1. KSSLA Leadership in Turbulent Times Summit 15th June 2018
The Journey of Encompass Multi-Speciality Community Provider (one of the NHS Vanguards) in the development and spread of a new model of care. *
KSSLA Leadership in Turbulent Times Summit
15th June 2018
Leadership challenges of rolling out a new model of care;
* Rabindranath Tagore

2. Encompass Multi-Speciality Community Provider (MCP)
14 GP practices across Ash, Canterbury, Faversham, Sandwich and Whitstable,
in partnership with Health and Social Care.
We are part of the NHS “vanguard programme”, which means we made a bid to NHS England for special funding to improve the health of local people by testing new models of care.

3. Five Local care Hubs – 180,784 patients
Whitstable
2 practices – 38,574
Sandwich & Ash
3 practices – 17,444
Canterbury N
4 practices – 47,391
Faversham
2 practices - 30,743
This is based on Q data. Actual Population
Faversham
Faversham Medical practice 13,613
Newton Place surgery 17,530
2 practices – 31,143
Whitstable
Whitstable Medical Practice 35,820
Saddleton Road Surgery 2,754
2 practices – 38,574
Sandwich & Ash The market Place surgery 8,145
Ash surgery, 4702
The Butchery 4,597
3 practices – ,444
Canterbury S
New Dover Road 10,141
Canterbury Medical Practice 20,425
University Medical Centre 16,066
3 practices – 46,632
Canterbury N
Northgate Medical Practice 19,418
Sturry Surgery 16,965
Canterbury Health Centre 5,229
3 practices – 41,612
Canterbury S
3 practices – 46,632

4. GP Practice at scale built around Person/ Population Health needs
Encompass MCP – Health, Social Care, Voluntary and Community involvement working together at scale – The Local Care Hub model
Number of People
GP Practice at scale built around Person/ Population Health needs
Integrated
Admission Avoidance
Routine, Prevention and Proactive Care
–Integrated Case Management (ICM patient centred approach for admission avoidance, anticipatory care planning.
Emergency and Reactive Care – ICM approach for admission avoidance, rapid/ emergency response to avoid hospital admission to keep people well at home.
Acute Care
- When intervention is essential.
Working with IDT for
repatriation at the earliest opportunity.
Tertiary Care - For highly specialist intervention.
Repatriation at the earliest opportunity.
Systems of Care
Local Care Hubs
Total Population 180,784
Each Hub – 30 to 50,000
Level of Acuity

5. Moderate Relative Risk
New Models of Care: different approaches are needed to manage our population
Patient Cohorts
Integrated Case Management
* £19.6m
Health Condition
Management
* £3.6m
Supported
Self-care and PREVENTION
* £1.3m
Our Approach
Very High
Relative Risk
Intense ICM
High Relative Risk
Integrated case management (ICM
Moderate Relative Risk
Co-ordinated self care
Low Relative Risk
Promoting wellbeing
Most vulnerable/ frail/ elderly/ multiple co-morbidities
( 5.9% Population)
Relatively fit and coping
Health complaint
(16% population)
Generally well
(78% population)
* Acute expenditure on emergency admissions

6. Multi-Disciplinary Team
CHOC core team includes:
Our Integrated Case Management (ICM) Approach
Health and social
care coordinator
Social Care representative / social worker
Clinical Services
Pharmacist
Mental Health worker GP
Social Prescribing
Care plan
Community nurse
/ LTC Nurse
Nurse Specialist
Geriatrician
Agreed with patient/carer
Administrator
Allied Health Professional
Additional members which vary locally:
Fire and
rescue
Police
Acute
specialists
Integrated Discharge Team

7. Health condition management
Supporting and empowering people who have long term physical and mental health conditions is important. The aim is to keep people well and avoid hospital admission.
Some of this involves moving
some services, historically
provided within a hospital
setting, into the community,
extending the roles of GPs and other health care professionals
Provision of specialist
clinics in a community
setting , priority for cardiology, respiratory/ pneumonia, rheumatology and frailty.
Fast access to services within the community to avoid
attendance at A&E such as the community catheter clinics
Catheter service began th centre opened June 2017
Ensuring that mental
health is given the
same level of
importance as
physical health, means
provision of services to
support people with
with long term mental health problems
Dementia Support worker in place
Patients identified through population modelling, down to GP caseload
Group Psycho-education showing positive results

8. Supported self care
Supporting people to make healthier lifestyle choices to avoid prevent able diseases. The aim;
Building strong social networks
Exercising more
Eating more healthily
Feeling more supported and in control of lives
Reduction in healthcare interventions for patients identified with a social prescribing need
Social Prescribing – gaining real momentum in year 3
Health Trainers roll out across all CHOCs
An initiative in schools to keep children active
Giving people information to make informed decisions about their
own health:
WaitLess- providing positive benefits for the urgent care system
WaitLess, the APP which provides real time data on MIUs and A&E departments in east Kent; linked to Health Help Now - providing people with symptom advice and guidance on treatment

9. Directory of Services Catheter service: 4th centre opened June 17
CHOC MDTs: all 5 in place
Community Geriatricians: integrated in CHOC MDTs
Dementia Support worker in place
GPwSI: Training underway (Linked to Tiers of Care)
Health and Social Care co-ordinators: organise the MDTs
Health Trainers: rolled out across
all CHOCs
Group Psycho-education showing positive results
Community Pharmacists: supporting CHOC MDTs and Home First
Social Prescribing: gaining real momentum in year 3
WaitLess: providing positive benefits for the urgent care system
Directory of Services
Rapid home visiting service supporting GP Home Visits

10. Activity deflections Patient experience £3.4m Planned model forecast
First time in years I feel confident enough to go outside and hang my washing on the line.
33.1%
6.4%
Short stay Admissions
A&E minor attendance
Amazed at how quickly things happened and we are extremely happy with the outcome / support.
8.2%
Emergency Admissions
22.6%
Catheter related Admissions
I have gained a lot of insight about a condition I have had for 17 years.
Now more confident and independent. Changed my life.
Catheter clinics
There has been a reduction in the rate of admissions per 1,000 population for catheter-related conditions of 24.7% for the period Jun 2016 to Jun 2017 compared to the baseline period (2014/15).
Community Hub Operating Centres
There has been a reduction in the rate of emergency admissions per 1,000 population of 5.7% for the period Jun 2016 to Jun 2017 compared to the baseline period (2014/15).
There has also been a reduction in the rate of short stay admissions with no procedure per 1,000 population of 27.3% for the period Jun 2016 to Jun 2017 compared to the baseline period (2014/15).
Waitless
There has been a shift of minor attendances from A&Es to minor injury facilities of 5.8% for the period Jan 2017 to Aug 2017 compared to the baseline period (2015/16).
£3.4m
Planned model forecast
2017/18 net savings
So good. I broke my leg and needed it checked immediately and with this app it told me what hospital had quicker service and how long it will be to wait - excellent.

11. Encompass Has Helped Define The Model For Local Care Across Kent and Medway
Local care is a new model of delivery of integrated health and care services close to where people live.
It is a collective commitment of the health and care system in Kent and Medway to fundamentally transform how and where we will support people to keep well and live well.

12. Moderate Relative Risk
Local Care: A New Model of Delivering Services To Our Population Across Kent and Medway
Most vulnerable/ frail/ elderly/ multiple co-morbidities
( 5.9% Population)
Relatively fit and
coping with
Health complaint
(16% population)
Generally well
(78% population)
Our Population
Localities
Federations
Clusters
Local Care Services
Our Approach to
deliver the new model
Very High
Relative Risk
MDT working
High Relative Risk
Moderate Relative Risk
Co-ordinated self care
Low Relative Risk
Promoting wellbeing

13. Our eight ambitions for Dorothy and those like her
Implementing local care
Our eight ambitions for Dorothy and those like her
Our ultimate aim for older people is to support their needs better and stop them going into hospital.
We know that every day in Kent and Medway around 1,000 people are in a hospital bed when they don’t need to be or want to be.
Some of the reasons why older people stay too long in hospital are:
they have to wait for care to be in place to support them going home
they need a social care assessment or an occupational health assessment
or they need a residential home place.
To illustrate how we would like to improve care and treat more people at home, we’ve created ‘Dorothy’, an example patient. By demonstrating what we think her care should look like, we can look at how our proposed model might work.
So imagine Dorothy is 79, and frail. She has type 2 diabetes, Chronic Obstructive Pulmonary Disease (COPD), memory loss and depression. She lives with her husband Bill, who also has type 2 diabetes, and is her main carer.
We have eight ambitions for Dorothy and people like her which are:
helping Dorothy to look after herself
organising her care better
keeping her safe in her home
joining-up the team looking after her
having one number for her to call for help, advice or support
responding rapidly to her at home when she becomes unwell and needs it
making sure Dorothy can get home from hospital quickly and safely
giving Dorothy, her GP and the people looking after her better access to expert advice and faster access to her test results in the community
The following eight slides will explore these further …

14. Localities - 8 Clinical Commissioning Group (CCGs)
Dartford Gravesham and Swanley
Medway
DGS&S
Swale
Thanet
There is a plan for each of the 8 CCG localities for Local Care which has been developed across Health, Care and the Voluntary Sector
Canterbury
and
Coastal
South
Kent
Coast
West Kent
Ashford
Federations - Groups of GPs who have come together with partners to deliver services for populations of ,000
The remit of a GP Federation is generally to share responsibility for delivering high quality, patient-focussed services for its communities. This can include developing services specifically to suit local needs which are more easily commissioned ‘at scale’

15. (Also referred to as Primary Care Networks /Home)
Clusters –
smaller Local Care multi-disciplinary teams (MDTs) based around GP practices for populations of 30,000-50,000. Focussed on working together to deliver Dorothy’s care through MDT working. Some will be based in ‘hubs’- physical buildings to deliver care, others will be virtual. Supporting services i.e. primary care teams, community teams, social care teams, voluntary/third sector.
This will be achieved by the single point of access, an integrated health and social care MDT, liaison with specialist services and other supporting services
Local care already happening in places across Kent e.g. Encompass, Thanet Primary Care Homes
Between now and 2021 all of Kent and Medway having implemented all of care models
Starting in different places
Localities providing services to 30 to 50k
29 in total
Groups 1, 2, 3
(Also referred to as Primary Care Networks /Home)

16. Local Care services -
GP practices continuing to deliver primary care services.
Community health and social care teams delivering care
closer to home supported by the voluntary and care sector,
helping to build stronger communities and developing ways
for individuals to self manage.
Over time, this model will help to support primary care resilience such that GPs will be better supported to care for their local communities. We also will see a reduction in pressure on large acute hospitals, helping us to provide effective and sustainable hospitals services into the future

17. Moderate Relative Risk
Most vulnerable/ frail/ elderly/ multiple co-morbidities
( 5.9% Population)
Relatively fit and
coping with
Health complaint
(16% population)
Generally well
(78% population)
Very High
Relative Risk
MDT working
High Relative Risk
Moderate Relative Risk
Co-ordinated self care
Low Relative Risk
Promoting wellbeing
– Implementing this model in full for those 154,743 people
in Kent could bring;
35% reduction to A&E attendances and non-elective admissions

18. Progress to Date
Detailed Locality plans for investment and implementation of multi- disciplinary teams around GP clusters across Kent and Medway – all at various levels of maturity
Local Care Conference focussing on MDT working April 2018 – 200 attendees across health, care, voluntary, and charitable sector
Getting local care right for the public means health and social care professionals truly working as multi-disciplinary teams (MDTs) - video of MDT poem
What is an MDT?

19. Next…..
Work on “industrialising” care navigation and social prescribing
Estates
Technology
Workforce

20. Lessons Learnt: Above all- Ability to “hold your nerve”
Workforc
Workforce (recruitment, retention, realignment, new roles) –working together strategically on workforce design, education and rotation across acute and community
Governance (data sharing of patient information, IT and confidentiality) – ensuring due diligence is undertaken prior to implementation
WHY?
HOW?
WHAT? OD
Organisational Development and Engagement - the importance of this must not be underestimated; it’s all about the relationships, building trust and having a shared vision, “THE WHY”
Comms
Meaningful communications (internal and external) - it is worth investing time in a stakeholder engagement plan
Funding
Timing and release of central funding in order to be able to implement - for the vanguard delays in release of funds to invest to save had an impact on ability to deliver
Above all- Ability to “hold your nerve”

21. Cathy Bellman,
Local Care Lead,
Kent and Medway STP
Mobile:
Gayle Savage
HUB Development Manager
 Canterbury Local Care Team
   Mobile: