WARWICKSHIRE HEALTH AND WELLBEING BOARD Date: 1 May 2019
From: Rachael Danter, System Transformation Director Title: Better Health, Better Care, Better Value Programme Update 03 Better Health, Better Care, Better Value
1 1 Purpose The purpose of this report is to provide the Warwickshire Health and Wellbeing Board with an update on the Better Health, Better Care, Better Value programme and work streams, highlighting any key points as necessary.
2 Recommendations The board is asked to note this report and its contents
3 Background 3.1 Integrated Care System Update Following the publication of the NHS Long Term along with a 5 year investment schedule to support delivery work is underway to respond to this. Systems are asked to develop a 5 year plan (5 year refresh) which should highlight what activities will be delivered over the next 5 years in what timescales, in order to meet the LTP requirements.
This plan will need to be underpinned by a 5-year system-wide financial strategy and a capacity and resource plan. This 5 year Plan will be a refresh of the previous BHBCBV plan and provides us with an opportunity to identify what part that the BHBCBV programme will play over the next five years in supporting successful delivery of ‘the Vision for Population Health’ as well as detailing how the Coventry and Warwickshire NHS system, working with partner organisations will deliver the NHS LTP requirements.
The Transformation Plan will need to describe how and what we will deliver over the next 5 years. It will also need to show where investment will be placed and the impact of that investment in terms of improved outcomes and increased capacity and performance. Recognising our financial position, a significant part of the Plan will need to articulate how we will take costs out of our system.
Finally, the Plan needs to be developed and owned by our system leaders, our clinicians, our staff, our partners and our patients and the public. The Plan will need to identify all the activities that will be undertaken at Place, System and Network in order to maximise our opportunities as a system.
It will need to highlight how we will deliver our Constitutional targets and the milestones identified in the LTP as well as a number of system-wide transformation programmes. There are currently a number of key work-streams within our architecture that will need to work with the wider system to identify opportunities and reflect these in their individual work-stream plans. These work-streams are identified below:
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These work-streams have already identified their plan for 2019/20, which represents the first year of the 5 year Plan. Once the work-streams have identified the activities that need to be undertaken over the remaining four years the plans will be updated and the system then needs to map the activities into system and Place to be clear where the activities will occur.
Underpinning the Transformation Strategy needs to be a Financial Recovery plan which identifies where new investment will be placed but also where costs will be removed from the system to allow us to move towards a financially sustainable position. 3.2 Place Based Planning – 2019/2020 The NHS Long Term Plan (LTP) describes 2019/20 as a transition year for the NHS as we move from our traditional, competitive ways of working towards a more collaborative and integrated approach.
During this period, the Coventry and Warwickshire health and social care system, will focus on three key priorities; continue to deliver great care for our patients; to develop, test and embed the building blocks which allow us to transform the way we commission and provide services in the future; and to refresh our system Health and Well Being Strategy and develop an associated five year Transformational Delivery Plan that ensures we deliver the best quality and outcomes for our population, within the resources available.
The priorities are outlined below. 3.2.1 Priority One Throughout 2019/20, the BHBCBV programme will maintain over-arching responsibility for driving system-wide achievement of all national deliverables including the NHS Constitutional Standards and the targets/milestones identified in the LTP.
Each programme workstream has already identified the national deliverables for 2019/20 underpinned by a project plan. Where appropriate, these plans are mirrored at organisation and Place level to ensure system alignment. Cancer Maternity and Paediatrics Mental Health and LD Urgent and Emergency Primary & Community Transformational Assurance Statements Workforce Digital Estates Waste Reduction Population Health Management Proactive and Elective (inc. MSK) Stroke Frailty Pharmacy ICS Development Aligned Incentive Contract
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Priority Two Significant transformational change is expected over the next five years. As such, in 2019/20 we will have all the necessary foundations in place to commence this transformational change at three levels; System, Place and Network. At system level, the BHBCBV programme will be redesigned to better support system-wide transformational projects and performance such as our ‘single shared-care’ record project, system-wide estates and digital strategies and a system-wide performance framework.
Priority Three In response to the NHS LTP we will take the opportunity throughout the spring and summer of 2019/20 to work with our Health and Well Being Boards, our Local Authority colleagues, other partners, our staff and the patients and populations of Coventry and Warwickshire to refresh our system-wide Health and Well Being Strategy. This will be underpinned by a revised system Transformation Delivery Plan that outlines the programmes of work we will undertake over the next five years to deliver the best quality and outcomes for our patients and population within the resources available. 3.4 Clinical Strategy – Update on identified priorities The clinical strategy sets out the current issues being faced across Coventry and Warwickshire’s health and care system and identifies priority areas where services could be improved and transformed to deliver better outcomes for local people. Following on from the last update around the key priorities, please see an update below.
3.4.1 Frailty The overall aim is to support every individual to stay as independent as they can for as long as possible by supporting them to increase their resources/ resilience and ability to bounce back from setbacks. The Initial focus on areas where there may be low value interventions: • Care Homes • Polypharmacy • Acute front door • Procedures in last year of life • Falls Some areas may require pump priming investment to enable change but should release resource/ or minimise growth over the short to medium term. This will allow investment in other areas where we think there is currently unmet need. Objectives, criteria and standards for each area are being developed with different members of the group supporting each area of focus.
3.4.2 Mental Health and Emotional Wellbeing The key focus of this group is to reduce MH in-patient demand to reduce related out of area placements (Low value intervention). Next steps include: • Producing logic models of several developing schemes (PCDU, HIU, Suicide Prevention HIU, physical checks for SMI, Street Triage, Safe Havens) to understand their potential impact and timescales • Qualitative review of case notes of people admitted to MH in-patient unit to understand pathway, opportunities for intervention and whether proposed interventions could have made a difference.
3.4.3 Musculoskeletal (MSK) The overarching aim is to de-medicalisation of the MSK pathways. The short-term objectives include: • Understand the current MSK pathways in each place, the plans that have been developed and the progress with these plans. • Challenge to what extent these plans align with best practice pathways and will release the indicative opportunities (RightCare and Model Hospital) • Release resources for investment in other programmes where there is unmet and/or growing need.
3.5 Transformational Programmes of Work 3.5.1 Proactive and Preventative The P&P workstream is focused on creating the system conditions for an uplift in prevention across health and social care. Standards and KPIs related to prevention form part of the business as usual of the Public Health team but are not overseen by this workstream. The P&P Executive met on 21 March to approve the future role, purpose and governance of the workstream, with a proposed refocusing in the context of the NHS Long Term Plan and refresh of the STP plan to include additional work themes that align with the development of a ‘Vision for Population Health Management. This will include consideration of how work to embed prevention across other STP workstreams could be further progressed. In the meantime, performance against the current Programme Mandate is strong. The Place Forum met on 6 March – it has now agreed an outcomes framework to enable oversight of direction of travel against the agreed system outcomes (Concordat) and is overseeing the delivery of the Year of Wellbeing 2019 which is galvanising energy and resources to upscale prevention across the system. The P&P workstream has a key role in providing intelligence to other workstreams through place-based JSNAs to ensure all workstreams are informed about health and care needs and assets at a local level. These are well underway in Warwickshire, with wave one (6 areas) completed, wave 2 under way (another 6 areas) and a further 8 by April 2020. Results are being widely 03 Better Health, Better Care, Better Value Page 5 of 10 shared, so commissioners can use them in their plan. In Coventry engagement activity on the pilot JSNAs has completed and a first citywide assessment will be reported to Health and Wellbeing Board on 8 April, to inform the refreshed Health and Wellbeing Strategy, and 2 initial place-based assessments are being finalised.
3.5.2 Maternity and Paediatrics Work is progressing well in Maternity to deliver the recommendations of Better Births. All assurance checkpoints with NHSE have been met. The Maternity Voice Partnerships (MVP) model has been agreed and recruitment to the paid chair role was undertaken on 19th March 2019. The post was successfully appointed, and the SRO will work with the incoming chair to develop a final work programme for the MVP. This will be signed off by LMS Board in May 2019. A detailed financial plan has been requested by the regional NHS E team, this is in development by senior finance leads and Heads of Midwifery, with support from the PMO. The aim is to submit this ahead of the next local NHS England deep dive in May 2019. The Paediatrics and Neonatal Clinical Steering Group (PCSG) are developing a paper for the provider alliance outlining pre-modelling work that has been undertaken by the relevant clinical and managerial leads. This paper will be received by the Provider Alliance Group (PAG) in April 2019.
3.5.3 Mental Health and Emotional Wellbeing Training sessions for GPs continue to take place to improve the dementia diagnosis rate in Coventry and Warwickshire. Feedback continues to be positive. The 6-month pilot of the Psychiatric Decision Unit went live on 11th February with all 6 of the proposed chairs now operational. This model aims to divert mental health patients away from the Emergency Department whilst they are being assessed so should start to help to improve flow in the acute trusts.
3.5.4 Planned Care The Better Health, Better Care, Better Value partners have continued to align work to both the national and local objectives. The STP is making good progress against all seven of NHS England’s national milestones. The First Contact Practitioner went live week commencing 25th February with a pilot in place in Stratford, initially for 2 sessions per week with a plan to increase as patient demand across Network increases. The system wide capacity and demand model was approved at the STP Board for implementation for Trauma and Orthopedics, mobilisation plans will now be developed. Strategic commissioners are looking to collect opinions from a range of people including staff, patients and other stakeholders around their experiences of Planned Care and 03 Better Health, Better Care, Better Value Page 6 of 10 about what good care looks like. The feedback from this engagement will be used to develop a set of “desirable criteria” and a draft outcomes framework for planned care.
3.5.6 Productivity and Efficiency Work is underway to procure and embed a shared finance system across the four NHS Trusts in Coventry and Warwickshire. The ambition is to have a system-wide finance solution hosted by one lead provider. Work continues to develop the programme plan to implement the system. Upgrade and migration to Integra 2 is underway at UHCW, WVT and CWPT. Implementation plans for SWFT and GEH, who are not currently on any version of Integra, are being developed. It is currently anticipated that SWFT and GEH will not go live on Integra until March 2020. Successful deployment and implementation of the same finance system across the health economy will improve effectiveness and efficiency in procurement, payment and debt recovery processes, as well as improve financial control. This has the potential to reduce the cost of back office functions through consolidating functions, standardisation and adopting best practice. 3.5.7 Urgent and Emergency Care
18.104.22.168 Demand and Capacity System All three acute providers now have real-time UEC capacity and demand systems in place and as such the work-stream will be on target to deliver the national requirement. 3.6 Enabling Programmes of Work
3.6.1 Estates and Digital Health As we move towards the spring-summer planning for the five-year refresh, these two Workstreams will become integral to the development and implementation of our 5-year plan. Over the coming weeks, the Estates and Digital Health workstreams will be working with the clinical workstreams to identify their estates and digital health requirements and priorities. Following this, there will be the distilling of this information to support the development of a joined-up strategy for Digital Health and Estates to address the enabling priorities of the workstreams and secure future capital funding. This work will feed into the refresh of the 5-year plan.
3.6.2 Workforce A refresh of the infrastructure to support the workforce transformation agenda and the delivery of the workforce priorities has been undertaken. This has involved reviewing the membership of the Local Workforce Action Board and putting in place the underpinning 03 Better Health, Better Care, Better Value Page 7 of 10 sub-groups that will drive forward the priorities. These subgroups are: • Workforce planning; • Recruitment and Retention • Leadership and Organisational Development • Education and Development (a group that spans Coventry and Warwickshire and Herefordshire & Worcestershire) The following priorities have been identified for 2019/20: • Recruitment & Retention • Developing & embedding ‘new roles’ • Skills development for the existing workforce • Development of career pathways Investment plan for workforce development priorities for 2019-2020 will be considered at the next LWAB meeting in April
3.7 Related Programmes of Work 3.7.1 Cancer NHS Long Term Plan and priorities for Cancer Alliances Published in January 2019, the NHS Long Term Plan outlines several commitments to building and developing work already underway because of the Cancer Taskforce recommendations, including the programmes being delivered by the Cancer Alliances. The key priorities are: • Diagnose 75% of cancers at stage 1 or 2 by 2028, including lowering the age for bowel screening, rolling out HPV primary screening and extending lung health checks. • Roll out new Rapid Diagnostic Centres across the country so patients displaying symptoms of cancer can be assessed and diagnosed in as little as a day. • Introduce a new, faster diagnosis standard which will ensure that patients receive a definitive diagnosis or ruling out of cancer within 28 days. • Deliver personalised cancer care for all, giving patients more say over the care they receive. • Secure our place at the cutting edge of research, offering genomic testing to all cancer patients who would benefit, and speeding up the adoption of new, effective tests and treatments. There is an acknowledgement that as the LTP is implemented; Cancer Alliances will continue to be the driving force for change locally, building on the extensive transformation work already underway across the country. The 2019/2020 Planning Guidance re-affirms the central role of Cancer Alliances as system leaders, working with 03 Better Health, Better Care, Better Value Page 8 of 10 and on behalf of their Sustainability and Transformation Partnerships and Integrated Care Systems.
3.7.2 Cancer: Transformation programmes update Transformation funding for 2018/2019 of £8.8m capital and £6.5m revenue has been secured and in September 2018, the national cancer team advised that the Alliance would receive an additional £2.04m. The latter will be targeted at improving urological pathways. In November 2018 WMCA requested some changes be made with regards to funding to allow for the next steps of the digital pathology project to be delivered. This has been agreed. Allocation of funding in Phase 1 has now been distributed via a series of Accountability Frameworks developed with STPs outlining the specific transformation priorities and objectives to be achieved by each of the six STPs in the Alliance’s region. The Alliance is required to report quarterly on progress against delivery plans linked to NHS England Planning Guidance 2018/2019. Reporting includes financial plans; actuals; forecast outturn; risks and mitigations. To assist with reporting requirements, transformation funded posts are being advertised within STPs and delivery managers are being appointed to work for the West Midlands Combined Authority(WMCA).
3.7.3 Living with and beyond cancer (LWBC) The 2018/2019 planning guidance requires clinically agreed protocols for stratifying breast cancer patients from 1 April 2019. In December 2018 the Board agreed the WMCA personalised follow-up model for breast cancer. STPs are required to develop mechanisms to record and report on progress towards implementation, including detailed data on the specific elements of the Recovery package. Post treatment, patients will move to a follow-up pathway that suits their needs and ensures they can get rapid access to clinical support where they are worried that their cancer may have recurred. This approach will be followed for colorectal cancers in 2020 and other cancers by 2023. So long as it is robust and ensures that no patient is ‘lost to follow-up’, remote monitoring can be paper based. The Alliance is currently reviewing the available technical solutions for remote monitoring and will be holding an event in late February 2019 to explore a region-wide solution with industry partners, Somerset and Infoflex. A lead for LWBC from each STP will be appointed and they will form a steering group to deliver this programme across the Alliance footprint. STP digital roadmaps should include LWBC remote monitoring implementation plans.
03 Better Health, Better Care, Better Value Page 9 of 10 3.8 Stroke – Progress and current status of the pre-consultation business case • Over 200 people were invited to participate in a non-financial option appraisal for the location of stroke rehabilitation beds. These beds would be required by the small percentage of people who were not able to receive their rehabilitation at home. Over 40 people attended the event held on 5 November, and participants included representatives of the public, patients and professionals. • On conclusion of this event, the workforce planning was completed, and we are currently awaiting advice from the expert stroke clinical network as to the adequacy of the proposed rehabilitation workforce. • Once we have confirmed the workforce, the final costings of proposals can be concluded, and the financial option appraisal completed. The pre-consultation case will then be presented for signing off with the health commissioners and Better Health Better Care Better Value Board, as ready for presentation to NHSE for assurance testing. At this stage we will know whether the case is suitable for public consultation. A timeline of key events is shown below. • Further work has been concluded on ensuring that at times of peak and surge demand, the hospital services can accommodate the additional stroke patients ensuring adequate access to diagnostic and specialist bedded services. • The Integrated Impact Assessment of the proposals has been updated following the nonfinancial option appraisal. The detailed report and a summary are shortly to be made available as evidence of our consideration of assessment of the equality, travel, and health impacts of proposals prior to any decision to go to pubic consultation. • Each NHS provider trust, is being asked to sign off the final proposals as deliverable and sustainable, prior to the final pre-consultation business case being tested for assurance by NHS England. As NHS organisations are currently going through the final phases of contracting and operational planning for 2019/20, and NHSE and NHS Improvement are reforming under the leadership of Simon Stevens as the new single Chief Executive, it is not possible to forecast with certainty a timescale for the NHSE assurance review.
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Report Author(s): Lorraine Laing Name and Job Title: Head of STP PMO On behalf of: Better Health, Better Care, Better Value Board Telephone and E-mail Contact: firstname.lastname@example.org Enquiries should be directed to the above person.