Bedfordshire, Luton and Milton Keynes (BLMK) Single...

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Bedfordshire, Luton and Milton Keynes (BLMK)Single System Operating Plan 2019/2020

Narrative

11th April 2019 version 1.0

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Version Control V1.0 For Submission and Publication

Publication

Date

11th April 2019

Description This document has been produced to set out the BLMK system priorities for 2019/20. It updates last year’s Single

System Operating Plan as the focus in 2019/20 is:

1.To progress important initiatives already underway

2. Develop more ambitious longer-term plans taking into account the views of our residents and the NHS long-term plan

(Jan 2019).

Distribution

Summary

Draft v0.1 21st January ICS Team – Updated 2018/19 Single System Operating Plan

Draft v0.2 23rd January ICS Team - Version Circulated for updating

Draft v0.3 13th February ICS Team – Full draft having commissioned updates from across system

Draft v0.4 19th February ICS Team – Draft submitted to NHS England

Draft v0.5 18th March ICS Team – Final draft for Planning Leads

Draft v0.6 26th March ICS Team – Version to CEOs for sign-off

Final v1.0 11th April ICS Team – Incorporating any comments from CEOs and final review of

organisational plans

Executive SummaryThis is Bedfordshire, Luton and Milton Keynes (BLMK) IntegratedCare System’s (ICS’s) System Operating Plan for 2019/20. Thisplan describes how the BLMK ICS aims to:

• Improve the wellbeing and health of our residents during2019/20 and beyond by reducing the over-reliance on acuteservices, strengthening out of hospital services, challenginginefficiency and driving the prevention agenda.

• In so doing we will deliver:

– the Quadruple aim (see Figure 1)

– the NHS Long Term Plan

– The agreed BLMK financial system control plan

This plan provides a strategic framework for our work togetheras a partnership during 2019/20.

Section 1 of the plan sets out the BLMK background and someof the issues facing our residents. Section 2 then covers thenational context and our triple tier approach of locality (PrimaryCare Networks), place (Local Authority) and scale (ICS).

Section 3 then goes on to explore our vision for the ICS and includes a brief assessment of the progress we made in 2018/19.

Section 4 sets out our priority workstreams and details how we are making progress on them at place, in Bedford, Central Bedfordshire, Luton and Milton Keynes. Section 5 describes the work we have planned for priority groups and conditions identified in the NHS Long Term Plan.

Section 6 considers our finances and work on estates, before section 7 looks at our most important asset, our workforce. Our staff have told us that working together in partnership we can achieve much more for our residents than is possible as single organisational entities.

Transforming the way we work takes time and section 8 considers our work during 2019 to create a long term plan for the ICS. In doing this we will be listening to what really matters to residents.

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Figure 1: the Quadruple AimSource: https://thekinetixgroup.com/the-era-of-the-quadruple-aim/

https://thekinetixgroup.com/the-era-of-the-quadruple-aim/

Foreword by Richard Carr (Senior Responsible Officer)

2018/19 was the first year BLMK has operated as an Integrated Care System (ICS). We are getting used to this new way of working and can recognise the benefits in taking a more collaborative approach.

There have been significant achievements, especially in thedevelopment of primary care networks and social prescribing as weseek to develop more preventative, proactive care.

2019/20 is a transition year – the last year of working on the NHSFive Year Forward View and the first year of working on deliveringthe NHS Long Term Plan.

To determine our priorities for the longer-term we are havingconversations with our residents and developing long-term plansfor the Autumn.

We have therefore taken a pragmatic approach for this year,updating the 2018/19 plan, whilst adding some new prioritiesbased on the evidence of the RightCare programme and on issueswhere we can improve against our peers. This means enhanced ICSwork programmes on respiratory, cardiovascular disease and HighIntensity Users.

Although we are generally a high performing system, we alsorecognise we have more to do to tackle long waits for elective care,to deliver NHS Constitution standards for cancer treatments and tomeet mental health targets.

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.

We are delighted that the NHS Long Term Plan recognisesIntegrated Care Systems as the future, which gives extra impetusto our collaboration. Working beyond our individualorganisational interests to focus on achieving the best outcomesfor our residents is a ‘noble cause’ by which everybody workingin health and care in BLMK should be motivated.

As an ICS we build up from our places (the four Local Authorityareas) and much of this plan reflects the local delivery happeningat place. We working to improve our governance to support theright balance between place and system. Sometimes place takesprecedence, when for instance we are integrating health andsocial care. At other times, there are economies in doing thingson a broader scale, such as our digital strategy.

Our System Operating Plan 2019/20 contains our collectiveproposals for action. It can only be achieved in partnership witheach other, including in partnership with our residents. Thankyou to all those who will be working so hard to make it happen.I look forward to seeing our progress as an Integrated CareSystem over the next year and to us working together to delivertangible improvements to the health and wellbeing of ourpopulation.

Richard Carr,

SRO for BLMK ICS and CEO of Central Bedfordshire Council

1. Introduction

Welcome to our second Bedfordshire, Luton and Milton Keynes (BLMK)System Operating Plan. Our Sustainability and TransformationPartnership (STP) is one of the ten first wave Integrated Care Systems(ICSs) and our plan reflects this, bringing together our individualorganisational plans to support our work as one system. We havecontinued to grow and develop as a system in the last year, building onour track record of delivery and collaborative working.

The plan describes the ambitions of the transformation programmeswe are undertaking across BLMK. It sets out the high level workprogrammes for how we will:

– deliver our vision as set out in our original STP plan;

– deliver the national priorities;

– improve wellbeing and health across each of our places;

– improve quality of care;

– improve efficiency and productivity.

The plan acts as an umbrella for the plans developed and owned byeach of our four place-based Transformation Boards and theoperational plans for our NHS partners. It is underpinned by detailedactivity and financial trajectories and supported by workforce anddigital plans. A high level snapshot of each ‘place based plan’ is shownin summary within this narrative.

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It has been developed in the context of national policyand local needs, illustrated below.

National

NHS Long Term Plan

ICS Memorandum of Understanding

BLMK Footprint

BLMK Sustainability and Transformation Plan and Single System Operating Plan 18/19

CCG Commissioning Intentions

Place

Central Bedfordshire Health & Wellbeing Strategy

Bedford Borough Health & Wellbeing Strategy

Luton Health & Wellbeing Strategy

Milton Keynes Health & Wellbeing Strategy

Bedfordshire, Luton & Milton Keynes (BLMK)– Almost one million people live in Bedford Borough, Central Bedfordshire, Luton

and Milton Keynes. These are four very different places that are also diverse within themselves. These differences affect what local people need from their health and social care services.

– BLMK has a combined population of 932,000 which is projected to grow to 1,081,000 by 2035 if recent trends continue. The number of people aged 85 and over is projected to double by 2035 and there will be higher than average growth the number of adults aged 65 and over and the number of children and young people aged 10-19 years old.

– Luton is the most urban, most deprived and most ethnically diverse of the four local authority areas; Bedford Borough and Milton Keynes are urban with significant ethnic minority communities and areas of deprivation as well as some rural areas; Central Bedfordshire is the most rural, least deprived and least diverse of the four areas. It does however have pockets of deprivation and around 30% of its residents use acute hospitals outside of the BLMK footprint.

– BLMK falls within the Oxford-Cambridge Arc, which, as a whole, is expected to house 1 million new homes by 2050. BLMK partners are working together to ensure appropriate health and social care infrastructure is in place to meet the challenges of this significant growth in BLMK population.

– There are also significant differences in demographics, ethnic diversity and deprivation within the footprint which our plans need to be alive to. Across the BLMK geography we have some significant variances in health and wellbeing outcomes. For example, healthy life expectancy, an estimate of the average number of years lived in good health, varies from 61.3 years for men in Luton to 67.6 years for women in Central Bedfordshire.

– There are 102 GP practices within the BLMK footprint, with 424 WTE GPs. At 2837 the average list size per GP compares unfavourably with England as a whole (with Luton a particular outlier at 3336 patients per GP)

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N.B. Distance to hospitals outside our ICS not shown to scale.

What should be our focus?

In 2019/20 we retain the rationale that we set out previously that we think we can do better than the fragmented health and care system we have at the moment. Working together means putting our residents at the heart of the services we provide, rather than focusing on which institution is providing them.

And there are other reasons that mean we need to work differently to make sure we have the best health and care services available for local people now and in the future:

– Our population is growing. Recent trends suggest that, by 2035, around 150,000 more people will be living in our region. There are ambitious potential plans to accommodate a step-change in housing development through development of the Oxford-Cambridge Arc, which would bring even more homes and growth for BLMK.

– We still have significant health inequalities in Bedfordshire, Luton and Milton Keynes. In some parts of BLMK there is an 11 year difference in life expectancy between the least and most deprived areas.

– Demand for our health services is increasing at a faster rate than ever before – around 10% more people every year come to our A&E departments, and more than people than ever are being admitted to hospital.

– We need to do more to recruit and retain doctors, nurses and other health and care professionals. Around 25% of the GPs in Bedfordshire, Luton and Milton Keynes are eligible for retirement in the next five years. Recruiting specialist consultants is becoming increasingly challenging. Changes in how nurse training is funded, and the uncertainty created by Brexit, means fewer nurses are coming into the profession.

– We need to focus on the challenges within the Care Market. Market sustainability, as well as recruiting and retaining a skilled and capable workforce is key to delivering our priorities for promoting independence and keeping people at home, in their communities with care for much longer, when it is appropriate to do so.

– We focus much of our resource on treating rather than preventing ill health. – The money is challenging with increasing numbers of people living longer with more complex health needs, and

increasing demand for health and care services. – More detail on the health challenges facing our residents are contained on the following two slides.

These are compelling reasons to change, and the 15 organisations* that make up the health and care system in Bedfordshire, Luton and Milton Keynes are committed to working together to ensure those changes deliver the best possible health and care services for residents now and in the years to come.

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* Luton Council does not participate in the formal governance of the BLMK ICS but has a protocol in place with the ICS to support joint working.

The current health and wellbeing of our residents I

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•Life expectancy across BLMK has been rising for decades but in the last couple of years this rise has slowed or halted. Male life expectancy at birth ranges from 78.3 years in Luton to 81.4 years in Central Bedfordshire, and for females it ranges from 82.3 years in Luton to 84.4 years in Central Bedfordshire. Female healthy life expectancy ranges from 62.7 in Luton to 67.6 years in Central Bedfordshire, whilst male healthy life expectancy ranges from 61.3 in Luton to 66.4 in Central Bedfordshire. (ONS, healthy life expectancy at birth 2015-17)

•There are significant gradients of life expectancy within each local authority area. For men the life expectancy gap between the least and most deprived areas is largest in Bedford Borough (11.4 years); for women it is largest in Milton Keynes (7.4 years). (PHE, Slope Index of Inequality 2015-17)

Life expectancy and health inequalities

•Wider determinants of health including social, economic and environmental factors contribute to at least 60% of health outcomes (Buck & Maguire (2015) Inequalities in Life Expectancy, King’s Fund)

•An estimated 32,600 households across BLMK experience fuel poverty. (DBEIS, Fuel Poverty data 2016)

•Less than half of adult social care users in BLMK report that they have as much social contact as they would like. (NHS Digital, ASCS 2016-17)

Wider determinants of health

•In 2017/18 53% of pregnant women did not receive a seasonal flu vaccination in BLMK. (PHE, Seasonal flu vaccine uptake 2017-18)•Coverage of childhood immunisations is generally ok, but the proportion of children receiving two doses of the measles mumps and rubella vaccine fell short of the 95% national target. (PHE, COVER 2017-18)

•1 in 5 children aged 5 to 6 are overweight or obese, rising to 1 in 3 by age 10 to 11. (NHS Digital, NCMP 2016-17)•In line with the national trend, hospital admissions for self-harm have risen in recent years across Bedford Borough, Central Bedfordshire and Luton. (NHS Digital, HES 2016-17)

•Four unhealthy behaviours are responsible for the majority of preventable ill health and mortality: smoking, poor diet, lack of physical activity and excessive alcohol consumption (Buck & Frosini (2012) Clustering of unhealthy behaviours over time, King’s Fund).

•More than a third of adults in Bedford Borough consume more than 14 units of alcohol a week and in Milton Keynes and Luton, alcohol related admission have fallen slightly. (PHE, Health Survey for England, 2011-14)

•The proportion of adults who are overweight or obese ranges from 60.2% in Bedford Borough to 65.6% in Milton Keynes. (PHE, ALS 2016-17)

Health behaviours and risk factors

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•Across BLMK the leading causes of preventable mortality are cancer and cardiovascular disease, followed by respiratory disease and liver disease. (PHE, ONS mortality extracts, 2015-17)

•1 year survival for breast cancer are worse than England for Luton and Milton Keynes CCG; 1 year survival for lung cancer is worse than England for Bedfordshire CCG; and 1 year survival for colorectal cancer is worse than England for Luton CCG. (ONS, 1-year Cancer Survival 2016)

•The incidence of alcohol-related cancers is similar to England across BLMK. (PHE, Risk Factor Intelligence team 2014-16)

•Cervical screening coverage has fallen across BLMK, in line with the national trend. (PHE, NHAIS 2018)

•There are an estimated 89,000 adults across BLMK with undiagnosed high blood pressure and 27,100 who are not treated to target. There are an estimated 7,200 adults with undiagnosed atrial fibrillation (AF), which is a major risk factor for stroke, and 2,400 adults with high risk AF who are not optimally treated. (NHS, Size of the Prize 2015/16)

•The rate of premature mortality from cardiovascular diseases and heart disease are significantly worse in Luton. (PHE, ONS mortality extracts 2015-17)

•The prevalence of diabetes is rising for all BLMK CCGs. The proportion of diabetes patients who achieve treatment targets for blood sugar, blood pressure and cholesterol is lower than England for Luton CCG. (NHS Digital, NDA 2016-17)

•Emergency admissions for asthma in under 19s is higher than England for Luton and Milton Keynes CCGs. Emergency admissions for children with lower respiratory tract infections are rising for Bedfordshire and Luton CCGs. (NHS Digital, NHS Outcomes Framework 2017-18)

•Across BLMK there are between 1,235 and 1,895 women with mild-to moderate perinatal depression or anxiety. (NHS Digital, HES 2015-16)

•The proportion of adults in BLMK with anxiety or depression entering Improving Access to Psychological Therapies (talking therapies) has historically been lower than the England average, and the rates of planned and emergency admissions for mental health are higher than expected for Bedfordshire and Luton CCGs. (NHS Digital, IAPT KPIs 2012-13)

•Emergency admissions due to falls in adults over 65 have risen across BLMK and the rate of hip fractures has risen in Bedford Borough, Luton and Milton Keynes. (NHS Digital, HES 2017-18)

•There are 5,662 people in BLMK with a diagnosis of dementia but a further 3,896 are thought to be undiagnosed. (NHS Digital, QOF 2017-18)

•By the age of 65 most adults have two or more long term conditions (what’s known as multimorbidity). Multimorbidity is more common in more deprived neighbourhoods, and while older people tend to have more long term conditions there are more people under 65 withmultimorbidity than over 65. (GP Patient Survey, 2018)

Morbidity and Mortality

The current health and wellbeing of our residents II

Most data cited here is available online here: https://fingertips.phe.org.uk/

2. Context & Purpose– The NHS England Long-term Plan for the NHS sets out an enhanced role for ICSs as the future for the NHS.[1] This includes:

» “Through ICSs, commissioners will make shared decisions with providers on how to use resources, design services and improve population health.”

» “Each ICS will be required to implement integral services that prevent avoidable hospitalisation and tackle the wider determinants of mental and physical ill-health.”

» “ICSs will agree system-wide objectives with the relevant NHS England/NHS Improvement regional director and be accountable for their performance against these objectives. This will be a combination of national and local priorities for care quality and health outcomes, reductions in inequalities, implementation of integrated care models and improvements in financial and operational performance. ICSs will then have the opportunity to earn greater authority as they develop and perform.”

» “As ICSs take hold, we will support organisations to take on greater collaborative responsibility. There will be a clear expectation that strong, successful organisations not only provide high-quality care and financial stewardship from an institutional perspective, but also take on responsibility, with system providers, for wider objectives in relation to the use of NHS resources and population health. This will mean that neither trusts nor CCGs will pursue actions which, whilst potentially improving their institutional financial position, would result in a worse position for the system overall. This will be supported by a system oversight approach which reviews organisational and system objectives alongside the performance of individual organisations, whereby our regions seek to understand the drivers of challenges facing organisations and ensure that solutions reflect the wider system changes required.”

– This document sets out a single narrative for the BLMK ICS and aligns with the key assumptions for income, expenditure, activity and workforce across BLMK as outlined in separate financial and activity plans.

– It provides a summary of the priorities for 2019/2020 to drive better care delivery and health outcomes for our local population, whilst at the same time making significant progress in ensuring a sustainable financial position.

– It also sets out the thinking of the system on the development of a BLMK longer-term plan to set the future priorities for wellbeing and health and respond to the national plan.

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[1] CCGs and Council Executives remain the statutory commissioners for health and social care.

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Our Triple Tier Model

BLMK was one of the pioneers of the Triple Tier Model – the suggestion that the key levels of health and care are locality (Primary Care Networks), place (Local Authority) and scale (ICS). This has been adopted by the NHS Long Term Plan. It is our belief that services should be organised as locally as possible, where safety and efficiency allows.

Triple Tier Model

1) At scale Primary (and extended primary) Care

2) Population Health Management approach

3) Out of Hospital services wrapped around GP locality networks

@Lo

calit

y1) Pooled commissioning2) Systems Integration3) System level

transformation & development

4) System self-regulation

@Sc

ale1) Health & Wellbeing Strategies

2) Integrated Outcomes Based Commissioning

3) Integrated Service Delivery4) Managing risk in partnership

@Pl

ace

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Health and Care in BLMK

Social Care and Public Health

Clinical Commissioning Groups

Mental Health

Community Health Services

Acute Services Primary Care *

Ambulance

Bedford Borough Council

Bedford-shire CCG

East London NHS Foundat-ion Trust

East London NHS Foundation Trust and Cambridge-shire Community Services NHS Trust

Bedford NHS Hospital Trust

4 Networks East Of England Ambulance Service NHS Trust

Central Bedfordshire Council

5 Networks

Luton and Dunstable NHS Foundation Trust

Luton Council Luton CCG

4 Networks

Milton Keynes Council

Milton Keynes CCG

Central and North West London NHS Foundation Trust

Milton Keynes University Hospital NHS Foundation Trust

7 Networks South Central Ambulance Service NHS Foundation Trust

The key organisations in providing health and care services across BLMK are set out in this table. There are also a wealth of important voluntary sector and wider public service partners.

Bedford Borough

Central Bedfordshire

Luton

Milton Keynes

* Number and Configuration of networks currently being reviewed

Place

Vision Statement

We are working together to improve the health and wellbeing of the people living in Bedfordshire, Luton and Milton Keynes, and are responsible for making sure people get the information, support and access to services they need to live healthy lives for as long as possible. We are working together to make sure local people know how stay healthy. And when people are ill or need social, mental health or community support, that those services are delivered in a way that meets their needs and are delivered in the best place –whether that’s in someone’s home, the local community, a GP surgery, an integrated health and care hub or a hospital.

We want to put an end to a health and care system that starts and stops because the organisations involved don’t work together. Wewant to put our residents at the heart of our health and care system and make sure services are delivered around their needs.

We want to support the thousands of doctors, nurses and other health and care staff working in our organisations to deliver the bestcare and services they can now and for future generations.

We have a responsibility to work together to respond to the challenges our health and social care system faces today to make sure

local people have the best possible health and care services in the years ahead.

What does our system look like now?

There are 15 statutory organisations* responsible for delivering or organising the delivery of health and care services in Bedfordshire, Luton and Milton Keynes. These include local councils (who organise a range of statutory services including social care and public health), hospitals, clinical commissioning groups (led by GPs and responsible for the planning and buying of NHS healthcare), and organisations providing community and mental health services. There are also many, many charities, voluntary carers and community groups providing help, care and support to residents.

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3. VisionWhy we are doing what we’re doing

* Luton Council does not participate in the formal governance of the BLMK ICS but has a protocol in place with the ICS to support joint working.

Now and the futureCurrently, many organisations work independently and provide the care and services that is within the scope of their contract. This means that people who need those services from multiple organisations have to work out how and where to get them. Sometimes that’s simple – most of us know who our GP is, or how to call 111, how to get emergency care at A&E or by calling 999. But sometimes it’s very complicated – many of us wouldn’t know who to contact if our elderly relative was about to be discharged from hospital and needed transport, community care support and care from a district nurse.

Organisations working separately means that patients and residents are not always at the centre of services. Care starts and stops at the door of the organisations responsible for providing it. This means people – often at their most vulnerable – have the challenging task of navigating a complex health and care system.

We think we can do better.

What do we want the future to look like?

That every person in Bedfordshire, Luton and Milton Keynes can live healthy lives for as long as possible. People will have the knowledge and support to live healthy lives and to manage their long-term conditions and are able to participate in their communities. We will tackle the lifestyle behaviours that have a negative impact on health (smoking, alcohol, poor diet and physical inactivity) and promote mental wellbeing.

That every resident has access to community, mental health, primary and social care that is personalised and organised around the individual. Primary Care Networks, where GPs work hand-in-hand with specialists across community, mental health and social care,pharmacy and therapy services are established for every community.

That there is parity of esteem for mental health and learning disability services, with services built around the needs of residents.

That the three acute hospitals provide services for their populations, with every resident having access to world-class specialist care as close to home as possible.

That care records are shared so there is real continuity of care, and data is used to predict and plan health care interventions and proactively meet the demand for services.

For Bedford Borough, Central Bedfordshire, Luton and Milton Keynes to develop as an ICS with shared goals and targets focussed on improving health outcomes and services for local people with local democratic legitimacy and the support of statutory boards.

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Progress in 2018/2019In summary, in 2018/19 we have achieved the following:

• Establishing social prescribing schemes (allowing referral to local non-clinical services that can improve wellbeing and health) in all four places with 1,000 residents benefitting .

• Creating 20 primary care networks across the ICS (typically serving 30,000-70,000 people) which bring together GPs, community, mental health and social care services. These networks are starting to segment their populations to enable proactive population health management.

• Progressed work to develop shared care records across the ICS, allowing clinicians to make better and safer decisions about care.

• Securing £10 million funding for improved stroke rehabilitation facilities in Bedford and a pathway unit to reduce pressure on A&E in Milton Keynes.

• Programmes underway in all areas to join up care for those with complex needs and/or frequent users of health services. The Milton Keynes High Intensity User programme was a finalist in the HSJ Awards 2018 Improvement in Emergency and Urgent Care category.

• Faecal Immunochemical Testing (FiT) has been rolled out across BLMK, to identify bowel cancer earlier.

• Rolled out red bag scheme for Care Home residents and improving digital infrastructure of care homes with nhs.net and wifi.

• Successfully bidding for £1.2 million of funding to establish an effective perinatal mental health service across the ICS.

• The ICS has attracted in £36 million of external funding (e.g. on digital and cancer) since 2016-17.

• The creation of one Executive Team for the 3 Clinical Commissioning Groups (CCGs), a system focus.

4. Priority Workstreams

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Prevention: Preventing ill health and promoting good health by giving people the knowledge and ability, individually and through local communities, to manage their own health effectively.

Primary, Community & Social Care: Delivering high quality and resilient primary, community and social care services across Bedfordshire, Luton and Milton Keynes.

Sustainable Secondary Care: Delivering high quality and sustainable secondary (hospital) care services across Bedfordshire, Luton and Milton Keynes

Digitalisation: Working together to design and deliver a digital programme, maximising the use of information technology to support the delivery of care and services in the community, in primary and secondary care and residents’ homes.

Re-Design: Working together to make sure the right services are available in the right place, at the right time for everyone using health and social care in Bedfordshire, Luton and Milton Keynes.

P1

P2

P5

P4

P3

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‘Place Based’ Delivery 2019/2020

There are four places in BLMK, which correspond to the fourLocal Authorities: Bedford Borough, Central Bedfordshire,Luton and Milton Keynes.

Bedford Borough and Central Bedfordshire are covered by oneCCG and there are often similarities in the work they are doing(albeit with key local nuances) so sometimes their deliveryactions are the same or joint.

The majority of delivery happens either within primary carenetworks or at place. The following slides therefore set outdetail on the priority areas and what is happening at place todeliver this.

Approaches to delivery at place will be co-produced by NHSproviders and commissioners, local authorities and otherpartners. Delivery will be monitored by the place-basedTransformation Boards.

Priority 1 – Prevention

BLMK approach

To strengthen and implement approaches and interventions to support the BLMK System to deliver the NHS Long Term Plan, ‘Prevention is better than cure’ vision and the ambitions within the Health and Wellbeing Strategies. This will be achieved through embedding a preventative approach throughout the BLMK system to reduce avoidable demand on Health and Care.

The proposed actions in each part of the system* include:

ICS:• Share best practice, evidence and evaluation of approaches for prevention, including social determinants of health.• Establish a system wide CVD prevention programme including identification and proactive management of residents with

increasing risk. • Focused communications to support prevention in the working age population with multi-morbidity. • Support providers of care to embed prevention to support both patients and staff – including supported self-assessment of

prevention, the dissemination of work-place wellbeing principles and delivery of personalisation training for staff• Develop a network of Healthy Living Pharmacies to support people to self manage and self care.

Place:• Identify sustainable funding to maintain and expand current social prescribing programmes.• Support primary care networks to integrate prevention within their population health management.• Facilitate a self-care network to increase access to health and wellbeing programmes, to support individuals and families to reduce

their chances of becoming unwell.• Support people in communities to engage in local action to help themselves and others to stay well (Social Movements)• Implement Joint Health and Wellbeing Strategies

Neighbourhood / Primary Care Networks:• Integrate prevention into population health management approaches

* the division between ICS, place and neighbourhood is illustrative, we are aware that some actions need to occur across the system

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Priority 1 – Prevention: Place Based Response

Luton

• Develop and Implement Luton’s Health and Wellbeing Strategy including the place based approach building on community assets, enabling people to help themselves and others stay well

• Further development of the jointly commissioned Social Prescribing to support primary care clusters to integrate prevention within their population health management pathways

• Identification of undiagnosed hypertension and CVD to detect and treat by proactive and motivate residents to reduce risk factors

• Promoting mental wellbeing via co-production and implementation of the reimagining mental health offer

• Implement a wide ranging healthy weight strategy for children, including support for families

Milton Keynes

Early detection and treatment of CVD:Continue to deliver MK Healthy Heartsprogramme that has a focus on increasingthe detection and treatment ofhypertension by proactive managementof residents with increasing risk

Social Prescribing:Embed and expand LiveLife MK social prescribing programme for adult residents with non-clinical presentations and support primary care clusters to integrate prevention within their population health management pathways

Deliver a Self-Care Programme:to increase access to health and wellbeing programmes and to support individuals and families to reduce their changes of becoming unwell by:

▪ Taking a whole systems approach to improve the health and wellbeing of our communities through the use of innovative approaches and new models of care to support residents to quit smoking, achieve a healthy weight and reduce alcohol use.

▪ Developing stakeholder engagement as part of the Social Movement Programme to support people in communities to engage in local action to help themselves and others to say well

Funding in place to continue Social Prescribing service aligned to named GP surgeries for 2019/20. Working with partners to develop and implement the Social Prescribing Link Worker as part of the 5 year Framework for GP contract reform.

Prevention work with Age UK and Red Cross to support people at home / less reliance on health and social care services.

Prevention work with the Fire and Rescue Service to support people with dementia and their carers to remain safe.

Implement the Joint Health and Wellbeing Strategy.

Bedford Borough Central Bedfordshire

• Embed social prescribing programmes across Central Bedfordshire, integrating with link workers (in LTP) to support primary care clusters to address the social determinants of health.

• Build the self-care network to increase access to health and wellbeing programmes, to support individuals and families to reduce their chances of becoming unwell.

• Implement the Joint Health and Wellbeing Strategy including testing a new place based approach building on community assets, enabling people to help themselves and others stay well. Use the outputs of the Health Needs Assessments to identify actions to improve mental health and wellbeing.

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Priority 2 – Delivering high quality and resilient primary, community and social care servicesBLMK deliverables – Primary Care NetworksAlign financial levers and incentives to support Primary Care Network (PCN) development: CCG collaborative to utilise existing and new funding streams, as well as national contract changes , to foster bottom up service / workforce re-design Work with innovative PCNs to ensure necessary governance is in place: individual practices in a local area will enter into a network contract, as an extension of their current contract, and have designated funds through which all network resources will flowIdentify named responsible Clinical Lead for each PCN: to be encouraged in all places as a priority to ensure both managerial and clinical leadership are embedded within all NetworksContinued programme of leadership development: a joint ICS and CCG collaborative approach providing the necessary coaching and mentorship to build strong managerial and clinical Network capabilities, identifying a team of subject matter experts across BLMK Deploy Population Health Management Solutions for each place: to support PCNs to understand the areas of greatest need and develop integrated professional services to meet themFocused emphasis moving to a truly integrated PCN team with GP leading the co-ordination of patient care: taking further steps to ensure the wider workforce become s integrated within Networks serving the needs of their population, and are not just pseudo teams (extended professionals placed alongside general practice ). Removing the need for referral and hand-off between care professionals Encourage a new dynamic between commissioners and providers and, importantly, between providers: work with system leads to give Network teams , consisting of commissioners, providers, voluntary sector and public, the permission to co-design services based on their populations identified need , to reduce inequalities and deliver more person-centred careWork to align place based service models with emerging PCN population based models: utilising opportunities for scale to support bottom up Network developmentEmbed systematic methods of Quality Improvement (QI) to ensure the PCN development model is self-sustaining: support PCNs by developing their teams improvement capabilities, including QI skills and data analytics

• Implementation of PCN contracts and associated schemes (e.g. deployment of new roles such as social prescribing)

• Leadership of PCNs to be established as per NHS Long Term Plan

LutonNetwork Development 3 accelerator sites out of 4 networks. Non- accelerated cluster learning from accelerated clusters and implementing core PCH methodology with basic governance in place.Demonstrable shift in focus from ‘place’ to ‘PCN’

Milton KeynesPrimary Care Home Model - 7 Clusters (networks) focusing on short, medium and long term development plansRollout of new models of care as a proactive approach to population health management (e.g. Care Navigation) through risk stratification to identify bio psychosocial needs for a given population (now in pilot phased with a planned rollout across all clusters)


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Bedford Borough

Priority 2 – Delivering high quality and resilient primary, community and social care services

LutonAll Clusters (emerging Networks)• Right size to care (30 – 70,000)• Good financial alignment with investment

encouraging PCN• Appropriate governance (MoU /ToR )in

place demonstrating a commitment to collaborate - allowing utilisation of funds and resources to support Network development

• Embedding a Population Health Management (PHM) approach

• Population segmentation complete• Priority population segments agreed • Core (task) groups identified including

patient / voluntary sector representatives to review population need, service models and workforce development

Accelerated Clusters (emerging Networks)• Development of Network support team

(Project Manager, Finance & PHM lead)• Move to a single primary and community

care provider team (not a pseudo team)• Evaluation embedded as BAU• Network contract in place• Leadership and subject matter experts

available to ensure sustainable Network approach

Milton Keynes▪ Care Navigation approach utilises

multi disciplinary personalised care skills sets from health, social and 3rd

sector to focus on high intensity users and enable care in the most appropriate setting

▪ Development of e-Consultations to improve patients access to first-line treatments (pilot phase which plans for further rollout across clusters)

• Rollout of leadership programme for primary care staff and development of skill sets within primary care to support multi disciplinary working (e.g., physician assistant pilot programme with a view to roll out across BLMK)

▪ Working with BLMK partners to develop a Primary Care Strategy for investment of £1.50 per head funding flows into clusters which may include a number of target support offers to improve patient outcomes

▪ Continue to implement the digital and estate strategy requirements across primary care clusters

• PMS scheme for 19/20 to support PC Network practices to work together with other health and social care teams to develop and expand MDT working.

• Capital Funding has been applied for to develop Healthcare Hubs in localities to act as a focal point for Primary care Networks, providing a range of primary care and out of hospital services – closer to home.

• Continued delivery of workforce programme (training, new roles development, recruitment)

• Continued digital development (MJOG, online consultation development)


Integrated Health Care Hubs - Development of OBCs for two Integrated Health and Care Hubs and procurement of design and build contracts.

21

BLMK approach – Primary Care Networks Continued

Bedford Borough

Priority 2 – Delivering high quality and resilient primary, community and social care servicesBLMK approachComplex Care (Adults):People with complex needs , multiple long terms conditions and those at high risk of deterioration. ▪ BLMK has developed and is now adopting a house of care approach (see next slide), which provides a standardised framework for each ‘place’ to

develop local models of care; ensuring key components of care feature in all models and are aligned to the aspirations of our Primary Care Networks.

▪ High Intensity User (HIUs) Programmes are an integral element of providing enhanced support to people with complex needs across BLMK. Each place has initially prioritised different cohorts – and ‘place’ models will evolve and be developed through shared learning across primary care networks, place and at ICS level.

Luton

High Intensity UsersPriority cohort is under review in line with NHSE definition – due to the planned, staged, expansion of the previous cohort to all people who are 65+ and moderately or severely frail (approx. 7500).Currently supported by daily data feeds from acute hospital to the community services generating an automated referral. Individual patient data is triangulated across community services, primary care, social care and mental health partners to identify which patients are known/not known to services. Enhanced integrated case management support and required interventions are then coordinated via daily huddles and weekly MDT meetings. Programme is led and coordinated by community provider

Milton Keynes

High Intensity UsersPriority cohort is people who are 18+ and the highest users of emergency services and have had 20 plus A&E attendances (mixed in terms of presentation issues and include a range of vulnerable adults).Supported by collaborative working across a range of professionals - police/social care/voluntary sector etc.MDTs are hosted in primary care hubs and social prescribing is an integral element where link workers can provide intensive and bespoke support

Bedford Borough

Current Cohort of approx. 250

.

High Intensity UsersPriority cohort is people who have had 5 or more ambulance conveyances, 4 or more non elective admissions or 6 or more A&E attendances; both adults and children.

Supported by business intelligence team providing pseudonymised GP practice level HIU reports.

Monthly locality reports highlight HIUs and ‘tracking’ of individual HIU activity each month. Practices work through lists of HIUs identifying appropriate interventions and / or referral eg to MDTs.

Supporting the High Intensity Serenity Integrated Mentoring (SIM) model.

Commissioners and provider proposing work through lists to test bed emergency service wide system process to support HIUs.

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Current Cohort of approx. 400

.

Complex Care: House of Care Approach

23

Priority 2 – Delivering high quality and resilient primary, community and social care servicesBLMK approachComplex Care (Adults):People with complex needs , multiple long terms conditions and those at high risk of deterioration. ▪ BLMK has undertaken self-assessment against ‘NHSE Enhanced Health in Care Homes Framework’ and identified and agreed ten ‘system-wide’

priorities to drive forward further implementation of the EHCH framework; complimenting current planned initiatives ‘at place’.▪ BLMK has undertaken self-assessment against ‘National Ambitions for Palliative & End of Life Care’ and identified two major ‘system-wide ‘

priorities to drive forward improvements in care at end of life, in particular to reduce need for emergency hospital admissions for people in last 3 months of life.

▪ BLMK has and will continue to work alongside NHSE and local stakeholders to develop robust methods of measuring impact of our house of care approach; ensuring that the benefits and limitations of the plethora of data tools and data sets are recognised.

LutonA Framework for Frailty in LutonThe main aim of this programme is to promote healthy ageing, to case find frail elderly, proactively manage their care and reduce the need for older people, those aged over 65, to be urgently admitted to hospital. This will be achieved through system-wide development and implementation of a framework; clearly describing the interventions and services across health & social care that will support older people with healthy ageing and to remain in their own home for as long as possible. The framework describes the offer for each frailty cohort; fit, mild, moderate and severe.

Milton Keynes

a) Care HomesWe will continue to focus on a system wide ‘placed based’ delivery to:

▪ Embed care and support planning across all 27 care homes including optimisation of medicines

▪ Strengthen localised pathways (e.g., independent Assessor and Urinary Tract Infection hydration rollout)

▪ Continue to make progress on the roll out of the digital programme and in 19/20 pilot remote patient monitoring for care/link workers

Bedford BoroughCare Home Residents• Trusted Assessor model in

place at Bedford and Luton and Dunstable Hospitals.

• Further embed Red bags• Annual medicines

management reviews undertaken by BCCG care home pharmacist.

• A pilot using the Whzantechnology commenced in 2018 and conclude at the end of May 2019. A final pilot evaluation report will be produced during June/July 2019.

Central BedfordshireEnhanced health in care homes• Expand Trusted Assessor model beyond

Bedford and Luton and Dunstable to other hospitals used by Central Bedfordshire residents.

• Further embed use of Red bags• Broaden programme of medicines

management reviews and support to MDTs.

• Patient Centred Software in use in CBC Homes and accessible to health professionals and relatives

• A pilot using the Whzan technology (identifies patients requiring clinical intervention) commenced in 2018 in 7 Care Homes will conclude at the end of May 2019 with plans for wider roll out subject to evaluation of the pilot.

• All care homes to achieve a minimum of bronze digitisation in 19/20. • Implementation of local solution to telemedicine to care homes in line

with the ‘Airedale’ model.• Development and implementation of a Bedfordshire wide Complex Care

Team service model to all care homes.• End of Life Care training into all care homes.

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BLMK approach - Complex Proactive Care Continued

Bedford BoroughComplex Care - All residents• Complex care management in care

homes.• Community Provider Incentive

Scheme to develop named cohort of patients within agreed criteria to be proactively managed by community provider supported by GPs, social care, and third sector to avoid A&E attendances and admissions.

• Streamlining community referrals to ensure people receive the care they need at the time they need it. Focus is now on transferring all referrals to electronic referrals.

• Discharge to assess (D2A) embedded at BHT. Work underway to improve the D2A pathway at L&D for BCCG discharges.

• Proactive MDTs have been established across Bedfordshire across health and social care.

End of Life (EoL)• Further work being undertaken to

increase the number of Advanced Care Plans rolled out to Bedfordshire residents. An audit of Training for EoL is underway to ascertain gaps.

• A new CHC fast track pathway has been rolled out to North & Mid Beds.

LutonCare Home ResidentsWhere people can longer remain in their own home, the framework for frailty seeks to ensure that the best possible care is provided for older people in residential & nursing settings.

This will be regularly reviewed through self-assessment against NHSE Enhanced Health in Care Homes Framework.

End of LifePeople at end of life will experience coordinated care in line with National Ambitions for Palliative & End of Life Care to support reduction in need for emergency admissions in the last 3 months of life.Our key focus areas are:▪ Improving identification and

access to co-ordinated person-centred health and social care in the last years of life

▪ Enhancing health and social care professional's ability to support people in the last years of life.

▪ Promoting community awareness and involvement.

Milton Keynesb) Frail & Older Person’s Model of Care (>65 years) to reduce avoidable hospital admissions will focus on:▪ Embedding a system wide, holistic

multi-disciplinary model across healthand social care (including third sector)to provide a person centredcoordinated response to individualneeds

▪ Each person having a co-producedindividualised Care Plan with anidentified case manager andappropriate support service (utilisingthird sector capacity) to deliver personcentric holistic are

▪ Creating a Digital Shared Care recordwith multi agency access to view,record and store information to informclinical decision making and provideconsistency of health and social carepackages that meet a service user’sneeds

▪ Implementing comprehensive geriatricassessments (CGA) for all appropriatepeople to ensure collaboration acrosshealth and social agencies to reduceacute episodes and strengthen shareddecision making and joint actionplanning

▪ Utilising the Care Navigation ‘SinglePoint of Access’ as the standard forproactive, personalised care planningand support provided through multi-agency skilled teams co-located withinprimary care clusters

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Central BedfordshireComplex Care - All residents• Continuing Improved Better Care

Fund funded support Complex care management in care homes, in two localities.

• Streamlining referrals through SPoAfor community health services.

• Focus is now on transferring all referrals to electronic referrals.

• Proactive MDTs have been established across Bedfordshire, across health and social care.

• Widen use of Person Tracker by MDTs to enable proactive care and prevent readmissions.

• Developing Key Worker role for complex care management.

• Expand social prescribing through Community Wellbeing Champions

End of Life (EoL)• Focus on person centred care at EoL

and increase the use of Advanced Care Plans.

• An audit of Training for EOL is underway to ascertain gaps.

• A new CHC fast track pathway will be rolled out across Central Bedfordshire.

• Increase use of personal health budgets

• A Bedfordshire wide training and education programme for EoL is being

developed. Work progressing to plan and then roll out the EPACS system.


BLMK approach - Complex Proactive Care Continued

Bedford Borough

Transitions of Care• BCCG commissioned additional winter

beds during 2018/19 to support discharge of medically fit patients. These beds will be phased down from the end of March to the end of May 2019 in view of hospital pressures.

• D2A embedded at BHT. Work underway to improve the D2A pathway at L&D for BCCG discharges.

• In line with the 10 year plan, BCCG will work with Bedford Hospital, in order to extend the hours of Ambulatory Emergency Care to cover 12 hours a day, 7 days a week by Sept 2019.

• The Urgent Treatment Centre (UTC) opened on 1st October 2018 and is located in Cauldwell Medical Centre, on BHT site. BCCG will continue to review and develop the UTC throughout the duration of the pilot to ensure to include direct referrals form the ambulance service

• The Bedfordshire and Luton Integrated Urgent Care service (IUC) is on track to implement all requirements in the NHSE revised specification for IUCs by March 2019. This includes 24/7 Clinical Advisory Service (Commenced January 2019), directly bookable GP appointments through 111 (50% in place for BCCG @ January 2019) and *6 Direct Access for Care Homes to a Clinician during the out of hours period

Luton

Transitions of Care - between inpatient hospital settings and community or care home settings for adults with social care needsOur ambition is that person centred care and support is planned and delivered during admission to, and discharge from, hospital via:▪ Integrated hospital

discharge service▪ Implementation of all

requirements of NHSE revised Integrated Urgent Care service (IUC) specification

▪ Further embedding of ‘Red Bag Scheme’ to improve quality of transfers to/from care homes

▪ Collaborative working across local authority and clinical commissioning to support care homes in delivering high quality of care via a care home champion model.

▪ Implementation of digital/technology enablers e.g Bed capacity tracker, discharge app

Milton Keynes

c) End of Life (EoL) Transformation Programme will focus on:• Rollout of the Elective Palliative Care

solution (EPaCCS) across MiltonKeynes geographical boundaries

• Embed Universal EoL Trainingprogrammes for healthcareprofessionals and develop ‘online’support tools

• Rollout GP Advanced Care Planningacross primary care clusters to assistwith identifying and planning EoL carepackages for people

• Increase utilisation of PersonalBudgets for EoL service users

d) Transitions of Care▪ Utilising the National ‘Home 1st’

principles to ensure that as manydischarges as possible can beappropriately made to the patient’sown home (as a default)

▪ Continuing to manage and maintainthe current performance forimproving Delayed Transfers of Care.

▪ Undertake a review of intermediatecare with council and voluntary sectorpartners in order to reduceduplication across the system (e.g.neuro-rehab pathways)

▪ Working with community providers toalign service delivery within PrimaryCare clusters (e.g. district nursing andincontinence service) 26


Transitions of Care• Expand discharge to assess model

across all hospitals and improve pathways for Central Bedfordshire residents.

• Implement a ‘Home First’ approach• Integrated triage service with single

for intermediate and social care reablement pathways with single management.

• Integrated hospital discharge service expanded with continuing use of DToC tracker to expedite transitions of care.

• Investment in 7 day services across health and social care.

• extend the hours of Ambulatory Emergency Care to cover 12 hours a day, 7 days a week by September 2019.

• Incentive payment to Homecare Providers to hold packages of care for customers in hospital.

• Continue to review and develop the Urgent Treatment Centre including direct referrals from the ambulance service.

• Implement 24/7 Clinical Advisory Service (Commenced January 2019)

• Implement directly bookable GP appointments through 111 (50% in place for BCCG @ January 2019)


BLMK approachDiabetes: BLMK Diabetes Network overseeing implementation of NHSE Transformation Funding and opportunities for shared services.

Bedford BoroughTo improve health outcomes and reduce unplanned episodes of care:• Three-year NHS Diabetes

Prevention Programme providing education and support for people at risk of diabetes to help prevent or delay onset

• Patient participation in care planning as part of annual review including jointly agreed care plan

• Early identification of foot problems and referral to specialist MDFT services, to reduce hospital admissions for people with diabetes, reduced length of stay and reduction in foot amputations

• Investment within the Integrated Community Diabetes Service to support patients who are struggling to optimise control of their diabetes and tailored support to practices where indicated by current outcomes.

• Healthcare professional training to increase competencies in diabetes treatment and care

Luton• Multidisciplinary community-based

integrated service delivery / pathways

• Reduction in unwarranted variation• Maximise structured education for

patients (DESMOND and Pulmonary Rehabilitation)

• Three-year NHS Diabetes Prevention Programme providing education and support for people at risk of diabetes to help prevent or delay onset


• Early identification of foot problems and referral to specialist MDFT services, to reduce hospital admissions for people with diabetes, reduced length of stay and reduction in foot amputations

• Investment within the Integrated Community Diabetes Service to support patients who are struggling to optimise control of their diabetes and tailored support to practices where indicated by current outcomes and performance

• Healthcare professional training to increase competencies in diabetes treatment and care

Milton KeynesContinue with diabetes transformation programme to:

• Deliver NHS Diabetes Prevention Programme to all patients at risk of developing Type 2 diabetes which will include a digital intervention in addition to face to face support

• Increase treatment targets utilising ‘Year of Care’ model to improve competencies in primary care supported by the diabetes community specialist service

• Utilise digital applications (e.g., My DESMOND and HeLP) to support people with diabetes self manage their condition

• Maintain service delivery for high risk/active foot care services to continue reductions in amputation rates 27

Central BedfordshireTo improve health outcomes and reduce unplanned episodes of care:• Good clinical engagement.• Improvement of support through

integration of IAPT into diabetes pathways across the ICS.

• Bid for a new App to record blood glucose levels digitally has been submitted to NHS E

• Three-year NHS Diabetes Prevention Programme providing education and support for people at risk of diabetes to help prevent

• Funding secured for roll out of diabetes healthcare professional training across BLMK on EDEN –Effective Diabetes Education Now and CDEP – Cambridge Diabetes Education Programme.


• Early identification of foot problems and referral to specialist MDFT services.

• Investment within the Integrated Community Diabetes Service to support patients who are struggling to optimise control of their diabetes and tailored support to practices where indicated by current outcomes.

Priority 2 – Delivering high quality and resilient primary, community and social care servicesBLMK approachMental Health: Delivery of the Mental Health Five Year Forward View and implementing new models of care across the system.

Bedford Borough

• Develop new and integrated models of primary and community mental health care to support adults and older adults with mental health problems aligned with the primary care networks

• Continued work to improve dementia diagnosis and post-diagnostic care

• Expanding support for people experiencing a mental health crisis

• Continue to focus on prevention and tackling health inequalities such as improving physical health care for people with severe mental illness and mental health care for people affected by homelessness

Luton

• Role out of expanded Individual Placement and Support Service if successful in national bid

• Improving access to psychological therapies (IAPT) for people with common mental health problems and supporting with recovery.



Milton Keynes

Dementia Pathway(s) of careImproving the care of people with dementia by:▪ Implementation of home-

treatment services in orderto help people to maintainindependence.

▪ Providing additionalsupport services to patientsand families in crisis inorder to prevent avoidableacute admissions

▪ Increasing capacity forplacements particularly forthose with challengingbehaviours

Mental HealthAddressing the National Priorities by:▪ Working with partners

across BLMK ICS to deliver physical health checks to 60% of patients with serious mental illness (SMI) on registers.

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• Continued work to improve dementia diagnosis and post-diagnostic care


• Continue to focus on prevention and tackling health inequalities such as improving physical health care for people with severe mental illness and mental health care for people affected by homelessness


BLMK approachMental Health Continued: Delivery of the Mental Health Five Year Forward View and implementing new models of care across the system.

Bedford Borough

• Further develop the perinatal community mental health service.

• Build upon Bedfordshire Wellbeing Service (IAPT) delivering benefits to people with long-term conditions via integrated care

• Continue the work to support and develop supported section 117 aftercare with Local Authorities

• Reduce out of area placements and develop mental health liaison services and in-patient care.

• Continue to focus on suicide prevention

• Further develop support for carers

Luton• Continue to focus on

prevention and tackling health inequalities such as improving physical health care for people with severe mental illness and mental health care for people affected by homelessness


• Continue the work to support and develop supported section 117 placements with Local Authorities



Milton Keynes

Addressing the National Priorities by:▪ Developing options to support

patients requiring inpatient care provision including repatriation of out of area placements

▪ Continuing to improve access and treatment waiting time for IAPT services.

▪ Expanding and embedding the integrated mental health model into Milton Keynes Primary Care Cluster development plans to deliver a cohesive multi-disciplinary approach for holistic patient care

▪ Increasing capacity within the Adults Crisis Team(s) to provide 24/7 cover and helpline support.

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• Build upon Bedfordshire Wellbeing Service (IAPT) delivering benefits to people with long-term conditions via integrated care

• Continue the work to support and develop supported section 117 aftercare with Local Authorities



• Further develop support for carers

Priority 2 – Delivering high quality and resilient primary, community and social care servicesBLMK approachChildren and Young People Mental Health: Delivery of the Five Year Forward View for Mental Health and implementing new models of care across the system

Bedford Borough

• Developing models of care that are age appropriate, closer to home and bring together physical and mental health services through an integrated approach across health, social care, education and the voluntary sector.

• Increasing access to mental health support for children and young people

• Continue to implement the BLMK Local Transformation Plan

• Continue to develop Early Intervention and schools and college support

Luton





• Continue to focus on self-harm and suicide prevention.

• Development of a CAMHS tier 2 service, with SPOA and step up/down pathways

Milton Keynes

Develop and integrate ‘place based’ Mental Health & Wellbeing Local transformation plans to strengthen early/preventative intervention to:▪ Ensure good access to

specialist mental health assessment and treatment and deliver access and waiting times

▪ Improve the pathway for complex and challenging behaviour by identifying new models of care that strengthen early help and prevent escalation/crisis

▪ Developing pathways for a multi agency approach and identifying opportunities for delivering ‘at scale’ for very specialist services

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Priority 2 – Delivering high quality and resilient primary, community and social care servicesBLMK approachChildren and Young People Mental Health Continued: Delivery of the Five Year Forward View for Mental Health and implementing new models of care across the system

Bedford Borough


• Developing new models of care to support children and young people experiencing a mental health crisis

• Reducing out of area placements and developing seamless pathways for inpatient admission with specialist commissioning

• Improving access and support for children and young people with an eating disorder and developing the Eating Disorders Service

• Improving transition to adulthood by exploring a new approach for 0-25 year olds.

Luton





Milton Keynes

Develop and integrate ‘place based’ Mental Health & Wellbeing Local transformation plans to strengthen early/preventative intervention to:▪ Developing new models of

care to support children and young people experiencing a mental health crisis and prevent admission to tier 4 units

▪ Improving access and support for children and young people with an eating disorder and developing the Eating Disorders Service

▪ Improving transition to adulthood by exploring a new approach for 0-25 year olds

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BLMK approachChildren and Young People (CYP) Physical Health: Improving services for CYP including access, digital and challenging behaviour.

Luton• Transforming SEND services to

reflect inspection recommendations, including improving access , revising pathways and increasing capacity

• Reconfiguring SALT model to improve early intervention

• Further developing Rapid Response Team to increase admission avoidance

• Develop an injury prevention/minimisation scheme to reduce avoidable admissions.

• Healthy weight strategy and innovative weight management delivery

• Work collaboratively across BLMK to improve outcomes for CYP with Special Educational Needs and Disabilities and review joint commissioning opportunities for therapy services.

Milton Keynes▪ Reducing avoidable attendances at

emergency departments (and zerolength of stay hospital admissions)through learning programmes forcommunity, primary care, rapid responsenursing, care coordination, improvingself care and consistent use of the shortstay tariff

▪ Building on positive Special EducationNeeds and Disabilities (SEND) agenda

▪ Reviewing quality and provision of healthassessments for Looked After Childrenand implement East of England protocolfor reciprocal funding arrangements

▪ Establishing a Children and YoungPersons’ Transforming Care OperationalGroup to drive consistent approach toCare Education Treatment Review, earlyidentification of need and personalisedsupport

▪ Safeguarding vulnerable children andyoung people by improvingidentification and help for childreneffected by:

• Abuse and Neglect• CSE, FGM, Domestic Violence• Children who live in families

effected by mental ill health,drugs and alcohol

• Develop resilient and confident primary care teams to look after CYP with acute presentations with symptoms in the community.

• Reduce non elective activity through roll out of a children's urgent care strategy.

• Develop Digital based solutions for CYP and carers to help with their self-care.

• Improve provision across BLMK for CYP with Complex and challenging behaviour by developing new models of care to prevent admission.

• Work collaboratively across BLMK to improve outcomes for CYP with Special Educational Needs and Disabilities (SEND) and review joint commissioning opportunities for therapies.

• Embed the East of England protocol for reciprocal funding for our Looked after children to improve access to services out of area.


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Bedford Borough


Milton Keynes

Working in close partnership with keystakeholders across BLMK on:▪ Transforming Care Programme to meet

the trajectories set in the Long Term Planby 2020/21

▪ Development of a 7 day crisis serviceand forensic community support

▪ Implementation of the 12 pointdischarge plan for all inpatient care

We will continue with our ‘place based’ deliverables focusing on:

1. Increasing the number of people on the learning disability registers in GP practices by providing support to primary care clusters

2. Developing and implementing action plans to increase uptake of annual health checks for 50% of people on the learning disability register by 19/20 and 75% of people by 2020/21

3. Increasing workforce capacity for reviewers to undertake local LeDeR reviews as part of the service improvements outlined in the Learning Disabilities Mortality Review (LeDeR)

4. Strengthening the Autism Pathway to ensure it is compliant with statutory guidance and the Autism Act 2009

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Luton

1. Delivering fully integrated health and social care commissioning;

2. Developing robust partnerships with people with learning disabilities, their families and carers to commission high quality local support;

3. Adopting a strengths-based approach to commissioning, using a joined up approach based on need to provide early intervention and prevention;

4. Developing a place-based provider alliance that can implement personalised commissioned for people with high support and complex needs;

5. Reshaping accommodation and support offer including the development of emergency accommodation with intensive support to reduce reliance on inpatient services;

6. Development of Forensic Support Services across BLMK;

7. Improving access to physical and mental health services in the community through appropriate reasonable adjustments, increasing annual health checks and ensuring people are supported to manage their own health through facilitated access to wellbeing activities;

1. Transforming Care Programme to meet the trajectories set in the Long Term Plan by 2020/21

2. Implementation of the 12 point discharge plan for all inpatient care

3. Progression of community CTRs to ensure all preventable admissions using dynamic risk frameworks.

4. Development of an all age forensic community step-up/step down provision

We will continue with our ‘place based’ deliverables:1. Review of specialist learning disability provision inclusive

of The Coppice Bedfordshire and Luton’s crisis unit for people with learning disability and mental health needs.

2. Progressing a preferred provider framework3. Via PMS reinvestment we will:

• Increase the number of people on the learning disability registers in GP practices.

• Increase uptake of annual health check.• Support of medication reviews in support of

STOMP (Stop over medication of people with learning disability)

4. Increasing workforce capacity for reviewers to undertake local LeDeR reviews as part of the service improvements outlined in the Learning Disabilities Mortality Review (LeDeR) ensuring trends and learning are shared.

Central Bedfordshire will also:• Finalise a joint commissioning strategy for people with

learning disabilities and a market position statement• Focus on meeting accommodation needs for people with

learning disabilities.• Develop an all age strategy and plan for people with

Autism.

Bedford Borough Central Bedfordshire

BLMK approachLearning Disability and Autism: Progressing the Transforming Care Programme and focus on place support for people with a learning disability.

Priority 3 – Sustainable Secondary Care

BLMK approachSecondary Care resilience & sustainability – BLMK is working with its 3 acute trusts to ensure they can deliver excellent care into the future in a sustainable way. This includes the proposed merger of Luton & Dunstable Hospital and Bedford Hospital. Central to the merger proposal is taking the “best of both” hospitals – service delivery models, people, information technology – to improve patient care and patient experience.

Milton Keynes Acute Footprint

Urgent and Emergency Care focusing on:▪ Same Day Care (ambulatory urgent care) pathways will be optimised in

order to reduce unnecessary emergency admissions▪ A combined Urgent Treatment Centre and Integrated Urgent Care

Clinical Assessment Service which will increasingly identify potential forshared resource and integrated working, including the increasinglyprominent NHS 111 Online

▪ Directly booked appointment via NHS 111 will continue to bedeveloped and expanded, increasing the number of appointmentsavailable at various care providers (in-hours GP, Urgent TreatmentCentre, out-of-hours GP, extended access GP)

▪ Increasing levels of support will be made available to ambulance crews inorder to support them to avoid conveyance to hospital (whereappropriate). These include a GP-advice telephone line and specialistMental Health support embedded within the ambulance call centre

NHS Long Term Plan: ▪ Work underway to understand the impact on secondary care revised

financial plans and priorities within the Long Term Plan▪ Ensure that our RTT plans will continue to focus on ‘zero tolerance’ for

52 week waits. Detailed trajectories for meeting NHS Constitutional Standards are included in the MK CCG Operational Plan.

▪ Continue to work with local providers to offer alternative options if waits for treatment exceeds 26 weeks

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Luton and Bedfordshire Acute Footprint

Proposed MergerThe Luton and Dunstable (L&D) proposed acquisition of Bedford Hospital (BHT) is to provide a new Trust for the people of Luton and Bedfordshire, creating the scale necessary for efficient, high quality care. This is a proposed merger of two good hospitals and we have committed to maintaining the core services of A&E, paediatrics and maternity on the Bedford site. We have a long history of working together and already provide some joint clinical services to the county and beyond, such as vascular surgery, head and neck cancer services, cervical cancer screening services, neonatal intensive care, and stroke services. At the moment the integration work with Bedford Hospital (BHT) remains paused as we wait to hear further news on the L&D’s capital proposal

However, the Trusts are progressing the plan to integrate the two pathology services following the repatriation of services from Viapath from 1 April 2020. This can be actioned outside of the merger process through a contractual joint venture.

Priority 3 – Sustainable Secondary Care

BLMK approachSecondary Care resilience & sustainability – Continued

Milton Keynes Acute Footprint

Quality and Efficiency focusing on:▪ Expanding advice and guidance services to

support further collaborative working between primary and secondary care (e.g. Tele-dermatology system will be trialled with outcomes and learning disseminated across BLMK)

▪ Delivering more Ophthalmology care in the community, align our clinical pathways across BLMK and where possible commissioning at scale for specific conditions (e.g. glaucoma, cataracts)

▪ Participation in the national Local Health and Care Record Exemplars (LHCRE) with Oxfordshire, Buckinghamshire and Berkshire to deliver an information sharing environment between health and care partners

35

Luton and Bedfordshire Acute Footprint

7 Day ServicesAs per the NHS Long Term Plan and national commitment to delivering 7 day services, a local baseline exercise and gap analysis is underway. Following completion of this analysis, a detailed action plan will be developed in partnership with our key providers.

HubsWork is also underway as part of the hub developments to identify suitable out of hospital services for inclusion in the hub models, providing a range of outpatient and diagnostic services for our local community. This enables improved co-ordination of patient care with primary care clinicians and also releases vital capacity in secondary care for cancer and specialist services.

Elective Care TransformationThe aim of the programme of work is to deliver better health outcomes for patients needing planned care by ensuring that only those who need secondary care are referred there. The agreed priorities are to:

· Deliver the NHS Constitution Referral to Treatment standards ensuring that there is a ‘zero tolerance’ to 52 week breaches. Detailed trajectories for meeting NHS Constitutional Standards are included in the Luton and Bedfordshire CCGs Operational Plans.

· Deliver patient choice and continue NHS e-Referral roll out· Improve use of Advice and Guidance with local providers· Streamline elective care pathways through outpatient redesign and avoiding

suboptimal follow ups

Bedford Borough

Priority 4 – Digitalisation

BLMK approachShared Care Record: Development of the shared care tender document to be released to market Q2. Tender assessment during Q3and award of preferred bidder and final contract negotiation Q3, start of contractual delivery in Q4.Supporting the delivery of the wider shared care record into the Thames Valley LHCRE through Milton Keynes and Hertfordshire and West Suffolk to ensure continuity of care.Investigation of pilot scheme for children with life limiting conditionsTechnology: SMS messaging in practices rolled out across ICS; Continued development online consultations; Continued development of Telehealth monitoring Care Homes following evaluation of pilot. Continued expansion of Care home connections including Systm1.Maternity Digital strategy finalised by Q2. Personalised care strategy finalised Q2. Develop digital opportunities in line with Primary Care Home model.Embracing digital opportunities such as NHS App and TECS to support self management and access to services and extending eSCR availability.Whole population health analytics: Development of business case for single ICS system that supports Place based commissioning working with P5 to capture future plansInformation Governance: BLMK information sharing agreements electronic in Q1; Data-sharing model to continue to be developed; Assurance of on-going compliance with GDPR across the care homes – process for local quality team to be completed in Q2.

• Social care workforce agile working.• Commissioning case management system (SWIFT

replacement) for Bedford and Central Bedfordshire.Shared Care Record• Delivery of the fast follower programme based on FHiR

standards to facilitate record sharing• Patient consultation on shared care record in Q2 Whole population health analytics• Evaluation of Luton frailty pilot and develop expansion TECS• Explore place based pilot projects Q2Primary Care• Rollout of MJOG system to practices• Continued rollout of online consultations• Work to enable use of use NHSE app• Exploration of S1 template solution

Luton

Shared Care Record• Local Digital Road Map to

support GDE programme• Contract for new clinical

applications that are digitally enabled let in q1

• Early adoption of GPConnect• Patient consultation on shared

care record in Q2 Whole population health analytics• Evaluation of frailty pilot and

continue expansionTECS• Explore place based pilot

projects Q2• Develop digital service for

children with life limiting conditions

Milton KeynesShared Care Record• Mobile Working with access to patient

record at point of care• Connectivity – Healthcare professionals

having Wi-Fi access to clinical applicationsWhole Population Health Analytics• Continued work across system on joint,

integrated population health analytics capability & actuarial analysis

Empowering the Citizen/Patient Facing Services• Increase patient access to & use of their

primary care based HER.• E-Consultation pilot with Wiggly-Amps to

provide integrated remote triage and care Clinical decision support pathways in Dermatology & Gastro

• Digital support for Care Navigation Service to support LTC self-care

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Central Bedfordshire• Care Homes undertaking IG toolkit

readiness and completion of DSP Toolkit

Priority 5 – System Redesign

Bedford Borough

Bedford Borough Officer Transformation Groupestablished

East London Foundation Trust has developed a transformation plan for community health services which will be implemented from April 2019.

Providers are collaborating on an integrated approach to step-down provision and reablement.

Luton

Transformation Board established in Luton.

The Concordat between Luton CCG and Luton Borough Council will continue to be implemented and the CCG and Council commissioning and public health teams have been co-located since December 2018, whilst there has been increased joint commissioning of services via Section 75 agreements.

The work on integrated care for Luton residents over 65 with 2 or more admissions in the last year is considering future provision of services.

Milton Keynes

Integration (Transformation) Board Established and agreeing/overseeing transformational service changes via high level System Delivery (Place) Plan

Whole Population Health Management ApproachFollowing on from the work in 2018/19 as a BLMK ‘test site’ for whole population health analytics, system partners will practically work with the ‘linked data’ set to gain deeper insight within Clusters & agreed clinical areas.

System Integration Begin integration of commissioning functions as agreed by Integration Board: Phase 1 – MK Steps to Integration: 6 Areas

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Transformation Board established

East London Foundation Trust has developed a transformation plan for community health services which will be implemented from April 2019.

A Programme Group has been established to lead on the developing more integrated provision in Central Bedfordshire.

Central Bedfordshire has established a Provider Alliance, which includes the Private, Voluntary and Independent care sector.

BLMK approachBLMK is a wave one ICS.Now one Executive Team for the three CCGs has been established, we are working to define which activities will operate at scale (across the ICS), place (Borough) and locality (primary care network). Population Health is now established as a sub-group of P5, recognising that population health is a key component of our redesigned system, with clear links to the digital enabling tools (P4) and primary care networks as the unit at which patient segmentation will occur (P2).The development of more integrated provision is being considered at place level, as is work on risk/gain share mechanisms between providers and commissioners. P5 in 19/20 will be leading on the development of the ICS longer-term plan, which will be aggregated up from four place-based long-term plans. The desire is to have a public conversation on these plans in order to inform the development of an outcomes framework for the ICS.

5. NHS Long Term Plan Priorities

Chapter 3 of the NHS Long Term Plan details areas where there needs to be further progress on care quality and outcomes. This section of our System Operating Plan highlights work ongoing and being initiated to improve care for priority groups and conditions:

• Maternity services• Children and young people’s health• Learning disability and autism• Cancer• Cardiovascular disease• Stroke care• Respiratory disease• Mental health services (adult and children)• Personalisation

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Maternity2019/2020 DELIVERABLESSafety of maternity services• Significant, identifiable progress towards the “halve it “ ambition- phase 2 of

BLMK wide quality and performance dashboard completed• Establishment of mature BLMK Serious Incident panel with robust process

for sharing the learning• Work with HSIB to develop joint process for standardising the approach to

maternity investigations• Single LMS wide Safety Action Plan supported by LMS wide learning events• Standardised LMS wide maternity guidelines

Continuity of Carer (CoC)• From March 20% of women booked will be on a CoC pathway• Evaluation of pilots and plans developed to achieve 51% by 2021

Prevention• Baby friendly Initiative accreditation achieved for all services• Improved uptake for vaccinations• Increased access and attendance at smoking cessation services• Improved access to Maternal obesity information• Improved process for information sharing with Health Visiting at 24 weeks

Neonatal Critical Care• Established Neonatal Task and Finish Group that will develop the BLMK

plans Choice & Personalisation• Fully operational Midwifery led birthing unit (MLBU) at Milton Keynes• Evaluation of PCP pilots and agreement of PCP format for BLMK• Digital options for PCP evaluated Perinatal Mental Health• New service launched in Luton and Bedford• Recruitment completed to enable to enhanced service in Milton KeynesFinance & Digital• Costed model for maternity services across the LMS• Established Digital Task and Finish (TAF) that will develop the local digital

plan and roadmap formulated

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The BLMK LMS Transformation plan aims to bring together maternity services across Bedford, Luton and Milton Keynes to deliver maternity services in a sustainable way as recommended in Better Births and in line with the NHS Long term Plan. As a result of it’s transformation plan, BLMK will:

Continue to improve the safety of maternity services, ensuring that:

• Standardised care is delivered in line with a fully implemented Saving Babies Lives

Care Bundle (Version 2)

• Rates of still birth, neonatal death, maternal death and serious brain injury during

birth are reduced by 50% by 2025

• There is transparency of reporting for serious incidents and external review of

incidents (Healthcare safety investigation-HSIB)

Implement Continuity of Carer so that:

• By March 2021, most women will receive continuity of carer during pregnancy,

birth and postnatally

• We are targeting those who will benefit most- BAME groups, vulnerable women

and those in the most deprived areas

Improve access to prevention services and interventions:

• Smoking cessation, Folic acid, Infant feeding, Maternal medicine network

Improve choice and personalisation of maternity services so that by 2020/21:

• All women have a personalised care plan (PCP)

• All women report that they have choice & have experienced personalised care

• And by 2023/24 all women will be able to access their maternity record via a

digital care record

Review and improve neonatal critical care to:

• Reduce term admissions and embed action plan for Transitional Care

• Implement Perinatal Mortality reviewing Tool & share learning

• Create workforce fit for purpose

• Develop effective data collection processes

Improve our provision of perinatal mental health services (PMH) to ensure:

• Increased access to services across BLMK

• Care provided from pre-conception to 24 months postnatally

• Increased support available to partners and families

• Develop outreach clinics and closer links from PMH to maternity services

Children and Young People’s Health

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2019/2020 DELIVERABLES

Deliverables in Q1 and Q2• Work with transforming primary care program and

develop strategy to include priorities and service provision for CYP including community based rapid assessment service

• Workshop to scope digital solutions available for CYP and carers

• Scope community provision of behaviour psychology, OT and parental respite provision for CYP with complex and challenging behaviour

• Undertake a system wide needs assessment for children with autism, ADHD and Neurodevelopment to identify gaps in service provision and work collaboratively to implement changes.

• Investigate the provision of step down/step up for children with complex and challenging behaviour facility in BLMK and develop an options appraisal for decision.

• Organise a summit for children with complex needs and special education needs. The summit will identify key deliverables to improve service provision.

1. Develop resilient and confident primary care teams to look after CYP with acute presentations with symptoms in the community which will take additional funding

2. Develop Digital based solutions for CYP and carers to help with their self-care which will require additional funding

3. Develop provision across BLMK for CYP with Complex and challenging behaviour. Increased investment is required in intensive, crisis and forensic community support will also enable more people to receive personalised care in the community, closer to home, and reduce preventable admissions to inpatient services.

4. Work collaboratively across BLMK to improve outcomes for CYP with Special Educational Needs and Disabilities, in accordance with statutory requirements for health and education. Particularly in CYP with Autism, ADHD and Neurodevelopmental presentations. This will need additional funding to deliver on statutory requirements that need to be provided by CYP who are classified as SEND across BLMK.

Transforming Care

2019/2020 DeliverablesMarket Shaping• Close working with each BLMK place-based Provider Alliance to develop

provider market.• Joining up market-shaping strategies across four LA areas to establish a

single BLMK approach to working with independent/voluntary sectors.

Physical and Mental Health Improvement• Ensure equitable access to universal services.• >75% Health Check achievement.• Continuation of learning from LeDeR programme.• Reducing inequalities for people with LD and/or Autism.All-age Intensive Support Services• Cross-sector Positive Behaviour Support (PBS) provider training.• Scoping & development of CYP intensive support service.• Review NHS inpatient provision at The Coppice and Campbell Centre.

Community Forensic Support• Alongside ICS Mental Health workstream, establish and commission a

BLMK-wide Community-based Forensic Support model.

All-age Dynamic Risk Register (DRR)• Evaluation of existing DRRs in place across BLMK.• Improvement of process and outcomes from DRR approach.• Reduced risk of admission for people on DRRs.Autistic Spectrum Disorder & Pathological Demand Avoidance Pathways• Improved access to diagnostic pathways, particularly for CYP.• Pathway review: establish needs-based approach to services.• Neurodevelopmental pathway review.Personalisation• Broader implementation & increased use of Personal Health Budgets.• Application of learning from Integrated Personal Commissioning.Prevention and Early Intervention• Supporting families to improve community resilience.• Link to SEND workstream to improve awareness and support for CYP with

LD and/or autism.• Develop needs-based approach to services through pathway review.

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The BLMK Transforming Care Partnership Plan brings together commissioners and providers of services for people with Learning Disabilities and/or Autism across Bedford, Luton and Milton Keynes to improve outcomes and life experience in line with the NHS Long Term Plan. As a result of it’s transformation plan, through personalisation and co-production BLMK will:

Meet inpatient targets:

• ≤ 13 CCG-commissioned adult inpatients by end 2019/20; and

• ≤ 13 NHS England-commissioned adult inpatients by end 2019/20.

• ≤ 6 children and young people inpatients by end 2019/20.

• All inpatients on 12-point discharge plan.

• Improved resilience and support for people at risk of admission.

• 100% compliance with policies for Care, (Education) and Treatment

Reviews and Local Area Emergency Protocols

Use Capital Bids to support our work:

• Development and submission of BLMK bids for capital development to

support partnership aims and priorities.

Refresh the partnership and our governance :

• Review of TCP members, aims and plans.

• Agreement and implementation of new governance model for partnership.

Deliver a workforce plan:

• Implementation of partnership-wide workforce plans in collaboration with

LWAB and HEE.

Deliver Children & Young People Plans:

• Delivery of aims and priority areas in plans for children and young people

with a learning disability and/or autism.

• Focussed work on closing the gap between Tier 4 inpatient services and

universal CAMHS support in the community.

Improve outcomes and experience for people:

• Expand implementation of STOMP/STAMP Programme*.

• Implement new National Learning Disability Improvement Standards.

• Implement recommendations on restricting use of seclusion, long-term

segregation and restraint.

(*Stopping Over-Medication of People with a learning disability and/or autism / Supporting Treatment and Appropriate Medication in Paediatrics)

Cancer


Q1

Continue to reduce variation in diagnostic phase for lung, prostate and colorectal cancer

• mpMRI accessibility for prostate cancer

• Straight to test for colorectal

• Hot reporting and CT within 72 hrs in lung

• Roll out of Comprehensive Cancer Control (CCC) in Luton CCG

• Enhanced cancer rehab in the community across BLMK

Q2

• Embedding improved pathways for Lung, Prostate and Colorectal Cancer diagnosis within 28 days

• Initiation of FIT testing in secondary care and embedding the best practice colorectal pathway

• Work up local solution for managing patients with vague symptoms

• Begin scoping and delivery of Stratified Follow up in colorectal

Q3

• Development &Implementation of improved pathway for Upper GI Patients

• Second Phase roll out in Bedford and MK of Cancer Care in the Community

Q4

• Full Implementation of transformational pathways in place for Lung, Prostate and Colorectal

Ongoing from 18/19

• Meet targets for cancer wait times and monitor progress to 28 days

• Improve screening uptake for Bowel, Breast and Cervical screening programmes

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To support planning & delivery of the Long Term Plan ambitions for Cancer and the CCG Assurance statements, BLMK ICS has established local governance across all commissioners, providers, patient representatives and charities. Work with new reconfigured Cancer Alliance structures. The focus of work centres on:Early Diagnosis, Prevention & Screening• Increased public awareness of risk factors, signs & symptoms of cancer in

particular cervical cancer as per Long Term Plan• Roll out of HPV Primary screening programme as per Long Term Plan• Increased uptake of all cancer screening • Monitor the impact of pilot in Luton for Lung Health Checks Model and the

impact on early diagnosis• Roll out of FIT for Bowel cancer Screening as per Long Term Plan• Improve one year survival rates• Work towards Cancer definitive diagnosis or ruled out within 28 days by

2021 Cancer Alliance Rapid diagnostic centres.• Increase people diagnosed at stage 1 or 2 - aim for 75% by 2028Waiting Times• Meet and maintain all 8 cancer waiting time (CWT) including 62 day

operating standards across the ICS• Implement best practice timed pathways across all settings for: lung,

prostate, upper GI and lower GI• Monitor reduction of long waiters (104 day breeches)• Implementation of the new East of England Inter Trust Transfer PolicyImplementing New Models of Care• Review outcome of pilot sites for Rapid Diagnostic Assessment Centres and

implement BLMK model• Stratified Follow Up system in place for recurrence of all clinically

appropriate cancers as per Long Term Plan• Design services that meet the need of people Living with and Beyond

Cancer• Implementation of Radiotherapy Networks

Detailed trajectories for meeting NHS Constitutional Standards are included in CCG Operational Plans.

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Cardiovascular


Q1

1. Review baseline activity, outcome and expenditure data for AF and hypertension (RightCare, Public Health, Model Hospital GIRFT) by CCG and benchmark by peers

2. Outline effective interventions appropriate to BLMK to increase detection and optimal management of AF and hypertension.

3. Facilitate a cardiovascular stakeholders action planning workshop to agree and commit to actions for the BLMK CVD Prevention Programme.

Q2

1. Evaluate and identify resources required following workshop

2. Monitor outcomes from action planning plans

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Heart and circulatory disease, also known as cardiovascular disease (CVD), causes a quarter of all deaths in the UK and is the largest cause of premature mortality in deprived areas.To support planning & delivery of the Long Term Plan ambitions in this area Priority 1 has identified CVD prevention as a local priority, with a dedicated programme of work to develop a BLMK CVD Prevention programme.

The first focus of work is summarised below:-

Early detection of Hypertension and Atrial Fibrillation (AF)Approximately 35% of people with AF, and 40% people with hypertension are undiagnosed. Learning from AF/hypertension opportunistic screening pilot with community pharmacy and an evidence review will scope a CVD prevention approach.➢ Establish effective intervention approach to increase detection rates

Optimised treatment of Hypertension and Atrial Fibrillation (AF)An estimated 160 heart attacks and 240 strokes expected to be averted within three years though optimal anti-hypertensive treatment.

An estimated 190 strokes averted within three years by optimally treating high risk AF patients. ➢ Action-Planning workshop with all stakeholders to be held in April.

Delegates to commit to 30, 60 and 90 day actions to progress CVD prevention locally.

Stroke2019/2020 DELIVERABLES

GIRFT Review of Stroke Services

The national Getting It Right First Time (GIRFT) leads will be

reviewing our stroke services during the first quarter of 2019/20,

as part of their standard review programme of stroke networks

and the quality of services provided.

The outcome of this GIRFT review will help us as a system

determine our way forward on stroke.

Stroke Rehabilitation

The ICS have successfully bid for capital funding for a new stroke rehabilitation unit at Bedford hospital. This will help stroke survivors to achieve a good quality of life and maximise independence. The model is built on the premise that rehabilitation should begin as soon as possible after a person has a stroke, and continue for as long as is clinically appropriate, to ensure the best possible recovery.

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As the NHS Long Term Plan notes, Stroke is the fourth single leading cause of death in the UK and the single largest cause of complex disability.

The evidence is clear that having rapid access to brain scans and

thrombolysis leads to better outcomes. This has most successfully

done by centralising care in fewer hyper-acute units with dedicated

staff and equipment.*

We have moved to doing interventional stroke care on only 2 out of our

3 sites, and in 2019/20 we need to consider the case for further

change, to ensure patients get the best outcomes.

* Hunter, R., Davie, C., Rudd, A., Thompson, A. & Walker, H. (2013) Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model. PLOS ONE. 8 (8), e70420. Available from: https://doi.org/10.1371/journal.pone.0070420Morris, S., Hunter, R., Angus, R., Boaden, R., McKevitt, C., Perry, C., Pursani, N., Rudd, A., Schwamm, L., Turner, S., Tyrell, P., Wolfe, C. & Fulop N. (2014) Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. British Medical Journal. 349, g4757. Available from: https://doi.org/10.1136/bmj.g4757

Respiratory

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Respiratory disease affects one in five people in England and is the third biggest cause of death. As a result, it is identified as a national priority in the NHS Long Term Plan. At system level, RightCare data shows that respiratory disease is a major driver of non-elective activity in BLMK – indicating that there is significant opportunity to improve treatment and support for people with and at risk of respiratory disease.

Priority areas for 19/20In 2019/20 we will work with place-based leads to design and deliver an ICS-level respiratory programme in BLMK. We propose focusing initially on consistent implementation of three high impact interventions identified as priorities in the NHS Long Term Plan:

Early detection and accurate diagnosis of COPD• Proactive case-finding for people at risk of COPD• Quality-assured education and training for healthcare professionals in

the use and interpretation of spirometry to enable early diagnosis

Optimising inhaler technique for COPD and asthma patients• Medicine reviews in community pharmacy, including educating patients

on the correct use of inhalers• Building techniques to improve inhaler use into a patient’s annual review

Improving access to pulmonary rehabilitation • Ensuring all eligible patients are encouraged to attend a pulmonary

rehabilitation course, with sessions held at convenient venues and times• Developing more flexible delivery models to meet users’ needs,

including digital tools such as myCOPD.


Q1 1. Review baseline activity, outcome and expenditure data for respiratory disease (RightCare, Public Health, Model Hospital GIRFT) by CCG and benchmark by peers.

2. Outline effective interventions appropriate to BLMK to increase detection and optimal management of respiratory disease.

3. Facilitate a respiratory stakeholders’ action planning workshop to agree and commit to actions at BLMK and place-level as appropriate, including an agreed approach to measuring success.

Q2 1. Develop a system-level respiratory programme focused on implementation of a limited set of high impact interventions, as agreed at the stakeholder workshop.

2. Put in place a consistent approach to monitoring outcomes.

Mental Health


Q1

1. Refreshed ICS Mental Health Programme Board governance to effectively balance FYFVMH delivery assurance with transformation planning

2. Focus on delivering key FYFV priorities

3. Preparation of mental health element of ICS response to long term plan

Q2


2. Preparation of mental health element of ICS response to long term plan

3. Consensus models for mental health in the neighbourhoods, CYP and crisis care

Q3


2. Implementation of relevant mental health elements of ICS response to long term plan

Q4


2. Implementation of relevant mental health elements of ICS response to long term plan

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During 2019/20, the BLMK ICS will take steps to deliver the Five Year Forward View for Mental Health, whilst developing our plans for the delivery of the Long Term Plan, with a particular focus on children & young people (0 to 25), eating disorders, mental health in the neighbourhoods, crisis care, suicide reduction and workforce. The ICS has a Mental Health Programme Board in place, which will work with the four place-based Transformation Boards to assure FYFV delivery and develop our Long Term Plan transformation plans.

Steps to implement the Five Year Forward View for Mental Health (FYFVMH)The BLMK ICS will continue to focus on the delivery of FYFV priorities in 2019/20, in particular:Improving access for mental health support for children and young peopleImproving access for children & young people with an eating disorderImproving access to psychological therapies (IAPT) & recovery for people with common mental health problems, including people with long term conditionsIncreasing the number of people being diagnosed with dementia and improving post-diagnostic careImproving physical health care for people with severe mental illness (SMI)Improving services for people experiencing a mental health crisisImproving quality of care for people experiencing their first episode of psychosis Delivering our suicide reduction plans.

NHS Long Term Plan

The BLMK ICS develop our plans for delivery of the Long Term Plan, engaging with the other

STP workstreams and with key transformation workstreams focusing on:

Children & young people (0 to 25)Eating disordersMental health in the neighbourhoodsCrisis careSuicide reduction WorkforceFinance & investment (long term plan support).

We also aim to progress local priorities, including developing options for the future of inpatient services in Bedfordshire and, in working with NHS England Specialised Commissioning, Tier 4 CAMHS beds.

In line with the planning guidance requirement, ICS leaders, including ELFT as the lead provider, have reviewed the CCG investment plans against the Five Year Forward View for Mental Health (FYFVMH) and planning guidance priorities for 2019/20. Whilst we are finalising the detailed contractual arrangements to support investment into the FYFVMHpriorities, we can confirm that providers and commissioners have reviewed and agreed investment plans in principle, and are satisfied that funding is in place to meet the requirements of FYFMH. There are the following risks:

• Dementia diagnosis in Bedfordshire is a risk, commissioners and providers will continue to work closely to mitigate the risk in 2019/20

• CAMHS Tier 4 continues to be a risk, in 2019/20 we hope to work with NHS England specialised commissioning in the context of the pending Public Health England demand & capacity review and approach to New Models of Care, to develop local Tier 4 capacity

• Within Milton Keynes there are risks against the IAPT 22% target and 24/7 Crisis Response Home Treatment teams, commissioners and providers will continue to work closely to mitigate the risk in 2019/20.

Detailed trajectories for meeting Mental Health NHS Constitutional Standards are included in CCG Operational Plans.

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Mental Health Continued

Personalisation

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BLMK are a Level 1 Demonstrator site for the Personalised Care Programme, embedding the NHSE Comprehensive Model of Personalised Care. This includes:

▪ Personalised care and support planning through delivery of training & mentoring staff, with plans completed using an MDT approach

▪ Proactive coordination of care, community based approaches, including social prescribing, community groups, peer support and similar activities. Ensuring Personalised Care complements the local population health management approach.

▪ Patient Activation Measure (PAM) or equivalent to determine ability to self-manage and to tailor support.

▪ Shared Decision Making self-assessment checklist in one or more high priority clinical situations.

▪ Self-management support and health coaching, as well as similar interventions.

▪ Personal Health Budgets (PHB) and Integrated Personal Budgets, to enable choice and control. 85% of home care packages delivered through a PHB.

▪ Co-production of the model across BLMK, ensuring those with lived experience have a direct role in shaping policy


Activity data (number of

people)Basis of Counting

19/20

Target

Patient Activation

Measure (PAM)People completing the PAM

6432

Equivalent to PAMAgreed alternatives to PAM e.g.

MH Outcome Star

Self-management

support or health

coaching

People referred for self-

management support, health

coaching and similar

interventions

5609

Community-based

approaches

People referred for social

prescribing community groups,

peer support and similar

activities.

24,000

Personalised care and

support plansNumber of plans or reviews 7441

Personal health budgets

and integrated personal

budgets

Number of people with a

personal health budget

1300

6. Finance - Headlines

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• The funding settlement for the NHS includes an additional £20.5bn by 2023/24• BLMK has received a 6.1% uplift on its financial allocation for 2019/20 which is

welcomed by the system but the system has still had a testing round of contractual discussions which have necessitated increased levels of efficiency to ensure that all forecast activities can be afforded. The conclusion of these negotiations has resulted in a system wide efficiency requirement of £84m for 2019/20.

• Strong efforts have been made to conclude the contractual discussions with the objective of taking costs out of the system and avoid some of the traditional PbR contractual negotiations. Significant progress has been made in this regard to different contracting mechanisms and joint commitment to efficiency savings which have been built into contracts.

• Potential benefits of applying the synergy across the ICS have yet to be fully explored which could result in further reduction of inefficiencies within the system

• The majority of contracts were signed by 21st March 2019• The system is now working on the delivery of contractual values, improved outcomes and

management of system risk and opportunity• Individual organisations have now submitted their operational plans and an exercise has

taken place to consolidate theses for the ICS and triangulate this information with the SOP narrative.

Capital Planning & Estates

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• BLMK Estates Workbook developed July 2018, provides framework for estates planning across the system and is set in the context of considerable housing growth in our area.

• Number of schemes in progress (business case development) where national capital has been secured, including development of Primary Care Hub in Bedford, Stroke Rehabilitation Unit and Pathway Unit for Milton Keynes. Two schemes at Bedford Hospital have now been successfully delivered.

• Organisations within the BLMK system have submitted Capital plans that reflect those developments they have assurance over funding upon. With regard to the submitted plan, this equates to £85m in 19/20.

• This will be funded by £47.7m of internally generated resources, £18.2m from loans, £11.1m of PDC and £8m of donations.

• Headlines schemes in the programme relate to the building of the cancer centre at MKFT (£8.6m), and Luton and Dunstable developing a Helipad (£4m).

• The capital programme for the system over the next three years equates to £238.7m.• Our priority remains capital to support redevelopment at Luton and Dunstable Hospital.• Further planning in progress, particularly in relation to Primary Care Hubs, with a variety of capital funding

options.

INFORMATION TECHNOLOGY (see P4 digital for further detail)

• National capital (HSLI) secured to deliver interoperability architecture across BLMK system, 2019-2022., including shared care record.

• ETTF Schemes e.g. tactical interoperability schemes, Care Home connectivity with System 1 (achieving bronze level, starting to achieve silver level), assistive technology and enhancing digital access for patients

• Global Digital Exemplar (GDE) programmes at each of the Acute Trusts

7. Workforce

Having the right numbers of health and care staff equipped with the skills, values and behaviours to deliver the best, integrated care services now and for future generations, is critical to the successful delivery of our plans.

The workforce challenges across BLMK are similar to the national picture outlined within the Long Term Plan for NHS staff and by local government for Social Care staff. Carers, the voluntary, charitable and independent sectors are also a vital component to the makeup of our caring communities.

We are working to deliver national priorities for the expansion of numbers of staff in critical groups such GPs, nursing and mental health. Our focus, however, is also upon introducing new roles and ways of working, alongside a digitally enabled approach, which means that integrated health and social care teams are offering personalised, needs-based care, within primary care networks and across systems of care, such as respiratory and diabetes.

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BLMK Workforce

What we have achieved so farWe have developed a BLMK Health & Care workforce strategy and have adopted a workforce development academy approach to its delivery. A few key achievements within 2018/19 have included:

Grow Our OwnWe have increased our numbers of WTE GPs from 415 in Sep 2017 to 424 in Dec 2018 (excluding registrars and including leavers/retired), which meets our forecast trajectories for GP expansion in BLMK. Our general practice nursing numbers are also increasing , as are new roles such as clinical pharmacists, social prescribers and clinical administrators.

Adaptable Skills; Flexible ApproachA Home-Based Staff BLMK workforce development group is developing an education and training framework, learning portal and training passport to support skills development for staff in nursing, residential and domiciliary care settings.

BLMK; A great place to work and learnWe have launched a BLMK staff facing ‘Live, Learn and Work’ website, focused on supporting staff development, attracting staff to work locally and retaining our existing staff. This website currently has over 300 hits a month, with further development on-going.

Developing leaders and OrganisationsWe have created a ‘Stepping Into My Shoes’ staff interchange initiative. Staff have the opportunity to shadow, mentor and share learning across our organisations and health and care sectors, supporting the development of system values and behaviours and enabling staff to identify and address some of the barriers to working in an integrated way. Hundreds of staff have also come together through ‘Clinical Conversations’ including topics such as mental health and prevention to discuss how we can best work together to meet the needs of residents.

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Health & Care Workforce Strategy

How we will build on this in 2019/20

2019/20 Deliverables

Grow our Own • Develop models for integrated/rotational apprenticeships across health and social care

• Introduce a BLMK collaborative approach to commissioning education and training programmes with our local higher education institutes

Adaptable Skills; Flexible Approach • Develop a Primary Care Network (PCN) workforce model to identify critical workforce gaps, supply, retention and recruitment strategies across health and social care services which support the development and resilience of PCN teams

• Expand our mental health workforce aligned to the delivery of the mental health Five Year Forward View

• Develop a workforce plan to support the delivery of our Cancer, Learning Disability, Maternity and Digital Transformation programmes

BLMK: A Great Place to Live, Learn and Work

• Develop youth attraction strategies which increase the supply of the health and care workforce through adopting innovative ways of working with schools and education institutes

Developing Leaders and Organisations

• Introduce a Systems Leadership programme across health, social care and wider public sector e.g. police, fire etc. to develop leadership skills which focus on population need and community assets to support the health and wellbeing of our local population

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8. Developing our long term plan with our population

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We are now at a point where it makes sense to do longer-term planning for wellbeing, health and care services as:1. With the Integrated Care System (ICS) established, there is a real opportunity to

focus on what matters to residents in terms of their wellbeing and health.2. The national long-term plan for the NHS has been published and we need to think

locally how we make it happen.3. Funding for the NHS has been set for the next five years so there is more certainty

(although there is less for Local Authorities awaiting the Spending Review and Social Care Green Paper), enabling such planning.

4. We know the population is growing significantly in the BLMK area and services need to develop to reflect this.

Doing such planning will also fulfil a requirement from NHS England that each STP or ICS has a longer-term plan.

Given the distinct nature of the four places making up BLMK, we think it makes sense to have place-based longer-term plans on which the BLMK ICS longer-term plan is built. Each of the four place-based plans will be developed and owned by all key partners, Local Authorities, NHS commissioners and providers.

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BLMK Plan

Milton Keynes Plan

Bedford Borough Plan


Plan

Luton Plan

Planning from the bottom-up

Crucially, the plans will also be developed for and with our population and front line staff.

We are proposing four principles that will underpin everything we do in developing longer term plans.

1. We think about residents’ whole needs, not dealing with specific problems or issues in isolation. We want to integrate care around individuals, not treat them as a list of ailments.

2. We care as much about what keeps us healthy as how to sort out the things that make us unwell. We should be focusing on wellness not illness, helping people live longer lives in good health.

3. We will aim to improve access to quality local health and care services. This will be at home, in our communities and, where absolutely necessary, in specialist settings such as hospitals.

4. We will develop and deliver plans for our future health and care services which provide value for money. We will have an affordable, joined up and sustainable system.

Our principles for wellbeing, health and care

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March - May

Healthwatch Engagement

May/ June

Healthwatch Report

May - July

ICS Phase 1 -Listening

September

ICS Phase 2 -Feedback

October BLMK draft plan

November

BLMK plan submission

BLMK engagement activity in 2019 will have two distinct phases – Phase 1 will be focused on understanding what is important to local communities and Phase 2 which will be about sharing what we’ve heard and how this will shape our plan. Timeline is below:

Communications & Engagement with our residents A place-based approachOur engagement approach will mirror and support the development of place-based plans in our four areas -Bedford, Central Bedfordshire, Luton and Milton Keynes - to ensure they are informed and shaped by those living in this area. We will use local teams and networks to deliver on our overarching aims and principles established across the footprint.

Communications and engagement leads in our four areas will work closely with ICS planning leads, Healthwatch, voluntary organisations and wider local networks to develop and deliver tailored communications and engagement activity to support local priorities and involve local communities.

Our approachAll our communications and engagement will be planned, clear and informative. We are committed to openness, transparency and participation and want to establish a reputation for this through our communications and engagement. We want local people to trust that we listen to them and that we design local healthcare with them and for them, and that they are directly involved in developing new models of care.

Engaging with local communitiesOur developing plans will reflect the activity we propose to undertake across our stakeholder groups, considering how we can inform, involve and influence and taking into account local elections taking place early May. Our focus will be on staff, elected representatives, voluntary organisations and the public.

Glossary

Acronym/Word Meaning

ADHDAttention deficit hyperactivity disorder

AF Atrial Fibrillation

BAME group Black, Asian and Minority Ethnic

BCCG Bedfordshire Clinical Commisioning Group

BHT Bedford Hospital Trust

BLMKBedfordshire, Luton & Milton Keynes

CAKES Children Assessment Knowledge

CAMHS Children and Adolescent Mental Health Services

CCC Comprehensive Cancer Control

CCG Clinical Commissioning Group

CDEP Cambridge Diabetes Education Programme

CHC Continuing Healthcare

CoC pathway Continuity of Care

COPDChronic Obstructive Pulmonary Disease

CSE Child Sexual Exploitation

CT Computed tomography -CT scan

CTRs Certified Therapeutic Recreation Specialist

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CVD Cardio Vascular Disease

CWT Cancer waiting time

CYP Children and Young People

DSP ToolkitData Security and Protection Toolkit

EDENEffective Diabetes Education Now

EHCHEnhanced Health in Care Homes

EoL End of Life

EPaCCS Elective Palliative Care Solution

ETTF Estates and Technology Transformation Fund

FGM Female gential mutation

FHiR Fast Healthcare Interoperability Resources

FiT Faecal Immunochemical Testing- stool test designed to identify possible signs of bowel disease

FYFV Five Year Forward View

FYFVMH Five Year Forward View for Mental Health

GDE Global Digital Exemplar

GI Gastro Intestinal

GIRFT Getting It Right First Time

Acronym/Word Meaning HEE Health Education England

HeLPHealth Education Library for People

HIU High Intensity User

HPV Human papillomavirus

HSLI Health System Led Investment programme

IAPT Improving Access to Psychological Therapies

ICS Integrated Care System

IG ToolkitInformation Governance Toolkit

IUC Integrated Urgent Care service

L&D Luton and Dunstable Hospital

LA Local Authority

LD Learning Disability

LeDeRLearning Disability's Mortality Review

LHCRELocal Health and Care Record Exemplars

LTP Long Term Plan

LWABLocal Workforce Advisory Board

MDFT Multi Disciplinary Foot Team

MDT Multi Disciplinary Team

MJOG System providing patient messaging services for GP practices


MKFTMilton Keynes Foundation Trust

MLBU Midwifery led birthing unit

MoUmemorandum of Understanding

mpMRI multiparametric magnetic resonance imaging

My DESMOND Diabetes Education and Self Management for Ongoing and Newly Diagnosed

NHSE NHS England

OBC's Outline Business Case

OT Occupational Therapy

PAM Patient Activation Measure

PbR Payment by Results

PCN Primary Care Network-network of Primary Care professionals

PCP Primary Care Provider

PHB Personal Health Bugdets

PHMPopulation Health Management

Place Four local authority areas

PMS scheme Portfolio Management Scheme

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Pseudonymised Anonymised information

Red Bag scheme Communication aid to improve care home residents care between care home and hospitals

RightCare Programme

Programme created to improve people's health and outcomes.

RTT Referral To Treatment

SALT Speech and Language Therapy

SENDSpecial Education Needs and Disability

SIM

Serenity integrated Mentoring (see https://highintensitynetwork.org/resources)

SMI Severe/Serious Mental Illness

SOP System Operating Plan

SPoA Single Point of Access

STAMP Supporting Treatment and Appropriate Medication in Paediatrics

STOMP Stop over medication of people with learning disability

STPSustainability and Transformation Plan


SWIFT Case Management System

TAF Task and finish

TCP Transforming Care Partnerships

TECS Technology Enables Care Services

ToR Terms of Reference

UTC Urgent Treatment Centre

Viapath Provider of pathology services

Whzan Digital health monitoring system

Wiggly-Amps Software solutions company for healthcare

WTE Whole time equivalent

YTD Year to date

Glossary Continued

https://highintensitynetwork.org/resources

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