Knowsley Health and Social Care Transformation · Through this document Knowsley CCG and Knowsley...

Knowsley Health and Social Care Transformation Programme

Design and implementation plan for an Integrated Care Service Model for Knowsley

Knowsley Health and Social Care Transformation

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Version Control

Document details Programme Health and social care transformation programme Status Final Version

Document summary The document defines the design and implementation plans for the integration of primary, community and social care services in Knowsley.

Through this document Knowsley CCG and Knowsley Metropolitan Borough Council seeks to mobilise the Transformation work programme of further integrated working across health and social care services within Knowsley.

Version control details Version Date Description / purpose of changes 0.1-2.6 Feb-March Internal project team working drafts 3.0 11th March Draft for review by AO 4.0, 4.1 17th March Designed document and amendments 4.3, 4.4 30th March Amendments following AO feedback 4.7 11 April Amends post prioritisation, Ops plan and Governing Body 5.0 28 May Amends, Finances, STP and formatting 5.2 9 June GP practices list amended, draft for KMBC review 6.0 9 August Comments from KMBC integrated 6.1 15th Nov Final comments from KMBC ASC integrated 7.0 22nd Nov Final edit for Governing Body approval

8.0 1st Dec Final version Governing Body approved


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Contents

Version Control ....................................................................................................................................................... 2

Contents ................................................................................................................................................................. 3

Figures and tables .............................................................................................................................................. 4

Introduction ............................................................................................................................................................ 6

Background ........................................................................................................................................................ 6

Strategic Context ................................................................................................................................................ 6

The diagnostic .................................................................................................................................................... 7

1. The case for change ....................................................................................................................................... 9

1.1. Demographics and Demand ................................................................................................................ 10

1.2. Finance and Sustainability................................................................................................................... 14

1.3. Securing our future workforce ............................................................................................................ 15

1.4. Technology as an enabler for better care ........................................................................................... 17

2. Our vision, governance and principles for change ....................................................................................... 21

2.1. Vision................................................................................................................................................... 21

2.2. Design principles ................................................................................................................................. 21

2.3. Governance ......................................................................................................................................... 22

2.4. The design process – co-production: .................................................................................................. 25

3. Our model for integrated health and social care ......................................................................................... 27

3.1 Primary care at the centre: ................................................................................................................. 27

3.2 Multi-specialty working:...................................................................................................................... 27

3.3 Improved access to primary care ........................................................................................................ 28

3.4 Transformed community services ........................................................................................................ 32

3.5 Support for care / nursing homes ....................................................................................................... 40

3.6 Cross cutting workstreams .................................................................................................................. 41

4 Operating model .......................................................................................................................................... 43

4.1 Self-care support ................................................................................................................................. 43

4.2 Care Coordination ............................................................................................................................... 44

4.3 Care planning & case management .................................................................................................... 44

4.4 Implementation of transformed services ........................................................................................... 49

4.5 Multi-Disciplinary working .................................................................................................................. 50

4.6 Assessment – entry into MDT care ..................................................................................................... 57

4.7 Primary care enhanced access ............................................................................................................ 58

4.8 Nursing home support ........................................................................................................................ 58

4.9 Resident stories ................................................................................................................................... 58

4.10 Opportunities for subsequent years’ transformation ......................................................................... 61


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5 Impact on and interaction with the wider health and care system ............................................................. 63

5.1 Transition in and out of acute care ..................................................................................................... 63

5.2 Interaction with wider council services............................................................................................... 64

5.3 Interaction with the Voluntary Sector ................................................................................................ 67

6 Care outcomes and quality .......................................................................................................................... 70

6.1 Target outcomes for the new Model of Care ...................................................................................... 70

6.2 Equality and quality impact assessment ............................................................................................. 74

7. Finance and sustainability............................................................................................................................ 76

7.1 The local financial challenge for Knowsley.......................................................................................... 76

7.2 Delivering the outcomes for the people of Knowsley – opportunities ............................................... 77

7.3 Modelling the impact of a transformed service offering for the people of Knowsley ........................ 78

7.4 Activity Split assumptions ................................................................................................................... 78

7.5 Activity & Tariff Growth assumptions ................................................................................................. 79

7.6 The Affordability Model ...................................................................................................................... 80

8 Enablers ....................................................................................................................................................... 82

8.1 Risk Stratification ................................................................................................................................ 82

8.2 Diagnostics .......................................................................................................................................... 82

8.3 Screening and early detection............................................................................................................. 82

8.4 Workforce ........................................................................................................................................... 82

8.5 Digital, IT & Information Sharing......................................................................................................... 85

8.6 Communications and engagement ..................................................................................................... 85

8.7 Estate .................................................................................................................................................. 87

9 Timelines and implementation plan ............................................................................................................ 89

9.1 2016/17 In-year transformation ......................................................................................................... 89

9.2 Implementation plan........................................................................................................................... 90

10 Next steps .................................................................................................................................................... 92

Appendix A: Quality and Service Standards ......................................................................................................... 94

Appendix B: Current locality services ................................................................................................................... 98

Appendix C: MDT Terms of Reference for pilot stages of care model ............................................................... 101

Appendix D: Accountable Care Coordinator Role Description ........................................................................... 106

Figures and tables

Figure 1: STP planning levels .................................................................................................................................. 6 Figure 2: The case for change in Knowsley Care Services....................................................................................... 9 Figure 3: Primary care workforce age distribution ............................................................................................... 15 Figure 4: Transformation Governance.................................................................................................................. 23


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Figure 5: Community services wrapped around primary care ............................................................................. 27 Figure 6: Enhanced primary and community offer ............................................................................................... 28 Figure 7: Primary care communication channels ................................................................................................. 30 Figure 8: Multi channel access model .................................................................................................................. 31 Figure 9: Transformed Community Services......................................................................................................... 32 Figure 10: Coordinated, multi-specialty care........................................................................................................ 33 Figure 11: Illustrative service configuration ......................................................................................................... 34 Figure 12: Locality key figures .............................................................................................................................. 38 Figure 13: Social care referrals – in/out Borough GP surgery split ....................................................................... 39 Figure 14: Social care referrals split by locality .................................................................................................... 40 Figure 15: Nuffield Predictive Model .................................................................................................................... 40 Figure 16: Non elective admissions from Care Homes ......................................................................................... 41 Figure 17: Case management ............................................................................................................................... 46 Figure 18: Settings of care delivery ...................................................................................................................... 46 Figure 19: Care planning and case management.................................................................................................. 48 Figure 21: The Multi-Disciplinary Team ................................................................................................................ 50 Figure 22: Pyramid of need - MDT support .......................................................................................................... 53 Figure 23: MDT levels of operation ...................................................................................................................... 53 Figure 24: MDT to referral and interaction .......................................................................................................... 54 Figure 25: Resident experience story A ................................................................................................................ 59 Figure 26: Resident experience story B ................................................................................................................ 60 Figure 27: Integrated Model of Care .................................................................................................................... 61 Figure 28: Hospital-PoA Notification options ....................................................................................................... 63 Figure 29: Working with the Voluntary Sector ..................................................................................................... 68 Figure 30: Population outcome ............................................................................................................................ 74 Figure 32: Locality activity split insert .................................................................................................................. 79 Figure 33: Workforce structure ............................................................................................................................ 83 Figure 34: Suggested locations for Locality Multi Specialist Centres ................................................................... 87 Figure 35: Implementation phases ....................................................................................................................... 89 Figure 36: Implementation activities .................................................................................................................... 90

Table 1: Knowsley Health and Social Care Design Principles ................................................................................ 21 Table 2: GP practices per locality.......................................................................................................................... 37 Table 3: Social care current workforce ................................................................................................................. 39 Table 4: Service implementation per care setting ................................................................................................ 49 Table 5: MDT - Clinical team members................................................................................................................. 55 Table 6: MDT – administrative team members .................................................................................................... 57 Table 7: Potential outcomes ................................................................................................................................. 71 Table 8: Services currently available in potential Locality centres ....................................................................... 98


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Introduction

Background

Knowsley CCG and Knowsley Metropolitan Borough Council have been long committed to integrated care and more collaborative working across the local health and care system. Significant work has been done to date across primary, community and social care to align teams across the services and improve communication, in line with Knowsley’s Health and Wellbeing Strategy 2016-2020.

Alongside this, Knowsley CCG has been partnering with CCGs across Cheshire and Merseyside in looking at improved quality and efficiency across hospitals. Improved capacity and capability in out of hospital care, across primary and community care settings as well as care at home, is a critical aspect of the development.

Strategic Context

In accordance with NHS England Planning Guidance, Knowsley CCG is in the process of producing two plans:

1. A five year Sustainability and Transformation Plan (STP) 2. A two year Operational Plan for 2016-2018

The Sustainability and Transformation Plan (STP) is a long term plan, on a wider health and social care system basis, and covers all areas of CCG and NHSE commissioned activity. It is planned on the following levels:

Figure 1: STP planning levels

The one year operational plan for 2016/17 covered the plans and progress of Knowsley CCG.


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It is proposed that this document can be used to inform both the operational plan and the STP, as it covers both short term change plans as well as longer term goals and directions of travel.

The diagnostic

To consolidate and progress the work already in train in Knowsley to improve quality and efficiency of care services, a diagnostic exercise was conducted in 2015 to look at the workings of the CCG and partners. The following recommendations were made:

To address these recommendations, a transformation programme was launched by Knowsley CCG along with Knowsley Metropolitan Borough Council, charged with designing a robust programme for the integration of health and social care services in Knowsley.

The design phase included a series of design workshops with senior stakeholders from KMBC and the CCG, followed by a several conversations with larger groups of stakeholders (primary care staff, Healthwatch, members of the community) to share the emerging model, socialise the key ideas and receive feedback.

This document outlines the agreed model of care, as well as the operational structure, enablers, implementation plans and timelines for the implementation of the model across Knowsley.

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Section 1

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1. The case for change

Along with the rest of the UK, Knowsley faces continuing and deepening challenges of an ageing demographic, unhealthy lifestyles and behaviours, areas of deprivation, extreme budgetary constraints on public services and a stretched, ageing workforce.

The four primary headlines of the case for change in Knowsley have been defined below.

Figure 2: The case for change in Knowsley Care Services

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1.1. Demographics and Demand1

1.1.1. Population age The population in Knowsley is ageing significantly, and projections for the future anticipate this growth amongst the elderly will continue. There are currently 24, 037 adults aged over 65 in Knowsley (representing 16.5% of the total population), and this is predicted to rise to 34,000 by 2030 (approx. 20-22%).

The rise in the population over 80 years is even starker, predicted to rise from 6,000 currently to 10,000 by 2030.

Over 60 year olds represent 22% of the population, while at the other end of the population spectrum almost a third (31.5%) is aged under 25. As a result of this distribution the dependency ratio in Knowsley is quite high at 63.4:100 meaning there are 63.4 individuals who are dependent (either children or those of a pensionable age). This ratio is predicted to rise to 80:100 by 2033, primarily due to the increase in an ageing population.

1.1.2. Life expectancy Life expectancy in Knowsley has gone up in recent years, but remains lower than the national average: male life expectancy at 75 is 10.59 (11.52 in England), while female life expectancy at 75 is 12.30 (13.26 in England).

Healthy life expectancy in Knowsley is the 6th lowest in England for males, at 56.9 years in 2010-2012; for females it is the 10th lowest in England, at 57.5. Healthy life expectancy and disability-free life expectancy are two areas of particular problem for Knowsley population health.

1.1.3. Population health and wellbeing Knowsley has high levels of unemployment and social deprivation, impacting negatively on population health. It is the 2nd most deprived local authority area in England (out of 297).

Knowsley residents experience significantly worse health than the rest of the country with a high prevalence of smoking, alcohol consumption, inactivity or obesity, leading also to high rates of many diseases such as cancer, heart disease and respiratory disease. Mental health issues such as depression are also prevalent, as are injuries due to falls in the over 65:

Physical disability is locally expected to increase by 3.5%, while hearing impairment

in individuals >65 is expected to rise by 30% 11% of adults in Knowsley suffer from depression, while levels of depression amongst

those over 65 is expected to increase by 13% (14% for severe depression) by 2020, leading to comorbidities

1 All data in this section was taken from the 2015 JSNA and is subject to final confirmations.

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Incidences of dementia are expected to increase by 23% by 2020, reaching 1,966 individuals (1,594 in 2012)

Social isolation: 5,922 individuals over 75 in Knowsley currently live alone, projected to increase by 32% by 2030 to 7,829. 49% of women with unpaid care report not being able to get to places in their local area and often stay in their home, making it difficult to access local services.

The borough thus has significant numbers of people with complex needs, disabilities and multiple long term conditions, many of whom are dependent on health and social care services. Though these individuals span all ages, the main pressures on residential, nursing and adult social care come from the older population over 65.

1.1.4. Pressures on Adult Social Care Within Knowsley 2,908 older adults were supported by Adult Social Care in 2013/14, and this number is expected to increase as the population over 65 increases.

Residential and nursing care admissions in Knowsley are higher than the national average. These admissions saw an increase of 33.1 per 100,000 population >65 over the 5 years to 2013/14. There is an average of 18.2 admissions per month in Knowsley (with understandable peaks during extreme weather). 48% of these admissions were due to the individual being “unsafe when unsupervised at home”, while 53.8% had dementia.

The average age at admission to permanent care in Knowsley is 83.1. Females are more often admitted than males, which is in keeping with their proportion in the population over 65.

The average rate of admissions to short term placements in Knowsley is 12 admissions a month.

Knowsley has 17,865 unpaid carers, equating to 12.2% of the population. Among these the proportion of those providing care for more than 20 hrs per week has increased, affecting their lifestyle and employment opportunities. Of the 17,865 unpaid carers 2,784 reported long term health problems, while 3,554 are aged 65 and over. The ongoing support of unpaid carers is a particular issue; while the demand for care grows, workforce participation and geographic mobility changes make the availability of unpaid care uncertain.

The implementation of the Care Act has seen increased support for carers across Knowsley, yet has also increased the pressure on services providing the support. While improved management of individuals requiring care and increased support for carers will reduce the long term demand on services, in the short term this represents and additional pressure on services.

By 2020 Knowsley is expecting:

A 14% increase in individuals >65 with long term limiting illness;

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A 15% increase in individuals >65 unable to manage at least one, of a range of domestic tasks;

A 16% increase in those who cannot manage at least one self-care task

Care act, transition costs and figures

In just 5 years, over £100 million in funding has been lost across the council. The Council’s medium-term financial plan forecasts budget gaps of up to £27m for the three-year period 2017 - 20.

The Care Act 2014 brought new responsibilities for local authorities, with new eligibility for services, support for carers, new areas of work around information, advice, prevention, support for the care market and safeguarding.

Under the reinforced duties of the Act, Knowsley is currently meeting demand for advocacy, however more work is required to ensure that an independent advocate is identified and commissioned as soon as is required; and whether there are enough advocates to meet demand.

The Council provides online links to independent advice, but this area present opportunity for further development as there are no independent financial advisors specialising in care costs in the Knowsley area.

The feedback from the first year has highlighted that carers are benefitting from the advice and referral process that forms part of the preventative offer, especially employment and benefit information, as well as advice regarding health alternatives. There is a need to reduce assessments functions for eligible services and increase the prevention offer focused on the maintenance of the caring role.

The Council has commenced work on a community assets programme to develop community co-production, resilience and enterprise (see 5.2.3).

1.1.5. Pressures on healthcare Individuals with long term conditions, such as heart disease, respiratory disease and diabetes are the most frequent users of care services, accounting for 50% of all GP appointments and 70% of all inpatient bed days in Knowsley.

The demand for mental health services is expected to increase by 37.2%. Individuals with severe mental health conditions such as Alzheimer’s have a high rate of hospital admission in Knowsley, currently 215 per 100,000 (compared with 80/100,000 in England). It’s been noted that individuals suffering with dementia and physical health conditions in care homes are more likely to be admitted to hospital for physical conditions particularly as a result of avoidable conditions such as urinary tract infections and dehydration.

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The incidence of falls in Knowsley is high compared to the average in England, at 14 per 1,000 populations over 65. Individuals aged 80-89 have the highest rate of hospital admissions due to falls, while this population group as noted is set to increase dramatically – current projections suggest that falls amongst the over 80 are likely to increase by 45% by 2030. This increased number of falls is accompanied by high levels of osteoporosis in Knowsley, which increases the impact of falls and fractures.

1.1.6. Culture Public services in the UK are facing an unprecedented period of financial constraints. With resources – both financial and human – in short supply, it is more urgent than ever to make best use of any and all resources available. This maximum utility of resources can be reached through partnership and collaboration: pooled budgets can go further; better communication and co-working increases the effectiveness and efficiency of staff; improved system-wide planning can avoid duplication and waste.

Yet times of austerity and scarcity often drive systems and people in the opposite direction. Austerity causes organisations, departments and often individuals to further entrench themselves in their own work, between their own walls. The system wide stress of austerity often brings about an understandable but misguided instinct to preserve and protect at the expense of communication, openness and integration.

It is critical to challenge this culture and foster and encourage increased communication and collaboration among the care services. ‘Good will’ and a spirit of support and co-working are critical if the different professions and professionals are to succeed in their desire to provide the best quality of care possible. Handovers between services are a particularly sensitive point and must be paid attention to so as to ensure individuals do not find themselves unsupported in between services but that service is continuous, safe and caring.

In this regard the Community and Voluntary Sector (CVS) are also crucial. CVS offer support to statutory services in terms of provision, but can also influence culture and behaviour by offering an alternative approach to patient centred care and a challenge the entrenched, unconscious behaviours of public services.

Yet this partnership and collaboration are needed not only within the care system and between professionals, but with the wider public as well. When real change is needed, it is imperative to have an open and mature conversation with the public about the services available, their likely future and the requirements of sustainability. It is crucial that the public has a real understanding of the role they have to play in supporting the future of the care system – the responsibility they have both in their use of the system’s support and the maintenance of their own health. While the NHS and Local Authorities are committed to invest every effort in maintaining population health and wellbeing, it is likewise crucial that the population do their best to maintain their own health, adopting responsible health

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behaviours and lifestyles and having a mature and considered approach in their use of services provided.

1.2. Finance and Sustainability

The CCG is facing considerable pressure on its budgets heading into 2017/18. The balance of reducing demand for secondary care based services and providing more care within the community and through increasing access to primary care services will require a shift in activity and funding away from hospitals as well as targeting any new NHS funds towards improving out of hospital services and continuing to invest in local primary care infrastructure, capacity and resilience schemes.

To achieve this, the CCG is required not only to manage demand for acute services but to enable development of services through the revised service model and achieve a recurrent financial surplus in line with the NHS Business Rules.

If the CCG did not develop further proactive plans to manage demand and transform local services the pressure on health economy finances would be severe, leading to a significant financial gap of c£24m by 2020.

KMBC Finance figures:

From 2017/18 onwards, the Council will be adopting a performance-based approach to its Financial Strategy. The core principles of this approach will be that the Authority’s budgets should be allocated to deliver the most sustainable impact on the Council’s priorities and to ensure that statutory and regulatory requirements are met most efficiently and effectively.

To enable this, the approach to budget setting and service planning will be integrated further, with budget allocations more directly linked to agreed performance levels, expected levels of efficiency, and the adoption of key policy principles including prevention, behaviour change and social value. Resources will be invested in services and interventions to enable the delivery of agreed priorities and reallocated away from services where reduced performance is acceptable or transformation opportunities enable performance to be sustained with fewer resources. This will also generate future potential savings options.

The Council’s three year forecast savings target of up to £27m for the three-year period 2017 - 20. This is after savings already approved for implementation in 2017/18 of £5.522m. Of these savings circa £3.153m are already approved to be implemented by Adult Social Care.

The Assistant Director of Adult Social Care will be required to provide a three year plan on how the service will be changed and how savings will be delivered.

The Council also faces significant financial pressures in particular from care services due to the significant increases to the National Living Wage planned between 2016/17 and

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2019/20. The Government in response has introduced the Adult Social Care Precept of 2% per annum on the Council Tax base. However, this additional resource only provides for about a third of the costs of the National Living Wage and does not address wider pressures facing Adult Social Care.

1.3. Securing our future workforce

1.3.1. Primary care workforce – an ageing workforce As in many other areas in the NHS, Knowsley is facing not only an ageing population but also an ageing workforce. With care professions globally struggling to recruit and attract young talent, a growing percentage of the workforce in healthcare is approaching retirement age while insufficient numbers are entering the workforce post-training to maintain a sustainable and growing workforce to meet the growing demand.

As depicted in figure 3 below (Health Education England), 44% of practice nurses in Knowsley are aged 50 or above (not accounting for those of unknown age). This means 44% of nurses currently working in GP practices in Knowsley are likely to retire over the next 5 to 10 years. Yet, with only 2% of nurses under the age of 30 and 29% below 50, it is simple to see there are insufficient numbers currently in the system to fill the gap once the older generation retire.

GP workforce numbers tell a similar story if slightly less extreme, with 41% currently aged 50 or over and only 26% below 50 (the rest unknown).

50%

40%

30%

20%

10%

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Primary care workforce age distribution < 29 30 to 49 50 to 69 70 < Un-known age

Age

% Nurse % GPs

Figure 3: Primary care workforce age distribution

The imminent workforce crisis described above is echoed across community nursing and other providers across the NHS and the UK, who similarly describe low numbers of young

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talent entering the workforce pool while an increasingly larger percentage are approaching retirement age.

1.3.2. Community healthcare workforce The majority of community services workforce are employed through the 5 Boroughs Partnership NHS Foundation Trust, although a number of NHS, voluntary sector and informal workers (i.e. carers) currently provide care and healthcare services to the people of Knowsley.

Pressures on recruitment and retention as well as challenges faced by people who are formal and informal carers will require a focus over the next five years to ensure that services are sustainable and there is a sufficiently skilled workforce to meet needs of the local population.

1.3.3. Social care workforce Constraints on Knowsley council budgets has potential to impact on all council provided and commissioned services. Further key risks to social care workforce sustainability are also present, primarily domiciliary care workers. Issues around the attraction and retention of staff arise from limited opportunities for training and limited career progression prospects, added to the impact of the living wage, which has increased the cost pressure of already stretched care providers limiting their ability to expand their workforce.

Joint working between health and social care teams through the continued integration of local services will require careful planning and risk assessment if the proposed benefits of joint working through closer integration are to be maintained and accelerated.

Sickness levels are also a significant risk to the workforce (18 days per FTE as at end Sept against an ASC target of 14 days and the council target of 8 days).

Staff turnover including senior managers have been high. More focused recruitment drives should hopefully stabilise this pattern. In addition, availability of DOLS Best Interest Assessors is a particular problem (but we are not alone in this).

A comprehensive workforce development programme is being developed in the council which will understand the needs of the service and has the key components to future proof the social care workforce.

1.3.4. Other workforce issues Other issues in workforce do not relate to age, but to pay, contracts and training. Variation in pay for instance amongst care and support workers drives a high level of turnover, making recruitment more complicated and creating a lack in consistency and harming relationship building with individuals cared for. Agency work and the variation and flexibility of contracts offered also harm NHS recruitment, adding to the challenges. Elsewhere in the system a lack of leadership as well as insufficient clarity on responsibilities from Health Education England

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and employers mean there is not currently one body who is taking ownership of finding a solution for the challenges. This forces each provider to solve the issues as best they can, creating a high level of risk across the system.

While some of these issues are not within the gift of the Knowsley local economy to solve, new ways of working and better collaboration across providers can go a long way to improving the situation.

1.4. Technology as an enabler for better care

Technology has been developed that can change many and various aspects of health and care. From remote and mobile working that improves professionals’ efficiency, through online booking systems for the convenience of peoples, to remote monitoring technology that enables vulnerable and at-risk individuals to be and feel secure on their own in their home and all the way to remarkable digital advances in healthcare, the possibilities and opportunities are endless.

Yet currently the uptake of these technological advancements and options in Knowsley is rather low. Whether due to underinvestment, lack of adequate business processes, reluctance on behalf of individuals or lack of connectivity compatibility, only a small number of the benefits offered by technology are currently realised in Knowsley.

1.4.1. Shared care records Truly integrated care processes and improved efficiencies depend on sharing care records and information, allowing different professionals to access the same information, view care plans, care interventions, assessments, diagnostics and results, understand previous activity and have strong background knowledge about the individual’s characteristics and circumstances. Without shared records care professionals and clinicians are having to request information with each interaction, and are lacking sufficient detail in a timely manner. This causes significant inefficiencies and potential risks, as well as reducing the quality of the individual’s experience.

1.4.2. Remote working Professionals who work in the community, such as district nurses or occupational therapists, need care records with them when visiting individuals’ homes – they are also required of course to update any records with the latest information and the results of any intervention or care session. While this is in place for social workers it is not in place uniformly across all community care profession, and travel and administrative time is often wasted by professionals who have to travel back and forth to central offices to collect paperwork and return to the office to input data and update records. Remote working has proven very powerful in improving the efficiency of community professionals, releasing more time for them to provide care.

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1.4.3. Assistive technology Various digital and technological advancements are currently being used to improve the safety and independence of vulnerable individuals at home. Examples are: remote monitoring and notification systems, allowing clinicians to monitor the condition of patients without needing to make a home visit; alarm systems for persons and homes, that enable individuals suffering from dementia or other limiting conditions to remain in their home in safety; ‘brain in hand’ devices that support individuals with autism or other neural conditions to manage daily tasks with no help or supervision; and many other safety, care and communication devices. All these have proven dramatically powerful in improving the safety and security of vulnerable people, allowing a much more cost effective care system in which residential admissions and expensive care packages have been dramatically reduced. The use of technology has been shown to reduce cost, ensure the sustainability of social and care services and allows professionals to spend more time on high value personal interventions.

The potential role for AT is very wide but is currently under-exploited. Greater awareness and understanding needs to be secured across all stakeholders including clients and their carers, care providers, care needs assessors and reviewers, and commissioners.

Effective use of AT can help promote the independence of individual service users, mitigate against carer breakdowns, reduce the safeguarding risks for vulnerable service users and open up new service improvement opportunities for providers and commissioning managers.

The strategic direction for AT in Knowsley therefore comprises several key strands:

• Improving and refining the focus of AT to more closely match support for identified

risks and needs • Introducing specific assessment and monitoring to measure the impact of AT (greater

client independence and cost savings) • Embedding the prescription and use of AT (and essential accompanying human

services) as a regular or ‘default’ element of all care packages and care environments, displacing rather than supplementing traditional care elements

Underpinning these strands are several cultural and practical developments together with an emphasis on widening the awareness of AT, not as a specialist and separate topic but as an intrinsic part of care and support alongside human capital.

The key projects going forward currently include:

- A mailshot going to all homes in Knowsley setting out the benefits of AT and which

invites responses through a FREEPOST service as well by phone or through the Council website.

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- A small team of Independent Living Assessment Officers has been created whose role will be to actively promote and demonstrate AT to service users, carers, managers and service commissioners.

- Service users and / or their carers can already try out a range of updated AT equipment at the Centre for Independent Living

- Installation of the “Just Checking” software in five supported living properties which will lead to greater independence for residents and therefore less intrusive and expensive care packages.

- Development of a “24/7” service which will provide a rapid response to urgent / emergency situations when alerted via AT equipment installed in service users’ homes.

- In partnership with Liverpool Housing Trust, a range of AT equipment has been included in the specification for the new supported living scheme at Maytree Court, which is due to be completed by January 2017.

1.4.4. The requirement The development of the new model of care must include better utilisation of digital solutions to improve service quality, safety and efficiency and enable care closer to home, and better use of data to enable more tailored and timely service planning.

A programme is in place in Knowsley and across Cheshire and Merseyside to develop a clear roadmap for the increased use of assistive technology, yet similar developments and improved uptake of technology across healthcare services will be crucial to maximising the technological potential to service provision.

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2. Our vision, governance and principles for change

2.1. Vision

Taking into consideration the needs of our population as outlined above in section 1, our vision for care services in Knowsley is:

Care services will be commissioned and be provided in the most appropriate place, tailored to the people who need them and available when they need them. The local community will be encouraged and supported to stay healthy, be responsible for their own lifestyle choices and be involved in their own care.

The vision focuses on our ambition to ensure we meet the needs of our local population at all levels – across Merseyside, in partnership with neighbouring councils and CCGs, at a Borough level and within our localities, providing the right services where they are required and where they will achieve the best possible outcomes. The vision also highlights our commitment to ensure we support our peoples to regain control of their lifestyle, health behaviours and even care packages, as we believe significant improvement in health outcomes requires a true partnership between the individual at the centre and the professionals supporting them. Having listened to our people we know that they wish to remain at home and surrounded by their family, carers and friends whenever possible, only attend hospital when absolutely necessary and remain active and independent for as long as they can. We also have a duty and a responsibility to ensure care services in Knowsley remain sustainable and affordable for generations to come, while maintaining quality and access.

2.2. Design principles

To ensure all future decisions around the commissioning and provision of care services in Knowsley align with our vision, we have agreed on a number of design principles to govern our planning:

Table 1: Knowsley Health and Social Care Design Principles

01 Needs based and high quality:

Services will be safe, designed to address identified population needs and delivering improved outcomes in line with national and international best practice. They will be designed in partnership with the public, providers and other partners and supported by practitioner education.

02 Coordinated:

Assessments and care provision will be coordinated across primary and secondary healthcare, social care, community care, wider council services and the third sector, while

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recognising and working with the individual’s family, environment, characteristics and background.03 Enabling

03 Enabling People accessing services as well as their carers will take an active role in agreeing plans for their care and support, encouraged to be as responsible and active as possible. Support will be designed to meet their broader health and wellbeing needs, striving to allow people to stay in their home with maximum independence.

04 Local and accessible

Services will be provided closer to home, in the community or digitally wherever possible and coordinated locally, improving efficiency, experience, accessibility and availability.

05 Technology enabled

Care services in Knowsley will make best use of technology available, with the use of resources sustained through increased efficiency and information sharing and an emphasis on prioritisation and value for money.

These principles are key in determining the service model agreed, the operational details underpinning the service model and the implementation and change processes that will be used in making the new care model a reality. We appreciate that at times the different principles might be at odds with one another, such as in cases where the needs-based approach and the quality requirements might go against a very local, small scale provision. Accepting this fact, the principles will allow and necessitate a conscious process of consideration, prioritisation and purposeful, evidenced decision making.

Section 5 below outlines the outcomes planned for the new model of care. Service and population outcomes are linked back to the principles as defined above.

2.3. Governance

Given the size, scale and breadth of the proposed Knowsley Health and Social Transformation programme, it is essential that robust governance arrangements are in place to ensure: coordination of the whole programme; rapid, transparent decision making; visibility and management of dependencies; assurance of implementation of new service models; and monitoring success in the achievement of improving health outcomes for the people of Knowsley.

The key elements of the proposed structure are:

Co-ordination of the core programme elements parallel enabling / development

work-streams Maintaining dedicated capacity and resource to support the programme.

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Development of a transformed service model and operating model redesign; Service modelling, including activity and workforce implications Communication & engagement oversight.

The proposed programme governance arrangements are outlined in the diagram below.

Figure 4: Transformation Governance

These arrangements will be kept under review and will require a change in focus of the Transformation Change Board to ensure that delivery pace and focus are maintained.

2.3.1. The scope of change for this programme Population health outcomes are closely aligned not only to health and social care provision, but to wider determinants of health such as lifestyle, educational attainment, employment status, family surroundings, income level and others. While we in Knowsley are committed to improving the lives of our peoples across the board, the programme of transformation outlined here is concerned with changing particular areas of care planning and provision. The plans have been produced in collaboration with all relevant stakeholders, to ensure the services provided are aligned to and complement other areas of public service provision and social planning and support.

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In scope: This programme outlines the transformation of community and social care services in Knowsley, namely:

GP Services – 7 day access Community services / nursing, incl. specialist condition nursing and support to nursing

and care homes Adult social care

Out of scope:

Primary care Though 7 day access and support to care homes will be looked at through this programme, additionally this report will not address core list based services.

The CCG has prioritised an ambitious primary care development plan including development of a primary care Long Term Conditions service. The management of interdependencies between these complimentary activities will be managed through the internal governance of the CCG through existing operational programme structures.

Children’s services The integrated model proposed is primarily focused on supporting individuals with complex needs or those who require support from multiple professional care services. As such, the care delivered in this way will be available to any member of the Knowsley community whose needs necessitate such support, regardless of age. Nevertheless, the Council provision of specialist children’s services such as education, early years, safeguarding and cared for children will not be reviewed or changed within the scope of this programme. The programme will however ensure the model is aligned to and compatible with these services and address the issues of transition from child to adult services, and will include children’s centres as part of the locality initiative.

Population health and wellbeing While the improvement of population health is critical to the future sustainability of care services and critical for the improved health and wellbeing outcomes of the peoples of Knowsley, the delivery of public health campaigns, public health interventions or the provision of advice and guidance are beyond the remit of this transformation programme. These are expected to be delivered across Knowsley and at times the wider footprint of Liverpool City Region by the Council and partners, and will be aligned with the integrated care model. Healthy living as part of condition management and preventing deterioration will be included in the model.

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Acute care Services provided within acute settings are not in scope for change within this programme, which does not encompass hospital transformation – an area of work which is part of ongoing work via the STP. Nevertheless the interaction with and handover between acute care and community / social care will be dealt with under the integrated model proposed.

2.4. The design process – co-production:

In designing the integrated model of care, it was of course imperative to ensure the involvement of commissioners, providers, staff, voluntary sector representatives and members of the public.

Initial stages of model design were therefore developed by two working groups. Membership has been drawn from the CCG Governing Body, CCG Executive Team and operational managers and lead Directors from Knowsley Borough Council, representing commissioning, nursing, primary care, adult social care, children’s services and public health. The groups developed the initial first definitions of the model based on best practice guidelines and working examples from elsewhere.

Healthwatch will continue to be consulted to discuss both the model as a whole and advise on support and of the community and voluntary sector. The model was also taken to a large public engagement event, to allow service users and carer representatives to input their perspective and ensure the model suits their needs and would support them well.

2.4.1. Primary care feedback: The material was then taken to a Protected Time Event on 25 February 2016 – a working event for primary care staff, including GPs, nurses, managers and other colleagues representing all of Knowsley’s GP practices, who worked through key questions in the model and improved the design.

A number of additional areas for consideration were identified. These include:-

Combined Retinal Screening and diabetic foot service as a one stop appointment. Out of hours services for phlebotomy and screening. Greater access to intermediate care facilities Healthy Homes Scheme Patient information on condition and condition management Information on prescription Supporting patients in self-management Increasing shared consultations for patients with multiple professionals

Section 3

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3. Our model for integrated health and social care

Building on the vision and design principles agreed, the integrated community model will be centred on individuals, families and local communities and their needs.

3.1 Primary care at the centre:

As the clinically accountable individual for care will still be the GP, it is imperative that GPs remain at the centre of the new care model. Further, to ensure GPs have the capacity to support personal and detailed case management, and increased access to primary care to enable 7 day access – by increasing availability for those individuals who require simple, core list-based services, GPs will have more time during core hours to support complex patients with the level of intensity necessary.

3.2 Multi-specialty working:

Around the GPs and working with them, it was agreed that teams across primary care, community care, social care and the voluntary sector will work in seamless collaboration to ensure a whole-person view of care and support, and ensure the individuals experience coordinated care. This multi-specialty collaboration and co-working will ensure care quality improves and pressures on GPs will decrease as complex patients are better supported by multi-professional teams working directly with individuals and their carers. This rounded support, looking at individuals’ health but also social and lifestyle needs, will enable GPs to perform at the top of their licence and spend their time giving the highest level of health care.

Figure 5 below illustrates primary care at the heart of community based care and support.

Figure 5: Community services wrapped around primary care

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To enable the above to work optimally then, three core building blocks are required:

1. Increased capacity and access in primary care 2. Transformed community and social care offer, structured to support integrated

multi-specialty / provider working 3. Improved support to nursing homes, as a complex group with a high risk of

deterioration or hospital admission.

Figure 6 below highlights the emphasis of the enhanced community model – sat alongside the universal core services offer and acute care, the model, as described in section 2.4, is concerned with the improved access GP offer and the enhanced community offer:

Figure 6: Enhanced primary and community offer

3.3 Improved access to primary care

General Practice will be enhanced to increase its capacity to support personalised case management through the local commitment to primary care access 7 days per week. This will increase the availability for those individuals who require, prioritise and choose alternative channels of access (e.g. through email and telephone) and the convenience of alternative times and locations over seeing their registered GP. This will enable General Practice to have more time during core hours to support complex patients with the level of intensity necessary through its existing contractual arrangements.

In designing one of three building blocks of integrated health and social care the accessible model of primary care is based upon the following principles:

• Be accessible and equitable across geographies • Be simple to access and navigate • Be seamless from the patient’s perspective (regardless of organisational boundaries) • Support self-care • Support high user and vulnerable groups • Provide identified points of access • Be cost effective and financially sustainable

The prioritisation of 7-day access will support improved equity of access to care services, greater convenience and choice in location, appointment times and the channel most suitable for the patient and carer. Importantly it will provide additional capacity to enable better

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support to those with the most complex needs and will actively support the MDT care provided to patients.

3.3.1 Enhanced access points at a locality level The hours available for enhanced access will wrap around and supplement the core hours of general practice (8am to 6.30pm, Monday to Friday). This will create both capacity and choice from 6.30 to 8pm, Monday to Friday, 8am – 8pm Saturday with the availability on Sunday to be determined based on engagement with the public regarding their preferences for Sunday. Where this demand is prevalent and cost-effective it will be 8am to 8pm on Sunday.

To ensure that the enhanced hours are suitably supported by core provision of primary medical services by patients’ registered GP practice. There will be an expectation of the minimum level of access (e.g. defined number of appointments per 1,000 patients) for each practice in Knowsley. This will provide a consistent, high-standard of access during core hours supplemented by additional capacity and choice during evening and weekends.

The service will delivered from 4 locality-based sites. These will be defined following engagement with local people to determine their preferences and will be considered alongside the availability of suitable premises.

Where possible we will use a consistent team of staff who know and understand Knowsley and can support people to access onward care and support, where necessary at the point of access. Continuity and consistency in the quality and effectiveness of the service will make it a familiar experience for patients and the public.

The 7 day access to general practice will be supported by:

• All patients are able to access appointments at any of the sites • Locality ‘enhanced access’ sites have read and write access to the patient’s GP record

to support informed clinical decisions including, ‘first-time’ (negating the need for the patient to re-visit their own registered practice) about any onward care

• Appointments to ‘enhanced access’ sites will be accessed (see 3.1.3 for details of channels of access to care) through:

o the patients’ own practices o 111 as ‘defined access point’ of the primary care service offered by their

registered GP practice and an enhanced access site of their choice o the enhanced access site directly

3.3.2 Supporting self-care, choice and empowering access to the right service, first time

To provide a consistent point of reference, advice and direction there will be further development of the local Directory of Care Services. This will provide the point of information for local people about how to access care most appropriately and conveniently, and will

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create the opportunity for people to self-refer, where appropriate, to services such as physiotherapy without the requirement to see a GP first.

To achieve this we will create and publish a single on-line tool for clinicians, patients the public and support staff. This will enable local people and care staff to direct and select the option suitable to them and will include selecting the opportunity to access primary care at a location and time convenient to them. To supplement this we will ensure that support staff (e.g. practice reception staff) will receive regular training to support patients and the public to make the appropriate choice of care services for them at the outset of their initial point of contact.

The Directory of Service will become the single source of information including for people who access the GP practice directly, through 111 service or on-line.

Care Navigators will also be put in place – a CVS based role, who will help individuals who require support to optimally identify and access the resources available.

3.3.3 Developing alternative and digital access channels It is our aspiration that the residents of Knowsley will be able to make one call, click or contact in order to make an appointment. This will be achieved through supporting primary care teams optimise the use of technology and actively promote online services to patients. The ‘channels’ we will introduce include appointment booking, prescription ordering, viewing medical records and email consultations and are set out below.

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Figure 7: Primary care communication channels

This multi-channel access model will enhance the choice and convenience for patients and is depicted below:

Figure 8: Multi channel access model

3.3.4 Centralised home visiting service Improving access to general practice services cannot simply be achieved through increasing face to face appointments. To provide responsive care services to all patients there is a requirement to address the access to clinical advice for the most vulnerable who can often be those who are less mobile. In developing our access to primary care we are committed to improve the home-visiting services for local people.

Our response to this is to provide responsive urgent home visiting for patients when requested by the patient's GP. This will be provided by a blend of GPs and Nurse Practitioners who will:

• Visit quickly within defined and clinically appropriate response times • Have access to the patient’s record (with read and write access) • Have available to them the presenting complaint and relevant history transferred by

the practice • Direct access telephone number for the patient’s registered practice with named

contact in case of queries and requirement for liaison and coordination • Work in partnership with MDTs

This team will be accessed by the registered practice for urgent home visiting subject to specific exclusions where there is a requirement for continuity of care to be maintained by the patient’s registered practice. Such exclusions will include for those at the end of their lives and are already supported through detailed case management approaches and support.

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The home visiting services will be linked to social care teams, ensuring social care needs are addressed simultaneously and so improving the support offered and avoiding exacerbation and potential unnecessary admissions into care.

3.3.5 Future considerations

In addition to the above steps taken to deliver better access, 7 days per week there is opportunity to consider whether local GP practices may collaborate to create alternative capacity to that currently replicated at each individual GP practice. Models of care elsewhere in the country have seen groups of practices, through the local doctors and nurses; create centralised response centres (in their local area) where they respond to telephone, email and on-line contacts throughout the day.

This would be in addition to supporting people to access their registered general practice in the traditional way. It would provide an alternative choice, and not replacement of general practice, for local people. The rationale for such models is to centralise local clinicians to enable them to more efficiently respond to contacts from their local registered lists. This has the benefits of economies of scale and increased resilience.

3.4 Transformed community services

Services will support and provide:

Figure 9: Transformed Community Services

3.4.1 Multi-specialty working Practice nursing, social work and other community care teams will be structured to work in Multi-Disciplinary Teams (MDTs), supporting proactive, enabling and continuous care. These teams will be responsible for assessment, care planning and care delivery, and by working

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together will ensure the interventions of each professional are aligned throughout and achieve best clinical and quality life outcomes for the individuals. These teams will also be responsible for referral or delegation to any other services required (specialist services, core community support, voluntary sector services).

Care closer to home: To make the ambition of care closer to home a reality and ensure individuals need only go to hospital when this is clinically necessary, the multi-specialty teams will deliver care at different settings, both at an individual’s home, at GP practices or at community based multi- specialty centres.

Enabling care: All individuals will be supported to remain as independent as possible and full partners in their own care. Individuals will be coached to manage their own condition, receive lifestyle advice and support and be support to proactively prevent deterioration or exacerbation of any existing or potential conditions.

3.4.2 Care coordination To ensure the smooth running of all care and support and the optimal, proactive management of individuals with complex needs, Case Managers will be allocated to those individuals with complex or intense need. The coordinators will act as a central cog for person-centred, holistic care, both supporting individuals and carers directly – acting as their direct point of contact – but also coordinating and supporting the work of the various professionals in the multi- specialty team to ensure alignment and communication. Figure 10 below illustrates the care coordinator, carer and GP at the heart of care with the MDT around them:

Figure 10: Coordinated, multi-specialty care

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3.4.3 Configuration of care services Services will be located optimally to address local population social and healthcare needs: local needs will determine the volume and availability required for each service, such that some services will be provided by a team in each locality whereas other more specialist services will be provided by a central team across the whole borough (figure 12 below).

Similarly, individual localities’ population characteristics will be taken into consideration when planning local services, allowing for tailored workforce, estate and resource planning. This will mean local services might be configured differently in different localities of Knowsley depending on local social and healthcare needs.

As an illustration / example:

Teams providing case management, risk stratification, social care services, social prescribing and community diagnostics are likely to provide support across a locality footprint, enabling them to work tightly through the MDT and with the local GP practices providing the required level of support for the people of that locality. Teams providing rapid response services, crisis intervention, re-ablement and carer support are likely to provide support for the whole borough, as these services will experience lower levels of demand and the borough-wide footprint will enable best use of resources and expertise.

An illustrative example of the scale / configuration of services is in figure 11 below:

Figure 11: Illustrative service configuration

A detailed breakdown of team configuration is detailed in the operational model below in section 4.

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3.4.4 Localities Knowsley care services are provided across four localities: Kirkby, East Knowsley, West Knowsley and Halewood. Looking at geographic characteristics, population densities and population care needs it was decided the four localities indeed represent the optimal configuration of care services and allows the best efficiency of care resources. Therefore an MDT will be established per each of the four localities – emerging evidence to date recommends MDTs function at a scale covering roughly 20,000-40,000 population, which tallies well with the proposed population sizes of the localities in Knowsley.

The population is not divided equally between the four, with Halewood numbering only 18,000 people. Nevertheless it remains a distinct locality due to its separated geography. Kirkby is the largest locality, with a population of 50,000, while East and West Knowsley contain roughly 45,000 each.

The map and table below outline the practice alignment to the four locality areas. These have been developed on the basis of geographical alignment. It is recognised that Halewood has a noticeably smaller population than each of the other three localities.

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Kirkby Halew

ood East Know

sley W

est

Table 2: GP practices per locality

Knowsley GP Practices

Practice Name Practice Code List Size (Apr 16)

Dr Maassarani & Partners N83608 10728

Millbrook MC N83032 11241

St Laurence's MC N83033 6266

Dr Thong N83601 3846

Trentham MC N83055 5208

Wingate MC N83009 12326

Total population registered: 49,615

Hollies MC N83605 3897

Dr Kinloch & Partner N83013 5149

Roseheath Surgery N83031 2320

Aston (Halewood Centre)* N83028*

2264

Aston (Camberley Drive)* 2702


Cedar Cross MC N83609 3167

Cross Lane Surgery N83611 2697

Longview MC N83043 4026

Nutgrove Villa Surgery N83633 3533

Park House MC N83024 7464

Prescot MC N83603 5316

St John's Surgery N83612 3029

Tarbock MC N83047 3725

Aston Healthcare (Manor Farm)* N83028*

6699

Aston (Whiston)* 4882


Bluebell Medical Practice N83015 4047

Colby MC N83610 2235

Cornerways MC N83025 6382

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Knowsley

Dinas Lane MC N83014 9749

Hillside House Surgery N83621 3000

Pilch Lane Surgery N83030 4892

Primrose Medical Practice N83622 2494

Dr Rigby & Partners N83018 8431

Roby MC N83619 1885

Aston (Gresford MC)*

Aston (Knowsley Village)*

N83028*

3777 2405

Aston (North Huyton)* 2690


*26 practices hold contracts in Knowsley; Aston Healthcare holds one contracts but operates across 7 sites, marked in the table above.

As highlighted earlier in the report there are differing needs and current health outcomes for locality populations. The table below highlights some of the main differentials in terms of population / demographic changes, life expectancy and highlights differing mortality for priority health improvement focus areas, such as cardiovascular disease and cancer.

Figure 12: Locality key figures

The table highlights the potential to provide more intensive focussed support in specific localities which would be targeted at improving local health outcomes for locality residents.

3.4.5 Community nursing and core community services based workforce. The current Community and Mental health services are predominantly provided by Five Boroughs Partnership (5BP) and Merseycare (Mental Health Services for Kirkby). These are predominantly block based financial agreements, driven by a range of contractual services specifications.

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It is proposed that there will be a requirement for four locality teams (core community workforce). This differs from the current service offer of three locality teams (North, Central & South). The evolving of the community nursing / allied health professional / mental health practitioner roles in supporting effective proactive support to the population is pivotal and needs to align with the preferred model of locality based service delivery.

3.4.6 Core social care services Social care workforce in Knowsley has been structured to work to the four localities described, yet with one team per each two localities – North/West team (Kirkby and West Knowlsley – 60% of current workforce) and South/East team (East Knowsley and Halewood – 40%).

Current staffing structures:

Table 3: Social care current workforce

North (Kirkby) / West Knowsley South (Halewood) / East Knowsley

20 practitioners in total:

1 Team Manager 2 Senior Practitioners 10 Social Workers (+ 2 vacancies) 5 Assistant Care Managers

18 practitioners in total:

1 Team Manager 2 Senior Practitioners 10 Social Workers 4 Assistant Care Managers.

When aligning social work support to health support, complications arise when Knowlsey residents (who are under the care of Knowsley Council) are registered with GPs outside of Knowsley CCG GPs. Current numbers are illustrated in figure 12 below:

Social Care Current Referrals (total: 2348)

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233 In borough surgery out of borough surgery

1770

no currently known surgery

Figure 13: Social care referrals – in/out Borough GP surgery split

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In borough referrals are split among the four localities as below, showing highest numbers of referrals currently in Kirkby – in accordance with the relative population sizes:

Social Care Current Referrals in Borough (total: 1770)

152

476

580

Kirkby

East Knowsley

West Knowsley

Halewood

562

Figure 14: Social care referrals split by locality

3.5 Support for care / nursing homes

Nursing & care homes account for 4% (1,983) of the total (54,701) In Patient spells and 10% (14,015) of the total bed days (134,650) associated with Knowsley CCG. It is proposed that a fifth ‘locality’ be defined as the population who reside in Care Homes and Nursing Homes, as they traditionally have specific needs and require distinct support from GPs, nurses and social workers. They could therefore be better managed by a team who are solely focused in supporting them rather than be supported as part of the general population. This programme will link with the Quality Improvement Team and current schemes of Knowsley MBC to reduce the rate of admission for people entering care home placements.

Figure 15: Nuffield Predictive Model

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The information below outlines total volume of activity derived from the care homes with the highest number of IP non-elective admissions and occupied bed days. The information is not adjusted for number of care home beds or placements per year. There chart highlights that a number of admissions have relatively short length of stay and could be a an indication of potential to enhance services in the care and nursing home setting, which will enable residents to be supported in their usual domicile residence.

Figure 16: Non elective admissions from Care Homes

3.6 Cross cutting workstreams

To ensure the model optimally supports all populations in Knowsley with complex needs and as described under the Governance in section 2.3, five workstreams have been prioritised in the CCG Operational Plan for 2016/17 and beyond that will work to define condition-specific pathways using the model described here. These are:

Long Term Conditions Mental Health Cancer Urgent care Primary Care

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Section 4

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4 Operating model

4.1 Self-care support

In looking at ways to improve both the quality of life of individuals who suffer from long term conditions and the sustainability of care services, it is critical to look at ways in which individuals can better care for themselves and learn to manage their own condition.

Self-management or self-care encompasses those actions or behaviours taken by people to recognise, treat and manage their own healthcare needs independently or in partnership with the healthcare system.

4.1.1 Evidence to support self-care: Self-management programmes have been shown to reduce unplanned hospital admissions for some conditions such as chronic obstructive pulmonary disease (COPD) and asthma2.

Various papers have demonstrated the effectiveness of long term conditions interventions. The research has found that there are significant health, social and cost benefits of self- management:

Department of Health research in to the economic benefits of self-care3 has indicated

a potential cost saving of over £450 per person per year following an investment in self-management as a result of patients using health services more efficiently

There is a growing international research base to show that self-care and the ability of people to self-manage provides significant economic and personal benefit

The evidence shows that well designed and delivered interventions to support self- management, particularly individually focused interventions, designed to build self-efficacy, have a positive effect on:

Clinical symptoms and outcomes Attitudes and behaviours Quality of life A better and less wasteful use of healthcare resources

4.1.2 Self-care support – options: There are various approaches to self-care and many interventions available. These include:

Self-management education (this can be disease specific or generic, and can utilise

different techniques and settings such as one on one coaching, group work, written materials or online programmes)

Self-monitoring, including telehealth and telecare

2 Purdy, 2010 3 Purdy 2010

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Patient-to-patient education and support groups or programmes Training for professionals in techniques to support self-management and behaviour

change

Key elements from the evidence show that:

It is beneficial to tailor interventions to specific conditions, such as diabetes4

Patient education has proven beneficial for physical conditions, whereas mental health conditions have shown to be better supported by behavioural interventions

It is important to involve the individuals and their carers in creating a personalised self-management action plan, which could include:

– Education programmes, medicines management advice and support – Tele-care and tele-health for self-monitoring – Psychological interventions – Access for individuals to their own records5

– Health-coaching – Behaviour change programmes, encouraging healthier living

4.2 Care Coordination

Following patient cohort identification utilising the risk stratification methodologies, all health and care elements of the care plan will be co-ordinated by a designated Accountable Care Co- ordinator (role description in appendix C below). The accountable care co-ordinator will work with the individual to agree the care plan and act as the dedicated point of contact for the patient, carer and family. The coordinator will also ensure that assessment of multi- disciplinary need, including carer’s assessment is undertaken.

Co-ordination will include support to the patient cohort in primary and secondary prevention, proactive health and care interventions and supportive transition between care settings and across multi-professional and organisational boundaries.

The Coordinator will also be responsible for non-clinical monitoring, including contacting the patient regularly between care interventions and ensuring all care professionals have inputted any required information into the care plan.

4.3 Care planning & case management

4.3.1 The care plan Care planning can mean different things to different care professionals, and indeed to members of the community. Care plans are currently created for different care services –

4 de Silva 2011 5 Richmond Group of Charities and The King’s Fund 2012

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primary care, community care, mental health, social care, acute care. Yet a plan pulling them all together is lacking.

For the integrated care model and true case management to work as effectively and efficiently as possible, it is crucial that a single care plan is created which incorporates high level information from each professional as well as the individual’s own goals and responsibilities. The care plan should be accessible to care professionals, the individual and the carer.

Key principles for the care plan:

A single, integrated document, relating to holistic needs and goals Led and owned by the individual and/or carer, and accessible and usable by them Reviewed and refreshed when required – if goals are not met, if the support network

has changed or if an acute episode or other major event took place A focus on clear goals: clinical goals as well as the person’s own goals, that are

meaningful to them Focus on continuous care, progress, prevention and early intervention, not only

reactive care

The plan should include:

Physical health, mental health and social care needs Interventions that need to be carried out by different professionals and/or the MDT Trigger points for MDT review or escalation Lifestyle advice / self-care actions Safeguarding information and any risk management considerations Clinical and personal goals defined carefully, that are realistic, practical and expressed

in specific and clear terms Advice and guidance for the individual and carer on how to respond to certain

occurrences and when to seek further help Emergency arrangements, and End of life plan and expectations.

4.3.2 Care plan creation and review: The care plan will be created in partnership between the individual, their carer, their GP and the core multi-specialty team. A plan of action should be agreed that not only answers the care and clinical needs, but takes into account the individual’s wishes, goals and available resources.

The plan is a live document, ideally stored digitally, allowing it to be updated by different individuals as required. It should be written in a language clear to the individual and carer, rather than overly technical or clinical.

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The plan will be reviewed regularly by the Care Coordinator and the individual together, so that progress and any issues can be monitored and recorded if necessary.

The plan should be reviewed every six months, or if one of the following takes place:

Key goals are missed There has been significant improvement or exacerbation in the individual’s condition A safeguarding consideration has been raised The support network has changed (i.e. a carer is no longer available, family

circumstances have changed) An acute episode or other major event takes place

4.3.3 Settings of care delivery: The delivery of the care plan is the collective responsibility of the individual, their GP and the MDT. Ultimate clinical responsibility lies with the GP.

Four core settings of care delivery are defined:

Figure 18: Settings of care delivery

At a locality multi-specialty centre:

An individual will receive care at the multi-specialist centre whenever possible and appropriate. Care activities will be delivered primarily by members of the MDT – matrons, mental health practitioners, district nurses, therapists or other professionals.

Other professionals may provide care at the multi-specialist centre as required, such as perhaps Diabetes, Respiratory or Older Persons specialists / consultants who may provide care at the multi-specialist centre for a number of complex-need individuals who are cared for by the MDT.

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Video links and phone facilities will be available to the care professionals to seek consultation and support where required.

At the individual’s home:

Care will be delivered at the individual’s home for those individuals who have limited mobility and are unable to safely travel to a multi-specialty centre or other care setting.

Where possible this will be delivered by core members of the MDT, such as a district nurse, therapist or other, and wherever possible at the same time as other activities such as monitoring or assessments. Where necessary the care will be provided by other professionals engaged through links and referrals with wider services (Community Nursing, Social Care and other).

Education and coaching as well as certain elements of assessment, training and reablement will be provided at the individual’s home where appropriate, to be incorporated into normal daily routine.

At the GP practice

Individuals under the care of the MDT may still visit their GP when needed, though it is envisaged this will become less frequent with the proactive management and support of the care coordinator and the MDT.

GPs maintain clinical freedom to treat their patients and arrange appointments when they deem it necessary. GPs do have equal obligation as the rest of the MDT to ensure the MDT members are aware of any intervention that took place and that the care plan is adequately updated, this will be enabled through improved record sharing processes.

Elsewhere

Individuals cared for by the MDT may visit other care locations as necessary, such as local hospitals. This might be for diagnostics that are not available at the multi- specialist centre, or specialist input if the demand for that input does not justify the specialist clinic at the multi-specialty centre.

4.3.4 Case Management: A case management approach is already established in Knowsley within GP practices, which is combined with the deployment of a risk stratification tool (currently Health intelligence’s CDR Intel is being used, though an alternative tool is also being considered – the Aristotle BI tool used by the CSU). This is done to identify patients with complex needs. The development of the locality multi-disciplinary teams, outlined in this programme will provide the joint

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working processes to proactively plan care and enable monitoring of patients outcomes and achievement of agreed personal health and wellbeing goals.

Through a strengthening of the integrated approach with social care and partner organisations, including the voluntary and faith sector, patients and their carers will have increased visibility and involvement in the development of their integrated care plans.

Benefits for registered population.

Keeping their health and social care requirements well managed, at or near home in

a community setting, supporting them to maximise independence for as long as possible.

Reducing the likelihood of a hospital admission or long-term nursing or residential care.

Benefits for the NHS and Social Care.

Fewer people going to hospital or residential / nursing home requiring

institutionalised treatment and interventions. Improved productivity of community based health and social teams through reduced

duplication of effort

Figure 19: Care planning and case management

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4.4 Implementation of transformed services

The following schemes and work programmes have been identified as priorities for development or ongoing implementation though the development of the Knowlsey BCF plans for 2016/17. These are aligned to the 5 workstreams noted in section 3.4.

A unified implementation plan for each of the elements identified have commenced development as part of the prioritisation exercise that was completed during the development of the CCG 2016/17 Operational plan. These build upon the schemes progressed through the BCF development over the past 2 years. These have included

Alignment of social care & Adult Social Care pathway redesign Carer support Hospital Intermediate Care in-reach service Additional Community nursing capacity Step up / step down facility Services to support independent living Nursing home quality initiative Community navigator Directory of services

A refreshed and up to date Directory of Services and data sharing requirements will be a core enabler to the successful implementation of the operating model.

Table 4: Service implementation per care setting

Population health

GP services Locality care Borough services Acute / hospital care

• Health promotion

• Personal and community resilience

• Structured education, information and advocacy

• Core GP Services

• Primary Mental Health

• Primary / Secondary Prevention

• Therapy support

• Screening / Risk Stratification

• Risk Stratification • Case Management • Care Navigation • Community diagnostics • Social care • Social Prescribing • Medicines

Optimisation • CAMHS • Secondary Prevention • Joint care assessment

and planning • End of life planning

and care

• Crisis intervention

• Specialist care (consultants, specialist nursing)

• Intermediate care

• Rapid access diagnostics

• Reablement • Continuing

healthcare • Admission

prevention

• Urgent Admitted care

• Liaison psychiatry

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• Independent

living • Carer support • Care homes

The schemes described and changes in services work towards reduced acute and unplanned activity, and contribute to the QIPP target for CCG. Schemes such as Locality Working and MDTs, Nursing and Care Home support and Referral Quality are priority QIPP schemes for 2016/17 and 2017/18, complemented by service changes such as those for respiratory and CVD services.

4.5 Multi-Disciplinary working

Whilst the overall ambition is to standardise the operational approach of working through a Multi-disciplinary Team approach, care will be taken to ensure that local flexibilities are enabled to ensure joint teams are able to appropriately respond the needs of local populations and changing identified need.

Figure 20: The Multi-Disciplinary Team

The MDTs for Knowsley localities will be GP led with the core ambition of supporting those identified as most at risk of health deterioration or admission to hospital utilising recognised

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risk stratification methodologies and co-ordinated multi-professional response provided in people’s own homes, where this is practicable.

NHS England (NHSE) has outlined its desire for the GP to be the accountable professional for the care of the patient. This will be the consultant in charge when a patient is under direct secondary care management.

GPs will require support and necessary infrastructure to support the effective functioning of the MDT. The operational dynamic of the MDT should not be as a static entity and will require refinement and review of operational processes on an ongoing basis.

There are a number of MDT competency frameworks which could inform the final operating model for the Knowsley locality MDTs

4.5.1 Referral and handover into the MDT Referral to the MDT will be through a single ‘MDT referral portal access’ for each of the locality MDTs. This will enable administrative co-ordination, suitable triage and where required deflection to into direct care co-ordination for cases which do not require full MDT consideration.

Specific administrative support to facilitate the operational functioning of each of the locality MDTs is required to ensure professional and clinical staff are not diverted into managing the administrative processes of the MDT.

4.5.2 MDT operation We will form four locality multi-disciplinary teams (MDTs), one for each locality. A fifth MDT will focus on supporting the population of care and nursing homes as outlined in section 3.3 above.

4.5.2.1 Core MDT Operation

Staff from a range of professions will be co-located which will encourage closer working and will allow staff to collaboratively plan their approach to care.

Daily handover/’check and adjust’ meetings and informal contact will support improved relationships between staff and will allow for better communication both internally and with other local organisations.

The MDT will be responsible for working together to identify patients who may benefit from an intervention, in particular to avoid a hospital admission e.g. patients with a condition which isn’t being actively managed. Once this need is identified, other members of the team such as generic workers will work under the supervision of senior team members to deliver the appropriate care or advice.

4.5.2.2 MDT meetings

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It is proposed that MDT teams will meet once monthly to discuss and review priority patients across the locality. This would include patients identified by any health and care professional, but will include as a minimum those identified following attendance at A&E or following multiple admission to acute care. The most important factor in referral for consideration at the MDT will be professional judgement which will compliment identified core referral criteria.

Representation from each GP practice in the locality is required at the meeting. The representative might be a GP, but could also be a Matron or Practice Nurse as appropriate as long as the individual is a care professional (i.e. not administrative).

4.5.3 Review and monitoring As outlined in figures 22 and 23 below6, it is proposed that MDTs will actively support individuals whose needs or complexity have reached the minimum threshold; two levels of intensity of need are outlined, each requiring a different frequency of monitoring and intervention. Individuals who do not require MDT support but still suffer with long term / complex conditions will be monitored by their GP practice and referring into the MDT should the need arise.

Individuals with intense need will be reviewed monthly, with the daily operation of the MDT managed through the daily ‘huddle’ or ‘check and adjust’ meetings. The core threshold criteria for this group are outlined in figure 16 below, yet trigger points specific to an individual can and should be included in their care plan (such as rapid weight gain or loss to trigger an MDT and/or medication review).

Individuals who have a risk of admission or deterioration will be reviewed bi-monthly or when a special review is triggered.

Stable patients will be reviewed on a 6 monthly basis as a minimum by their GP practice, and referred to discussion at the MDT if necessary.

In between MDT reviews patients will be proactively and regularly managed by the relevant professionals in the MDT as well as the designated accountable care co-ordinator. All professionals who come in contact with the patient are responsible to ensure that all relevant information and updates have been inputted in the care plan as required and any amendments necessary are made.

Figure 22 illustrates the proportion of the population who would require MDT support:

6 Numbers in figure 17 were taken from Risk Stratification and Disease register data as received by Knowsley CCG.

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Figure 21: Pyramid of need - MDT support

While figure 23 illustrates proposed key activities and referral thresholds.

Figure 22: MDT levels of operation

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An outline Terms of Reference for the MDTs used in the pilot stages of the model is detailed at appendix C of this report.

4.5.4 Referrals from the MDT & Primary Care

4.5.4.1 Workflow to Locality Core Team

The locality core team will receive referrals from primary care GPs and other members of the multi-disciplinary team.

4.5.4.2 Referral to services

To ensure optimisation of the core community services referrals should be electronically referred in to each locality team. Through the development of the locality pilot issues such as interoperability and information governance will be tested, reviewed and operational solutions identified.

Referrals to commissioned services, including secondary care will continue through current referral processes.

Figure 23: MDT to referral and interaction

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4.5.5 Roles and responsibilities

Team members – care / clinical functions:

Table 5: MDT - Clinical team members

Position Role / responsibilities

Care Operations Manager

Individual member of the community / patient

Carer

(professional or family member)

Coordinate care plan delivery for a group of individuals in their care, closely working with any Case Managers and other team members

Build a strong supportive relationship with the individuals in their care

Be the central and direct point of contact for the individual and their family/carer

Coordinate other professionals caring for the individual Be responsible for self-management support Bridge the gap between the clinician and the individuals Assist in navigation of the health and social care system Healthy behaviours adoption Ownership of care plan Adherence to care plan and any care/treatment guidance Self-care and self-management as possible Communication with carer, care ops manager and other

team members Daily support and care of individual with self-care,

lifestyle and other needs Monitoring Communication with Care Operations Manager and wider

team as necessary Senior medical lead – GP Senior clinician, overseeing care

Senior input into care planning Work with all team members to ensure optimal clinical

support for individuals with complex need Support continued quality improvement Seek consultant input when required

Community Matron Heads complex patient care Take a leadership role within the team

Care Navigator Information, advice and guidance Navigation to voluntary sector services and community

resources Navigation to Council resources and support (e.g.

housing, benefits, etc.)

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Case Manager (function)

Depending on core need, the Case Management function would be performed as part of a wider professional role, and could be a:

- Nurse / matron - OT - Mental health

practitioner - Social worker - Pharmacist - Dietician

Specialist nurses, consultants

Act as Case Manager for a small group of individuals under the care of the MDT

Provide specialist professional care to all individuals under the care of the MDT who require it (can be delegated to wider core team if needed)

In special cases, might also be a more specialist function such as a Diabetes Specialist Nurse, caring for individuals with complex need in their specialty

Provide expert input into the care plan development and review process

All professional individuals are responsible for forming links with wider core teams, i.e. social work, mental health, district nursing, pharmacy etc.

Specialists will be consulted for their expert input when

required, and provide a source of expertise for the team members

In special cases, a specialist might be asked to function as Case Manager, caring for individuals with complex need in their specialty

Any sub-specialties not normally part of the MDT will be provided through wider services in the Borough specialist teams and through the existing Respiratory and Diabetes MDTs

Social work teams will also form a core element of the community team. Work to identify specific resource requirements will be confirmed during implementation.

Team members – administrative functions:

The following three posts represent the potential requirement for administrative support required to enable the operational delivery of MDTs and ensure that clinical time is focussed as much as possible on direct patient and population need.

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Table 6: MDT – administrative team members

Position Role / responsibilities

Service Manager Oversee and manage the ongoing operation of the service

Manage resourcing and performance management, ensuring consistency in line management approach

Report on team performance and outcomes vial management structures as required

Support continuous service improvement Analyst Conduct regular analysis of performance

Complete bespoke analysis to support service improvement

Additional tasks TBD during implementation and iterated through pilot

Administrator(s) Support and enable daily operation of the MDT team Support information management, ensuring all

clinicians update records as required and all data is correctly gathered

Logistics planning and support for team members, ensuring clinical spaces are booked etc.

4.6 Assessment – entry into MDT care

Any individual who is referred into the service will receive a comprehensive assessment, encompassing cognitive, social and physical abilities and needs.

It is critical to ensure that when entering the care of the MDT; MDT members have full and up to date information about the individual’s needs but also existing treatments and medications.

Prior to the initial consultation with the individual, data collection from the different professionals / services will take place. Where possible this data collection should happen automatically or digitally using the information systems available. Care records should be updated on EMIS Web.

More information will then be added by the individual themselves and their carer, as well as the Care Coordinator and any other professionals on the first encounter. Any professional clinical assessments needed will be booked and carried out – wherever possible different professional assessments will be carried out simultaneously to improve efficiency and accuracy and avoid duplication.

Existing care plans will be reviewed as part of this process, or a new care plan created if one is not already in place.

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Modelled into the activity and financial model:

4.7 Primary care enhanced access

Increased access to primary care provision is being developed by the CCG. This will include extending access over the weekends from three differing locations within the borough. It is anticipated that utilisation of these services will increase over time and has the potential to decrease pressure on services within current core hours. It is however possible that the increased capacity will increase overall demand for primary care services on overall terms.

4.8 Nursing home support

Admissions from Nursing Homes represent a significant flow of activity for the CCG; often these are attendances via A&E with discharge or short stay admissions. Building on the current ‘quality in nursing homes’ initiative it is proposed that an MDT approach is developed to provide further support for nursing homes to support residents to be cared for in the home rather than be admitted to hospital.

4.9 Resident stories

Dennis

Dennis is 87. He used to work as a bus driver but retired over twenty years ago. He separated from his wife many years ago and she has since passed away. His daughter lives with him but has her own life and little time to spend with him.

Dennis has COPD which makes him very breathless when he walks even short distances. Dennis is unsteady on his feet and fell over a few weeks ago after which he spent the night in hospital. Since the fall he has been experiencing back pain and struggles to walk.

Although he lives with his daughter who is his main carer, she is out a lot and often comes back late at night. Dennis is worried about her mental health, but doesn’t know how to speak to her about it. He does not like to ask her to help him if he can avoid it because she often looks tired and unhappy and he doesn’t want to put pressure on her.

Now In the future

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Dennis is given advice over the phone about ways in which he can manage the situation with his daughter, but decides not to pursue these options as he is anxious about confronting her.

A care assessor comes to see Dennis, who is largely able to care for himself but does need some help with washing and dressing. Dennis feels like he is on the mend and is very eager to keep the care input he receives to a minimum.

Dennis and the care assessor jointly plan a six-week reablement package of morning carer visits to help Dennis regain the independence he previously had. Equipment to help Dennis carry out activities independently is ordered for him.

Through daily visits, Dennis’ carer is able to monitor how Dennis is managing and recognises that he is becoming more frail.

Dennis has been using a community bus service to do his shopping but is finding it increasingly more tiring. His carer proposes that a weekly shopping service is provided for him and he agrees. However, this means he is leaving the house less often and he feels isolated and bored.

After the six-weeks of reablement support Dennis is feeling somewhat better in himself but he is only partly achieving his care goals. Dennis finds that he often tries to carry out tasks independently only to find that he doesn’t have the physical strength to do so. He is still worried about his daughter but doesn’t know what to do about it.

Figure 24: Resident experience story A

An MDT gets together and Dennis and his daughter are both invited to talk about all the support options available.

Dennis’s daughter is given a carer’s assessment and offered counselling. This helps her deal with some of the difficulties she is going through and she is able to provide more support to Dennis as a result.

The social worker on the team identifies that Dennis spends a lot of time alone and puts him in touch with a local third sector organisation. Dennis begins taking weekly singing classes where he makes a number of friends, and joins a Bridge club.

The MDT, which includes a physiotherapist and a specialist respiratory nurse, plan a six-week reablement and rehab programme to help him get his strength back and manage his COPD better.

Dennis takes up a weekly shopping service, as he does struggle with the bags, but now that he has singing lessons and Bridge games he does not miss the shopping so much.

His contact with friends of his own age makes it easier for Dennis to accept his physical limitations, and also gives him more motivation to try harder with his physical exercises. His daughter feels less under pressure, and with the Counselling she is improving her quality of life.

After the six-weeks of reablement support Dennis is feeling better, though there are still tasks he struggles with. He agrees to continue his physiotherapy exercises and continued carer visits, though the visits are no longer required daily.

Dennis is relieved that his daughter looks happier, and between the two of them they now have a home routine they are much more comfortable with. Dennis is regaining his strength and his social life improves his mood.

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Sally

Sally is a 62 lady, living with her husband Simon; they don’t have any children. Sally is a retired office worker and Simon still works as a postman.

Following an operation to remove the slipped disc, Sally has problems eating. She is scared to swallow as she feels like food is getting stuck and she coughs every time she tries to eat or drink. She is not eating very much as a result and is losing weight as well as feeling more tired and weaker than usual

In addition, Sally has started to feel unwell. She is worried she is developing a chest infection like the two she had while she was in hospital for her operation.

Now In the future

Sally waits for four days before a speech and language therapist can come and see her. When the therapist visits she is concerned that Sally may have developed a chest infection so makes a referral back to her GP.

The therapist also makes a referral to Rehab physiotherapy team to help Sally with maintaining her mobility and movement in her joints.

The GP visits Sally and confirms that she does have a chest infection. The GP prescribes some antibiotics and arranges to come back and see her again the next day

The speech and language therapist visits three times over the next week to provide advice and support for Sally and her husband, but notes that Sally’s difficulty in swallowing is getting worse.

Sally becomes unable to swallow safely at all and she is admitted to hospital twice in the following weeks.

In this time, Sally experiences lots of movement between care locations and is seen by a number of different people who ask her similar questions.

She finds the experience exhausting and is worried about the stress it is causing her husband.

Following discharge, Sally continues to be visited by the therapist and physiotherapist

Once Sally begins to manage eating and drinking safely the therapists make their visits less frequent.

Working with a dietician, Sally’s weight is also improving.

Sally eventually feels confident in managing her own care and in discharged from the therapist service.

Figure 25: Resident experience story B

A therapist is automatically linked to Sally’s case and will provide a check- up visit at Sally’s home very soon after her discharge

The GP also refers Sally to a community dietician and a community pharmacist who can carry out home visits as required

Sally can access more complex medical support in the community and therefore does not need to be admitted to hospital so early

Sally’s therapists all work towards achieving the goals on her single care plan

Sally learns techniques that enable her to take charge of her own care

The therapists involved in Sally’s care follow up with her 24 hours after discharge from the service to check she is doing well

Sally is confident that her GP is up-to- date on all the treatment she has received over the last weeks and she knows who to contact if she experiences any further difficulties

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The diagram below outlines the final proposed service model for Knowsley Health and Social Care Transformation.

Figure 26: Integrated Model of Care

4.10 Opportunities for subsequent years’ transformation

Indicative high level timeline for transformation over years 2-5 years is contained in the table below. This will need to be refreshed on an annual basis as part of annual operational plans developed by commissioning organisations and based on prevailing financial forecasts each year.

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Section 5

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5 Impact on and interaction with the wider health and care system

5.1 Transition in and out of acute care

5.1.1 Communication and notification It is important for continuous care and optimal communication that the care coordination is continued throughout a care pathway, even though an admission to acute care. Likewise, for optimal support and avoidance of confusion it is crucial that GPs and other care teams know of any admission of a patient in their care.

It is proposed that providers will therefore be required to notify of a patient’s admission to the Locality Point of Access. The Locality will be determined by the GP with whom the patient is registered.

Once a notification has reached the Locality point of access, the following will take place depending on the patient:

• For all occasions, the admission will be noted on the patient record on EMIS Web (to

which the MDT team will have access) • A patient who has an Accountable Care Coordinator: the Coordinator will be notified,

who can then take any action required with the MDT and the GP or any other relevant professionals

• A patient who does not have a coordinator but has been under the care of the MDT, the MDT will be notified

The schematic below outlines the potential information flow which could be operationalised as part of a single locality point of access. The final care pathway and information flow will be developed as part of any pilot process for development of locality working.

Figure 27: Hospital-PoA Notification options

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5.1.2 Care Coordination throughout For optimal care, the Care Coordinator should be notified of any key decisions taken or stages of the patient’s care within the hospital pathway, to enable coordination and communication with the family and community services as required.

5.1.3 Discharge Effective discharge planning and timely initiation of assessments and transfer of care processes are critical to the improving experience and outcomes of patients with complex health and social care needs. From April 1st 2016, Knowsley started to operate with a Knowsley dedicated Hospital Discharge Team which brings together Social Work, Reablement and Intermediate Care Therapy Assessments. The next steps for the development of the service will be to include District Nurse Liaison to create a fully integrated service. Taking an integrated approach to assessment and discharge planning will ensure patients receive the right care, at the right time and in the right place.

The service will work across the borough supporting any Knowsley resident requiring supported discharge from an Acute Trust. The aim of the service is to work on a ‘pull’ approach to hospital discharges, providing timely assessments and co-ordinated discharge planning so Knowsley patients do not stay in hospital longer than necessary. The integrated team will have detailed knowledge of borough services and will ensure discharge plans are tailored to the needs of individuals. They will connect with locality teams to ensure patients receive the appropriate support to remain at home and reduce the chance of readmission. The service will proactively identify frequent fliers, linking with locality teams to support admission avoidance plans.

The service will also provide a borough wide view of the system in terms of community beds, reablement and care package capacity. This will be a key enabler to effective management of patient flow and capacity through the system.

5.1.4 Impact on acute services Through the development of its 2016/17 Operational Plan the CCG has identified £3.3m of QIPP opportunities, which focus on the development of health and care services being offered within community or primary care settings. The development of locality integrated working, support for nursing homes, increasing access to primary care services and appropriate referrals management are priority areas to support achievement of the Knowsley CCG QIPP and nationally mandated priority must do’s identified by NHS England.

5.2 Interaction with wider council services

5.2.1 Public health

The Knowsley Health and Wellbeing Board have developed a strategy for improving outcomes for the population of Knowsley. A new strategy for 2016-2020 is currently under development and being considered through a consultation process. Once published the

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document will provide the framework and objectives for continuing to improve health and wellbeing outcomes for the local population. http://www.knowsleyhwb.org.uk/

5.2.2 Safeguarding People who are at risk or are experiencing abuse or neglect will be protected by a robust safeguarding process that is understood by all partners whi are clear about their responsibilities. The person at risk will be at the centre of the process, their wishes and expectations will be met and risk reduced as much as possible.

We will ensure that all partners understand the thresholds for safeguarding and work together to manage risks and develop more risk aware communities. A Quality Assurance unit will be developed to ensure that safeguarding process is routinely audited and there is a focus in continued learning and improvement. The ‘Making Safeguarding Personal’ guidance will be embedded to ensure that enquiries meet the persons wishes and expectations and they are involved throughout the process.

5.2.3 Community Assets Programme The Council has developed a Community Asset programme that is promoting the Asset based approach to supporting some Adult Social Care needs. Spending review plans and an increasingly aging population means that there will be a larger demand with less Council resources to meet it. The Community Assets programme is designed to address this gap through alternative means.

The programme has been developed through three pilot sites across the borough to look trial new and innovate ways of building on community strengths to help people in neighbourhoods to support each other and people in need. It is intended that micro enterprises will be developed following a series of community events. The events will identify good community ideas and help them develop or expand. This will have the dual benefit of meeting social care needs and providing alternative employment opportunities at a local level.

The Community Asset pilot sites will also trial a range of community/care navigator solutions to see where they can be most successfully used across the borough. Where there are successes within the pilot sites, the conditions will be replicated across other localities.

The pilots will run between 12 months and 2 years, however, where there are clear benefits to the area, these will be implemented borough wide where possible.

5.2.4 Digital Inclusion It is currently estimated, based on recent research, that 17%-21% of adults in Knowsley have never used the internet7. This is a concern as the internet has potential to significantly

7 Knowsley Digital Inclusion Strategy 2015-2017

http://www.knowsleyhwb.org.uk/

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improve lives, and the ability to access and make use of the internet is an increasingly vital part of everyday life.

Digital exclusion is strongly associated with factors such as unemployment, living in social housing and disability – factors which are disproportionately represented in Knowsley compared to the national average. Reasons for digital exclusions are commonly the same as the reasons for marginalisation and social exclusion, such as limited income or lack of the right skills. Based on local and national research, those most at risk of digital exclusion are: Unemployed people; People with disabilities; People in social housing; older adults; those aged 45 – 64; Children in poverty; Homeless, and; Offenders. These individuals are also those most at risk of reduced healthcare outcomes, comorbidity of conditions, and lower overall wellbeing.

The Knowsley Partnership has therefore agreed on the Digital Inclusion Strategy, centring around five core objectives:

1) Motivation – encourage those who are not engaged to participate 2) Skills – support people to develop their digital skills 3) Access – ensure residents and businesses have access to affordable connectivity and

equipment 4) Channel shift – provide high quality online services 5) Growth – support business and social value organisations to utilise digital technology to

enable growth

To achieve each of the objectives a numbers of key actions that will be taken locally have been outlined, which include actions such as:

• Communication materials • Mobilising digital champions, volunteers, friends, family members and colleagues to

raise digital skills • Developing a range of conveniently located and free to use access points across the

Borough to meet the needs of residents who do not have access at home • Taking a coordinated approach across all partners to channel shift, and • Support existing and emerging businesses and social value organisations to build and

capitalize on digital connectivity and capabilities and help them make smart use of information technology and data.

Digital inclusion is important to health and wellbeing as well as the efficiency of care services, as it can enable and promote:

• Reduced loneliness, allowing individuals easier communication with family members

further away and easier access to social activities • Easier access to advice about lifestyle, diet and healthy behaviours

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• Easier access to advice about minor ailments • Access to support groups, patient groups and other local networks, which help

individuals with disabilities, long term conditions or other difficulties find the support they need from individuals who understand them best

• The use of online booking systems for GP services and other community services • Skype appointments and consultations where available • Improved employment opportunities, which are aligned to better health and

wellbeing

Digital Inclusion support will complement the whole-person support given by the MDT, and will be navigated to as required by the Care Navigators or Care Operations Managers.

5.3 Interaction with the Voluntary Sector

The voluntary, third and faith sectors play a vital role in the delivery of health, social and wellbeing services to the population of Knowsley, both in the development of services through re-design and improvement, as well as partners in direct services delivery. Through the development of our ongoing communications and engagement approach we will seek pro-active and meaningful involvement of the sector during further development and implementation of our service transformation programme.

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Figure 28: Working with the Voluntary Sector

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Section 6

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6 Care outcomes and quality

In accordance with the agreed vision of the transformed model of care, the key aims of the new model are the improved health, wellbeing and quality of life of the population of Knowsley. These have been detailed and defined below.

At the same time, in the transformation journey and on the way to those population outcomes, it is key to understand the service model outcomes and interim states of the service. This is to enable careful implementation planning as well as monitoring and understanding progress and the impact of the various service changes.

As such this outcomes chapter will look both at the population outcomes and service model outcomes, and map both to the design principles agreed.

Social Care quality/improvement outcomes targets and plans for subsequent years

The council has a key role in ensuring the effectiveness of services is closely monitored both in terms of quality, their financial sustainability and their ability to act early to prevent harm to vulnerable people. As we move forward there will be an ever increasing need to demonstrate that services are value for money and can deliver the outcomes that are expected.

The principles of the council’s commissioning approach is to work with providers to free them up to deliver outcomes, with respect for the expertise of front facing services, and to support providers to invest in a quality workforce and commit to driving up quality standards.

The council will have in place robust, evidence based standards and our contractual and commissioning expectations will be built on these. Providers who want to improve will be supported to do so but there will be real sanctions for those who do not, or who fail to safeguard or provide a caring service for people who need our services.

6.1 Target outcomes for the new Model of Care

Population outcomes are defined as population health and wellbeing outcomes measured through clinical targets or quality of life / experience measures rather than service activity / configuration.

Service model outcomes are defined as service characteristics, configurations or offerings which have been achieved or made available through the workings of the new model.

The following represent the range of potential outcomes, further definition and agreement with providers will be required to develop further and agree into contractual agreements as appropriate.

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Table 7: Potential outcomes

Category Service outcome Population outcome Target / measurement

Primary care:

Seven day access achieved

GP collaboration established across localities

MDTs operationalised across a GP cluster and caring for individuals with complex needs

Online appointment booking and prescription renewals available

Sustainable workforce

Reduced demand on GP services

Reduced GP appointments for non-medical causes

Acute care: Though services within acute settings are out of scope for this programme of work, the following outcomes are intrinsic to the service and relate to the acute sector: Extended specialist

support in community settings (‘community consultants’)

Consultant advice / support for primary care

Enhanced supportive discharge

Increased numbers of people still at home xx days after discharge from inpatient service

Reduced frequency of admissions to hospital

Reduced frequency of A&E attendance

% reduction in ambulance conveyance 999

X% reduction in 999 calls

Avoidable admissions: A reduction of 5% in Avoidable admissions across whole population; A reduction of 10% in Avoidable admissions across population with Long Term Conditions

Community care:

Care co-ordination established and coordinators / navigators in post

Community nurses / nursing teams aligned to localities

Increased percentage of care given at home

Percentage of people with complex needs who have a named care co-ordinator

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Community

diagnostics available in community hubs

Social prescribing and befriending services established and used widely

MDTs operationalised across all four localities

Crisis intervention – rapid response within 2 hours

Adherence to care plan

Percentage of people and carers who report their care plan targets are being met

Percentage of people and carers who report their care plan meets their need during a crisis

Overarching: Single, personal

health and care records

Care records shared across health, social and voluntary sector support

Carers integrated into workforce

Single point of access for Knowsley care services available to members of the community

Online directory of services as well as advice and guidance resources

Health and social care spend optimised and system ‘right sized’

Routine ‘telemonitoring’ and optimal use of data

Health related quality of life

Self-diagnosis and self-treatment of minor ailments

Increased self- management of LTCs

Reduction in unhealthy behaviours

Increased healthy behaviours / lifestyle

Decreased anxiety during transition between care settings

Increased health literacy

Increased self- management of care

Increased personal resilience and empowerment

Care Coordination: Top 5% of need in the population have a named Care Coordinator Care plans: All individuals with a Long Term Condition diagnosis / who have been added to a disease register have a care plan within 3 months; Technology: Organisations sharing care records / individuals with access to online records

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Social care Seven day working

achieved Increased

assessment for home hazards for over 70s

Social workers / teams aligned to the four localities

Carer support in place

Reablement: Achieve an effectiveness measure of 90%, measured by individuals still at home after 91 days Long term care admissions: A reduction of 10% in average number of admissions into long term residential care; Average age on admission to care to increase Delayed transfers of care: A reduction of 5% in delayed transfers of care

Falls A reduction of 15% in hospital admissions as a result of a fall

Population level outcomes are further broken down into interim milestones and stages of development in figure 30 below.

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Figure 29: Population outcome

6.2 Equality and quality impact assessment

Each scheme will have a full Equality Impact Assessment carried out in compliance with the national regulations and guidance and CCG Governance mechanisms.

Section 7

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7. Finance and sustainability

The Knowsley Health and Social care economy is faced with significant financial pressure which is borne of increasing demand for local services, and an ageing population

Over the next five years the funding gap for Knowsley CCG alone is c£24m, which if not addressed will have a further fundamental impact on health and social care services for the local population. Without transformative and joint action the underlying financial positon for both commissioners and the range of local service providers will further deteriorate.

Through the transformation programme, the CCG and Knowsley Borough Council are aiming to ensure that local services are available to the local population which:

Improve the health and wellbeing outcomes for the local Knowsley population Ensure that services are delivered locally and are effective and safe Enable increased use of available technologies

7.1 The local financial challenge for Knowsley

As outlined in the case for change in section 1.2

Rates of referral from GPs have marginally increased and were above the 2015/16 plan.

Overall increasing demand for health and social care service Increase in specific areas such as Trauma and orthopaedics, Gynaecology, Endoscopy

and Ophthalmology

A small number of patients within Knowsley 581 people (0.35%) consume 10% of total healthcare spend for the borough. There are a high number of admissions from our Nursing and Care Homes.

Demand for health services is growing due to a wide range of factors including an ageing population, higher expectations from the population, increased range of health and wellbeing supportive technology, and unhealthy lifestyles coupled with increasing use of Accident & Emergency and other health services by patients, and (increasing?) referral rates from Primary Care into Secondary care settings.

We have already evidence that we are able to redesign care pathways and manage demand within Knowsley; this is evidenced following the introduction of specialist community CVD and COPD services.

We have already identified £7.29m of identified Quality, Innovation, Productivity and Prevention plans for 2016/17, and a further £8m for 2017/18. Further work on the final development of schemes from this transformation plan will be needed to provide assurance

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that the financial gap for 2016/17 can be closed and the CCG deliver a surplus of between 0.1% and 1% in line with its control total.

The future four year challenge for CCGs and Knowsley Borough Council will be the limited increases or real reductions in funding over the next 4 years.

The financial challenges facing Knowsley CCG will require many tough decisions to be made around future delivery of services, although the CCG is predicted to achieve a 1% surplus in 2016/17 on the baseline budget of £261mn by 2019/20, without concerted action the deficit could reach c£24m.

In addition, despite the Care Act social care budgets continue to be severely constrained which may continue to adversely impact on the demand for council services including pressures on social care services.

The challenge for NHS providers is that they will need to maintain service provision within real potential for zero growth or reduced contract values. For 2016/17 NHS providers have been set challenging savings and control totals, which at current levels do not ensure ongoing financially sustainability or clearing of their underlying financial deficits.

Whilst CCG allocations have been identified for the next three years, the forward economic position confirms that after 2016/17 there will continue to be a significant annual financial challenge confronting health and social care commissioners and providers to the extent that significant further efficiencies and productivity gains will be needed.

At the same time, commissioners need to reinvest resources in improvements and consider the possible requirement to move certain elements of care, and therefore associated funding, out of hospital and into the community, in the best interests of patients. This will present further pressure and challenges for acute providers, who will need to respond to changing demand and potential requirements to reduce their cost base.

7.2 Delivering the outcomes for the people of Knowsley – opportunities

There are potential three main types of opportunity.

Keeping people out of hospital who can have care delivered closer to home or preferably in their own home

Service integration and effective multi-disciplinary working Working to improve the health and wellbeing outcomes for Knowsley residents

through improved self-care.

The majority of benefits will be borne from further integration of services and care pathways leading to removal of areas of duplication, such as multiple assessments, simplified referral mechanisms and

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Operational benefits will emerge from clearer signposting and understanding of service provision, reduced emergency admissions / unscheduled attendances and reducing the need for admission to longer term care in residential and care homes.

In order to ensure that the change options are affordable during the transition and over the longer-term of the Knowsley Health and Social care Transformation programme, the test of affordability and sustainability remain a core feature of our service design principles.

Whilst we have agreed design principles which are outlined in section 2.2, we have jointly agreed that criteria will be system-wide in focus, and based on the overarching principles of the reconfiguration.

The development of the Knowsley Health and Social Care Transformation plan with a focus on implementing a new model of care for Knowsley will provide the foundation to continue to clinically and financially sustainable for the long-term and delivered through Commissioners, Providers and Local Authorities working together in partnership.

7.3 Modelling the impact of a transformed service offering for the people of Knowsley

The aim of the affordability model is to provide a mechanism to understand the potential impact of proposed initiatives on the activity and financial flows across organisations within the Borough. The model will provide insight into the overall affordability of the proposed changes over a 5 year planning horizon.

Any shifting of activity as a result of transition will have associated financial considerations e.g. between acute providers, from acute to the community or across other parts of the wider health and social care system within Knowsley. This may involve capital investment, an element of dual running costs during any planned transition phase and a potential need to release excess estate / facilities.

The future delivery model needs to be tested primarily against commissioner affordability, coupled with evidence that providers can deliver any revised pattern of services from within agreed tariff, or contract block payment arrangements.

Pump priming funding will be required over a short bridging period – timeframe to be identified and agreed. Moving forward, it is proposed that Knowsley CCG will utilise a benefits-driven approach to developing options for change, with financial hurdle criteria to ensure that the options are affordable and that the recommended option is the best way of improving patient care while contributing to financial balance.

7.4 Activity Split assumptions

The total CCG activity for each service category was split by locality as accurately as possible.

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GP list sizes have been used to allocate Primary Care, Community and Mental Health activity to the appropriate locality

FIMS & SUS activity data relating activity to GP Surgeries has been used to allocate Acute (Elective), Urgent Care and Mental Health OP activity to the appropriate locality

All activity associated with Aston Healthcare Limited has been distributed as 0 to Kirkby, 35.48% to West Knowsley, 45.15% to East Knowsley and 19.36% to Halewood, as suggested by the associated list sizes and branch location.

The model has been built to allow for activity split input when the assumptions are more refined in Knowsley CCG

Extended list split, Mental Health split, Community split, Manual split

Locality Activity split:

CCG list split

Locality 1 Locality 2 Locality 3 Locality 4 Locality 5

Kirkby East KnowsleyWest Knowsley Halewood Other

GP list split 29.81% 27.50% 32.79% 9.90% 0.00%

Extended list split

Mental Health 29.81% 27.50% 32.79% 9.90% 0.00%

Community 29.81% 27.50% 32.79% 9.90% 0.00%

Manual split 1

Figure 30: Locality activity split insert

7.5 Activity & Tariff Growth assumptions

Underlying growth assumptions have been taken from ONS data and Knowsley CCG Financial Plans to estimate the yearly activity growth in the following categories:

Demographic growth at 0.24% (based on 14/15 growth) Tariff growth at 1.10% as agreed by Knowsley CCG Primary Care growth at 3% as established by The Health and Social Care Information

Centre, Trends in Consultation Rates in General Practice 1995 to 2008: Analysis of the Research® database

The model has been built to allow for Non-Demographic growth input when the assumptions are more refined in Knowsley CCG

Primary Care growth, Acute (Elective) growth, Urgent Care growth, Mental Health

growth, Community growth

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7.6 The Affordability Model

The aim of the affordability model is to provide a mechanism to understand the potential impact of proposed initiatives on the activity and financial flows across organisations within the Borough. The model will provide insight into the overall affordability of the proposed changes over a 5 year planning horizon.

The affordability model will ultimately demonstrate the optimum level of intervention required by Transformational Change Schemes in Knowsley CCG to give the best and most affordable outcome over 5 years

By understanding what happens if you:

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Section a

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8 Enablers

8.1 Risk Stratification

Two risk stratification tools are currently being used in Knowsley: Health intelligence’s CDR Intel, and the Aristotle BI tool used by the CSU. The two are being compared for quality and accuracy to enable a final choice to be made.

8.2 Diagnostics

The potential for increasing near patient testing including expansion of accessibility to local plain x-ray services will continue to be explored through the development of services such as the local community step-up/step-down service.

8.3 Screening and early detection

Access to early diagnostics and timely referral to secondary care treatment are crucial to the outcomes of people diagnosed with Cancer.

• Cervical screening coverage in Knowsley was 77.2% in 2013/14, lower than England

(77.8%) and the North West region (76.9%). Since 2007/08, cervical screening coverage has increased by 3.2% in Knowsley but has fallen across England and the North West region over the same period.

• Breast cancer screening coverage in Knowsley was 64.7% in 2013/14, lower than England (72.3%) and the North West region (70.0%). Coverage of breast cancer screening in Knowsley fell by 3.5% in the last 3 years, but increased by 0.6% from 2012/13.

• Bowel cancer screening coverage in Knowsley was 49.1% in 2013/14, lower than England (58.5%), the North West region (57.4%) and Liverpool City Region (52.7%). Bowel cancer screening coverage has increased by 6.4% since 2009/10 in Knowsley.8

8.4 Workforce

To enable real new ways of working, improved collaboration and a more proactive approach, it is critical to define the required workforce – in terms of the structures and locations, new roles, and any new training and development requirements.

We intend to create a system where:

Support is tailored to individual need, regardless of setting Individuals are able to make informed decisions about their care and support Holistic support is routinely included in individualised care and support plans Co-production of care plans and services supports people to actively engage in the

design and delivery of services

8 Source: Public Health Statistical Compendium 2014/15

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Staff can work in creative, person centred ways across traditional organisation boundaries and specialisms.

Proactive care means we eliminate preventable hospital admissions Early supported discharge is the norm.

In order for the workforce to deliver the new service model, we will focus on three key areas.

1. Structures 2. Roles 3. Learning and Development

8.4.1 Structures The workforce will be organised in cluster and locality teams with specialist teams and services working across all localities:

Figure 31: Workforce structure

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Benefits of the new structure The new structure will support the people of Knowsley in a number of ways including:

Proactive Care Rapid Response and Crisis Intervention Early supported discharge

8.4.2 Roles To enable true multi-specialty working and seamless, integrated care, teams will be composed of a mixture of professionals. We will make best use of skill and grade mix to ensure that care is holistic and is tailored to need.

District Nurses, Community Matrons and Practice Nurses

These three roles could work more closely in the future, ultimately assuming a single governance and employment model.

Within five years we will have improved the integration between practice and community nursing and these staff will be working very closely with nursing staff in Care Homes. This approach means that patients will not need appointments with different professionals. E.g. a routine appointment might include a review of the patient’s care plan, and their flu vaccination. These staff will work towards a model of co-production, aiming for at least half of patients to have been involved in their care plan by year three. We will develop shared training for practice and community nurses in year one and will develop options for a shared governance / employment model with GPs over the next 2-5 years.

Other roles may be defined for the model, such as Assistant Practitioners, Advanced Practitioners or Care Navigators.

8.4.3 Learning & Development We will encourage networked learning, whereby staff across different professions learns together. The model will require a mind-set shift for staff to enable them to develop skills across pathways, localities and traditional team boundaries. Staff will challenge each other through peer review and we will develop approaches to learning through reviewing progress as they develop their skills in the co-production of care plans and achievement of patient- defined outcomes. We will adopt a mixture of formal and informal learning opportunities.

Joint working with the Voluntary and other Sectors

We will work with voluntary organisations to support them in training community members / staff e.g. a Consultant in Diabetes may attend a support group / meeting run by a voluntary organisation to educate community members and staff. We will also make use of voluntary organisations to educate care staff, e.g. asking community groups to provide nursing staff with training around culturally specific issues.

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We will deliver training to staff in care homes to enable staff to develop more confidence and better skills in dealing with individuals on the end of life pathway. This will aim to reduce GP call outs and 999 calls made for patients within care homes.

Mentorship & development

The new service model will enable staff to access professional supervision, mentorship and support from a range of sources within and outside of their own profession. We will introduce peer supervision for staff where appropriate so that staff within the MDT can supervise each other on a cross-professional basis. This will be supported by very clear governance arrangements so that everyone has a clear point of contact should any issues arise. There is a professional line of accountability of practice within each profession and we will ensure that all staff have a professional manager with whom they can discuss any profession specific issues.

8.5 Digital, IT & Information Sharing

Information management and making best use of technology will be a core enabler to the effective working between health and care professionals and support to effectiveness of the MDT approach. As core element of the implementation of the Transformation Programme will be the requirement to agree an approach to information sharing underpinned by robust information governance and interoperability mechanisms.

Short term: EMIS Web

Knowsley GPs currently utilise EMIS web. It is initially proposed that professionals from community and social care be given read/write access to EMIS Web, on which records could be shared. Similar rights should be given to hospital teams so they are able to notify the correct individuals (in the Locality Points of Access) of any admission or impending discharge.

Future: assessment and roadmap for interoperability

In the long run, more systematic interoperability is required and should be put in place. Several key policy imperatives, such as patient ownership of and access to their records, joint care records and ‘a paperless NHS by 2018’ are all key drivers for this.

It is proposed that as part of the implementation plans for the integration of care services a thorough assessment is carried out of existing IT systems across local providers and options for interoperability, so that a roadmap to robust interoperability can be created.

8.6 Communications and engagement

Tailored, timely communications and engagement activities for this type of programme necessitate a real project focus and a joint framework of co-production, ensuring all

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stakeholders own and are accountable for decisions rather than just being kept informed of activities and progress.

It is therefore critical that positive engagement, formal and informal communication activities are tailored to support and enable the different stages of the programme, from mobilisation through to implementation.

Given the importance of communications and engagement for the successful delivery of the programme, we collaboration between the CCG and Council communications and engagement team to identify the best channels and methods of communication and utilise the agreed governance structure to sign off messaging. This may include using social media (intranet based) rather than time consuming meetings to solicit views and opportunities from staff, partners or members of the public.

Objectives to be achieved through the communication and engagement approach.

• Maintenance of staff morale through transparent two way communication and

engagement activities.

• Understanding of and rationale for the ‘Health and Social Care Transformation Programme’, including the need to secure financial sustainability, to enable the health and social care economy to continue to commission and ensure provision of high quality care to local patients.

• Draw on ideas from front line staff e.g. practice and council staff

• For staff, patients and the local population that clinical safety will not be compromised

as a result of the programme.

• For local commissioners, ensuring the Transformation Programme is recognised as providing a platform for local financial stability within the context of health and care system sustainability.

• Positive management of external communications which maintain confidence in the

leadership and CCG / Council reputation.

A detailed communication and engagement plan was created for Knowsley CCG in 2015. It is proposed the strategy, approach and tools detailed in the plan are used to ensure all stakeholder groups – commissioners, providers, senior managers, staff and members of the community – are all engaged to the maximum degree possible to ensure a real culture and behavioural change takes place. For a true transformation of the care economy and population health it is crucial that all stakeholders know of, understand and are bought in to the changes proposed.

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8.7 Estate

We will build on existing CCG strategy and estates priorities. It is proposed that the MDT and associated workforce are co-located, to enable optimal collaboration and fast handovers between services. Co-location also fosters greater understanding between professionals and mutual upskilling, and eases referral allocation when those come in from GPs or elsewhere.

Several existing LIFT Primary Care Resource Centres exist in Knowsley, and it is proposed that among those four are chosen which will house the MDT services and associated nursing and social work teams:

Figure 32: Suggested locations for Locality Multi Specialist Centres

The services currently available in each of them are listed in Appendix B.

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Section 9

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9 Timelines and implementation plan

9.1 2016/17 In-year transformation

The table below highlights the process which is being followed in the development and implementation of the Health and Social Care Transformation Plan. Detailed operational implementation plans are currently under development and are being led by the Director of Planning and Performance with support from the Knowsley CCG Programme management team.

Figure 33: Implementation phases

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9.2 Implementation plan

Development of detailed operational implementation plans and milestone achievement will be managed through the Knowsley Programme Management approach.

Figure 34: Implementation activities

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Section 10

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I

Knowsley Health and Social Care Transformation Knowsley Council

rH:J;j Knovvsley

Clinical Cornrnissioning Group

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10 Next steps

lmt1ate enablers and validate

Transform and Trans1t1on

V ISIOn

To agree a shared vision of

future state and benefits

•

•

To prepare the landscape for transformation

To implement roll out theagreed solutions

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Appendices

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Appendix A: Quality and Service Standards

NHS Constitution

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/ha ndbook-to-the-nhs-constitution.pdf

The Department of Health refreshed 2001 guidance ‘Intermediate Care – Halfway

Home’ July 2009 as part of the ‘preventative package for older people’. Transforming Community Services – Quality Framework (2010) Care Quality Commission: Essential Quality Standards of Quality and Safety (2010) Common Core Principles for Supporting People with Dementia (2011) The Health & Social Care Act 2008: Code of practice on the prevention and control of

infections and related guidelines (2010) Disclosure and Barring checks Mental Health Capacity Act 2008 Deprivation of Liberty Safeguards 2009 The Controlled Drugs (Supervision of Management and Use) Regulations 2013 Human Medicines Regulations 2012 Serious Incident Framework 2013. http://www.england.nhs.uk/wp-

content/uploads/2013/03/sif-guide.pdf National Patient Safety Agency (2010). National Framework for Reporting and Learning

from Serious Incidents Requiring Investigation. Available at http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173

Working Together to Safeguard Children 2013 Personalised health and care 2020: a framework for action Nov 2014

Applicable Standards Set Out in Guidance and/or Issued by a Competent Body

Ready to Go: Planning the discharge and transfer of patients from hospital and intermediate care (DH 2010)

Royal College of Physicians National Clinical Guideline for Stroke (2008) Immunisation Against Infectious Diseases (DH 2006) plus updates via

http://www.dh.gov.uk/en/PublicationsandStatistics/Publications/PublicationsPolicyan dGuidance/DH_079917

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/handbook-to-the-nhs-constitution.pdf

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/handbook-to-the-nhs-constitution.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf



http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173

http://www.dh.gov.uk/en/PublicationsandStatistics/Publications/PublicationsPolicyandGuidance/DH_079917



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Applicable Local Standards

Safeguarding Adults and Children policies and procedures Pressure Ulcer Prevention and Management policy Local governance policies and procedures Infection, prevention and control guidance and reporting CCG prescribing guidelines, policies and commissioning statements

Quality Imaging Services for Primary Care: Good Practice Guide (Joint publication of Royal College of General Practitioners and Royal College of Radiologists, May 2013)

www.rcr.ac.uk/publications.aspx?PageID=310&PublicationID=393

The NHS supports the need to develop improved access to diagnostic tests as part of the drive to reduce waiting times and improve choice options for patients. The need to develop community based diagnostic services is supported by the Royal College of Radiologists and Royal College of General Practitioners as part of a service strategy to improve access to tests and ensure these tests are delivered at the right stage of the patient care pathway

Other guidance available:

NHS England Safe, Compassionate care for frail older people using an integrated care pathway: practical guide for commissioners, providers and nursing, medical and allied health professional leaders (Feb 2014)

www.england.nhs.uk/wp-content/uploads/.../safe-comp-care.pdf

Parity of Esteem (2014) www.england.nhs.uk/ourwork/qual-clin-lead/pe/

NHS England has established a Parity of Esteem Programme in order to focus effort and resources on improving clinical services and health outcomes. The intention is to recognise the difference in care and outcomes that often relates to people with mental health conditions and that may lead to physical aspects of their health, such as the management of chronic disease, being neglected.

NHS England Call to Action – Improving General Practice (NHS England 2014)

www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/igp-cta/

Hospital Discharge: The Patient, Carer and Doctor Perspective (Feb 2014)

www.nhsconfed.org/Key.../Commentary-summary2-250214.aspx

Care Quality Commission: Essential Standards for Quality and Safety

http://www.rcr.ac.uk/publications.aspx?PageID=310&PublicationID=393

http://www.england.nhs.uk/wp-content/uploads/.../safe-comp-care.pdf

http://www.england.nhs.uk/ourwork/qual-clin-lead/pe/

http://www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/igp-cta/

http://www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/igp-cta/

http://www.nhsconfed.org/Key.../Commentary-summary2-250214.aspx

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http://www.cqc.org.uk/content/essential-standards

The Family Nurse Partnership Programme, Department of Health http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1 28402.pdf

Care planning guidance is available at:

http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf

Standard contract General Terms

http://www.england.nhs.uk/wp-content/uploads/2015/03/15-nhs-contrct-gen-conditions.pdf

Francis report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013)

https://www.gov.uk/publications/report-of-the-mid-staffordshire-nhs-foundation-trust- public-inquiry

This report outlines recommendations which address health treatment and care quality and governance issues at the heart of all patient interactions with the NHS, including the need to:

Foster a common culture shared by all in the service of putting the patient first

Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated

Provide a professionally endorsed and evidence-based means of compliance

with these fundamental standards which can be understood and adopted by the staff who have to provide the service

Ensure openness, transparency and candour throughout the system about

matters of concern

Ensure that the relentless focus of the healthcare regulator is on policing compliance with these standards

Make all those who provide care for patients – individuals and organisations –

properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service

Provide for a proper degree of accountability for senior managers and leaders

to place all with responsibility for protecting the interests of patients on a level playing field

http://www.cqc.org.uk/content/essential-standards

http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128402.pdf

http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128402.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf

http://www.england.nhs.uk/wp-content/uploads/2015/03/15-nhs-contrct-gen-conditions.pdf

https://www.gov.uk/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry



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Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do

Develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system.

Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report - Professor Sir Bruce Keogh KBE

Patients, carers and members of the public will increasingly feel like they are

being treated as vital and equal partners in the design and assessment of their local NHS. They should also be confident that their feedback is being listened to and see how this is impacting on their own care and the care of others

No hospital, however big, small or remote, will be an island unto itself.

Professional, academic and managerial isolation will be a thing of the past.

Nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness of the patients they are caring for and be transparently reported by trust boards.

All NHS organisations will understand the positive impact that happy and

engaged staff has on patient outcomes, including mortality rates, and will be making this a key part of their quality improvement strategy.

The boards and leadership of provider and commissioning organisations will be

confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public, will have rapid access to accurate, insightful and easy to use data about quality at service line level.

We will have made demonstrable progress towards reducing avoidable deaths

in our hospitals, rather than debating what mortality statistics can and can’t tell us about the quality of care hospitals are providing.

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Appendix B: Current locality services

Table 8: Services currently available in potential Locality centres

Centre: Services available:

West Knowsley

Bluebell: IAPT CRDS service CVD Service Phlebotomy Pharmacy ET hours GP services Diabetes

PCMHS Lifestyle adviser SLT Health trainers Dietician Physio / MCAS Paediatric dietician Doppler clinic

Stockbridge village health centre:

Treatment rooms IAPT Podiatry PCMHS Lifestyle adviser Dietician

Paediatric continence Orthotics Stop smoking Adult continence Baby Club Wellbeing coach

North Huyton: Sexual health IAPT Podiatry CRDS service TB service Phlebotomy PCMHS SLT Health trainers

Physio / MCAS Weight management Orthotics Alder Hey Nursery nurse Ophthalmology / eye clinic Wellbeing coach Immunisation

Maggie O'Neill Community Centre, Huyton:

RASASC

The Peake Centre, Huyton:

Drug / alcohol CRI

Stockbridge village health club:

SLT Orthotics Children’s orthotics

Alder Hey Paediatric therapies

East Knowsley

Nutgrove Villa : Treatment rooms IAPT Podiatry HOSAR VIC

Phlebotomy Weekend

GP services PCMHS Audiology Bowel screening DEPO clinic Dietician Stop smoking

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Manor farm: Minor surgery Sexual health IAPT CRDS service Phlebotomy PCMHS

Whiston: IAPT Podiatry CRDS service CVD service Pharmacy ET hours GP services Diabetes PCMHS 5BP Mental health consultant

Lifestyle adviser SLT Weight management Family futures Adult continence Baby Club SLT Audiology Physio / MCAS Weight management Paediatric dietician School health Orthoptist Universal Child Health Stop smoking

Longview: Minor surgery

IAPT CVD service PCMHS

Prescot MC: Treatment rooms IAPT Podiatry Phlebotomy ET hours GP services PCMHS SLT Health trainers

Wellbeing Coach Counsellor Medicines management Audiology Bowel screening DEPO Clinic Dietician Weight management Orthotics Adult continence Ophthalmology / eye clinic

The Peak Centre, Huyton:

Drug / alcohol CRI

The Arch: Sexual health

Kirkby

Tower Hill: Dental IAPT Podiatry CRDS service CVD service Phlebotomy Pharmacy ET hours GP services Diabetes PCMHS

Westvale clinic: Podiatry PCMHS SLT

Lifestyle adviser SLT Health trainers Audiology Dietician Paediatric dietician Weight management Orthotics Doppler clinic Liverpool Women’s Hospital Family futures Health trainers Orthoptist Ophthalmology / eye clinic

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St Chad’s: Dental Treatment rooms Minor Surgery Sexual health Drug / alcohol CRI IAPT CRDS Service CVD Service HOSAR VIC Phlebotomy Pharmacy ET Hours GP services PCMHS

Lifestyle Advisor DEPO Clinic Weight management Orthotics Stop Smoking Alder Hey (Children’s) Liverpool Women’s Hospital Child Health Assessment Retinopathy Bereavement Services Family Futures Adult Continence Warfarin Leg ulcers

Halewood

Halewood Health Centre:

Treatment rooms Minor Surgery Sexual health IAPT Podiatry CRDS service CVD service TB service HOSAR VIC Phlebotomy Pharmacy ET hours

GP services PCMHS Lifestyle adviser SLT Health trainers Audiology Physio / MCAS Weight management Orthotics Universal child health Stop smoking Retinopathy Baby club

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Appendix C: MDT Terms of Reference for pilot stages of care model

Locality Services – MDT – Terms of Reference

Introduction

The aim of this model of working is the establishment of locality multidisciplinary teams to bring together Primary Community Health Services, Mental Health Services, Secondary Care and Social Care. These teams will be positioned in each of the four areas of Knowsley and their core function will be to ensure that individuals with complex needs, high vulnerability and / or risk are managed in a proactive manner.

This approach will also build on the existing relationships that already exist between service providers within Knowsley

The expected outcomes of this approach will be:-

• To deliver improved quality of care and patient safety • To reduce the number of preventable hospital attendances, admissions and readmissions • Improved health outcomes for local people, including:

o Reduction in early mortality o Improvement in quality of life o Improved independence and ability to remain at home

• To support patients in accessing the right care, at the right time, at the right place

o Reduction in avoidable hospital admissions o Reduction in

avoidable A&E Attendances o Reduced avoidable demand on Primary Care

• Increased community care given at home / closer to home • To optimise the use of primary care time

Involved Agencies

The core members of the Locality MDT will be:-

• GP • Social Services • Mental Health (Merseycare – Kirkby / 5BP Knowsley East / West / Halewood) • Community Matron • Community District Nurse / Specialist Nurses • Allied Health Care Professionals

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Other members of the Locality Health Care Team may be co-opted as / when required, including Falls Service, Drugs and Alcohol services, Carers services and other voluntary / third sector care provision/

It is expected and required that members of the MDT who attend this forum will be able to act as both a ‘decision maker’ and appropriately represent the professional views and responsibilities of the services that they represent, and will take full responsibility for the onward completion or delegation of any tasks or care planning delegated to them.

Frequency and Location

The MDT will be held on a regular basis, for 2 hours, on a rolling rota system in each GP practice cluster in Kirkby to ensure all key members of the MDT can contribute.

At a later stage consideration will be given to using a centrally located base and utilising technology such as video conferencing / teleconferencing to allow participation.

The chosen model will be regularly reviewed and amended as / when needed following feedback from the MDT and key partners.

Organisation and Administration

Individuals to be discussed at the MDT will be identified and / or agreed with the hosting GP practice that will have 6 slots of 20 minutes duration over a 2 hour period to utilise.

It is anticipated that for the smooth and timely running of the MDT that there will be:-

• 5 minutes for presentation of case • 10 minutes for MDT discussion • 5 minutes for creation of a care plan / appointment of a Care Coordinator and a threshold agreed for the individual to return to the MDT for further discussion

• Very complex cases may be allocated 2 or more slots

The hosting practice will forward the list of identified patients to the MDT Coordinator @ 5BP, taking into consideration local Information Governance requirements, at least 1 week prior to the timetabled MDT to allow for all members of the MDT to receive this information at least a week prior to the MDT to allow members of the MDT to adequately prepare for the meeting

It is expected and required that all MDT members will therefore attend fully briefed and with

sufficient background knowledge to each individual to allow them to make a constructive contribution to the MDT

At the end of the discussion about the individual a Care Coordinator will be appointed from the service that most appropriately meets the individual’s primary need. The Care Coordinator will be responsible for the onward completion or delegation of any tasks or care planning delegated to

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them, and to bring the individual back to the MDT only if the agreed actions either cannot be completed or do not realise the expected benefits to the individual.

To allow for all members of the MDT to have a concise record of the individual discussion a simple template will be populated and distributed to all participants, again taking into account local Information Governance requirements.

Criteria

As the MDT is a time limited resource it is expected that the consideration is given to the best use of the allocated time and that appropriate individuals only are discussed in this forum

The GP’s for the hosting practice will therefore be the ‘gatekeeper’ for their individual MDT slots.

Any other member of the MDT who wishes to discuss an individual should therefore discuss the case directly with the relevant GP for inclusion onto the MDT.

The proposed criteria for inclusion for discussion will be:-

• Individual identified from top 2% of appropriate Risk Stratification software OR

• Individual considered ‘at considerable risk’ of emergency admissions to hospital, taking into

account known risk factors of:-

• Recent diagnosis of long term condition • Multiple Long Term conditions • Failure to cope with diagnosis and lifestyle changes / non concordance with medication /

services / support mechanisms • Social Isolation / carer breakdown / carer concerns / Housing concerns • Mental Health problems – specifically Anxiety and or Depression / Substance Misuse • Falls • Polypharmacy

Current Exclusion Criteria:-

• Under 18’s • Any individual that doesn’t fulfil above guidance.

Final Draft V1.0 28th October 2016

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MDT Care Plan

Individual ID

NHS Number

DOB

Date of MDT

GP / Practice

Referring Partner

Reason for inclusion in MDT

Information Sharing

Agency Name Name of

Professional Information Shared

GP

Social Services

Mental Health

Community Matron

Community District Nurse AHPs

Other Agencies

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Care Planning

Identified Care Coordinator

Please consider:-

• Carer Needs / Support – would carer benefit from carer support or assessment? • History of Falls – would individual benefit from Falls Assessment? • IF MDT can support any unmet need with current commissioned services – If not – what is

the ‘best fit’ for this individual? • How plan will be communicated to all members of MDT and / or individual / carer • Would consideration of ‘bespoke commissioning’ support this individual? • If so how? What resources would be needed? Is it ‘achievable’?

• Threshold for reviewing individual back at MDT

Care Need Identified by MDT

Action Required Agency Responsible

Date for Completion

Review Threshold

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Appendix D: Accountable Care Coordinator Role Description

Outline role descriptor (For future consideration)

o Planning care for the named people they care for o Ensuring triggers are acted upon by the team o Ensuring reviews are scheduled as needed o Developing knowledge of local services o Establishing links with local service providers o Providing feedback on services to inform improvement o Working in a team of multidisciplinary professionals o Working collaboratively with other staff in care co-ordinator roles and cover

leave, sickness etc., when required o Participating in the induction and training of new members of staff and

contribute to development of the role o Identify and report any issues o Help identify high risk individuals and ensure they receive a care planning

consultation o Facilitate co-design and deliver care plans:

Liaise with and facilitate input from different professionals Ensure individual and carer’s wishes considered

o Support the case manager and/ or GP to implement the plans and report to them on the status of referrals and any new problems

o Actively participate in multidisciplinary meetings o Prevent unnecessary admission to hospitals and care homes and support

early discharge o Explain the management of a individuals pathway to clinical staff o First point of contact for people they care for / carers o Enable access to local services o Provide basic information about available benefits and refer for more advice if

required o Act as an advocate ensuring that other staff members are performing their

duties for the individual o Approx. 1 care co-ordinator per 5’000 (active caseload will be significantly less

as per primary care navigators with a ratio of 1:20’000 but caseload of 40-60 people

• Ensure all decisions are documented in the care plan and that the care plan is available to health care professionals from other services

• Every interaction between a health care professional (whether as part of the ICT or wider system) and the individual receiving care needs to be fully documented with a definitive plan within 24 hours of the plan being formulated

• Must be documented in the care plan to allow every health care professional and the individual receiving care to access them at any time

• Plan must be available online 24 hours a day 7 days a week

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• Must ensure that any change in the setting of care or change in the plans for a person are communicated to the integrated care team for review and that the follow up is appropriately scheduled

• Co-ordinate with members of the ICT as needed to support members of associated services

• Ensure all case or plan reviews are brought to the appropriate forum for discussion • Ensure services are keeping the care co-ordinator up-to-date through ad-hoc but

pro-active, regular checks • In the case of review by another service (and on the basis that the care co-ordinator

is informed within 24 hours as required) the care co-ordinator must ensure the individual is raised with the practice team at the daily huddle for discussion and potential escalation to the ICT

• Within 5 days of discharge , schedule an ICT review for that week in the case of highest need individuals in order to discuss their care package and any appropriate escalations or de-escalations in the level of care

• When an admission of high need individual triggers the activation of a discharge, support the discharge co-ordinator as needed to help ensure that a person is discharged in a timely and appropriate manner with the relevant supports.

NB: Taken from NWL Service Redesign Model


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