Strategic Commissioning Approach to Improving Patient

Flow

Deborah JonesChief Operating Officer

NHS Highland

Highland Quality Approach

The Golden Thread

National Programmes

Local Delivery

Plan

Improvement and Co

production Plan

Operational delivery

Plans

Team Plans

Individual Objectives

LUCAP

Strategic Commissioning

Why the Pressure?

Week commencing 14th July 2014 saw a significant increase in patient flow pressures in Raigmore Hospital

Delayed DischargesCurrent NHS Highland Delayed Discharge Position

Opportunity Cost of Delays

24,000 bed days lost to delayed discharge equates to circa £8m OPPORTUNITY COST

2013/14 Care @ Home Position

Hospital unmet need• 40 people @ 10 hours per week• around 400 hours per week / £322k per

annumCommunity unmet need:• 246 people @ 10 hours per week• 2,460 hours per week / £2m per annum

– Estimated cost of current unmet need is £2.3m p.a.

– Market split 60% (in house) / 40% (independent sector)

– In-house provision more expensive– Competition between providers to

recruit– Not all geographical areas of

operation sustainable– Inconsistent (and some poor) quality

of provision

2013 Care Homes Position

• 59 care homes for older people / 1,741 beds

• In-house - 12% of beds / average size of 13.5 beds

• IS - 88% of beds / average size of 35 beds• Average occupancy of 95%• 39% of care home beds during 2013

adequate or less • December 2013: 63% of vacant care home

placements were unavailable due to quality

• Low or no respite, intermediate or palliative care beds

• Lack of trained and experienced staff; poor quality care resulting from a high turnover of staff

• Not all care homes have en-suite

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%

10.4%

15.7%

12.8%

38.3%

21.4%

1.4%

Care Home Gradings 2013IS and In House Minimum Care

And Support Grading

So what?

Strategic Commissioning

• Integrated through lead agency approach• Establishment of joint commissioning approach with

third and independent sector colleagues• Co-produced strategic commissioning plan – led by

third and independent sector colleagues• Co-chairmanship of adult commissioning group with

CEO of an independent care provider• Risk management and cultural change required

amongst our staff

Care @ Home2014

• Level playing field, means commissioning across sectors, not protecting in house service.

• Collaborative zoning, means providers can access cost effective “runs”, not scattered provision

• Paying (75p) to achieve compliance with Living Wage

• Developing a single tariff for all providers which can be enhanced for rurality and complexity

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Care at Home Gradings 2014IS and In House Care and

Support Gradings July 2014

Independent/Third Sector

In House

Market Changes

Quality of Provision

North Highland Changes in Provision

2014 Care Homes Position

By 2019 • 95% all provision to be grade 4 or above • A range of models (eg intermediate care / step

up/ down/ supported accommodation)– Flexible and responsive services

Through• Establishment of service improvement lead to

support independent sector care homes• Development of quality standards to be included

in all contracts• Commissioning short term re-abling care, as an

alternative to hospital;• New models of care such as housing with

support• Collaboration on workforce issues to ensure a

sustainable pool of sufficiently trained and qualified staff;

• Collaboration with communities on alternative models to meet local needs.

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

0.0% 5.0% 10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%

2.6%

2.9%

27.5%

45.7%

19.9%

1.4%

Care Home Gradings 2014IS and In House Care and

Support Grading July 2014

Raigmore

This is now… We are Implementing…

• Daily Quality and Patient Safety Huddle in Raigmore but includes a whole system approach

• Ambulatory Care• Changes to Out of Hours (impact

Raigmore PCEC)• Reconfiguring Beds

LUCAPKey Workstreams

Making The Community The Right Place and Developing the

Primary Care Services

• Community Pull• Falls and Frailty• Care @ Home

Capacity• Reduce A&E

Attendance

Flow and the Acute Hospital

• Flowology through our Hospitals

• Ambulatory Care

Promoting Senior Decision Making

• Review of Medical Rotas

• Review of exiting model for medical receiving

Assuring Effective and Safe Care 24/7

at the Hospital Front Door

• Front Door Services

• Increase Consultant Capacity in A&E

Cross Cutting Themes

• Modern Apprenticeships• Transport Co-Ordinator• Increase Emphasis and Alternative Roles (Workforce)• Information Management

Thank You

Any questions?