation) CCG estimate for West Kent Expenditure (funding pressure) Source: Nuffield Trust, 2012; West Kent CCG budgets 2011/12, Feb 2013; NHS, Kent County Council population estimates Note: England population estimate 53 m in 2012/13 growing to 55 m in 2017/18; West Kent population estimate 0. 466 m in 2012/13 growing to 0. 49 m in 2017/18 § These are nominal figures, i. e. , inflation has not been excluded § Providers have to make further efficiencies to cover pay and prices 5

West Kent’s rate of A&E attendances is about average within its peer group A&E attendance rates per 1, 000 population for West Kent CCG against ONS peers While West Kent CCG performs strongly compared to national and SHA average, its performance versus ONS peers does not suggest that improvement opportunities have been exhausted Source: NHS Comparators 12/13 (rolling annual up to Q 2) Note: West Kent CCG has been compared against groups in ‘Prospering Southern England’ 6

West Kent’s emergency admissions rate is higher than its peers Emergency admission rates per 1, 000 population for West Kent CCG against ONS peers While West Kent CCG performs strongly compared to national and SHA average, its performance versus ONS peers does not suggest that improvement opportunities have been exhausted Source: NHS Comparators 12/13 (rolling annual up to Q 2) Note: West Kent CCG has been compared against groups in ‘Prospering Southern England’ 7

Especially emergency admissions in General Medicine have risen strongly Rolling-annual Emergency Admissions at West Kent CCG for General Medicine (Apr 09 – Mar 10=100) Substantial reductions in Length of Stay were achieved Source: SUS (Apr 09 – Nov 12) Note: Patients with LOS over a year have been excluded 8

Elective care activity in West Kent keeps going up Rolling-annual DC, ELIP and OP activity at West Kent (Apr 09 – Mar 10=100) Pembury opens Sep 2011 147 124 115 Source: SUS (Apr 09 – Nov 12) Note: Patients with LOS over a year have been excluded 9

Doing more of the same better, faster will not be enough ‘Scissors of Doom’ ✓ Costs Funding ✗ 10

Contents • The Challenge • The Mapping the Future Process • Blueprint Principles 11

Mapping the Future describes what future services should look like to help us make consistent decisions Without an agreed vision of the future, decisions about individual services may be in conflict Mapping the Future develops a Blueprint that guides strategies of individual services 12

The MTF programme is built on a broad base of involving patients, the and providers • There have beenpublic four events for patientall representatives, clinicians, health and care • • • professionals and managers covering around four clinical topics as exemplars for how systems could be reorganised – Falls and mobility – Dementia and cognitive impairment – Urgent and emergency care – Respiratory diseases Participants considered why services need to change and evidence about what types of services have been developed elsewhere They used this and their experience and judgement to describe the characteristics of the future health and care system They looked at the whole spectrum of health from prevention through to recovery and at where services and support might be best provided The outputs from the four workshops were analysed individually – there were many common themes. These were developed into a composite ‘first draft’ Mapping the Future picture which was discussed at a fifth workshop on the 24 th June The Blueprint was also discussed at a 2 -day People’s Forum in early September 13

The Blueprint went through several iterations. . . 13 May 21 May - 7 June – End June Early July 14

. . . And was thoroughly tested with all stakeholders 8 -12 July summer early September late September on going 15

This programme is founded on a broad base of participation Participating Organisations • Members of the public • Patient Forum • Patient Participation Groups from several GP practices • Age UK • Carers First • Meritium Independent Living • Alzheimer’s Society • Lucy Care Homes • Crossroads • White Gate Design • Public Engagement Agency • Local GPs • Maidstone and Tunbridge Well NHS Trust • Kent Community Health NHS Trust • Kent Mental Health Partnership NHS Trust • Southeast Coast Ambulance Service • Health and Wellbeing Board • Kent County Council • NHS England Local Area Team • NHS West Kent CCG In total over 200 individuals participated in the Mapping Events and public engagement 16

Contents • The Challenge • The Mapping the Future Process • Blueprint Principles 17

Mapping the Future: underlying principles Pressures on • 4% annual growth in demand for care West Kent • No additional funds to cover increase in demand – very likely additional pressures on available funds (e. g. , social care budget) • Many other “boxes to tick” for provider organisations (e. g. , FT applications) • Failure of securing viability would result in take-overs, rationing and worse quality Foundation for our sustainable West Kent • West Kent will have a clear and credible plan of services that is shared and supported by commissioners and all providers and brings the best outcomes for local people • The whole approach to health and care has to change – piecemeal changes focusing on individual services and conditions will not be sufficient • Changes must be clinician-led and involve patients and the wider public • West Kent can learn from evidence of what was tried and what worked from elsewhere and develop our own solution to fit our population and geography • Instead of small pilots, West Kent will take some risk, accept that some things may not and be adept at learning and adapting quickly 18

The outcomes we should aim for § Consistent, high quality health and social care services that are interconnected and available round the clock § A system that offers the most effective and efficient care so that people get the right care in the right place by professionals with the right skills the first time § Proactive care which aims to prevent people from developing illnesses and limiting the severity of their conditions § Individuals and carers are active partners in their care, receiving personalised and coordinated services and support § Care is organised in a way that enables people to be as independent as possible and to only visit hospital when it is absolutely essential § Health and care services that are efficient in the way they use resources 19

Open Questions for the Blueprint Health and Wellbeing Self and Informal Care New Primary Care Mobile Clinical Services Urgent Transfer New Secondary Care System Enablers § Who sets priorities for system-wide programmes (top level governance)? § How best can the contributions of third sector organisations to health improvement be harnessed and who should lead this? § Should there be incentives for patients for the willingness to take on greater responsibility oneself? § How should integration with Social Services work? What parts of Social Services should be within NPC, e. g. , only free or also means-tested? § Are community care centres (incl. community hospitals) required (at what capacity), or should mainly GP practices used as infrastructure? § Does this imply a consolidation of all rapid response services into one? Right now, several services provide some level of MCS: GP home visits, Community rapid response teams, OOH cars, ambulance paramedics, mental health rapid response teams § How will the necessary changes in protocols be agreed between commissioners, ambulance service , new primary care and new secondary care? Does the organisation have the flexibility to respond to West Kent’s specific needs? § How do we ensure Blueprint improvement levers are compatible with provider plurality and do not reduce positive effects of choice and competition? § What technology implications are there for outreaching into community settings? § How should clinical governance be changed to underpin the respective roles and linkages between primary and secondary care (physical and mental health) § How do we ensure integrated commissioning arrangements are clear and robust? § What funding mechanisms (e. g. , Year of Care) will be deployed for Blueprint? § How far will information sharing protocols o in securing flows of patient information between providers? 20 § How would any cross organisational investment in information systems be handled?

Blueprint for Physical and Mental Healthcare HEALTH AND WELLBEING SYSTEM ENABLERS NEW SECONDARY CARE URGENT TRANSFER SERVICE TERTIARY SERVICES MOBILE CLINICAL SERVICE NEW PRIMARY CARE GP Practices Community services MENTAL HEALTH CARE SELF AND INFORMAL CARE OOH Social care Expert patients Pharmacies Patient information System capacity and performance information 21

Health and Wellbeing The Blueprint § Whole system approach with campaigns on alcohol, smoking and obesity § Communities and individuals with capacity to support themselves and each other § All levers used to tackle health determinants – e. g. , Health education, environmental health, housing eligibility and maintenance, trading standards, standards and specifications of health and social care contracts Self and Informal Care § People are supported to take responsibility for their health and care § People fully informed and take part in discussions about future plans § People are supported to stay independent and at home for as long as possible § Local communities and voluntary organisations are encouraged to provide support New Primary Care § GP practices, community services, OOH, social work and mental health as integrated team that can respond round the clock, easily accessible, seamless service § Some services brought into community (e. g. , diagnostics) § Pro-active care and prevention Mobile Clinical Services § Helpline for advice to patients and carers, supported by GPs and well supervised , aware of all available services real-time § Paramedics provide care to people at the point where they become ill, as part of integrated team with same similar pathways and protocols and access to information Urgent Transfer New Secondary Care System Enablers § Transfer patients with urgent care needs to best setting, not necessarily only to A%E § Provide a range of treatments and diagnostic tests to patients on the way § More use is made of transport services by voluntary and community organisations § Urgent and planned care managed as separate entities for optimum efficiency § Some services concentrated in larger centres § Urgent care as part of a total system connected with NPC and Mobile Services § Clear agreements between NPC and specialists about their responsibilities and risks § Access to shared medical records and care plans for all care professionals anywhere § Improved communications and relationships between all care professionals § Risk management across the system contribute to more efficient and effective care (financial risk and clinical governance) 22 § Financial and contractual levers aligned