Programme for Health Service Improvement

Emerging Clinical Service Framework

CARDIFF AND VALE NHS TRUSTYMDDIRIEDOLAETH GIG CAERDYDD A’R

FRO

Aims & Objective

To establish whether there is a broad clinical consensus on the emerging direction of travel within the health care community

To debate emerging issues To create clinical champions To agree next steps

Programme for Health Service Improvement in Cardiff and the Vale of Glamorgan

- Joint programme with our two local LHBs (with LA and HCW involvement)

- New approach to service planning- Strategic Outline Plan by November

- Single strategic document- Describes our model of care for the future- Describes our capital requirements for next 3

– 5 years

- Recognised need for regional dimension

CARDIFF AND VALE NHS TRUSTYMDDIRIEDOLAETH GIG CAERDYDD A’R

FRO

Designed For Life (1)

Improved Performance

Reducing Inequalitie

s Clinical Excellence

Sustainability

Designed for Life - Creating World

Class Health and Social Care

Clinical Networks

Strong Commissioning

Research & Development

Workforce redesign

IM&T

Community involvemen

t

Designed For Life (2)Levels of Care

Local acute services

Services provided at home & in the community

Specialist and Critical Care Centres

Tertiary and highly specialist services

Determinants of Health

Effectiveness Best PracticeLocal Needs

Policy Development

Card

iff a

nd

V

ale

NH

S T

rust

Bro

M

org

an

nw

g

NH

S T

rust

Why change?

Ageing population Clinical standards are rising New targets – Access 2009…. Resources are finite New technologies Working hours Teaching and research Stronger commissioning….. Etc.,

Where we have come from

Change is not new to this health community Emergency services Maternity services Children’s services Mental health services Etc.,

Resource Context

Resource Context

Financial Levels of growth expected to decrease

with associated funding shortfalls increasing

Each organisation is in recovery (£51.5m in 2006/07 including HCW) , and traditional means of efficient savings are being exhausted.

Two local authorities experiencing significant financial pressures

Resource Context

Staffing - Contractual changes impacting on all staff

Agenda for Change Modernising Medical Careers European Working Times Directive – 48 hour

working week by August 2009 Consultant contract GMS and primary care contracts Feminisation of workforce Age profile (46% nurses and 34% Trust

doctors and 70% principal GPs aged 40 – 60 years)

Multiple job holding

Resource Context

Estates and IM&T Much of Trust estate no longer fit for

purpose e.g. Rookwood, West Wing, surgical services for children, Llandough, health centres etc., etc.,

Potential planning blight re. IM&T subject to clarity around scope of Informing Health Care

Opportunities through use of new technologies need to be seized

Clinical Services Strategy

Key Assumptions….

Our users will: Be more confident in using information

and technology Expect responsive, personal and high

quality integrated services Want to receive more care at home, or

as close to home as possible

Clinical Services Strategy Workstreams

Primary & Community Services including Long term condition management Unscheduled care Rehabilitation & intermediate care

Acute and emergency care Tertiary and Specialist (including Cancer

& children’s services) Mental Health Clinical support

Primary and Community Services – emerging model

Network of high quality primary care practices working within defined localities (4 in Cardiff, 3 in Vale)

7 localities as basis for managing access to core community based services managed through resource centres (real or virtual) aimed at enabling individuals to maintain their health and independence

Cardiff Localities

91,693

(18 practices)

93,902

(12 practices)

82,640

(13 practices)

81,700

(11 practices)

Vale Localities

Western Vale 26,678(3 practices

East Vale 38,003(7 practices)

Central Vale 54,974(7 practices)

Resource Centres

Supporting networks of local practices

Basis for locality focused services Virtual or real Tesco Extra/Tesco Express model Health and social care (including

links with independent sector)

Key Issues…

Creating capacity within primary and community services to accommodate presssures of demographic change, service change etc.,

Creating confidence in new ways of working and mechanisms to measure impact of change

Location of resource centres and commitment to locality model (primary care and Trust)

Locality management models

Long Term Condition Management Model – Emerging model

Key Themes Increased support for self care Strengthening and supporting primary care Ensuring access to responsive specialist care Managing the most vulnerable individuals by anticipating their needs

Achieved by: The use of information systems to identifying and support individuals

with long term condition Stratifying individuals by risk Involving patients, and their carers where appropriate, in their own

care A well equipped and educated multi disciplinary workforce Co-ordinating care in line with agreed pathways and protocols Integrating care across organisational boundaries Aiming to minimise unnecessary visits and admissions Providing care in the least intensive setting, including the home

Long Term Condition Management Model

70-80% population with long term condition

High risk patientsCare Management

Highly complexpatients

Case Management

Health Promotion

Level 3

Case manager actively managing and joining up care

Level 2

Multi-disciplinary teams, proactively managing in line with agreed protocols and pathways for managing specific conditions

Level 1

Individuals supported to actively managing their own care

Key Issues…

Case management model who has the lead – primary care? Trust? Joint?

Workforce development – who are our case managers?

Capacity and commitment to delivering against agreed care pathways

Integrated Community Based Rehabilitation and Intermediate Care Services – Emerging Model

A multi-disciplinary team based on resource centre populations providing:

- Rapid assessment service- Acute/rapid response- Community based active rehabilitation and Reablement- Maintenance and prevention services

Direct Access to Specialist Support Services working across localities, for example:

- Acute day treatment services - community based inpatient rehabilitation beds- Hospital based diagnostic support services- long term condition management support services- specific condition based expert teams – eg Parkinsons/stroke/continence

Community based rehabilitation and recovery model

Rapid Assessment Service

Maintenance and Prevention Services

Community Based Active Rehab & Reablement

Acute / Rapid Response

Identified lead consultantGPwSIs

Nurse consultants / specialists / rehab nurses / acute nurses /

community nursesTherapists - physio, OT, SLTHome care / social workers

Diagnostic support staffIntermediate care support staff

more specialist services e.g. stroke, continence

acute day treatment services

in-r

ea

ch

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Key Issues…

Commitment to locality based model

Number and location of community inpatient capacity Trust clinical view maximum of 3 ideally linked to resource

centres (2 in Cardiff, one in Vale)

Single in-patient stroke unit

Clear view on spinal and neuro rehabilitation

Ensuring model addresses needs of all adults requiring rehabilitation (not just older people)

Addressing capacity within independent sector to support people with continuing care needs

Mental Health Services – Emerging Model

Provides model for wider programme…. Investment in community based

services to reduce dependence on institutional care

Elderly care assessment on DGH site

Key Issues…

Vale of Glamorgan LHB commissioning intentions re. Western Vale

Links with locality model for other community services (including Resource Centres)

Developing capacity within the independent sector to support continuing care for older people with mental health needs

Unscheduled Care – Emerging Model

Network of core GMS Services / Primary care services in OoH

Extended primary care

including case

management, nursing

home team, expert patient

programme etc.,

(resource centres)

Specialist rapid access clinics incl diagnostics

MAU (UHW/Llan)

SAU (UHW)

Acute rehab

Community based rehab/

reablement

Acute admission with agreed care

plan

Community based inpatient

Community Rehab

Elective Discharge

support

Community nursing

Paramedic / NHSD

Voluntary Sector

Palliative Care

OPD

Extended Primary Care

Intermediate Care

Acute Care

A&E

Mental Health Crisis Team

Emergency social care

Elderly Care Assessment

Service

Rapid/Acute

response team

Acu

te R

esp

on

se

Co

nta

ct C

entr

e

Key Issues…

Opportunities for more integrated out of hours models – how do we take these forward?

Walk in Centres – is there a role for something new?

Ensuring alternatives to admission address issues associated with medical responsibility

Elective and Emergency Care – Emerging Model

Clear separation of emergency and elective workstreams

Clearer separation of local and specialist workstreams

Pathway/Protocol driven care Supports effective teaching and

research Environment fit for purpose

C&V Clinical Strategy Summary of Hospital Profiles

Llandough Acute medical admissions

(Vale and W Cardiff) General Medicine All intermediate surgery CAVOC Midwifery unit EMI assessment Gynae cancer ? Cancer surgical centre…

Supported by appropriate diagnostic & support services including rationalised labs etc.,

UHW A&E Acute medicine (Central &

East Cardiff) General Medicine All emergency surgery All complex surgery Specialist/tertiary services All inpatient paeds Obstetrics/MLU

Key Issues…

Elective surgical model

Ensuring effective locality flows to achieve balance across two sites in relation to medicine

Surgical Cancer services model

Specialist and Tertiary – Emerging models

Effective networks to manage tension of access and excellence

Potential for increased role as specialist centre for South Wales- Surgical cancer- Surgery for children

HCW Reviews Neurosurgery Thoracic ….

Key Issues…

Ability and incentives to make networks work effectively

Lack of robust regional planning, commissioning and delivery mechanisms

Critical mass and VFM

Clinical Support Services

Using technology to support local diagnostic services Near patient testing Pathology rationalisation PACS

Key Issues…

Implications & links to all Wales Diagnostics Strategy work

Ability and commitment to rationalise services across multiple sites

Impact of telecare strategy

Emerging Clinical Strategy Framework….?

Increasingly local care – less care in main acute hospitals

Primary care practices Resource centres and community based services

Acute and emergency hospitals

Intermediate care and

rehabilitation

GP/Nurse led beds

Outpatients

Minor emergencies

Day-therapy services

Day-case surgery – local

anaesthetic

Diagnostics(such as

X-ray)

Patient Education

and support

Local Authority Services

Primary care team

and therapy Services

Minor procedures

Clinics (for example

diabetes and CHD)

Tertiary and specialised services

Elective (non-urgent)

surgery

Inpatient cancer

services

Complex diagnostics

Specialist outpatients

Secondary emergency services

Acute women’s and children’s

services

Major accident and emergencies

Well-men and well-women

clinics

Rehabilitation support

Voluntary sector

services

Community services

Local facilities throughout the

area

Resource centres serving networks of @ 50 – 80,000 populations

University Hospital of Wales, Llandough

Increasingly specialist care – more care in major hospitals

How will we deliver care?

Patient pathway not professional convenience.. Acuity based not “ology” based… multi-disciplinary not medical … Integrated not silo…What’s stopping us?

Patient experience Political environment (external) Professional standards (including teaching & research) Pathway and processes (and clinical linkages) Physical capacity and environment Pounds and pence People

Where will we deliver care?

What, if anything, is an exception to the emerging clinical strategy?

Why? Patient experience Political environment (external) Professional standards (including teaching &

research) Pathway and processes (and clinical linkages) Physical capacity and environment Pounds and pence People

Key Issues for SOP

Resource Centre models for each locality Commitment to locality model

Elective surgical services profile Separation of emergency and elective

Inpatient/community rehabilitation model 3 community inpatient units

Unscheduled care model Scope/commitment to integration

Independent Sector…….

Hazard Warning

We will need to:

Agree some core assumptions

Ensure we build in flexibility

Predicting the future is difficult and we will get

some things wrong