health and care transformation in oxfordshire · care closer to home so that people in oxfordshire...
TRANSCRIPT
Health and Care Transformation in Oxfordshire
Stuart Bell – Chief Executive Oxford Health NHS Foundation Trust
Monday 6 June
Objectives for today
• This event signals the start of a public conversation about the case for change in transforming health and care in Oxfordshire and the emerging models of care.
• We want to get your views to help inform our thinking and help us to develop plans as part of an on-going process that will lead to public consultation later in the year.
Context: Oxfordshire in a snapshot
• 672,000+ people – the population has grown by more than 10% in the past 15 years and is growing
• 1/3 of which live in towns or villages of less than 10,000 people
• Levels of disability are low (compared to national averages) but 90,000 residents report being limited in their daily activities
• Whilst healthy behaviours are more prevalent in Oxfordshire – 55% of our population is overweight or obese
• Linked to this is the number of people with diabetes which is forecast to increase by 32% by 2013
• £704 million budget for health care in the county
In Oxfordshire our health needs are changing
INCREASING PREVENTABLE DISEASE
In Oxfordshire our population is changing
22,000
homes
new
homesPlanned for
Bicester and Didcot
In 2011: Black and minority ethnic (BME) communities make up 9% of our population
That’s 60,000 people. Almost double the 2001 figure. The biggest BME population growth areas are in Oxford and Chwerwell
In Oxfordshire disease levels are rising
Obesity, COPD and diabetes continue to increase
• 61% of Oxfordshire’s adult population were overweight or obese
• The number of people with diabetes is forecasted to jump 32% to 41,000 by 2030
Dementia prevalence rising
Source: Oxfordshire JSNA, March 2015; APHO Diabetes Prevalence Model for England, 2009; Most Capable Provider Assessment – Older People, June 2014
Much of this disease is preventable and stems from
• Unhealthy lifestyles e.g. inactivity, obesity, smoking and alcohol consumption
• Inequalities in health e.g. smoking rates are twice as high in manual workers than the County average (insert chart from the ‘prevention’ presentation as an illustration or use the map of Index of Multiple Deprivation)
In Oxfordshire our health needs are challenging
Ageing population
65+: 18% increase forecast to grow to 140k people by 2025
85+: 30% increase forecast to grow to 22k people by 2025
Source: Oxfordshire JSNA, March 2015; APHO Diabetes Prevalence Model for England, 2009; Most Capable Provider Assessment – Older People, June 2014
In Oxfordshire we could do better . . .
…we are increasingly struggling across the system to deliver good access for our people when they need it
In Oxfordshire we could do better
We have identified 3 health and wellbeing Gaps we can help to fill:
• A lifestyle and motivation gap which we can help to fill through making it easier for people to help themselves using apps and the web
• A service gap in which we help all professionals prevent ill health by helping to improve unhealthy lifestyles
• A community gap in which we plan for healthier community design and, as the County’s largest employer, work harder to improve our workforce’s health
In Oxfordshire we are facing many challenges
• Increasing hospital demand
• Increasing complexity
• Increasing cost pressures
• Workforce pressures
• GPs under pressure
• ‘Sickness’- crisis response
• How to make a shift from sickness services to preventative services
• 20% over next 5 years
• Long term conditions & frailty
• New drugs and inflation
• Recruitment & retention
• Extended hours & 7 day services
• New model of ‘anticipatory’ care
• How to tackle inequalities at source
The challenges facing health and social care are many and varied:
The Oxfordshire Transformation Programme
NHS and social care services, with Healthwatch and Lay representative
Our aims:
• Reduce preventable ill health and level up inequalities
• Provide innovative ways of delivering high quality outcomes for an expanding population that lives longer with increasing healthcare needs
• Maximise the value of the Oxfordshire health and social care £
• Find ways to become better at preventing and managing our health
• Help individuals to take greater responsibility for their own health
• Interactions and expectations are changing, for example Health ‘Apps’
We are: Abingdon Federation
South East Federation
Early messages – non elective admissions
Think about flow through the hospital as well as admission avoidance…
Length of
stay
NEL
admis % Beds %
0-2 days 33,244 65.4% 61 10.7%
3-7 days 10,101 19.9% 123 21.5%
8-14 days 4,027 7.9% 115 20.0%
15+ days 3,496 6.9% 273 47.7%
Total 50,868 573
Oxfordshire Vision
Staff make full use of their skillsets, cutting across organisational boundaries, supported by modern technology
The best bed is your own bedYou are only admitted to a bed when and where it’s absolutely
appropriate to your needs
Resources and infrastructure reallocated
to match need and enhance convenience
on-line monitoring, longer appointments, diagnostic centres in the community
Accountability to patients will be clear and consistent A designated clinician responsible for their patient 24/7
Prevent what can be prevented and level up
inequalities
Care closer to home
So that people in Oxfordshire can get more care at home – or closer to home . To do this we will:
• increase people’s confidence to manage their own care
• General Practice as ‘the gate keeper’
• deliver more integrated GP, community, hospital & social care
• manage the population’s health to improve outcomes
• Increase the capacity of community workforce
• Organisations working together across Oxfordshire
• Services focusing on quality, experience and outcomes
Care Closer to home Model
• DAMON TO INSERT REVISED MODEL as per Joes email
How can we achieve our ambition?
The NHS Five Year Forward View (5YFV)
• £560 billion to deliver 5YFV
• £8.4 billion real terms growth for Sustainability & Transformation
• £22bn financial ‘gap’
• Invest in 3 key GAPS/Challenges
The NHS Five Year Forward View (5YFV)
For Oxfordshire:
• £1.2 billion pa
• £6 billion spend 2016-’21
• Oxfordshire £ increasing
• £150m for Sustainability & Transformation
• £600 million financial ‘pressure
0
50
100
150
200
250
16/17 17/18 18/19 19/20 20/21
£200m
Buckinghamshire, Oxfordshire & Berkshire West - A Snap Shot of ‘BOB’ STP
Alliance with Bucks & Berks West:
• 1.8m population
• £2.5bn funding allocation
• £5-600m funding pressure
• 7 Clinical Commissioning Groups
• 6 Foundation & NHS Trusts
• 14 local authorities
• STP Lead David Smith OCCG
Buckinghamshire, Oxfordshire & Berkshire West - A Snap Shot of ‘BOB’ STP
Alliance with Bucks & Berks West:
• Scaled Public & Population health
• Mental Health care services
• U&E Care, Cancer & Maternity
• Workforce
• Primary Care sustainability
• Reducing/avoiding variation
Next Steps
1
April to Sept
2016
October to Dec
2016
Emerging clinical
models
Refined clinical
models
Models, Options
& Proposals 2 3 4
Discuss the Case for Change, focusing on trends & challenges in our current health care provisions along the pathways
Review best practices and case examples on models of care and discuss potential implications for Oxfordshire
Discuss and input into emerging views on the best practice care models
Discuss with consultants and clinicians involved in driving this work
Review and input into emerging models of care
Launch public consultation on new care models
Review refined models of care
Discuss high level requirements from different care settings, including out of hospital care
Consult on options and proposals for the new care models
Seek public feedback on models and options
Compelling case
for change
2017
PATIENT & PUBLIC ENGAGEMENT PATIENT & PUBLIC CONSULTATION
Questions?
Clinical Review
Bruno Holthof – Chief Executive
Oxford University Hospitals NHS Foundation Trust
Dr Joe McManners – Clinical Chair
Oxfordshire Clinical Commissioning Group
Clinical Pathway Reviews
The starting point in developing future models of care is to identify current
challenges & discuss what good looks like for pathways & look at what patients are
telling us about their care . . .
We are reviewing:
Urgent &
emergency
care
Maternity &
children's
services
Care provision for women planning to have children and expecting mothers from pre-conception, antenatal, birth and post-natal.
Care provision for children (below age 18) from universal prevention, primary and urgent care, more targeted community care and protection for vulnerable children to specialist acute and tertiary care
Mostly healthy: people under 75 who are mainly healthy, but may require urgent care from time to time.
People with long term conditions: people who either have a known, pre-existing condition or who are quickly and easily identifiable as having one so that they can be directed – or will direct themselves – to the service they need, thus avoiding overburdening the acute emergency pathway, including A&E.
Frail, mostly elderly: people with ‘undifferentiated’, complex needs requiring rapid assessment and for whom A&E may not be the ideal way to access the care they need. They may also be best cared for outside the acute setting, at least after the first few days.
The integrated provision of prevention, self-care, community, primary and ambulatory care are important for people with long term conditions and frail patients to avoid emergency admissions
What are we reviewing cont’d
Elective,
diagnostics &
specialist care
Care provision for people who require planned, routine or specialist medical or surgical services from self-care, self-assessment, diagnostics, consultation, treatments to rehab and follow up.
Mental Health
Care provision for adults who require mental health services Care provision for children and young people (CAMHS) The integration of mental and physical health needs
Learning
Disabilities
Care provision for children and adults people who require services to support them with a learning disability and / or autism
Access to health checks or health care, especially in an emergency Improve quality of care for people with higher functioning autistic spectrum
disorder what often fall between services
Maternity services - vision
• The right woman, into the right part of the service and cared for by the right professional
• Early booking with effective early risk assessment
• Informed choice but real choice
• Appropriate pathways of care including birth
• Sustained continuity of care
Maternity – quality gap
• Informed choice – impact on capacity, balanced with
clinical safety
• Preconception care – consistency of provision
• Continuity of care – guidelines, pathways, midwifery and
medical care, affordable and sustainable
• Medical risk assessment – consistency of delivery, early
enough in pregnancy
• Staffing – Royal College of Gynaecologist standards for
obstetric units, midwife to birth ratios
• Estates – some not fit for purpose, some under-utilised,
others need more capacity
• Technology – community based diagnostics, care records
What patients have told us is important to them
More breastfeeding support
The need for adequate staffing – particularly midwives
The importance of informed choice
More and better postnatal care
More education for parents
Better involvement of the father
Children’s Services - vision
We want Oxfordshire to be the best place in England for children and young people to grow up in. We will work with every child and young person to give them the best start in life and to develop the skills, confidence and opportunities they need to achieve their full potential. This means we will:
• Work with others, including parents, schools and the third sector to promote health and to build resilience in all children and young people.
• Work with families and communities to support successful self-care for minor illnesses, injury and long term and/or life limiting conditions so that children can live productive lives (e.g going to school) in ways they choose.
• Provide care as close to home as possible, when clinically feasible and when hospital
inpatient care is the best option, enable the family to stay close to their child and their
child to stay in hospital for as short a time as possible.
• Deliver care through clinical pathways and multi-disciplinary teams
• Develop the skills of our staff through working in multi-disciplinary teams
• Aspire to have every child and family who has contact with our services report having had a great “experience” of them.
• Aspire to employ and develop a workforce who have a great “experience” of working for children in Oxfordshire
Children’s services – quality gap
• Severe pressure in primary care, particularly in terms of capacity, confidence, knowledge and skills.
• Using hospitals to treat conditions that could be managed in the community
• Access to high quality paediatric/child health expertise in the community
• Lack of integrated pathways
• Inappropriate use of services, health literacy
• Early intervention – poverty and disadvantage
• Patient experience – travel, waiting times
What patients have told us
• Help is needed for people to navigate the health and social care systems
• The importance the Carer plays in supporting a person, to involve the Carer more and the need for more support for young Carers
Urgent & emergency care - vision
• Optimisation of outcomes for patients
• Convenience versus value for money
Thames Valley Urgent Care Vision
A&E & Ambulance – quality gap
• 95% wait <4 hours in A&E; OUH 88.7% March 2016
• 999 emergency RED calls
• Delayed Transfers of Care (DToC)
121 (26 May snapshot) delays
DToC Days delayed as % of occupied beds: target 3.5%
oQ3 15/16 OUHFT 12.6%, OHFT 8%
• Numbers rising steadily year on year
1% increase overall, 3-4% young children, older adults
Quality gap – workforce shortages
• Oxfordshire cost of living, difficulty to retain staff
• Primary care – increased pressure on GPs GPs Retiring early
Lack of capable generalists
Out of hours GPs
• Emergency Care Practitioners
• Domiciliary care
• Skills in non-hospital settings e.g. podiatrists
• Nurses for nursing homes (ageing carers)
• Weekend opening of West Oxfordshire EMU
• RACU recruitment challenge in Henley
• 7 day working shortfalls to be reviewed
Quality Gap in the community
• Constraints in ability to admit in community beds
Nature and size of bed-stock
• Poor estate in some community hospitals
Expensive to maintain
• Cost of community hospital admissions
• Limited evidence of outcomes from community hospitals
• Not enough capacity to meet known Home Care and Reablement need
• Limited step up due to nature of bed stock
Wrong beds, wrong patients, wrong time
• Excess LOS
Total LOS and individual LOS across pathway, acute and community
• Technology – systems that do not talk
What patients have told us
• Consistent, good quality care for older people across health services with equal and fair treatment available for all
• The importance of ensuring that new services are tailored to support a diverse range of needs
• The needs of patients in rural areas are often different and that patients would benefit from services located closer to home where this is possible
• The importance of more preventative measures - particularly in relation to the health and wellbeing of older people, and to prevent obesity
• More integrated working across different agencies
• Remember patients are individuals and that these targets/outcome measures are not appropriate for all
• The differences and/or inequalities that exist in health across the population of Oxfordshire as well as the differing needs/issues affecting those that live on the county boundaries
• The importance the Carer plays in supporting a person, to involve the Carer more and the need for more support for young Carers
• A need to change attitudes and empower patients to take control and ownership of their own health. In addition a need to change the belief that hospital is the only place where professionals can be seen
Elective, diagnostics and specialist care - vision
High quality and efficient services would be :
• Linear and clearly defined with known quality and outcome for the majority of patients Patient seen at the right time with the right information, right clinician in the right place.
• Decisions made with the patient and should always be “value adding” with a best practice pathway approach to reduce variation
• Processes support the above
• Real time tests, results and diagnosis
• Joint audit programmes, research etc
Elective, diagnostics and specialist care – quality gap
• Workforce particularly primary care under pressure so making more referrals
• Availability of workforce to deliver; specialist nurses, physio, GPs and Drs in specific areas.
• Constitution standards not met in some specialities (Non-admitted and admitted); ENT, Ophthalmology, T&O, Gynaecology, Cardiology
• Access to outpatients and surgery needs to sooner particularly after waits for diagnostics
• Cancer standards met but not consistent
• Estate not fit for purpose and requires repair and upgrading
• Patient experience; parking, processes, communication
• No shared patient record across the system
• Development of IM and T solutions not keeping pace with developments in technology
• Fragmented communication between professionals; direct discussion and advice for GPs to avoid referral, clinic letters.
• Late diagnosis of cancer meaning treatment prolonged and more expensive.
• Variation across the system with no best practice clear pathways in many areas
What patients have told us
• Use innovation and technology, both to benefit patient care and to create greater efficiencies within the NHS. This includes things such as social media, mobile technology, electronic patient records and telehealth
• Improve quality of services, staff and ensure consistancy of quality
• A need to change attitudes and empower patients to take control and ownership of their own health. In addition a need to change the belief that hospital is the only place where professionals can be seen
Mental Health - vision
An all age approach to mental health and well-being delivering• A 7 day service Right Care, Right Time,
Right Quality• An integrated approach to mental and
physical health• Promoting good mental health and
preventing poor mental health
Implementing parity of esteem through• Oxfordshire’s Mental Health Crisis
Concordat• The OCCG-OHFT outcomes based contract
for mental health• The OCCG-OHFT IAPT and wellbeing
contract• The Oxfordshire Local Transformation
Plan for Children and Young People• Memory Assessment and the Dementia
Support Service
Mental Health – quality gap
• Differential access to services depending on age; waits for CAMHS
• Lack of specialist local accommodation: autism (CYP and adult) and EMI
• Confusion/risk around urgent care pathway
• Confusion/risk around perinatal pathway
• Lack of mental and physical health integration
• Secondary waits for higher tier psychology
• Support for carers that supports the cared-for
• Lack of integrated patient records
What patients have told us
• Young people said that their appointments were in school hours, which created problems for them. They didn't want other students to know where they were going and so sometimes skipped school altogether to attend the appointment and avoid the situation.
Learning Disabilities - vision
1. Having a good, meaningful and “ordinary” life
2. Person centred support
3. Families and people able to design and buy their own services, when they choose to
4. Having the right support close to home
5. Easy access to health services when you need them
6. Early intervention and prevention for children and families
7. All age support and continuity of care when preparing and / or moving into adulthood
8. Effective management of crises
9. Choice, control and equity
Transforming Care Plan 2016-19
Learning Disabilities – quality gap
• There is a variation in health checks that people with LD receive in primary care and the overall level is <50%
• People with higher functioning autistic spectrum disorder (without LD) often fall between services
• People with LD and /or ASD report significant challenges in accessing healthcare, especially in an emergency
• People with LD and co-morbid MH are more likely to be detained under MHA83
• Lack of a forensic pathway for people with LD leading to unnecessarily long inpatient stays
What patients have told us
• There was a different level of quality service from different staff, some being very cooperative and responsive whilst others were very slow to respond
• Support to young people and families whilst waiting for appointments
• Post diagnosis support for ASD and ADHD
• Support for families while they are waiting for their first appointment
Workshop sessions
• You’ll hear about the emerging models of care
• We’d like your views on:
What (if anything) needs to be added to our case for change across the transformation programme?
What (if anything) needs to be added to our vision in this area?
What do you like about the emerging model(s) of care?
What do you think we can do to improve the model(s)?
Questions?
Patient Panel
What you have told us today & next steps
Insert themes from the day / comments
We want to continue the conversation . . .
• The Oxfordshire Transformation Programme will be involving patients and the public in the development of proposals for new models of care and possible service options.
• A full public consultation is scheduled to take place later in the year.
We want to continue the conversation . . .
There is a range of communications and engagement activities which will take place during the pre-consultation period and will include:
• Six patient and public engagement events throughout the summer
• Presentation and discussion at meetings of key community and voluntary sector groups
• Briefings for the County Council and District Councils
• Briefings for Oxfordshire MPs
• Updates and reports to Oxfordshire’s Joint Health Overview and Scrutiny Committee, including a discussion at the June meeting about the plans for pre-consultation engagement planned for the summer period
• Updates to Oxfordshire’s Health and Wellbeing Board
• Online information on the Transformation Programme website which we hope to launch next week.
How do you want to be involved and kept informed of developments?
• Sign up to Talking Health: the CCG online consultation tool and we will send you notifications of the work and updates: consult.oxfordshireccg.nhs.uk
• Send us a letter: Communications & Engagement Team Oxfordshire Clinical Commissioning Group, FREEPOST RRRKBZBTASXU, Jubilee House, 5510 John Smith Drive, Oxford Business Park South, OXFORD, OX4 2LH
• Phone: 01865 334638
• Email: [email protected]