Hampshire and Isle of Wight Health Care System STP Delivery Plan Final Draft 21 October 2016 Introduction 1 This document is the Delivery Plan of the Hampshire and Isle of Wight Health (HIOW) and Care System Sustainability & Transformation Plan (STP). It summaries the challenges we face, our vision for Hampshire and the Isle of Wight, and the action we are taking to address our challenges and deliver our vision. The plan sets out the details of our six core delivery programmes and our four enabling programmes – the priority work that partners in the health and care system are undertaking together to transform outcomes, improve satisfaction of patients and communities, and deliver financial sustainability. Each programme has senior clinical and managerial leadership, detailed programme plans underpinned by robust analysis, clear delivery milestones, and consensus about the priorities and approach to delivery. Delivering our plan will result in tangible benefits and improvements for local people and communities. We are: Investing in prevention and supporting people to look after their own health We are implementing a series of evidence based solutions focused on primary & secondary prevention and behaviour change, supported by technology. This will improve healthy life expectancy, improve cancer survival rates, and reduce dependency on health and care services. Tackling obesity in childhood and improving life choices will deliver long term benefits. Strengthening and investing in primary and community care We are implementing the GP Forward View in HIOW. GP practices are collaborating and working at scale to deliver access for urgent needs across an extended 7 day period. Services operating within the currently fragmented out of hospital system are coming together to deliver a single, coordinated extended primary care team for local populations. More specialist care is being delivered in primary care settings. New models of integrated care for children are being delivered across our system. Simplifying the urgent and emergency care system, We are simplifying the urgent and emergency care system, making it more accessible to patients. As a result we will consistently deliver the A&E and ambulance standards. We are improving patient flow, ensuring that best practice is implemented in every locality without delay, and investing in home based care capacity. This will mean that Delayed Transfers of Care are lower than the national 3.5% requirement Improving the quality of hospital services Acute hospital providers are working as an Alliance to reconfigure unsustainable acute services to improve outcomes and optimise the delivery for the population in Southern Hampshire and on the Isle of Wight. Supporting services will be reviewed to ensure that provision is efficient and cost effective. We will determine the best option for a sustainable configuration of acute services in North & Mid Hampshire and work together to deliver the agreed option. We are implementing the national recommendations , including those in maternity services to improve outcomes and reduce variations in practice. Making tangible improvements to mental health services We are making tangible improvements to mental health services for children and adults, and services for people with learning disabilities. We are committed to valuing mental and physical health equally to ensure that support for mental health is embedded holistically across the system and not seen in isolation in order to achieve parity of esteem. The four HIOW Trusts providing mental health services (SHFT, Solent NHST, Sussex Partnership FT and IoW NHST), commissioners, local authorities, third sector organisations and people who use services, are working together in an Alliance to deliver a shared model of care with standardised pathways and enact the Five Year Forward View for Mental Health. Creating a financially sustainable health system for the future As we transform services to improve patient experience and outcomes, we are also reducing overall system costs and avoiding future cost pressures from unmitigated growth in demand. We are striving for top quartile efficiency and productivity in all sectors. We are adapting financial flows and contracting and payment mechanisms to align outcomes, metrics and financial incentives to support optimum patient outcomes, improved decision making and financial stability. Through a combination of efficiency savings and transformation set out in this plan, and using £60m of the STP fund, we will deliver at least a break even position by 2020/21. We are working to identify a further £60m of savings to deliver our surplus requirements. Our plans are underpinned by a new way of working between NHS providers and commissioners and social care, with shared responsibility for delivery and partnership behaviours becoming the new norm. We will manage our workforce as one Hampshire and Isle of Wight system. We are investing together in digital technology. Our leadership and organisational development programme assists us to create the culture necessary for success. Our delivery infrastructure includes robust programme and project management, and clear governance systems. Our plan is overleaf. Hampshire & Isle of Wight STP Delivery Plan Contents: Introduction and summary of the delivery plan…….……….. Section One     10-24  Overview of our delivery programmes  Plan on a page for each of our 6 core delivery programmes  Plan on a page for each of our 4 enabling programmes Section Three Ensuring successful delivery in HIOW……………………...… Section Four Finance and Activity Plan…………………………..……...…… Section Five Summary.................................................................................. Appendices 3-9 Our case for change and our vision for Hampshire and the Isle of Wight The impact we expect to have for citizens and for our system Our priority actions The support for our plans among organisations Our delivery programmes…..…………………………………… Section Two 2         25-28 Culture, Leadership & OD System Approach to Quality and Equality Engagement and consultation on the STP Our delivery architecture and processes 29-36 Summary of the financial case Investment requirements (including capital) Expected savings Activity Plan and workforce requirements 37-39  Master programme plan  Risks and Assurance  Our commitment & Next steps See separate documents Glossary................................................................................... 40-41 Programme & Projects pack.................................................. Estates Workbook……………………………...……………….. A B Section 1: Summary The case for change our plan Our cha?enges: Demand for health 8: care is growing at an unsustainable rate as people are living longer with multiple chronic conditions. Whilst people are living longer, they are increasingly spending longerin poor health. Too many people are admitted to hospital and stay in hospital longer than they need to. In most sectors we struggle to recruit and retain sufficient numbers of staff. There is a projected gap between the funding available and the cost of delivering NHS services of ?577m by 202021. There is an additional gap in social care of ?192m TOW As a result, many of our critical health and social care services are under severe pressure. To address these challenges we are: Changing how care is delivered - Renewing our system focus on prevention 8x self care - Accelerating the introduction of new models of care in each locality in HIDW: investing in primary care and building local placed based integrated physical Ii mental health a social care, proactively managing the needs of the local population - Addressing the issues that delay patients being discharged from hospital - Redesigning unsustainable acute hospital services - Enacting the Five Year Forward View for Mental Health in Hampshire and the Isle of Wight K. Driving productivity 8; ef?ciency - Delivering ef?ciency programmes in providers (using benchmarks such as Rightcare and Carter) and reducing the costs of commissioning - Delivering system ef?ciencies through greater clinical and back office collaboration - Estate rationalisation to addressing our unaffordable infrastructure Transforming our HIOW workforce - Working as one HIUW health and care system to manage staffing, development, recruitment 8: retention Investing in digital transformation - Building a fully integrated digital health and social care record, accessible by staff from any location - Putting in place technology to shift care closer to home unlock the power of data to improve decision making Redesigning how we work together - Changing ourgovernance arrangements so that organisations operate more effectively together - Building our capability 8: cufture to deliver - Recon?guring our commissioning systems l?l Impact for citizens and our system: Impact for citizens f. - Staying well and Independent: people are better supported to stay well 8: independent, with greater con?dence to manage their own health and wellbeing - Better experience of care More people have a positive experience of care, which isjoined up and is tailored to meet the personal and holistic needs of individuals - Better health outcomes for people with long term conditions and chronic physical a mental health issues - Better access to primary care 8am?8pm in each locality - More healthy years of life through earlier diagnosis and intervention - Higher Quality Acute Care: all citizens able to access safe acute services offering the best clinical outcomes, f" days a week - Improved mental health care: consistently good, co? ordinated mental health services and a timely response experienced by citizens in a mental health crisis - Minimal delays in Hospital: following a acute care in hospital stay are transferred home without delay Impact on our health 8. care system National access targets will be delivered for the HIUW population - Reductions in HIOW rates of smoking, obesity and alcohol related health conditions - Activity growth in the acute sector reduced. activity a emergency admissions to be maintained at 1% lower than 2016?? levels, by 2020f21 - Workforce: no overall growth in the total HIDW health and care workforce. - Delayed Transfers of Care rate reduced to and maintained at 3.5% - Bed capacity will be used more effectively and the equivalent of c300 beds will be released - Estate footprint reduced by 19% and estate costs reduced by ?24m - Commissioning and system infrastructure costs reduced - Deliver a breakeven position: through ef?ciency and transformation, and using of the STP Fund, we can close the gap by 2020321 - Undertaking further work to deliver a surplus ?nancial position :s :s ueld .mc ,10 mag/LIer Key components of our new system of care 4 Characteristics of the new system: We are designing and introducing a new system of care to address the challenges we face. The figure opposite describes our ambition for the health and care system being developed in Hampshire. The diagram, below right, illustrates the key components of the future model:  Citizens are able to proactively manage their own health  Citizens have easy to access and tailored support in the community  Citizens find it easy to access specialist care in the community  Citizens have the best quality and most innovative care available to them  While these changes will mean fewer and shorter journeys for most, we recognise that some, particularly those on the Isle of Wight, may need to travel further for care than today. Partners are aware of this and will work to minimise the impact. New working arrangements between organisations to enable delivery: As providers and commissioners of care we have agreed to share our resources and risk and to collaborate in a new way to deliver this plan. Current System New System Reactive and focused on treating illness Proactive, designed to support wellness at every step Emphasis is on the care professional People are empowered, supported and encouraged to take responsibility for their own health and wellness A lot of care is delivered in hospital An avoidable hospital admission is considered a failure Services are variable in availability and quality Removal of unwarranted variation and access to care 7 days a week where there is need Focused on organisations New models of care based around the person Mental wellbeing and physical health considered separately Holistic needs of individuals considered throughout our whole system Components of our future model: Section One: Key components of our new system of care The core characteristics of the health and care system being created for Hampshire and the Isle of Wight are summarised below. Place based systems of integrated care the bedrock of our plan We are delivering this new model through three vanguard programmes and through transformation programmes in Portsmouth & Southampton City, as illustrated below: These programmes will deliver place based integrated care through consolidated single points of access and sustainable primary care in each locality in HIOW, with 5 ‘big ticket’ interventions consistently implemented: Foundation for independence & self care We will deploy an eConsult platform for primary care supporting self-care and channelling people to the optimal care settings. We are also introducing care navigators & social prescribing: shifting current primary care activity to a nonclinical workforce Fully Integrated Primary Care Primary care working at scale to deliver urgent care across 7 days. Joined up, enhanced multiprofessional primary care teams with extended skills and extended access care hubs in localities Integrated Intermediate Care Integrated health and social care including: domiciliary recovery and rehab teams, non-acute beds, urgent community response, Emergency Department liaison. Complex & End of Life Care Dedicated support from the multi professional team for those patients at greatest risk, including the 0.5% of patients with the most complex needs and those at end of life. LTCs: Diabetes & Respiratory More specialist cases managed in primary care setting, specialist roles as a core part of the local primary care team, and consultants working to support shared management of cases with GPs without the need for formal referral. Section One: Key components of our system of care Our local place based services in Southampton, Isle of Wight, Portsmouth and in natural communities in Hampshire are the bedrock of our plan, each one brings together primary, community, social, mental health, and voluntary sector services into a multi-disciplinary team providing extended access and simplified care for the local population. 5 Our priority actions to transform service delivery 6 Our priority actions as a health and care system in HIOW are: By the end of 2016/7: In 2017/18: To deliver a radical upgrade in prevention, early intervention and self care ❶ We are implementing a series of evidence based solutions focused on primary & secondary prevention and behaviour change, supported by technology. This will improve healthy life expectancy & reduce dependency on health and care services. We will being doing more prevent the development of mental health problems and supporting early intervention across primary care. All NHS organisations will have a MECC plan and acute trusts will have a robust pathway for smoking cessation. Evidence based programmes will be implemented that impact on smoking rates, cancer screening A&E attendance & sexual health. To accelerate the introduction of new models of care in each community in HIOW ❷ We are supporting people to live independently, providing extended access to primary care, delivering the GP Five Year Forward View and ensuring proactive joined-up care for people with chronic conditions. This will reduce demand for acute services & effect a shift towards more planned care. 15% of integrated primary care hubs will be operational. 75% of integrated primary care hubs will be operational. National diabetes pathways fully implemented. To address the issues that delay patients being discharged from hospital ❸ We are improving patient flow, ensuring that best practice is implemented in every locality without delay, and investing in home based care capacity. This will mean that Delayed Transfers of Care are lower than the national 3.5% requirement. Every patient in hospital will have a discharge plan which is understood by professionals; the patient and their carers. Implementation underway of a collective approach to grow the domiciliary care workforce and capacity. To ensure the provision of sustainable acute services across HIOW ❹ Acute hospital providers are working as an Alliance to reconfigure unsustainable acute services to improve outcomes and optimise the delivery for the population. Supporting services will be reviewed to ensure that provision is efficient and cost effective. We will determine the best option for a sustainable configuration of acute services in North & Mid Hampshire and work together to deliver the agreed option. Sustainable solutions will be agreed for priority specialties across Hampshire and the Isle of Wight. Implementation underway of transformation plans in back office services, pharmacy, pathology, radiology and outpatients. ❺ To improve the quality, capacity and access to mental health services in HIOW ❻ The four HIOW Trusts providing mental health services (SHFT, Solent NHST, Sussex Partnership FT and IoW NHST), commissioners, local authorities, third sector organisations and people who use services, working together in an Alliance to deliver a shared model of care with standardised pathways and enact the Five Year Forward View for Mental Health. The best option for configuration of services in North & Mid Hampshire will have been identified. We will commission mental health services on an Alliance wide basis initially focussing on out of area placements and crisis response. Consultation on and agreement of option for configuration of services in North & Mid Hants. A local recovery based solution replacing high cost out of area residential long term rehabilitation will be in place. To underpin and enable this transformation we are working as one HIOW to manage our staffing, recruitment and retention, with one workforce strategy, building the digital and estate infrastructure to support change, and adapting the way we commission care to enable transformational change. Section One: Our delivery priorities As leaders of the health and care system in HIOW, we are working together to transform outcomes and improve the satisfaction of local people who use our services. We are committed to valuing mental and physical health equally to ensure that support for mental health is embedded holistically across the system. Through the STP we have come together to address our pressing local issues and deliver longer term sustainability by working at scale. Impact and benefits for Hampshire and the Isle of Wight Impact of our plan for HIOW citizens Staying well and Independent Better experience of care People living in HIOW are better supported to stay well & independent, with greater confidence to manage their own health and wellbeing More people in HIOW have a positive experience of care, which is joined up and is tailored to meet the personal and holistic needs of individuals Better Health Outcomes Better Access to Care People in HIOW with long term conditions and multiple chronic physical and mental health issues experience better health outcomes All citizens are able to access primary care in their locality between 8am-8pm and at weekends More Healthy Years of Life Higher Quality Acute Care Earlier diagnosis of physical and mental health conditions, leading to improved outcomes & survival rates, & more healthy years of life All citizens able to access safe acute services offering the best clinical outcomes, 7 days a week Improved Mental Health Care Minimal delays in Hospital Consistently good, coordinated, timely response experienced by citizens in a mental health crisis, and consistently high quality mental health services Patients receive more of their care at home and in their community, and following a acute care in hospital stay are transferred home without delay Impact of our plan on our system Reduction in presentations of preventable conditions Activity Changes Reductions in HIOW rates of smoking, obesity and alcohol related health conditions Activity growth in the acute sector will be reduced. A&E attendances and emergency admissions are expected to be maintained at 1% lower than 2016/17 levels, by 2020/21 Workforce Bed reductions There will be no overall growth in the total HIOW health and care workforce. We will decrease reliance on agency workers, and flex staff resources across the system Impact of our plan on value and affordability Bed capacity will be used more effectively to generate 9% efficiency in our acute bed stock (c300 beds). The Potential Gap If the NHS across HIOW does nothing to deliver efficiencies and cost improvements and change the demand and delivery of health care, it will have a financial gap of £577m by 2020/21 Using Our Share Of The STF We anticipate receiving £119m of the STF, of which we propose using £60m to fund the underlying model of services and £59m to invest directly in transforming services Finding The Additional Savings Estate Access Targets Estate footprint reduced by 19% and estate costs reduced by £24m National access targets will be delivered for the HIOW population Delayed Transfers of Care DTOC rate reduced to and maintained at 3.5% Financial Breakeven Through efficiency and transformation, and using £60m of the STP Fund, we can close the £577m gap by 2020/21 to deliver a breakeven position Recent commissioner and provider control totals require a surplus of £50m in 2017/18 and £74m in 2018/19. This requires additional savings and we are exploring further options to achieve this Closing The Finance Gap Together with £60m from the STF, our STP will deliver savings of £517m, closing the financial gap and achieving financial balance Social Care And Public Health Pressures Over the next four years, that is further exacerbated by a further £192m social care and public health pressures Moving Ahead We are committed to working as one system, focused on reducing and avoiding costs. We will develop suitable planning, financial flows, contracting and risk management processes to enable this​ Investing In Estate We anticipate a capital investment of around £195m all such investment will require business case approval by relevant statutory organisation Section One: Impact and benefits for HIOW Implementation of our STP will improve both the physical and mental health and wellbeing of citizens in HIOW, and lead to a clinically and financially sustainable health and care system. The impact expected through the delivery of our plan is summarised below. 7 STP Integration & Governance to support delivery As we move from STP development to joint delivery, our governance arrangements have been revised. The arrangements reflect the fundamentally different approach to system leadership that is required to deliver our plans: substantial changes to our roles and relationships with citizens, a joined up approach between agencies, with many partners working together in new ways and building trust and working relationships around a common goal. A Hampshire and Isle of Wight Health and Wellbeing Group will provide strategic political and clinical oversight of the STP: setting the overall direction, delivering system wide organisational agreement and enabling key decisions to be made and implemented that:     best serve the interests of citizens across HIOW. respect the prime importance of ‘place’. drive a sense of collective corporacy where individual organisational/professional/interest group interests do not trump what is in the interests of the common good (people first, system next, organisation last). provide effective, high quality services within available resources. The Group will be a Joint Committee of the existing four Health & Wellbeing Boards and its membership will include the chairs/vice chairs of the four HWBs, and it will provide a structure to achieve the political and clinical leadership consensus to grip the strategic issues facing health and care services in HIOW. Our plans enable and support greater integration of health and adult social care in HIOW The Adult Social Care Alliance of the four Councils Chief Officers for social care have agreed to work together and across boundaries to help deliver the ambition within the STP particularly taking a lead role in the Patient Flow work and in partnership with NHS colleagues in the New Models of Care work. Each Health and Well Being Board working in partnership with A &E Boards, has a plan for reducing Delayed Transfers to at least 3.5% and has embraced the good practice identified in the NHSE Quick Guides and the New Models of Care. Southampton has a joined up commissioning approach and a joint hospital discharge team which has helped to deliver improved patient flow and timely discharge. This is part of a wider plan to integrate services and commissioning across the NHS and the Council. Portsmouth has had integrated commissioning for many years and their plans have taken a proactive pull approach to improving patient flow which fits with the Patient Flow Workstream as well as the new models of care. Learning from what works in other care pathways has been key to a new approach as has making changes to the cultural attitudes in clinical and professional staff towards change. The IOW is a Vanguard area and has a strong integrated approach with joint visible Council and NHS leadership of change and challenge. The link to improved Patient Flow is clear and the development of the vanguard demonstrates implementation of new models of care. Hampshire is implementing a Transformation Programme which has redesigned the social care service to the Acute Hospital Trusts and has recommissioned domiciliary care from a wider provider base. The HWB Board has overseen this work and it is aligned to the work of the STP workstream. Accountability across HIOW The STP does not change the accountabilities held by the statutory Boards / Local Authorities, and four Health and Wellbeing Boards established across the Hampshire and Isle of Wight Sustainability and Transformation Plan footprint. The Accountable Officers of the constituent organisations are fully accountable to their boards and may work with delegated authority within the limits imposed by the organisation’s agreed scheme of delegation. They will be responsible for ensuring that their Boards are able to fully discharge their accountabilities by ensuring there is regular and timely briefing of Boards and Health and Wellbeing Boards on the STP programme, risks, opportunities and decisions. Detailed business cases for any system investment will be reviewed by the Executive Delivery Board and, if necessary, ratified by the relevant statutory Boards. Moreover, any proposed arrangements for sharing risk and reward at a wider system level will not only require statutory Board sign off, but also the development of a scheme of delegation to be agreed by Boards that sets out how assurance arrangements will be discharged. In recognition of the challenge of balancing pace and delivery, with a decision making process that requires the input and assent of 20 different statutory bodies and four Health and Wellbeing Boards, the STP governance arrangements will: • utilise opportunities to discharge accountability by working together. • establish multi-organisational working groups to collectively develop and make joint recommendations to the Executive Delivery Board. • explore opportunities to reduce complexity: For example, commissioners in part of Hampshire are developing proposals to appoint a single accountable officer to represent a number of CCG Governing Bodies. • only take decisions at the HIOW STP level where this adds value. This will include: • setting and assuring the overall strategic vision for health and care across Hampshire and the Isle of Wight. • developing and assuring the delivery of hyper-acute and specialised physical and mental health services for the citizens of Hampshire and the Isle of Wight. • developing and assuring the delivery of the strategic workforce transformation proposals. • developing and assuring the delivery of the digital and intelligence transformation proposals. • reviewing and making recommendation to statutory Boards on business cases for system wide investment. Section One: STP Governance Strategic Governance and Oversight 8 STP Delivery Structure 9 Executive Governance & Leadership Hampshire and the Isle of Wight health and care providers and commissioners have worked together to produce an overarching Hampshire and Isle of Wight STP. Given the size and diversity of the STP footprint, it has been agreed that the overarching STP will comprise a number of Local Delivery Systems, which bring the local commissioners and providers together to articulate the changes required at a local system level and how and when they are going to be achieved. In many cases these Local Delivery Systems preceded the STP and have established governance and operational delivery arrangements in place. The footprints for these are as follows: • North and Mid Hampshire • Portsmouth and South East Hampshire • Isle of Wight • Southampton • South West Hampshire • Frimley Health (noting that whilst the Frimley Health system operates as self-contained STP, it continues to have a critical relationship with the Hampshire and Isle of Wight health and care system). An STP Executive Delivery Group for HIOW is being established, which will: There are a number of key programmes which span Hampshire and the Isle of Wight, including strategic workforce development, acute physical and mental health development, digital transformation and strategic investment models. However, it is recognised that the Local Delivery Systems will be the engine rooms for change, and the route to secure clinical, patient and public engagement. In the Portsmouth and South East Hampshire Local Delivery System, for example, the local commissioning and provider partners will create an aligned two year operating plan, setting out how the STP ambitions will be enacted through a new integrated governance and leadership system: an Accountable Care System. The Local Delivery System's Operating Plan will set out how the local system's share of the overarching STP's financial savings, activity shifts and performance improvement requirements will be met and how risk will be identified, shared and collectively mitigated. Alongside the accountability discharged by the local statutory organisations, the Portsmouth and South East Hampshire Local Delivery System will also be held to account by the overarching STP Delivery Group for delivery that enables the whole STP to deliver. This diagram represents current thinking but may change over time as the STP governance and delivery approach is further developed      Secure agreement of the plan Monitor progress of core programmes Hold each other to account for delivery of the overall STP Agree decisions in relation to the allocation of transformation monies and the STP operating plan Enable development and delivery of the agreed operating plan and contracts The delivery of the STP will be challenging and a long term commitment is required to achieve the desired outcomes. The Executive Delivery Group is therefore being created with OD support to determine purpose, values and behaviours and to ‘learn by doing’; working through real examples and scenarios that will develop its capabilities. Section One: STP Governance Delivery Model Section 2: Our delivery programmes To deliver our shared priorities we are working together across Hampshire and the Isle of Wight in ten delivery programmes: six core programmes focused on transforming the way health both physical and mental health and care is delivered (summarised below), and four enabling programmes to create the infrastructure, environment and capabilities to deliver successfully (summarised overleaf). This portfolio of programmes is our shared system delivery plan for the STP. Core Programme ❶ Prevention at scale ❷ New Care Models ❸ Effective Patient Flow and Discharge ❹ Solent Acute Alliance ❺ North & Mid Hampshire configuration ❻ Mental Health Alliance Programme Objective Expected Impact and benefits for patients, communities and services To improve healthy life expectancy and reduce dependency on health  Improving Health and Wellbeing, with more people able to manage their own and care services through a radical upgrade in prevention, early health conditions reducing the need and demand for health services intervention and self care: a sustained focus on delivering prevention  More people supported to give up smoking, achieve a healthy weight and drink sensibly (reducing lifestyle related diseases) at scale in HIOW  Efficiencies of £10m by 2020/21 To improve the health, wellbeing and independence of HIOW  Improved outcomes for people with long term conditions/multiple co-morbidities population through the accelerated introduction of New Models of  Reduced A&E attendances/hospital admissions for frail older people and people Care and ensure the sustainability of General Practice within a model with chronic conditions of wider integrated health and care. This will be delivered through the  More people maintaining independent home living Vanguard programmes and local health system New Care Models  Sustainable General Practice offering extended access delivery arrangements  Efficiencies of £46m by 2020/21 To ensure no patient stays longer in an acute or community bed based  Patients supported in the setting most appropriate to their health and care care than their clinical condition and care programme demands and as needs a result reduce the rate of delayed transfers of care by improving  Improvements in LOS for patients discharge planning and patient flow, and by investing in capacity to  Reduced requirement for hospital beds of up to 300 beds across HIOW care for patients in more appropriate and cost effective settings  Efficiencies of £15m by 2020/21 To deliver the highest quality, safe and sustainable acute services to  All patients able to consistently access the safest acute services offering the best southern Hampshire and the Isle of Wight. To improve outcomes, clinical outcomes, 7 days a week & delivery of the national access targets for the reduce clinical variation & cost through collaboration between UHS, Southern Hampshire/IOW population PHT, IoW NHST & Lymington Hospital. Provide equity of access, highest  Reduced variation and duplication in acute service provision  Efficiencies of £165m by 2020/21 quality, safe services for the population. To create a sustainable, high quality and affordable configuration of  Sustainable access to 24/7 consultant delivered acute care for North & Mid Hampshire population, improved outcomes through care closer to home & acute services for the population of North & Mid Hampshire and the delivery of the national access targets out-of-hospital services to support that configuration (linking with the  Efficiencies of £41m by 2020/21 New Models of Care programme)  Improved quality and performance targets To improve quality, capacity and access to MH services in HIOW.  All people in HIOW will have early diagnoses to enable access to evidence based Achieved by the four HIOW Trusts providing mental health services care, improved outcomes and reduced premature mortality (SHFT, Solent NHST, Sussex Partnership FT and IoW NHST),  Enhanced community care & improved response for people with a mental health commissioners, local authorities, 3rd sector & people who use services, crisis. Reduced out-of-area placements for patients requiring inpatient care working together in an Alliance to deliver a shared model of care with  Efficiencies of £28m by 2020/21 standardised pathways Section Two: Core Delivery Programmes Summary Delivering our plan: The 6 core programmes 10 Delivering our plan: 4 enabling programmes Enabling Programme Programme Objective Expected Impact and benefits for patients, communities and services ❼ Digital Infrastructure To give patients control of their information and how it is used, allowing patients to manage their long term conditions safely and enable patients to access care at a time, place and way that suits them. To build a fully integrated digital health and social care record, and the infrastructure to allow staff to access it from any location.  An integrated care record for all GP registered citizens in Hampshire and IoW  Flexible IT systems enabling care professionals to work from any location, with access to citizens health and care records  Citizens able to self manage their health and care plans – eg managing appointments, updating details, logging symptoms  Real time information to support clinical decision making ❽ Estate Infrastructure rationalisation To provide the estate infrastructure needed to deliver the new models of care and to deliver savings by rationalising the public sector estate in Hampshire and the Isle of Wight  Improved collaboration & co-ordination of HIOW estates expertise and information will mean that we can improve our planning capability at STP and local level  Providing estate that can be used flexibly and enable new ways of working  Reducing demand for estate will generate efficiencies and savings through reduced running costs and release of land for other purposes  Improving the condition and maintenance of our estate will mean that citizens can access services in fit for purpose facilities across Hampshire and IOW  Release surplus land for housing and reducing operating costs in our buildings across HIOW ❾ Workforce To ensure we have the right people, skills and capabilities to support the transformed health and care system by working as one HIOW to manage staffing, development, recruitment and retention.  A flexible workforce shared across geographical and organisational boundaries, working in new ways with extended skills to deliver the workforce transformation that underpins the STP core programmes  Health and care roles that attract local people, to strengthen community based workforce  Significant reduction in the use of temporary and agency workers  Increasing the time our staff spend making the best use of their skills/experience  No overall growth in the workforce over the next five years ❿ New Commissioning Models To adapt our methods, tools, resources and architecture for commissioning health and care, to reduce unnecessary duplication of commissioning work and facilitate the delivery of the STP. To generate cost reductions in expenditure on Continuing Health Care and Prescribing through working at scale.  Collaboration across five Hampshire CCGs and the establishment of single leadership across four CCGs, strengthened integration with Hampshire County Council, increasing the ability to unlock savings and reducing unaffordable infrastructure.  Single approach and shared infrastructure for the commissioning of hyper-acute and specialised physical and mental health services for the population of HIOW - driving improved outcomes, service resilience and delivering organisational inefficiencies  Capitated outcomes based contracts procured for at least three places by 2019/20  Efficiencies of £36m in CHC, £58m in prescribing costs and reduced system infrastructure costs by £10m Section Two: Enabling Programmes Summary The table below summarises the objectives and expected impacts of our four enabling programmes to create the infrastructure, environment and capabilities to deliver successfully. A ‘plan on a page’ summary of each core and enabling programme is set out on the following pages of this document, providing details of the rationale, the benefits to be delivered, the measurable impacts and metrics, the key milestones, stakeholders, management arrangements and key risks for each programme. 11 Core Programme 1: Prevention at Scale 12 Projects Timescales Programme Description Working across the system we will deliver initiatives to prevent poor health consistently and at scale, integrating with public health, CCG and vanguard agendas • Project baseline analysis – identifying current delivery • Initiatives at Scale delivery plans developed and implementation prepared Implementing initiatives at scale • • • • • Outcomes and benefits to be delivered By 16/17 – Delivery plans for scaled up behaviour change initiatives that will improve health outcomes will be developed By 17/18 – more people will have; given up smoking prior to surgery, been screened for cancer; access to lifestyle behaviour change support  Improving Health and Wellbeing – reducing the gap between how long people live and how long they live in good health  More people able to manage their own health conditions reducing the need and demand for health services  More people supported to give up smoking, achieve a healthy weight and drink sensibly (reducing lifestyle related diseases)  Increased proportion of cancers detected early, leading to better outcomes/survival Investments Required: £0.6m SAVINGS: £10m per annum by 2020/21 2017 /18 2018 /19 2019 /20 2020 /21 Behaviour change delivery plans developed Implementing behaviour change Service redesign and change delivery plans developed Implementing service redesign and change Key personnel CEO/SRO Sponsor – Sallie Bacon, Acting Director Public Health, Hampshire County Council Programme Director – Simon Bryant, Associate Director of Public Health (Interim) Fiona Harris Consultant in Public Health (Locum), Hampshire County Council Public Health leads in Southampton, Portsmouth, IOW & NHS E(W) Finance – Loretta Outhwaite, Finance Director IOW CCG Quality Lead: Carole Alstrom – Deputy Director of Quality – Southampton CCG Stakeholders involved  Revenue investment assumed and financial benefit 2016 /17    Acute Trust – Providing emergency and Surgical care Public Health Service Providers Primary Care Community Care       Mental Health Service providers Local Authorities STP Partners Work streams HEE NHSE – Screening and Immunisations CCG’s Public and patients For project detail see appendix A The aim of the Prevention workstream is to improve the health and wellbeing of our population by • Supporting more people to be in good health for longer (improving healthy life expectancy) and reducing variations in outcomes (improving equality) • Targeting interventions to improve self-management for people with key long term conditions (Diabetes, Respiratory, Cancer, Mental Health) to improve outcomes and reduce variation • Developing our infrastructure, using technological (including digital) solutions to reduce demand for and dependency on health and care services • Developing our workforce to be health champions; having ‘healthy conversations’ at every contact. Improving the health of our workforce as well as the people of HIOW Projects Section Two: Core Programmes Programme Objective: To improve healthy life expectancy and reduce dependency on health and care services through a radical upgrade in prevention, early intervention and self care: a sustained focus on delivering prevention at scale in HIOW Core Programme 2: New Models of Integrated Care 13 Projects Timescales Programme Description The programme will deliver place-based integrated care in each HIOW locality, focusing on the accelerated spread and consistent implementation of 5 ‘big ticket’ interventions Foundation for independence & self care Integrated Intermediate Care Complex & End of Life Care Joined up, enhanced multiprofessional primary care team and extended access care hubs in localities Integrated health & social care: domiciliary recovery & rehab teams, non-acute beds, urgent community response Dedicated support for those patients at greatest risk, including the 0.5% of patients with the most complex needs LTCs: Diabetes & Respiratory Moving to a delayered community model for Long Term Conditions, including case finding, shared care & psychological support These are driven by the three MCP/PACS vanguards and new care models programme arrangements. with structured clinical engagement and co-production with other STP Workstreams where there are key pathway interfaces ( e.g. acute alliance for complex , EOL care and LTCs). Successful delivery will mean patients are enabled to stay independent for longer, have improved experience and engagement in health and care decisions alongside improved access and outcomes facilitated by proven care models Outcomes and benefits to be delivered By 16/17 – 15% of integrated primary care hubs will be operational By 17/18 - 75% of integrated primary care hubs operational. National diabetes pathways fully implemented     Improved outcomes for people with long term conditions/multiple co-morbidities Reduced A&E attendances/admissions for target conditions More people maintaining independent home living Extended primary care access and increased GP capacity to manage complex care due to improved skill-mix in wider workforce  More sustainable local health and care economy Revenue investment assumed and financial benefit Investments Required: £36m per annum by 2020/21 + funding for national priorities Savings: £45.6m per annum by 2020/21 2016 /17 2017 /18 2018 /19 2019 /20 2020 /21 Foundation for independence & self care Fully Integrated Primary Care Integrated Intermediate Care (Health & Social) Complex Care & End of Life LTC - Diabetes & Respiratory Key personnel CEO/SRO Sponsor: Karen Baker Programme Director: Alex Whitfield, Chief Operating Officer, Solent Programme Director: Chris Ash, Strategy Director, Southern Health Finance Lead: Andrew Strevens, FD Solent Project manager: Becky Whale Clinical Leads: Dr Barbara Rushton, Dr Sue Robinson, Dr Sarah Schofield Quality Leads: Sara Courtney, Acting Director of Nursing, Southern Health & Julia Barton Chief Quality, Officer/Chief Nurse, Fareham & Gosport and SE Hants CCG Stakeholders involved • • • • • • NHS Improvement UHS, PHT, HHFT, IOWT SCAS All CCG’s NHS England Public and politicians • • • • • • HCC, SCC, PCC and IOW Council Public representative organisations Solent and Southern Primary care CQC Voluntary and Community Sector For project detail see appendix A Care navigators & social prescribing: building skills & capacity to shift current primary care activity to a non-clinical workforce Fully Integrated Primary Care Projects Section Two: Core Programmes Programme Objective: To improve the health, wellbeing and independence of HIOW population through the accelerated introduction of New Models of Care and ensure the sustainability of General Practice within a model of wider integrated health and care. This will be delivered through the Vanguard programmes and local health system New Care Models delivery arrangements Core Programme 3: Effective Flow And Discharge 14 Programme Description Projects Timescales To address the issue of rising delayed transfers of care in HIOW we will deliver a 4 project plan focused on the underlying causes: For project detail see appendix A • To ensure that every patient has a Discharge Plan, informed by their presenting condition & known social circumstances, and which is understood by professionals; the patient; their relatives and carers (where appropriate) and includes plans for any anticipated future care needs • To improve the value stream and utilisation of existing or reduced acute & community care space and resources, to provide safer, more effective patient and systems flow and resilience. • To identify patients with complex needs early in their journey and design an appropriate Onward Care support that prevent readmission, eliminate elongated acute spells and minimise patient decompensation • To develop and provide cost effective Onward Health & Social Care services that where possible , reduces the cost of care whilst maximising patient outcomes Outcomes and benefits to be delivered By 16/17 - Every patient in hospital will have a discharge plan which is understood by professionals; the patient and their carers. By 17/18 - Implementation underway of a collective approach to grow the domiciliary care workforce and capacity 1. Patients supported in the setting most appropriate to their health and care needs leading to improvements in LOS for patients currently residing in acute and community hospital beds (P1) 2. Improvements in LOS for patients staying 7-30 Days through multi agency stranded patient review (P1 & 2) 3. Improvements in LOS for episodes of 2-7 Days through SAFER effective flow management , removal of internal delay and 7 day services (P1 & 2) 4. Improvements in LOS for episodes of 0-2 days though the implementation of ambulatory care front door turnaround teams (P2) Revenue investment assumed and financial benefit Investments Required: £1m in 16/17 SAVINGS: £15m annum by 2020/21 per Key personnel Joint SRO: Graham Allen, Director of Adult Services HCC Joint SRO: Heather Hauschild, Chief Officer West Hampshire CCG Programme Director: Jane Ansell, West Hampshire CCG Programme Adviser: Sarah Mitchell, Social Care Consultant (HCC) Finance Lead: Mike Fulford, Finance Director, West Hampshire CCG Programme Manager: Mike Richardson, SHFT Quality Lead: Fiona Hoskins, Deputy Director of Quality, NE Hants & Farnham CCG Stakeholders involved • • • • Patients/ Public through Wessex voices Primary Care & Community Services Voluntary Sector NHSI/NHSE/WAHSN • • • • Crisis care concordat HIOW CCGs NHS England HIOW Adult Social Care Alliance Section Two: Core Programmes Programme Objective: To ensure no patient stays longer in an acute or community bed based care than their clinical condition and care programme demands and as a result reduce the rate of delayed transfers of care by improving discharge planning and patient flow, and by investing in capacity to care for patients in more appropriate and cost effective settings. Core Programme 4: Solent Acute Alliance 15 Projects Timescales Programme Description Projects 2016/17 2017/18 2018/19 2019/20 Back Office Services Review Pathology consortia (re-visited) Clinical Services Review Theatre Capacity Review Pharmacy collaboration OP Digital CIP planning and delivery Outcomes and benefits to be delivered By 16/17 – Sustainable solutions will be agreed for priority specialties across Hampshire and the Isle of Wight.        By 17/18 - Implementation underway of transformation plans in back office services, pharmacy, pathology, radiology and outpatients. Reduced clinical variation and improved outcomes Sustainable acute service to the Isle of Wight Improved length of stay Channel shift (digital outpatients) Elective demand control (in-line with best practice/guidance) Efficiencies of £156m by 2020/21 Additional opportunities of £9m (elective demand reduction via RightCare). 40% of the estimated opportunity sits with North and Mid Hampshire Revenue investment assumed and financial benefit Investments Required: £0.5m SAVINGS: £165m per annum by 2020/21 2020/21 For project detail see appendix A An Alliance between three hospital trusts to improve outcomes and optimise the delivery of acute care to the local population, ensuring sustainable acute services to the Isle of Wight. This will be delivered by structured clinical service reviews. A first wave of collaborative transformational supporting services projects will include: Back Office Services Review; Pathology consortia (re-visited); Theatre Capacity Review; Pharmacy collaboration; Estates/Capital ; and Out Patient Digital Services. The Better Birth Maternity Pioneer programme will also be implemented. The acute alliance support the objectives of the cancer alliance and are linking directly with relevant clinical service reviews and prevention projects, including increased screening uptake and delayering access to increase early diagnosis. Key personnel The Chair of the Alliance Steering Group – Sir Ian Carruthers Chief Exec Lead – Fiona Dalton Programme Director – Tristan Chapman Finance Lead – David French Medical Director Lead– Simon Holmes Director of Strategy Lead – Jon Burwell Informatics lead- Adrian Byrne Quality Leads: Alan Sheward, Director of Nursing & Quality IOW NHS Trust, ​Cathy Stone, Director of Nursing, Portsmouth Hospitals NHS Trust. Stakeholders involved • • • • NHS Improvement All CCG’s NHS England Public & patients • Community Services • Primary care • CQC • Cancer Alliance Section Two: Two Core Programmes Section Programme Objective: To deliver the highest quality, safe and sustainable acute services to southern Hampshire and the Isle of Wight. To improve outcomes, reduce clinical variation and lower cost, through collaboration between UHS, PHT, IoW NHST & Lymington Hospital. To provide equity of access to the highest quality, safe services for the population. Solent Acute Alliance: Clinical Service Review project 16 reduce clinical variation and lower cost, through collaboration between UHS, PHT, IoW NHST & Lymington Hospital. Benchmark against rightcare data and investigate clinical flows and outcomes. Project Description Project Timescales - Clinical service review phasing UHS, PHT and the Isle of Wight Hospital Trusts will work as one to deliver the best health care outcomes delivered at the best value for the whole, collective population. Serving a population of 1.3m we will develop and deliver services that benchmark with the best in the world. Care will be delivered locally where possible, but centrally where this improves outcomes. Trusts will remain sovereign organisations responsible for performance, quality, safety and finance. The alliance will facilitate service reconfiguration whilst maintaining individual financial stability. Vascular Spinal ENT Urology Haematology Colorectal Surgery Max Fax Paediatrics Neonatal ICU The clinical service reviews build on successful joint working in Cancer services across Alliance trusts. Dermatology By 16/17 – 16 services will start a phased 3 month service review period with clinical and strategy colleague across the trusts  Reduction in LoS  Improved outcome metrics  Reduction in admissions By 17/18 – Business cases developed and approved for each service, estates reconfiguration works planned.  Reduction in OP/FU attendances  Sustainable plan for services on IOW  Delivery of national standards (RTT, 7 day services) Qu 2 - 3 IOW service model - principles Principles for service configuration include providing equal access to the highest quality service to the population, core services being provided at each centre, specialty collaborations using hub and spoke models, support of 24/7 provision and effective use of estate. Outcomes and benefits to be delivered Qu 4 – 1 (2017) For project detail see appendix A We will work with community providers allowing seamless services, and providing care and contact only when it offers best value. The alliance will support changes in clinical pathways or operational structures when these changes provide significant benefits in clinical outcomes, value, safety, resilience, expertise and delivery of national standards. Qu 3-4 Projects Oct 16-Sept 17 Renal Gastroenterology Oncology Cardiology Radiology General surgery Key personnel Simon Holmes- Medical Director PHT Mark Pugh- Medical Director IOW Derek Sandeman- Medical Director UHS Clinical leads x 16(x3 trusts) Management and strategy leads Finance lead Stakeholders involved • Public & patients • NHS Improvement • NHS England • Primary care • Community Services • All CCG’s • CQC Section Two: Core Programmes Project Objective: To deliver the highest quality, safe and sustainable acute services to southern Hampshire and the Isle of Wight. To improve outcomes, Core Programme 5: North & Mid Hampshire 17 Projects Timescales Programme Description Project 2016 /17 2017 /18 2018 /19 2019 /20 2020 /21 Review of acute care configuration OOH models developed in line with new models of care programme Public consultation Outcomes and benefits to be delivered By 16/17 - The best option for configuration of services in North & Mid Hampshire will have been identified Reconfiguration By 17/18 - Consultation on and agreement of option for configuration of services in North & Mid Hants  Sustainable access to 24/7 consultant delivered acute care for the North & Mid Hampshire population and improved outcomes through care closer to home  Improved quality and performance targets  Deliver performance targets  Delayer / remove boundaries between acute/community/primary care/mental health/social care  Deliver system level savings  Align incentives in the system to deliver a shared control total  Efficiencies of £60m by 2020/21 Progress population based contracting for outcomes Key personnel CEO/SRO Sponsor – Heather Hauschild , Chief Officer West Hampshire CCG , Mary Edwards, Chief Exec Hampshire Hospitals & Paul Sly Interim Accountable Officer North Hants CCG Clinical Sponsor – Tim Cotton, Andrew Bishop & Nicola Decker Programme Director – Heather Mitchell , Director of Strategy , West Hants CCG Programme Director - Niki Cartwright, Interim Director of delivery NHCCG Finance Lead – Mike Fulford, Finance Director, West Hants CCG; Pam Hobbs, Finance Director North Hants CCG & Malcolm Ace FD HHFT Quality Lead: Edmund Cartwright, Deputy Director of Nursing, West Hants CCG Stakeholders involved Revenue investment assumed and financial benefit Investments Required: £TBCm dependant on recommended configuration SAVINGS: £41m CIP per annum by 2020/21 • • • • NHS – GP’s Specialist Commissioning, HHFT, UHS, SHFT, CCG’s, SCAS Public & Patient Groups Government – Local authorities, HCC, Public Health, Local Councillors / MP’s Regulators – NHSE, NHSI For project detail see appendix A A sustainable, quality configuration of acute services for the population of North and Mid Hampshire will be achieved through 3 key activities: • Review and deliver the optimum acute care configuration for North and Mid Hampshire • Deliver new models of care (incorporated in New Care Models programme) • Deliver of provider CiP plans Section Two: Core Programmes Programme Objective: To create a sustainable, high quality and affordable configuration of acute services for the population of North & Mid Hampshire and the out-of-hospital services to support that configuration (linking with the New Models of Care programme) Core Programme 6: Mental Health Alliance 18 Programme Description Projects Timescales We are committed to valuing mental and physical health equally to ensure that support for mental health is embedded holistically across the system and not seen in isolation in order to achieve parity of esteem. We will ensure that people experience a seamless coherent pathway that incorporates the key principles of prevention, risk reduction, early intervention and treatment through to end of life care. The Five Year Forward View for Mental Health, Dementia Implementation Plan, Future in Mind and the Wessex Clinical Network Strategic Vision provide us with a blueprint for realising improvements and investment by 2020 /21 and the mechanism for mobilising the system. We will achieve this by working at scale to: Review and transform : • acute and community mental health care pathways • rehabilitation and out of area placements • mental health crisis care pathways Transformation of mental health services for children and young people including access to tier four beds for young people will be aligned to the Mental Health Alliance and the STP delivery plan. This transformation programme will be underpinned by integrated approaches to commissioning mental health services on an Alliance wide basis . We are committed to reviewing how money from physical health services can be transferred into mental health services. We will develop the workforce to deliver holistic and integrated services for people. Projects Outcomes and benefits to be delivered Key personnel Revenue investment assumed and financial benefit Investments Required: £45m assumed to include partial funding of 5YFV. Additional funding required from STF to meet full 5YFV SAVINGS: £28m per annum by 2020/21 2018 /19 2019 /20 2020 /21 Acute and community mental health pathway review and redesign Review and redesign of the HIOW Mental Health Rehabilitation Pathway - Out of Area Placement Protocol Mental Health Crisis Pathways CEO Sponsor: Sue Harriman, Solent NHS Trust Medical Director and SRO: Dr Lesley Stevens Programme Director: Hilary Kelly, HIOW STP Quality Lead: Mandy Rayani - Chief Nurse, Solent NHS Trust By 17/18 - A local recovery based solution replacing high cost out of area residential long term rehabilitation will be in place • Adult mental health services will provide timely access to recovery based person centred care in the lease restrictive setting for the least amount of time • People in mental health crisis have access to 24/7 services • Services will meet the ‘Core 24’ service standard for liaison mental health • Out of area placements will be reduced with the aim to eliminate these by 2020/21 • Young people will have improved access to emotional wellbeing services through the Future in Mind Transformation Plans 2017 /18 For project detail see appendix A By 16/17 - different approaches to commissioning mental health services on an Alliance wide basis initially focussing on out of area placements and crisis response will be agreed 2016 /17 To support delivery of this programme we have formed a Mental Health Alliance with membership from HIOW Mental Health Providers, CCGs, Local Authorities and the third sector. Over the development of this plan we have sought clinical input and leadership through our STP Mental Health Clinical Reference Group To support the work of the Alliance and our aspiration for developing new ways of commissioning we have in place an STP Mental Health CCG Planning Group Stakeholders involved • • • • • • NHSI Primary care CQC Voluntary & Community Sector Wessex voices: patient & public Wessex Mental Health and Dementia Clinical Network • • • • • • • Crisis Care Concordat HIOW CCGs Surrey and Borders NHSFT NHS England HCC, SCC, PCC, IOW Council Health Education England Wessex Academic Health Science Network Section Two: Core Programmes Programme Objective - To improve the quality, capacity and access to mental health services in HIOW. This will be achieved by the four HIOW Trusts providing mental health services (SHFT, Solent NHST, Sussex Partnership FT and IoW NHST), commissioners, local authorities, third sector organisations and people who use services, working together in an Alliance to deliver a shared model of care with standardised pathways Enabling Programme 7: Digital 19 Programme Description Projects Timescales • In addition the footprint will share the benefits and potential the ‘digital centre of excellence’ award given to the University Hospital Southampton. A strategic roadmap for the delivery of the programme has been developed and agreed. Patient Portal E-Prescribing & Medicine Reconciliation Optimising intelligence capability SCAS LiveLink Pilot Key Personnel Lisa Franklin - SRO Dr Mark Kelsey – Clinical Lead Roshan Patel – Finance Lead Andy Eyles – Programme Director Mandy McClenan – Acting Programme Manager Stakeholders involved All HIOW partners and programmes £35.4m Revenue: £10m per annum by 2020/21 2019 /20 2020 /21 Patient Data Sharing Initiative (Phase 1) Care co-ordination centre Infrastructure By 17/18 – Made Wi-Fi available across all care settings, rolled out e-consultations to 90% of GP Practices, deployed the infrastructure to support the care coordination centre and completed the SCAS livelink pilot. 2018/19 HIOW Technical Strategy Channel Shift (Phase 1-e-consultations) Investment required Required: 2017/18 Wi-Fi for HIOW & Cyber Security  An integrated care record for all GP registered citizens in Hampshire and IoW  Flexible IT systems enabling care professionals to work from any location, with access to citizens health and care records  Citizens able to self manage their health and care plans – eg managing appointments, updating details, logging symptoms  Real time information to support clinical decision making Investments capital 2016/17 Digital Communications across Care Providers Outcomes and benefits to be delivered By 16/17 – We would have developed a robust technical strategy, commenced a major upgrade to the integrated care record and rolled out econsultations to 50% of GP Practices Critical Projects For project detail see appendix A This workstream is designed to:  increase the quality of service provision  reduce the pressure on care services and  improve efficiency The ambitions of this programme are to:  Provide an integrated digital health and care record  Unlock the power of data to inform decision making at point of care  Deliver the technology to shift care closer to home  Establish a platform to manage Population Health  Drive up digital participation of service users  Drive up digital maturity in provider organisations Section Two: Enabling Programmes Programme Objective: To give patients control of their information and how it is used, allowing patients to manage their long term conditions safely and enable patients to access care at a time, place and way that suits them. To build a fully integrated digital health and social care record, and the infrastructure to allow staff to access it from any location. Enabling Programme 7: Digital 20 How will Digital enable Digitalthe core programmes? Transformational Benefits Solent Acute Alliance New Models of Care Mental Health Alliance Effective Patient Flow and Discharge Prevention at Scale North & Mid Hampshire configuration       Integrated complex care plans allow multi-disciplinary teams to develop and deliver plans for identified groups of patients, by providing a single up-to-date record which can be shared and updated across a whole health community.    Digital care plans that includes social care information and patients' personal circumstances provide the admitting hospital with the information they need to assess. As a result preparations for complex discharges can begin much earlier in the process.    Help clinicians to identify those at risk using intelligent analytics to target brief intervention Link patients directly to their results and advice on treatment, if needed  How will the Digital Programme enable the 6 core programmes Core A shared record would enable all health and social providers to access a single source of patient information which would reduce the need for patients to repeat information, save professionals time and reduce duplication of diagnostics. Programme Patient Data Sharing Initiative Patient Portal  A patient portal will allow patients to co-manage their healthcare online reducing the need for hospital visits. It will offer 24/7 support and information, allow patients to cancel and re-book appointments online, view their record and facilitate online consultations       Helping to keep relatives/carers informed and engaged.       Provide patient access to self help interventions for smoking, alcohol interventions, weight self-management and increasing activity levels. Linking to health portal can help personalise information E-Prescribing & Medicine Reconciliation Safer and more effective prescribing through a fully integrated, end to end medicines management which allows automated supply, decision support and real time monitoring. This will comprise EPMA in hospitals including closed loop prescribing for safety, medicines reconciliation and standards for coding (DM+D).        Ensuring that TTOs are ready and available immediately the patient is discharged from Hospital Digital Communications Instant messaging and telepresence enables professionals in different care settings to interact easily with group video calls enabling multi-disciplinary teams to meet online.     Wi-Fi for HIOW & Cyber Security Ability for staff to access and update patient records, and for patients to access online resources at all health and social care sites.      Broadly available Wifi will allow community teams that are either co-located or working in the community to get access to their line of business of systems and the HHR.      Channel Shift (Phase 1-econsultations) Provides access online resources 24/7. Reduces need for face-to-face consultations, leading to practice efficiency savings. Provides opportunity to collect comprehensive history and early identification of symptoms leading to more productive consultations.   Care coordination centre Infrastructure A HIOW level ‘flight deck’ for co-ordinating health and care service delivery, building upon the infrastructure for 999 and 111 calls, providing routing for primary care appointments, referring to clinical hubs, and improving maintaining a live directory of services.       Improved decision support directly influencing the effectiveness and efficiency of resource deployment.       Unlocking the power of information we have is central to our digital roadmap. The analytics capability will drive improvements in service outcomes at a population health commissioning level as well as at a clinical decision making level. Providing risk analysis, cohort identification & tracking, outcome evaluation and clinically lead intelligence & research.       Optimising intelligence capability   Section Two: Enabling Programmes Project Digital Project Enabling Programme 8: Estates 21 Programme Description Projects Timescales The Estates programme has two core and interdependent objectives: 1. To enable delivery of the STP core transformational workstreams and 2. To drive improvement in the condition, functionality and efficiency of the Hampshire and IOW estate. Milestone • • • • • • • Improved planning through better sharing of information and expertise. Reduced demand for estate which will release surplus estate for other uses such as housing. Current estate has been classified to identify key strategic sites to be fully utilised and estate that is no longer providing a high quality environment for staff and patients. The priority is to replace the worst estate. Increased utilisation of key strategic sites to meet requirements of core STP workstreams and improve efficiency. This will ensure that services are provided from the best facilities, contributing to improved patient health and wellbeing. A small number of utilisation audits have been completed which have identified scope to increase utilisation by up to 30%. Flexible estates solutions that enable new care models to be delivered. A core group of HIOW estates leads is in place and are supporting all STP workstreams and the local estates forums. 4 HIOW estates workshops have been held, including primary care commissioners, to identify the estates solutions which enable new models of care including area and local health hubs. These will provide extended access and an enhanced range of services which reduce the need for patients to travel to the main hospital. Redesigned facilities which facilitate increased mobile working, working closely with the digital and workforce enabling teams. We will increase the number of hot desk facilities to enable staff to access bases closer to their patients, reducing travel and increasing productivity. Optimised use of estate as part of ‘One Public Estate’ programmes enabling patients to access a wider range of services as part of one-stop shops that are tailored to meet local needs. 19% reduction in estates footprint and £24m revenue saving by 2020/21 Revenue investment assumed and financial benefit Investments Required: £5.3m SAVINGS: £24m per annum by 2020/21 2017 /18 2018 /19 2019 /20 2020 /21 Reduce Demand Increased utilisation Flexible working Reducing operating costs One public estate and shared service STP estates transformation Key personnel • • • • Inger Bird( SRO and Programme Director) Michelle Spandley ( Chief Finance Officer) Becky Whale (Programme Manager) Strategic Estates Advisors and Estates Leads from provider organisations, CHP and NHS Property Services Stakeholders involved • • • • • • All enabling and core programmes Local Estates Forums and Strategic Partnership Board One Public Estate programme Housing providers Elected representatives Communications team For project detail see appendix A Outcomes and benefits to be delivered 2016 /17 Section Two: Enabling Programmes Programme Objective: To provide the estate infrastructure needed to deliver the new models of care and to deliver savings by rationalising the public sector estate in Hampshire and the Isle of Wight Enabling Programme 9: Workforce 22 Programme Description Projects Timescales Outcomes and benefits to be delivered By 16/17 – Control of pay costs and use of agency workforce. Detailed plans developed with each work stream By 17/18 - Implementation underway of workforce transformation plans to deliver the STP core programmes and the HIOW system approach to staffing  A flexible workforce shared across geographical and organisational boundaries, working in new ways with extended skills to deliver the core STP programmes  Health and care roles which are more attractive to local people, enabling the development of a stronger community based workforce  Significant reduction in the use of temporary and agency workers  Increasing the time our staff spend making the best use of their skills and experience  No overall growth in the workforce over the next five years Projects 2016 /17 2017 /18 2018 /19 Recruitment and Retention a) Strategy b) Recruitment hot-spots System wide use of resources a) Workforce b) corporate back office functions Technology Education and Development a) Making best use of our resources b) Ensuring our staff are best equipped for the future Engagement and Organisational Change Key personnel The workforce financial benefits are quantified within each of the core programmes. However anticipated workforce cost reduction will be:  Reduce system temporary staff spending costs by 10% Stakeholders involved  Reduce corporate costs by 15% through redesigning services for the system rather than each organisation within the system  No system increase in workforce costs. 2020 /21 Workforce planning and Information Sue Harriman (CEO/Lead AO for workforce) Sandra Grant (Programme Director) Ruth Monger (Co Chair of LWAB) Health Education Wessex Local Workforce Action Board members HR Directors across H&IOW & Staff Side representatives Financial benefits 2019 /20 All enabling and core programmes Staff and staff side Communications team For project detail see appendix A To work as one system to develop the right people, skills and capabilities to support the transformed health and care system. By working as one we will ensure we remove organisational and professional boundaries and make better use of resources across the system. We will exploit the potential of new technology and reduce unnecessary competition for limited staffing resources. Section Two: Enabling Programmes Programme Objective: To ensure we have the right people, skills and capabilities to support the transformed health and care system by working as one HIOW to manage staffing, development, recruitment and retention. Enabling Programme 10: New Commissioning Models 23 Programme Description Outcomes and benefits to be delivered • • • • • Outcome based commissioning to local populations with aligned incentives within the system to facilitate the delivery of patient-centred integrated services Effective Commissioning at scale to allow management of system control total and to develop the role and structure of commissioning within the new contract system, releasing efficiencies . Place based solutions to move at pace in the delivery of new models of care and acute alliances. Improved performance in timely delivery of CHC processes. Improved patient outcomes benefits and savings benefits through reduced variation in prescribing practices. Financial benefit SAVINGS: Reduced system infrastructure costs £10m per annum by 2020/21 CHC £36m. Prescribing £58m. Projects 2016 /17 2017 /18 2018 /19 2019 /20 2020 /21 Commissioning transformation Delivery of CHC processes Reduce variation in prescribing practices Key personnel CEO Sponsor – Dr Jim Hogan Programme Director – Heather Mitchell Programme Advisor - Innes Richens & Helen Shields Finance Lead – James Rimmer The eight Clinical Commissioning Groups across Hampshire and the Isle of Wight have established a Commissioning Board and a commitment to collaborate fully on the commissioning of acute physical and mental health services. Stakeholders involved NHS - GP’s, Specialist Commissioning, Acute Trusts, Community SCAS, Trusts, CCG’s, Pharmacies. Public and patient groups, Government - Local authorities, HCC, Public health, Local Councillors / MP’s Regulators – NHSE, NHSI For project detail see appendix A The Programme aims to align commissioning intentions and planning for the future form and function of commissioning across HIOW, to enable:  Commissioning activities orientated around tiers  Closer integration of health and social care commissioning around ‘placebased’ solutions  Contracting and payment approaches that support the implementation of new models of care & alliance / MCP / PACS or ACO contracting , including progressing: PACs model in NE Hampshire and Farnham  Accountable care system for Portsmouth, SE Hampshire and Fareham and Gosport  My Life a Full Life on the Isle of Wight  Develop place based systems across Hampshire (building on the Vanguard work of Better Local Care) and Southampton. Additionally, the Programme aims to improve the delivery of CHC processes and reduce variation in prescribing practices. Projects Timescales Section Two: Enabling Programmes Programme Objective: To adapt our methods, tools, resources and architecture for commissioning health and care, to reduce unnecessary duplication of commissioning work and facilitate the delivery of the STP. To generate cost reductions in expenditure on Continuing Health Care and Prescribing through working at scale. Section 3: Ensuring successful delivery 24 Culture, Leadership & OD An example is the culture change we are delivering in primary care in the Hampshire MCP – ‘Better Local Care’. Dr Nigel Watson MBBS FRCGP, Chair SW New Forest Vanguard, CEO Wessex Local Medical Committees states: ‘GPs provide the vast majority of daily contacts with patients. Practices, supported by a range of health and care professionals, are moving towards working in wider natural communities of care to provide services, including self care and prevention, integrating with community services, using a common health record and looking at better ways to deliver care for patients with long-term conditions or who need urgent care’. A Further example is the moves we have made to fully integrated local delivery models. Simon Jupp, Director of Strategy, Portsmouth Hospitals NHS Trust states ‘The willingness of all partners to create a sustainable health and social care system on behalf of the population we serve is inspiring and liberating’. We started to develop the STP plan in May 2016 with over 80 leaders including CEO’s Accountable officers clinical chairs and medical directors & met for a 2 day externally facilitated event that resulted in partnership working across the programmes such as, the commitment to the Solent acute alliance. We built on this in June with a further facilitated event with 60 leaders including Directors of Finance. What we have already seen developing as inclusive leaders agreed principles of working, resulting in different behaviours and fostering new ways of working. The failure of strategic change projects is rarely due to the content or structure of the plans put into action, it’s more to do with the role of informal networks in the organisations & systems affected by change. To make transformational change happen we will need to connect networks of people who ‘want’ to contribute. Developing our culture and OD plan Change model management cycle Change readiness assessment OD should provide the ability for a system to transform, reflect, learn, and improve systematically. In order to deliver the STP, system leaders at all levels need to build relationships of trust and respect across the system, in order to work effectively together and demonstrate values and behaviours which are consistent and honest. As a framework for System leadership we will use the framework below to start the development conversations ​To reap the benefits of the transformation of the STP, we must ensure adequate time and resource is invested in embedding the changes at the frontline of service delivery. For change to be effective, in addition to effective leadership, change management capabilities must be embedded within the portfolio, programme and project teams responsible for delivering change across the STP. In delivering the STP, we will use a we will use a framework for change that is based on best practice methodologies. ​A change readiness assessment will be conducted to outline the baseline change rate of the STP. Once the portfolio begins the delivery stage, frequent change readiness assessments will be conducted to calculate the change readiness rate. The vision for change Learning and development Delivering the benefits Managing performance Developing the leadership Change readiness assessment Change strategy and plan Commitment Cultural alignment Managing the project Organisational design Section Three: Ensuring successful delivery Moving from development to implementation As we move from STP development to implementation and delivery, partnership behaviours will become the new norm. It is acknowledged that no one organisation holds the solution to the system leadership challenge required to transform the health and care. Leaders across the HIOW system recognise that in order to realise the benefits of the transformation STP, we must ensure adequate time and resource is invested in embedding the changes needed. To that end senior leaders have been personally committing time and sharing resource to ensure that across HIOW we are already seeing a culture change, including an increase in partnership working. System Approach to Quality and Equality System Quality Aims Key workstream projects 1) 2) 3) 4) 5) STP Quality Impact Assessment process HIOW STP/Vanguard quality governance framework & toolkit HIOW quality data surveillance and analytics approach Draft quality metrics and contract schedules for new care models Agree core quality improvement priorities Immediate Priorities • Agree revised definitions for quality and clinical governance which will apply to the whole STP HIOW STP Level Local Health System Level footprint and integrated care pathways e.g. development & spread of Logic Model •Develop methods to evaluate the quality impact of service transformation plans •Develop specific requirements for quality in a shared approach to quality intelligence and analytics • Contribute to setting STP and local health outcomes •Develop a quality governance toolkit for use by all new models of care based on the 5 CQC domains •Agree what quality functions should be amended, stopped, or started •Influence key national stakeholders e.g. NMC, GMC, CQC, NHSI, NHSE Vanguard Team • Draft quality schedule for new models of care contract •Agree core quality metrics for quality in new models of care and across partners/pathways •Drive data for improvement to individual healthcare professional and service levels • Agree methods for monitoring quality across new provision platforms e.g. digital and voluntary services • Appoint quality leads into each locality • Ensure patient, public and carer voice in quality is central •Implement the quality governance toolkit at a local level •Collate and analyse quality datasets •Identification of transition quality risks and mitigation for these •Work to a programme of quality improvement initiatives •Use quality improvement science and evidence based methods HIOW STP equality and diversity principles HIOW STP member organisations are committed to promoting equality in the provision of health care services across the HIOW geography. The STP work streams are underpinned by the belief that it is only by achieving equality and celebrating diversity that we can provide quality services and improve the experience of people who use our services and the staff who care for them. Equality and diversity processes in the STP include: Equality Delivery System The public sector equality duty is embedded in each STP NHS member organisation through adherence to the NHS Equality Delivery System (EDS). Equality Standards compliance Through the process of individual organisation registration with the Care Quality Commission (CQC), NHS provider organisations are required to demonstrate compliance with the CQC’s essential standards for quality and safety. EQD embedded in STP QIA All STP work programmes will be subject to assessment at stage 1 and those whose quality or equality impact is deemed moderate or significant will be required to undertake a more in-depth stage 2 review before proceeding. EQD embedded in consultation processes The STP work programmes will actively seek opportunities to consult and engage with service users and the public who are representative of the 9 protected characteristic groups as part of its wider consultation and engagement programme. Section Three: System approach to quality The programme of transformation across HIOW presents clear opportunities for health and social care organisations to work together to fix current quality challenges. Our approach will not replace individual organisations quality duties but aims to deliver:  A more streamlined and efficient approach to quality measurement and monitoring  Opportunities to increase the patient/carer voice in defining, measuring and evaluating the quality of services  Better understanding of quality variation across the entire patient pathway rather than in silos  The structure, process and guidance needed by teams working on new models of care to ensure regulatory compliance  Better use of data, including the effective triangulation of multiple sources of data and quality surveillance that focuses on early warning and prevention rather than multiple investigations after the event  New provider/commissioner alliances and configurations which will support reconfigured services and organisations e.g. accountable care systems  A real focus on health gains, linking quality to population health outcomes in new and innovative ways  Agreement on the approach to defining, measuring and monitoring quality which will be required under new contractual arrangements. 25 Engagement and consultation on the STP 26 Strategic approach ​Substantial productive engagement with patients, voluntary and community groups and wider communities has and continues to be carried out across Hampshire and the Isle of Wight in support of the development of local health and care services. We will build on this strong framework in delivering the STP, using existing local channels and relationships within HIOW to engage with people as we develop and implement plans. We will develop key messages that can be used in all settings to describe and explain the purpose and vision of our STP. Clinical and nonclinical staff Patient representatives Voluntary and community groups Local people National and local political stakeholders Stakeholder Cloud Map Engaging with local people and voluntary and community groups We will continue to use our existing local channels within HIOW to engage and consult with people and local voluntary and community groups as we develop and implement plans. For example, the local population on the Isle of Wight was involved in developing the new vision for My Life a Full Life; there has been extensive engagement with the public in developing West Hampshire CCG’s locality plans through public events and focus groups; the Southern Hampshire Vanguard Multi-Specialty Community Provider programme involves local NHS, local government and voluntary organisations in extending and redesigning primary and community care across most of Hampshire. It is not intended to try to duplicate all the work that is already being carried out locally in the NHS community or to create a whole new suite of communication channels or engagement activity. Engagement about any proposed changes to existing services will continue to be carried out by the statutory body or bodies responsible for proposing the change, supported by relevant information from the STP. This will ensure that engagement is carried out at a local level and led by an organisation with which local people are already familiar, recognising that 'Hampshire and the Isle of Wight' is not a natural community of care and that people's loyalty is to their own GP and local hospital and then to the wider NHS as a whole. Engaging with our staff We will target messages at a local level through the relevant organisation to engage with our staff, recognising that 'Hampshire and the Isle of Wight' is not a natural community of care and that staff loyalties are to their employing organisation. Engaging with our local MPs and Councils Relationships already exist between health and care organisations in HIOW and local MPs, HWBs and Councils. These relationships will continue to be the conduits for ensuring these key stakeholders are kept informed and involved in delivering the STP. Formal consultation It is unlikely that formal consultation would be undertaken on something as allencompassing as the STP and across such a wide geography. Specific changes such as centralisation of a clinical service on the grounds of quality, safety and sustainability or a reconfiguration of services within a smaller geographical footprint (for example, north and mid Hampshire) are likely to be subject to formal consultation on a case by case basis. In such a case, the relevant statutory body or bodies would be responsible for carrying out any formal consultation on the proposed change. Section Three: Engagement and consultation Our communications and engagement strategy is based on informing, involving, sharing and listening. Our Delivery Architecture and Capability The MoP Definition Cycle defines what initiatives and changes the portfolio is going to deliver and plans for how those can be achieved. The MoP Delivery Cycle identifies practices to ensure the successful implementation of the planned portfolio initiative and to ensure the portfolio adapts to changes over time. Reporting and Monitoring The centre of excellence (COE) will be part of the role of the Core Group and will provide the means for programme and project teams to capture lessons. In this way, the organisation can continuously improve programme and project delivery. As part of the setup phase, the following 10 key principles will be adopted to inform the effective design and implementation of effective portfolio management: Single view of the portfolio Proposed Portfolio Management Governance Model Strategic alignment The portfolio will be managed using high-level dashboards to outline objectives, items for board attention, major risks and issues, status and delivery milestones. These will be repeated at both programme and portfolio level and be updated monthly for board review. In addition, to create an effective reporting infrastructure there is intention to plan and role out a web-based project extranet application. This web tool would facilitate engagement across portfolio, programme and project levels. Delivery Maturity Whilst HIOW contains individually competent organisations as a system our delivery capability is immature. Partners recognise this and are committed to purposeful investment and measured improvement. To do this we will benchmark ourselves using accepted best practice methodologies such as the Portfolio, Programme and Project Management Maturity Model (P3M3) seek to increase over time our skills base in Transformation and Change. Portfolio sufficiency Maximising return on investment Section Three: Delivery Architecture Best Practice Frameworks To enable and inform effective and collaborative decision making by the STP Steering Board, best practice portfolio (MoP*) and programme (MSP*) management frameworks are being established. This will ensure appropriate visibility and control of all HIOW STP transformation programmes and projects. In particular, as part of the MoP framework, the MoP Definition and Delivery Cycles will help to achieve the portfolio vision by optimising the balance and delivery of all in-scope programmes and projects. 27 Managing the delivery constraints Balancing the portfolio Effective and timely decision making data Execution focus Dealing with systemic risks Focus on things that matter P3M3 allows an assessment of the process employed, the competencies of people, the tools deployed and the management information used to manage and deliver improvements. This enables organisations to determine strengths and weaknesses in delivering change. *MoP: Management of Portfolios *MSP: Managing Successful Programmes Section 4: The Financial Gap 28 £m If NHS organisations across HIOW do nothing to deliver efficiencies and cost improvements and to change the demand for health care services, the way they are accessed and provided, we will have a financial gap of £577m (18% of commissioner allocations) by 2020/21 HIOW STP SYSTEM GAP 27 247 39 58 247 40 89 Circa £192m Financial Challenge by 19/20 31 18 53 577 102 90 Remaining Gap Specialised Services Primary Care 7 Day Services CCG Business Rules / Other Mental Health Community Prescribing Continuing Care Provider Cost Growth Activity Growth Allocations Increase 2016/17 Normalised Outturn Gap 700 600 500 400 300 200 100 -100 -200 -300 We will close our financial gap by: Transforming services to improve patient experience and outcomes, and at the same time reducing both overall system costs and avoiding future cost pressures from unmitigated growth in demand for services Working with social care to target investment where we will get best value and outcomes for our population; Working with local authorities to focus on prevention, and invest in primary and community services, and where appropriate avoid costly hospital admissions and focus on timely discharge from hospital; Striving for top quartile efficiency and productivity (including maximising Carter Review and Rightcare analysis opportunities) Adapting financial flows and current contracting and payment mechanisms to align outcomes, metrics and financial incentives to support optimum patient outcomes, improved decision making and financial stability. The environment is more challenging when the savings from social care are included into the picture Changing the Way We Work Hampshire County Council Southampton City Council Portsmouth City Council Isle of Wight Council Key themes from Social Care savings plans are : • Review current operating models; • Focus on early intervention & prevention, reducing reliance on Social care; • Focus on needs and better outcomes, withdrawing low impact services; • Improving efficiency & effectiveness; • Utilising technology & digital solutions. Many themes are common to Health and Social Care. We are committed to working together to maximise synergies in spending and savings opportunities, as well as avoiding unintended consequences of savings plans. As an example, Portsmouth are developing a joint health and social care operating plan. The financial plan represents collaborative working between CFOs and FDs in HIOW, working alongside our Local Authority peers. Each programme has senior finance support to ensure the robustness of our plans. Our future financial sustainability will only be a reality by working together collaboratively, with a relentless focus on overall cost reduction across HIOW. We are reorganising our delivery mechanisms to work together in the overall interests of financial sustainability rather than in organisational silos, developing aligned planning processes, investment decisions and risk management. The senior HIOW finance leadership now reviews in year financial performance and risk management against the overall control total. We have strengthened links with social care and improve our joint planning processes with our local authorities. An example for our system is Portsmouth’s work to develop a joint operating plan for health and social care. We are also reviewing financial flows and will adapt current contracting and payment mechanisms to align outcomes, metrics and financial incentives to support optimum patient outcomes and financial stability. Section Four: The Financial Gap Financial Challenge & Strategy Investing in Our Future: Revenue 29 Investments Local Investment Assumptions: GP £3 per head Mental Health (incl. 5YFV) Community Growth (Support to New Care Models) 7 Day Services (Support to New Care Models) Total Local Investments STP Investments Anticipated Support to bottom-line (STF) Transformation Funding Requested: GP Access Digital Roadmap Mental Health Cancer Maternity Prevention New Care Models Other (Further Support / Contingency) Total STP Investments H&IOW Indicative Share of National allocation 2017/18 2018/19 2019/20 2020/21 4.5 9.4 9.3 23.2 4.5 21.3 17.5 43.3 32.1 25.8 57.9 44.6 35.8 31.0 111.4 48.6 48.6 48.6 60.0 15.7 7.8 4.8 2.4 1.1 3.2 6.1 0.0 89.7 89.7 16.2 8.0 5.0 2.5 1.1 3.3 7.6 0.0 92.3 92.3 18.8 9.3 5.8 2.9 1.3 3.8 11.3 5.6 107.5 107.5 20.8 10.3 6.4 3.2 1.5 4.3 12.5 119.0 119.0 HIOW indicative share of the STF is £119m. We would like to invest £59m in services and utilise £60m to close the residual financial gap in 2020/21. Section Four: The Financial Gap Our plans will require investment in our new model of care, focusing on prevention, out of hospital care and digital technology. Based on a combination of local plans and national guidance received on investment in the 5 Year Forward View, our indicative investment plans are outlined below. Final investment will be subject to an agreed business case and value for money assessment. Investing in Our Future: Capital 30 STP Capital investment summary 2017/18 2018/19 2019/20 2020/21 Total £m £m £m £m £m MH Alliance Acute & PICU re-design 0.0 0.0 7.7 4.0 11.7 Solent Acute Alliance New theatres, path, pharmacy 15.5 11.3 1.0 - 27.8 Solent Acute Alliance Digital maturity 6.2 4.3 2.8 2.0 15.3 Digital Local Digital Roadmap 9.4 6.0 3.6 1.2 20.1 New Care Models Primary & Community hubs 43.4 65.1 0.0 0.0 108.5 New Care Models St Mary's CHC Portsmouth BC 5.9 5.4 0.0 0.0 11.3 HIOW STP Total 80.4 92.0 15.1 7.2 194.7 Foot note: • As the future configuration of services in North and Mid Hampshire is still in development, the financial plan has not been able to reflect the financial implications of this within the STP. However, it is anticipated that capital and revenue investment will be required, which will be considered as part of a future business case. • It should be noted that this does not represent a full capital picture for the entirety of the HIOW Section Four: The Financial Gap We need to invest in our capital infrastructure to secure our vision, subject to full business case assessment and access to capital funds: Closing the NHS Financial Gap: Work to Date 31 700 HIOW STP SYSTEM GAP - SOLUTIONS 600 500 £m 400 300 53 577 197 200 59 55 100 34 59 119 94 STP Funding STP Investment Estates / System Infrastructure Commissioner Transformation Schemes Delayed Transfers of Care / Prevention New Care Models Mental Health Alliance / Community CIP Acute Alliances Specialised Services Initial Gap - 25 Key Metrics Activity Our transformation plans will reduce growth in the secondary care sector as follows: Activity 2017/18 - 2020/21 Transformational Do Nothing Total Solutions Total 8.9% NEL Non Elective admissions (NEL) Elective admissions (EL) 8.7% EL Out Patient First appointment (OPF) 16.3% OPF Out Patient Follow Up (OPFU) 16.3% OPFU Emergency Department (ED) 9.3% ED Net Change after Transformation -9.6% NEL -3.5% EL -7.7% OPF -20.0% OPFU -10.2% ED Total -0.7% 5.2% 8.7% -3.7% -0.9% Beds We will use our bed capacity more effectively, and will seek to generate 9% efficiency in our acute bed stock (worth c.300 beds). Workforce We expect to spend the same amount in four years time on workforce costs (other than cost increases from any future pay and pensions increase), but in different settings and on different staff groups and skill mixes. We will decrease reliance on agency workers, flexing staff resources across the system and making the best use of technology. Section Four: The Financial Gap Through a combination of efficiency and transformation, and using £60m of the Sustainability and Transformation Fund, we can close the £577m gap by 2020/21 to deliver a breakeven position: Specialised Commissioning involving, sharing and listening. Pathways of care frequently include elements that should only be delivered in a limited number of providers but, across NHS South, there are 49 organisations that provide at least one acute specialised service, with just six providers accounting for half of the total spend; this includes University Hospitals Southampton NHS Foundation Trust, which accounts for an annual specialised commissioning spend of around £275 million (see chart). Ambition and vision for specialised commissioning The ambition of NHS England is to bring equity and excellence to the provision of specialised care through patient-centred, outcome-based commissioning. This requires coordination between provider organisations to ensure that care is delivered in specialist departments where necessary, with local repatriation where possible. Proposal The drive to meet commissioning specifications, reduce variation and improve value will result in fewer providers of specialist services. New models of care and innovative commissioning models are needed to support networked provision of services to address access and ensure long-term sustainability of high quality specialised care, requiring Specialised Commissioning to work closely with providers and STPs. Progress to date NHS England recently held seven triangulation events, which highlighted: • • • Areas of alignment between STP planning and Specialised Commissioning Areas where further work will be required to coordinate pathways across different STP footprints and NHS England regional boundaries Areas where alignment of commissioning within STPs brings about opportunities to improve planning, contract and transformational delivery Work will continue to address these areas. Finance and QIPP Delivery NHS England Specialised Commissioning (South) has calculated financial allocations based on the utilisation of specialised services by the STP (constituent CCGs) population. The ‘do nothing’ scenario for Specialised Commissioning within the STP sets out the financial impact of assumed growth based on national indicators for population growth for the CCGs in the STP. To close the gap (break even) and deliver against its elements of the financial gap, Specialised Commissioning is planning for both Transactional and Transformational QIPP, which will be cumulative over the duration of the STP. QIPP has been set at c3% for all providers across the STP (1.5% Transactional and 1.5% Transformational). This amounts to £53 million for the HIOW area. The split is even across providers at the moment but Transformational schemes may have a greater impact on certain services. The accuracy of this figure therefore remains a significant risk for the STP. We will work with Specialised Commissioning to mitigate any risk the plans and the proposed approach may pose. Section Four: The Financial Gap NHS England has prescribed direct commissioning responsibility for specialised services (a range of services from renal dialysis and secure inpatient mental health services through to treatments for rareand cancers and life threatening genetic accounts for nearly 15% of total NHS spend. Our communications engagement strategy is disorders), based onwhich informing, 32 Closing the NHS Financial Gap: Further Work Underway 33 700 Meeting commissioner and provider control totals 55 100 25 94 63 34 59 119 63 STP Funding STP Investment Savings yet to be Identified Surplus Target Estates / System Infrastructure Commissioner Transformation Schemes Delayed Transfers of Care / Prevention - New Care Models Provider control totals have been set assuming the impact of introducing HRG4+. As the implementation of HRG4+ has not been adjusted in CCG allocations at the time of submission, we have not yet been able to fully assess the effect on the financial plan and the unidentified savings gap. This is therefore an unknown risk at this time. Should there be a material difference between the nationally modelled impact upon provider control totals and the local CCG allocations to neutralise CCG buying power then further discussions would be needed with our regulators. 59 Mental Health Alliance / Community CIP HIOW have approved the submission of a financial model that achieves the required surpluses on the basis that we: • We accelerate the delivery of net benefits consistent with the financial challenge in earlier years of the STP; • We explore early access to additional STF transformation funds; • All organisations work together to develop further more radical transformation plans to bridge any residual gap; • We use CCG non recurring headroom to support the STP in the delivery of its financial obligations. 197 200 Acute Alliances 2018/19 £m 11.8 62.6 74.4 300 53 577 Specialised Services 2017/18 £m 3.7 46.2 49.9 400 Initial Gap SURPLUS REQUIREMENT Commissioner Provider Increase in Financial Challenge 500 £m Commissioner and provider control totals have now been allocated and this has increased the 2017/18 and 2018/19 requirement above the previous submission which assumed breakeven was required. The control totals add to the challenge as follows: HIOW STP SYSTEM GAP - SOLUTIONS 600 The annual profile our the plans requires the following savings to be delivered: Investments Financial Gap to Break-even Provider Surplus Control Total Commissioner Surplus Control Total STF to support Financial Position Total Savings Required Savings % 2017/18 2018/19 2019/20 2020/21 195.1 315.0 435.8 576.6 46.2 62.6 62.6 62.6 3.7 11.8 9.4 0.3 48.6 48.6 48.6 60.0 196.3 340.8 459.2 579.5 34% 59% 79% 100% Section Four: The Financial Gap In order to achieve the control total surplus position the H&IOW system needs to deliver an additional £63m savings – which are yet to be identified. Impacts on Activity NEL EL Do Nothing Growth from 16/17 Activity 2017/18 – 2020/21 Transformational Net Hospital Solutions Change after Growth Transformation Containment 14,294 - 15,388 - 1,094 8.9% -9.6% -0.7% 18,966 8.7% 7,702 -3.5% 11,264 5.2% 89,978 - 42,215 47,763 OPF 16.3% OPFU ED -7.7% 8.7% 159,961 - 196,249 - 16.3% -20.0% -3.7% 54,416 - 59,993 - 5,577 9.3% -10.2% -0.9% -49050 -30184 -26% -16% 18866 36,288 XBD 10% Community Impact Planned Potential 1540 extra patients managed at home by primary care 9,000 short stay admissions avoided 5000 more complex cases managed in the community 7702 avoided admissions through shared decision making, clinical thresholds, reduced duplication 21,108 fewer hospital appointments through better ways of working 21,108 fewer hospital appointments referred to community alternatives 98,125 fewer routine face to face follow ups 98,125 follow-ups redirected to community alternatives e.g. stable glaucoma 18,000 extra patients managed in primary care 36,000 signposted to 24/7 community urgent care services 6000 people managed via education and web-based directories 50,000 alternative days of care provided out of hospital, at least in the short term. Includes 30,000 extra dom care visits or 82 more per day, and 20,000 extra days of health or social care Section Four: The Financial Gap Measure 34 Impacts on Workforce 35 Do Nothing – Total pay bill Solutions – Total pay bill Do Something –Total pay bill Comments GP 0.0% 0.0% 0.0% We will comply with growth expected in GP 5YFV GP support staff 0.0% 0.0% 0.0% Back office rationalisation 0.0% -10.0% -10.0% Estimate of share of system infrastructure savings target Qualified Ambulance Service Staff 8.3% -8.3% 0.0% NHS Infrastructure Support 6.9% -6.9% 0.0% Support To Clinical Staff 11.0% -11.0% 0.0% Medical And Dental 9.8% -9.8% 0.0% Registered Nursing, Midwifery and Health Visiting Staff 10.1% -10.1% 0.0% All Scientific, Therapeutic and Technical Staff 9.9% -9.9% 0.0% Total WTE 8.1% -8.3% -0.2% Assumption that provider pay bill will not increase from 16/17 levels Assumption that provider pay bill will not increase from 16/17 levels Assumption that provider pay bill will not increase from 16/17 levels Assumption that provider pay bill will not increase from 16/17 levels Assumption that provider pay bill will not increase from 16/17 levels Assumption that provider pay bill will not increase from 16/17 levels Assumption that provider pay bill will not increase from 16/17 levels NB: the workforce analysis is presented in this format to comply with NHSE guidance, however it should be noted that the workforce plans within STP have a greater specificity. This graphic representation is extremely broad in nature and must be taken in that context. • • • • • If we continue to deliver care within our current service models (The ‘Do Nothing’ position) there will need to be a significant increase across the majority of staff groups leading to a 8.1% increase in staff pay bill overall. The impact of our delivery programmes (The ‘Do Something’ position) will maintain overall staffing at current pay bill levels over the next 5 years We expect to spend the same amount in four years time on workforce costs (other than cost increases from any future pay and pensions increase) however the distribution and functionality of the workforce will change significantly. It should be noted that WTE may increase but pay bill will reduce by 0.2% In part, this will be achieved through; • Decrease reliance on agency workers by creating a HIOW-wide concordat and a county-wide bank system. As a result we will reduce system temporary staff spending costs by 10%. • Corporate functions will reduce costs by 15% through redesigning services for rather than each organisation within the system. New roles and competencies will be established and the workforce will be working across organisational boundaries with ease. We recognise health and care workforce turnover rates in HIOW are higher than the average for England and a high cost of living creates challenges for recruiting into the domiciliary sector. We will increase the retention of this workforce by increasing the standardisation of training, with the possibility of professional registration for those without academic qualifications and offering individuals the opportunity to deliver care in a variety of settings. We will develop a highly skilled integrated primary care workforce with a greater range of healthcare professionals including qualified nurses, allied health professionals and pharmacists, who are equipped with the skills and experience to work in integrated teams. We are developing a Community Provider Education Network to create the infrastructure needed to deliver a highly skilled multi-professional workforce to work alongside our GPs. Section Four: The Financial Gap Workforce Analysis - by 2020/21 Section 5: Summary programme plan, risks and issues 36 Summary programme plan and key milestone dates 2017 - 18 2016 - 17 Programme Projects Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Initiatives at scale 1. Prevention Behavious change Service redesign and change Mental health Foundation for independence & self care Fully Integrated Primary Care 2. New Care Models Integrated Intermediate Care (Health & Social) Complex Care & End of Life LTC - Diabetes, Respiritory & Cardiac Discharge Planning 3. Effective Pt Flow/DToC Effective management of Patient Flow Complex Discharge & Hard to Place Patients Development of Onward Services 2% business as usual CIP Clinical service review 4. Solent Acute Alliance Outpatient Digital Pathology Estates Pharmacy Theatres Back office service review 5. North & Mid Hampshire 6. Mental Health Alliance Optimum acute care configuration HHFT CIP Plan Acute and community mental health pathway review and redesign Review and redesign of the HIOW mental health rehab pathway Redesign and transformation of MH crisis care Patient data sharing initiative Patient portal 7. Digital E-Prescribing & Medicine reconciliation Digital communications across care providers Wi-Fi for HIOW & Cyber security Channel shift Care coordination centre infrastructure Optimising intelligence capability Reduce demand 8. Estates Increasing utilisation Flexible working Reduce operating costs One public estate and shared services STP transformation 9. Workforce Workforce planning and information Recruitment and retention System wide use of resources Technology Education and development Engagement and organisational change Transformation 10. Commissioning Continuing healthcare (CHC) Prescribing LEGEND IMPLEMENTATION DATE KEY MILESTONE CLOSEDOWN DATE 2019 - 20 2018 - 19 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 2020 - 21 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Section Five: Summary Programme Plan Hampshire & Isle of Wight STP Risks and Assurance 37 Identified key portfolio issues and risks There is collective agreement across the health and care system to work differently to support transformation and sustain high quality services for local people. Significant progress has been made in developing a number of system-wide approaches to risk sharing and mitigation, including: The STP will identify and manage risk in accordance with standard the NHS risk management approach. • the partners to the Solent Acute Alliance have established core principles of financial risk management to enable greater collaboration between organisations • local GP practices in Gosport have established a model of clinical collaboration that allows then to work together to provide services (such as same day urgent appointments) for local people. The practices share in the management of financial and clinical risk. • the eight Clinical Commissioning Groups across Hampshire and the Isle of Wight have established a Commissioning Board and a commitment to collaborate fully on the commissioning of acute physical and mental health services. It is the ambition of the eight CCGs and specialised commissioners in Hampshire and the Isle of Wight to develop a new way of working with provider partners to share the a number of components of risk (including utilisation risk, production cost risk and volatility risk.) Assurance The HIOW STP recognises the important of achieving and implementing change under the Five Year Forward View, GP and Mental Health plans. The scope of the HIOW STP will assure that focus is directed upon delivering the objectives of these plans, as well as acting as a key tool in assessing the success of the STP. Dashboards are being developed which integrate Portfolio, Programme and Project level reporting and will provide ‘at a glance’ transparency of engagement progress and benefits realisation. Assurance and reporting will be supported using a cloud based programme and project infrastructure that will capture key information from across the programmes, enable simple and consistent updates and reporting by project leads, and facilitate collaboration across organisations in delivery of shared projects Risk scoring = consequence x likelihood (C x L) Consequence score 5 Catastrophic 4 Major 3 Moderate 2 Minor 1 Negligible Likelihood score 1 (rare) 2 (unlikely) 3 (possible) 4 (likely) 5 4 3 2 1 10 8 6 4 2 15 12 9 6 3 20 16 12 8 4 5 (almost certain) 25 20 15 10 5 Using this approach the items below have been identified as perceived risks that could potentially have a significant impact upon the STP, and hence will need to be managed accordingly. Insufficient engagement with local MPs and Councillors may result in challenge, contradictory messages and potential delays in implementation Planning and modelling assumptions are untested and therefore do not make the financial savings Impacts of the wider local authority and STP footprints are unconfirmed and may affect the achievement of financial savings The scale and nature of some service transformation plans could have a negative impact on clinical outcomes Service transformation plans and timescales for implementation could destabilise current service provision if not managed effectively Individual providers may be required to focus on regulatory compliance (quality, leadership and/or finance) and have reduced transformation capacity or capability Insufficient capital available to deliver changes There are insufficient people with the skills and capability to deliver the improvements required (Programmes and service provision) Potential for judicial review on any activity Insufficient engagement with clinicians may result in challenge, contradictory messages and potential delays in implementation This risk analysis will be extended to focus on the issues and risks associated at programme and project level. Section Five: Risk and Assurance System-wide leadership and approach to risk Our commitment 38 All organisations have received and commented on the content of the STP. The views from Statutory Boards and partner organisations and agencies have been critical and amendments have been incorporated into the submission. Statutory partners consider that the STP represents the right strategic direction for health and care across Hampshire and the Isle of Wight. Further work will continue beyond 21 October 2016 notably on: • • • • refining the governance model, including further development of the model of governance between the STP and the sub-STP local delivery systems; ensuring that the focus on sustainability does not detract from the drive for innovative transformation continued work with Local Authority partners to further understand the impending two year local authority transformation plans and the impact and opportunities these will have on the wider STP Translating the strategic intent and impact of the STP into operational plans for each of the STP local delivery systems, defining the specifics around what they will deliver for each of the workstreams at what pace, and the finance, activity, quality and outcome changes. The STP is therefore submitted, recognising the extent of continued collaborative working across the system. The strategic direction and content of the STP will form the opening basis of the operating planning process for 2017/18 and 2018/19. NHS Trusts Frimley Park Hospital NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust Isle of Wight NHS Trust Portsmouth Hospitals NHS Trust Solent NHS Trust South Central Ambulance Service NHS Trust Southern Health NHS Trust University Hospitals Southampton NHS Foundation Trust Clinical Commissioning Groups Fareham and Gosport CCG Isle of Wight CCG North East Hampshire and Farnham CCG North Hampshire CCG Portsmouth CCG Southampton City CCG South-East Hampshire CCG West Hampshire CCG Wessex Local Medical Committees Local authorities Hampshire County Council Isle of Wight Council Portsmouth City Council Southampton City Council Health & Well being Boards Hampshire Health and Wellbeing Board Isle of Wight Health and Wellbeing Board Portsmouth Health and Wellbeing Board Southampton Health and Wellbeing Board Thames Valley and Wessex Leadership Academy​ Wessex Academic Health Science Network Wessex Clinical Networks and Senate Health Education Wessex NHS England South (Wessex) NHS Improvement Section Five: Our Commitment Over the course of the past months, a number of drafts of the Hampshire and Isle of Wight Sustainability and Transformation Plan [STP] have been considered by the constituent statutory bodies across the STP footprint. Glossary 39 Academic Health Science Network (http://wessexahsn.org.uk/) OD Organisational Development CQC Care Quality Commission OPE One Public Estate ED Emergency Department Attendances OPF Out Patient First Appointments EL Elective Care OPFU Out Patient Follow Up Appointments EQD Equality & Diversity ETTF Estates & Technology Transformation Fund PACS Primary Acute Community Services HCC Hampshire County Council (www.hants.gov.uk) PCC Portsmouth City Council (www.portsmouth.gov.uk) HEE Health Education England (www.hee.nhs.uk) PHT Portsmouth Hospitals Trust (www.porthosp.nhs.uk/) HHR Hampshire Health Record PICU Paediatric Intensive Care Unit HIOW Hampshire and the Isle of Wight QIA Quality Impact Assessment HWB Health and Wellbeing Board SCAS South Central Ambulance Service NHS Trust (www.scas.nhs.uk) IOW NHST Isle of Wight NHS Trust (www.iow.nhs.uk/) SCC Southampton City Council (www.southampton.gov.uk) LoS Length of Stay SHFT Southern Health NHS Foundation Trust (www.southernhealth.nhs.uk) LWAB Local Workforce Action Board Solent NHST Solent NHS Trust (www.solent.nhs.uk) MCP Multispecialty Community Provider (www.england.nhs.uk/ourwork/futurenhs/new-caremodels/community-sites) STP Sustainability and Transformation Plan MECC Making Every Contact Count (www.makingeverycontactcount.co.uk) TSOs Third Sector Organisations MOP Management of portfolios TVWLA Thames Valley and Wessex Leadership Academy (www.tvwleadershipacademy.nhs.uk) MSP Managing successful programmes UHS University Hospitals Southampton NHS Foundation Trust (www.uhs.nhs.uk) NEL Non-Electives admissions XBD Excess Bed Days Glossary AHSN Definition of terms A branch of secondary health care where a patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery. Typically this takes place in hospital Area health hubs Typically serving a population of 100k-200k, these will be open between 8am and 8pm seven days a week and offer the same range of services as a local health hub plus X-ray services, specialist clinics, access to beds on other NHS sites and, in some cases, a minor injuries unit Capitated outcomes based contracts Planning and providing services based around populations rather than treatment Care navigator A new role that helps to co-ordinate a person's care and make sure they can gain access to any services and community support they want or need; often based in a GP surgery Clinical commissioning groups (CCGs) Statutory NHS bodies led by local GPs that are responsible for the planning and commissioning of health care services for their local area Continuing health care A package of ongoing care that is arranged and funded solely by the NHS where the individual has been found to have a 'primary health need' arising as a result of disability, accident or illness Domiciliary care Also known as home care, is a term for care and support provided by the local council that allows people to remain in their home during later life, whilst still receiving assistance with their personal care needs Extended primary care Teams that include GPs, practice nurses and community nurses (including nurse practitioners and palliative care and other specialist nurses), midwives, health visitors Hampshire Health Record (HHR) This is a computer system used in the NHS in Hampshire to share important information safely about a patient with those treating them. This leads to faster and more accurate care. The Hampshire Health Record shows the medication you are currently taking, your allergies, test results and other critical medical and care information. Health and care staff can access your information if they have your permission to do so. Local Health hub Typically serving a population of 30k-50k, these will be open between 8am and 8pm on weekdays, offering same day access for urgent primary care, community and specialist clinics, an extended primary care team and wellbeing and illness prevention support Natural communities Geographical areas based on a center of population and its surrounding communities that allows health care to be tailored more accurately to local needs and, more importantly, helps identify the main causes of some common and preventable diseases New models of (integrated) care Make health services more accessible and more effective for patients, improving both their experiences and the outcomes of their care and treatment. This could mean fewer trips to hospitals as cancer and dementia specialists hold clinics local surgeries, one point of call for family doctors, community nurses, social and mental health services, or access to blood tests, dialysis or even chemotherapy closer to home Parity of Esteem Valuing mental health equally with physical health Place-based services Where providers of services work together to improve health and care for the populations they serve, collaborating to manage the common resources available to them Primary care A patient's main source for regular medical care, such as the services provided by a GP practice Secondary care Medical care that is provided by a specialist after a patient is referred to them by a GP, usually in a hospital or specialist center Social prescribing This is a way of linking patients in primary care with sources of support within the community. For example, a GP might refer a patient to a local support group for their long-term condition alongside existing treatments to improve the patient's health and well-being. Tertiary care Highly specialised medical care, usually over an extended period of time, that involves advanced and complex procedures and treatments in a specialised setting Third sector organisations (TSOs) A term used to describe the range of organisations that are neither public sector nor private sector. It includes voluntary and community organisations (both registered charities and other organisations such as associations, self-help groups and community groups), social enterprises and co-operatives Vanguards Individual organisations and partnerships coming together to pilot new ways of providing care for local people that will act as blueprints for the future NHS Glossary Acute care 40