Buckinghamshire Integrated Care System · Our Challenges Health and Wellbeing – Variation in...
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Buckinghamshire Integrated Care System (BCCG Ops Plan integrated within) Operational Plan 2019-20
Transcript of Buckinghamshire Integrated Care System · Our Challenges Health and Wellbeing – Variation in...
Buckinghamshire Integrated Care System (BCCG Ops Plan integrated within)
Operational Plan
2019-20
ICS Operations Plan Commitment and Signature Approval
Date of Commitment and Agreement:
Signed ________________________________
Neil Macdonald
Chief Executive, Buckinghamshire Healthcare NHS Trust
Signed ________________________________
Rachel Shimmin
Chief Executive, Buckinghamshire County Council
Signed ________________________________
Stuart Bell
Chief Executive, Oxford Health NHS Foundation Trust
Signed ________________________________
Louise Patten
Chief Executive, Buckinghamshire Clinical Commissioning Group
Signed ________________________________
Laks Khangura
Chief Executive, FedBucks
Signed ________________________________
Will Hancock
Chief Executive, South Central Ambulance Service NHS Trust
Contents
SECTION 1
Introduction and Overview
3
SECTION 2
System Transformation
8
SECTION 3
Population Health and Prevention Portfolio
14
SECTION 4
Access, Care and Efficiency Portfolio
19
SECTION 5
Accident and Emergency Delivery Board
27
SECTION 6
Integrated Care Portfolio
31
SECTION 7
Mental Health Delivery Board
35
SECTION 8
Professional Support Services
39
SECTION 9
Digital Transformation Delivery Board
50
SECTION 10
Finances
54
SECTION 11
Closing Summary
66
Section 1 Introduction and Overview
Introduction
The Buckinghamshire Integrated Care System vision is
‘Everyone working together so that the people of
Buckinghamshire have happy and healthier lives’
The purpose of this plan is to set out how we plan on
tackling the challenges facing our local health and care
economy as we continue to develop our Integrated
Care System. We will start by outlining our starting
point and our ambitions. The plan is more than a
strategic statement as it will provide direction to the
system and the key deliverables and milestones
expected within 19/20.
We understand the financial and operational
challenges we face and we commit to work
collaboratively as a system to address these
challenges head on. In addition, this plan focuses on
transforming the system to ensure we provide a high
quality service.
Our plan is to ensure efficient use of the
Buckinghamshire £ and continue to meet the needs of
the population. This Plan is an integration of the ICS
and Buckinghamshire CCG Operations Plans.
The strategic focus of this plan will be around our
system transformation, governance, structure, and
organisational development .
The operational focus of this plan will be around on
finance, performance and quality. There will be
particular focus on how we will manage our
performance with clear actions outlined that will be
taken locally to support the wider effort to drive
improved performance and quality.
Strategic Priorities
ICS Vision, Objectives, Core Pillars & Enablers
Vision
Everyone working together so that the people of Buckinghamshire have happy and healthier lives
Objectives
Professional
Support
Services
Woirkstreams
A&E Delivery
Board
Access, Care &
Efficiency
Portfolio
Integrated Care
Portfolio
Population
Health and
Prevention
Portfolio
System
Assurance
Board
Develop the ICS
supporting infrastructure to
deliver better value for
money and reduce
duplication
Develop a resilient
Integrated Care System
that meets the on the day
need of patients consistent
with constitutional
requirements.
Progress a whole system
approach to transforming
health and care to deliver
resilience, better patient
outcomes, experience and
efficiency
Deliver the ICS Financial
Control Total and required
System Efficiencies
Redesign care pathways
to improve patient
experience, clinical
outcomes and make the
best use of clinical and
digital resources
Core Pillars Enablers
People supported to live independently
Care integrated locally to provide better
support closer to home
Improved urgent and emergency care
services
Improved resilience in primary care services
Reduced unwarranted variations in quality
and efficiency of planned care
Improved outcomes for people suffering
mental health illness
Improved survival rates for cancer
Digital transformation implementing IT
platforms that support integrated care
Long term operational and financial
sustainability
Mental Health
Delivery Board
Our Challenges Health and Wellbeing – Variation in health and wellbeing outcomes for different people across Buckinghamshire Care and Quality – Difference in the quality of care received by people across our area and inconsistencies in reaching national standards Finance and Efficiency – Increasing pressure on resources within the system – annual financial gap of c. £50m within the Buckinghamshire health and care system
Our programmes and priorities
Population Health Mgmt – will help people to stay healthy and avoid getting unwell through: • Tackling wider determinants of health • Upgrading primary prevention • Extending secondary prevention • Supporting people to live independently Integrated Primary & Community Services – will support individuals who are unwell by providing care at home or in the community through: • Integrating health and social care • Developing Community Health Care
Centre’s • Ensuring sustainable Primary Care
Networks • Improve/Enhance Urgent Care • Transforming Mental Health and Learning
Disability Services Access, Care & Efficiency (ACE) – will ensure the right access, with the right care and intervention, at the right time through: • Delivering cancer transformation priorities
and sustaining cancer performance • Optimising medicines (clinical , cost
effectiveness & safety) • Improving maternity services • Elective Care transformation Urgent & Emergency Care – will implement the non elective demand management programme • Delivering the 7 UEC domains • Winter planning will lead system resilience
and planning (including winter) • Roll out demand and capacity model and
system capability
Underpinned by our enabling programmes
Leading and Working Differently – focuses on giving the health and care workforce the skills and expertise needed to deliver new models of care. Programmes include: • Working differently • New ways of delivery • Single Leadership Digitally-Enabled System - Increasing the use of technology in the health and care system to support new approaches to service delivery • Shared care record • Intelligent working • Independent self care • Continuing digital operations • Enabling technologies
Professional Support Services– supports the ICS transformation and delivery by: • Designing & implementing a system
delivery framework designed as a bespoke P3 model to support programme management and managing the Verto Pro tool
• Providing grip & control and assurance • Providing support , guidance & advice to
the ICS Programme Delivery Boards. • Development of Corporate Governance • One Public Estate • System I|Infomatics supporting data and
value driven decision making
And overseen through Programme Delivery Boards – Accountable to ICS Implementation Board and responsible for delivering the programmes of work within the portfolio: • Defining and prioritising transformation
in line with ICS Ops plan. • Driving and delivering robust planning
including financial recovery • Managing strategic risk, issues &
resources • Oversight & focus on continuous
improvement Implementation Board - Established to implement and develop integrated health and care services across the partners in the Buckinghamshire system. In addition it will drive the delivery and performance of the integrated care system in Buckinghamshire. The Partnership Board – Accountable to H&WB. Chief Execs are representatives of their organisations and will be responsible for ensuring that appropriate governance arrangements are in place to seek full Governing Body/Boards/Bucks CC/Cabinet support for any key system-wide decisions. The Board provide s support and challenge to the ICS Executive Group. The Health and Wellbeing Board (H&WB) will provide oversight and guidance as required.
Will achieve the following Outcomes
Health and Wellbeing • Helping more children and young people
grow, develop and achieve • Stay healthier for longer, leading to fewer
people classified as overweight or obese, smoking, and drinking alcohol
• Taking control over own care Care and Quality • Equal standard of care • Improved health and care outcomes • Improved access to services 7 days a week • More joined up care • More opportunities to be cared for closer to
home • Improved patient experience Finance and Efficiency • Closing the financial gap • Improve efficiency and productivity • Reduced waiting times • Reduced ED attendances • Reduced ED admissions • Reduced length of stay • Increase in efficiency of services • The right workforce to meet our future care
needs
Plan on a Page
Develop Integrated Care System
ICS Strategic Framework developed
ICS Delivery Plan developed
Single Accountability and Assurance Framework
MOU with constituent organisations agreed and signed
Implementation Board driving delivery and performance
Design/Solution Group stood up for ICP development
Designate Corporate Functions (Finance/PMO/BI)
Quality and Safety will be improved through digital
transformation; enablement of continuity of care and through
proactive case management
Resource sustainability will be realised by more proactive
community based care, increased productivity, and new care
models
Deliver safe, effective, high quality care
A&E 4 hour
Referral to Treatment Incomplete Pathways
Diagnostic Test Waiting Times
Cancer Waits – 2 weeks; 31 days; 62 days
People with first episode of Psychosis starting treatment within
2 weeks of referral;
IAPT Waiting Times
Delayed Transfers of Care
Proportion of older people (65 and older) who were still at
homes 91 days
Admissions to residential and care homes
Patient experience will be improved by joining up care and
designing services with local people to better meet the needs of
individuals
Ensure a long term operational and financially
sustainable system
Establish a Single Control Total
Single efficiency and investment plan
Estates (One Public Estate) Strategy
Resources allocated to prevention and early intervention
Resources allocated to primary and community care
Employees who feel they have access to appropriate training and
development opportunities
Employees recommending Buckinghamshire as a good place to
work
Preventive measures, and improvements to out of hospital services
for people with complex needs will improve patient outcomes
Improve population health and wellbeing
Prevention Strategy
New Model of Care
Health and Wellbeing Improvement Priorities
Life expectancy at birth
Infant mortality
Emergency hospital admissions for intentional self-harm
Health-related quality of life for people with long-term physical and
mental health conditions
Preventive measures, and improvements to out of hospital
services for people with complex needs will improve patient
outcomes
Your community, Your care : Developing Buckinghamshire Together
How we ensure deliver of our plan on a page….
Strategic Priorities, Benefits & Metrics….
Develop the ICS
supporting infrastructure to
deliver better value for
money and reduce
duplication
Develop a resilient
Integrated Care System
that meets the on the day
need of patients consistent
with constitutional
requirements.
Progress a whole system
approach to transforming
health and care to deliver
resilience, better patient
outcomes, experience and
efficiency
Deliver the ICS Financial
Control Total and required
System Efficiencies
Redesign care pathways
to improve patient
experience, clinical
outcomes and make the
best use of clinical and
digital resources
• Greater resilience and
capacity within the
primary care sector
• Development of new
models of care which
are more integrated and
delivered closer to
patients’ homes
• Patients being seen in
the most appropriate
setting
• Services located where
they are needed which
provides care in a
timely manner
• Patients to receive
more of their care
closer to home
• Greater reliance on
technology to free up
clinical time for more
complex tasks
• Services provided at a
lower cost to the
residents.
• Increased public and
patient involvement and
understanding
• New ways of working
together to resolve
issues
• New payment
mechanisms
• Clear investment
programmes based on
objectives
• Improved decision
making to support
health
• A system that is
delivering financial
recovery
• Access to GP services
including evenings and
weekends for 100% of
population
• Proportion of practices
care planning through
integrated teams
• 4 hour A&E standard
performance against
agreed trajectory
• Reduced growth in A&E
attendances
• Reduced growth in NEL
admissions
• DTOC performance
• NEL and EL
admissions per 100k
• ALOS (MH, Community
and Acute)
• Aggregate £ savings
from projects
• Patient experience
measure (to be defined)
• Patient outcome
measures (to be
defined)
• Reduction of out of area
placements
• Presence of an OD plan
• Workforce bundle
metrics (TBC)
• Presence of a 3 year
‘roadmap’ that delivers
the KPIs
• Presence of a PHM
blueprint
• New contract form
agreed and in place
• Presence of an
OD/workforce plan
• BHT CT performance
• System CT
performance
• Agreed financial
strategy in place for
19/20 and 20/21
• Successful system
efficiency programme
• System control total
met
Pri
ori
ties
Prio
rities B
enefits
Metrics an
d O
utco
mes
Ben
efit
s M
etri
cs a
nd
Ou
tco
mes
Section 2 System Demographics and
Challenges
Population and Demographics – Case for change: Inequalities
People in Buckinghamshire are generally healthier than the England
average. Buckinghamshire is one of the 20% least deprived
counties/unitary authorities in England.
The age profile of the Buckinghamshire population differs from that of
England. Bucks has smaller proportions of children aged 5-14 years and
young adults 20 -34 years, and it has a larger proportion of adults aged 40
to 59.
Based on a three-year average for 2014-16, life expectancy at birth for both
men (81.9 years) and women (84.9 years) in Buckinghamshire was higher
than in England (79.5 and 83.1 respectively). However, the gap between
life expectancy in the least- and most-deprived fifths of the population is 4.7
years for women and 5.2 years for men.
The infant mortality rate in Buckinghamshire in 2015-17 was 4.1 per 1,000
live births which was similar to the England average of 3.9 per 1,000. In
Buckinghamshire, 11% of children live in low income families
Unhealthy lifestyles present a major challenge for the population. In 2016/17, 27.2% of Year 6 children (corresponding to 1,384
children) and 57.8% of adults (approximately 239,000 adults) were either overweight or obese.
The prevalence of smoking among adults in Buckinghamshire who were manual workers was reported as 17.5% in 2017
(compared to the average prevalence for all adults in Buckinghamshire of 9.6%). In Buckinghamshire, 1 in 5 adults are drinking
at levels that lead to an increased risk of cancer, high blood pressure and other conditions.
Compared to women in Buckinghamshire, the rates for under-75 mortality are higher for men for all cause mortality,
cardiovascular-related mortality and cancer-related mortality. The rates for under-75 mortality for cardiovascular and cancer are
significantly higher for the most deprived compared to the least deprived.
Hospital stays for self-harm in Buckinghamshire are better than the England average but are higher for women compared to men.
Demographic change on services
The Buckinghamshire predicted population growth will impact significantly on the demand for health and social care within the county and
therefore it is essential that we work as a system to address the challenges which we face.
In the time period 2018 to 2033 we will see a significant increase in the older population with the 65 plus population increasing by 40% (an
extra 41,000 people) and the 80 plus population by 70% to 50,000 (an extra 20,500 people).
In the same time period the number of young adults 18-20’s will increase by 14% (an extra 2,100 people) and the number of children will
increase by 9% (an extra 10,500). The BME population is expected to increase by 43,000 over 20 year period (2011-2031) to 20% of
overall population.
There is expected to be a four fold increase in number of Buckinghamshire residents living in most deprived areas in the county with the
population increasing from 113,000 in 2015 by 21,000 over the next 15 years to a total of 134,000 people in 2031 (23% of total
population)
Health Challenges
Childhood obesity is similar to
the England average at
reception and year 6 but widely
varies within the county.
Higher
number of
children
aged 5-19
and adults
aged 40-64.
Wide variations
in the
percentage on
limiting long term
illness or
disability by
ward for whole
of BOB (Bucks,
Oxford and West
Berkshire) STP.
Among all wards
in the worst BOB
quintile, 12
wards are in
Bucks.
Low birth weight is
similar to the
England average.
Life expectancy at birth in
most deprived population
quintile is lower than in the
least deprived population
quintile and the gap between
the least and most deprived
quintiles is widening among
both males and females.
Premature births
are similar to the
England average
but are increasing.
Prevalence of
most major long
term conditions
are comparable
with South East
and England
averages except
CKD (Chronic
Kidney Disease)
and depression,
which are lower.
.
Hypertension is
lower than the
England
averages both
for observed
and expected
prevalence.
Totally (exclusively)
breast fed babies rate is
significantly lower
among babies born to
mothers in most
deprived quintiles
compared to least
deprived.
. The population of
Buckinghamshire
is characterised
by the following:
1 in 5 adults
are physically
inactive
2 in 3 adults are
overweight or
obese
1 in 8 adults are at
risk of developing
diabetes
1 in 9 adults
smoke
System, Financial, and Care and Quality Challenges and Lessons Learnt in 18/19
System Challenges
• Difficulty in moving away from the focus on individual organisations into system
thinking and focus on places and populations
• Tension in regard to system objectives and organisational accountabilities and
statutory requirements and concerns. This leads to organisation protectionism.
• Developing and embedding a shared narrative with a shared vision and purpose
and shift from a reactive minds-et to a proactive vision
• Building of understanding and rapport and appreciation of each others challenges
• Ability to recognise conflicts, work through them and create and environment that
makes it safe to challenge
• Ability to move away from a competitive approach and focus on a bigger strategic
picture and system issues
• Lack of investment in time and resource to build system transformation on back of
other system pressures such as finance and performance
System Lessons learnt:
• Don’t underestimate the challenge ahead; integrated care requires a new way of
working and system thinking. Must have an agreed strategy upfront to include
priorities
• It’s not easy, system must be resilient and ready to work collaboratively; cant
underestimate the requirement for strong relationships and partnerships
• Integrated Care is not responsible for delivering care but for getting organisations
to work collaboratively by integrating the planning and commissioning od care in a
local geographic area.
• Difficult decisions and conversations are required. We may have to stop or change
the way we are providing health and care – need to move to asset based
discussions focussed on resilience and self-reliance and empowering people to
take
• System must fully understand the significant role played by Population Health and
Digital Transformation is changing the way we operate; We must understand our
population and the communities they live in and the significant impact digital
transformation can fundamentally support and change our service offer -
streamlining the patient journey and putting their health in care
• It must not be under estimated that the integrated care system is about building
relationships and trust at all levels and ensuring we are person centered, resilient
and persistent.
• records into one accessible data warehouse pulled using one digital system
Financial Lessons Learnt:
• Ensure there is transparency and open book approach by all parties
• Embed transparency and clarity in financial reporting
• Investment in transformation – not everything has a return on investment
• Move away from QIPPs and CIPs to system efficiencies and how to take costs out
of the system
• Remove duplication
• Agree the narrative and be consistent with regulators and each other and all staff
• Financial recovery may take longer than one year – may be a multi-year financial
plan.
• Maximise PSF/ CSF – we learned the hard way!
Care and Quality Challenges:
• Variation in quality of care
• Standards achieved not meeting national targets
• Shortage of key workforce groups
• Emergency admissions from babies aged 0-13 days (inclusive) are significantly
higher than England average
• Proportion of NHS health checks given to eligible population is below national
target of 50%
• Childhood immunisation update is below the national target of 95% among
children aged 2 and 5 years.
• Proportion of annual health checks among eligible people with learning disabilities
was significantly lower in 2014/15 and 2015/16 but increased in 2016/17 making it
just comparable with England average
• Emergency hospital admissions for falls injuries among people aged 65 years and
above has increased since 2010/11.
• Uptake rates for cervical cancer screening is lower than the national target and it
varies widely within Buckinghamshire.
Performance Challenges
The construction of our provider contracts ensures that we improve our position on NHS Constitution standards .
Processes to improve the achievement of the standards have been implemented and significant progress has been made and will continue
against the following standards:
Cancer Performance
RTT Performance
A&E 4 Hour Wait
Performance
Ambulance Response
Times Performance
The ICS remains committed to maintain and improve performance against these core standards utilising transformation of services to
achieve this.
There are currently specific performance challenges in relation to:
Delayed Transfer of
Care
Continuing Healthcare
Assessments
Dementia Diagnosis
Rates
Mixed Sex Accommodation
Learning Disability
Health Checks
Mental Health Care
Programme Approach –
Risk Assessment
Mental Health Care
Programme Approach –
Crisis Mental Health
Out of Area Placements
Bed Occupancy
Length of Stay
Section 3 System Transformation
System Transformation Narrative
The ICS has established a system transformation and delivery programme through which system transformation plans and strategies have been formalised
and operationalised. The programmes of work have:
• Be designed collaboratively, with all system partners, to transform the way we deliver care to the benefit of the system population, enabling the delivery of
local and national priorities, whilst maintaining a strong focus on clinical leadership.
• Address the MOU with NHS E and guide the system as it continues towards becoming a fully integrated care system.
• Integrate and work collaboratively across the system to ensure successful delivery.
• Have a clear set of objectives, deliverables, milestones, outcomes & benefits and risks & issues.
Each programme has a steering group that will report monthly into the programme delivery board. Each board has a managerial and clinical leadership with
members representative of all partners across the system as relevant. The Portfolio SRO reports monthly into the ICS Implementation Board. The System
has established a system PMO to support and monitor outcomes and benefits, deliverables, risks and issues. The ICS Portfolio Office reports to the ICS
Managing Director and supports management and reporting/monitoring of the ICS Implementation Board and Partnership Board.
Key principles that underpin our transformation:
• Priority to strengthening relationships and trust between system partners; fundamental to our success
• Driven by data and evidence; Population risk stratification and segmentation to drive our efforts and capacity to the right place and time
• Supported by new ways of contracting/commissioning; aligning with the STP and commissioning at scale (Strategic and Tactical)
• Driven by strong clinical & system leadership; emphasis on collective & distributed leadership that have dedicated time to fulfil ICS roles
• Representative of all geographies and stakeholders including voluntary sector and residents; better engagement means better outcomes
• Open and transparent with agreed system control total and efficiencies as needed; working together to solve financial challenges
• Aligned and collaborative decision making with streamlined governance that is not hindered by statutory requirements
• Share the risk and benefits as a whole – agree investment of efficiencies as a system
Strategic Priorities
Develop the ICS supporting
infrastructure to deliver better
value for money and reduce
duplication
Develop a resilient Integrated
Care System that meets the on
the day need of patients
consistent with constitutional
requirements.
Progress a whole system
approach to transforming health
and care to deliver resilience,
better patient outcomes,
experience and efficiency
Deliver the ICS Financial Control
Total and required System
Efficiencies
Redesign care pathways to
improve patient experience,
clinical outcomes and make the
best use of clinical and digital
resources
19/20 Transformation Priorities
ICS model transitions to ICP and
CCG & STP development
Non- Elective Demand
Management
Community Care Model and
Locality Development Elective Care and Capacity
Community Care Model and
Locality Development System Efficiency and
Performance Adult Social Care Transformation
Digital Transformation
Integration at different levels of population
7
Level Purpose What we are doing
Neighbourhood level
13 clusters/ PCNs
operating at 30-50k
~50k
• Strengthen primary care
• Network practices
• Proactive & integrated
models for defined
population
• Establishing PCNs
• Clinicians using patient level
data for case identification
• Use data to analyse needs and
identify people at risk of
becoming acutely
unwell/experiencing longer
term health inequalities
• Community asset mapping &
link community resources to
impact outcomes
Place level
Buckinghamshire
ICP
~250-500k
• Typically borough/council
level
• Integrate hospital, council &
primary care teams / services
• Hold GP networks to account
• Integrated Community Services
Model of Care
• Identify population segments with
high utilisation or unmet need
• Drive down inequalities of
outcome, access and delivery
• Inclusion in town-level planning
of wider determinants and
community resources
• Integrated Care Providers
building capability to track
patients and combine real-time
workforce, bed capacity and
activity data to identify
productivity opportunities.
System level
BOB ICS
1+m
• System strategy & planning
• Hold places to account
• Implement strategic change
• Manage performance and £
• Develop ICS 5 year strategy
• Establish at scale opportunities
• Align the STP priorities
ICS to ICP Narrative
Buckinghamshire ICS is clear in its intent to develop its health and care system to delivering high quality, place based care. It is also
working closely with Oxfordshire and the STP to ensure that opportunities for collaborative working are maximised within and across the
system.
To enable the ICS to progress on this journey in 2019/20 the system partners have committed to moving to an ICP as a system priority:
Mapping the commissioning functions to either ‘place’ or ‘system’ and embarking on a transition journey
to ensure these functions are either delegated to ‘place’ or retained at CCG level (CCG will work at
scale across the STP);
Continue to strengthen our governance infrastructure to enable Buckinghamshire partners to hold each
other to account for integrated care planning and delivery, ensuring that the system moves towards a
planned sustainable operating model;
Developing a cross organisational director team between system partners that will oversee the evolving
ICP locally;
Consider movement of resource to facilitate the transformation of out of hospital care as part of our system
recovery plan;
Further develop the model of clinical and care leadership so that it can hold delegated responsibility for
some CCG functions and starts to act as the voice of health and care professionals at a place based level;
Continue to pursue a place based strategy for the development of our enabling services to ensure we
streamline organisational support into a strong system wide support infrastructure that delivers on behalf of
all six partner organisations;
Work closely with STP Lead and Berkshire West to ensure we develop a consistent approach to our planning
and delivery at place and / or system level.
ICS Partnership Board
ICS Implementation Board
Health &
Wellbeing Board
System
Assurance Board
(Quality/Finance/
Performance
ICS Structure
Integrated Care
Programme
Delivery Board
Population
Health &
Prevention
Programme
Delivery Board
Accountability
for:
Urgent &
Emergency
Care
Winter
Resilience
South Facing
Bucks
Children and
Young People
Urgent Care
Accountability
for:
Community
Services
Integration
Primary Care
Adult Social
Care
Care Homes
Accountability
for:
Population
Health Data &
Analysis
Prevention &
Self Care
Social
Prescribing
Health
Inequalities
Access, Care &
Efficiency
Programme
Delivery Board
Accountability
for:
Elective Care
Meds
Management
Cancer
Maternity
Long Term
Conditions
Children &
Young People
A&E Delivery
Board
Professional
Support Services
Workstreams
Accountability
for:
Estates
Organisational
development
Workforce
Comms &
engagement
Back Office
Integration and
Efficiency
Portfolio Office
Accountability
for:
Mental Health
CAMHS
Transformation
Learning
Disabilities
Mental Health &
Learning
Disabilities
Delivery Board
Digital
Transformation
Delivery Board
Accountability
for:
Digital
Transformation
Interoperability
GPIT
Business
Intelligence
EMIS
LHCRE
Clinical & Care
Forum
Children and
Young People
(TBC)
Strategic Risks and Mitigation
Risk Mitigation
Capacity of clinicians within the system to engage in ICS
Programmes
Continue to further system wide ownership of ICS priorities,
engagement plan and commitment to achieve transformation and
change – provide backfill support for clinician time as possible
Limited engagement with patients and the public over transformation
and change initiatives
Delivery of the engagement framework will support a consistent
approach – Maintain a robust communication network and create a
range of communications media to our local population and
workforce
Increase in demand for services with insufficient capacity within the
system to cope
Review of activity levels and system pressures to ensure early
intervention is carried out to deliver safe care and recover standards
System financial pressures and system partner organisation
priorities present a barrier to transformation and change
Manage improvements within a shared financial control total and
leverage flexibility to offset under-performance in one organisation
over performance in another.
Failure to deliver system control total Robust financial process and aligned operational plans in place
across the system. Joint System Financial Recovery Plan in
progress. Support from NHS E/I on system diagnostic. System
efficiency group in place.
System-wide workforce pressures Work to develop a robust workforce strategy and look at innovative
ways to attract and recruit staff across the system
Section 4 Population Health and
Prevention
Population Health & Prevention Narrative
Vision
The Buckinghamshire vision is to improve the health and wellbeing of the entire population of Buckinghamshire, whilst reducing health
inequalities within and across defined population groups. This will require action on the broader determinants of health, lifestyles and health
care quality, access and variation.
We are using the population health management approach to help our primary care networks and our system understand the needs and
priorities in their population and deliver improved outcomes, reduce unwarranted variation, improve efficiency and staff wellbeing and narrow
inequalities. Our approach will engage individuals and communities and build on their strengths and assets , promoting individual and
community resilience and enabling people to have a good start in life, grow up and live as well and independently as possible. We will
create an environment that supports people to live healthy lives and feel in control and be able to care for themselves and each other.
We are adopting a shared approach to prevention across partners in Buckinghamshire that we have co-designed with all NHS organisations,
local government, police, fire, Department for Work and Pensions and the voluntary sector. Each organisation will agree its unique
contribution to the prevention agenda which will differ between organisations. In addition to this we will have a shared focus in 2019/20 on
reducing social isolation. We are developing a shared approach to social prescribing across the ICS involving health, social care and the
voluntary and community sector.
Within the Buckinghamshire ICS we have agreed to embed prevention , self care and tackling inequalities in all our workstreams across the
ICS.
Our Population Health Management approach includes population segmentation and stratification in order to identify the most impactable
groups – and, in turn, design and target interventions to prevent ill-health and to improve care and reduce unwarranted variations in
outcomes. It will inform our strategy and priorities for action.
Through population health management we aim to :
• Keeping healthy people healthy and independent for longer
• Supporting people with long term conditions successfully manage their conditions through self-care and an asset and strength based
approach to provision of care
• Adopting a systematic approach to prevention across the Buckinghamshire footprint at a sufficient scale to improve outcomes and reduce
health inequalities.
PHM is a journey not a destination, and not a digital system or tool. The process is reliant on quality of data to inform population health
informatics. There are existing levels of expertise across the system carrying out various pieces of population health activity. This programme
is to develop a system-wide approach that supports system priorities, specifically locality and PCN development.
Overall/System Residents and Patients Health and Care Professionals
• To achieve the 5 aims of PHM by
embedding PHM approach across the ICS
• To embed a consistent, systematic
approach to prevention across the ICS at a
sufficient scale to improve outcomes
• To embed a consistent, systematic
approach to self-care across the ICS at a
sufficient scale to improve outcomes
• To embed a consistent, systematic
approach to reducing health and care
inequalities across the ICS
• To understand the greatest health need
and match NHS service to meet them
• To unite healthcare from across the system
to coordinate better care across the ICS
• Support the delivery of new models of care
and best practice based on PHM
intelligence and outputs from the
Professional Reference Groups
• To use de-personalised data extracted
from local records, in line with IG
safeguards, to enable more sophisticated
population health management approaches
• Health risk assessments to support life-
style choices and behaviour change
• Have the knowledge, skills and confidence
to optimise health and wellbeing – self care
• Reduced duplication in interactions with
multiple services
• Upload data and goals to clinical record via
apps and devices
• Able to access personal health record
• Digitally interact with care professionals
• Direct booking from home
• Social prescribing will improve the range,
diversity and availability of support to the
public
• Clinically-based decision-support tools at
the point of care
• Access re-identification services to support
intervention
• Access shared care records across the
continuum of care
• Access intelligence to understand if
patients receive the right level of care, in
the right setting at the right time
• Access to information to promote
accountability and service improvement
• Identify efficiency improvements to improve
value for money
• Understand variation through comparison
to improve outcomes
• Provide information which supports
collaborative working between multiple
organisations
• Using data to take long term planning
decisions which ensure sustainability and
evaluate decisions fairly
• Use and strengthen our use of community
resources
• Support Primary care networks to assess
their local population by risk of unwarranted
health outcomes
• Collaborate with local community services
to make support available to people where
it is most needed
Population Health & Prevention Objectives
Framework for Population Health Management
Infrastructure: what are the basic building blocks that must be in place?
1. Organisational Factors - defined population, shared leadership & decision making structure
2. Digitalised care providers and common longitudinal patient record
3. Integrated data architecture and single version of the truth
4. Information Governance that ensures data is shared safely, securely and legally
Intelligence: opportunities to improve care quality, efficiency and equity
1. Supporting capabilities such as advanced analytical tools and software and system wide multi-
disciplinary analytical teams, supplemented by specialist skills
2. Analyses - to understand health and wellbeing needs of the population, opportunities to improve care,
and manage risk
3. Reporting the performance of the ICS as a whole in a range of different formats
4. Outcome based: moving from performance to outcome based reporting
Interventions: proactive clinical and non-clinical interventions to prevent illness, reduce the risk of
hospitalisation and address inequalities.
1. Workforce development – upskilling teams, realigning and creating new roles
2. Community well-being approaches, social prescribing and social value projects
3. Assistive technologies, machine learning and digital tools to empower patients and smooth care
transitions
Incentives (Funding and risk): introducing new funding models to support the development of population –
centred, outcome based care, while also developing arrangement for risk sharing
1. Governance model– agree on risk sharing and managing funds. Responsive to risk
2. Assistive technologies and digital tools to empower patients and smooth care transitions
3. Incentives alignment, ROI modelling and risk sharing mechanisms
4. Confidence within the intelligence analysis
5. Resilience and sustainability of providers - not an additional burden on GPs
Factors Affecting Health Status and Outcomes
Contributors to health outcomes
Health Behaviours
30% Clinical Care
20%
Socioeconomic Factors
40% Built Environment
10%
Smoking 10%
Diet/Exercise 10%
Alcohol use 5%
Poor sexual health 5%
Access to care 10%
Quality of care 10%
Education 10%
Community Safety 5%
Family/Social Support
5%
Income 10%
Employment 10%
Environmental Quality
5%
Built Environment 5%
We need to take action on all fronts
System Partners are working in various degrees across the contributors to health outcomes, this approach minimises the lost
contribution to society through poor health and the direct costs to the health and care system of addressing avoidable ill-health and
care needs; the overall impact affects all residents in the system
Population Health & Prevention Milestones & Deliverables
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Develop enhanced locality
profiles with 3 localities to
inform planning and care
model delivery
• Supporting localities in
understanding which
interventions will be most
effective in addressing local
need
• Co-design the optimum
pathway for respiratory and
cardiac medicine informed by
PHM data and best evidence
• Design and agree processes
for embedding prevention, self
care and inequalities
reduction in all care pathways
• All organisations sign up to
system wide approach to
prevention
• Agree organisational
commitments to prevention
agenda e.g. on smoking, social
isolation, broader determinants
and start to develop ICS
implementation plan
• Develop enhanced locality
profiles with remaining
localities .
• Implementation of population
segmentation and risk
stratification for localities
participating in new integrated
care model
• Co-design the optimum
pathway for people with multi
morbidity
• Implement smoking cessation
approach across ICS as part of
ICS prevention plan
• Develop a system wide action
plan to tackle social isolation
and deliver a co-ordinated
programme for social
prescribing
• Ensure viable infrastructure for
data storage, flows and
analysis
• Implementation of population
segmentation and risk
stratification for localities
participating in new integrated
care model
• Embed new Multi morbidity
pathway and deliver analysis
to support better management
of people with multi-morbidity
and inform case management
• Supported each locality to
understand its local population
needs and service utilisation
patterns including variation
between practices.
• Embed system wide approach
to MECC and strength based
conversations
• Implementation of the social
isolation and social prescribing
action plans
• Agree and embed system risk
stratification approach with
networks
• Identify population health
improvement opportunities for
20/21
• Implementation of population
segmentation and risk
stratification for localities
participating in new integrated
care model
• Evaluate PHM maturity based
on NHSE maturity matrix
• Ensure MDTs are supported to
undertake risk stratification
using their practice registered
population
Population Health & Prevention Outcomes, Benefits, Risks and Mitigation
Outcomes Benefits
• Improved health and well-being of the population
• Reduced health and care inequalities
• Enhanced experience of care
• Reduced per capita cost of health care and improve productivity
• Increased well-being and engagement of the workforce
• Improved Health outcomes across the whole population
• Support people to stay well and take an active role in their care
• Improved quality of life for people with long term conditions
• Improved patient journey and experience
• Delayed or reduced need for health and social care services
• Decreased cost of care over the long term
Risks Mitigation
Unresolved information governance (IG) and data sharing
arrangements across organisations will put the delivery of PHM at
risk
Obtain expert advice on IG to ensure development of robust and
future-proof data sharing agreements with all relevant
organisations
Development of a programme that can be implemented at scale
and sustained over time in the context of limited resources and
competing priorities
Develop an implementation plan that is a phased approach with
prioritised deliverables and activity
Lack of capacity to deliver PHM Programme
Lack of analytical capacity and capabilities to deliver PHM
analyses
Ensure optimal use of resource based on activity
Develop a long term solution ,building on existing capabilities i.e .
Graphnet
The lack of an agreed valid risk stratification tool delays the
development of locality plans or lack of engagement with risk
stratification tools among localities
Lack of clinical engagement with PHM processes and
implementation
Develop viable short-term solutions to meet requirements and a
long-term sustainable tool
This risk will be mitigated by holding workshops and training
throughout the footprint, including catch up sessions with thorough
documentation
Lack of public engagement in initiatives This risk will be mitigated through a continual review of
communication across ICS and best practice through a range of
methods to ensure engagement
Staff engagement impacting prevention opportunities This risk will be mitigated by: holding workshops and training
throughout the ICS; senior leadership engagement; and
exploration of barriers & incentives for change
Poor data quality hampers analysis Clinical engagement to improve data quality
Level Purpose of PHM – Short term Purpose of PHM – Long term
GPs/Clusters –
PCNs –
Localities
(Neighbourhood
~50k)
• Strengthen wellbeing at ward and GP
network/practice level
• Support networking of practices and other non-
hospital services
• Proactive care & integrated models for defined
population
• Clinicians using patient level data for case
identification and management and optimising how
patients are directed through
• Have 100% primary care network coverage
• Develop proactive and differentiated models of care
• Offer greater scope of services in primary care
• Use data to analyse needs and identify people at risk of
becoming acutely unwell/experiencing longer term health
inequalities
• Broader use of community resources for wellbeing
Buckinghamshire
ICS (Place
~250-500k)
• Typically borough/council level
• Integrate hospital, council and primary care
teams/services
• Segmentation, risk stratification, and actuarial analysis
to identify opportunities to redesign care and develop
proactive interventions to prevent illness and reduce
hospitalisation
• Integrated Care Providers building capability to track
patients and combine real-time workforce, bed capacity
and activity data to identify productivity opportunities.
• Identify population segments with high utilisation or unmet
need (population health analyses) and drive down
inequalities of outcome, access and delivery
• Develop integrated services and teams (NHS and social
care) to keep people out of hospital
• Network hospitals and mental health services to improve
resilience and standardise care
• Design new provider collaborations, alliances, contracts or
organisational forms to ‘hard-wire’ integrated
teams/services.
• Inclusion in town-level planning of wider determinants and
community resources
System
1m+
• Population Health Strategy based on whole population
health needs assessment and gap analysis to identify
overall priorities
• Whole population profiling and system modelling to
understand risk and potential mitigations
• Commissioning of outcome based care
• Management performance and hold system to account
over population health outcomes
• Tools such as Graphnet
• Provision of population health analyses for places that
segment by need and resource utilisation as well as
opportunities to address wider determinants
• Implement interoperable systems that allow data to flow
between providers in real time, enabling proactive services
• Establish collaborations between trusts (including groups,
chains or mergers) to standardise care and improve
efficiency
• Bring all stakeholders in the system together with a
common approach to population health
The Buckinghamshire ICS is focused on the Neighbourhood and Place based levels and what that looks like in 19/20 built upon the work we
have already done in 18/19 as well as integration with the System, Region, and National Levels ensuring activity is completed at scale and best
bang for Buckinghamshire £.
Population Health Management at Different Scales
Prevention, Self Care and Long Term Conditions (LTC)
Prevention is a key priority in our vision of moving care upstream i.e. out of hospital and closer to home. It encompasses primary, secondary
and tertiary prevention throughout the lifetime of our population
The ICS recognises the continued need to take action on obesity, smoking, alcohol and physical activity and social isolation to reduce the risk
to individuals, communities and the subsequent NHS challenge of managing diseases such as diabetes, cardiovascular and respiratory
disease, cancers and mental illness.
We will work closely with Public Health, Hospitals, Local Authority and other key partners to prevent ill health and ensure seamless provision
of services is available, so when people do require health services, they are delivered locally through an Integrated Care System.
Our vision is an inspired, informed and confident population who are motivated to make life choices that have positive impacts on health and
wellbeing and reducing the incidence, prevalence of LTCs and impact of living with one. We need to also address the broader determinants of
health and ensure we are promoting environments that make healthy choices the easy choices.
Our Objectives:
• For prevention to be recognised as a priority for investment for the Integrated Care System (ICS)
• People have the inspiration, knowledge and confidence to best manage their health & wellbeing
• Those at risk are identified early and supported to best manage their lives on a daily basis
• Support for people with Long Term Conditions is holistic, integrated, person centred, best practice and in line with the "as close to home"
philosophy
• Buckinghamshire’s ICS workforce is supported, inspired, motivated and committed to prevention
• Innovate, try things, learn from them, and share with others across the system
• Resources are deployed to maximise impact on health & social outcomes
Our approach to prevention will be based on the continued implementation and support of key activities across the ICS in the areas below:
Prevention, Self Care and Long Term Conditions (LTC)
Primary Care Development Scheme
The Primary Care Development Scheme supports and encourages practices to identify and
engage with patients so as to prevent and/or better manage Long Term Conditions. It replaces
certain elements of the Quality Outcomes Framework and enables us to develop a foundation
across general practice to standardise approaches to care with improved outcomes and
reduction in variation. It will be supported in 2019/20 and will benefit from improved insights using
a Population Health Analysis approach.
The 9 activities below provide examples of the areas of focus for the coming year:
Diabetes and Diabetes Prevention
Increasing prevalence rates of diabetes are a significant and growing challenge to the health
economy. By identifying more of those at risk of developing type 2 diabetes and encouraging
their attendance at education / disease management courses, potential sufferers can be
encouraged to take proactive steps to change their lifestyle and lower their future life risks. It is
expected that between 30 and 60% of people can prevent pre-diabetes from developing into type
2 diabetes..
For those with an existing diagnosis of Type 2 Diabetes we aim to increase the numbers of
patients that are referred to and attend a diabetes management course to learn about their
diabetes and how to manage it on a day to day basis. Alongside this we aim to increase the
number of patients that receive the eight recommended care processes for their disease and
meet the three clinical targets for their care and reduce clinical variation across Buckinghamshire.
Live Well Stay Well
The Integrated Lifestyle Service Live
Well Stay Well (LWSW) was re-
commissioned with colleagues in
Public Health in April 2018. The
service has expanded to provide an
online assessment and more services
are provided directly to the patient
without the need for onward referrals.
The service provides a personalised
offer of interventions for healthier
lifestyle services including smoking
cessation, child and adult weight
management, sleeping better and LTC
management, with the offer of the
psychological support needed to alter
negative habits and motivate change.
Live Well Stay Well is one of the
fundamental enablers needed to
prevent the rise in long term
conditions. It is our priority to embed
the service throughout our clinical
pathways and to raise awareness to
the general public for self-referral as
well as amongst health and social care
professionals.
Hypertension
Public Health England estimates that up to 50,000 people in Bucks have as yet undiagnosed
hypertension putting a large proportion of the population at risk of developing cardiovascular
disease. Furthermore, 20% of those on treatment do not achieve optimal control. We will
continue to work closely with practices to increase identification, promote lifestyle changes and
optimise treatment so that long term health risks can be reduced or avoided.
Comorbidity
Long Term Conditions such as diabetes, respiratory and cardiac disease do not occur in isolation. Often people will have to contend with
more than one Long Term Condition and the impact that these have on people’s lives & health is substantial. We will work to support
integrated disease management and ensure that patients are managed holistically and in the context of their lives rather than as separate
diseases. We will work to ensure the Integrated Care System supports the whole person and will work to ensure that professionals have the
right skills and networks to manage and support seamlessly.
Prevention, Self Care and Long Term Conditions (LTC)
Care & Support Planning (CSP)
Care and Support Planning (CSP) has
been shown to increase patient and carer
confidence in their ability to self-care and
manage their illnesses better. The
implementation and expansion of CSP
supports our Prevention and Primary Care
Strategy and the Five Year Forward View
by involving patients and their carers in
deciding what is important to them, setting
individualised goals and action plans
encouraging effective self-care with
support. In 19/20 we will continue to
develop and roll out its use across other
long term conditions including COPD,
asthma, & cardiovascular diseases.
Chronic Obstructive Pulmonary
Disease (COPD)
Flu vaccination is one of the most
beneficial interventions for our
patients with COPD, and combined
with the provision of self-
administered emergency standby
medication, has been shown to
reduce the need for hospital
admissions and empowers patients
to self-care more easily. We will
continue to increase participation in
flu vaccination programmes for
vulnerable adults and encourage
confidence in appropriate self-
administration of standby
medications.
Social Prescribing:
Social prescribing is a way of linking patients and residents with sources of support within the community. It provides a non-medical referral
option that can operate alongside existing treatments to improve health and well-being. The government’s first loneliness strategy
highlighted that GPs have said they are seeing between one and five people a day suffering with loneliness, which is linked to a range of
damaging health impacts, like heart disease, strokes and Alzheimer’s disease.
The formation of the Buckinghamshire Social Prescribing Steering Group, including organisations from local authorities and the voluntary
sector is working to make our social prescribing services more accessible to the population and to raise its profile amongst professionals
and the public. We will continue to take forward and develop social prescribing for Buckinghamshire residents.
Key enablers such as Care Navigators within Primary Care, a Countywide Directory of Services and an integrated approach amongst
services providers with the engagement of the voluntary sector and steps we have support and will continue to enhance.
Make Every Contact Count (MECC) &
Motivational Interviewing
Making Every Contact Count (MECC) supports
organisations and their staff to maximise on the
opportunity they have when meeting with the
public to promote health and enable them to make
changes to improve their health and wellbeing.
Telling people what to do is not the most effective
way to help them change. MECC is about altering
how we interact with people through having
Healthy Conversations and delivering ‘very brief’
or ‘brief’ evidence-based interventions to
encourage lifestyle and behavioural change; the
core elements of which are stopping smoking,
increasing physical activity, reducing alcohol
consumption, maintaining a healthy weight and
diet, and promoting mental and emotional health
and wellbeing. We have expanded the access to
MECC training throughout Buckinghamshire and
we will continue to provide more professionals
who have the opportunity to deliver MECC with
the tools and techniques to do so.
Section 5 Access, Care and Efficiency
Portfolio
Access, Care & Efficiency Narrative
Objectives
Cancer Medicines Optimisation Elective Care Maternity
• Deliver cancer transformation
priorities agreed with
Thames Valley Cancer
Alliance (TVCA); work
includes delivering and &
sustaining cancer
performance
• Increase screening &
improve early diagnosis
• Improve support for those
Living With & Beyond Cancer
(LWBC)
• Deliver optimised medicines
in terms of clinical
effectiveness, value and
safety
• Deliver our local elective
care transformation
priorities i.e. MSK,
ophthalmology, outpatients &
national priorities
• Deliver constitutional
standards & develop
elective care demand
management programme
• Deliver local priorities as
agreed with the BOB LMS
designed to reduce rates of
stillbirth, neonatal death,
maternal death and brain
injury during birth whilst
increasing choice and
personalisation
• Implement continuity of care
model
Vision
The Access, Care, & Efficiency (ACE) Portfolio is about ensuring the right access, with right care and intervention, at right time and place in
the most efficient way ensuring the best patient experience and outcomes while managing activity and demand appropriately and efficiently
to maintain operational and financial sustainability. The ACE portfolio will manage the Cancer, Medicines Management and Optimisation,
Elective Care Priorities Programmes and support the Maternity programme which is led by the STP.
Cancer Narrative
Vision
Working as a system with partners from Thames Valley Cancer Alliance (TVCA), Public Health, Macmillan and Cancer Research UK, a
programme of work has been locally developed and is in it’s second year of delivery. The programme continues to develop and is working to
create a system that meets current standards (2 week wait, 31 day and 62 day) as well as preparing for the emerging new standards (28 days).
Objectives
• Improve screening uptake and early detection
• Improved diagnostics
• Improved patient pathways and outcomes for those living with and beyond cancer
• Meeting performance standards (2 week wait, 31 days and 62 days)
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Agreement of programme for lower and
upper GI pathways
• Develop programme for risk stratified
pathway (following recruitment of PM)
• Develop proposal for cancer coordination
centre
• Delivery of LWBC programme with
Macmillan to improve support for
patients, such as improved mental health
support, better communication and
training to staff
• Complete review of lower pathway & upper
GI pathway
• Expansion of primary care programme to
improve screening
• Roll out of GP Toolkit
• Development of risk stratified pathways
• Improve coordination of patients through all
cancer pathways
• System working to improve endoscopy
demand & capacity
• Commence pathway redesign
programme
• Development of programme for
GP toolkit roll out and
expansion of primary care
programme.
• Review opportunities for
endoscopy service capacity
and demand management
• Commence endoscopy
programme of work
• Progress towards the
2020/21 ambition of 62%
of cancer patients
diagnosed at stage 1 or 2
• Continued review and
assessment of
programme of work
including launch of new
pathways
Cancer
Risks Mitigation
Sustainably achieve 62 day standard
• Close monitoring within the system.
• Close working with TVCA and NHSE to understand wider system /
provider challenges affecting programmes.
• Work towards new coordination centre for cancer to improve
monitoring and reduce breaches
Achieve system readiness for new 28 day standard • Close monitoring within the system.
• Improve 2ww pathways to improve diagnostic times
• Explore (through pathways and endoscopy) opportunities to
commence tests and diagnostics early.
Cancer
The national ambitions for cancer as set out in ‘Achieving World Class Cancer outcomes: A strategy for England 2015-2020’ have been well
publicised and form the basis for service improvement work for cancer. It is well documented that England currently lags behind Europe in
first year survival for cancer. It is national policy to halve this gap between England and the best in Europe.
One year survival rates
One year survival rates of cancer within Buckinghamshire are
73% for all cancers which is a slight improvement from last year
(71.9%) and above the national average of 72.3%. Whilst this
figure is one of the best within Thames Valley, Buckinghamshire
is aiming for survival rates higher than the target of 75% by 2021.
Following last year’s national parliamentary recognition for being
in the top 20 CCGs in the country for improvement in first year
survival for our cancer patients, programmes of work, supported
by Thames Valley Cancer Alliance (TVCA) are underway to
further improve and sustain this.
Prevention and Equality
It is well evidenced that the best way to improve outcomes for
cancer is to prevent people developing the disease. Around 40%
of all cancers are believed to be caused by lifestyle and
behavioural factors and could be prevented with lifestyle
changes. The ICS is delivering a targeted action plan, alongside
established lifestyle programmes, to improve prevention through
education and wellbeing. This includes working collaboratively
with Public Health to find new ways to engage with harder to
reach individuals and our more diverse communities.
Screening and Early Diagnosis / Detection
Cancers that are diagnosed through screening are often discovered at an early, more treatable stage. The ICS is working towards increasing
the uptake of screening across the region for the three national screening programmes (breast, bowel and cervical). Across
Buckinghamshire, screening uptake is generally above the national average. However, the ICS recognises there is still variation across
localities, which is often linked to levels of deprivation and poorer health outcomes. Reducing the inequality gap in cancer is a key target of
the ICS.
The ICS has worked closely with Public Health and Cancer Research UK (CRUK) to do a more detailed analysis of the county by GP
practice and population to establish where the variations lie and what the factors may be for low uptake. This has enabled a targeted
programme of work to commence that is focusing on populations of greater need and allowing better, targeted engagement with practices,
different communities and age groups to ensure there is an improved uptake of screening. This work is being supported by Thames Valley
Cancer Alliance (TVCA) with funding to improve screening uptake locally and a quality improvement toolkit to support GP practices.
Identification of cancer champions in primary care, training events for primary care teams and hosting community events to engage with the
public are all actions that have been undertaken in the last year as part of the programme of work to improve screening uptake and public
awareness. This will continue in FY19/20.
Cancer
Increase Screening & Improve Early diagnosis / detection
Improving early diagnosis of cancer is recognised as the single most important factor for the UK to improve cancer patient survival. Part
of the reason for poorer cancer survival rate is due to later presentation and slower diagnosis of patients with symptoms of cancer
compared to other countries. Earlier diagnosis depends on i) people being aware of symptoms and signs of cancer and approaching their
GP, and ii) healthcare services acting swiftly to diagnose them. Whilst the detection rate in Buckinghamshire is slightly above the national
average, there is still room for improvement - earlier diagnosis is a key indicator within Thames Valley.
Work is underway to raise patient awareness of the importance of early diagnosis of cancer. In 2018/19, the CCG, secondary care,
Public Health and primary care colleagues working together as an ICS to support the promotion of the national ‘Be Clear on Cancer’
campaigns. The ICS is also leading a programme of work that includes hosting community events/ publicity especially for those groups
where there may be cultural issues delaying early diagnosis. Training in primary care has been and will continue to be a feature to
support staff and patients in primary care. Furthermore, the development of a Vague Symptoms clinic in Buckinghamshire has paved the
way for improved diagnostics and access. Going forward, the ICS will be working with TVCA in the development of Rapid Diagnostics
services in Buckinghamshire to support 31 day standard and emerging 28 day standard.
The ICS is continuing to work closely with GPs to improve the proportion of cancers which are detected via the two week wait fast track
pathway, reducing those which are picked up in A&E or other acute admissions. This work has also supported the development of a
‘vague symptoms’ clinic within BHT, utilising funding from TVCA. The ICS continues to work with the STP partners to develop pathways
to facilitate ‘straight to test’ where appropriate.
In 2018/19, the system invested in additional capacity, using a Vanguard to support Endoscopy services meet high demand. The ICS is
working collaboratively to review demand and capacity within Endoscopy services to provide sustainable service provision going forward.
Cancer
Living with and beyond cancer
The ICS has been working closely with system partners and MacMillan
to develop services for patients Living With and Beyond Cancer
(LWBC). A work stream has been set up focusing on this which has
seen strong engagement from services users, carers and providers to
identify opportunities to improve services and patient experience.
A programme of work is now being developed to explore some of the
key themes that relate to mental health support, coordination of care
and training for different services (primary and secondary care).
Furthermore, the improvement in services will incorporate the
standardisation of holistic needs assessments.
Delivering Cancer Transformation Priorities - Treatment Pathways / Performance targets
Referral-to-Treatment (RTT) performance and waiting list management are monitored on a weekly basis to ensure 2 week, 31 day and
62 day targets continue to be met and safety is maintained for patients that may breach the target. Lists for the 62 day pathway with our
major providers are reviewed at 35 days to ensure complex pathways (tertiary referrals for example) are appropriately managed. This
work is being supported locally following the appointment of a Regional Supra MDT Coordinator based in Oxford.
Cancer performance at 62 days continues to be a challenge nationally as well as in Buckinghamshire. However, following redesign of
urology pathways, lung pathway, development of the vague symptoms clinic and monitoring of all patients. The success of improved
performance has been founded on the collaborative working of all system partners. The next step is to ensure this is sustained as well as
strive for all pathways and interventions to be effective and efficient – to improve outcomes for all patients. This forms the wider
programme of work, the Cancer team within the ICS has developed and are delivering over a 5 year period (2016-2021).
Trusts have a target of 80% for staging at diagnosis - many systems are currently below this target and Buckinghamshire is no exception.
Whilst there has been an increase in the number of patients staged at diagnosis for certain tumour groups, this is continues to be an area
for improvement with local acute providers. The target of 80% needs to be achieved nationally by 2021 and is being supported by TVCA.
Medicines Optimisation Narrative
Vision
The vision of Bucks ICS Pharmacy and Medicines Optimisation is to provide the right medicine at the right time in the right place in order to
deliver the best outcomes for patients and the best value for the system. The delivery of Improved patient outcomes and medicines value will be
through a single seamless ICS collaborative approach.
Objectives
Value - Enable access to clinically and cost effective treatment and support people to take their medicines as intended to ensure the health
outcomes they want.
Safety – Reduce the harm from medicines. To reduce the waste of medicines. To improve patients understanding and ability to manage their
own medicines. To tackle antimicrobial resistance.
Integration – Establish local infrastructure, leadership and governance to support medicines optimisation across health and care organisations.
Agree a workforce strategy to encourage a highly skilled workforce to be developed and to stay in Bucks with flexibility across the system
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Primary care development
scheme launch including MO
targets
• Joint resource team structure
out for consultation & agreed
• Medicines Value and
Medicines safety groups
initiated
• Biosimilar switch programme
complete
• Business case for
anticoagulation service
agreed
• ICS preventing harm form
meds group initiated
• E invoicing implemented
• TCAM referral process in place
• Recruitment to Joint resource
team complete
• Anticoagulation ITT
• Implement monthly monitoring
monthly to assure targets
maintained
a. Biosimilars
b. Top 10 model hospital
c. Financial run rate/budget
d. OTC value meds
e. Low value (18 items) meds
f. Antibiotics
• Process to identify and spread
learning from incidents and
concerns agreed.
• Community Pharmacy
Business in BHT – complete
scoping of opportunity to
expand service provision to
Oxford
• E-prescribing exemplar ward
operational
• Agree Thames Valley MO
work plan for 2020/21
• Evaluate targets
• Develop targets for 20/20
Medicines Optimisation Outcomes, Benefits, Risks and Mitigation
Risks Mitigation
IT support to implement TCAM and e-prescribing etc. Programme board review / discuss /escalate current workload and
emerging pressures.
Lack of resources to deliver; inability to recruit to new Joint teams Programme board review / discuss /escalate current workload and
emerging pressures.
Lack of clinical engagement from all system partners Programme board review / discuss /escalate current workload and
emerging pressures.
Outcomes Benefits
• Optimise use of biosimilars and other Model hospital top 10 metrics
• Reduce use of OTC and low value medicines
• Optimise Medicine Use Reviews by community pharmacy
• Reduction in patient risk from medicines
• Reduction in waste of medicines
• Implement a single ICS governance structure
• Financial balance
• Improved patient outcomes
• Reduction in medicines related admissions
• Improved flexibility of workforce
• Improved communication within pharmacy workforce
Elective Care Narrative
Vision
The Elective Care Transformation Programme aims to ensure that we deliver the right access to services, with right care and intervention, at the
right time and place in the most efficient way ensuring the best patient experience and outcomes, while managing activity and demand
appropriately and efficiently to maintain operational and financial sustainability.
Objectives
• Delivery of local/national elective care transformation priorities i.e. MSK, Ophthalmology, Outpatients
• Delivery of constitutional standards for elective care
The transformation programme in conjunction with other programmes of work aims to deliver:
• Reduction in GP levels of activity where other, more appropriate, support could be provided
• Reduction in demand for elective hospital services
• Re-design of outpatients
• Reduce variation, duplication and the number of avoidable contacts with individuals
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Identify Right Care opportunities
in Cardiovascular and
Respiratory
• Scope opportunity for
community ophthalmology
• Roll out MSK pilots for MDT
clinics and first contact
practitioner (FCP)
• Outpatients: review current
activity and scope opportunities
for reduction in face to face
activity through use of digital
technology
• Embed National Elective Care
Programme initiatives
• Implement STP review
initiatives
• Ophthalmology: develop business
case for the community model
• MSK: embed service model and
monitor expected outcomes
• MSK: further expansion of FCP
pilot
• Outpatients: follow on from Q1
• Implementation of right care
opportunities for cardiovascular &
respiratory
• Evaluate Consult Connect project
• MSK: Further expansion of FCP
pilot
• Ophthalmology: develop business
case for the community model
• Outpatient: start to see service
change
• MSK: implementation of full MSK
model
• Prepare for implementation of
ophthalmology model
Outcomes Benefits
• Reduction in activity: Initial & Follow Up in & Out of County
• Reduced Planned Admissions
• Increased Care Closer to Home – Referrals to be managed
as for advice and guidance including self-referral
• Improved Patient Satisfaction
• Multi-disciplinary teams used to better manage complex
patients (right person, right place, right time) with access to
care navigators
• Improved GP and patient education and support
• Patients are supported to achieve their jointly agreed goals
through shared decision making to better support patients to
make fully informed choice
• Reduction of unexplained variation in referral and/or intervention
rates and thus releasing resource to minimise unmet demand
• Reduction in unnecessary admissions to hospital and reduction
in associated patient safety risk
• Equitable access to resources and services delivered through a
‘one stop shop’ setting wherever clinically possible
• Reduction in avoidable attendances, diagnostics and patient
journeys
• Best use of IM&T to include single patient records
Elective Care Outcomes, Benefits, Risks and Mitigation
Risks Mitigation
Capacity insufficient to support current or new work:
this includes contractual support and monitoring performance
support and monitoring project delivery
• Programme board review / discuss current workload and
emerging pressures.
• Programme board escalate where additional work /
responsibility is required of them.
• Review all work to assess current / future project requirements
and resource alignment. Any shortfall in resource to be
escalated to Exec for discussion / prioritisation / investment
Continuity of team - If a member of the current programme board
leaves the programme board and / or the organisation then Project
delivery would be at risk (in terms of delivery, programme or both),
knowledge of services could be lost and provider and stakeholder
engagement / relationship could be at risk - where a good
relationship has been developed
• Team support and supervision of all staff
• Support staff development (through effective and clear PDPs)
• Ensure all projects / services have succession planning in place
• Ensure work is shared so that multiple team members share
skills, work and knowledge
Maternity Narrative
Vision
Our vision for maternity services in Buckinghamshire is to ensure they are safe, personalised, kinder, professional and more family friendly;
where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support
that is centred around their individual needs and circumstances. And for all staff to be supported to deliver care which is women centred,
working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break
down organisational and professional boundaries.
Objectives
• Review the quality of maternity services provision for women across Buckinghamshire and across other referral points in line with the agreed
service specification and dashboard.
• Ensure that the BOB STP - Local Maternity System (LMS) implementation plan and action plan for Buckinghamshire is implemented, and
ensure own local key priorities and plans to transform maternity services are implemented to include reduce rates of stillbirth, neonatal
death, maternal death and brain injury during birth whilst increasing choice and personalisation
• Ensure that women’s feedback is heard and contributes to strategic planning.
• Agree key initiatives to improve the quality of maternity services for women across Buckinghamshire, in line with national guidance and
recommendations.
• Monitor the implementation and achievement of key initiatives and targeted service improvements in maternity care provision.
• Support collaborative working and decision making that improves the maternity care provision outcomes in Buckinghamshire.
• Support effective partnerships working between health, local authority and wider partnership organisations in Buckinghamshire.
• Ensure consistency in implementation of relevant policies in an evidence-based, cost effective and safe manner, and support wider CCG
commissioning intentions.
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Commencing wave 3 of
neonatal/maternity safety
collaborative in April 2019
• Implementing continuity of
carer models for 20% of
women from April 2019 with a
focus on diabetic women and
socially/psychologically
vulnerable women
• Scoping the opportunities at
BHT to implement first series of
continuity models, gathering
learning from early adopter sites
• Increase resources to
strengthen access to specialist
perinatal mental health services
• Personalised care plans for all
women
• Consider creation of community
hubs to enable women to
access care in the community
from their midwife and from a
range of others services,
particularly for antenatal and
postnatal care
• BOB LMS will meet the interim
target of achieving a 10%
reduction across all appropriate
measures by March 2020
Children & Young People Narrative
Vision
Our vision for Children & Young People in Buckinghamshire is focused on ensuring the improved health and care outcomes for children and
young people. The aim in 19/20 is to develop programme plan which will inform a longer term programme of work which responds to the
requirements of the children and young people in Buckinghamshire and the requirements set out in the NHS Long Term Plan. We will seek to
align all of the work we are currently doing in the system around children and young people .
Objectives
• CYP have access to earlier interventions and support across the health and care system
• A collaborative system approach that is agile and flexible allowing for new and innovative approaches to CYP
• A fundamental cultural change in the way children and young people are managed; a well skilled and developed CYP workforce
• A CYP programme that ensures:
• Increased joint commissioning around early help, early interventions, and prevention
• Improved access to secondary mental health services
• Access to eating disorder services
• Aligns with work around people with learning disabilities and autism
• Well established engagement programme across CYP that ensures children, young people, their parents and carers are engaged in a
variety of ways and on a range of subjects to inform our decision making and ensures our commitment to co-production
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Current understanding of the
work across the system under
the children and young people
banner
• Draft programme plan to align
current activity and NHS Long
Term Plan
• System resourcing proposal
based on current resources
available
• Quantitative data collection of
CYP health needs
• Complete Asset mapping
• Socialisation of draft programme
plan
• Extend review and focus on
existing projects around social
prescribing, MECC, Physical
activity and social campaigns
• Assessment of parental health
literacy and options to
commission training programme
to address identified needs
• Initial discussions with AEDB
around UEC integration to
interpret health needs
• Complete assessment on health
needs and mapping of current
services to develop a project
plan
• Develop a shared vision of
neurodiverse child and
adolescent population and
develop a coherent pathway
• Review options for
commissioning a responsive
support programme around
families
• Assess 19/20 progress
• Develop 20/21 programme of
work
• Raise awareness of the cultural
changes required with schools
and families around children
with Neurodiversity
• Assess projects/schemes with
CYP
• Review CYP activity levels for
opportunities to create system
efficiencies
Outcomes Benefits
• Increased self-reported satisfaction by CYP on access to
advice and support
• Positive impact on the behavioural drivers for patients
seeking a health care consultation and remove the perceived
health threat for common child health illnesses
• Proactive management of care closer to home to maintain a
better connection with their families and friends and improve
how they interact with local services
• A reduction in the number of children and young people
referred for secondary ASD/ADHD services
• Reduction in the number of children and young people
inappropriately attending or accessing urgent care services
in crisis or with non urgent conditions
Children & Young People Outcomes, Benefits, Risks and Mitigation
Risks Mitigation
Without sufficient dedicated resources, the programme will not
achieve its objectives
Mitigation through re-allocation of resources and potential
investment through transformation funds
Planning for CYPs services takes place across different
geographies, Risk that competing priorities will reduce delivery and
impact.
Mitigation is through alignment of CYP activity under one ICS CYP
steering group that reports into a system portfolio board which
promotes the system objectives and agreed activity
Recruitment and retention of staff with CYP skill set remains
difficult
Reviewing different ways of recruiting and utilising available
resources and workforce to deliver services
Engagement with children and young people, parents, carers and
extended family, schools and other agencies is an essential part of
a successful programme
Ensure appropriate representation across Buckinghamshire sits on
the ICS CYP steering group
Section 6 Accident & Emergency Delivery
Board
Accident & Emergency Delivery Board Narrative Vision
To provide integrated urgent and emergency care services to the people of Buckinghamshire, where patient and staff time is valued.
As patients become unwell, they move between health and social care providers seamlessly, accessing a responsive service, close to home and
tailored to their individual needs. When hospital level care is provided, this is provided in an ambulatory setting wherever possible, or in specialty
assessment units, with only patients who truly require emergency department input accessing the service. When patients who stay in hospital are
clinically optimised, they return to their home wherever possible. Assessment for long-term care and support is undertaken out of hospital, in the
most appropriate setting, and at the right time for the person.
Objectives
• Community admission and attendance avoidance – keeping more people at home
• A & E admission avoidance – supporting getting people home sooner
• Preventing discharge delays – stopping unnecessarily prolonged stays in hospital
• Coordinate system partners and work to deliver A&E performance of 95% by year end, working to locally agreed trajectories
• Reduce extended length of stay (>6 days and >20 days) / bed occupancy and continued focus on reducing DTOC
• Save patient and staff time by reducing unnecessary delays
• Roll out demand and capacity model and system capability
• Provide assurance that system plans (including plans for winter) are in place and will deliver required resilience
• Proactively lead Buckinghamshire ICS UEC planning (including seasonal variation) and coordinate system response during periods of
pressure, ensuring cross border coordination & liaison within the STP and with Regional/national team
• Develop, deliver and track the Buckinghamshire ICS Non-Elective Demand Management Programme, ensuring that best practice is delivered
and that project plans & outcomes are tracked
• Work closely with developing primary care networks and community teams to ensure that clinical variation and opportunities for reducing NEL
by community transformation are understood and supported
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Robust offer of A&E
alternatives; Consultant
connect, Clinical Assessment
and Treatment Service
(CATS), Multidisciplinary Day
assessment Unit (MuDAS),
UTC
• Winter system wash up and
19/20 planning event
• GP streaming expansion and
aim for 25% of SMH activity
• Increase access to ambulatory
emergency care/same day
emergency care and sub-
specialty teams to increase 0
day length of stay
• Mental Health Urgent Care
pathways (safe havens in &
psych liaison on site at BHT)
• Full Implementation of 7
UEC domains deliverables
(plans against each domain
in place)
• Develop and secure system
partner sign off for winter
plan
• Develop AEDB component
of 20/21 operations plan
Accident & Emergency Delivery Board Outcomes and Benefits
Outcomes Benefits
• Delivery of NHS constitutional standards related to urgent care
• Continue the system wide focus on delivering reductions in LoS
and the number of patients who remain in a hospital bed over
20 days
• Every acute hospital with a type 1 A&E department will move to
a comprehensive model of Same Day Emergency Care (SDEC)
– 12 hours a day 7 days a week
• Continue to build on the system adoption of the Emergency
Care Data Set (ECDS)
• Increase the proportion of attendances through GP streaming
and further reduce Type 1 attendances in the ED
• Robust and consistent implementation of clinical standards in
the hospital
• Continue the work to reduce Delayed Transfers of Care (DToC)
so enabling patients to be discharged home/closer to home in a
timely and compassionate manner
• Acute hospital to provide a robust frailty service for at least 70
hours per week
• Further develop the Clinical Assessment Service (CAS) within
the Integrated Urgent Care Hub to act as a single point of
access for patients and work to achieve long term ambitions as
per NHS Long Term Plan by 2023
• Delivery of the system NeL demand management programme
• Complete a full demand and capacity programme of work
• Maintain robust processes for reducing Ambulance handover
delays , and a clear focus on reducing conveyance to the ED
• Ensure ambulance providers are meeting thei r response time
targets
• Implement a comprehensive ICS demand and capacity
dashboard
• Improved outcomes and experience for paediatric NEL patients
• Increase weekend discharges
• Better patient experience, seven days a week
• Increase the proportion of acute admissions discharged on the
day of attendance from a fifth to a third.
• Reduction of congestion in ED’s
• Reduction of outliers in hospital
• Improve patient flow
• Reduction in DToC and LoS
• Financial efficiencies
• Improved 4 hour standard performance
• Enable targeted planning based on intelligent demand and
capacity modelling
• Improved turnaround time for Ambulance crews to respond to
call outs in the community
• Improved ambulance response times
• Accurate and intelligent real time data for partners across the
ICS
Section 7 Integrated Care Portfolio
Integrated Care Narrative
Vision
The Integrated Care Portfolio has been established to build 24/7 sustainable resilience and capacity across the system by further
developing primary care and community services, and will support the ICS in delivering it’s strategic aims/goals.
Objectives
• 24/7 access to GP led care and new models of care enabled by GP clusters.
• Comprehensive cover across the 24/7 period as appropriate to GP clusters with a single point of access for rapid response to avoid
admissions and support prompt discharge from A&E.
• Integration with community services and actively supported in the care of residents with complex needs and those at the end of life by
consistent and high quality community services and primary care
• Discharge to Assess (D2A), Integrated Discharge Teams, Trusted Assessor, RRIC & Integrated Reablement transformed into an
integrated Short Term Interventions Team, Single Point of Access (SPA)
• Primary Care Networks (PCN) and Leadership Development, ensuring links with OD/Workforce and business intelligence (data) work
streams
• Integration with community physical health services and social care, as well as developing clear pathways for people with serious and
enduring mental health with a focus on improving outcomes and mortality
• ASC - integration across the system with a focus on prevention, reducing duplication, increasing health & well-being and self-help,
and ensuring linkages with integrated teams and the community care model
• Transforming care and services for people with learning disabilities and/or autism who also have, or are at risk of developing a mental
health condition or behaviours described as challenging; and building upon the personal strengths and social networks of individuals
• Extending the “assets-based” approach to all aspects of social care
• Implementation of an integrated Preparing for Adulthood service, bringing together services in Children's and Adult Services, with
phase 2 exploring opportunities for integration with Health.
Integrated Care Milestones and Deliverables
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Implementation of Delivery
plan for Locality Teams
Development
• Development of a
Community Services
Programme Plan
• Evaluation Framework
• CAMHS Transformation
• Specialist Perinatal MH
Service Implementation
• Agreed business case and
implementation plan for
single reablement service,
single manager in place
• Agreed business case and
implementation plan for
single hospital discharge
service
• Proposed model for SPA
• IT - Data sharing
agreements signed &
read/write interoperability
between practices enabled.
• OD solution to support
Locality Networks go live
• Sustainable D2A model (in
collaboration with Integrated
Care)
• PHM Segmentation
Information by Locality
• Execution of Delivery Plans
• 5 Year Community Services
Strategy(Part of 5 year ICS
Plan)
• IAPT Expansion
• Tier 4 PICU
• Business s case and
implementation plan for SPA
• Implementation of PfA
• 100% of the county covered
by Primary Care Networks
(PCNs) at level 2 of the
maturity matrix
• Full implementation of single
reablement service
• Full implementation of Phase 1
of hospital discharge service
• Implementation of SPA
• Complete review and
proposals for opportunities to
integrate aspects of the ASC
Front Door with Health
services
• Leadership & OD support in
place
• Implementation of Suicide
Prevention Strategy
• Community and Crisis
Remodelling
• Full implementation of Phase
2 (final) of hospital discharge
service
• Fully operational SPA
• Review of opportunities for
integration opportunities of
PfA
• 100% of PCNs achieved level
3 maturity
• Top 3 priorities for service
development in each Locality
Network implemented
• Progress made towards
delivering 20/21 waiting time
standards for CYP eating
disorder services.
• 53% of patients requiring early
intervention for psychosis
receiving NICE concordant
care within two weeks
• Reduction in inappropriate
adult acute out of area
placements
• All commissioned activity is
recorded and reported through
the Mental Health Services
Dataset
Integrated Care Outcomes, Benefits, Risks and Mitigation
Outcomes Benefits
• Improve access to integrated services within the community and
general practice
• Improved outcomes for adults & children suffering from mental
health illness & learning disabilities
• Reduce growth in outpatient appointments
• Reduce growth in non-elective admissions
• Reduce community hospital length of stay from step-up and
step-down beds
• Improved integration of services provided to people with
complex needs among multiple providers
• More frail people regaining their previous levels of
independence following a critical incident
• More people living at home for longer; and reduced admissions
and length of stay in residential and nursing care
• Reduce number of delayed transfers of care across all
providers, including stranded and super-stranded patients
• Improved experience for residents (and their carers) leaving
acute services
• Reduced hospital admissions
• Reduced duplication in services, leading to improved
experiences for residents and staff
Risks Mitigation
Lack of capacity system wide to support transformation Implementing a system wide prioritisation approach
Complexity and level of change greater than system capability to
manage
Ensure a clear change model is in place and transformation
completed using a phased approach
Organisations revert to protectionist mode and unwilling to release
autonomy
Continue to work collaboratively across the system through an
open and transparent approach and build strong partnerships
Section 8 Mental Health Delivery Board
Mental Health Narrative
Vision
Buckinghamshire ICS has continued to work towards achievement of the ambitions of the five year forward view with partners from across the health and care system
with Mental Health remaining a prominent feature and priority for the Buckinghamshire integrated care system (ICS). Engagement with people that have lived experience
of the condition has been a key focus for the ICS over the last 12 months, utilising the insight to inform the commissioning, design and delivery of services over the next
three to five years; forming the basis for Buckinghamshire’s all age mental health strategy
Objectives
• There needs to be a clearer focus on earlier intervention for young people; particularly in schools, to help raise awareness of mental health as a condition and support
young people proactively; there is significant evidence to show that 50% of mental health problems are established by the age of 14.
• Mental Health stigma is still a problem for people living with the condition, in particular those that have not yet sought support and the barriers that this creates to
accessing support.
• Care needs to be made more easily accessible particularly for people when they are in crisis; service users and their carers need to know where they can access
support quickly when they need it most.
• The physical health needs of those that have a mental health problem need to be considered in all aspects of care to close the gap between people that have a
severe and enduring mental illness dying on average 20 years earlier than the rest of the population.
• Continue to increase access to CAMHS for under 18's.
• Expand IAPT services to meet 19% of the anticipated need within Buckinghamshire.
• Approximately 250 women will access a specialist perinatal mental health service.
• Reduction in out of area placements.
• Implementations of a crisis resolution and home treatment team
• Implementation of an individual placement and support service to get service users into paid employment.
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Publish the all age mental health
strategy
• Continue to develop the mental
health urgent care pathway
particularly with regards to
alternative resources for people in
crisis
• Embed delirium pathway into
system working
• Increase the number of people with
a severe and enduring mental
illness accessing annual health
checks
• Ensure that insight from people with
lived experience is at the centre of
all commissioning work undertaken.
• Implement mental health support
teams in schools and work towards
95% meeting 6 week target for
referral to treatment for children and
young people needing to access
mental health services
• Expand the access to IAPT services
particularly with regards to long
term conditions
• Review dementia diagnostic
pathways with the aim of meeting
the national diagnosis target of
67%.
• Establish mental health links with
newly agreed primary care networks
• Review of 19/20 objectives and
deliverables
• individual placement and support
service go live (subject to
successful bid)
• Roll out of standardised
psychosocial assessment and
guidance for workforce working with
for those at risk of suicide or
repeated self harm.
• Develop 20/21 objectives and
deliverables
Learning Disability Narrative
Vision
Our aspiration is to provide positive outcomes for people with a learning disability and to help them to live healthy, happy, independent lives
within their community. Services provided should offer best quality and value through a whole systems approach to the health and social care
needs of people with a learning disability and/or autism.
Objectives
• Ensure that people have the best health possible through health checks, health action plans and access to mainstream services
• Actively support physical and mental health services to make reasonable adjustments to meet the needs of adults with learning disabilities
where these are best suited to meet their needs
• To develop a competent workforce including establishing a programme to deliver training and support in positive behaviour approaches .This
work aims to ensure a consistent approach to challenging behaviour to be applied across ages and agencies. This work should support
reduced admissions to hospital and earlier discharge .
• Improve community services through a whole systems approach to health and social care working together so that people with a learning
disability and/or autism and their families have a more joined-up experience of care
• To develop support and intervention services to those at risk of offending and support discharge from hospital for those exiting the criminal
justice system through development of the BOB wide Forensic pathway
• Use Access All Areas event to showcase the wide range of services to support people with a learning disability in Buckinghamshire to live well
and stay well
• Ensure timely discharge to the community for children and young people and adults through development of market to particularly support
those with more complex needs and behaviour that challenges. To work with specialist commissioning to ensure CCG representation at
CETRs
• Service users and parents /carers views are represented at the existing TCP Board . This will be continued through 2019/20 to ensure the
views of the service users are steering local developments
• The CCG is a member of a Learning from Deaths report (LeDeR) steering group and have a named person with lead responsibility.
COMPLETE.
• There is a robust CCG plan in place to ensure that high quality LeDeR reviews are undertaken within 6 months of the notification of death to
the local area. This includes a bespoke approach to the engagement of families and carers in the review process.
• The System LeDeR process contains a multidisciplinary approach to the review and sign off of LeDeR Reviews, this ensures the quality of the
review process and to date 100% of cases have been approved at first submission.
• The CCG working with the system have an approach in place to analyse and address the themes and recommendations from completed
LeDeR reviews. Direct input to Links to the ICS Learning from Deaths Group, respective Safeguarding Boards and Learning Disability Forums.
• An annual report is submitted to the appropriate board/committee for all statutory partners, demonstrating action taken and outcomes from
LeDeR reviews
Learning Disability Milestones and Deliverables
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Colocation of health and social
care teams to enhance
integrated working
• Continue work to develop BOB
forensic pathway to ensure the
timely discharge of those in
need of community forensic
support pre and post
admission to hospital
• Scope system wide workforce
training needs
• Plan access all areas event
• Work with NHSE specialist
commissioners to develop
process to enable CCG
representation at inpatient
CETR
• Extend monthly adult planning
meeting to include CYP to
facilitate development of
dynamic at risk register
• LeDeR: Annual system report
for the learning from 18/19 to
inform improvement plan for
19/20.
• LeDeR: Reduction in caseload
from 18/19 cohort cases by
50%
• LeDeR: Run a series of
engagement education and
development workshops linked
to learning and improvement
from LeDeR themes.
• Develop plan for establishment
of community forensic pathway
• Develop plan for meeting
workforce training needs and
competencies
• Develop plan for future
procurement/market
development
• Promote access all areas
event
• Work with children’s services
to ensure CETR process is
completed in a timely way and
consider alternatives to
admission that can be
developed
• LeDeR: Evaluation and review
of LeDeR system process for
the Bucks System
• Identify demands and map
future demands in supported
living and residential provision
to enable procurement /market
development (needs analysis)
• Deliver against plan for
forensic pathway
• Access all areas event
• Deliver market development /
procurement event
• Plan training event for
workforce
• Consider procurement
opportunities
• 75% of people 14+ on the GP
learning disabilities register
receive an annual health check
• Operationalise and embed
Forensic pathway work
• Review access all areas event
Section 9 Professional Support Services
Portfolio Office & Governance Vision
An enterprise-wide approach that enables world class proficiency to successfully execute a portfolio of change initiatives and continuous
improvement through sound methodology and proven best practices working collaboratively across Buckinghamshire and integrated with BOB
Objectives
• Serve as the service’s authority on Change Management and Continuous Improvement methods and practices; Developing a flexible , cost
effective and agile integrated approach while reducing risk, complexity, duplication and ensuring best use of resources available
• Delivery Focused; Build Change Management and Continuous Improvement maturity across the service
• Fully operational P3 management system that supports strategic planning, integration, effective resource allocation, and executive reporting
• Build strong partnerships working collaboratively through a Clear and Concise Communication and Engagement structure
• Be honest brokers with change initiative viability, return on investment, and benefits realised; test and challenge support function
• Bridge the business gap between strategy and execution by implementing effective and efficient project and programme governance
• Improved visibility and insight into Change initiatives and Continuous Improvement performance
• Increase confidence in planning - A well defined baseline plan underpinned by an appropriate level of detailed planning gives confidence that
benefits are achievable; Setting and embedding standards to ensure a common approach to delivery
• Increase confidence in status - Clear and consistent reporting across each programme/project of work, underpinned by reliable data supports
effective leadership; Regular and standardised project reporting to manage costs, resources, timescales, and quality
• Strive to be a catalyst – Game Changer to achieve utmost potential from business and people
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Review System Delivery Framework & VERTO PRO
• Stand-up System Assurance Board; align system activity
• Review of System Reporting Mechanisms
• Design a decision-making/evaluation framework
• Complete ICS Maturity Assessment
• Design/Propose system change management methodology
• Plan for 5 yr strategy design
• Implement decision-making evaluation framework for 20/21 programmes of work/activity
• Start development of 5 yr strategy
• Start development of 20/21 system efficiency programme
• Review VERTO PRO and system delivery framework
• Review of System Transformation in 19/20 and develop proposal for 20/21
• Draft 19/20 Green Paper on System Transformation
• Start development of 20/21 operations plans
ICS Organisational Development and Workforce Strategy
•Common language
•Shared understanding of the ICS
•Common standards
•Common behaviours
•Integrated culture
•Commitment to ICS design and strategy
Values
•Leadership
•Attraction, recruitment & retention of staff
•Employee communications
•Consultation with staff, unions, employee reps
•Staff surveys
Staff Engagement
•Integrating the way we deliver services
•Transformation projects
•Skills development
•Career pathways
•Job design
•Common measures of performance & success
•Agile working – desks/buildings
•Flexible working – MOU to move staff across organisations
•Closer integration of health and social care HR processes and back office teams
•Introducing digital solutions and ways of working using technology
Workforce design and planning
Organisational Development
Vision
The development of a sustainable workforce, empowered to support self-care and health promotion, will be delivered through the new integrated models of care.
Our workforce strategy was developed to ensure that a sustainable workforce would be in place to deliver our vision for our population and we are proactively
working with our system partners to ensure a sustainable clinical, career and business model
Objectives
Shared understanding of the ICS, its vision, aims and objectives across all staff within the system
Common language used where ambiguity currently exists
Evidence that staff across the ICS are emotionally and intellectually committed
• Shared values and standards in use across all staff groups and embedded in relevant policies and procedures
Common behaviours are being role modelled and embedded into all improvement initiatives
New cultural norms are agreed and in evidence across all staff groups
Leadership messages are joined up & consistent across partner organisations
Each partner’s objectives make clear reference to ICS vision & strategy
Results relating to ICS vision & strategy are rewarded, recognised, celebrated
We have the right people in place to drive the change, break down the barriers and role model the right behaviours
The ability to adapt, innovate and evolve to achieve sustainably improved system performance
ICS has the organisational priority & leaders are given the time and resources to focus and deliver improvements in: effective
communication, reputation, culture of innovation, culture of flexibility, service user satisfaction, future orientation, performance against
agreed standards and community involvement.
ICS models are uniformly understood
Everyone understands the part they play to build and support ICS models
Behaviours, attitudes and/or actions that work against ICS models
Organisational Development and Workforce Narrative
What is next:
Develop a OD Delivery
plan for remaining 18/19
and 19/20; ICS Portfolio
Office already developed a
draft based on information
we provided, we will be
socialising on 22
November
Develop a single
secondment
agreement and
honorary contract
across the ICS
Adopt the STP
passport
approach to
Statutory and
Mandatory
training
Align/co-ordinate
elements of
apprenticeships
across BHT, BCC
and the CCG.
ICS OD & Workforce Strategy
“Will doing it together make it even better?”
Engagement, Values & Culture
Leadership
Workforce Design & Planning
Shared understanding of the ICS
Common language
Common standards & values
Common behaviours
Integrated culture
Leaders with shared ICS vision and strategy
Capability and capacity to lead across ICS
Commitment to ICS deliver Care Model and Operating
Model
Integrated planning and working at all levels
Common measures of system performance & success
Suitably skilled staff pulling together regardless of their
organisation to deliver care
Flexible workplace structure to support system working
Positive reputation for public sector working in Bucks
ICS
Aligned educational opportunities to grow our own
teams
Joined up corporate support systems and services
Organisational Development
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Leadership development
programmes are open to
partners across the system and
include work projects with an
ICS dimension
• Working group to drive
integrated planning forward and
help lobby/influence formed
• Right staff with the right skills in
the right place in place starting
with an assessment of ‘as is’ for
Mar 2019 and working towards
‘to be’. Progress with Localities
to be prioritized for delivery by
Apr 2019
• New rotational roles developed
• Jointly agreed sets of
competencies and skills
supporting system roles in place
• Develop a OD Delivery plan for
remaining 18/19 and 19/20; ICS
Portfolio Office already
developed a draft based on
information we provided, we will
be socialising on 22 November
• Improved Staff Survey results
on engagement in 2020
• Shared management model
across the system promoted
• New development opportunities
agreed
• New approach to bank/agency
roles in place for Sep 2019
• Align/co-ordinate elements of
apprenticeships across BHT,
BCC and the CCG.
• Staff moving around partners
within Bucks experience smooth
on boarding
• Develop a single secondment
agreement and honorary
contract across the ICS
• Back office spend is optimised
• Adopt the STP passport
approach to Statutory and
Mandatory training
Clinical and Care Leadership Narrative
Health and social care systems exist to serve a defined population whether the cohort is cut by place, need, demography or condition.
Clinical and care engagement in the design of services that will ultimately be delivered by the clinical and care community (the care-
givers) should go without saying. However over time care givers have had variable input to the direction of travel
The inception of CCGs re-established a very strong clinical leadership within the design and commissioning of services which was
noted as one of the success of the Health and Social Care Act of 2012; having said that the clinical input was primarily from GPs.
That GP leadership was seen as strong collaborative and effective in Bucks, but is was just that: GP leadership. Building on that we have
seen a much more joined up approach to pathway design across the interfaces over the past few years with establishment of strong
relationships, one of the essential foundation stones of integrated working.
ICS status further catalyses that collaborative approach, not only between clinicians within different parts of the health system but also with
the social care colleagues
Delivery of high quality affordable health and social care must reflect the needs to the population it is designed to serve, must have
achievable objectives, must deliver good value for money, must include mechanisms that keep track on delivery and concurrently plan the
next phase of design. It is clear therefore that both commissioner and provider capabilities need to be integrated.
To achieve the aims set out above strong ongoing clinical and care leadership is essential, we must design our systems to embed that
clinical and care element at all levels within our ICS to:
• Contribute to design of services
• Align and drive strategy
• Provide/source expert opinion as required
• Quality assure and feedback
• Engage with the wider community of care givers
• Provide a respected public facing element for the ICS
Clinical and Care Leadership Activity in 19/20
What is next:
• Strengthen the senate in its decision making process, the framework within which it operates
• Establish robust ToR for the senate and strengthen links within ICS structure and with the wider community
• Set senate forward agenda: it must align to the Bucks strategy, act as a reference group to support decision making at ICS
implementation board; needs consistent core membership to maintain stability but also be able to flex depending on the agenda
• Senate has buy in from all partners : needs consistent attendance
• PCN development is key to success of the care model, support CCG directors and FedBucks to get the buy in from practices to
form the base for PCNs
• Contribute to the OD work stream where appropriate as we grow local leaders of the future
• Embed ICS thinking into CPD
• Aim to use Surrey model of ICS items within PDP at appraisal
• Support pathway development that aligns to the strategic direction, drives up quality of delivery, is reflective of the need of the
population and is affordable across the system
• Engage the population of Bucks in the design of future model of services
• Create an engagement process that allows all care givers within Bucks a process by which their voice can be heard
• Build a communication plan that supports the clinical and care model
• Planned 121 discussions with partners in Feb 2019 to review objectives for collective clinical engagement
• Planned Ongoing promotion of the importance of clinical and care leadership and influence at all levels within the ICS
• Strengthen the senate as the reference group that can contribute to all elements within the ICS, it should be the go to place
to develop the clinical case for change. Needs tight management to keep its work aligned to the forward strategy for Bucks
ICS, whilst at the same time needs an element of freedom to develop new opportunities for transformation and engagement,
and act in an advisory capacity to the ICS implementation board
• Clinical and care senate work current future plan includes:
• Develop the case for change for childrens services
• Oversight of variation in 2ww referral patterns
• Hypertension diagnosis rates and effective treatment
Ensuring Clinical Accountability
Our ICS partners have agreed on the principles required for a new model of care based around primary care networks or ‘clusters’ supported
by a multi-skilled and integrated community team. Thirteen such clusters have been identified and are currently working on memorandum of
understandings which support working together in a new model of care provision with agreed health outcomes for the people of Bucks, within
our cost envelope.
Next steps are to harness the motivation for care teams “without walls” and encourage clinically-led care pathway design resulting in shared
responsibility for delivering improved clinical outcomes centred on the person. We will start this with four care pathways in 2018/19 – frailty,
long term conditions, mental health and urgent care.
We will require the correct balance of system, organisation and locality leadership, empowerment and authority to enact change. To do this
we will need to identify clinical leaders. All clinical leaders will have clarity of role with well-defined responsibilities and accountabilities. The
scope of each role will be clear - including non-clinical responsibilities. Any areas of ambiguity or uncertainty will be clarified to include areas
such as supervision arrangements, lines of accountability, line-management responsibilities and where the responsibility lies for the quality
and standard of care provided by a team.
The clinical leadership functions will include:
There will be appropriate measures in place to monitor the safety, quality and outcomes of care provided according to pre-defined standards.
This will be especially important in areas of significant service change. Quality will be reviewed on a regular basis within a culture of
supportive peer support and continuous development.
Buckinghamshire ICS Estates
As part of BOB we are developing a strategic investment programme for our estates and the use of capital to enhance health and care
environments. Existing capital funding is being used to improve A&E at Stoke Mandeville (phase 2 to be completed in 2020) and develop
Primary Care Hubs in Buckinghamshire. There were also recent successful wave 4 bids for Child and Adolescent Mental Health Services in
Berkshire, low secure learning disability unit in Oxfordshire and investment in the delivery suite theatre at the John Radcliffe Hospital.
Our strategy will support the development of facilities to meet acute care needs of our growing populations (including theatres, critical care
and maternity services), to develop integrated health and care centres and to further support improvements in primary care. While all sources
of capital are being considered we anticipate wave 5 NHS capital programme in spring 2020 and Buckinghamshire ICS is working to ensure
feasibility and business cases are in place by the end of 2019.
Key Deliverables 2019/20 Completion
A&E refurbishment July 2020
Primary Care Hubs business case April 2019
Buckingham Health and Care Centre Business
Case
July 2019
Stoke Mandeville Hospital acute services feasibility
study
April 2020
Community hub pilots in Iver, Marlow Library and
Buckingham
Ongoing
Buckinghamshire estate supports the overall strategic
direction for the ICS – new integrated models of care,
meet the local population needs and growth i.e. right
locations, right condition, right sized
Modern, flagship buildings, centres of excellence
such as National Spinal Injuries Centre, Innovation
Centre)
High quality, modern and flexible use estates
Overhead costs to perform below national average
Energy efficient sites
Backlog maintenance under control as part of a
scheduled rolling funded plan
Our vision for Estates
Developing Health and Care Centres
Section 10 Digital Transformation Delivery
Board
ICS Digital Vision and Strategies
Technology
Strategy Information
Strategy
Digital Strategy
The Tools • Single digital front door – council and
health • PHR - Patient Held Record - access and
ability to update their care record • E-bookings/Self-check ins - Interactive
on-line resources and wearable technology
• Digital enabled workforce – training, development and access to digital tools/devices
• Virtual consultations - choice between physical and virtual consultations (where appropriate) – requires significant business change
Transformation • Empowering patients to actively manage
their health and care and help to improve services through digital participation
• Empowering staff • Remote monitoring for preventive and
self-care management
Using technology to
shape service around
individual need
Vision: • Joined up public sector
• Business process redesign,
• Business transformation – not
replicating current processes
To empower individuals to actively
manage their health and care through
improved digital service delivery
Using data to model current and future
service provision with the aim to deliver
care at the most local point of need
The Tools • Build single version of the truth using
the data in CareCentric – spanning all care and health
• Develop/use modelling tools that can be used across Bucks
• Implement predictive analytics / population health management tools on the CareCentric data layer
Transformation • Understanding our capacity / demand
– understanding the determinants of care and health needs
• Shift from a reactive to proactive management using predictive data and investing in modelling
• 24/7 patient tracking in real time – move to controlling demand and patient flow
• Real time access to performance, outcomes, alerting and effectiveness data - real time dashboards
The Tools • Single sign on • Mobile access / remote working • Desktop and server refresh • New voice and data network (ICS wide
WAN/LAN/WiFi) • My Care Record - Shared record • Robust Cyber security • Single domain • Video conferencing across ICS • Open standard interfaces • Careflow Connect – clinical comms
across the ICS • EPMA – electronic prescribing • EObs – real-time recording of patient
observations (in hospital)
Transformation • Real-time data / information • Standardised workflows • Standardised patient flows
ICS Digital Transformation and Interoperability
Executive Summary
Digital Transformation serves as the underlying enabler of all transformation of services & care and provides new technology platforms for the
delivery of new care models, removing boundaries between care settings which is a cornerstone of the new 10 Year Programme.
2018/19 saw the core enablers laid down and the emergence of new national vision through the LHCRE programme
2019/20 will see the takeup and development of the shared record including closer working with Frimley and West Berkshire Connected Care
and further linking of records and datasets through the Thames Valley and Surrey Local Health and Care Record Exemplar (TVS LHCRE)
Partnership and the Cancer Care Alliance.
Objectives
• Develop a fully integrated, linked data set (realised by “My Care Record”)
• Integrate Primary Care and Community systems to deliver efficiencies and enhance the linked data set (realised by EMIS Clinical Services)
• Ensure delivery of a “fit for purpose” analytical and modelling tool. (realised by Graphnet PHM/BI)
• Coordinate with system-wide transformation partners regarding other relevant tools, data streams and analytics
• Commission and deliver a data system for supporting self-care (realised by Personal Held Record)
• Support delivery of the digital Patient Activation Measures (PAM) (realised by Personal Held Record)
• Deliver a Portal for clinicians to view patient information and outputs from any risk stratification (realised by Graphnet PHM/BI)
• Utilise learning form PHIE group to inform decisions regarding tools and analytical/digital capabilities and capacity through DTSG)
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• My Care Record live
• PHM/BI reports from Graphnet
used in decision making
• Ask NHS Self triage tool rolled
out to 30% Bucks Practices
• Direct EMIS to EMIS referrals
enabled for approved services
via EMIS Clinical Services
• EMIS Mobile rolled out to pilot
ACHT team using EMIS
Clinical services
• 111 Direct Booking into pilot
practices
• Social Care integration into
Shared Record
• Merged data platforms with
Frimley ICS
• Personal Held Record (PHR)
live via LTC Team
• LHCRE IG Framework
• Ask NHS Self triage tool rolled
out to 60% Bucks Practices
• EMIS Clinical Services
benefits realisation
• 111 Direct booking into
Improved Access Hubs
• CareFlow across ICS
• Integrated analytics with TVS
LHCRE
• Ask NHS Self triage tool rolled
out to all Bucks Practices
• Ask NHS Benefits realisation
• Direct Booking Benefits
realisation
• Embedding transformations
and optimising utilisation
GPIT & Digital Transformation Programme
Executive Summary
The GPIT & Digital Transformation programme is carried out by SCW CSU and supports Primary Care and the wider community with IT provision
and transformation services to enable new and improved ways of working. This underpins key Primary Care and wider Health and Social Care
national initiatives such as the NHS Long term plan. The teams work in collaboration with Buckinghamshire CCG and Primary Care sites to
transform and continually improve the planning and delivery of digital services to GP practice end users and patients.
Objectives
• Maintain & improve the local IT infrastructure to meet the required standards for the future e.g. Windows 10 and HSCN (N3 replacement).
• Enable new ways of working by providing improved mobile technology, software and applications where and when needed.
• Providing and facilitating the use of patient centred technology.
• To continue to progress the national Paperless by 2020 agenda with Primary Care and other NHS and private providers in increasing uptake
of electronic communication and messaging systems thereby reducing paper use.
• Supporting end users to maximise the utilisation of the new technologies delivered.
• Provide IT support for GP practice mergers, premises moves, expansions and clinical system changes
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• Commence deployment of:
• HSCN
• Docman 10
• PC replacements
• Mobile devices
• Continue to support practices to meet
national targets for:
• GP Online
• EPS
• Plan upgrade to Windows 10.
• Maintain IT support for GP practice
issues.
• Continue support for :
• Electronic messaging
• Change to Snomed
• Plan deployment of clinical decision
support tool.
• Pilot the deployment of NHSmail in
Care Homes.
• Progress deployment of:
• HSCN
• Docman 10
• PC replacements
• Mobile devices
• Continue to support practices to meet
national targets for:
• GP Online
• EPS
• Progress the upgrade to Windows 10.
• Maintain IT support for GP practice
issues.
• Continue support for :
• Electronic messaging
• Change to Snomed
• Deploy clinical decision support tool.
• Review pilot of NHSmail in Care
Homes & plan next steps.
• Progress deployment of:
• HSCN
• Docman 10
• PC replacements
• Mobile devices
• Continue to support practices to meet
national targets for:
• GP Online
• EPS
• Complete the upgrade to Windows
10.
• Maintain IT support for GP practice
issues.
• Continue support for :
• Electronic messaging
• Change to Snomed
• Progress deployment of:
• HSCN
• Docman 10
• PC replacements
• Mobile devices
• Continue to support practices to meet
national targets for:
• GP Online
• EPS
• Maintain IT support for GP practice
issues.
• Continue support for :
• Electronic messaging
System Informatics
Executive Summary
Business intelligence (BI) is a set of methodologies, processes, tools and technologies that transform raw data into meaningful, useful and
actionable information. Once processed, this data can be used to enable more effective strategic, tactical and operational insights and decision-
making which will mean larger efficiency savings and better care for patients. A common understanding of BI will allow stakeholders to identify a
common problem, enabling productive joint problem solving behaviour in a more efficient manner. Applying this approach to systemic views is
essential to the transformation agenda.
Objectives
• Interface of BI with other services is key to allowing it to operate at full potential.
• Analytics will help drive improvements in population health, quality of care provision, workforce effectiveness and financial sustainability of the
system.
• The focus of analytics should be to use a holistic approach to ensure longevity.
• The system will require high quality data processed through a local digital roadmap to generate a productive output.
• Data collection and quality must be prioritised, matching resources to greatest need.
• The analysis output needs to be instructive and clear with effective dashboards
19/20 Key Milestones and Deliverables
Q1 Q2 Q3 Q4
• System-wide BI Leadership
• Sustainable capacity and
skills for delivering
population health
management (PHM) and
wider health insight
programme long-term
• Accessibility of the current
reports and data
• Applicability of the current
30+ reports and dashboards
• Analysis and triangulation of
the datasets
• Maximising current reports
and dashboards
•
• Strategic insight and
intelligence capacity
• Place-based approach
• A more rapid, collaborative
approach
• More active involvement of
BCCG in strategic initiatives
• Establishment of clarity on
how Buckinghamshire CCG
and ICS will operate
together.
• Agree BI Transformation
proposal
• Implement BI
Transformation
Communication and Engagement
Vision
Ensure that all stakeholders are well informed and have the opportunity to contribute to the development, implementation and success of the ICS;
through the most appropriate channels to meet their specific needs.
We will involve people in what is changing through engagement, co-design and co-production to ensure we get it right first time whilst
communication will be plain English and jargon free, using the Flesch-Kincaid readability tool. We will ensure stakeholders have every
opportunity to be involved.
Objectives
• Involvement of Buckinghamshire residents in shaping the services we plan, commission and deliver
• Understanding of all our audiences and how to reach all groups including those we don’t hear from
• Improved patient and service user experience for those receiving NHS and/or social care services
• Improved understanding of the system and how to navigate ensuring single points of access and seamless service delivery
• Greater understanding of the system and what the changes in each organisation mean for each other
• Involvement of staff in identifying opportunities for better integration
• Increased knowledge of each others roles and how they contribute to residents health and well-being
• Improved understanding of health and care as one system
• Spreading good practice across the system
• Using real examples and demonstrating the strengths in our system will support our recruitment and retention drives showing
Buckinghamshire as a “good place to work”
Programme Communication & Engagement
April – June 2019 July – September October – December January – March 2020
• ICS Staff Health and Social Care
Roadshows – across whole
system (including promotion of
Staff Ideas Scheme)
• Engagement on Long Term Plan
• Continued promotion of
Buckinghamshire ICS website
• Continued publication of ICS
newsletter
• Publication of ICS Glossary of
terms
• Launch of ICS Digital
Engagement tool
• Launch of ICS Citizens Panel
• Dignity in Care Awards
• Continued work of Getting
Buckinghamshire Involved
Steering Group
• Promotion of Buckinghamshire
Online Directory (Community
asset mapping tool)
• Planning and drafting Digital
Communications Plans
including:
- Adult Social Care digital
Front Door
- My Care Record
(LCHRE, i-Cares)
• Continue delivery of work
stream communications and
engagement plans
• Continue delivery of Digital
Communications plans
• Support for communications
and engagement activity for
Community Hubs
• Continue ongoing staff
communications
• Continue delivery of work
stream communications and
engagement plans
• Continue delivery of work
stream communications and
engagement plans
• Review Communications
and Engagement Plan
Section 111 Finances
ICS Financial Plan
Financial sustainability continues to be one of the strategic aims of the ICS and significant amount of shared resource has been and will
continue to be required to support this.
The allocations for 19/20 provide welcome additional funding for both providers and commissioners, however, the majority of new funding is
committed to cover inflation, tariff changes and the requirements of the Long Term Plan.
CCG Allocation 2019/20
Average Allocation per Head of Population £
Buckinghamshire CCG 1,150
England average 1,321
The above implies that the CCG is under-funded by a minimum of 10% on an average allocation per head (after taking into account the
distance from target) and therefore should potentially be doing -10% activity when compared to the NHS England average.
As a result of changes to the national allocation methodology, Buckinghamshire CCG has moved its core allocation from being 2.69%
below target allocation in 2018/19 to 2.61% below target funding in 2019/20.
ICS Financial Plan – Gap Analysis and Efficiency Requirement
The underlying deficit across the ICS is circ £53m as shown below. The gross efficiency target in the plan for 2019/20 is £33.7m (£43.7m less
£10m Control Total).
BHT
£000s
CCG
£000s
TOTAL
£000s
2018/19 deficit (25,407) (10,072)
Non-recurrent Funding 2,174 (6,049)
Other non-recurrent action (1,928) (11,869)
Recurrent position (25,161) (27,990) (53,151)
Allocation increase 18,561 40,631
Price/tariff inflation 2,785 (11,890)
Investments (846)
MH and community commitments (2,551)
Growth (3,400) (14,637)
Cost pressures/cost associated with growth (1,620) (13,889)
Rebuild contingencies/reserves 0 (3,690)
Sub Total (8,835) (34,862) (43,697)
Efficiency 8,835 24,862
Control Total* 0 (10,000) (10,000)
* Excludes CCG CSF of £10m
The ICS is focussing on the top 3 schemes that will take costs out of the system. There is a system efficiency group set up supported by the PMO.
ICS Financial Plan – Compliance with Financial Rules
The system’s ability to comply with the financial rules is assessed below, with the main risk highlighted around the achievement of individual
and system control totals:
BHT CCG
Break-even in year within their overall allocation. Risk adjusted
deficit of £21.2m
Have a cumulative surplus of at least 1% of allocation.
Set aside a contingency which is 0.5% of overall allocation.
Invest into Mental Health services to ensure spend in 19-20 is 6.4% more
than spend in 18-19
Achievement of control total Risk adjusted
deficit of £21.2m
Achievement of system control total
Financial RuleCurrent Rating
Net risks and therefore non-
compliant plan
ICS Financial Plan – Activity Growth
High level growth assumptions are outlined below:
Commissioning segment £000s
BHT (based on detail projections) 0.9%
Other Acute (targeted to reduce risk in the system) 1.5%
Prescribing (5.6% gross growth less £2m QIPP) 2.4%
CHC (5.5% gross growth less £2m QIPP) 2.2%
BCF (as per guidance) 1.8%
Community 1.7%
Ambulance (9s contract as per guidance) 2.17%
BHT Financial Plan
The Initial draft financial plan for 2019/20 delivers a break-even position consistent with the NHSI Control Total letter, although importantly,
this is before the application of commissioner QIPP and other initiatives to address the ICS financial gap. The Trust accepts the NHSI Control
Total to deliver break-even for 2019/20 and funding offer therein. The plan assumes in-year delivery of the efficiency plan of £7.0m for
2019/20 (1.6% of income) in line with national planning guidance. The trust expects the final efficiency plan target to increase to c£15.0m
(c3.5% of income) once the response to commissioner QIPP and the ICS financial recovery is included. The final efficiency plan for 2019/20
will be developed through collaboration and working with the ICS over the next 7 to 8 weeks
Rinstated Plan Forecast Forecast
£m 2017/18 2018/19 2018/19 2019/20
Bucks CCG contract 243.0 245.7 245.7 271.9
Associates and Other CCG Contracts 50.0 55.9 59.6 63.3
Wessex ( Spec Comm) Contract 69.7 69.0 68.1 72.3
Other Commissioners 19.8 25.3 18.9 24.2
Operatin Income from Patient Care Activities 382.5 395.9 392.3 431.7
Other Operating Income 25.1 23.2 27.1 27.1
Employee Expenses (249.9) (250.1) (261.3) (277.7)
Operating Expenses excluding Employee expenses (149.2) (157.0) (168.4) (179.4)
Operating surplus/(deficit) 8.5 12.0 (10.3) 1.7
Net finance costs (14.0) (14.0) (14.1) (15.1)
Other gains/(losses) including disposal of assets 0.0 0.0 0.0 0.0
Surplus/(deficit) - pre PSF (5.5) (2.0) (24.4) (13.4)
Technical Adjustments
Add back all I&E impairments/(reversals) (1.7) 0 0 0
Retain impact of DEL I&E (impairments)/reversals 0.0 0 0 0
Remove capital donations/grants I&E impact (0.7) (1.0) (1.0)
Adjusted financial performance surplus/(deficit) including PSF (7.9) (2.0) (25.4) (14.4)
Provider Sustainability Fund (PSF) non-recurrent 5.0 11.9 0 14.4
Surplus/ (Deficit) - post-PSF (2.9) 9.9 (25.4) 0.0
BHT Financial Plan
Risks & Mitigations: The trust has identified key risks and will be reviewing mitigations for the following.
1. Delivery of the agreed forecast outturn for 2018/19 and opening position for 2019/20.
2. Carrying of c£5m of balance sheet risk in to 2019/20.
3. Lost income resulting from cancelled elective work.
4. Managing agency spend and premium staff costs due to vacancy rates.
5. Managing unplanned in-year cost pressures.
6. Delivery of the efficiency plan.
7. Limited capital funding.
8. Increased maintenance as aged estate and equipment requires replacement/repair.
9. Potential effect of the revaluation of land and buildings and asset lives.
Any residual risk is likely to impact the trust’s ability to achieve its financial plan in 2019/20.
Efficiency : The Efficiency Improvement Programme 2019/20 aims to achieve long term productivity gains and efficiencies at no more cost,
grow commercial income, building on cross-system working linked to the Bucks ICS. The programme currently stands at £12.5m, with an
unidentified gap of £2.5m to achieve a total of £15m savings. However, this is at an early stage of development.
The trust has an established governance process which will continue into 2019/20. Executive Directors will be accountable for benefits
realisation in their sponsored programme workstreams. Divisional Directors will be responsible for delivery of project plans to ensure local
ownership. PMO and Service Improvement Teams will facilitate and monitor delivery .
The Efficiency Improvement Programme is made up of 11 workstreams covering :
- Agency/workforce - Back Office. - Commercial Income - Diagnostics/Pathology - Housekeeping
- Estates/Facilities - Patient Flow - Outpatients Productivity - Pharmacy/Drugs - Procurement/Non Pay
- Theatres productivity & Elective Pathway
At present wave 1 of workshops are being completed, and wave 2 due to take place at the end of February/ start of March, with CCG/ STP
system input.
CCG Financial Plan
The financial plan is summarised below. The underlying exit run-rate out of 2018/19 is a deficit of £28.1m.
Revenue Resource Limit
£ 000 2018/19 blank12019/20
Recurrent 693,131 733,762
Non-Recurrent 10,266 -
Total In-Year allocation 703,397 733,762
Income and Expenditure
Acute 360,235 379,869
Mental Health 63,020 67,674
Community 56,802 58,901
Continuing Care 58,649 59,356
Primary Care 82,493 83,024
Other Programme 12,813 7,712
Primary Care Co-Commissioning 68,564 72,890
Total Programme Costs 702,575 729,425
Running Costs 10,893 10,646
Contingency - 3,690
Total Costs 713,468 743,761
£ 000 2018/19 2019/20
Underspend/(Deficit) In-Year Movement (10,072) (10,000)
In-Year (RAG) RED RED
Net Risk/Headroom (11,212)
Risk Adjusted Underspend/(Deficit) (21,212)
Risk Adjusted Underspend/(Deficit) (RAG) RED
Note
Reported
Position
Underlying
Exit Run
Rate
2017/18 1 (£19.0m) (£32.6m)
2018/19 2 (£15.5m) (£28.1m)
2019/20 3 (£10m)
1 Underlying deficit. Reported deficit was (£19.0m)
2 Planned deficit as per 30 April submission. Excludes
CSF funding from NHS England.
3 Based on CCG assumptions. Excludes CSF funding
from NHS England.
CCG Financial Plan
The financial plan has been prepared taking into account NHS England specific assumptions around growth and inflation and the business
rules set out in the refreshed planning guidance. These are summarised in the table below:
NHS ENGLAND PLANNING ASSUMPTIONS & BUSINESS RULES 2019-20
Business Rules Minimum 0.5% Contingency Fund Held 0.5%
Mental Health Investment Standard (MHIS) requirement 6.4% ( 5.7% allocation growth + 0.7%) 6.4%
£1.50/head – Primary Care Networks Achieved
Growth & Inflation
Assumptions
Demographic Growth-local determination based on ONS age profiled weighted population
projections
0.8%
Prescribing Inflation expected range 4%-7% gross – (plan includes 5.6% gross less £2m QIPP ) 2.4% net
Continuing Healthcare inflation – 5.6% gross ( plan includes 5.6% gross less £2m QIPP) 2.2% net
Net QIPP Savings of £24.8m 3.4%
Running Costs Not to exceed management costs allowance in each financial year (budget included £20.66 per
head, however, plan to underspend to move towards 20% recurrent reduction required from
1/4/2020). The CCG will reduce costs by 10% in 2019/20 and a further 10% ahead of 2020/21,
Achieved
- £18.88
per head
Control Total The CCG has unidentified QIPP of £11.2m and this is shown as a net risk. The risk adjusted
deficit position is £21.2m (£10m planned deficit + £11.2m unidentified QIPP). The underlying exit
run-rate exiting from 2018/19 is £28.1m deficit.
Risk
Adjusted
Deficit
Savings – the financial gap for 2019/20 is £34.8m to break even. The risk assessed savings target is £24.8m equating to 3.4% of resource.
The Control Total is a deficit of £10m. As outlined above in the financial challenges section, the CCGs are committed to recovery and have
worked hard over the past couple of years with robust PMO support established, working across the Bucks system, and reviewed all areas of
opportunities available to us from which our main priority initiatives, existing and proposed, have been developed. These include:
As part of our ICS focus we have agreed with Buckinghamshire Healthcare NHS Trust that we will implement joint plans in relation to both
elective and non-elective activity. This will be informed by our analysis of Right Care and focus in particular on respiratory, MSK, Outpatient
transformation and Frail non-electives.
• Right Care Value Packs • National Benchmarking Information • Difficult Decisions Document
• Menu of Opportunities • National Vanguards • NHS 10 point efficiency plan
• Continuing Healthcare Packages in terms of cost and against agreed eligibility criteria
Overall Surplus/Deficit - the CCG faced a deficit position of £15.5m in 2018/19 and successfully received non recurrent Commissioner
Sustainability Funding (CSF) of £15.5m from NHSE, assuming the plan position is met, to achieve the required in year break-even position
(underlying is £28.1m deficit). In terms of the CT for 2019/20 of £10m, the CCG is current showing a risk adjusted deficit of £21.2m (the
balance of £11.2m being unidentified QIPP). The CCG will aim to close this gap for the final submission. This poses a huge challenge to both
the CCG and ICS.
CCG Financial Plan
Risks and Mitigations
• NHS Continuing Healthcare – Further increase in demand for placements/packages of care, once assessed as meeting the eligibility
criteria, remains a risk.
• Savings delivery – The cash releasing target for 2019/20 of £24.8m (3.4%) carries a significant risk of non-delivery to the CCG with
£11.2m of system efficiencies unidentified currently, and this has been shown as a corresponding net risk to the plan. This will be mitigated
by a strengthening of our Programme Management Office (PMO) and continued focus on identifying further opportunities, as well as cross
system working in the ICS. Diagnostic support from NHS E/I will help us focus on 3 most effective cost-reducing schemes across the
system. Further savings may be required to reflect contract offers.
• Prescribing –Spend in this area is well managed and QIPP schemes in prescribing have been developed, whilst the schemes are robust
and the rationale is clear there is a risk they may be offset by increasing pressure, however, it is anticipated that full year impact of
schemes commenced in 2018/19 will aid mitigation during 2019/20
• Impact of historic deficit – The CCG finished 2017/18 with a deficit position of £19.1m and £3.24m of this has been carried forward as an
historic deficit. 2018/19 is currently on track to achieve the in-year break even target and as such there is no perceived impact of further
historic deficit above 17/18 levels. This is not anticipated to be required to be repaid in 2019/20 and so no impact assumed on the 2019/20
plan.
• IR Changes and pbr tariff changes – the impact of proposed changes within this area will need to be worked through when pbr tariff
consultation is concluded and further guidance is received, but, could potentially pose a risk to the Bucks system.
• Acute over-performance – A risk that demands for acute services, such as emergency care and elective care exceeds the level of growth
assumed within the plan. Over-performance could also occur as a result of non-delivery of the QIPP programme.
If such risks occur, they will be mitigated by the use of contingency initially, although there will be the need to implement additional actions,
such as extra QIPP schemes, disinvestment and decommissioning as required.
The CCG has put a financial recovery plan in place and as such, all discretionary expenditure and planned investments are held until
evidence of value based outcomes are received through robust business cases. The ICS will now work on a longer-term joint FRP.
Resource Limit – the CCG’s resource limit increased in 2019/20 to £733.8m. The increases are due to core growth 5.7% (£35.4m);
delegated primary care growth 6.3% ( £4.3m). There has also been an additional recurrent allocation of £0.9m The CCG remains below target
allocation by 2.6% (but 10.3% below when we compare it to the national NHS England funding).
Running Costs – such budgets remain static in line with NHSE guidance. This results in a budget of £20.66 per head of population in
2019/20 of which only £18.88 per head is planned to be spent in year, a move towards the 20% recurrent reduction requirement from 1/4/2020.
ICS Financial Plan – Next steps on Finance and Closing the gap
The ICS has a system gap in 2019/20, there are unidentified efficiencies. Both the CCG and Trust are working together to close this gap
ahead of the next submission.
In terms of main areas of focus:
• NHS E/I support on system diagnostic to understand drivers of deficit and focussed areas for efficiencies
• Review of activity using Right Care (supported by NHS E Rightcare delivery partner) and other available data sources to reflect our
‘under allocation’ – focus on clinical thresholds and basis of referral
• System efficiency team set up to ensure delivery of system efficiency and transformation by reducing costs across the system
• System Financial Recovery plan being developed over a 3 year time-frame
• Support from Monmouth in terms of reviewing IFR and coding for Independent Sector contracts/London and Frimley
• Support from national team on maximising Continuing Healthcare Opportunity
Section 12 Closing Summary
Section 6: Closing Statement
1
5
2
4
3
We aim to deliver improvements in the quality and value for money of care we provide, working to deliver the
national priorities and our three core programmes and six enablers:
Integrated Care
Prevention & Inequalities
Care quality & outcomes
Workforce
Digital
Efficiency
Engagement
BOB STP Priorities Our Priorities
Mental Health
Community Service Integration
PCNs
Non-Elective Demand
Management
Elective Care Transformation
Adult Social Care
Transformation
Digital Transformation
OD/Workforce
One Public Estate
System wide-PMO
Communication and Engagement
Finance
Population Health
Our Enablers
Change needs to happen as close to people as possible, putting the person at the centre of what we do. This is
why local relationships are the basis of our plans; moving from traditional cultures to embracing a transformational
system approach, where we help each other to better deliver continuous improvement;
Health and Care Centre’s will bring social, physical and mental health care closer together and local health and
care partnerships will come together to deliver care where council and NHS commissioners plan and pay for
services together;
Housing, employment and access to green spaces can have the biggest impact on health. Local
government has a key role to play and health research is helping us to target those people at risk.
We are committed to meaningful conversations with staff and communities and we will continue
to engage people in the design, development and delivery of our plans;
Closing Summary
6
We must balance the social, physical, and mental health care against a financial deficit while
meeting operational needs creating long term sustainability and maintaining investment in people.
7
We will invest in the development and skills of our workforce to enable them to
provide the best possible care. We have produced a plan to achieve this which
also covers recruitment and retention.
8
The financial challenge we face is the biggest in a generation. Our response is around getting
the best value from every Buckinghamshire pound. We will also be very open about the
choices we have to make to live within our means.
9 Over the past twelve months our partnership has made major strides
towards working together to improve social, physical and mental health care
10 What will this all mean:
Buckinghamshire people supported to live independently
Care integrated locally to provide a better support closer to home
If you have multiple health conditions, there will be a team supporting your physical, social and mental health needs.
‘Everyone working together so that the people of Buckinghamshire have happy and healthy lives’
Closing Summary
Section 13 Appendices
Appendices
1. Glossary of Terms
2. Link to System Partner Operations Plans 19-20
3. System Performance Details
4. System Financial Details
Glossary of Terms
Buckinghamshire Integrated Teams is a team of health and care professionals working together transforming, integrating and improving
care services and support.
Business Intelligence comprises of the strategies and technologies used by industry for data analysis or business information. Business
Intelligence technologies provide historical, current and predictive views of business operations.
CareCentric is a clinical portal which opens up the electronic health record to authorised users on smartphones and tablets. It gives care
professionals access to patient data wherever they need it, whether at various locations within a hospital or GP practice, at other hospitals,
in the community or at home.
Careflow is a communication platform available on any mobile or web device delivering faster clinical communication, better collaboration
and safer care.
Clinician is someone whose prime function is to manage a sick person with the purpose of alleviating the total effect of the persons illness.
Commissioning is the process of procuring health services. It is a complex process, involving the assessment and understanding of a
population's health needs, the planning of services to meet those needs and securing services on a limited budget, then monitoring the
services procured.
Continuing Healthcare is the name given to a package of continuing care which is, arranged and funded solely by the NHS, for people
with ongoing healthcare needs who meet the national NHS continuing healthcare eligibility criteria.
Egton Medical Information Systems (EMIS) supplies patient electronic records and software.
Frailty is related to the ageing process, that is, simply getting older. It describes how our bodies gradually lose their in-built reserves,
leaving us vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in
medication or environment. In medicine, frailty defines the group of older people who are at highest risk of adverse outcomes such as falls,
disability, admission to hospital, or the need for long-term care.
Integrated Care also known as integrated health, coordinated care, comprehensive care, seamless care, or transmural care, is a worldwide
trend in health care reforms and new organisational arrangements focusing on more coordinated and integrated forms of care provision.
Interventions is an effort that promotes behaviour that improves mental and physical health, or discourages or reframes those with health
risks, as part of a public health promotion program.
Glossary of Terms
Memorandum of Understanding is an agreement between two (bilateral) or more (multilateral) parties. It expresses a convergence of will
between the parties, indicating an intended common line of action.
Person Held Record is a health record where health data and information related to the care of a patient is maintained by the patient.
Planned Care are health services and treatments that are not as a consequence of a health accident or emergency. This type of care is
arranged in advance and, generally, follows a referral from a GP.
Population Health is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a
single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.
Population Segmentation is based on identifying segments of the population whose needs could be better met in delivering benefit against
the quadruple aim. Often this will initially be based on a presenting problem, e.g. fall, but behind the presenting problem will be a more
complex set of health and well-being needs that need to be more fully understood to enable better care and support models to be developed
and delivered.
Reablement is the service usually provided to people for up to six weeks to encourage them to achieve their goals and to be as
independent as they can be.
Social Prescribing sometimes referred to as community referral, is a means of enabling GPs, nurses and other primary care professionals
to refer people to a range of local, non-clinical services.
System Partner Operational Plans 19-20
