end of year 2016-17 programme progress against plan

End of year 2016-17Programme progress against plan

Introduction

This End of Year Programme progress update is an opportunity to demonstrate the progress made on the Isle of Wight during 2016/17 and celebrate and share the positive outcomes.

Some initiatives which have been developed through the transformation work to date have now been mainstreamed in to contracts or made part of business as usual – for example Care Navigation, Crisis Response.

Work to make the ‘Vanguard’ a business as usual part of the Island wide delivery, and work to link the Island wide transformation plan to the STP and Local Delivery system is ongoing.

Mapping Island transformation projects to the PACS Matrix Care Elements

PACS Matrix Care Element Local Initiatives aligned to PACS framework

Whole population – prevention and population health management

• Isle Find It• Isle Help• Prevention & Early Intervention strategy• Big White Wall

• Care Navigators• Local Area Coordinators• Community Navigation• Community Roles assessment• Pharmacy First

Urgent care needs – integrated access and rapid response service

• Integrated Care Hub & Integrated Access• Crisis Team• Ambulatory Care• Patient Flow and discharge

• Mental Health Serenity Street Triage• Patient Flow• Falls Clinic• Paediatric Assessment Unit

Ongoing care needs – enhanced primary and community care

• Primary Care Federation pilot projects • Technology Enabled Care – Care Home pilot

Highest care needs – coordinated community based and inpatient care

• Case Management of highest risk • Integrated Locality Service• Acute Frailty Service

• Shared packages of care (Earl Mountbatten Hospice)

Contract, commissioning and funding • Recruitment of Assistant Director of Integrated Commissioning• Recruitment of Assistant Director of Integrated Provision

Flexible use of workforce and estates • Integrated End of Life Training• Wi-fi sites enabled• Recruitment Portal

• Dementia Training• Workforce Plan – current gaps• Island Estates Strategy

Building shared care records and business intelligence systems

• Dashboard development• Information Governance• TEC Strategy

• Risk Stratification tool• Evaluation & measurement• Community IT solution

Cultural and change • Whole Integrated System Re-design• Acute Service Re-design• Integrated governance and assurance

• Parish and Town Council work (ongoing)• System-wide values and behaviour

framework• Staff Engagement (ongoing)

Project Care Navigation

Progress within the quarter

• The project continues to deliver across the Island with 102 new referrals in December 2016 and an open caseload of 358. The team have responded to a number of people in Crisis and have been promoting Winter Warmth messages to ensure older people are keeping safe and warm in the colder weather. The rapid response ‘Winter in a Box’ supplies are again available. The team have been able to respond to a number of clients lacking basic items in their homes e.g. fridge, and through charitable grants to purchase items for them. This is vital in keeping people safe and well in their own homes.

• This case study was highlighted in the BBC Inside Out programme which demonstrates the support given by the Care Navigator and the prevention of a hospital admission. Case Study - Male, 68. Referral from Community Nurse who was supporting cardiac problems. A same day visit was undertaken on a Friday afternoon, as the client had no money, food or power, to see him through the weekend as he did not qualify for help from Social Services. He was reported as not managing his medication and living with mental health problems. The nurse was concerned he would be admitted to hospital if support could not be found.

• The Community Roles report provided early assessment on the roles and functions of new community roles (Care Navigators, Community Navigators, Community Care Facilitators and Local Area Co-ordinators) . It was subject to independent review and the report was presented to the Joint Commissioning Board on 1 March 2017. The report highlighted the similarities and differences of care navigation with other community roles. Since review Care Navigation has now been mainstreamed in to contracts in 2017/18.

Depth • 3740 people have been seen by a care navigator since early 2014.• Of the people supported, 75% were female and the average age was 79.1 years old.

Scale • 9 Care Navigators currently provide full island coverage.• Care Navigators are locality-based in GP surgeries and work with people for up to 6 visits .

Sustainability • Full island coverage by Care Navigators has been achieved• The Care Navigator service has become mainstreamed in to contracts for 2017/8.Early findings on sustainability include:• Encouraging the use of the diverse skill-set within the group of Care Navigators was seen as vital for sustainability.• Further qualitative work to investigate impact and sustainability is planned for 2017/18.

New Care Model Review – Programme Progress against Plan1. Whole population- prevention and population health management


Project Care Navigation (continued)

Impact Combined Measure of Success (CMS) analysis 89 cases were analysed (before and after scores in all three change areas)• Headline 1: 79% of cases positively affected at least one change area (Wellbeing or Frailty or Quality of Life)• Headline 2: 66% of cases positively affected Wellbeing (27% no change)• Headline 3: 6.7% of cases positively affected Frailty (88% no change)• Headline 4: 49% of cases positively affected Quality of Life (46% no change)

Table interpretation: the majority of care navigation work led to one of these four combinations of changes: • 32.6% of cases had a positive effect on wellbeing and quality of life, but no effect on frailty.• 24.7% of cases had a positive effect on wellbeing, but no effect on frailty or quality of life.• 18.0% of cases reported no change (positive or negative) in any change area.• 7.9% of cases had a positive effect on quality of life, but no effect on wellbeing or frailty.

Change types

Change area Cases % of 89 cases Wellbeing Frailty Quality of Life

1 Positive change + No change + Positive change 29 32.6

2 Positive change + No change + No change 22 24.7

3 No change + No change + No change 16 18.0

4 No change + No change + Positive change 7 7.9

5 Positive change + Negative change + Positive change 4 4.5

6 Negative change + No change + No change 3 3.4

7 Positive change + Positive change + Positive change 2 2.2

8 Negative change + Positive change + Negative change 2 2.2

9 Positive change + Positive change + Negative change 1 1.1

10 Positive change + No change + Negative change 1 1.1

11 No change + Positive change + Positive change 1 1.1

12 Negative change + No change + Positive change 1 1.1

Project Local Area Co-ordination


• LACs continue to support complex cases.• 3 new LACs have been employed (since Jan 2017). • Work has started to increase access to non-health data (e.g. council police, employment data) for evaluation. LACs have

reported the importance of non-health data • The Community Roles report highlighted how LACs work in an integrated manner with other community roles.

Depth • To date, 560 people have received LAC support.• The predominant presenting issue was a mental health issue (25% of people seen to date).• 50.2% of people supported were female.• 48% were under 55 years old, 40% were over 55 years old (12% unknown age).• 64% of people receiving LAC support are economically inactive (e.g. unemployed, retired, receiving benefits).

Scale • 9 LACs are currently employed across the Island giving 75% Island coverage• Employment by locality: West & Central (4 LACs), South (3 LACs) and North & East (2 LACs).• Each LAC works with a population of approximately 10-12,000 people. • Introductions to the LAC service have come from approximately 25 different locations – but predominately from

community settings, mental health services, and self-introduction.

Sustainability • 66% of LAC funding has become mainstream in to Public Health contracts.• Further work to investigate the challenges of sustainability is planned in 2017/18.

Impact LAC-reported outcomes:• 100% of people gain confidence to self-manage.• 92.9% of people improve their family/social situation.• 57.1% of people broaden their social network. • 50.0% people improve their health/wellbeing. People-reported outcomes:• Positive effects for all: More confidence to control my own health care; Feel less isolated; Visit GP less; Attended new

community groups.• Positive effects for some: More active; Able to manage my medications; Able to manage my long-term condition.• Limited effects on: Starting new employment; Starting any form of educational course.


New Care Model Review – Programme Progress against Plan2. Urgent care needs- Integrated access and rapid response service

Project Ambulatory care


• Appropriate patients have continued to be processed through this pathway.• A review of documentation use has begun to improve patient tracking and support evaluation work.

Depth • 176 patients have been through the ambulatory care service since 1st Nov 2016

Scale • Started 1st Nov 2016, 5 days a week service, 1 consultant, 3 locum consultants, 1 locum SHO, nurse support provided.

Sustainability • Requires further development of patient recording/tracking methods for more accurate activity data.• This service has now become part of standard operating model in Trust.• Work planned in 2017/18 to evaluate fully including cost based analysis.

Impact • 87% of patients were discharged home and thus avoided an admission. • 80% of patients were seen by a Consultant within 4 hours.• 80% of patients were discharged within 4 hours.Success story: A patient attended the AEC on 10/11/16 who had a non-specific abdominal bloating/ache. He had been reviewed by his GP who was concerned as there was no clear cause and requested for review in AEC. On attendance, the patient felt well in himself however, there was a query that his raised CRP could be related to relapse of Lymphoma. A CT CAP was required to rule out recurrence/progress of lymphoma. Unfortunately the patient couldn’t have the CT scan that day due to unavailability of a slot but an agreement was reached to do the scan the next day at 09:00 with a review of the patient in AEC afterwards. The CT CAP, which did not show anything new or any progression, except left sided trivial pleural effusion. The patient was reassured and prescribed a 5 days course of Amoxicillin for him in view of raised CRP, mild shadowing left base on the chest x-ray and trivial left sided pleural effusion that could have possibly have been lower respiratory tract infection. The patient was then discharged and was able to continue to go on his holiday that afternoon.The ambulatory care consultant received this message: “Just a simple thank you very much for all the care, attention and support I received after being referred to the ambulatory care on 10-11 November. I cannot even begin to guess at all the amount of organising you had to have undertaken, in such an incredible short space of time, to ensure it was safe for me to travel on my holiday cruise. As a result I had the most marvellous time. Please pass on my gratitude to all those involved– many, many thanks.”

New Care Model Review – Programme Progress against Plan3. Ongoing care needs- enhanced primary and community care

Project Primary Care Federation Projects


New primary care teams – this project investigated the workload in General Practice and different ways of dealing with it.Clinical Triage – this project has developed new delivery models to open up options for partners, salaried clinicians and managers to develop strategies for managing demand for general practice by building community networks, connecting with the voluntary sector, and supporting patient activation and self-care. Remote Access – this project has worked to develop online / telephone / skype / app / email primary care services using GPs and Advanced Nurse Practitioners to manage consultations without seeing patients face-to-face. Admin & back office – this project has worked to design and deliver processes to share best practice across general practice.

Depth New primary care teams – a baseline audit across 4 practices analysed 2,006 appointments for ‘avoidability’. Clinical Triage – Standard Operating Procedures have been shared across Localities and an audit of demand and capacity is underway. Remote Access - trialling messaging via System One and to gain information on remote consultation.Admin & back office - production of administrative SOPs to share Island wide across practices.

Scale Pilots spread across island localities:New primary care teams - Follow-up audit planned for May 2017. Patients are being given a satisfaction survey when attending their MSK clinic appointment. MSK practitioners trial started 30th Jan for 12 weeks across 4 practices.Clinical Triage – 4 practices conducted an audit. A follow-up audit is planned for May 2017. Remote Access – 6 practices have participated in a review of remote access. Admin & back office – 5 practices were included in developing shared SOPs.

Sustainability Pilots have been GP owned and led, further activity is incorporated in to Primary Care elements of Single Change Plan. Some elements may require discussion with practices regarding future funding.

Impact New primary care teams – 96% of patients surveyed were happy to see an MSK practitioner and did not wish they’d seen a GP instead. Clinical Triage – service change being tested, e.g. sick note SOP being used. The baseline audit revealed 26% of GP appointments were avoidable. 7.2% of GP appointments could have been dealt with by an MSK practitioner and 11.8% by an advanced practice nurse. Admin & back office – 15 shared SOPs have been produced and agreed, e.g. SOPs for temporary residents, registering new patients, keeping medication safe.

New Care Model Review – Programme Progress against Plan3. Ongoing care needs- enhanced primary and community care

Project Technology Enabled Care


A pilot in care homes since May 2016 which uses technology to monitor biometric health data and the risk indicators . This data improves health monitoring and the ability to share the data with GPs, community nurses and ambulance crews. The pilot has now been independently evaluated by the MLAFL Evaluation team. A TEC strategy for the Island has been written and is in the initial consultation stage.

Depth TEC pilot is embedded in four care homes and is currently being extended out to a further 7 homes in the West Wight area.

Scale The pilot has been implemented in two nursing care homes and two residential homes; a total of 111 beds.

Sustainability Although at a small scale the pilots show significant impact on A&E activity, and emergency admissions. Arguably other savings may be possible such as reduced Ambulance journeys. Funding will be needed to continue delivery and extended role out. The strategy document will make specific recommendations related to short term opportunities and will be considered by the Joint Commissioning Board. The evaluation study estimates that a £160k investment in year one and 80k investment in year two (to cover implementation in 80% of care/nursing home beds) could deliver savings in excess of £500k.

Other sources of Social Services funding eg. ‘one off funding’ is being considered for investment in this area.

Impact Pilot impact to date:(i) 24% reduction in emergency admissions compared to baseline data.(ii) 24% reduction in associated activity including 111 calls and A&E activity.(iii) Rapid access to patient data for faster assessment (iv) Positive patient feedback e.g. residents report “comfortable assessment experience”. (v) Care home staff report increase ‘empowerment’ and have developed new skills and interact more effectively with

residents. (vi) Saved GP time primarily through the avoidance of GP visits to homes for face-to-face contact.(vii) Residents’ families report feel better supported due to increased monitoring

New Care Model Review – Programme Progress against Plan4.Highest care needs- coordinated community based and inpatient care

Project Case management of highest risk


• The appointment of a temporary Case management / MDT coordinator in January has positively impacted the delivery of this project with 13 out of 16 Island GP practices now signed up to the initiative and 7 x Case Management meetings taking place in January. Of the 13 participating practices, 100% have consent gained and 69% have staff trained to use the ACG risk stratification tool and 69% have completed their first Case Review meeting which reflects quick progress within a limited time scale. Continued focus will be on compliance of case review meetings.

• Weekly project meetings with the Operational Leads has been initiated and is proving beneficial to keep communication and milestone tasks on track. Post conversations at various project meetings, it has been agreed that there is a need for support and education for GP coordinators in the compliance of the Case Review processes. Therefore a ‘Case management / MDT Networking Workshop’ took place on Tuesday 11th April 2017. All coordinators have been invited to gain awareness of best practice, IG compliance and collaboration to enable successful safe and proactive Case Review meetings.

• The MLAFL evaluation team have been working with the project leads to confirm KPI’s and scope out the R-Outcomes Survey to sample patients that have participated in the Case Management for highest risk meetings.

• In addition, the implementation of a pilot for a shared IT platform (Microsoft One Drive) to facilitate the multi-disciplinary meetings is now underway with St Helens surgery lined up for participation, pilot to commence in April 2017. This pilot seeks to evaluate a suitable shared IT platform for both case management of the highest risk and the wider Integrated Locality Service.

Depth Reliable and detailed information of activity not yet available, however, early indications are: • Overall, 24 meetings have occurred between January and March 2017.• Approximately 12 staff are involved in each meeting (30% GPs, 30% nurses 30% others e.g. care navigator, LAC, social

worker, MLAFL case management coordinator).• Approximately 1 to 2 patients are discussed at each meeting. • The profile of those discussed at the meeting: average 80 years old, have 6+ long term conditions, and have a high

probability of emergency hospitalisation. • Care plans have been developed for some patients, but in some cases not for patients who already had a palliative care

plan, an AUA care plan, or an anticipatory care plan, or a combination of these.

New Care Model Review – Programme Progress against Plan4.Highest care needs- coordinated community based and inpatient care

Project Case management of highest risk (continued)

Scale To date 13 (81%) of the 16 surgeries on the Island have implemented the process with varying degrees of success. The next stage will be to look at generic documentation and processes and making sure best practice is implemented and the service is business as usual.

Sustainability Challenges to sustainability include:• Confirmed funding for the Local Incentive Scheme (LIS) to be agreed. Not continuing results in risk around engagement by

GP practices and sustainability of the project will cease. Meeting in April 2017 scheduled to discuss linkages with the Integrated Locality Service and next steps re funding.

• Still in early stages within a few surgeries and impact will influence engagement.• Maintaining and managing clear processes and documentation at each GP location is vital for success. This was poor to start

but improvements have been operationalised by the case management coordinator. • Several GP locations have not allocated a particular staff member to be a practice coordinator to work on the commitments

signed up to in the LIS. This has caused problems with continuity of arrangements and will be discussed as part of the Networking Workshop in April 2017.

• Whilst the majority of surgeries are engaged, processes to manage information from care management meetings are not fully in place. In particular, a place to securely save and store documentation; this will be addressed through the shared IT platform pilot.

Impact Early anecdotal feedback from GP coordinators include:• A positive sense of collaborative working.• It’s helped avoid too many people asking the same questions and as a result the patient not knowing who to ask/asking

everyone.• The informed consent tool is a good introduction method to get patients to consider the wider options in care planning.• They admit the processes will run smoothly once embedded and this will really help their most vulnerable patients. • Input at the meetings from LACs, care navigators and social workers has been invaluable.

AHSN will be undertaking impact evaluation in 2017/18.

New Care Model Review – Programme Progress against Plan4. Highest care needs- coordinated community based and inpatient care

Project Shared packages of care – Earl Mountbatten Hospice (EMH)


People with complex needs require more frequent domiciliary care often with two carers attending per visit (doubled up care) and those approaching end of life need specialist end of life care. Through the shared packages of care project the EMH Care@Home Team provide this additional care by working in partnership with other care agencies(one carer from EMH visiting the person with another carer from a partner agency).

Depth This pilot is in early stages and joined up working with other Domicillary Care providers has been challenging. The Care@Home Team Manager has been working on alternative ways of working together for the benefit of future patients. Following participation on the EMH End of Life Training, 5 care agencies have expressed an interest to undertake shift working alongside EMH Care@Home Team. It is anticipated that this will enhance understanding of the philosophy and practice of End of Life Care and enable further roll out of shared packages of care.

Scale Pilot in early stages.

Sustainability Ongoing funding will continue via NHS continuing healthcare . EMH will continue to develop the Care@Home Team and are looking at the extension of this team in order to support the needs of more patients who are in the last days/weeks of life, in their own homes.

Procurement of care agency support for an individual does not yet operate as a single process. The sustainability of this approach depends heavily on organising and agreeing procurement into a single process across all 13 care agencies.

Impact In early pilot stages, evaluation still required.


Project Integrated Locality Service


North East Locality: Following go-live in February 2017, Lead Locality Nurse and Lead Social Worker are now based at the Locality Hub in Ryde. Full representation of all core staffing groups is present at every weekly Case Review meeting; real time learning is informing most appropriate cohort to be discussed. Updated Privacy Impact Assessment completed and ratified. Other ILS staff are dropping in to the centre to hot-desk, for joint meetings and to work more closely together to ensure greater collaboration and integrated care. Timelines under development for relocation of other identified community staff groups.

Project management: Development of a formal Project Board underway to ensure Operational lead and Exec Sponsor are effectively held to account on progress against time, cost and quality. Estates, Accommodation & Access Task & Finish sub-group established to work on operational issues for short term Locality Hubs and to guide the strategic perspective regarding long term Locality Hubs. Scoping for activities to be included within Phase 2 delivery plans underway.

Resources: Locality Manager posts - in process of establishing governance and arrangements of posts, NE Locality Manager appointed.

Depth • Weekly ILS meetings have occurred between 17/1/17 and 22/3/17.• 11 core staff have been involved in ILS meetings. Staff include: Locality Lead Nurse, Locality Social Worker,

Advanced Clinical Practitioner, Community Matron, Care Navigator, Occupational Therapist, Reablement Manager, Local Area Coordinator, Crisis Response representative, Associate Community Matron, Case Review coordinator.

• The profile of these people were mainly frail older people with a minimum of two long term conditions. However they presented with complex needs arising from a change in either health or social circumstances. 90% of the people discussed were over 65 with an even split between male and female.

• ILS action plans and these were developed after the ILS meeting where required.


Project Integrated Locality Service (continued)

Scale Pilot phase in North East Locality is ongoing. Rollout plan:

To make this a manageable process, it has been agreed that initially ‘core ILS’ (green boxes below) will form part of the

first phase of integrated locality services and as the model develops, additional services closely involved in a person’s care

will be added to the model in each locality.


Project Integrated Locality Service (continued)

Sustainability Other challenges to roll-out include:

• Staff engagement in early stages – initially concept of ILS was not clearly understood and this is being resolved• Agreement around move to ILS model is now business as usual for community operational teams• Referral criteria and process not clearly understood. PDSA cycle used and solutions identified including:o Simplified referral formo Reiteration of boundaryo Staff briefing prepared

• Information governance and necessary consent form being developed and communicated (Privacy Impact Assessment process)

• Cultural shift in working in a more integrated way - further Team building days planned

Impact Focus of 17/18 AHSN work is to support evaluation of impact. Some early qualitative findings include:

• Referrals to other disciplines has been reported as quicker, thus improving the patient journey.• A better understanding of other disciplines and new roles such as Care Navigators and LACs. • Improved signposting to the third sector, releasing capacity of registered professionals. • A recognition that referrals made to ILS at an earlier stage in the person’s journey will impact a greater change in

the model of care delivery. • As a result of the early ILS development workshops, networking between health, social care, third sector and

emergency services has increased. • Sharing of terminology and criteria thresholds has taken place improving the understanding of different cultures

within organisation.

New Care Model Review – Programme Progress against Plan6. Flexible use of workforce and estates

Project End of life training


Earl Mountbatten Hospice (EMH) have provided End of Life training to staff from any part of the IW healthcare system. Two forms of training were developed, End of Life (half-day course) and End of Life & Dementia (half-day course) to address a gaps in staff knowledge and support development. Also, training has been provided to District Nurses as part of the NHS Continuing Healthcare training programme to inform of the processes of Fast Track applications.

Depth • 114 staff have been on the EoL training and 152 staff have been on the EoL and Dementia training. • The type of staff attending both type of training included: Residential and Nursing Home Care, Domiciliary Care Agency, IOW Council,

trained nurses from HM Prisons, Social Workers, trainers from IW College, St. Marys Hospital Renal Unit.• The second element of training was around NHS Continuing Health Care training to GPS and District Nurses, however, this was

adapted due to feedback from GPs and has since been provided on the Drs Induction programme at St Marys Hospital (7 junior Drs attended]. The purpose was to improve the identification of patients in the last few days/weeks of life who have complex health needs and would be eligible for NHS Continuing Healthcare under Fast Track processes.

Scale • This training has been widely welcomed and appreciated by a range of health and social care workers

Sustainability EMH have committed to provide, EoL training up to March 2019.Challenges to sustainability were:• Trainees not turning up due to the nature of the training being free (although it is possible to charge a discretionary £10 for non-

attendance). • High staff turnover, i.e. people leaving their post before the training was delivered. • Consideration of how to link NHS Continuing Healthcare training to existing mandatory training.

Impact EoL training – survey findings indicated improvements in nearly all training areas:• Confident to recognise dying (80% went from average to good)• Confident to talk about death and dying to residents and their families (80% went from average to good)• Confident to handle strong emotions e.g. anger or distress (75% went from average to good)• Confident to identify a patient or relative’s concerns (70% went from average to good)• Confident to recognise and discuss spiritual issues with individuals (75% went from average to good)• Confident to deliver compassionate care to a dying resident (most rated themselves as good and this was the same after the training)EoL and dementia training – survey findings indicated improvements in nearly all training areas:• Confident to look after a person with dementia (most rated themselves as good and this was the same after the training)• Understand the different types of dementia (50% went from good to very good)• Confident to handle strong emotions in people with dementia (50% went from good to very good)• Confident to identify the concerns of a person with dementia (60% went from good to very good)• Confident to communicate with people with dementia (most rated themselves as good and this was the same after the training)• Confident to deliver compassionate care to a dying person with dementia (70% went from good to very good)

New Care Model Review – Programme Progress against Plan6. Flexible use of workforce and estates

Project Dementia training


Tier 1 Dementia training consists of a one-hour session for staff to introduce them to the issues and challenges of living with dementia. Tier 1 training has continued to be delivered throughout the quarter. In February 2017, Tier 1 training for all NHS Trust staff was publically announced as mandatory.

Depth Tier 1 dementia training has been delivered via one of these 4 routes: • Dementia Awareness - Tier 1• Dementia Awareness - TT e-Learning• Dementia Tier 1 Classroom Training• Care Certificate Induction (with Tier 1 dementia training embedded within)

Scale • To date, 1103 NHS Trust & non-NHS Trust staff have attended the Tier 1 dementia training. • 76% of trainees were NHS Trust staff, 12% were Care Home staff, 6% were GP staff, and 6% were other staff such as IW Council,

IW CCG and hospice staff.

Sustainability • In October 2016, Tier 1 dementia training was included in the NHS Trust staff induction process. • In February 2017, Tier 1 training for all NHS Trust staff was publically announced as mandatory. • Plans for an ‘acute dementia lead’ have been agreed in principle and the source of funding is being sought. The lead role will hold

responsibility of supporting training and taking forward the ‘train the trainer’ work.

Impact 246 staff surveys about Tier 1 training have been analysed.• 91% reported an increased understanding of the challenges faced by people with dementia (90% reported in 6 month follow-up

survey).• 88% perceived they now worked with people with dementia more efficiently (90% reported in 6 month follow-up survey).• 50% perceived a reduction in staff assaults by people with dementia - due to staff having a better understanding of how to

communicate with people with dementia.

New Care Model Review – Programme Progress against Plan7. Building shared care records and business intelligence systems

Project Dashboard development


Continued Business Intelligence solution development incorporating NHS Inpatient, A&E, Outpatient and Mental Health, and Age UK data, and exploring options for incorporation of Adult Social Care data with adult social care colleagues. Recent development and incorporation of length of stay variation and admissions against discharge rates compared with A&E wait times to demonstrate relationship between LOS predictability and better discharge processes, and bed capacity usage against A&E ability to admit patients against A&E wait times.

Depth BI solution currently analyses over 1.5 million rows of data related to NHS and Age UK data. Data is updated monthly, and development and functionality is developed on a continuous basis, providing detail on inpatient admissions, discharges, length of stay, length of stay variance by specialty and admission day of the week, A&E wait times, re-admissions, long term conditions, first and follow up outpatient ratios, with analysis available by Age, Age group, Locality, diagnoses etc.

Scale System currently has access primarily to acute data covering from 2014-15 to end of 2016-17Further developments to include Adult Social Care data at a detailed level, and GP data to allow insight into the relationships between GP, Acute and community systems as a single entity.

Sustainability Data is provided by the Trust Informatics team on a monthly basis, database and BI development continues from within the System Wide Transformation Team, including analysis.

Impact The BI solution retains detail behind the reports allowing data exploration in real time: questions can be asked of the data and almost immediate answers are produced, and allowing cross examination between separate but inter-related datasets e.g. inpatient and A&E data. This has allowed changes in the system to be demonstrated in greater detail, and also to highlight cohorts of patients for further support, moving forward


Project Information Governance


This has been an issue both in terms of delivering integrated care pathways (e.g. Case management for those at highest risk, ILS, Care Navigators) and sharing data for the purposes of performance measurement and evaluation. We have developed a system wide information governance framework which complies with legislation and best practice. IG issues will continue to be addressed to enable greater access to data to support improved service delivery and the provision of system wide business intelligence.

Depth Privacy impact assessments have been or are being carried out for key projects with the inclusion of robust consent forms. Consent forms have been developed for both service delivery and evaluation.

Scale The information governance framework has been signed by all key partners including some GPs and voluntary sector organisations (e.g. EMH and Age UK).

Sustainability Staff currently working across the system have been involved in the development of privacy impact assessments, consent forms and operational data sharing agreements supported by expertise from the CSU in order to enhance skills in this area, enabling sustainability of approach.

Impact This work has enabled sharing of personal confidential information for the purposes of delivery and evaluating our new model of care. Whilst adhering to data protection legislation and protecting the right to privacy for our population.


Project Risk Stratification Tool


The ACG risk stratification tool is being used by the case management for those at most risk project to identify people at high risk of emergency admission to hospital particularly those with a high number of chronic medical conditions. This tool combines primary (diagnosis, GP activity and medications) and secondary care information (inpatient, outpatient and A&E / WIC), using NHS Number as the link.

Depth It has 137,000+ rows of information (i.e. 1 row per patient) and over 100 columns of information covering risk models, activity, costs, demographics, conditions etc. The tool now also includes the IMD scores for each patient, a mortality risk score and will soon include the frailty index score which practices will be mandated to review next year. The prediction models it includes are;

risk of high resource use (cost) risk of emergency admission risk of any admission risk of extended length of stay risk of high pharmacy cost

Scale 13 of the 16 Island practices have signed up and to date 9 have staff trained to use the tool.

Sustainability Support is provided by the CSU to enable long term use of the tool by the practices (staff training and ongoing technical support) and standard reports have been created to assist practices by saving their time when running reports.

Impact In addition to being used to identify people suitable for the case management for those at most risk the tool is also helping to identify unmet need. For example one practice has reviewed their list of patients with a diagnosis or medication that may indicate they have dementia.


Project Evaluation & Measurement


Academic partner - The Wessex Area Health Science Network (AHSN) working in partnership with the CSU have been commissioned to deliver elements of evaluation for our programme. They are working in partnership with the system wide in-house evaluation team to deliver evaluation of the new model of care and deeper dives into specific projects in order to determine what has worked, for whom and the resultant impact.

Depth • Projects to be studied in depth are; ambulatory care, integrated locality services and case management for those at most risk.

• Further qualitative evaluation using the R Outcomes tool will be carried out for Care Navigators and Local Area Coordinators.

Scale • The in-depth studies will be synthesised to give a macro level system wide evaluation of this key elements of our new care model.

• Economic evaluation and modelling will be carried out to investigate the impact on care costs.

Sustainability Programme Directors across Hampshire and IOW Vanguards are working together to identify if working at scale, linked to the STP in this area, will deliver further benefits.

Impact This work will inform local decision making, strategy and service development and allow for the Isle of Wight to contribute to the learning from implementing new models of care. The results of the evaluation will also add to the body of knowledge regarding integration of health and social care and the advancement of the prevention agenda.

New Care Model Review – Programme Progress against Plan8. Cultural and change

Project Whole Integrated System Redesign (WISR)

Progress to date

Agreed System-wide New Care Models vision• The Isle of Wight’s key statutory partners have developed and formally signed-off a shared new care models vision for the

future configuration of the IW’s health and social care services which will:o Promote and support the health and wellbeing of IW residentso Put people at the centre of the way in which health and wellbeing supports are accessed and organisedo Enable people to take more control and responsibility for managing their health and wellbeing by promoting

prevention, self-care and self-management within communitieso Reshaping statutory services to ensure that people with health and care needs can access the right service in the

right place at the right time• This vision (see next slides) provides a shared road map by which the Island envisages that services will in future be

organised in three main care settings:o Community – self-care, self-management and preventiono Locality – integrated community care, providing local access to a range of support traditionally provided separately

in primary care, social care, community services and some hospital based serviceso Urgent and planned care services – people will only be admitted to hospital if they need treatment that cannot

safely be provided in the community

Public engagement and involvement in the Case for Change Following a comprehensive period of staff and public involvement and engagement, which included sending-out Caring for Our Island – Time to Act to 69,000 households and over 400 people attending a series of 21 public events, over 700 formal responses were received from the public. This identified a set of initiatives which were taken forward as part of the system-widetransformation programme.• Mental health community crisis café• Ambulatory Care • Acute Frailty service


Project Whole Integrated System Redesign (continued)

Depth Working groups including members of the public were able to co-produce redesign solutions. Dedicated forums meant different groups e.g. carers, youth groups were able to make in-depth contributions to the process. Mental health service users continue to take part in fortnightly task and finish groups to inform the development of the Safe Haven.

Scale Across all localities and cohorts, 18 events attended by 189 people, 3 public engagement events attended by 197 people, 317 people reached through direct community conversations, 230 community groups, including hard to reach groups, were contacted, 69,000 households mailed with information and a survey (723 responses received), 315 members of staff attending variety of staff events.

Sustainability We are maintaining ongoing dialogue with Healthwatch IW, Community Action IW and the Patients Council to continue to seek patient and public engagement around the complete programme of work to deliver the new care model. We have also commissioned additional co-production training through Healthwatch IW & Wessex Voices and have commissioned Healthwatch IW to develop a patient practice group forum to ensure that we are engaging this group of the population. We have also continued to fund a post within Community Action IW to support us with our engagement with community groups and especially those that are seldom heard. We also have a standing update on the Medicine for Members sessions attended each time by 50-80 of the Trust’s membership base. The next stage of the service re-design process now underway with Acute Service Re-design.

Impact Patients and the wider public have been able to influence key decisions relating to the redesign of services and continue to be involved in the development of key initiatives. We have developed good working relationships with Healthwatch IW and the Patients Council. Identified initiatives are now being implemented in to business as usual.


Project: Acute Service Re-design (ASR)

Progress within the quarter:• Building on the New Care Models developed through WISR, the Acute Services Redesign project will define the next level of detail to

enable the realisation of this system-wide vision by developing the blueprint for the future configuration of safe and sustainable acute services to meet the needs of Island residents into the future.

• The Redesign will describe the range of clinical services to be provided as part of the vision for developing St. Mary’s Hospital to provide Urgent and Planned Care services. It will define:

o The clinical adjacencies needed to provide the appropriate range of on-Island acute serviceso The services that will be provided as In-reach services by other providers within the Solent Acute Alliance o The services which will need to be provided off-Island by Solent Acute Alliance partners.

• The final Blueprint will be developed into detailed implementation plans as part of the IW overall system-wide change programme.

➢ Phase 1: Overall Service Model Framework completed (9th March):• Case for Change – clinical quality, access & affordability complete• Overall Target Operating Models (TOMs) have been agreed defining a range of options between ‘Reconfiguration’

(Collaborate/Transform) & ‘Significant Reconfiguration’ (Re-scope/Transfer) ➢ Phase 2: Individual Specialty Redesign plans by 31st May providing the detailed service pathway reconfiguration proposals within

the overall Service Model Framework• The C4C & TOMs are now being worked up by the individual specialty redesign groups (commenced 8th March)

➢ Phase 3: Produce final Blueprint and develop Business Cases for implementation by 31st July

➢ Phase 4: Formal Public Consultation phase from 1st September

2017 March April May June July Aug Sept Oct Nov Dec 2018 Jan Feb Mar

Phase 1 Framework

9th March 2017

Phase 2Redesign Plans 31st May 2017

Phase 3 Blueprint &

Business Cases31st July 2017

Phase 4 Formal Public Consultation

1st September 2017

Phased Implementation from Jan 2018

Full Implementation by 1st April 2018

Re-scope: Revise the level of service provision e.g. repatriation of activity

from off-island, reduction in service and /or access

Target operating model 2 Target operating model 3

Collaborate: Increase the amount of collaborative working both internally and

with external partners e.g. shared pathways, workforce, capacity sharing

Transform: Redesign of clinical pathways to enhance delivery and efficiencies e.g. exploring new models of care, ‘top-of-

licence’ workforce models

Transfer: Cease delivery of a service / speciality and transfer to other providers

2 3Target operating model 1

As-is: No change to current service offer or method of

delivery

1

AS IS RECONFIGURATIONSIGNIFICANT

RECONFIGURATION

The range within which solutions can be found to achieve service sustainability

No change in service configuration is not an option

• The consultant body is strongly in agreement with the assertion that ‘no change’ (TOM 1) is not an option.• Thus 2 target operating models (TOMs) have been developed that define a range of potential options to reconfigure each

service to achieve sustainability, where some services may require more radical choices than others.• For each individual speciality, redesign options need to fall within the range established by Target Operating Models 2 & 3

ASR Target Operating Models (TOMs)


KEY ACUTE SERVICESREVISED TARGET OPERATING MODEL 2:

RECONFIGURATIONREVISED TARGET OPERATING MODEL 3:

SIGNIFICANT RECONFIGURATION

TRANSFORMATION OF SERVICE SCOPE AND DELIVERY (PARTIAL) TRANSFER OF SERVICE DELIVERY

A&E (EMERGENCY MEDICINE)

• Service transformation with a focus on admission avoidance and rapid transfer to alliance partner.

• 24/7 GP led urgent care centre.• Rapid transfer through emergency service to mainland

providers as required.

ACUTE MEDICAL INTAKE• Re-designed ambulatory care provision to support 24h

ambulatory care with in-reach support from medical specialties.

• No acute intake.• Day case medical treatment and diagnostics.• Outpatient medical services.

ACUTE (ADULT) SURGICAL INTAKE

• Cease some elements of elective / emergency surgical activity. • Joint appointments to secure viable rotas to maintain on-call

services.

• No acute intake.• Day case surgical treatment and diagnostics.• Outpatient surgical services.

ADULT CRITICAL CARE (INTENSIVE CARE)

• Flexible ICU/HDU bed numbers and staffing with an improved local network.

• Close critical care unit.• Option to retain HDU beds for stabilisation and transfer

purposes.

CARDIOLOGY (NON-INTERVENTIONAL)

• In-reach support to MAU and ambulatory care. • Service reconfiguration with focus on collaborative working

models.

• Outpatient cardiac rehabilitation unit.• Day case medical treatment and diagnostics.• Outpatient medical services.

ACUTE STROKE UNIT• Redesign of stroke treatment protocols enabling rapid transfer

of hyperacute patients suitable for intervention.• Transfer of all hyperacute patients through emergency

services to mainland.

CONSULTANT LED OBSTETRIC SERVICES

• Movement from a Level 3 to Level 2 NICU service with concomitant redesign of obstetric protocols ensuring patients are treated at the right place and the right time.

• Midwifery led obstetrics unit.• High-risk pregnancy managed through in-reach services with

off-island delivery.• Rapid transfer through emergency services to mainland

providers as required.

ACUTE (NON-SPECIALISED)PAEDIATRICS AND PAEDIATRIC SURGERY

• 12 hour paediatric assessment unit co-located with inpatient ward with reduced bed base.

• Paediatric urgent care• No paediatric surgery emergency service.• Rapid transfer through emergency service pathways to

mainland services as required.

The range within which solutions can be found to achieve service sustainability.

New Care Model Review – Programme Progress against Plan8. Cultural and change TARGET OPERATING MODEL OPTIONS


Project Parish and Town Council work


Following a small allocation of Vanguard funding, Island Town & Parish Councils are supporting community engagement activities with a specific focus on raising awareness of access to self-care and well being services , improving understanding of the MLAFL philosophy and providing a community partnership liaison role for Integrated Locality Services.Lead town and parish councils have been secured for the three localities and are meeting quarterly as a group to review cross-Island developments.• South Wight and West & Central engaging well with other parishes and community partners in their locality (Ryde

recruited to post).• Locality areas have engaged with Primary Care Consultation through this mechanism and are looking at other key issues

relevant to their locality. • Early relationships building well with Locality Management Groups.

Depth Town and parish councils and community partners are coming together in the South Wight Locality for a regular, six-weekly locality forums with engagement steadily increasing. West & Central are currently embarking on a similar approach and Ryde intend to do the same once they have recruited to post.

Scale All three Island localities are covered with 33 individual town and parish councils on the Isle of Wight. 11 out of 13 parishes in the South Wight Locality now have a MLAFL advocate and West & Central are seeking to recruit similar advocates across their locality.

Sustainability It is intended that the current partnership model continues in 2017-18 and that, during that time, the locality leads are asked to seek to make arrangements to maintain the model of engagement without the funding i.e. to operate the arrangements under business as usual.

Impact It is hoped that through the community partnership model we will improve the understanding of MLAFL as a new care model amongst community partners, that we will have a genuine dialogue with the community through the locality leads, that people will know how to access self-care and wellbeing services and in each locality the population and its partners are contributing to thriving communities. We are currently developing mechanisms to measure impact.


Project Governance structure


Following implementation of a system-wide governance structure in Autumn 2016 and associated reporting structures, the MLAFL programme has continued to be managed via the new governance structure throughout the quarter. The recent requirement for the Island, as a Local Delivery System of the STP, to put an LDS Delivery Board in place has led to a refresh of the system-wide governance structure to ensure:• delivery of the IW single change plan is effectively prioritised and managed• linkages to STP groups are clear with Executive representation defined• formal programme and project management structures are in place to drive delivery of transformation activity• any duplication/overlap of existing group functions are removed• attendees time is maximised (acknowledging the Island has less senior management resource than other areas)

Depth The governance review will look across IW Council, CCG and NHS Trust contributions to the existing system-wide governance structure with particular focus on alignment with the STP.

Sustainability The system-wide integrated governance structure is the mechanism by which the Island drives forward and oversees delivery of transformation as a single health and social care system. This transformation work has been recognised as business as usual and changes made in the last year to implement this.

Impact • Joint decision-making• Clarity on system-wide plan• Reduced duplication of resources

What has changed for people?

Person outcomes

Population wide approach

• A health and wellbeing survey is being developed, which will be disseminated to people across the Island. The survey is aimed at investigating people’s attitudes to their health and wellbeing, their experience of health and social care services and their propensity to engage with the new model of care e.g. use of technology and to self care. Due to the population approach it will gather data from people who may or may not have accessed our new care model or indeed health and social care services at all. It is envisaged that this survey will be repeated regularly (possibly every two years) which will give a clear picture of changing experience and attitudes of the Island population.

Programme level approach

• Together with our academic partner we are rolling out the use of ‘R outcomes’ which is a validated survey tool used to gain insights into people’s experience of service delivery and feelings towards their health and care. This survey tool will be used in our major projects where we know people have accessed a new way of service delivery. It is hoped this approach will help support conclusions around individual initiatives attribution.

Interim findings - R-outcomes survey

• So far, 134 people have completed the R-outcomes survey (scores for those receiving either Care Navigation or Local Area Coordination support have been combined).

• Improvements at follow-up have been reported on all 4 domains of the R-outcomes survey (see graph). The follow-up group have consistently higher scores than the referral group.

• More detailed findings, by each survey question and by community role, can be viewed in the supplementary information pack.

• The R-outcomes survey will be used in several other areas of the MLAFL programme (e.g. Ambulatory care, Integrated Locality Working, Case management for highest risk). Findings will be combined for a programme view of impact on people.

0

10

20

30

40

50

60

70

80

90

Health StatusAggregate Score

(On referraln=96; On

follow-up n=34)

HealthConfidence

Aggregate Score(On referral

n=96; Onfollow-up n=34)

PersonalWellbeing



PatientExperience



R-outcomes person surveys - Interim findings

Onreferralgroup

Onfollow-upgroup

What has changed for staff?

Types of evaluationSeveral different types of evaluation have been used to measure what has changed for staff • R-outcomes survey (LACs and CNs to date – broader work planned)• In-depth interviews with staff (LACs and CNs to date – broader work planned)• Staff Survey developed

The following is planned for 17/18 • R-outcomes staff survey will be carried out more broadly in service areas where

transformation changes are being made• Using Normalisation Process Theory (NPT) approach to understand the

challenges of implementing new ways of working (across all initiatives)• Staff survey to be piloted and rolled out to staff across the wider system

The West Wight model of integrated community working

• The West Wight model currently operates as a monthly meeting involving the Local Area Coordinator (LAC), Care Navigator (CN), Community Navigator (CommNav), and a practice-based nurse consultant.

• The practice-based nurse consultant acts as an excellent bridge to statutory services in the area.

• During meetings they discuss referring/introducing people to each other as well as ensure the right support to address the needs of the person. This is being extended to other clinicians in the future.

• This model is being adopted in other parts of the Island.

Findings from staff interviews• Before integrated working was established, without

knowing it the CN and LAC could duplicate work by seeing the same person.

• Telephone contact between the roles has been established so advice can be shared.

• Joint visits by two or more different roles have been provided when a holistic approach has been warranted.

• Inappropriate referrals to CN (e.g. someone under 50 years old or with complex mental health needs) can be quickly referred/introduced onto the LAC (whose experience and scope to support long-term was more appropriate).

• Often a CN referral to another statutory service may be delayed for weeks. In the meantime, the CN has previously asked the LAC to engage with the person to start social engagement work to fill the gap.

System Impact: 2016/17 A & E Admissions

What the data shows• Updated actual figures continue to out perform Q2 projection• Yellow area represents volume of emergency admissions ‘avoided’ from the NCM ‘do nothing’ projected model in 2016/17• Admissions numbers for Q3 and Q4 lower than originally forecast

How we have impacted changeIncreased usage of 111, Crisis Team, MDT, Falls Clinic, Isle Help, Pharmacy First, Care Navigators and Local Area Coordinators have all contributed to diverting people away from Emergency Services in the first instance

Updated A&E Admissions against ‘do nothing’ scenario

Milestones

2009 - Beacon Walk in Centre opened

Oct 2011 -111 Service commenced

Sep 2016 - Patient Flow Bundle Pilot Scheme

Oct 2016 – Beacon Centre becomes Urgent Care Centre

Nov 2016 – Ambulatory Care commences

Jan 2017 – Frailty added to Ambulatory Care Service

System Impact: 2016/17 A & E Attendances

What the data shows • Continue to see fewer attendances in 2016 compared with 2015 and 2017 appears to continue this trend• Compared with the 2015/16 attendances down approx. 3% from 2015-16• Non Island Residents visiting A&E is approximately 1 in 10 attendances throughout the year, rising to 1 in 5 during August

How we have impacted changeIncreased usage of 111, Crisis Team, Falls Clinic, Isle Help, Pharmacy First, Care Navigators and Local Area Coordinators have all contributed to diverting people away from Emergency Services in the first instance.

Continued reduction in A&E Attendances 2015-16 Monthly A&E attendances Residents and Non Residents

System Impact: 2016/17 Ambulance call outcomes

What the data shows• See, Treat & Conveys are up approximately 6% from 2014-15, however the percentage of overall activity has remained constant as a larger

proportion of demand has been met by telephone triage• Telephone triage up from 14% in 2014-15 and 19% in 2015-16 to 24% in 2016-17• Calls resulting in no treatment have been reduced to virtually zero indicating more efficient use of service.

How we have impacted changeCost avoidance through demand being proactively managed by more cost effective telephone advice and signposting, contributing to maintained ‘See & Treat’ activity where increase was expected. Improved quality evidenced by eliminating ‘no treatment’ calls (in yellow).

Ambulance See, Hear & Convey Activity levels by Quarter 14/15 – 16/17

Financial Summary Update: Cost Avoidance

The table above gives a financial update on previously projected cost avoidance for Accident & Emergency attendances and admissions and Ambulance activity.• Original projections estimated cost avoidance of £675k by the end of 2016/17• Updated full year activity data indicates an overall cost avoidance estimate of £2.1m at year end

System Impact: 4 things we have learned in 2016/17

• Emergency admissions continue to outperform the expected do nothing position, in the region of £2.0M cost avoidance, even when considering during the summer period the increase in activity from mainland/overseas visitors is comparable to a fourth locality.

• 111 Service continues to help divert pressure away from emergency services, and now shows a greater proportion of referrals away from statutory services to other forms of support or telephone advice.

• Use of reporting by locality has highlighted variation and enabled system to start to focus plans around this. For example , North East Wight Locality fast-track roll out of the Integrated Locality Service.

• Since April 2015 admission rates for the 65+ age group have increased by 9% - further breakdown shows people aged 85+ over are largely contributing to this increase, and also have an average length of stay of nearly 3 times that of the 65-69 age group, indicating frailty is a main contributor and is a priority focus for 2017/18.

Finance

The full allocation of £4.74m was received n 16/17 and has been allocated in line with the table below.

Scheme Description

2016-17

Agreed

Allocation

Mth 1-12

Budget

Mth 1-12

Actual Spend

Budget

Under/(Over)

spend

£ £ £ £

Enabling Transformation 3,201,146 3,201,146 2,897,730 303,416

Highest Needs 261,520 261,520 245,230 16,290

Ongoing Care Needs 489,072 489,072 413,505 75,567

Urgent Care Needs 616,918 616,918 532,047 84,871

Whole Population 772,092 772,092 715,028 57,064

Direct Local Contribution (Old MLAFL) (600,748) (600,748) (63,540) (537,208)

TOTAL EXPENDITURE - BUDGET & ACTUAL 4,740,000 4,740,000 4,740,000 -

Workstream Sharing/Learning Quarter 4 (January to March 2017)

Whole Programme • Joint presentation by Nicola Longson , Anita Cameron-Smith & Nik Attfield to King’s Fund event on 21/03/17 to share learning of PACS and MCP working.

• 23 February – PACS Community of Practice Meeting (Attendees Nicola, Jon Burwell and Margarita Kitova)

Transforming

Community

Services

Integrated Locality Service:• Adult Social Care and Trust joint procedures established using best practice from both services. • Recognition of need for shared language and key definitions – glossary to be developed.Serenity Safe Haven - the project is using best practice identified from Safe Havens already in place in Aldershot/ Redhill. The project is using the co-production ethos to design the service with active service user involvement.Case Management of highest risk:• Training documentation created covering account requests, website links, user guide, videos, shortcut reports, patient

names application, EDC codes, Chronic Conditions, issue resolution.• The MDT Coordinator has been really productive in providing support and coaching to practices who are conducting their

initial Case Management meetings via Standard Operation Procedures, training and guidance. The longer term aim is for practices and MDT teams to share their knowledge and success with their contemporaries and locality partners to encourage sustainability and continued use of best practice.

• Post conversations at various project meetings, it has been agreed that there is a need for support and education for MDT Co-Ordinators in the compliance of Case Review processes. Therefore a ‘MDT Networking Workshop’ has been booked for Tuesday 11th April 2017. All MDT Co-ordinators have been invited along with key parties to gain awareness of Best Practice, IG Compliance and collaboration to enable successful safe and proactive Case Review meetings. Part of the scoping work for the One Drive pilot is also highlighting clear process maps of best practice that will be shared at the workshop.

Prevention and Early Intervention:• The Local Area Coordination Team were awarded the ‘Bold and Ambitious’ Isle of Wight Council Employee Recognition

Award 2016.• An expression of interest has been accepted to work as one of 9 areas nationally with the New Care Models Team

Empowering People and Communities work stream.Primary Care Pathfinder Projects:• Visits conducted to Hedge End Medical Centre, Emsworth to look at Remote Consultation. Lesson Learned shared with the

IOW.

What have we shared and learned?

Workstream Sharing/Learning Quarter 4 (January to March 2017)

Communications &

Engagement

• Visits held on 6th January (City & Hackney CCG), 25th January (Symphony (Somerset & Yeovil) vanguard.

• National AHP lead Suzanne Rastrick visited on 25/01/17

• Care Navigator stories filmed for NCM sharing, further filming planned with LACs

• NHS England National Director for Operations & Information; Matthew Swindells visit 3 February – met with

stakeholders across system and visited Integrated Care Hub, Serenity mental health project with Hants Police and Isle

Help (single source info and advice portal)

• Video shorts being developed to add to toolkit for stakeholders (including other vanguards)

• Roy Lilley visit to Island to see range of activities including West Wight health and care collaboration in practice• Facilitated visit from Caroline Latta who is involved in several vanguard projects in the North of England• Video shorts being developed to add to toolkit for stakeholders (including other vanguards)• Potential participation in Health & Care Show June (Empowering patients and communities’ session), 7000 delegates.• Regular monthly comms and engagement Steering Group held with comms leads from across the system

Evaluation &

Measurement

• The evaluation team attended the NCM evaluation leads workshop on 28/02/17 and shared the methods and

approaches being used on the Island to evaluate our new model of care.

What have we shared and learned? (continued)

end of year 2016-17 programme progress against plan

Documents