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South West Strategic Clinical Networks

Work Programme 2015/16

OFFICIAL

South West Strategic Clinical Networks Work Programme 2015/16

Version number: FINAL

First published: May 2015

Prepared by: Sunita Berry Associate Director, SWSCN & Senate

Classification: (OFFICIAL)

The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.

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Work Programmes

Cancer Clinical NetworkCardiovascular Disease (incorporating cardiac, stroke, diabetes and renal disease)

Clinical NetworkMaternity and Children’s Clinical Network

Mental Health, Dementia and Neurological Conditions Clinical NetworkIntegrated Personal Commissioning

Rehabilitation

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Programme Name: Cancer Lead: Helen Thomas Date: 22 April 2015

Background

Cancer is one of the mandated work programmes.

Priority programme objectives and expected outcomesObjectives:

Early Diagnosis161,000 urgent referrals a year

Diagnostics161,000 urgent referrals a year

• Be Clear on Cancer• Support for GPs

• Access to diagnostics for GPs• Diagnostic Capacity for Cancer Waits

Cancer Waits27,000 cancers diagnosed a year

Survivorship150,000 people living with & beyond cancer

• Redesigning Pathways to Support Early Diagnosis and Cancer Waits

• Improving Inter Trust Referrals

• Care Plans and Treatment Summaries• Health & Wellbeing Clinics• Stratified Follow Up• Primary Care Cancer Care Reviews


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Priority programme deliverablesAll programme deliverable are linked the 5YFV – which calls for “better prevention, swifter access to diagnosis, and better treatment and care for all those diagnosed with cancer”. Cancer is also the number one priority on the NHS England business plan.

Programme Timeline Deliverable

Support Providers and their CCG in delivery of cancer waits. Engage with and promote the outputs of the Cancer Waiting Times taskforce and the regional tri-partite (NHS England, Monitor, TDA)

Ongoing Monthly reports

Develop operation delivery networks for cancer December 2015 Sustainable network arrangements for 12 providers coving 12 tumour groups in two geographies in the South West. Reciprocal arrangements in place for remaining two providers.

Early Diagnosis Programme – GP Practice Support

Develop direct access referral criteria following new NICE Guidance

March 2016 Training of one GP from each of 60% of the 642 practices in the South West.Linked package of work with these practices of practice review and support visit from CRUK Primary Care Cancer facilitators

Referral criteriaTrain up to 250 practice nurse in cancer March 2016 Trained nursesEarly Diagnosis Programme – Implementation of new NICE Referral Guidelines for Suspected Cancer

July 2015 Revised pro formas with network agreed clinical contentAgreed pathways for referral direct to diagnosticsRevised access policy adapted to new guidanceEducation and Communication events in for twelve healthcare communities

Support Be Clear on Cancer campaigns To be confirmed by national team

Communication eventsConfirmed plans by each provider and CCG in response

Develop practice level information of variation in use of diagnostics

October 2015 Information

Develop information to support demand and capacity planning for acute radiology services

October 2015 Information

Deliver ACE Programme Colorectal Project – review of Colorectal Diagnostic Pathway

September 2015March 2016

Revised pathways and models of care across South WestCommissioning intentions in 8 CCGs to reflect outcomes of project.

Support Lung and Unknown Primary ACE ProjectsMonitor staging completeness using National Cancer Registration Service portal

Ongoing Staging completeness

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Complete review of chemotherapy protocols and agree method for maintaining them

June 2015 Protocols on website and agreement on maintenance

Run Network Cross Cutting groups (Radiotherapy, Chemotherapy, Children & Young People)

Ongoing Run 3 meetings of each group in 2015/16

Support SWAG & Peninsula Survivorship Groups Ongoing Support 3 meetings of each group in 2015/16Support pilot of personal health budgets for cancer patients

March 2016 Personal health budgets in place. Number of patients supported to be confirmed.

Seek to revise QoF payments to align with national Cancer Survivorship Initiative

January 2016 Local QoF criteria

Agree Network Indicators October 2016 Agreed indicators

Budget summaryBudget - £190,000

Area Expenditure £

Clinical Director 40,000Clinical Network Support Functions Meetings & extending support function 30,000

Early Diagnosis GP Update Training – 1 per practice 45,000NICE Referral Events x 12 24,000Radiology Information 10,000Sub-total 79,000

Living With & Beyond Cancer 20,000Contingency 21,000

Total 190,000


Stakeholders

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All CCGs and Acute Providers in the South WestMacmillan GPsMacmillan Cancer SupportCancer Research UKLocal Cancer research Networks

Dependencies / key interfacesThe Cancer Work Programme depends upon:

Imaging services Endoscopy services Development of psychological support Individual Personal Commissioning Rehabilitation

Alignment with AHSNsNeither of the AHSNs have any work streams in cancer

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Programme Name:Cardiovascular (CV) Network

Lead:Michelle Roe

Date:12 May 2015

Background

The work of the CV (cardiac, stroke, renal and diabetes) Network supports the implementation of the NHS 5 Year forward View and contributes to a number of NHS England’s business priorities and NHS Constitutional standards as outlined below:

Urgent and emergency care – reducing emergency admissions New care models – seven day working; out of hospital care; networks of care, enabling specialised and CCG commissioned services to deliver

whole patient pathway Reducing variation Empowering patients to manage their own health Improving patient safety

Priority programme objectives and expected outcomes

Programme Outcomes

Urgent & Emergency CareTo improve patient outcomes by providing robust evidence to CCGs and Specialised Commissioning (SC) regarding service model configurations for acute stroke and complex cardiology across the SW

To produce an options appraisal with recommendations for all SW CCGs and SC regarding configuration of stroke and complex cardiology services to implement national guidance e.g. SC national service specs, NHS Business plan and urgent and emergency care review.

Stroke-to reduce variation in acute care:o Increase thrombolysis rates to be in line with national average of 11.6% (SW

thrombolysis rates vary between 2.9-16.5%) QTR 3 2014o Increase access to HASU within 4 hours to be in line with national average of 57% (SW

access rates vary between 20.9-71.4%) QTR 3 2014 PPCI to deliver DTN within 120mins (in line with European guidance) for 75% of patients.

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New Care ModelsPrevention of complications in patient with diabetes through better glycaemic control.

Seven day working, to support the implementation of resilient and sustainable stroke services across the SW.

To identify opportunities to deliver new models of renal care within existing resources

To increase direct referral from SWAST to Diabetic specialist services.

To increase the number of HASU’s that are providing 7 day stroke services in line with national standards.

To increase the uptake of home therapies (PD and HHD), target to be agreed by SC CQUIN.

Reducing VariationTo reduce the number of lower limb amputations in high risk diabetic patients. The national average of lower limb amputation is 2.6 per 1000 people with diabetes, in the SW; this can vary between 2.5 to 4.7.

Reduce the number of lower limb amputations in high risk diabetic patients in line with the national average.

PreventionEmpowering patients to manage their own health and behavioural change interventions through medicines optimisation. This is in line with prevention strategies (e.g.PHE- Tackling high blood pressure, National Think Kidneys programme etc.)

To pilot with 3 CCGs the use of ’scratch cards’ and patient self-management tools (e.g. Know your numbers) in the medicine review process.

Improving Patient SafetySupporting the implementation of the Patient Safety Alert: Standardising the early identification of Acute Kidney Injury/ AKI NICE guidance (CG169)

To improve early diagnosis and assessment of risk factors for AKI through the implementation of e-alert systems in 14 acute trusts.

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Priority programme deliverables

Programme Timescales

Deliverables

Urgent & Emergency CareTo improve patient outcomes by providing robust evidence to CCGs and Specialised Commissioning (SC) regarding service model configurations for acute stroke and complex cardiology across the SW.

Sept 2015

Oct 2015

Nov 2015

To produce service maps and profiles for complex cardiac and stroke services across the SW

To produce an options appraisal with recommendations for all SW CCGs and SC regarding configuration of stroke and complex cardiology services to inform the commissioning process.

Organise commissioner and provider events to inform of outcomes

New Care ModelsPrevention of complications in patient with diabetes through better glycaemic control.

Seven day working, to support the implementation of resilient and sustainable stroke services across the SW

To identify opportunities to deliver new models of renal care within existing resources

June 2015Sept 2015

Jan 2015March 2016

Dec 2016

March 2016

Benchmark emergency admission/SWAST activity across the SW Review current models of care and patient pathways to identify best practice

and areas for improvement. Provide recommendations on models of care to 11 CCGs and 14 providers Develop standards and policies to ensure clinical governance is assured

To develop standards for urgent models of care which support the implementation of seven day services for cardiac, stroke, renal and diabetes.

Review current resources within 5 SW renal Centres and model opportunities for service redesign.

Reducing VariationTo reduce the number of lower limb amputations in high risk diabetic patients in line with the national average.

May 2015

June 2015

July 2015

Dec 2015March 2016

Perform peer reviews of foot care services across the 14 providers and 11 CCGs across the SW

Produce report following each review with recommendations to improve service provision

Produce overall summary with RAG report to executive group to inform of outcomes of the reviews and areas requiring improvement.

Perform 6 monthly follow-up assessment to establish progress Develop training and education resource packages for primary care to improve

quality in foot checks including:o Undertake training needs analysis of practice nurseso Identify a range of options for primary care to access diabetes

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professional education.PreventionEmpowering Patients to manage their own health and behavioural change interventions through medicines optimisation

March 2016

Oct 2015

Oct 2015March 2016

Develop and implement education and training for pharmacists regarding each area (e.g. AKI, diabetes, AF and hypertension)

Develop resource package for the pharmacists regarding patient self-management tools.

Develop evaluation tool to establish outcomes of the pilot Evaluate the pilot

Improving Patient SafetySupporting the implementation of the Patient Safety Alert: Standardising the early identification of Acute Kidney Injury/ AKI NICE guidance (CG169)

March 2016

Sept 2015March 2016

To implement the adoption of e-alert systems To organise learning events across the SW to share learning and best practice. To measure improvements in early diagnosis and assessment of AKI

Budget summary

CVD SCN budget 2015/16Year End

Budget Comments

Clinical Director 42,000Primary Care Clinical Lead 30,000Ad Hoc Clinical Engagement 35,000 2 sessions per week / projectslearning events/forums/meetings 7,000Band 7 Project Manager 40,000 0.8wteContingency 20,000Admin 13,000 0.5wtePPE 3,000TOTAL 190,00

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Stakeholders

Alongside NHS and Public Health England the network has all Acute Providers, CCGs and Local Authorities across the network footprint as key stakeholders.PenCHORD (Peninsula Collaboration for Health Operational Research & Development)/NIHR CLAHRC South West Peninsula (PenCLAHRC)Pharmaceutical IndustryWoE and South West AHSNsNHS IQ and National Clinical LeadsVoluntary services (BHF, Stroke Association, Kidney Care Alliance, Diabetes UK)Stroke Research Network and South Western Ambulance Service NHS Foundation Trust

Dependencies / key interfaces

The SW CV SCN also supports the emergency and urgent care work and other cross-cutting work programmes within the Strategic Clinical Networks and Senate.

Alignment with AHSNsBoth AHSNs are leading on increasing the uptake of NOACs for AF with clinical specialist advice provided by the SCN.Both AHSNs are working on part of the diabetes pathway this is aligned to the SCN work programme to prevent duplication.

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Programme Name: Maternity and Children’s SCN

Lead: Richard Harris Date: May 2015

BackgroundThe South West Maternity and Children’s Strategic Clinical Network supports the delivery of the NHS Five Year Forward View, the NHS Constitution, the NHS England Business Plan and both NHS and Public Health Outcomes Frameworks along the life course from preconception to the transition to adulthood.

The network’s work programme has been established through a process of stakeholder engagement both locally in the South West and nationally. Local engagement has included provider, commissioning, third sector organisations and members of the public. The programme builds on the work and achievements of the network over the last two years and continues to address its six core priorities. The work programme was approved by the network’s steering group in April 2015.

Priority programme objectives and expected outcomesProgramme Outcomes

Reducing perinatal morbidity and mortality.Improving maternal outcomes and experience

Provision of safe and sustainable maternity services supporting maternal choice – in line with national figures approximately 75% of women in the South West currently give birth within consultant-led services.Reduction in stillbirth rates, currently approximately 5 per 1000 births, and admission of term babies to NICU.

Improving maternal and infant mental health through early identification and expert management

Improved equity of access to high quality perinatal and infant mental health services - approximately, 15% of women have some form of mental health issue relating to giving birth.

Reducing Avoidable Unplanned Hospital Admissions for Children and Young people

Reduction in unwarranted variations in care delivery and children and young people are treated in appropriate settings with care provided by appropriately skilled professionals.

Accessible and equitable Integrated services are provided for children and young people with palliative / end of life care needs.

Improved access to equitable, high quality, services for the estimated 3,300 children and young people in the South West with palliative care needs.

Improving quality of life for children and young people with long term conditions.

Reduction in unwarranted variations in care delivery and quality for children and young people with asthma, diabetes, epilepsy, learning disabilities and special educational needs.

Transition of children and young people to adulthood. Fewer children and young people reporting a poor experience of transition care in the South West.Paediatric Surgery Infants and children are treated as close to home as is clinically safe and there is the continued

availability of high-quality general paediatric surgery that is easily accessible to patients.

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Programme Name: Maternity and Children’s

Lead: Richard Harris Date: May 2015


Programme Timescales DeliverablesReducing perinatal morbidity and mortality.Improving maternal outcomes and experience

December 2015

March 2016

March 2016

Support provided, via the 9 Acute Trusts and 4 CCG’s currently represented on the SCN Maternity Group, to the national maternity services review

8 Trusts to implement appropriate elements of the NHS England reducing stillbirths care bundle

Development of an agreed model of care, in partnership with the SW Neonatal ODN, to reduce the admission of term babies to NICU.

Improving maternal and infant mental health through early identification and expert management

July 2015October 2015

March 2016March 2016

Optimised model for the PIMH care pathway in the SW established Implementation group established and work to restructure current service

provision started Initial commissioning intentions developed Patient experience and outcomes measures established and piloted in at

least 1 CCG

Reducing Avoidable Unplanned Hospital Admissions for Children and Young people

October 2015

2016

Consistent regional dataset established in partnership with PenCLAHRC for paediatric emergency/attendances across all 14 Acute Trusts.

Support provided, via the 14 Acute Trusts and 7 CCG’s currently represented on the SCN Maternity Group, to the SW urgent and emergency care network

Accessible and equitable Integrated services are provided for children and young people with palliative / end of life care needs.

May 2015September 2015March 2016

Network standards of care developed and agreed Standards self-assessment undertaken across the SW Commissioning recommendations developed for all 11 CCG’s

Improving quality of life for children and young people with long term conditions.

September 2015October 2016October 2016

Self-assessment against network SEND best practice standards undertaken Regional DMO/DCO forum established and first meeting held SEND work programme established with DMO/DCO forum to address gaps

identified in self-assessment process

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March 2016

September 2015

Working in partnership with the SW Respiratory network paediatric asthma inhaler technique training included in the annual programme for ST1-3 Paediatric registrars and ST4-5 doctors as well.

Work programmes established for paediatric diabetes and epilepsy

Transition of children and young people to adulthood.

October 2015

March 2016

March 2016September 2015

All Acute Trust transition steering groups to have developed work programmes for 2 disease areas

All Acute Trusts to have met 3 of the SW transition standards that are currently not fully met

Develop and pilot a SW-wide patient experience survey for transition. CAMHS transition work programme established

Paediatric Surgery Nov 2015Jan 2016Feb 2016

Self-assessment by units against the agreed standards completed Unit work plans developed to ensure the standards are met Commissioning recommendations made to all 11 CCG’s

Budget summary

Maternity and Children’s SCN Budget 2015-16 Approximate Monthly Expenditure Year End Total

Clinical Director 3,500 42,000Associate Clinical Director (Paediatrics) 2,000 24,000Clinical Lead (Paediatric Surgery) 1,000 12,000Network Administrative Support 500 6,000Second Quality Improvement Lead 3,500 42,000Standing Meetings 2,000 24,000Network Events N/A 20,000Contingency N/A 20,000

190,000

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StakeholdersAlongside NHS and Public Health England the network has all Acute and Mental Health Trusts, CCGs and Local Authorities across the network footprint as key stakeholders.

The SCN also works with a number of existing clinical networks within the South West including:• Paediatric surgery network• Respiratory network• Neonatal Operational Delivery Network• Children’s Palliative Care Network• South West Interest Group for Paediatric Epilepsy

Dependencies / key interfacesThe work Maternity and Children’s SCN has interdependencies with all of the other mandated networks, especially the Mental Health network which leads on the CAMHS work in the South West and with whom we collaborate closely on our perinatal and infant mental health work programme. The network also supports the emergency and urgent care work and other cross-cutting work programmes within the Strategic Clinical Networks and Senate.

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Programme Name: Mental Health and Dementia

Lead: Justine Faulkner Date: 12/05/15

BackgroundThe disparity in the quality and availability of mental health services is a long-standing issue. Despite mental health being the single largest cause of disability in the UK contributing 23% of the disease burden, there are approximately 470,000 adults with mental illnesses in the South West.

In 2015/16, the introduction of access and waiting times targets and significant additional investments will address the issue of disparity, moving services in the right direction to achieve parity of esteem between mental and physical health services. This work programme will successfully implement the steps required to invest prudently, and place CCGs in a position of readiness to deliver on the standards when they come in to place in April 2016.

This programme is aligned with, and will support, the regional priority programme for mental health.


Dementia Diagnosis - CCGs achieving and maintaining the national ambition of 67% DDR Patient numbers affected: 68,436

Dementia prevention - Regional consensus as to what good prevention activity looks like Patient numbers affected: 68,436

Early onset and rare dementias - Optimal pathway designed Patient numbers affected: 3,386

Mental health crisis care - All CCGs delivering on concordat action plans Patient numbers affected: 470,000

Liaison Psychiatry – Services in all EDs Patient numbers affected: 470,000

Early Intervention in Psychosis – All CCGs in state of readiness to deliver on access and waiting times targets April 2016 Patient numbers affected: 430

CAMHS - Specialist eating disorders services in place for April 2016 Patient numbers affected: 68,436

IAPT - All CCGs achieving access and recovery targets, and in a state of readiness to achieve access and waiting times targets in April 2016-Patient numbers affected: 17,000

Perinatal & Infant Mental Health - South West consensus as to optimal service model Patient numbers affected: 470,000

Personality Disorder - (PD) South West wide multi agency conference to ensure joint delivery of national PD guidance Patient numbers affected: 235,000

Smoking cessation in mental health Patient numbers affected: 720,000

Patient and Public Engagement - Engaging with MH service user organisations across the South West

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Programme Name: Mental Health and Dementia Lead: Justine Faulkner Date: 12/05/15


Dementia Diagnosis (DDR)- CCGs achieving and maintaining the national ambition of 67% DDR

Dementia prevention - Regional consensus as to what good prevention activity looks like- SCN-branded toolkit for commissioners to support them in commissioning these services

Early onset and rare dementias - Development of optimal regional pathway for rare dementias

Mental health crisis care - Quarterly crisis collaborative events- Maintain log of concordat action plans across the SW- Regional clinical consensus as to optimal MH care in A&E, and commissioning guidance in place to inform 15/16 contracting round

Liaison Psychiatry- Maintain ongoing comprehensive map of liaison psychiatry in the SW

Early Intervention in Psychosis- Map EI services across the region using the national tool, and-EI capacity modelling- Develop an EI KLOE for NHSE Ops colleagues

CAMHS- Engage with CAMHS stakeholders in the SW to establish an ODN- Facilitate a CAMHS co-commissioning pilot in NEW Devon- Support the SW CYPIAPT collaborative

IAPT- Achievement of the national waiting times standards for IAPT services by April 2016- SW IAPT providers meet national targets around access and recovery throughout 2015/16- Adequate IAPT workforce in place to achieve access recovery and waiting times targets

Perinatal & Infant Mental Health- Mapping PIMH services across the region- Achieve regional consensus as to an optimal PIMH pathway, and develop guidance to inform co-commissioning process

Personality Disorder

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– South West-wide multi-agency conference to ensure joint delivery of national PD guidance

Smoking cessation and mental health- Increase numbers of smoke-free mental health trusts- Reduction in the number of mental health patients who smoke in the South West

Patient and Public Engagement- Better engagement with mental health service user networks- Optimal service user and carer involvement in SCN work streams

Budget summary

£40k clinical time £100k programme budget - to include a £15k contingency fund

Stakeholders- Mental health service users, and their carers/families and organisations representing them- CCGs and Specialised Commissioning- NHS England Operations and Delivery, and Nursing and Quality colleagues- Regional mental health priority programme board- Mental health service providers, both statutory and voluntary- Local authorities- Health and wellbeing boards- South West CYPIAPT Collaborative- Emergency Services

Dependencies / key interfaces- AHSNs in the South- PHE- HESW- Regional mental health priority programme board- Other SCNs- NHSE Operations and Delivery and Nursing, and Quality colleagues- Mental health national team- SW CYPIAPT Collaborative

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Programme Name: Neurology Network Lead: Sunita Berry Date:20th April 2015

BackgroundThe work of the Neurology Network contributes to a number of NHS England’s business priorities as outlined below:

Urgent and emergency care – reducing emergency admissions through appropriate management/self-management Ensuring early access to appropriate services – elective care – enabling management of RTT Specialised services – enabling specialised and CCG commissioned services to deliver whole patient pathway


Reducing the number of emergency admissions by 5% for neurology through prototyping National Neurology Improvement Programme Support GP-led commissioning of neurology outpatients through commissioners group Developing the neurology emergency care plan QIPP with specialised services in the two specialist neuro centres in South West and to network

neurology providers of derogated neurology services, where appropriate Neuro rehabilitation – identify patients who might become eligible to hold a personal budget working with the IPC programme

Priority programme deliverablesSee above.

Programme Name: Neurology Network Lead: Sunita Berry Date:20th April 2015

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Budget summary

£50k – to support delivery of neuro improvement programme and develop framework for neurology clinical network/s for derogated servicesClinical Leadership – 1PA/weekProject Management – Associate Director – leads this work streamTo include a £5k contingency fund.

Stakeholders

All 14 acute trusts are participants in neurology improvement programme prototypingSWASTCCG commissioners – LTC commissioners – further conversations about engagement ongoingSpecialised commissionersNeurological Alliance and other neurology charities including Parkinson’s’ UK, MS Society etc.

Dependencies / key interfaces

Specialised ServicesSWASTUrgent and Emergency CareWhole systems change including 7 day workingElective Care

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Programme Name: South West IPC Programme

Lead: Frances Tippett Date: 23/4/15

BackgroundThe South West IPC programme is a collaborative involving organisations from the NHS, Local Government and the Voluntary and Community Sector across the region.

The South West IPC programme is one of nine national demonstrator sites.

In September 2014 Simon Stevens, Chief Executive of NHS England, launched the Integrated Personal Commissioning Programme. The programme is a partnership between NHS England, the Local Government Association (LGA), ADASS – Association of Directors of Adult Social Care and ‘Think Local Act Personal’.

The goals of the programme are: People with complex needs and their carers have better quality of life and can achieve the outcomes that are important to them Prevention of crises in people’s lives that lead to unplanned hospital admissions and institutional care Better integration and quality of care


The programme is aimed at groups of individuals who have high levels of need; who often have both health and social care needs, where a personalised approach would address acknowledged problems in current care provision, help prevent people from becoming more unwell, and enable people to retain their independence. Including: Children and young people with complex needs, including those eligible for education, health and care plans People with multiple long-term conditions, particularly older people with frailty People with learning disabilities with high support needs, including those who are in institutional settings or at risk of placement People with significant mental health needs, such as those eligible for the Care Programme Approach or those who use a lot of unplanned care

Integrated Personal Commissioning is based on two core elements: Care Model: Person-centred care and care planning, combined with an optional personal health and social care budget Financial Model: An integrated ,”year of care” capitated payment

As a demonstrator site we are expected to develop replicable solutions for delivery of IPC.

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Programme Name: South West IPC Programme Lead: Frances Tippett Date: 23/4/15

Priority programme deliverablesIn 2015/16 the South West IPC programme will…Making it happen Set up and start at least 30 implementation sites, each working with an average of 10 people Have implementation sites working with: Children with complex needs and their families People with multiple long term conditions, including older people with frailty People with severe learning disabilities People with significant mental health needs Form a regional Core Delivery team with people from health, social care and the voluntary and community sector to drive the work forward: Provide support and mentoring for implementation sites Link up with other change programmes with similar goals in the region to work together Deliver more Personal Health Budgets (PHBs) - at least 1,000 across the region by April 2016 Create a regional ‘Expertise Time Bank’ to help local areas share development work better

Managing the change Include people who need support in our work Be open about everything we do and publish all materials relating to this work online Maintain strong focus through high level regional leadership on South West IPC Programme Board Work with Health and Wellbeing Boards to ensure local priorities are supported

Person Centred Care and Support Significantly increase the use of person centred approaches in the region Work with the voluntary and community sector to develop peer leadership forums, advocacy, brokerage and 3 rd party budget management service

models Work with local areas to support increased self-management of care in implementation sites

The Right Skills Produce a region wide Development and Training Strategy to support Integration Develop and deliver a training and support package to support IPC implementation sites

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With the voluntary and community sector recruit and train Personal Assistants to support people Effectively use £600K from HESW for workforce development to support integration

Finance and Commissioning Develop methods to produce individual linked datasets; provide indicative cost and activity data via Symphony whilst under development Define a regional approach to developing, shadowing and implementing capitated budgets Work with sites to design and implement new contracting models suitable for their area Provide regional support through workshops to share knowledge and expertise

Getting People Involved Make video shorts showing people’s stories and describing what elements of the work look like Use traditional and social media to tell people how IPC fits in the future picture of healthcare Showcase work and make tools and resources available online

Checking IPC Programme is making a difference Develop a consistent approach to base-lining and monitoring the impact of change for use in all implementation sites Include experience of people using the service Include impact on health and wellbeing Include financial impact Include staff experience of change methods Work with the national team to support creation of the national evaluation framework Work with Healthwatch organisations, South West Forum and others to tell people about the benefits IPC can make to people’s lives

IPC is one of the future solutions defined in the Five Year Forward View “We will also introduce integrated personal commissioning (IPC), a new voluntary approach to blending health and social care funding for individuals with complex needs. As well as care plans and voluntary sector advocacy and support, IPC will provide an integrated, “year of care” budget that will be managed by people themselves or on their behalf by councils, the NHS or a voluntary organisation.” (NHS England Oct 2014)Links to other national duties and priorities: Supports the implementation of the Care Act 2014, supports delivery of the right to a personalise care plan as set out in “Everyone Counts, Planning for Patients 2014-18”


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Budget summary£600K National IPC Programme Board grant£600K indicative budget to support integration

Quality Improvement Programme Manager – Frances Tippett

Stakeholders

All CCGs and Local Authorities in the South West region have committed to be part of the IPC Programme. The voluntary and community sector are also a key partners in the South West IPC Programme. To date, a number of voluntary and community sectors are part of the programme and we are growing this collaboration through current engagement activity. Other organisations that will be key in the IPC development and that have committed to the South West IPC Programme are the South West Strategic Clinical Network, Health Education South West, South West Academic Health and Science Network, West of England Health and Science Network, Central, South and South West Commissioning Support Unit and the Avon Primary Care Research Collaborative. We are currently broadening our engagement to get formal sign up from providers and more voluntary and community sector organisations.

Dependencies / key interfacesFormal links are being made to other relevant key development initiatives for example Vanguard programme sites.Integration Pioneer sites in Cornwall and TorbaySEND pathfinder sites in the region

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Programme Name: A collaborative approach to rehabilitation, reablement, recovery, survivorship and prehab in the South West

Lead: Ruth Hall Date: 12:05:15

Background

Historically these pathways have focused on particular disease groups and not the needs of the patient. Rehabilitation is delivered by Health, while reablement by Social Care and there is survivorship for cancer patient and recovery in mental health, all delivering to discrete groups of people but with similar components.There are many synergies in these services and there is potential to exploit these. The population is getting older, living longer with an increasing number of co-morbidities. By 2018 it is expected that 2.9 million people will have 3 or more long term conditions. Some of these conditions may require disease specific intervention but time limited, and in the context of the individual patients’ needs.With the emergence of new therapies there are an increasing number of people surviving with disabilities, all contributing to increased demand on these pathways.These services are not meeting the needs of our patients and we have been hearing this from them for a while. They are being treated in and spending too long in locations that are not conducive to helping them live as independently as possible.The economic climate is challenging and inequity is rife.


To implement a single high level pathway and principles that for:• health and social care communities will ensure:-

better system flow; reduced lengths of stay; fewer delayed discharges;

• patients and carers will: have greater clarity about the services they will receive; experience services that are more “joined up” with fewer “hands offs”; experience fewer delays and receive more of their rehabilitation in the community, particularly in their own homes.

This will occur via a number of different geographical sites and in conjunction with the implementation of the IPC demonstrator site.These include – Gloucester & South Glos CCGs, Neuro rehab in the Peninsula.

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Programme Name: A collaborative approach to rehabilitation, reablement, recovery, survivorship and prehab in the South West


Priority programme objectives and expected outcomes (continued)The measurable outcomes will be to support people in the community and reduce their reliance on statutory services, resulting in people being seen as close to their home as possible. The whole system will become smoother; the services delivered in a timely manner, resulting in better use of the whole systems resources. This will enable people to receive the rehabilitation services they need, in the most appropriate setting, and by the most appropriately skilled staff group.

The populations impacted will be all adults who:• Have had an acute episode and have been treated for it,Or• Have been diagnosed or assessed,Or• Have been coping at home but are starting to struggle. They need some help to keep them independent,And• Do not have critical health or social care needs now. They want to understand both their own, their family and carers role. They want to understand how things might progress in the future and their family, and carers want their needs considered,• And who will benefit from a rehabilitative approach.The principles will be transferable to children’s services.


Programme Timescale DeliverablePrinciples and pathway:To identify any geographical areas that requires support in implementing the SW principles and pathway.

Adapt pathway to support Peninsular Neuro rehab patients and work with them to give system leadership. Work with all commissioners including specialised (NHS E) to recommend re-commissioning of services where appropriate.

Already adopted by S Glos and Glos CCG

Implementation to start in some localities in 2015/16

Staggered deliver in 2015/16, 3 CCGs already delivering now

Principles and pathway commissioned by all 11 CCG and 14 LA.

Re-commission services. Work with providers and 3 CCGs, 4 LA and NHS E

Embed the principles and pathway across South West

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FinanceWork with the NHSE SW DoF to produce a generic business case for ‘testing/comment’ by BNSSG DoFs.

By Mid 2015 Deliver a generic business case for all commissioners in the SW – 11 CCGS & 14 LA

PersonalisationUse rehab as a group of people for IPC. Identify an area to work with and link with the IPC personalisation work stream.To be part of the National group – Person Centred Care Models (LTC)

Within their time frame. Deliver IPC for rehab patients

CancerTo embed the rehab work programme with in the Cancer work programme.

Within 2015/16 To implement the principles and pathway for cancer patients when ‘living with and beyond cancer’. Initially to start in the NEW Devon and Cornwall CCGs working with the Providers

5YFVWork with the national team to identify how this work programme delivers the 5YFV, focusing on patient flow through the NHS and Social Care system.

Within 2015/16 Support the delivery of the 5YFV

All of the above will impact on the following priorities of the outcomes framework : Enhancing quality of life for people with long-term conditions in particular - Ensuring people feel supported to manage their condition, Improving

functional ability in people with long-term conditions, Reducing time spent in hospital by people with long-term conditions, Enhancing quality of life for carers, Enhancing quality of life for people with mental illness, Improving quality of life for people with multiple long-term conditions

Helping people to recover from episodes of ill health or following injury in particular - Emergency admissions for acute conditions that should not usually require hospital admission, Emergency readmissions within 30 days of discharge from hospital Improving outcomes from planned treatments, Improving recovery from injuries and trauma Improving recovery from stroke, Improving recovery from fragility fractures, Helping older people to recover their independence after illness or injury.

Programme Name: A collaborative approach to rehabilitation, reablement, recovery, survivorship


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and prehab in the South WestBudget summary2015/16 Clinical leadership will be funded via the Peninsula neuro rehab project (NHS England). Projects will be run by the localities with system leadership by the SW SCN.

StakeholdersAcute and Community rehab medical consultantsAcute and Community health and social care professionalsSouth West Acute & community TrustSouth West Social careSouth West ADASSHealth and social care commissionersSouth West Carer ForumSW patient groupsSouth West Neuro RehabSouth West Strategic Clinical NetworksSouth West PD nursesOther SCNsNHS EnglandCRGSW Professional NetworksSW Specialised Commissioning

Dependencies / key interfacesAs this work stream is about the flow of people through the health and social care system, it is dependent on all parts of the system working together putting the person at the centre of their care. The independent and voluntary sector is also an essential part of the system.

Programme Name: Urgent & Emergency Care

Lead: Sunita Berry Date: 20th April 2015

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Programme:

To support the development of Strategic Urgent and Emergency Care Networks. Enabling governance in line with direction of the Urgent & Emergency Care Review

Develop the platform for sharing across the two emergent networks and across the South Region

Coordinate the networks via participation in the South Region Programme Board

Support vanguards if successful.

Stakeholders SRG Chairs CE, Operational Directors and Medical Director of all NHS Trusts – acute, community and mental health Directors of Commissioning Regional Director of Ops and Delivery Sub-regional Directors of Ops and Delivery Monitor TDA Local Professional Network Leads ( Pharmacy, Dentistry, Optometry) Ambulance Trust SWAFST Regional and sub-regional Medical Director Urgent and Emergency clinicians (GPs, ED clinicians)

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