Our Clinical Strategy: Creating a Healthy Population
- Strategic Priorities
- Health and Wellbeing of our Communities
- Living Well
- Managing Illness
- Urgent and Emergency Care
- End of Life Care, including Frailty and Dementia
The following section describes the core clinical strategy for Lancashire and South Cumbria, outlining the direction we will take to develop our clinical services over the next ten years.
As a system, our core aims are to:
- Listen to the priorities of communities, local people and patients to deliver safe and sustainable high quality services
- Tackle some of the biggest health and care challenges to improve the health and wellbeing of local communities
- Join up health and care services to deliver better, joined-up care, closer to home
This section of the document provides a high-level overview of strategic priorities in terms of what we will do to achieve these aims.
Section 5: Financial Considerations of the Clinical Strategy links with the overall Lancashire and South Cumbria Financial Framework.
Section 6: Provides information of how the strategy will be mobilised, implemented and achieved.
To achieve this strategy, we will work to the following five principles:
Principle 1 - We will be led by population need and will strive to truly understand the holistic needs of our population by embedding a population health management approach and by targeting support and service provision from across our Integrated Care System partnerships.
Principle 2 - We will be led by our clinicians and care professionals and by their experience and ambition, to improve the quality of care provided and to reduce variation by adopting a best practice standards approach and consistent measurements of patient outcomes.
Principle 3 - We will continue to build on the strong collaborative working and the common purpose which have been central to our response to the pandemic. These positive features have underpinned the strong response across our health and care system and our aim is to further embed them in the way we work.
Principle 4 - We will also continue to build on the ‘system level’ thinking we have developed in our response to the pandemic, sharing and using our collective data to inform where resources are required, providing mutual aid to ensure all of our services remain robust and moving away from a single organisational focus. This has required a shift in our leadership style which will increasingly need to be system, rather than organisation, based to respond to the needs of our population. Part of this shift in system thinking requires:
- Better and more effective utilisation of our scarce workforce: as a system, we will think differently and consider the skills required to deliver patient centred care, rather than falling back on traditional professional and organisational boundaries. We will manage our workforce at a system level, developing a centralised recruitment function and a common identity for our Lancashire and South Cumbria staff
- Understanding how we make best use of our collective estate to enable the delivery of our clinical strategy.
Principle 5 - We will galvanise the progress made on embedding digital solutions to integrate our health and care services and modernise the way we interact with our community and patients. We have made great progress but have more to do to enable patients to practise self-care and live independently for longer; enable our clinical teams to work in a multidisciplinary way and enable the prediction and prevention of disease for our population. Digital advancements will in turn have implications for how we use our physical estate.
This strategy sets out the need for deep collaboration between constituent organisations. Genuine partnership working will be required if real culture change and transformation is to take place. The below table captures key aims of the transformation programme and their associated benefits:
Standardised clinical pathways
Reduce variation in access times and improve performance against core quality metrics. Modernise how services are accessed, for example, providing care closer to home.
Achieve key quality standards
Compliance with service specifications and GiRFT recommendations.
Embed personalised care
Increased self-management of conditions to reduce service demand and progression to higher levels of care.
Single Electronic Patient Record (EPR) to enable system working and to improve clinical practice.
Address workforce issues
Sustainable workforce and fully compliant rotas.
Address repatriation issues
Reduce length of stay and waiting times by developing a rehabilitation model and repatriation protocols.
Enable the right access to equipment and facilities
Patients and staff have equality of access to high quality facilities and equipment.
Provide increased research opportunities
A collaborative approach to research projects and clinical trials to attract larger national grants, giving the region a strong presence in the research arena and a reason for leading clinicians to join our workforce.
Our Ten-Year Journey
We will need to strike the right balance between responding to the current COVID-19 pandemic and maintaining a focus on our long-term clinical priorities. The pandemic has resulted in significant changes to services and working practices across our system. Throughout what has been an incredibly difficult and challenging period, some of the enforced changes have taken us forward in our goal to modernise, integrate and focus our services on the needs of individual patients. Our strategy aims to ‘lock in’ these changes where possible and build on the achievements we have secured. Furthermore, the close partnership working between our health, care and voluntary, charity and faith sectors has been essential to our response to the pandemic. These strong relationships are now the foundation for achieving our vision.
There are three key stages to our ten-year journey:
1. Short term:
- Up to March 2021
- Responding to the COVID-19 Pandemic
2. Medium Term:
April 2021 to March 2026
3. Long term:
- April 2026 to April 2030
Short-Term: Responding to the COVID-19 Pandemic
The current focus of our Integrated Care System is the ongoing response to the COVID-19 pandemic and addressing the impact on our communities, both the direct impact and the second-order impact such as the worsening of health inequalities and poor uptake of and lack of access to, non-COVID services. In response to the pandemic and in line with national guidance, a command and control structure has been put in place across Lancashire and South Cumbria to enable system working and a system-wide response. The command and control structure consists of Hospital and Out of Hospital Cells working together in partnership.
It is at this level that the immediate or short-term elements of the clinical strategy will be co-ordinated. In place until March 2021, the cell structure will ensure a consistent approach to restoring ‘business as usual’ and make the best use of our collective capital and resources.
The immediate focus is on meeting patient need and addressing the new priorities created by the COVID-19 pandemic. We will also ensure we learn and take forward the innovative service changes made during this period.
Our immediate priorities include:
- Ensuring the infrastructure and capacity of our health and care services are sufficient for any potential further surge in COVID-19 cases
- Ensuring our population accesses non-COVID-19 urgent care
- Re-establishing elective care
- Ensuring staff and carer wellbeing
- Targeting support to groups of the population who are disproportionately affected by COVID-19
- Assessing and responding to the wider determinants of health impacted by the pandemic (for example, mental illness, domestic violence, child safeguarding, economic hardship)
- Improving healthy behaviours, mental and physical wellbeing, mobilising community support and increasing self-support
- Taking forward the innovative service changes made to improve our health and care system.
Medium to Long Term: Strategic Priorities
Our objective is for the people of Lancashire and South Cumbria to have the best start in life so they can live well and age well. To achieve this we need to think wider than professional, organisational and health care boundaries, to how we can positively impact the first 1000 days of life and later embed the role of the citizen in leading healthy lifestyles, taking responsibility for self-care and accessing appropriate services. Further, when people fall ill and need care and support, and when they approach the end of their lives, they should be able to access flexible services tailored to the needs of the individual.
The following six sections set out medium to long term vision for the ICS to achieve our three key aims of delivering safe and sustainable high quality services, improving the health and wellbeing of local communities and delivering better, joined up care, closer to home.
Prevention and Health Education
Population Health Management
- Anticipatory care
- Self and Personalised Care
- Integrated Place-Based Care
- Intermediate Care
- Mental Health
- Learning Disability and Autism
- Maternity and Children’s Services
- Collaboration, Shared Services and Networks
- Planned and Elective Care
- Specialist and Acute Care
Urgent and emergency care
- Emergency Care
- Urgent Care
- Mental Health Urgent Assessment Centres
End of life care, including fraility and dementia
- Care of the Elderly
- Ending Life Well
- Palliative Care
- A healthy and happy productive workforce
- Development of clinical services in lockstep with the People Plan
Health and wellbeing of our communities
The NHS Long Term Plan set out the core aim to not only treat people when they are ill but to prevent illness. Prevention is about helping our communities stay healthy, happy and independent for as long as possible.
The case for change as described within section 3 identified several drivers that show we can make a positive difference if we focus on prevention. We have an ageing population and approximately 20% of our population live in the 10% most deprived areas nationally. There are high levels of mental health problems, including increased levels of suicide in some of our communities. Cardiovascular disease, heart failure, hypertension (high blood pressure), asthma, dementia and depression are more common in Lancashire and South Cumbria than the national average.
NHS prevention initiatives abound with national drivers around cutting smoking, reducing obesity, limiting alcohol intake and alcohol-related A&E issues and lowering air pollution. But the clinical strategy for Lancashire and South Cumbria needs to go beyond this. Our engagement with those working in community and voluntary organisations showed us that a healthy and happy community is one that is successful, both socially and economically. It is the cornerstone of what we are trying to achieve.
Our communities or our place are the interactions we have in our daily lives. Place is different for all of us; it is the local shops, schools, businesses, our employment and the environment in which we live. We must focus on the health and wellbeing of our communities alongside our communities, that is, those that share our place with us: the voluntary and faith sector, local employers, our schools, housing and other citizens.
Achieving this integration and focus at place will reduce the risk of ill health arising and supporting people to self-manage health conditions as effectively as possible and as close to home as possible. Recognising that hospital-based care and interventions need to be available when necessary, we want our communities to remain healthy, independent and well in their own homes and able to avoid needless hospital admissions.
Prevention is important at all stages of life. Around 20% of our lives are spent in poor health, and evidence suggests that the past gains in overall life expectancy may be becoming harder to achieve and that we are now living with more complex illnesses for longer. If we fail to get serious about prevention of both physical and mental ill-health, then recent progress in healthy life expectancies will stall, health inequalities will widen and the ability to fund beneficial new treatments will be crowded-out by the need to treat wholly avoidable illness.
Population Health Management
Population Health Management requires joined up working between specialists, primary and community care, and community/civic assets and citizens at neighbourhood level, driven by data. We have refreshed our digital strategy to put patients, communities, and the public at the heart of our offer. This serves as a significant shift in our thinking and approach. It will be at the core of the delivery of all priorities within this clinical strategy.
Population health management takes a risk-based approach to improve health outcomes and reduce inequalities across an entire population. It includes a focus on the wider determinants of health and the role of people and communities and is data driven to shift care to the left on the care continuum. It therefore helps health and care systems get the most value out of their allocated budgets. As an ICS, we will support population health management to be embedded at all levels of health, social care, and in place.
A change in mindset from addressing immediate and ongoing needs of those receiving care and treatment, to a strategy which considers health and wellbeing of populations.
Governance and decision-making that locks in earlier intervention and integration
- Electronic Patient Records across different settings
- Intelligence driven data response and transparency
- Accountability frameworks, value-based care and incentives
- Digital care at scale
Targeted population health analytics and digital tools for:
- System modelling
- Actuarial assessment
- Risk stratification and capacity modelling
- Clinical decision support tools
Impact and Innovations
- Target operating models of care
- Transformation and rapid improvement support
- Patient empowerment and activation (including self-care support, personalisation, assistive technologies and remote consultations)
- Demand management and capacity planning support solutions. System assurance and provider modernisation. Medicines management support
Together we will tackle the required culture change by focusing on data-driven risk stratification and embedding personalised care; this will enable our local health and care partnerships and neighbourhoods to focus resource on delivering the right care to the right people and providing them with the knowledge, skills and confidence to better manage their conditions and lead the life they want to.
We will focus on providing high quality care, driven by the data and system-wide integration through involvement of our workforce and service users.
- At a local neighbourhood level, through an ICS development programme, we will support our 41 Primary Care Networks to develop capability to deliver care consistently across Lancashire and South Cumbria
- We will create an environment for rapid spread of learning and best practice from pilots and demonstrators
- We will promote role redesign and culture change that delivers to population need, career progression, succession planning and clinicians’ ability to work at the top of their licence.
We will support the implementation of the strategy locally and the development of integrated population health management units by our local health and care partnerships. We will ensure the system is delivering consistently through benchmarking, clinical audit and the implementation of a clinical accountability framework and incentives.
We will invest in and develop Population Health Management specialist roles that will develop, implement, and evaluate comprehensive patient plans to ensure that we work collaboratively with patients so that they receive the support and care that is important to them.
This work will be supported by the SEED Alliance.
Population Health Management summary
Population Health Management
- Data foundations e.g. My GP, shared care record.
- Neighbourhood pilots moving to plan
- Creating intelligence capability
- Innovative Leaders
- At ICS, ICP neighbours
- Data driven culture to mobilise anticipatory integrated care
- Accountability framework/value-based payments
- Insights for engagement/social movements
- Patient held digital record
Long term condition management in neighbourhoods
- Primary care register, annual review, escalation management by appointment
- Integrated community teams
- MDT care plan onward referral
- Social prescribers/community connectors
- PCN MDT approach initiated
- Population health management
- Integrated teams
- Digital real time clinical MDT with remote testing and immediate care plan
- Real-time digitla multi-org MDT focussed on wide determinants
- Remote testing dropping data into care record and mobilising care planning
- Digital self-care
- Referral for advice, care plam, treatment
- Hand back to primary care
- Focus on complex and escalation
- Advice and guidance in place
- Holistic models of care using "virtual rooms" and digital capability to remove asynchronous care
- Consultant facilitates best practice across the population need triangle for their speciality, driving anticipatory care and prevention approaches
- Digital care pathways for accountability.
ICPs will implement individual care pathways, interactive electronic patient records, individual data stories, a mobile workforce and digital self-care.
We will sustain work on pathways of care, including initiation of digital pathway design. Our priority integrated pathways for improvement as identified within our ICS Strategy (January 2020) are:
- Mental health – adults, children and young people
- Learning disability and autism
- Urgent and emergency care
- Stroke services
- Planned care
- Maternity services
We will further develop partnership arrangements to support individuals and community development approaches, connecting people to support on the wider determinants of health to enable better health maintenance and improvement.
Our Primary Care Networks will work collaboratively with secondary care specialists to focus on long term conditions and the elderly, building a targeted operating model for long term condition management in the community.
Anticipatory care planning is more commonly applied to support those living with a long-term condition to plan for an expected change in health or social status. This differs from preventive care, which is any medical service that defends against health emergencies. Anticipatory Care includes doctor visits, such as annual physicals, and wellbeing appointments. Some medicines are preventive, such as immunisations, contraception and allergy medications.
Anticipatory care helps people to live well and independently for longer through proactive care for those at high risk of unwarranted outcomes. It focuses on groups of patients with similar characteristics (for example people living with multimorbidity and/or frailty) identified using validated tools (such as the electronic frailty index) supplemented by professional judgement, refined on the basis of their needs and risks (such as falls or social isolation) to create a dynamic list of patients who will be offered proactive care interventions to improve or sustain their health.
Complex population cohorts require the skills of different healthcare professionals working together as a multidisciplinary team. Through our PCNs we will know the needs of our patients and provide personalised care to ensure they are supported to live happy, independent lives.
In summary, we will take action to:
- Ensure that prevention activity and initiatives are considered for all ages and all members of our communities
- Have outcome-driven plans in place to systematically tackle factors that detrimentally impact on health and wellbeing, including smoking, dietary risks including obesity, alcohol consumption, activity levels and exercise and drug usage
- Truly understand the holistic needs of our population by embedding a Population Health Management approach
- Target action towards areas of the system that our information and thematic analysis identify as causes of early deaths for high risk populations
- Support our 41 Primary Care Networks to develop capacity to deliver care through an ICS development programme
- Create an environment for rapid spread of learning and best practice from pilots and demonstrators
- Promote role redesign that delivers to population need, career progression, and succession planning and which supports clinicians to work at the top of their licence
- Support the development of integrated population health management units by our local health and care partnerships
- Ensure the system is delivering consistently through benchmarking, clinical audit, and the implementation of a clinical accountability framework and incentives
- Invest in and develop Population Health Management specialist roles that will develop, implement, and evaluate comprehensive patient plans to ensure that patients receive appropriate overall input, to enable their recovery or management of complex, chronic health conditions.
- Establish virtual clinics so people can access information, advice and guidance to remain healthy and prevent ill-health
- Support the increased levels of self-care evident through the COVID-19 pandemic by sign-posting patients to available services and by providing health coaching interventions to build on this increased awareness of self-care
- Understand that self-care is about more than just health. We will work with our community groups and local authorities in place to support people to access advice on wider determinants of health, such as housing, childcare and employment.
We have an ambition to support people to have the best possible start in life. We want to ensure that people are healthy and independent for as long as possible and we want people to have happy, productive and fulfilling lives.
As outlined in the case for change, health outcomes are variable for people across Lancashire and South Cumbria and on average, health outcomes are worse than the national average. The number of people with multiple diseases is set to significantly rise over the next 10 to 20 years, and this is increasing the complexity of those needing care and support. Traditional NHS care has been largely based around acute, bed-based care. We know from empirical evidence and talking to our clinicians and care givers that the hospital setting is not the right place to care for a significant percentage of people currently in a hospital bed.
The role of non-acute or out of hospital services in providing a future health and social care system that is sustainable in the long term cannot be over-emphasised. We must align our clinical priorities to reduce demand on our hospitals with a focus on self-care, integrated place-based care and intermediate care.
Self-Care and Personalised Care
The evidence suggests that people who are confident to manage their own health conditions are less likely to need GP contact or emergency admission. We want to focus on providing people with the confidence to manage their own care more proactively and in turn reduce our spending on long term condition management. This will reduce our reliance on acute hospital care, with potential savings re-invested in community services and infrastructure.
As set out in the NHS Long Term Plan, personalised care aims to give people the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life. A one-size-fits-all health and care system simply cannot continue to meet the increasingly complex needs of people, nor their expectations.
Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual diverse strengths, needs and preferences. Evidence from existing social prescribing schemes and clinical expertise suggests that GP appointments can be prevented when individuals receive a social prescribing intervention and onward referral to appropriate services. We will enable citizens to take responsibility for their personal care through clearer digital access to advice and signposting to alternative support where appropriate.
Through our PCNs, digital and personal contacts, we will maximize our use of community assets to make every contact count. This means influencing behaviour change by utilising the many day to day interactions that organisations and people have with other people to encourage changes in behaviour that have a positive effect on the health and wellbeing of individuals, communities and populations.
Integrated Place-Based Care
Health and care services will be built around local communities. We will further integrate health and care services at a neighbourhood level, aligning wider partnership working within Primary Care Networks (PCNs).
Through our estates strategy we will invest in a place-based neighbourhood accommodation offer. This will support our neighbourhoods to become a social movement with residents and staff, such as within Fleetwood, building a Lancashire and South Cumbria ‘deal’ with communities and a positive and responsible interaction between the citizen and local services.
Healthier Fleetwood is a not-for-profit organisation supporting the physical and mental health of the Town's residents by connecting them to each other, services and voluntary groups in the community. As an individual's confidence grows they take more control of their own wellbeing and an active role in the decisions that affect them.
These social movements will shape local provisions and services to get to an end point of integrated population health management. This will develop in our work with PCNs to bolster the population groups with clinical support and support for tackling the wider determinants of health to enable them to have a healthy, happy life, be better protected against COVID-19 and improve Long Term Condition maintenance.
As an integrated part of a neighbourhood, our Primary Care and Community Services will draw on the expertise of secondary care specialists. With a focus on long term conditions and the elderly, integrated place-based care will build a new target operating model for long term condition management and elimination of asynchronous care with clear gateways for ‘on-boarding’ services into integrated teams e.g. community mental health.
Building on learning and advancements from the COVID-19 pandemic and as part of integrated place-based care, Primary Care will:
- Provide support for patients, carers and volunteers to self-manage their conditions, particularly of long-term health conditions
- Use virtual/digital technology where possible and appropriate while ensuring those who are vulnerable or without digital access do not suffer greater health inequalities or isolation
- Adopt consistent Advice and Guidance tools across the ICS: working so secondary care expertise is accessible earlier in the patient journey without the need for multiple ‘handovers of care’
- Provide Enhanced Care in Care Homes to support the most vulnerable to stay in their place of residence without unnecessary admission to hospital or need to access urgent care
- Work with community pharmacists to deliver medicine optimisation, structured medication reviews, prevention of adverse effects and antimicrobial resistance
- Focus on the areas of the local population that have greater health inequalities, including those with a learning disability, autism, frailty and dementia
- Provide timely access to Primary Care Mental Health for all ages through identifying people at risk and better support to families and use of real-time intelligence from the police, local authorities and NHS to support the communities in taking action in the right areas.
Early Cancer Diagnosis
Primary care will play a vital role in system-wide improvement efforts to increase the proportion of cancers diagnosed early. The role of primary care in early cancer diagnosis will be prioritised and the opportunity to request more diagnostics directly will support the expected increase in the number of patients who have delayed seeking advice or have had their referrals on hold.
Primary care networks will work to new service specifications for the early diagnosis of cancer, improving referral practice and screening uptake as a network.
This will include:
- Primary care will continue to work more closely with secondary care to reduce routine specialist follow ups with specialists being accessible to GPs for advice and guidance. We will move away from a culture of referral to one of discussion: saving time and achieving a better experience for the patient
- Leading and coordinating the contributions of practices and the PCN to increase the uptake of existing National Cancer Screening programmes among their local populations
- More investigations in primary care before the patient is referred to a specialist or Rapid Diagnostic Centre (RDC).
Our cancer experts will work as single teams across the system ensuring patients have access to expertise regardless of where they live. They will do this by providing a single point of access to a diagnostic pathway for all patients with symptoms that could indicate cancer and personalised, accurate and rapid diagnosis of patients’ symptoms by integrating existing diagnostic provision and utilising networked clinical expertise and information locally.
Built within our approach to integrated placed based care will be parity between our community and acute heath and care services and work is being undertaken to assess the current capacity for 7-day working across all community services.
Through knowing our most vulnerable population and what matters to them as individuals, we will shape services to meet their needs and not their medical condition. Our community workforce will develop generalist, not specialist, knowledge, with access to more specialist expertise through digital means. Working across traditional professional boundaries, our workforce will develop the skills and competencies to promote activities of daily living alongside performing clinical interventions.
We will increase our community capacity through an innovative and flexible workforce which stretches wider than health and social care, working across organisational boundaries in a shared culture and practice of preventing unnecessary hospital admissions or institutional care and supporting people to return home more quickly where a hospital admission has been necessary. This may include the introduction of hybrid roles to bridge acute and community care provision and the rapid training and recruitment of different staff groups to increase our workforce.
As local health and care partnerships, we will manage quality and performance in a consistent way which will ensure better comparison of provision across Lancashire and South Cumbria. Not only will this change mean more efficient care by reducing demand for expensive emergency and hospital treatment but it will also mean better quality care for people to stay well for longer, ensuring they get the best type of care in the right place for them.
We know that staying in hospital can have adverse effects for patients, such as deconditioning, harm (e.g. falls /confusion) and for many patients never returning to their homes after their hospital admission. We will continue the collaborative working between health and care providers to embed effective discharge processes and admission avoidance pathways and ensure a substantial reduction in the number of people who are staying in hospital without an acute medical need.
Intermediate care is the range of services which sit between primary care and urgent and acute hospital care. These health and care services support people to retain or regain skills which they may have lost due to injury or illness, thereby increasing their independence.
A recent review of intermediate care across Lancashire and South Cumbria showed that we currently have:
- 45,000 people supported by intermediate care services
- Circa 800 staff supporting people in their homes
- 445 occupied health and social care beds (5,335 episodes p.a. with average length of stay of 29 days)
- Different service models and offers across Lancashire and South Cumbria.
Intermediate Care Services
- Patient centred care - enhanced bed based intermediate care provision for people with complex needs who require nursing provision or monitoring as part of their rehabilitation or recuperation.
- Short term residential care - short term funded residential bed-based care, usually due to recuperation needs or lack of capacity in other provision.
- Home First - provision working under the assumption that people of better assessed and supported in their own homes.
- Crisis Home Care - time limited (usually up to 72 hours) social care provision to support people to remain home safely due to social care issues.
- Reablement - community based therapy-led service working with care providers to support people to regain skills which they may have lost due to injury or illness
- Residential intermediate care - bed based provision, primarily for older people, within residential care with a rehabilitation approach to assess and rehabilitate people following illness, deconditioning or injury.
We will have a single model of bed-based intermediate care across Lancashire and South Cumbria by developing and agreeing service specifications and working to consistent financial arrangements to ensure transparency on the commissioning and contracting arrangements.
The focus will be on realigning service provision to support people to remain well at home and to increase the number of social prescription referrals and personalised care interventions to avoid hospital admissions. This consistent approach will also allow us to compare the quality and performance of services across Lancashire and South Cumbria and address any unwarranted variation.
Within our local health and care partnerships, we will work to a clear purpose and role for reablement, recuperation, recovery and rehabilitation services which focus on proactively promoting wellbeing and independence through supporting people to remain well at home, bridging the gap between primary care, acute hospital and residential care provision.
Intermediate Care Services will be an integral part of the local Primary Care Network, will form part of the local community and will be accessible to patients across Lancashire and South Cumbria. Limited professional allied health expertise will be accessed remotely across the providers with the delivery of joint educational sessions and virtual assessments and interventions supported by rehabilitation assistants.
Mental Health, Learning Disability and Autism
We will aspire to ensure that everyone has equity of access to physical and mental health services irrespective of other conditions, background, age or the geography in which they live. Through physical and mental health services working together, people with mental ill health, a learning disability and/or autism will not have greater physical health inequalities than the wider population.
Parity of esteem between mental and physical health will be a continued goal. Through system-wide integration, shared decision making and implementation, we will as an ICS address the following strategic priorities:
- Improved transition between young people’s mental health services and adult services
- A targeted focus with partners on mental health prevention and promotion
- Local service provision wherever possible at ICP and neighbourhood level integrated across shared pathways that transcend organisation barriers and diagnoses
- Full implementation of the Thrive Model
- A consistent model of dementia care across all ICPs that provides support at all stages post-diagnosis
- Innovative rehabilitation and recovery services in partnership with other sectors to maximise life chances
- Robust and consistent perinatal services for women
- Emphasis on best practice and innovation through the SEED Alliance.
Professionals and the public need clear and accessible information about how to access local Improving Access to Psychological Therapies (IAPT) services and the range of choice available. This is particularly important to promote self-referral, improve access and address the fact that anxiety disorders are commonly under-detected. We also need to ensure timely access to IAPT services and achieve the prevalence (expected access rates (percentage of prevalence) is 22%) and recovery targets (at least 50% of people who complete treatment should recover).
- We will aim to reduce the need for our residents to be cared for in hospital. Hospitals should not become de facto homes; discharge planning should start from the point of admission - or earlier for a planned admission. This includes supporting local health and care partnerships to repatriate patients close to home where possible and provide care and treatment in the least restrictive setting
- We will provide recover and rehabilitation care within Lancashire and South Cumbria and reduce the number of patients receiving care outside of Lancashire and South Cumbria, away from their families and friends
- Equitable provision and access to community learning disability teams across Lancashire and South Cumbria.
When local people require mental health support, they should be able to access an effective range of age-appropriate services. At present, there is variation in access, provision, and clinical outcomes. All ICPs will consistently seek to deliver to several clear priorities:
- The provision of local assessment and treatment beds
- Expansion of community MDT intensive support learning disability teams to avoid unnecessary admission
- Clear pathways of support, advice and treatment when learning disability service users are in acute setting, a mental health setting or out of area
- Addressing wider determinants of health in terms of community connectivity and relationships, employment and addressing treatment inequalities.
We will prioritise five key actions to better provide care for people with autism:
- Mapping current provision against what is required
- Ensure early diagnosis and consistent pathways of treatment and intervention to avoid admission wherever possible
- The development of the outreach services to reduce the out of area placements and unnecessary admissions
- Increase the capability and capacity of mainstream providers through information, support and pathways to reduce inequalities and improve the experience of people with autism in these settings
- Ensure that any Lancashire and South Cumbria residents requiring the regional Autism Spectrum Disorder (ASD) services have access via defined pathways.
Maternity and Children’s Services
As a system, we aim to deliver high-quality, consistent care for families. We are committed to removing variation and boundaries; improving choice, safety and experience of maternity services and improving outcomes in line with national performance. This will result in:
- Reduced number of stillbirths and neonatal deaths
- Reduced number of brain injuries between labour and delivery of the placenta
- 100% of women having personalised care records, by 2020
- In line with national policy, achieve 20% year on year increase in the number of women receiving continuity of carer during pregnancy, birth and postnatally
- Increase the regional value of birthing events that include skin to skin contact (79%) to the national average (81%)
- Reduction in regional value of people smoking during pregnancy and at the time of delivery, from the current 27% to the national average of 21%
- Improved support and education around infant feeding.
Through the Local Maternity System (LMS), we will support all services towards compliance with the recommendations set out in the National Maternity Review, Better Births, (2016).
All women in Lancashire and South Cumbria will have four options for place of birth (NICE 2014):
- Midwife Led Unit attached to an obstetric unit
- Standalone Midwife Led Unit
- Obstetric Unit (consultant-led maternity services with midwifery support).
We will continue through the collaboration of our maternity services to offer both a safe environment for patients and a platform for staff to learn, share and train together. This will build on previous successful initiatives with a revised programme of emergency skills training being delivered collaboratively across all providers.
Through the LMS and as an ICS, we will provide co-ordination and assurance to demonstrate consistent care across the ICPs with regards to physical, social and psychological needs, midwifery development and multi-disciplinary learning, support for research and audit, strategies for community involvement and clear communication about the service and evidence of sharing learning with other maternity services.
In summary, we will take action to:
- Focus on giving the people the confidence to manage their own care proactively
- Build Health and Care Services around our local communities
- Prioritise the role of Primary Care in Early Cancer Diagnosis
- Establish multi-disciplinary early supportive discharge teams and trusted assessors within each of the local ICP areas
- Ensure parity between our community and acute heath and care services including an assessment around the potential for 7-day working across all community services
- Ensure that an effective range of age-appropriate mental health services are available across all ICPs, with reduced variation of access and service provision
- Ensure access to Improving Access to Psychological Therapies (IAPT)
- Ensure ICPs follow the “think home first” principles in all service planning and implementation
- Improve choice, safety and experience of our maternity services.
At some point in life, we will all experience ill health. When that happens, our aim is for people to receive support that meets their specific needs and helps them live as healthy and fulfilling a life as possible.
Strengthening prevention of avoidable illness through initiatives such as smoking cessation, diabetes prevention through obesity reduction and reduced respiratory hospitalisations from lower air pollution will over time lead to less illnesses. This goal will also be achieved through better support for patients, carers and volunteers and enhanced ‘supported self-management,’ particularly of long-term health conditions.
However, for people who do fall ill, the traditional structure and processes of the NHS have created services that can be inequitable and confusing. One the strategic aims of the ICS is working together to deliver better, joined-up care, closer to home. To make this a reality we need to look at options for affordably moving more planned care out of an acute setting closer to home, utilising technology wherever possible to best effect.
Organisations will need to collaborate and work more closely together, potentially with changes to current models of care to the ones currently in place. This includes making best use of our workforce and consideration for where services are delivered to ensure care is easily accessible.
Collaboration, Shared Services and Speciality Networks
Change to our acute services will be provider led and the four acute hospital trusts will increasingly work more closely together. They will work together to transform the ways in which patient pathways are organised and services are provided.
This will involve the development of Single Shared Services or Specialty Networks which bring providers together across Lancashire and South Cumbria to:
- Agree the key clinical standards that need to be achieved across the system, ensuring compliance to service specifications and best practice speciality guidance
- Standardise clinical pathways where required, reducing variation in access and service provision, with the aim to improve performance against agreed outcome measures and quality metrics. This will include aligning collectively with national programmes to drive improvements and reduce variation in costs and quality, such as Getting it Right First Time, RightCare and the Model Hospital
- Make best use of the whole workforce and expertise across the system. This should include
- Standardising clinical practice (as described above)
- Developing creative and flexible workforce models to address the sustainability of our rotas, ensure compliant rotas and move towards providing 7-day service models by pooling our resource and enabling working across our hospital and community sites
- Work to ensure optimum utilisation of our physical assets, equipment and estates across the region
- Take joint accountability for regional performance indicators
- Work in partnership with the Innovation Agency, the ICS Partnership Forum and Universities to consider new roles and innovations
- Work together towards a new acute hospital archetype, which will include the transformation of individual services, how care is provided, where and how they are accessed and the number and location of sites.
As well as transforming services, closer working at an acute provider level will also provide the opportunity for more efficient procurement, building on the work undertaken in response to the COVID-19 pandemic, such as system-wide procurement of critical care kit. It also provides the opportunity for a collaborative approach to research projects and clinical trials, which would attract larger national grants if based at a Lancashire and Cumbria wide level; having a stronger presence in research arenas will also attract more leading clinicians to our region.
Efficient delivery of clinical services
Single shared services and specialty networks offer opportunities for system level collaboration. However, in addition to this, there are opportunities to provide better quality and more efficient delivery of services at a local level. Our providers will drive operational efficiencies, such as those identified through Model Hospital.
A single Lancashire and South Cumbria Nursing Offer
We will recruit, train and grow our own nursing workforce within Lancashire and South Cumbria and collaborate on international nurse recruitment. We will make access easy by offering various entry points into the service such as apprenticeships, direct undergraduate access and supported career progression pathways for carers who wish to progress. Our nurses will work with parity of esteem across social, primary, community, mental health, learning disability and acute care.
Provision of a system-wide Electronic Patient Record system
To enable system working and to improve clinical practice, a single Electronic Patient Record (EPR) system will be introduced across our health and care system.
This system will be accessible for clinicians and appropriate clerical staff in all acute hospital Trusts; across our primary care settings; in all our community hospitals, specialist community services and clinics; social services and North West Ambulance Service.
The new system will be applicable to the whole patient journey and will include:
- Patient administration information including inpatients, outpatient, clinical coding
- A&E attendance information
- Discharge letters and clinic notes
- Pathology/radiology results for all Lancashire and South Cumbria provider trusts
- Clinical notes
- Immediate discharge summaries
- Scanned GP referral letters
- Community clinic notes
- Hospital care plans
- Cancer MDT reports
- Electronic Sign Off for inpatient results
- Multimedia including medical photography images and videos
- Critical patient information (patient alerts)
- Clinical documents from external sources
- Neurophysiology and cardiology results.
The Electronic Patient Record system will provide significant advantages, providing more complete information for clinicians, reducing the time spent by clinicians searching for information in different systems and improving the quality of care and the efficiency of services provided.
In addition, interaction between clinicians will be improved and the patient pathway will become more efficient; for example, an electronic discharge summary can be entered by the discharging clinician and reviewed by a pharmacist to sign off medication.
Increased critical care capacity
We will expand the critical care capacity across our system to increase the baseline number of beds, including the introduction of a flexible operational model to deal with any surges in activity (triggered when bed capacity is higher than 80%). This operational model is likely to include the transfer of staff from theatres and therefore has a consequence for the volume of elective care that can be provided, as the need for critical care beds and associated staffing increases.
To manage this, “Enhanced Care Models” will be introduced. Enhanced care, previously described as Level 1+ or 1½, is an intermediate level of care where a higher level of observation, monitoring and interventions can be provided than on a general ward but not requiring high dependency care/organ support. Enhanced care takes place in a ward setting, by a motivated and upskilled workforce, but provides ready access to the critical care team through established communication links. Elective care can be clearly defined and the outcome for the patient is highly predictable, making this an optimum model to optimise flow through the elective pathway. This will enable predictability of access, improve the patient experience and facilitate timely interventions.
Prioritisation of ICS Programmes
We are currently conducting a review of existing ICS programmes with a clear recognition that the ongoing response to the COVID-19 pandemic requires agility and responsiveness of available resource and capacity.
Currently there are 28 ICS programmes (identified below) that are at various stages of progress:
- Critical Care
- Intermediate Care
- Service Review: Theatre Efficiency/ Outpatients
- Diagnostic Service Collaborative
- Integrated LD and Autism Service Strategy
- Children & Young People’s Emotional Wellbeing & Mental Health
- Urgent and Emergency Care
- Acute Paediatric Services
- Head & Neck Services
- Vascular Services
- Strategic Workforce Planning
- Integrated Children & Young People’s Health
- Medicines Optimisation
- HIP2 Development
- Strategic Estates Infrastructure
- Corporate/ Shared Services Collaborative
- Primary & Community Care & Wellbeing Framework
- Digitally Enabled Care
- Strategic Workforce
- Adult Mental Health
- Better Births and Maternity
- Intensive & Hyper Acute Stroke Services
- Palliative & End of Life Care
- Population Health & Prevention Strategies
- Individual Patient Activity (IPA)
- Universal Personalised Care
- Cancer Alliance Leadership & Organisational Development
Access to specialist opinion
Outpatients traditionally serves three purposes: to provide advice and diagnosis for a patient and their GP; follow-up review after a hospital procedure and ongoing specialist input into a long-term condition. Technology means a face-to-face outpatient appointment is often no longer the fastest or most accurate way of providing specialist advice on diagnosis or ongoing patient care. In many ways, patients are already benefitting from new ways of accessing outpatient services. These include better support to GPs to avoid the need for a hospital referral, online booking systems, appointments closer to home, alternatives to traditional appointments where appropriate, including digital appointments and avoiding patients having to travel to unnecessary appointments.
Using digital technology as the default (where possible) and the implementation of consistent adoption of advice and guidance will transform patient access to specialist opinion. A more streamlined approach is better for patients, supports more productive use of consultant time and enables the capacity of outpatient clinics to be used more efficiently.
If specialist opinion is required beyond advice and guidance, this will be delivered to the following three key principles:
Principle 1: Providing care post discharge at home, wherever possible
By supporting the patient at home following hospital discharge and looking to restore the patient’s recovery and functional independence wherever possible, unnecessary contacts in the hospital can be avoided.
Principle 2: Using technology to best effect
As a default, whilst considering patient choice and vulnerability, the use of technology will be incorporated into outpatient pathways. Technology such as digital dictation, telemedicine, digital recording of consultations and remote monitoring will all be considered on a speciality basis. For example, implementing a single pathway from primary to secondary care with rapid access to specialist advice provided by a consultant led e-clinics can reduce wait times by up to 50%.
Significant progress in the use of digital technologies has been made in our response to COVID-19, with specialist advice and opinion being accessed through video consultations. All acute trusts have introduced ‘Attend Anywhere’ video consultations, and the use of this technology and the change in the pathway has reduced the volume of hospital-based outpatient appointments by over 30%.
Principle 3: Improving referral practices
Training and feedback on referrals given to all referrers, not just GPs, so that all health professionals continue to adapt and learn and patients get sent to the right person, first time.
Access to specialist opinion:
- We will recognise the public as individuals with varying health needs, personal pressures and the ability to manage their own treatment.
- Our patients will have more control over when and how care is received.
- We will deliver care that is convenient for the patient
- One stop clinics designed around a sympton
- Specialities and charities will work together to develop signposting resources and decision making aids
- Ability to book clinics from Urgent Care Triage
- Clinic templates that allow flexible timing depending on the complexity of need
- Access to flexible follow up appointments and the offer of patient initiated appointments replacing the need for follow up appointments.
In summary, we will take action to:
- Review the way in which our acute hospitals can work more collaboratively together, through single shared services and networked services
- Agree clinical standards across the region and standardise clinical pathways
- Expand our critical care capacity across our system and introduce Enhanced Care Models
- Change the way in which specialist opinion is accessed.
Accidents and acute illness necessitate rapid access to urgent or emergency care. Increasing demand on emergency services has resulted in a need for the Urgent and Emergency Care system to change to be fit for the future.
Life threating illnesses or accidents which require immediate, intensive treatment, provided through an Emergency Department at an acute hospital.
An illness or injury that needs urgent attention but is not a life-threatening situation. The people of Lancashire and South Cumbria should be able to access a triage function that gets them to the right place, first time.
Urgent and Emergency Care (UEC) services perform a critical role in supporting the people of Lancashire and South Cumbria during times of urgent need so they can return to health. However, as set out in the case for change, our accident and emergency departments across the region are consistently struggling to meet national performance targets.
Our urgent and emergency care services are changing to ensure that patients get the right care, in the right place, whenever they need it. Further enhancements and changes to our UEC services will ensure that we provide a modern, responsive service that people recognise and use effectively. This not only includes the services within our hospitals but the role of Urgent Primary Care and the North West Ambulance Service (NWAS).
Within Primary Care, the separation of on-the-day-urgent-care from the care of the multi-comorbidity/early significant diagnosis patient; clinicians working at the top of their licence; and longer appointments will support access and management of patients with Primary Care appropriate urgent care needs.
We will update and maintain our Directory of Services so NWAS can divert activity away from emergency departments to alternative services, supporting the provision of ‘hear and treat’ and ‘see and treat models’ and NHS 111.
The Long-Term Plan sets out action to ensure that patients are getting the care they need, in the right setting, at the right time, with an overarching driver of relieving pressure on A&E departments. As well as alternative options, such as Urgent Treatment Centres, those still requiring emergency care are increasingly being treated through ‘same day’ emergency care, without the need for admission and overnight stays. This in turn frees up bed capacity within hospital wards.
The NHS Long Term Plan sets out a series of commitments and ambitions in relation to emergency care services, which should also be implemented within Lancashire and South Cumbria:
- Provision of a 24/7 urgent care service, accessible via NHS 111, which can provide medical advice remotely and, if necessary, refer directly to Urgent Treatment Centres (UTCs), GP (in and out of hours), and other community services (pharmacy etc.), as well as ambulance and hospital services
- Implementing Same Day Emergency Care (SDEC) services across 100% of type 1 emergency departments, allowing for the rapid assessment, diagnosis and treatment of patients presenting with certain conditions and discharge home same day if clinically appropriate
- Focusing efforts to reduce the length of stay for patients in hospital longer than 21 days, reducing the risk of harm and providing care in the most clinically appropriate setting
- Working closely with primary and community care services to ensure an integrated, responsive healthcare service helping people stay well longer and receive preventative or primary treatment before it becomes an emergency.
There is still an apparent disconnect between people’s perception of an emergency or urgent care need compared to the clinical opinion. This disconnect is understandable in light of the public’s long-standing relationship with a traditional Accident and Emergency Department – a ‘brand’ seen as the one-stop-shop / front door of the NHS and a convenient and immediate answer to a variety of healthcare needs. Therefore, a focus for Lancashire and South Cumbria needs to be a communication and engagement exercise with communities to clarify for people what to expect from different emergency and urgent care settings, alongside a range of other services both in and out of hours.
Providing care in a crisis
Our urgent and emergency care services require improvement and we must work together across the system to provide highly responsive services which provide care as close to home as possible and which are safe and sustainable and of a consistently high quality. We will work together as a system to ensure our Emergency Departments and Urgent Treatment Centres consistently deliver the required quality standards.
It is important for us to provide a consistent offer so our population know what they can access and how, wherever they live. We will be clear about which services are type 1 Emergency Departments and which are Urgent Treatment Centres, so our population know which to access for what, without confusion. This includes having a consistent approach to patient streaming that links Emergency Departments to services at a neighbourhood level to improve system working so people access the right service, first time. We will stream primary care, urgent treatment patients, frailty patients, children and mental health patients away from our emergency departments, where appropriate, so they are available for those who need it most, when they need it.
We will support access to crisis mental health care by the alignment of Mental Health Urgent Assessment Centres to all major Emergency Departments. We will utilise digital technology to respond to category 3 and 4 calls where appropriate, so paramedic crews are available to respond to life-threatening emergencies.
In summary, we will take action to:
- Put in place a consistent system which provides intelligence about how our urgent and emergency care systems are performing, which can be shared across the system
- Provide a consistent urgent and emergency care offer across the system, with clarity on the services on offer
- Stream patients away from our emergency departments where possible and appropriate
- Put in place a triage function that gets people to the right place, first time along the full urgent care pathway
- Utilise digital technology such as video conferencing where appropriate
Align mental health urgent assessment centres to all major emergency departments.
End of life care is the care people receive as they enter the final period of life. The quality and accessibility of the care people receive during this period is a key priority for our region.
It is challenging to define ‘end of life’. But for the purposes of this strategy it includes people who could potentially die within the next 12 months, who meet one or more of the following criteria:
- Have an advanced incurable illness, such as cancer, dementia or motor neurone disease
- Are generally frail and have co-existing conditions that mean they could potentially die within 12 months
Have existing conditions which increase the risk of dying from a crisis in their condition
Have a life-threatening acute condition caused by a sudden catastrophic event, such as an accident or stroke.
Death and dying are inevitable. Having a good death can make an immeasurable difference to the person dying, as well as to those left behind. Planning for and anticipating the needs of people of all ages and conditions who are living with declining health, taking into account their priorities, preferences and wishes, supports good end of life care. This includes support for family members and those important to the person, extending to bereavement care.
A personalised approach to care at the end of life will result in an improved experience not only for the patient, but also their families and those important to them, those who provide care and the communities in which they live. It will also lead to more sustainable services. National end of life care statistics indicates that currently:
- Almost half of all deaths in England occur in hospital
- Nearly a quarter of all deaths in England occur in people’s own home
- Just over a quarter of all deaths in England occur in a care home or hospice
- The trend of dying in hospital continues to reduce (e.g. in 2004 nearly two thirds of deaths in England occurred in hospital)
- Cancer accounts for around 25% of deaths. Circulatory disease also accounts for around 25% of deaths and respiratory disease for 14% of deaths
- 70% of people do not die in the setting of their choice.
Palliative and End of Life Care
Palliative care is treatment, care and support for people with a life-limiting illness and for their family and friends.
The aim of palliative care is to help people have a good quality of life – this includes being as well and active as possible in the time people have left. It can involve:
- Managing physical symptoms such as pain
- Emotional, spiritual and psychological support
- Social care, including help with things like washing, dressing or eating
- Support for people’s family and friends.
As an ICS, we will raise public awareness of death and dying so the people of Lancashire and South Cumbria are willing and confident to have conversations about living and dying well and are able to support each other in times of crisis and loss.
The Palliative and End of Life Care Network for Lancashire and South Cumbria Programme (PEoLCN) aims to empower the people of Lancashire and South Cumbria and those who care for them, to live well before dying with peace and dignity, supported by care which is personalised, high quality and equally accessible to all. This includes the early identification of people at the end of life to be supported through GP palliative and supportive care registers, so their care is coordinated.
The strategic aim is for everyone to get personalised and meaningful care towards the end of their life. This means supporting them so they can live well, before dying with peace and dignity in the place of their choosing, supported by the people important to them. The access to care should be equitable across Lancashire and South Cumbria with no post code lottery. Our ICPs will:
- Support timely identification of patients who would benefit from end of life care planning and offer care accordingly
- Promote equitable access to palliative care, regardless of disease condition, place of care or socio-economic background of individuals
- Improve choice at the end of life through the Universal Personalised Care Model across all care settings
- Equip the health and social care workforce to deliver skilled end of life care
- Enable equitable access for the people of Lancashire and South Cumbria to receive bereavement care, including children and young people and those affected by sudden or traumatic death.
We will develop systems and services that maintain a healthy and happy productive workforce, that makes Lancashire and South Cumbria a number one place to work for clinicians and other staff.
Our Lancashire and South Cumbria People Plan is built around four priorities: compassionate leadership and systems development; a positive employment experience; opportunities for all; and building a sustainable workforce.
As an ICS, our ambition is to work with our partners – NHS, primary care, social care and VCSFE to deliver these priorities across the whole of our health and care workforce and volunteers.
It is important that our Clinical Strategy and People Plan work in lockstep. We cannot develop services that do not have the workforce to deliver them, equally our workforce plans and training must be informed by the skills and services required in the future to deliver to population and patient need.
Within our clinical services we shall be guided by the below key workforce principles:
- We will make the best use of the whole workforce and expertise across the system, reducing traditional organisational and role boundaries
- We will do only what needs to be done, at the right time, by the right person
- We will provide opportunities for portfolio roles that span neighbourhoods, through to job plans within hospital services – helping to knit our services and people more closely together
- Will we support our clinicians to work at the top of their licence, supported by evidence- based and protocol-driven care.