1. Berkshire West Integrated Care System
Programme Overview
November 2018

2. Financial sustainability Enabling infrastructure
Background
The Berkshire West health economy face significant service, workforce and financial challenges that the individual organisations identified were better addressed together:
Financial sustainability
Quality of service
and care outcomes
Enabling infrastructure
Apparent need to meet national targets across all providers
(A&E 4 hours, Delayed Transfers of Care, 2 week cancer waits and 18 weeks RTT)
Deliver Five Year Forward View
Demand for mental health beds and high demand induced delays in referrals to CAMHS, Crisis and home treatment services
Financial platform was not sustainable with all providers and CCGs under increasing pressure
Berkshire West health economy one of lowest funded in UK
Vast savings needed to be made by all organisations
Limited inter-operability between different systems and care services (i.e. lack of a common IT system results in duplication and delays)
Little room for expansion at Royal Berkshire hospital estate
Issues surrounding recruitment and retaining staff at both acute and mental health Trusts due to high living costs and commuting challenges
And the pressure is only going to increase…
The UK population is projected to increase by 3.6 million (5.5%) over the next 10 years
The proportion aged 85 and over is projected to double over the next 25 years.
It is estimated that over 18 million children, adults and older people in England will be living with at least one long term condition by 2025

3. Original founding principles
To enable people to take more responsibility for their own health and well-being
To evolve clinical pathways to be better integrated across providers to improve patient experience.
To move care closer to home, wherever appropriate
To increase the capability and capacity of primary, community and social care to provide multidisciplinary “wrap around” co-ordinated care that efficiently meets the patient’s needs.
To use a population health management approach to better understand the clinical needs of our population and maximise the opportunity to prevent, and to intervene early to reduce the need for more intensive on-going care.
To ensure a high quality, fit for purpose acute and specialist hospital service
To develop a shared Quality Strategy and systems and take a single, system wide approach to the delivery and monitoring of quality.

4. Berkshire West ICS
Made up of the 4x GP Alliances
Working collaboratively to establish a single integrated care system that will help to deliver high quality and sustainable healthcare services for the local population

5. Key objectives for BW ICS
Berkshire West ICS objectives
Enhancement of patient experience and outcomes
Improvement in the health and wellbeing of our population
Making faster progress in transforming the way care is delivered, as set out in the NHS Five Year Forward View, and in particular making tangible progress in urgent and emergency care reform, strengthening general practice and improving mental health and cancer services.
Managing these and other improvements within a shared financial control total and to deliver the system-wide efficiencies necessary to manage the local NHS budget.
Integrating services and funding, operating as an integrated health system, to manage the health of the local population, keeping people healthier for longer and reducing avoidable demand for healthcare services.
Demonstrating what can be achieved with strong local leadership and increased freedoms and flexibilities, and share learning with the wider NHS.
Financial sustainability across the ICS

6. How the ICS fits with wider organisations
The ICS is an important driver for implementing strategies from the STP into action that will result in measurable benefits that will be felt across the system. It also interplays with programmes of work taking place in the wider area and region.
Thames Valley_____________________________
e.g. Thames Valley Cancer Alliance
Thames Valley also sits within NHS England South East that supports the commissioning of high quality services and directly commission primary care and specialised services across Buckinghamshire, Oxfordshire, Berkshire, Hampshire & Isle of Wight, Kent & Medway, Surrey and Sussex. .
Berkshire West ICS
Thames Valley
BOB STP
Berkshire West 10
Buckinghamshire, Oxfordshire and Berkshire (BOB) Sustainability Transformation Partnership (STP)____
Population of 1.8 million,
7 Clinical Commissioning Groups (CCGs)
6 NHS Trusts
14 local authorities
175 GP surgeries
The ICS is a vehicle for delivering service transformation within the BOB footprint
Berkshire West 10____________________________
Royal Berkshire NHS Foundation Trust
Berkshire Healthcare NHS Foundation Trust
Berkshire West CCG (used to be 4x CCGs)
South Central Ambulance Service
3x Local Authorities

7. Programme Structure

8. ICS Governance and Leadership
Berkshire West CCG Governing Body and sub-committees
RBFT Board and sub-committees
BHFT Board and sub-committees
Leadership Team
Delivery Group
Chief Officers Group
BW10 Integration
Enablers
Workforce
Group
Digital Transformation Board
STP Groups
(e.g Prevention)
Unified Executive
Pharmacy
Quality & Safety
Comms & engagement
CFO Group
Joint BW10/ICS
Alcohol
Clinical Delivery Group
PROGRAMME BOARDS & sub groups
A&E Delivery Board
Long Term Conditions
Planned Care
Mental Health Delivery Group
Primary Care
Outpatients
Children’s
(TBC)
Bed modelling
Respiratory SG
Diabetes SG
Falls T&F
MSK T&F
Ophthalmology
(TBC)
(under review following OD session)
(TBC)
TBC

9. 18/19 Strategic Priorities
ICS Strategic Priorities: Key Projects
18/19 Strategic Priorities
Develop a resilient urgent care system that meets the on the day need of patients and is consistent with our constitutional requirements
To redesign care pathways to improve patient experience, clinical outcomes and make the best use of clinical and digital resources
Progress a whole system approach to transforming primary care to deliver resilience, better patient outcomes and experience and efficiency
Develop the ICS supporting infrastructure to deliver better value for money and reduce duplication
Deliver the ICS financial control total agreed to by the Boards of the constituent statutory organisations
Key projects
ED streaming
Urgent Treatment Centre at WBCH
Outpatients Programme
iMSK
Deliver the enhanced access requirements set out by the FYFV and ICS MOU
Develop the ICS implementation plan
Work with Kings Fund to Agree the ICS Vision and Objectives
Credible financial recovery plan for 19/20 and 20/21
High Intensity User project
Demand & Capacity Model for bedded care
Medicines optimisation
Cardiology
Implement networks / neighbourhoods of practices each with a registered population of 30-50k covering the localities in Berkshire West
Progress the workforce projects identified by the ICS Workforce Group
Develop and implement a new contractual form
Progressing transparency of cost information at SLR level
Develop IUC & Launch 111 online
Wellbeing service CPE
Respiratory
Long Term Conditions (Care planning and Integrated Falls assessment)
Strengthen the workforce through better recruitment and retention to support sustainability and expansion of primary care
Agree and deliver ICS comms & engagement programme
Agree blueprint for PHM and implement a solution
Produce a UEC Strategy for Berkshire West
Ophthalmology
Phlebotomy
Develop and work with provider Alliances to provide greater resilience and capacity in addition to enabling the implementation of new care models
Shared Corporate Services
Shared Estates project

10. ICS Strategic Priorities: Benefits & Metrics
Patients being seen in the most appropriate setting
Services located where they are needed which provide care in a timely manner
Fewer patients needing to access on the day services from the acute hospital
Patients to receive more of their care closer to home
Greater reliance on technology to free up clinical time for more complex tasks
Unlock estate capacity through fewer F2F appts
Services provided at a lower cost to the taxpayer
Patients to be able to see a GP 7 days a week from 1st October 2018
Greater resilience and capacity within the primary care sector
Development and deployment of new care models which are more integrated and delivered closer to patients’ homes
Increased public and patient involvement and understanding
New ways of working together to resolve issues
New payment mechanisms
Clear investment programmes based on objectives
Improved decision making to support health
A system that is delivering its financial trajectory
Metrics
4 hour A&E standard performance against the agreed trajectory
Reduced growth in A&E Attendances
Reduced growth in NEL admissions
DTOC performance
NEL and EL admissions per 100k
ALOS (MH, Community & Acute)
Aggregate £ savings from projects
Patient experience measure (to be defined)
Patient outcome measures (to be defined)
Reduction in Out of Area Placements
Workforce bundle metrics (TBC)
Access to GP services including evenings and weekends for 100% population by 01/10/18
Ensuring every practice implements at least 2 high impact “time to care” actions
Proportion of practices that are members of an alliance
Proportion of practices doing care planning through integrated teams
Workforce bundle metrics (TBC)
Presence of a 3 year ‘roadmap’ that delivers the KPIs
Presence of a PHM blueprint
New contract form agreed and in place
Presence of an OD plan
RBFT CT performance
BHFT CT performance
CCG CT performance
System CT performance
Agreed financial strategy in place for 19/20 and 20/21

11. Achievements so far…
Launch of Thames Valley Integrated Urgent Care Service (111)
Implementation of the Connected Care IT platform – shared care record for all patients across Berkshire West
Integrated Pain and Spinal Service - multi-disciplinary specialist assessments and treatments for patients with back and generalised persistent pain.
Design and implementation of new clinical pathways
Outpatients – Advanced Advice & Guidance
Primary care streaming model – evaluated and revised
New ways of doing business between ICS partner organisations
New risk share arrangements and partial system control total
New payment mechanisms
Alignment of incentives
Changed organisational landscape
Merged single CCG
Developed primary care alliances
Working with Local Authorities (i.e. bringing prevention in to ICS agenda)
Embedded clinical leadership through ICS Clinical Delivery Group
OD of ICS Programme Boards – designed to bring out the importance of system working, break down organisational barriers and ensure there are representatives from all parts of the system in key conversations

12. Case Studies: Outpatient Transformation

13. Berkshire West Outpatients Transformation
Old-fashioned model of delivery
Pressures on main acute site and under-utilised ‘satellite’ estate
Opportunities for new ways of working – ICS
Opportunities provided by technology
Many reasons to change
Berkshire West Outpatients Transformation Programme –
50% fewer outpatient appointments on the main acute site
Systematic-ally looking at all activity
Is the appointment value adding?
Can it be done virtually?
Can it be done in primary/
community care?
Can it be done on another site closer to people’s homes?
Can it be done in more flexible estate on the main site?
Multiple workstreams
Triage
Remote monitoring
One-stop shop
Online booking of clinic space
Hub and spoke model
Virtual clinics
Estate re-development – multi-purpose facilities
Patient-initiated follow-up
Consultants in the community

14. Current outpatient pathway
Primary Care
Patient attends appointment with GP resulting in a referral
Referral to service:
Routine
Urgent Elective
2 Week Wait
Secondary Care
Patient attends clinic appointment with specialist:
Nurse
Consultant
Establish Diagnosis & Decision to Treat
Radiology / Pathology etc.
Treatment
A treatment plan is made that may involve onwards referral to another specialist service
Primary Care
Tertiary Care
This is where we can intervene to offer patient-initiated follow-ups, at home or via Skype, telephone, remote monitoring or !
Follow-Up / After Care
Community Care
Patient is seen for follow-up or receives on-going after care within another service
DISCHARGE

15. Evolving landscape for outpatient services
Strategic landscape for outpatients
Workforce
Capacity
Capability
Skills
Technology
Mobile access
Remote monitoring
communication
Patient satisfaction
Brand
Patient experience
Patient engagement
Data
Big data
Performance
Analytics
Quality / outcomes
Contracting
Payment mechanisms
Funding models
Demand
Utilisation pattern
Changes in demographic structure
Integrated working/ Partnerships
Primary care
Secondary care
Community services
Mental health
Challenge: how can we get the best value for
Patients
Staff
Berkshire pound?

16. Current outpatient transformation projects
Physical health checks for patients living with a severe mental illness (SMI)
Development of a Primary Care model to complete physical health checks on people living with SMI and support them in accessing interventions to support lifestyle and behaviour changes.
Key metric:
50% people on the SMI register to have their PH checks completed in Primary Care
Multi-speciality use of DAWN for remote monitoring
Implementation of remote monitoring through the DAWN system into four new specialties: dermatology, neurology, gastroenterology and respiratory.
Key metric(s):
Reduction in clinical hours spent manual checks
Reduction in number of follow up appointments
Advanced Advice and Guidance
To implement an Advanced Advice and Guidance telephony solution to enable secondary care expertise to be provided to primary care – specialities include: renal, respiratory and cardiology.
Key metric(s):
Reduction in elective referrals
Reduction in emergency admissions
Patient Initiated Follow Ups (PIFU)
Putting the patient in control of further rheumatology outpatient appointments for their existing condition, so that they contact the hospital for an appointment depending on trigger criteria.
Key metric(s):
Reduction in waiting times for outpatient appointments
Release of 1500 clinic appointments

17. Case Studies: Care Home Programme

18. Aims of the Care Home Programme
Improve the quality of care to care home residents, by up skilling care home staff and providing clinical support directly in the care homes
Manage the cost of care across the system as a whole, through the reduction in inappropriate NELs, A&E attendances and SCAS contacts from care homes
Review all care home resident medication ensuring appropriate prescribing
Work across the Berkshire West 10 and Berkshire West ICS

19. Care Homes Programme - Successes to Date
Monthly Care home dashboard
Care home website :
Care home red bag :
Online bed availability portal :
Working with Graphnet on Care home residents alerts

20. Care Homes Programme - Successes to Date
Primary Care/GP Provision to care homes pilot
Joint Care home, RBH (Discharge team), Integrated Care Home Team, CHS and SCAS workshop:
- Communication  between the hospital and care home
- Quality of discharges back to care homes
- Reluctance to accept acute  assessments  
- Medications – limited availability of medications in evenings
and weekends
- Family – pressure/expectation from resident families to call
SCAS/999
Care home algorithms (SCAS) - Access to Urgent and Emergency Care