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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Learning from each other – via CQUINs

Engage with other early adopters to develop clinical standards for

community services

Apply locally to support gap analysis

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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

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General Practice

Questions ?