7 day services is only part of a whole system transformation
DESCRIPTION
Birmingham, Sandwell and Solihull Collaborative's presentation for the 7 Day services event in the West Midlands on the 11th June 2014.TRANSCRIPT
Seven Day Services Improvement Programme
Birmingham, Sandwell and Solihull Collaborative
7 Day Services Presentation
‘7 day services is only part of a whole system
transformation’
11 June 2014
Stage 1 : Providing the same level of health and social care services seven days a week across Birmingham to achieve consistent outcomes.
Stage 2 : With the integrated stage one platform in place the aim is “Level up”, quality and effectiveness across the breadth of the interfaces between acute health, community based health including primary care and social care services.
Locally recognise that 7 day working is part of a much larger requirement for whole system change and aware this could require fundamental changes to commissioning models and provider networks.
2
Vision
System Chronology
• June 2013 – Joint programme looking at integration for older adults – identified
7 day services as a key enabler for system wide transformation
• October 2013 - Created collaborative response to NHS IQ 7 days services early
adopter – including HeFT Acute, Community and Mental health along with social
care
• December 2013 – Winter pressure activity focused around 7 day services and
expanded the scope to include UHB and Sandwell and West Birmingham
acute’s.
• April 2104 – Key scheme within Birmingham Better Care Programme
• Now – Fundamental enabler for wider unplanned care transformation
Delivery & Governance
•CEO Forum operating at unit of planning level inc Sandwell and Solihull
•HWB – accountable for Birmingham BCF
•Birmingham Better Care Board – CEO and Clinical Exec leads level set up from
April 14
•Programme Group includes PM’s and business change managers will report into
Integration Board
•Scheme project groups – multi- organisational
•Executive Sponsors – commissioner and provider for each scheme
Birmingham Better Care Themes
Place Based
Integration
Care In A Crisis
System wide
enablers
Outcomes for People
The Care in a Crisis
Transformation Challenge
•Modelling a 7 day LOS for unplanned care in Birmingham hospitals and applying a 80:20 rule
identifies an opportunity of 800 beds
•Acute clinical leaders are broadly comfortable that a 7 day LOS target is appropriate
•Confirmed by Oak Group acuity reviews – local and national data
•Improved case finding for step up/down, discharge planning and new clinical philosophies
•7 day access to appropriate community services
•Philosophy of short term re-ablement/rehabilitation - return home should be common aspiration
•Integration between specialist, primary and social care including mental health
•New partnerships & new models of care to meet new challenges specifically dementia
The Place Based Integration
Challenge
•Long term support – proactive and preventative care
•Interdisciplinary teams established around primary care
•Accountable Community Professional
•Including the broader voluntary sector and other organisations within community
•Integrating specialist/ primary and social care including community organisations
•Case management informed by risk stratification
•Philosophy of early identification of changing need/ enablement
•Targeting the groups which will benefit most from intervention
System enablers
Whole transformation programme underpinned by
• Need for shared understanding on activity and financial scale of challenges –
case for change medium and long term
• Creation of campaign – the “Birmingham Conversation” , citizens, patients and
staff
• Recognised need for crucial system wide enablers ;
• 7 day services
• Data – NHS number as unique identifiers, Central Care Record
• Integration dashboard – being developed with CSU
• System wide acuity decision support tool
Birmingham BCF – Schemes
• Scheme BCF01 – Developing and agreeing the case for change
• Scheme BCF02 – Creating the impetus for change
• Scheme BCF03 – Accountable community professional
• Scheme BCF04 – Defining new Primary Care service delivery models
• Scheme BCF05 – Discharge from acute setting and step up/ down care
• Scheme BCF06 – Instigate 7 day health and social care services
• Scheme BCF07– Establish Combined point of access
• Scheme BCF08 – Improve data sharing between health and social care
Scheme BCF01 – Developing and agreeing the case for change
Sponsor – Barbara King, Mark Newbold
Deliverables :
• Unit of Planning - Collate respective financial and activity challenges – based on output
develop system wide options (Plan, A,B,C)
•‘As Is’ system diagnosis – by provider, commissioner, sub economy and system including
quality, spend, activity, performance, resource utilisation and savings challenge – system
level savings challenge – demographic impact
• Opportunities for improvement across productivity and efficiency, achieving best in class -
beyond best in class – include outcome metrics
• High impact areas and populations to focus efforts on and the quantum resource needed
to shift, investments and savings
• Viability assessment of system wide and sub economy achievability and associated
options
• Proposed response and contracting options for potential 15/16 delivery. Including steps to
achieve sign off within provider organisations.
• Commissioning intentions for 15/16
10
Scheme BCF02 – Creating the impetus for change
Sponsor – Peter Hay / Andrew Coward / Viv Tsesmelis
Description – To develop and implement a public and staff facing cross
organisational communication and engagement programme including shared tools
to support the conversation, which engages people in the challenge, listens to and
builds upon their ideas to meet our objectives and empowers them to change.
Deliverables :
The Birmingham Conversation
Leadership Development for Integrated Working
Frontline Workforce development
Engaging people in becoming active co-producers of health
11
Scheme BCF03 – Accountable community professional
Sponsor – Tracy Taylor / Sue Hartley / Nick Harding
Description – Put in place the appropriate activities to ensure role is
recognised and embedded across the city including required process
and assessment and plan documentation
Deliverables –
The role definition and supporting training and supervision
infrastructure.
The supporting agreements, documentation, systems and processes
to underpin the role and enable integrated care without duplication.
Capacity requirements for the role
Joint and trusted processes, assessments and plans, training
requirements and associated rollout across the identified workforce
Co-ordination of community MDT visits 12
Scheme BCF4– Defining new Primary Care service delivery models and associated
roles and infrastructure
Sponsor – Andrew Coward / Andrew Wakeman
Description –
1)Agree approaches to General Practice development, including NHS England where
appropriate, per CCG.
2)Develop interdisciplinary working between statutory services including social care, mental and
physical health, and evaluation of current IMPACT, Falls, EOL and support to care homes
initiatives.
3)Review current community support/development initiatives and voluntary sector services
currently commissioned across the whole system.
Deliverables
GP development plans * 3
Develop new service delivery models and associated commissioning plans for interdisciplinary
teams
Agreement on approach to community support/development initiatives and particularly the
commissioning of the voluntary sector
Agreed protocol for management of patient in a crisis (BCF05)
Proposal for number and geography of places
13
Scheme BCF05 – Discharge from acute setting and step up/ down care RAG STATUS
Sponsor – Barbara King / Andrew Catto
Description – Develop single trusted assessment and plans and the service delivery model
e.g. Co-ordination hub to ensure effective admissions avoidance and discharge into lower
levels of care. To include mental health services e.g. RAID, EOL care.
Procure clinical decision making support tool / Clinical Utilisation Review e.g. Oak Group.
Improving early discharge planning in hospitals
Develop Commissioning plan for Step up / down to ensure appropriate capacity and delivery
models across the city
Deliverables
Joint and trusted processes, assessments and plans, training requirements and associated
rollout across the identified workforce
Proposed service delivery model associated Business case
Procurement and implementation plan for support tool
Step up / down commissioning plan
Agreed protocol and management of patient at end of episode of care (BCF04)
Approach in shift in professional activity from acute to community setting e.g. Social Workers
14
Scheme BCF07– Establish Combined point of access
Sponsor – Tracy Taylor / Andy Williams
Project Manager - TBC 0.5 – plus solution architect role initially – options appraisal
, art of the possible
Description – As part of the city’s offer to all citizens, to enhance and expand a city
wide combined point of access to support self assessment and management, early
identification of need and proactive care.
Enhance and expand the city wide single point of access to support and align
service response times to Community alternatives for urgent care and links with
111.
Including wider elements of community health, mental health e.g. RAID, social
care, EOL care and the third sector. Utilise the single trusted assessment, to
manage real time capacity and flow info with aligned response KPIS across the
system
Care in the crisis co-ordination hub
15
Scheme BCF08 – Improve data sharing between health and social care
Sponsor – Gavin Ralston for CCR and Adrian Phillips BCC lead for overall uptake
on NHS on number in social care
Description – Ensure the NHS number is used consistently across the system as a
common identifier and routinely reported.
Ensure the effective roll out of the Midlands Central care record
Procure the Pi dashboard to support integrated care at an individual, provider and
commissioning level.
Deliverables
NHS Number being used as the primary identifier for all correspondence across
health and social care
NHS Number used as early as possible in the clinical process/care pathway
Real-time retrieval, or if batch tracing that there are clear processes in place for
ensuring that it is retrieved in a timely manner, for example, not after a week of the
patient being discharged.
All systems able to handle the NHS Number
API in place between all relevant systems
16
Scheme BCF06 – Instigate 7 day health and social care services across the
economy
Sponsor – Nick Harding / Andrew McKirgan
Description – To develop 7 day services at the interface between hospitals and out of hospital alternatives as per our City wide pioneer application. To ensure all services required are in place to enable a timely admission avoidance or discharge into lower levels of care 7 days a week.
Deliverables
Co-ordination of action plans for all organisations, using the NHS IQ seven day
services toolkit to baseline activity, by end June.
Continue engagement with NHS IQ and peer organisations as early adopter.
Common dashboard
17
About developing a sustainable health and social care system
Facing the future in ways that strengthen our common approaches – using Winter funding to test
approaches and assumptions to 7 day services focusing on hospital and community interfaces
Building upon already good practice in some areas: Trusted assessor at front and back door of
some acutes and integrated discharge hubs, Community Health SPA and rapid response, Mental
Health RAID & CERT, therapists and radiology at some acutes
Commitment to take evidence based approach to improve outcomes – developing dashboard
starting with improving acute outcomes
Learning from each other – via CQUINs, same CQUIN in each health provider contract, system
wide involvement in priorities for each organisation
Working with national programme to develop clinical standards for community and social care
services to aid local gap analysis
Developing role of General Practice in seven day services in the Better Care Programme
18
Context - Birmingham , Solihull and
Sandwell Collaborative Early Adopter
• Objective to provide the same level of health and social care services 7 days a week for across
Birmingham
• Winter pressures funding Birmingham City Council to provide social workers to work seven days
per week
• Sandwell & West Birmingham – started 1 November - with the aim of increasing weekend discharges, smoothing variance of flow across the week and avoiding hospital admissions
• HEFT – started 16 November - with the aim of smoothing discharge over 7 days and reducing current backlog
• UHB – started 21 December – with the aim of smoothing discharge over 7 days
• Extended to community hospitals in January
• Using experienced social workers from across the service to support 7 day services and appointed a manager to manage the weekend service
• Engaged with 125 nursing and residential providers to understand their issues and concerns of which 37 committed to admitting at weekends
19
BCC Winter Activity
• 577 Contacts made by BCC social workers to date across all sites
• 478 assessments completed by BCC social workers to date across all sites
• 74 discharged over weekend / bank holiday (80% with arranged support)
• 176 planned to be discharged in first 2 working days post weekend / bank holiday
20
Main support types arranged for those discharged at weekend or within 2 working days
%
Enablement 37%
Home care package 32%
Restart of existing package 8%
Family support 7%
BCC Winter Activity Data as at March 14
Winter funding provided to BCHC to increase community capacity to develop and deliver integrated care pathways 7 days a week in support of admission avoidance and early supported discharge from both acute and community bedded units including:
• Discharge to Assess – Trusted Assessor Role
• Development of Discharge Hubs
• Community Consultant Geriatrician in SPA
• Additional sub acute and Intermediate care beds
• Stroke early supported discharge pathway
• Increasing capacity across the community bedded units to enable better system flow
21
Community Health Trust Winter Activity
Each acute hospital has taken a slightly different approach :
•Utilising primary care – SWBH
•Supported Integrated Discharge – HEFT
• Supporting Mental Health Services - UHB
22
Acute Trusts- 7 day services:
• Whole system approach required to have an impact
• Developing relationships is crucial in order to change current behaviours and cultures
• Making effective use of home care assessors – we were missing opportunities to discharge into
the enablement programme even though it was a 7 day service
• Continuous learning to identify areas for improvement and proactively put plan in place to
address
• Grow social care services that we need to work with – Home care and enablement
• Developing service through enhanced assessment beds (now available at weekends) and interim
beds – new services commissioned for this winter have 7 day working in their contracts and
working with existing services to vary contracts
• Engage and listen to views of our stakeholders, such as nursing and residential homes
• Understand the overall effect – impact on length of stay as well as admission and discharge
23
Lessons learnt so far
• Initiatives judged to be delivering system benefit rolled on for 3 months and then subject to
further evaluation and confirmation of future funding via Birmingham Better Care
• Assessment of transferability of schemes across whole system and identifying any system gaps
• Involve service users, families and the community in co-design
24
Move from winter work to BAU
EXAMPLE FROM ONE ACUTE
TRUST
Mortality rates – same by day of
week
Discharge rates still reduced at weekend
0
2000
4000
6000
8000
10000
12000
14000
Mon Tue Wed Thur Fri Sat Sun
Day of Discharge
Discharges by day of discharge
0%
5%
10%
15%
20%
25%
242526272829303132333435363738394041424344454647484950515253 1 2 3 4 5 6 7 8 9 101112131415161718192021
% discharged at Weekend - Monday 4th June to Sunday 27th May (Nonelec Only)
LOS of stay varies but……
2.0
2.0
2.1
2.1
2.2
2.2
2.3
2.3
2.4
2.4
2.5
2.5
Mon Tue Wed Thur Fri Sat Sun
Day of Admission
Average LOS by day of admission
Who is available at weekend
Consultants - most patients seen every day of the week
Junior doctors – ward rounds but after that still reactive service mostly
Nursing
24/7 cover
Increasing seniority presence
Specialist nurse presence variable
Therapies
Major reconfiguration
Physiotherapy
OT very limited
SLT none
Clinical Support Services
Imaging
Routine lists at weekend
24/7 urgent
Discharge support
Pathology
Pharmacy
Social Care
Non-clinical support
Portering
Domestic services
Ward Clerks
Managerial
Still an on call system
Site Office
Key lessons
Whole team
Not just consultants
Developing Dashboard, visible to all
Utilising the 7 day standards at directorate level
Not a separate project
Same CQUIN across all health provider contracts
Linked to national toolkit
Community providers will use toolkit as basis of their
action plans
System partners involved in identifying priorities for
organisations
36
Learning from each other – via CQUINs
Engage with other early adopters to develop clinical standards for
community services
Apply locally to support gap analysis
37
Clinical Standards for Community and Social
Care
Maintain link with LAT and 3 CCGs as they develop approaches to
improving access across 7 days to improve the unplanned care system
38
General Practice
Questions ?