dorset urgent and emergency care strategy 2014 - 2016...2018/07/11 · 1.9. the dorset urgent and...

1

Supporting people in Dorset to lead healthier lives

Produced By: Hazel Thorp Review Date: April 2015

Dorset Urgent and Emergency Care Strategy 2014 - 2016

3

DORSET URGENT AND EMERGENCY CARE STRATEGY

2014-2016

CONTENTS

1 Executive Summary………………………………………………………………………………………………………… 4

2 Introduction……………………………………………………………………………………………………………………. 9

3 National and Local Context……………………………………………………………………………………………. 10

4 The Case for Change………………………………………………………………………………………………………. 13

5 Vision…………………………………………………………………………………………………………………………….. 16

6 Programme Areas………………………………………………………………………………………………………….. 17

7 Summary……………………………………………………………………………………………………………………….. 20

8 Key Policy and Best Practice Documents………………………………………………………………………… 21

APPENDICES

Appendix 1: Dorset Urgent Care Strategy Model………………………………………………………………….. 23

Appendix 2: Urgent and Emergency Care Report………………………………………………………………….. 25

Appendix 3: Dorset Urgent Care Board Action Plan………………………………………………………………. 32

Appendix 4: Key Reference Documents and Key Enablers…………………………………………………….. 41

4


2014-2016

1. EXECUTIVE SUMMARY

Introduction

1.1. Partners in the Dorset Heath and Social Care community have been working to jointly review the current urgent and emergency care systems and services in Dorset in conjunction with the King’s Fund during 2013/14. This strategy builds on the work already undertaken in Dorset on understanding the local urgent and emergency care systems and links with the delivery of the Better Together Programme, Clinical Services Review and Primary Care Development.

1.2. All organisations involved are committed to developing and delivering a single system approach to urgent and emergency care that provides a 24 hour, 7 day a week service that meets the needs of the residents of Dorset.

Rationale

1.3. Over a considerable period of time Urgent and Emergency Care Services in Dorset have developed in response to a wide range of national and local drivers such as evidence based practice, guidelines, NHS and Social Care policy changes. This has resulted in a range of services that can appear unrelated, fragmented, complicated with complex pathways and numerous access points making it challenging to navigate efficiently for the public, health and social care professionals alike.

1.4. In Dorset, as elsewhere, there has been a continuing increase in demand for Urgent and Emergency Care services across the whole system. The increasing numbers of older people, due to inward migration and people living longer is having an impact on the population in Dorset. The rise in the number of people with long terms conditions and the increasing public expectations means that managing this demand in the future is unsustainable within the current configuration of health and social care systems. In a period of severe financial constraint, local outward migration of workforce and all organisations competing for the same group of workers to deliver care means this is an increasingly challenging environment.

1.5. In order to meet current and future demand work needs to be undertaken to address the

underlying reasons for people accessing the urgent and emergency care services. This will require the alignment of services to enable closer working together to provide one simple, safe and effective system.

Vision

1.6. Our vision is to have an urgent and emergency care system that ensures that ‘People with an urgent care need are seen by the right health / social care professional, in the right setting, at the right time, quality and cost, with the right outcome’.

5

Outcome

1.7. This strategy’s intended outcome is to establish a health and social care system that is able to address the needs of the Dorset population within current resources available whilst delivering improved clinical outcomes, quality and experience.

1.8. There is currently an Urgent Care Dashboard that is in place and used by the Urgent Care Board to monitor performance. The System Resilience Group is to be established in August 2014 to look at both planned and un-planned activity will need to ensure that the dashboard is further developed. It will need to contain agreed indicators that monitor progress against the delivery of both the interim urgent care strategy plan and the overall strategic objectives.

Aims

1.9. The Dorset Urgent and Emergency Care Strategy will support the transformation of urgent care services across Dorset by working in partnership with primary, secondary, community, social care and voluntary sector services to deliver enhanced urgent care with an emphasis on prevention of avoidable admissions.

1.10. The aim is to ensure that each person is seen at the right time at the right place and by the right person.

Objectives

1.11. The strategy has nine key objectives to deliver the vision:

• The public are central to designing the right systems and are at the heart of decisions being made;

• The Dorset population will experience a service that is working as one integrated and whole system although provided by multiple agencies;

• People will be seen at the right time, by the right person with the right skills to manage their needs in the right place;

• People are safeguarded and treated with dignity and respect by a skilled, capable, flexible, integrated workforce;

• The public will be supported to self-care and get the right advice; • To reduce avoidable emergency hospital admissions and re-admissions; • To ensure resources are used efficiently and effectively; • To ensure the workforce strategy and ways of working will meet workforce capacity and

skills challenges of the future; • To complement other transformational programmes across the health and social care

system.

1.12. This strategy sets out the specific work programmes required to achieve these objectives. The programmes of work reflect the need to be innovative in redesigning the urgent and emergency care system, bringing existing services together to operate as a single system. People’s experience and needs will remain central and will contribute to informing the implementation of all work programmes.

6

Implementation

1.13. The implementation of this strategy will be overseen by the Systems Resilience Group, which will link closely with and support the delivery of the three other major change programmes in Dorset; the Better Together Programme, Clinical Services Review and the Primary Care Development Programme.

1.14. The Systems Resilience Group will establish specific sub-groups to design, plan and implement projects as required. All projects will fall into one of the six work programmes:

• Demand and Prevention; • Access; • Frail and Complex patients; • Patient Flow; • Responsive and Flexible.

1.15. This strategy incorporates current initiatives and projects, as well as setting out significant new areas of work such as the management of Frail and complex older people. It is recognised that much of the work being undertaken as part of the urgent and emergency care strategy by its very nature must link with and support the delivery of wider long term local and national objectives.

1.16. The Key Contributors throughout this strategy were:

• NHS Dorset Clinical Commissioning Group • Dorset County Council • South Western Ambulance Service NHS Foundation Trust • Bournemouth Borough Council • Dorset Healthcare University NHS Foundation Trust • Borough of Poole • Better Together Programme Management Office • Dorset County Hospital NHS Foundation Trust • Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust • Poole Hospital NHS Foundation Trust • King’s Fund.

1.17. The Dorset Urgent and Emergency Care Strategy is summarised on the following two pages.

9


2014-2016

2. INTRODUCTION

2.1. The Dorset Urgent and Emergency Care Strategy outlines the strategic vision and direction for the development and implementation of the urgent and emergency care system for the next two years to support the delivery of person centred quality care that is cost effective.

2.2. In recognition that there are other major transformational programmes being developed that may affect the Dorset Urgent and Emergency Care Strategy longer term plans, this document sets out the medium term plans over a two year period. These medium term plans will need to be regularly reviewed in light of any national and local developments such a requirement to support the delivery of the Dorset Operational Resilience and Capacity Plan.

2.3. This strategy has been developed by the Dorset Health and Social Care community through the Dorset Urgent Care Board, which is committed to reviewing and re-designing the current urgent and emergency care systems. The aim is to develop and implement an urgent and emergency care system which will ensure people are seen at the right time, in the right place, by the right person.

2.4. Considerable work has already been undertaken over the last eighteen months to map all

the current urgent and emergency care services available within Dorset. In addition during 2013/14 a series of initiatives were funded and evaluated to help inform the development of future services.

2.5. There is no doubt that the urgent and emergency care system in Dorset is extremely

complex and has developed in response to national and local drivers over an extended period of time rather than in a managed way. This is not unique to Dorset; as elsewhere, the systems in place are not designed to cater for the current and increasing levels in demand and activity for urgent and emergency care services.

2.6. A key task is to implement a new model of care in which all health and social care

professionals will work together more closely to meet the needs of people through clear co-ordinated services. This model of integrated care will focus much more on preventing ill health, supporting self-care, enhancing primary care, providing care in people’s homes and the community.

2.7. The Strategy defines specific work programmes built around an agreed overarching model

for Urgent and Emergency care in Dorset. 2.8. It is important to recognise that the development and delivery of the Dorset Urgent and

Emergency Care Strategy forms one part of four interrelated transformational programmes underway in Dorset. The other three are the ‘Better Together’ programme, the Clinical Services Review and Primary Care Development. The work of all four of these inter-related programmes is overseen by a partnership arrangement through the Better Together Sponsor Board.

2.9. For the purposes of this Strategy the definition of urgent and emergency care has been

aligned with the Department of Health (2011) as: ‘Range of health care services available to people who need medical advice and/or treatment quickly and unexpectedly……people and carers should expect 24/7, consistent and rigorous assessment of the urgency of their care need and an appropriate and prompt response to that need’.

10

3. NATIONAL AND LOCAL CONTEXT

National Context

3.1. The Francis Inquiry report (2013) examined the causes of the failings in care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009. It calls for a fundamental change in culture in the NHS, whereby patients care and safety is put first, with the patient being the priority in everything done. This Strategy takes into account the recommendations of this report by supporting a move towards designing future urgent and emergency care services in Dorset around the patient.

3.2. The NHS Outcomes Framework 2014/15 sets out high level national outcomes that the NHS should be aiming to improve, divided into five domains. Each of these domains has specific indicators, some of which relate to urgent and emergency care services: • Preventing people from dying prematurely; • Enhancing quality of life for people with long-term conditions; • Helping people to recover from episodes of ill health or following injury; • Ensuring that people have a positive experience of care; • Treating and caring for people in a safe environment and protecting them from

avoidable harm.

3.3. The Transforming urgent and emergency care services in England report (2012), following a comprehensive review by Sir Bruce Keogh, sets out five key elements for an effective urgent and emergency care system: • Provision of better support for people to self-care; • Help people with urgent care needs to get the right advice in the right place, first time; • Provide highly responsive urgent care services outside of hospital so people no longer

choose to queue in A&E; • Ensure that those people with more serious or life threatening emergency care needs

receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery;

• Connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts.

3.4. In 2013 Sir Bruce Keogh (Transforming urgent care services in England, Urgent and Emergency Care Review End of Phase 1), proposed a new blueprint for Urgent and Emergency Care across England. He advocated a system-wide transformation over the next three to five years, saying this is “the only way to create a sustainable solution and ensure future generations can have peace of mind that, when the unexpected happens, the NHS will still provide a rapid, high quality and responsive service free at the point of need.” The report also recognises that the current system is under intense, growing and unsustainable pressure, driven by rising demand from a population that is getting older, with a confusing and inconsistent array of services outside hospital, and high public trust in the A&E brand.

3.5. The Health and Social Care Act (2012) with the Better Care fund requirements increases the need for better dialogue and joint commissioning of services to deliver sustainable improvements in health and care outcomes through a person centred approach focussing on preventive and co-ordinated care to reduce emergency admissions. This will impact on and support the delivery of Urgent and Emergency care services in future.

11

3.6. The Operational Resilience and Capacity planning guidance for 2014/15(June 2014) sets out a requirement to extend the remit of Urgent Care Working Groups/Boards to include elective as well as non-elective care planning in future. This will mean the formation of System Resilience Groups (SRGs) with revised terms of reference and membership.

3.7. The new System Resilience Groups will be the forum in future where all partners across the health and social care system come together to undertake regular planning of service delivery. This group will need to oversee the delivery of any Urgent Care Strategy which should support the delivery of the annual Operational Resilience and Capacity Plan.

Local Context

3.8. The Strategy’s development and implementation has been, and will be influenced by a number of other key local priorities and programmes.

3.9. Through the implementation of the Dorset Clinical Commissioning Group Strategy 2014-2016 it is committed to: • Designing services around people; • Preventing ill health and reducing inequalities ; • Commissioning sustainable healthcare services; • Moving care closer to home.

3.10. In developing the Dorset Urgent Care Strategy 2014-2016 the extensive national Patient,

Public Initiative (PPI) work has been taken into account.

3.11. The Dorset Clinical Commissioning Group Strategy 2014-2016 will be delivered through a series of programmes that are inter dependent with the delivery of the urgent care programme, these are the: • Better Together and Better Care Fund Programme, which aims to transform health and

social care across Dorset to enable and deliver a sustainable improvement in health and social care outcomes through person centred outcomes focussed on preventative and co-ordinated care;

• Clinical Services Review, designed to review clinical services across Dorset, with the aim of developing a modern model of clinically sustainable, high quality health services across Dorset;

• Primary Care development, the aim of which is to play an active role in joint commissioning and the development of primary care services that supports modernising clinically sustainable, high quality health services. The strategy for primary care development will both inform and be informed by the Clinical Service Review. It will also include the delivery the primary care commissioning fund objectives for the Frail Older People;

• Clinical Commissioning Programmes, seven programmes that work with partners to review, design and commission clinical services across Dorset.

3.12. It is important to recognise that in Dorset there are some specific workforce issues that will create additional challenges to delivering not only the Urgent Care agenda but also the interdependent programmes.

3.13. In Dorset there is an ‘outflow’ in workforce available to deliver health and social care services related to the age of the population. This means that all health and social care providers are competing for limited human resources and this is especially difficult for recruiting sufficient staff members in lower paid roles.

12

3.14. The Bournemouth and Poole Health and Wellbeing Strategy 2012-2016 sets out its key priorities for the next three years based on a Joint Strategic Health Needs Analysis. It identifies three wider priorities that impact on the strategy :

• Reducing inequalities; • Promoting healthy life styles and preventing ill health; • Working together to deliver early intervention, high quality care and better value.

3.15. The Dorset Health and Wellbeing Board Strategy 2012-2016 sets out five priorities drawing

on their Joint Health Needs Assessment, the following will potentially support the urgent and emergency care agenda:

• Reducing circulatory disease; • Reducing the harms caused by road traffic collisions; • Reducing the harms caused by diabetes; • Improving care for people with dementia.

3.16. During 2013/14, the Dorset Clinical Commissioning Group invested in the region of £4 million

in service enhancements or developments that were anticipated to deliver in-year improvements and help alleviate seasonal pressures. Each of these projects was subject to an evaluation to determine their effectiveness against key performance indicators.

3.17. Proposals were invited from all stakeholder organisations and encouraged partnership working. Projects were then agreed and established around four hubs - Poole, Bournemouth, Dorchester and South Western Ambulance Services.

3.18. As a result of the evaluation of these projects, some funding has been continued during

2014/15 and the outcomes of these projects will help support the further development of this strategy’s work programmes. The projects that received continuing funding for 2014/15 include:

• Acute Hospital at home, which provides expert staff to care for patients in their own home environment where they remain throughout (West Dorset);

• Alternative Offer, an assessment of a patient’s long term care needs is carried out in their own home rather than hospital, giving a more accurate picture of the support required (West Dorset);

• Interim Care Pilot, this focuses on supporting and implementing the utilisation of residential and nursing home “interim beds” within Bournemouth and South-East locality of Dorset for patients requiring social care on discharge (Bournemouth);

• Virtual Ward; which builds a community multidisciplinary team and integrates health and social care delivery across all sectors for ‘patients’ (Bournemouth and Christchurch);

• Assisted discharge, the British Red Cross offers an assisted discharge service which support older patients to return home safely (Poole);

• Alcohol Nurse, helps manage patients with alcohol related conditions through alternative pathways (Poole);

• Rapid Response, an additional two Emergency Care Practitioners in Rapid Response Vehicles are made available in areas of high demand (East Dorset) between 08:00-18:00 hours daily, this service is accessed via the Single point of Access service (East Dorset);

• Advanced Nurse Practitioner, advanced nurse practitioner or emergency care practitioner is available within each of the three acute providers to see and treat patients as an alternative to other clinical input (Pan Dorset).

3.19 As part of the development and agreement of the Dorset Operational Resilience and Capacity Plan additional projects for 2014/15 will be agreed that support both the delivery of the urgent care agenda and referral to treatment time pressures.

13

4. THE CASE FOR CHANGE

4.1. In Dorset, as elsewhere, there has been a continuing rise in demand for urgent and emergency care services over the past decade. For example the number of attendances at local A&E departments has risen by 7% per month in April and May 2014 compared to the same period in 2013, despite the introduction of new services such as NHS 111.

4.2. The rate of demand and activity continues to increase supporting the case for change and can be easily demonstrated by comparing 2013/14 to 2014/15 (April/May) data (appendix 2) which demonstrates:

• The NHS 111 service has seen an average increase in call volume of around 485 patients per month;

• A 34% increase in Ambulance Dispatches and a 26% increase in those recommended to attend Emergency Departments;

• Ambulance conveyance rates are up throughout the county by around 7%; • Emergency Department attendances for Dorset Clinical Commissioning Group are

significantly higher than the average for 2013/14 with approximately 850 additional attendances per month. In Hours activity is up around 2%, OOH activity is up around 9%. A high proportion of people are discharged with no further care required;

• Emergency Admission data indicates that across Dorset on average there are 375 more admissions per month in 2014/15 than in 2013/14 with the majority of these patients admitted through Emergency Department.

4.3. A significant challenge to all Health and Social Care services is the continuing impact of the financial constraints with the need to meet these increasing demands on services with an increasingly older population.

4.4. The Better Care fund together with the Better Together Programme is seen as an enabler that will drive integration of health and social care services across Dorset. The pay for performance element of the fund will be linked solely to reducing total emergency admissions in 2015-16(target 3.5%).

4.5. The Dorset Urgent Care Board commissioned the King’s Fund to review the current urgent

and emergency care system during 2013/14, which included the following elements: • Examining the routine data for the health economy and comparing this with other

similar systems in the South of England and elsewhere; • Commissioning the Oak Group to undertake a large point prevalence study of admissions

across acute medicine, older people’s medicine and the community hospitals; • Reviewing existing urgent and emergency projects and initiatives; • Facilitating the development of a frail and complex people pathway.

4.6. As a result of the work undertaken by the King’s Fund and the Oak Group it is apparent that

there is nothing in the data to suggest any particular issues relating to the urgent and emergency care service within Dorset that are unique: • Emergency admissions are rising not out of line with national trends; • The current system is not designed to cater for the current activity levels and is

unsustainable in the longer term; • There is no single identifiable cause for the continuing increasing levels in demand and

activity so there will be no single solution; • The system is complex and confusing with multiple access points, making it confusing for

the public to navigate;

14

• Different services are available depending on geographical location or provider rather than patient need;

• A wide spectrum of initiatives will need to be not only implemented but also evaluated to determine effectiveness, quality and outcomes.

4.7. The King’s Fund review highlighted a number of action areas some of which could be delivered in the short term with others taking longer to develop, implement and achieve. One area was identified as having the potential to make a significant impact on services is ‘proactive management of the frail and older population’.

4.8. The key themes identified by both the King’s Fund and the Strategy Development Group as potential areas of work included:

Access

• Front door: problems in the Emergency Departments seem to be more related to issues about the way the system works and the flow of patients, the immediate focus should be more about improving flow ;

• Seven day working: although good progress has been made to date on implementing seven day working, more progress needs to be made especially to increase the number of discharges at weekends.

Discharges

• The most immediate and significant gain in the system in the short term is likely to be achieved by dealing with the issue of patients who have an extended stay in hospital but who could be discharged to other forms of care. The actions required to improve this situation are often internal. The ambition to ensure that patients do not have their assessment for continuing care undertaken in hospital is fully supported, it is recognised that some significant changes to the system will be required to facilitate this;

• Promotion of active discharge planning and the use of ‘Expected Discharge Dates’ is required. There needs to be a plan for each patient, reviewed every day and with escalation arrangements that operate in a timely manner;

• Greater emphasis must be placed on managing the journey and ensuring progression, rather than moving a person to ‘the next place’. Using Expected Discharge Dates to generate ‘pull’ from community services and better planning ahead by the hospitals will help ameliorate some of the problems caused by the different time clocks of hospitals, community services and social care. There needs to be much tighter agreement about the standards expected of each part of the system and how they respond to requests for help;

• Sharing the good practice of the discharge planning teams at Dorset County Hospital and Poole Hospital should be encouraged;

• The principle of a named professional responsible for discharge with the ward manager proactively overseeing the processes is in place at all three acute sites but in differing ways. Some cross organisational work to test the benefits of each model should be undertaken to embed good practice.

• There should be consideration to extending nurse led discharge.

Extended stays

• The Older Persons Assessment and Liaison team service available at Royal Bournemouth Hospital was identified as effective. Extending this type of service should be considered at the other two Dorset acute providers but it needs to form part of the wider rethinking of community and frailty services.

15

Frail and Complex Patients

• A consistent pathway for frail and complex patients should be developed that links primary, secondary and social care, it should support the proactive management of this group of these people within their own homes;

• Services for frailty need to be more radically reviewed and there should be a single service model across county or at least around each ‘hub’. A model that integrates hospital and community services more closely is required.

Integrated teams

• The Better Together Programme is progressing the work with developing and commissioning integrated teams:

∗ Team based approaches that bring together health and social care staff around clusters of GP practices has been identified as the preferred model;

∗ The simplification of the assessment approaches to develop a single approach across the county;

∗ Being able to share the core person record between organisations will be a key priority.

Patient Flow

• Simplification and alignment of services is a recurring theme. Over 60 access points to urgent and emergency care services have been identified during the King’s Fund review period making the system hard to navigate;

• The Single Point of Access helps but does not address the fundamental problem, further work needs to be undertaken to ensure that patients, health and social care professionals know how to access the services available.

4.9. Based on this work the Dorset Urgent Care Strategy Development Group identified the specific priority areas and projects to progress in the short to medium term these are set out in the action plan 2014-2016 Appendix 3.

4.10. As part of the Dorset Urgent Care Strategy Development Group meetings six key high impact priority areas to progress in the 2014/15 were identified. These areas are:

• Case Finding and Care Co-ordination: accelerate the work being undertaken on

developing locality Multi-Disciplinary Teams (MDT). Working with GP localities and practices to maximise the use of incentives in primary care including Direct Enhanced Services (DES) and the Older People Plan investment. The urgent care CQUINs will be used to incentivise other NHS providers. Investment in district nursing to undertake risk stratification including systematic case finding by using intelligence from all care sectors (primary, community, domiciliary and secondary care, Out of Hours, NHS 111, Single Point of Access and 999). The MDT meetings will offer targeted case management and care co-ordinators for high risk patients through frailty assessments and implementing anticipatory care plans for over 75’s. These will be shared across all care sectors.

• In-reach into Care homes: develop a focused and co-ordinated approach to systemic support and in reach into care homes, this links to the locality MDT key impact priority area.

16

• Emergency Department attendance avoidance programme: managing minor injuries and illness more effectively in primary care/secondary care through better workforce integration and service model changes. Exploring the potential for primary care clinical triage at the front door, including reviewing the OOH’s offer to consider open access.

• Ambulance service conveyance reduction: undertake diagnostic work to identify high impact changes that will increase see and treat rates and reduce conveyances. Review the outcomes of NHS 111 contacts and potential to link NHS 111 with access to Single Point of Access (SPOA).

• Hospital at Home: shared care services between outreach secondary care advanced practitioners and community intermediate care service to support higher acuity patients in crisis. Examples of the level of care provided would include a comprehensive geriatric assessment, the management of UTI/Chest infections, provision of hydration and IV antibiotic therapies, management of people with falls who have mild cognitive impairment.

• Care overnight: expansion across the patch of the Dorset County Council pilot that provides night visiting, linking it with primary care OOH’s and night nursing.

4.11. Whilst there remains work to be undertaken on refining and streamlining the current urgent

and emergency system, this is unlikely to meet the growing demands. It is accepted that there also needs to be a greater understanding and addressing of the underlying reasons for people accessing an urgent or emergency care service.

5. VISION

5.1. Dorset’s Vision for urgent and emergency care services is aligned to the vision outlined by Sir Bruce Keogh in ‘Transforming urgent and emergency care services in England’ (2012): ‘Patients with an urgent care need are seen by the right health / social care professional, in the right setting, at the right time, quality and cost, with the right outcome.

5.2 Our vision is to have an urgent and emergency care system that ensures that ‘People with an urgent care need are seen by the right health / social care professional, in the right setting, at the right time, quality and cost, with the right outcome’.

5.3 The objective is to have a health and social care system that is able to address the needs of

Dorset’s population, within the resources available, delivering improved quality and experience. (Appendix 1)

5.3 To deliver the vision all partners to the Dorset Urgent Care Strategy will need to work

together to deliver high quality services, which support the delivery of national best practice, standards and guidance and challenge existing ways of working by:

Developing:

• Further developing the System Resilience Group to oversee and support the effective delivery of urgent and emergency care across the whole system;

• Develop a system wide information dashboard for emergency and urgent care across the health and social care community;

• An improved and simplified system for urgent and emergency care; • An integrated health and social care system, which supports the delivery of services

outside of the hospital setting; • A 24/7 system which embraces 7 day working across all services.

17

Ensuring:

• Clear guidelines, impact assessments and success criteria for future pilots ad projects are developed and monitored;

• Alignment of work programmes with the Better Together Programme, Clinical Services Review and Primary Care Development;

• Value for money and reduction in financial overheads; • Improved public and personal experiences; • The System Resilience Group challenges existing ways of working and identifying where

there are duplications of service and inefficiencies within the system; • Public involvement is an integral component of the whole system;

Providing:

• Greater consistency, openness, transparency and candour; • Up-to-date and informative performance and activity data.

6. PROGRAMME AREAS

6.1. This section describes the five different components of the work programmes required to support the Strategy and plan for change.

6.2. It should be noted that these work programmes are linked to and are supported by the following work streams within the health and social community in Dorset:

• Clinical Service Review; • Better Together Programme and Better Care Fund; • Primary Care Development; • Operational Capacity and Resilience Planning process.

Prevention and Demand

6.3. It is essential to understand the nature of peoples’ needs for urgent and emergency care and how services are used. Whilst a greater understanding of the broad patterns of activity using current data is useful, it will not necessarily reflect the complexity of a person’s journey or the reasons behind the choices made by individuals about when and how to access services.

6.4. The model of urgent and emergency care for Dorset supports the fact that most health and social care should support people to look after themselves whether they have a minor illness or injury or a long-term condition. There is growing evidence that supporting self-care leads to:

• Improved health and quality of life; • Significant impact on the use of services; • Reduction in visits to outpatients and emergency departments.

Key deliverables • We will review evidence of best practice to support new approaches to delivery of

urgent and emergency care services; • We will reduce the overall demand in the system through a series of initiatives such

as flu planning, reducing permanent admissions to care homes and primary care commissioning for the proactive management of frail and complex people;

• We will enable better and more accurate capacity modelling and scenario planning across the system, through meeting national System Resilience planning requirement;

• We will work with the Wessex Senate Clinical Networks to reduce the number of under 5’s attending Emergency Departments and being admitted;

18

Access

6.5. The Single Point of Access (SPoA) provides a central point for healthcare professionals to access Dorset Community Services and provides call handling and clinical triage of referrals to community services to avoid unnecessary hospital admissions.

6.6. The NHS 111 service is well used in Dorset and it is making it easier for people to receive the right treatment, in the right place at the right time.

Key deliverables

• We will look at access and improve the quality and responsiveness of emergency services by ensuring patients receive urgent care in the most appropriate location 24 hours a day seven days a week;

• We will continue to promote and monitor the use of SPoA to enable healthcare professionals to be referred to community services and avoid unnecessary hospital admissions;

• We will continue to ensure up-to-date information is available on SPOA, including details on voluntary services across Dorset;

• We will work with SWAST to undertake an audit to ascertain the numbers of patients attending emergency departments following contact with the 111 service;

• We will trial adaptations to the 111 service, for example the addition of a GP working within the clinical hub;

• We will review usage of minor injury units and walk-in centres and complete an audit detailing which services are available at what time;

• We will expand 7 day services from 8am-8pm to improve services and provide more responsive and patient-centred delivery seven days a week;

• We will continue to develop a service which will enable healthcare professionals to call an Emergency Department Clinician for advice / guidance seven days a week;

• We will work to ensure all parts of the system work towards ensuring patients’ medicines are optimised prior to discharge;

• We will review end of life pathway to reduce inappropriate admissions, with a specific focus on nursing homes;

• Review primary care access across general practice as recommended by the Primary Care Foundation;

• Review the response standards and performance times for rapid response in the three emergency departments and assessment units;

• Develop a clear strategy for Emergency Ambulatory Care and short stay across the system that maximises the potential for admission avoidance, reduced length of stay and unnecessary hospitalisation.

• We will embed the role of the voluntary sector in support plans, building on the Red Cross Model which has been operating in Poole Hospital to support patients at the point of discharge;

• We will review and extend use of telemedicine and telehealth, specifically working with patients with long term conditions;

• We will continue to review pathways in order to identify mechanisms by which to develop skills and techniques and range of options which will help reduce anxiety and increase people’s confidence in their ability to self-care.

• We will develop a communication strategy aimed at both the local population and health and social care professionals to ensure all are aware of which services are available in line with the Choose Well Campaign.

19

Frail and complex patients

6.7. Frail and complex people are generally considered to be those over 75 years of age, possibly with multiple co-morbidities, who require health and / or social care assistance to remain independent and to minimise further deterioration in their care needs. A large proportion of the Dorset population is aged over 75 so there is a need to develop a frail and complex patient pathway.

Patient Flow

6.8. Simplification and alignment of services is a recurring theme nationally and locally. During the past eighteen months over 60 access points to urgent and emergency care services have been identified, making the current urgent and emergency care system hard to navigate.

6.9. The Single Point of Access helps but does not address the fundamental problem, further work needs to be undertaken to ensure that the public, health and social care professionals know how to access the services which meet their needs.

Key deliverables

• We will work to ensure integrated working both between health and social care and different health sectors;

• We will progress locality MDT working with GP Clusters to maximise incentives to undertake risk stratification to enable targeted case management and anticipatory care planning;

• We will review services for frailty and ensure there is a single service model across the county or at least around each ‘hub’;

• We will look for existing opportunities for reducing bed use by patients that could be cared for in other settings;

• We will develop services that address both mental and physical urgent care needs. • We will ensure discharge to assess teams are present in each hospital to proactively

manage frail elderly patients if they present at the front door and seek alternatives to admission;

• Move to a trusted assessor model for social care; • Undertake more diagnostic work to understand the impact of admissions from

nursing and residential care homes.

Key deliverables

• We will work to simplify and align services; • We will support the ‘Better Together’ programmes of work related to enhancement

of intermediate care /reablement and sharing advice and information on leaving hospital.

20

Responsive and flexible

6.10. It is essential that the urgent and emergency care system can respond to increases in demand, using services flexibly, maximising current and future technologies to proactively respond to surges in activity such as winter pressures.

7. GOVERNANCE ARRANGEMENTS

7.1. The development and implementation of the work undertaken as part of the Dorset Urgent Care Strategy is set within a structure that enables it to be co-ordinated with other wider National and Local transformational programmes and initiatives.

7.2. The Urgent Care Programme must now be considered as part of the wider Operational

Resilience and Capacity Planning agenda, due to recent national guidance.

7.3. All transformational programmes are overseen by the partnership group ‘Better Together Sponsor Board’ with each partner organisation having lead responsibility for relevant projects within the programmes through their organisational governance structures, illustrated below:

Key deliverables

• We will develop a Primary Care Vision, for Dorset within 6 months, via a Primary Care Summit;

• We will review the capacity and responsiveness of the Intermediate Care Service to ensure it is in line with the key deliverables of this strategy;

• We will look to address the workforce issue in domiciliary care by reviewing the way this is commissioned;

• We will review patient and public engagement feedback to ensure the views expressed by the public are addressed;

• We will improve information sharing capacity and integrating ICT systems. This agreement is being developed through the Better Together programme.

• We will ensure contracts are aligned to support the delivery of the urgent care agenda, including inclusion of: a joint standard operational policy, SAFER standard, flow bundles, discharge quality standards and monthly audit of emergency department standards.

21

8. SUMMARY

9.1. This Strategy outlines the overarching vision and strategic direction for urgent and emergency care services in Dorset for the next two years.

9.2. There is no doubt that the delivery of this Strategy will be challenging in a period of

increasing demand and public expectations within tight financial constraints. 9.3. The Urgent and Emergency Care Board which will become the System Resilience Group from

August 2014, will be responsible for the ownership, oversight and monitoring of the implementation plan. The Co-ordinating Care Clinical Commissioning Programme is responsible, as part of its role, to work with the work of the System Resilience Group links with other wider health and social care programmes.

9.4. It is acknowledged that the current Health and Social care climate is continually changing;

this will necessitate a review of the Strategy on at least a bi-annual basis with an annually updated action plan.

22

Primary Care

Appendix 1 Urgent and Emergency Care System

Single Point of Contact

(SPOA)

Locality Integrated

Teams

Urgent Care

(OOH)

Community Pharmacy

111

999 Self-Care

Acute Hospital Admission

Emergency Department

Telephone Advice

Major Trauma Centre

Home Home with package of care

Care Home

Social Care

Minor Injury Unit

Community Hospital

24


NHS Dorset Clinical Commissioning Group – Business Intelligence

Urgent and Emergency Care Report

Produced by: Jo Pritchard Data source: SUS/National Data Date published: 17/19/2014


Appendix 2

26

12/0

5/13

12

/05/

13

12/0

5/13

12

/05/

13

26/0

5/13

26

/05/

13

26/0

5/13

26

/05/

13

09/0

6/13

09

/06/

13

09/0

6/13

09

/06/

13

23/0

6/13

23

/06/

13

23/0

6/13

23

/06/

13

07/0

7/13

07

/07/

13

07/0

7/13

07

/07/

13

21/0

7/13

21

/07/

13

21/0

7/13

21

/07/

13

04/0

8/13

04

/08/

13

04/0

8/13

04

/08/

13

18/0

8/13

18

/08/

13

18/0

8/13

18

/08/

13

01/0

9/13

01

/09/

13

01/0

9/13

01

/09/

13

15/0

9/13

15

/09/

13

15/0

9/13

15

/09/

13

29/0

9/13

29

/09/

13

29/0

9/13

29

/09/

13

13/1

0/13

13

/10/

13

13/1

0/13

13

/10/

13

27/1

0/13

27

/10/

13

27/1

0/13

27

/10/

13

10/1

1/13

10

/11/

13

10/1

1/13

10

/11/

13

24/1

1/13

24

/11/

13

24/1

1/13

24

/11/

13

08/1

2/13

08

/12/

13

08/1

2/13

08

/12/

13

22/1

2/13

22

/12/

13

22/1

2/13

22

/12/

13

05/0

1/14

05

/01/

14

05/0

1/14

05

/01/

14

19/0

1/14

19

/01/

14

19/0

1/14

19

/01/

14

02/0

2/14

02

/02/

14

02/0

2/14

02

/02/

14

12/0

5/13

26

/05/

13

09/0

6/13

23

/06/

13

07/0

7/13

21

/07/

13

04/0

8/13

18

/08/

13

01/0

9/13

15

/09/

13

29/0

9/13

13

/10/

13

27/1

0/13

10

/11/

13

24/1

1/13

08

/12/

13

22/1

2/13

05

/01/

14

19/0

1/14

02

/02/

14

16/0

2/14

02

/03/

14

16/0

3/14

30

/03/

14

13/0

4/14

27

/04/

14

11/0

5/14

25

/05/

14

08/0

6/14

22

/06/

14

06/0

7/14

20

/07/

14

03/0

8/14

17

/08/

14

31/0

8/14

14

/09/

14

12/0

5/13

26

/05/

13

09/0

6/13

23

/06/

13

07/0

7/13

21

/07/

13

04/0

8/13

18

/08/

13

01/0

9/13

15

/09/

13

29/0

9/13

13

/10/

13

27/1

0/13

10

/11/

13

24/1

1/13

08

/12/

13

22/1

2/13

05

/01/

14

19/0

1/14

02

/02/

14

16/0

2/14

02

/03/

14

16/0

3/14

30

/03/

14

13/0

4/14

27

/04/

14

11/0

5/14

25

/05/

14

08/0

6/14

22

/06/

14

06/0

7/14

20

/07/

14

03/0

8/14

17

/08/

14

31/0

8/14

14

/09/

14

16/0

2/14

16

/02/

14

16/0

2/14

16

/02/

14

02/0

3/14

02

/03/

14

02/0

3/14

02

/03/

14

16/0

3/14

16

/03/

14

16/0

3/14

16

/03/

14

30/0

3/14

30

/03/

14

30/0

3/14

30

/03/

14

13/0

4/14

13

/04/

14

13/0

4/14

13

/04/

14

27/0

4/14

27

/04/

14

27/0

4/14

27

/04/

14

11/0

5/14

11

/05/

14

11/0

5/14

11

/05/

14

25/0

5/14

25

/05/

14

25/0

5/14

25

/05/

14

08/0

6/14

08

/06/

14

08/0

6/14

08

/06/

14

22/0

6/14

22

/06/

14

22/0

6/14

22

/06/

14

06/0

7/14

06

/07/

14

06/0

7/14

06

/07/

14

20/0

7/14

20

/07/

14

20/0

7/14

20

/07/

14

03/0

8/14

03

/08/

14

03/0

8/14

03

/08/

14

17/0

8/14

17

/08/

14

17/0

8/14

17

/08/

14

31/0

8/14

31

/08/

14

31/0

8/14

31

/08/

14

14/0

9/14

14

/09/

14

14/0

9/14

14

/09/

14

Calls Answered within 60 seconds

111 Service

105% 100%

95%

% Calls Answered within 60 Seconds Target

Week Ending 17/08/14 24/08/14 31/08/14 07/09/14 14/09/14

% Calls 95.7% 92.8% 92.4% 96.2% 95.1%

90% 85% 80% 75% 70% 65% 60%

Comparison of 2014/15 YTD to 2013/14

Weekly Ave. Ave. 13/14 Ave. 14/15 Diff % Diff

Calls Answered 3907 4302 395 10%

Calls Triaged 3725 4122 397 11%

Ambulance dispatches 292 391 98 34%

Attend A&E 183 230 48 26%

Attend primary care 2262 2403 141 6%

Attend Other Service 152 216 64 42% Not Recommended to Other Service 835 882 46 6%

14%

12%

10% 8%

6%

4%

2% 0%

Week Ending

% Of Triaged Calls Resulting in Ambulance Dispatch

11.5% 11.0% 10.9%

Week Ending

6000

5500

5000

4500

4000

3500

3000

2500

2000

1500

1000

Average(mean) No. Calls Triaged Control limits (2 stdev):-

Upper Limit: 4675 Average: 3859

Lower Limit: 3043

600

Average(mean) Ambulance Dispatches Control limits (2 stdev):- Upper Limit: 479

Average: 326 Lower Limit: 172

500

400

300

200

100

0

300

Average(mean) Recommended to Attend A&E

Control limits (2 stdev):- Upper Limit: 261


250

200

150

100

50

0

4000

3500

3000

2500

2000

1500

1000

500

0

Average(mean) Recommended to attend primary care Control limits (2 stdev):- Upper Limit: 2797


27

Dorset CCG

Hand

over

s O

ver 3

0 m

ins

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct

-12

Nov

-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul1

4

SWAST Red 1 Performance (Target 75%)

Ambulance Service

95%

SWAST Red 1 Performance Target

SWAST

Apr-14 May-14 Jun-14 Jul-14

Dorset CCG 90.3% 78.1% 84.5% 86.1%

SWAST 76.2% 75.3% 75.0% 73.7%

90% 85% 80% 75% 70% 65%

60%

Comparison of 2014/15 YTD to 2013/14

Monthly Averages Ave. 12/13 Ave. 13/14 Ave. 14/15

Diff

14/15 V 13/14 % Diff

60% 50%

52%

Non-Conveyances % of Total Calls - May-14

Calls 10,818 10,911 11,807 896 8%

Hear & Treat 701 780 984 204 26%

See & Treat 4,553 4,651 4,802 151 3%

See & Convey 5,563 5,480 6,021 541 10%

DCH 99 61 34 -26 -44%

PHT 57 60 64 3 6%

40%

30%

20%

10%

0%

46% 43% 43% 42%

37% 37% 34% 33%

31% 31%

27%

RBH 42 38 452 415 1096% SW IoW SC East of Eng

SE Cost W Mids Eng Yorkshire London NE E Mids NW

13,000

12,500

12,000

11,500

11,000

10,500

10,000

9,500

9,000

8,500

8,000

Average (mean) Total Calls Control limits (2 stdev):-

Upper Limit: 12,172 Average: 10,999

Lower Limit: 9,826

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

7,000

Average (mean) See and Convey

Control limits (2 stdev):- Upper Limit: 6,150

Average: 5,593 Lower Limit: 5,036

6,500

6,000

5,500

5,000

4,500

4,000

3,500

3,000 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

5,500

Average (mean) See & Treat Control limits (2 stdev):-

Upper Limit: 5,154 Average: 4,631

Lower Limit: 4,108

5,000

4,500

4,000

3,500

3,000


1,100

1,000

900

800

700

600

500

400

300

200

Average (mean) Hear & Treat Control limits (2 stdev):-

Upper Limit: 1,034 Average: 775

Lower Limit: 517


31

Dorset Urgent Care Strategy Action Plan 2014-16

Workstreams Lead Lead Programme Milestones / Key Tasks Timescale Progress Outcome

Measure

PREVENTION AND DEMAND Reduce overall demand on the system

FS Coordinating Care Clinical Commissioning Programme

Linking with Clinical Commissioning Programmes where significant growth in demand

- Maternity, reproductive and family health

- General medical and surgical - Cardiovascular, stroke, renal and

diabetes - Musculoskeletal and trauma - Mental health and learning

disabilities - Cancer and end of life

April14

Top 5 HRG admission codes identified: • Cardiac

Surgery • Paediatric/Neo

nates • Digestive • Respiratory • Musculoskeleta

l and trauma

Links made and areas of significant growth identified

TH/AD/HT

Potential actions discussed and agreed with individual Clinical Commissioning Programme Chairs

Dec 14 Actions agreed

Enable better and more accurate capacity modelling and scenario planning across the system

PD/FS/ESW/ SS

System Resilience Group /Cluster Groups

Urgent Care dashboard routinely available Capacity Planning models used to inform Organisational Resilience Capacity Plan (ORCP) and contracting round 2015/16 Review East Midlands Model for additional learning from best practice Implement findings from the Oak Report Explore existing options for reducing bed

Mar 15

• Dashboard developed

• ECIST review underway

• RTT/ORCP bids informed by predicted capacity issues

Local capacity management tool agreed. Development of the tool underway with an agreed project plan and timeline.

Appendix 3

32


Measure

use by patients that could be cared for in other settings

Reduce numbers of under 5’s attendances in Accident and Emergency and admissions

FS/KK Maternity, Reproductive and Family health Clinical Commissioning Programme

Participation in Wessex SCN work to reduce through education and pathway change

Mar 15

On-going project within the Maternity, Reproductive and Family health Clinical Commissioning Programme

Reduction in the number of under 5’s attending A&E departments

Expand Early Help Services and support on discharge through work with community and voluntary sector services

AW/ SAW

Better Together

Red cross services

Dec 14

Roll-out plan agreed for the early help services

Extend the use of telehealth/telemedicine specifically for patients with long term conditions

SS/FR Cardiovascular, Stroke, Renal and Diabetes Clinical Commissioning Programme

Review of evidence from Sussex Working with heart failure and COPD services to increase uptake.

Mar 15

Bournemouth and Christchurch Locality meeting taken place to consider role out

Roll-out plan with timelines for telehealth / telemedicine agreed

Extend falls and fracture prevention awareness and support

CS-F Musculoskeletal and Trauma Clinical Commissioning Programme

Review of current pathway to ensure optimum support

Mar 15

Joint Falls and Bone Health Strategy in place Fracture Liaison Services have been commissioned with DCH/PHFT/YDH Falls alert system in place with

Plan to extend falls and fracture awareness and support in place (with agreed timelines). Work

33


Measure

SWAST Review of fracture neck of femur pathway Osteoporosis Dorset providing education and support

underway.

Develop a communication strategy aimed at both the local population and health and social care professionals

KW Coordinating Care Clinical Commissioning Programme

Communication strategy in place A campaign to reduce demand on urgent care is on the agenda of the next pan-Dorset communications meeting to be held in December*which is attended by communications leads of acutes, DHUFT and Public Health Dorset.

A national campaign starts on 27 October to encourage people to get treatment earlier so they do not turn up very sick at A&E; this will run for six weeks

Jan 15

NHS Dorset CCG meeting with Healthwatch in October to discuss a joint campaign around winter messages. Advertisements have been placed in all local authority magazines for the Autumn / Winter encouraging people to use healthcare appropriately i.e. only attending A&E in a genuine emergency.Winter Communication plan in place as outlined in ORCP

Communication strategy in place. Delivery underway with key milestones

34


Measure

ACCESS Look at access and improve the quality and responsiveness of emergency services by ensuring patients receive urgent care in the most appropriate location 24/7

FS/SS/ESW

Cluster Groups

Establish an Integrated Model to manage the front door

Mar 15

ORCP funding is being utilised to look at front door options in each cluster area

Front door options identified Integrated model agreed

Review primary care access across general practice

JP Primary Care Development

Primary Care Vision for Dorset

Mar 15 ECIST review report will be used to support development

Primary Care Vision agreed

Review the response standards and performance times for rapid response in the three emergency departments and assessment units

FS

System Resilience Group

Provider review meeting Actions agreed at Provider review meeting Oct 14 All providers invited to

meeting 22 Oct 14

Agreed actions implemented

Promote and monitor the use of SPOA

TH/SB System Resilience Group

Ensure up-to-date information is available to SPOA

On-going DOS routinely updated and SPOA contract monitored

Build into contracts the requirement for providers to ensure the DOS is updated as required

35


Measure

FS/ S’OD

System Resilience Group /CordinatingCare Clinical Commissioning Programme

Agree role of SPOA in management of community beds

Dec 14 ECIST review of use of community beds planned

Role of SPOA in the management of community beds agreed

Work with SWAST to undertake an audit to ascertain the numbers of patients attending emergency departments following contact with the 111 service

SB / SWAST

Coordinating Care Clinical Commissioning Programme

Commission audit/ review of NHS111 Share findings and recommendations Agree and action recommendations

Dec 14

External cross commissioner Audit commisioned Deloitte draft report received

Recommendations implemented

Trial adaptations to the 111 service in line with service developments

SB / SWAST

Coordinating Care Clinical Commissioning Programme

Trial of GP in the clinical hub

Mar 15

Bid made against Urgent Care funds Deloitte draft report received

Lessons learnt applied

Review usage of minor injury units and walk-in centres

TH/PD Coordinating Care Clinical Commissioning Programme

Complete mapping of when and which services are available in MIUs Mechanism in place that provides up to date MIU availability to SWAST Oct 14 Mapping of service

complete

Ambulance crews use MIU effectivley and an alternative to ED

36


Measure

Expand 7 day services from 8am – 8pm across services

MM/RR/RMc


Diagnostics, pharmacy – impact to be considered Jan 15

Requirement included in the Cluster group TOR

Impact identified

RD/IC System Resilience Group

Social work – ensure assessments can be undertaken at weekends Dec 14 RD to update

Assessments underway

SO’D/ SS


Community hospital medical cover – to enable more step up and step down admissions through SWAST out of hours

Apr 15 To be discussed through contracting processes 15/16

Current arrangements for medical cover and issues identified. Ongoing model agreed and developed into contracts

RD System Resilience Group

Discharge into residential care at weekends. Meeting to be held to assess what needs to be in place to support this

Dec 14 RD to update

Meeting held and actions agreed and underway

Formalise process for health / social care professionals to contact Emergency Department Consultant (7 days a week)

FS/MM/RR/RMc


Actions agreed at Provider review meeting Oct 15 All providers invited to

meeting 22 Oct 14

Agreed actions implemented

Medicine Management specific FS/SS/ Cluster Review processes to ensure medicine Dec 14 Review

37


Measure

focus on discharge (7 days a week)

ESW Groups optimisation prior to discharge to care homes and community hospitals

current process and identify any required actions (with timeframes)

MM/RR/RMc


Review processes to ensure medicine optimisation prior to discharge

Dec 14

Processes reviewed and actions agreed as required

Review End of Life Pathway to reduce inappropriate admissions

RP/MW Cancer and End Of Life Clinical Commissioning Programme

Review current position CQC contacted to discuss performance standard that acts as a barrier/disincentive for Care homes/ Nursing Homes to support individuals with Preferred Place of Death plans in place

Jan 15

NHS Dorset CCG Quality team raised issue with CQC re performance standards

Current position reviewed Actions agreed

FRAIL AND COMPLEX PATIENTS

A consistent model/framework for frail and complex people

JP

Primary Care Development

Agree frailty model

Mar 15

Draft principles agreed to be progressed through Clinical Service Review

Anticipatory Care plans in place

Progress locality MDT working with GP Clusters to maximise incentives to undertake risk stratification to enable targeted case management and

JP Primary Care Development

Inclusion in Primary Care plan requirements 2013/14

Mar 15 Included in Primary Plan requirements

Incentives in place Increase in

38


Measure

anticipatory care planning risk stratification

Review services for frailty and ensure there is a single service model across the county or at least around each ‘hub’

FS/SS/ESW

Cluster groups/ Coordinating Care Clinical Commissioning Programme

Model developed and in place

Apr 15

Model agreed and implementation plan agreed

Implement integrated locality teams

SS Better Together

Develop financial Business Case

Sept 14

The full business case will be submitted to the Better Together Programme Board Nov 14 for approval

Business case complete

Develop robust Service Specification Service specification complete

Learn from trailblazers – Purbeck, Poole, Bridport and Bournemouth

2015/16

The transformational change leadership programme pilot with project teams from Bridport, Purbeck and Poole continues and will be reviewed shortly to assess the effectiveness and how it can be used more widely

Review complete – action plan for roll-out agreed

Develop closer Mental Health Services / Hospital / Community interfaces

KF-S Mental Health and Learning Disabilities

Understand the current issues in working closer with the services in community and acute hospital and community service providers, health

April 15

Work is under way in the following areas: Dementia and Long Term Conditions

Establish LTC pathway

39


Measure

Clinical Commissioning Programme

and social care Review Perinatal Mental Health in the context of the maternal mental health strategy.

April 15

(LTC A task and finish group with all key stakeholders to be facilitated by end November 14. Business case to be developed outlining options for future development of the perinatal MH pathways

Establish KPIs in contract 15/16

Evaluate Mental Health Street pilot to determine effectiveness for reducing ED admissions/avoidance for section 136 patients

Jan 15

The pilot has been operating since June 14. Service will be evaluated in December 14 to establish its effectiveness in relation to the use of section 136.

Outcomes from the evaluation

Plan for service improvements • MH Acute Care Pathway

Review • Specialist Dementia

Evaluation

April 15

Project plans are agreed. Benchmarking visits commenced 1st stage due to be completed by Mar 15

Reports to Steering Group

KF-S Mental Health and Learning Disabilities Clinical

Mental Health liaison service development

April 15

Model options for future provision of service produced. Options considered by CCP and

Revised Model specified and operational

40


Measure

Commissioning Programme

recommendation endorsed. Business case for investment being produced for consideration by CCC

Review discharge support models and ensure appropriate level of support in place locally

FS/SS/ESW

Cluster groups

Ensure discharge to assess teams are present in each hospital to proactively manage frail and complex patients

Jan 15 TB/PH/TM to update

Plans agreed Discharge to assess teams in place

TH Surge and Escalation Planning Group

Ensure effective discharge mechanisms are in place to prevent Delay Transfers of Care

Jan 15 Included in revised TOR for SAEPG

Mechanisms in place Revised Choice Policy agreed

Move to a trusted assessor model for social care

TB/BB/TM

Local Authorities

Trusted assessor model in place Apr 15 TB/BB/TM to update

Model in place

PATIENT FLOW

Simplification and alignment of services

FS/TH System Resilience Group

Use of consistent terminology across all services Oct 15 Agenda for next SRG

TH Surge and Escalation

Review and standardise triggers for resilience reports Nov 15 Discussions

commenced Oct Standard publicised

41


Measure

Planning Group

meeting and adherred too

Enhance intermediate care / reablement / rehabilitation capacity

PH Better Together

Review of services

The initial scope for intermediate care, rehabilitation and reablement work has been drafted and circulated to commissioners for comment. The timeline is agreed, identifying membership for steering group, scoping current position, considering data gathered and recommending options

Develop new specification for enhanced services

Mar 15

Timeline agreed, identifying membership for steering group, scope current position, consider data gathered and recommend options. Stakeholder event target February. Decision on future approach by end of March 2015

CS Workforce Explore workforce capacity and future requirements

42


Measure

Shared information, advice and support on leaving hospital

IC Better Together

Review Current Service

Dec 14

The scope of this work wa discussed at the last Programme Board and it was agreed that it should encompass information a advice in A & E departme and become part of the w of the Health & Social Ca Clusters (subgroups of th Systems Resilience Grou

Expand service across Dorset To be encompassed within the work programme for Cluster groups

Review Choice Policy Mar 15 Joint working with commissioners across sectors will be required

Develop a clear strategy for Emergency Ambulatory Care and short stay across the system

SS/FS/ESW


Strategy for Emergency and Ambulatory care developed

Mar 15 Agree AD/HT to pull draft strategy together Dec 14

Strategy published

Undertake more diagnostic work to understand the impact of admissions from nursing and residential care homes

FS


Provider review meeting Actions agreed at Provider review meeting

Oct 15 All providers invited to meeting 22 Oct 14

Emergency Department audit to be undertaken at all acute providers

SWAST, Acute providers and Primary


Audit completed by all acuter providers

Dec 14 Audit tool agreed and shared

43


Measure

Care

RESPONSIVE & FLEXIBLE

Review commissioning approach and workforce issues in relation to Domiciliary Care

PH Better Together

Consider more attractive contract mechanisms

Discussion held about initial brief for domiciliary care and further scoping work is in progress

Targeted recruitment

Growing the Workforce - Work has progressed with providers, Bournemouth University and their student population to grow the workforce; to seek out ways to better advertise and market employment opportunities in the domiciliary care sector.

Agree commissioning approach

Discussion held about initial brief for domiciliary care and further scoping work is in progress

Develop a primary care vision for Dorset

ESW Primary Care Development

Primary Care Vision developed Mar 15

44


Measure

Improve information sharing capacity and integration of ICT systems

AH/HC/DV

Better Together

ICT development fund bid for shared case summary

Oct 14

Following our submission of the Integrated Digital Care Fund Bid in July, an interview has taken place and we are planning for the possible award mid to late October. Once a decision has been made we have to respond in 7 days with a memorandum of understanding which includes a detailed implementation plan.

Use of NHS number as primary identifier TBA

This is included in the work plan of the Information Governance Group.

Develop information sharing agreement

April15

Pan Dorset Charter being produced which will include an overarching strapline mission statement

System integration

April15

Draft pre-award implementation plan being submitted to Better Together Programme Board 16 Oct 14.

Ensure patient and public involvement informs service developments

JM System Resilience Group

Review patient and public involvement work completed to date and planned with each provider

Feb15 Agenda item Nov 14 SRG to consider PPI reference group

45


Measure

Reduce the operating costs of the whole health and social care system without reducing the quality or scope of the service

LW Better Together

Financial strategy to be developed and agreed Mar 15

Finance Sub Group is working on the steps and process for achieving a Financial Strategy. Contingency plans

Ensure contracts are aligned to support the delivery of the urgent care agenda

TH Coordinating Care Clinical Commissioning Programme/ Contract managers

Inclusion of: a joint standard operational policy, SAFER Standard, flow bundles, discharge quality standards, monthly audit of emergency department standards into provider contracts

Apr 15 Include in Contract Planning Process for 15/16

Establish a programme management office approach for urgent care hosted by Clinical Commissioning Group

FS System Resilience Group / Coordinating Care Clinical Commissioning Programme

Agree funding stream Establish distinct programme team to ensure integration Dec 14

Integrated Programme Management Office approach

Develop a Memorandum of Understanding for escalation for all providers


Agreement on escalation Dec 14

SOP agreed

46

Key

Suzanne Birt (SB) Programme Lead, Dorset CCG

Tim Branson (TB) Service Manager, Enablement Services, Adult Social Care, Bournemouth Borough Council

Betty Butlin (BB) Service Manager Older People & Physical Disability, Borough of Poole

Harry Capron (HC) Head of Commissioning and Service Development, Dorset County Council

Ivor Cawthorn (IC) Strategic Commissioning Manager, Bournemouth Borough Council

Ruth Davis (RD) Commissioning and Improvement Project Manager, Dorset County Council

Anna Doherty (AD) Principal Programme Lead, Dorset CCG

Phil Dove (PD) Head of Performance Intelligence, Dorset CCG

Kath Florey-Saunders (KF-S) Head of Mental Health and Learning Disabilities Clinical Commissioning Programme, Dorset CCG

Andy Hadley (AH) Head of IT Development, Dorset CCG

Tracy Hill (TH) Principal Programme Lead, Dorset CCG

Phil Hornsby (PH) Head of Commissioning and Improvement - People Services, Borough of Poole

Karen Kirkham (KK) GP Chair for Maternity, Reproductive and Family Health Clinical Commissioning Programme, Dorset CCG

Rab McEwan Chief Operating Officer, Dorset County Hospital NHS Foundation Trust

Mark Mould (MM) Chief Operating Officer, Poole Hospital NHS Foundation Trust

Tessa, Murphy (TM) Service Manager, Adult & Community Services, Dorset County Council

Sally O’Donnell (S’OD) Acting Director of Community Health Services, Dorset Healthcare University NHS Foundation Trust

Jane Pike (JP) Director of Service Delivery, Dorset CCG

Rigo Pizarro (RP) Head of Programme, Dorset CCG

Richard Renaut (RR) Chief Operating Officer, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Fiona Richardson (FR) Head of Cardiovascular, Disease, Stroke and Diabetes Clinical Commissioning Programme, Dorset CCG

Sally Sandcraft (SS) Deputy Director of Review, Design and Delivery (East), Dorset CCG

47

Emma Seria-Walker (ESW) Deputy Director of Review, Design and Delivery (Mid), Dorset CCG

Cindy Shaw-Fletcher (CS-F) Head of Musculo-Skeletal Trauma Clinical Commissioning Programme, Dorset CCG

Frances Stevens (FS) Deputy Director of Review, Design and Delivery (West), Dorset CCG

Charles Summers (CS) Director of Engagement and Development, Dorset CCG

Hazel Thorp (HT) Head of Programme, Dorset CCG

David Vitty (DV) Head of Adult Social Care Services, Borough of Poole

Matt Wain (MW) Head of Patient Safety and Risk, Dorset CCG

Ali Waller (AW) Head of Commissioning and improvement, Adult Social Care, Dorset County Council

Sally-Ann Webb (SAW) Better Together Programme

Jodie Whaley (JW) Engagement and Communication Lead, Dorset CCG

Liz Wilkinson (LW) Executive Director of Finance, Bournemouth Borough Council

Keith Williams (KW) Public Relations Lead, Dorset CCG

48

Key Reference Documents • NHS Operating Framework 2012/13; • NHS England: Improving A&E Performance Gateway red: 00062; • Primary Care Foundation Urgent Care – A practice guide to transforming same-day care in

general practice (2009); • Royal College of General Practitioners Guidance for Commissioning Integrated Urgent and

Emergency Care – A Whole System Approach (2011); • Department of Health High Quality Care For all: NHS Next Stage Review (2008); • Department of Health Equity and Excellence: Liberating the NHS (2010); • Department of Health A Vision for Adult Social Care (2010); • The King’s Fund Avoiding Hospital Admissions (2010); • The Francis Report (2013) http://www.midstaffspublicinquiry.com/report (accessed 8 April

2013);

Key Enablers • National Clinical Indicators; • CQC and Monitor licensing and compliance with CQC’s “Essential Standards of Quality and

Safety”; • Existing and developing quality standards; • Quality, Innovation, Productivity and Prevention (QIPP) Programme; • Better Care Fund; • Primary Care Development Fund (Dorset); • GP Quality Outcome Framework (QOF); • Provider Contracts/Service Quality Review and Service Specifications; • Commissioning for Quality and Innovation (CQUIN) Payment.

Appendix 4

http://www.midstaffspublicinquiry.com/report