The changes being made

A number of changes have already been made as part of eight central programmes:

Enabling active communities (focusing on prevention and self-care): The area’s comprehensive self-care and prevention strategy includes self-management education and peer support, domestic abuse, persistent alcohol misuse, physical inactivity, breastfeeding, sexual health, child weight management and incontinence.

Services supporting people with lung disease or frailty and those recovering from cancer are now using patient activation measures (PAM) to help people better manage their condition. Patient activation describes the knowledge, skills and confidence a person has in managing their own health and care, and individuals work alongside their local healthcare professionals to better understand their levels of activation through a PAM questionnaire. Around 1,500 individuals completed a questionnaire in the first two years after its introduction, helping them to recognise and develop their own strengths and abilities.

A county-wide social prescribing service is now being delivered by staff in ‘community connector’ roles across all GP practices. The programme also includes innovative cultural commissioning which looks at the links between the arts and health outcomes.

Clinical programmes approach (focusing on transformational change across clinical programmes spanning 13 pathways):

  • A new primary community eye care service has been introduced offering consistent care across the county, including a range of secondary care eye services.
  • A Troponin-T chest pain pilot is showing a substantial increase in the percentage of patients discharged home from the emergency department during the one-hour trial (54%) compared with the control period (30%), leading to a full roll-out of this pathway.
  • An early diagnosis pathway has been introduced following a Macmillan investment of more than £4 million, which includes a GP masterclass programme, a community based ‘living with and beyond cancer’ service, and holistic needs assessments being undertaken in all three cancer site clinics.
  • New integrated commissioning hubs are streamlining pathways across health and social care, for example through the Healthy Homes joint action plan. As part of this plan, disabled facilities grant budgets have been pooled across councils, health and social care resulting in greater flexibility in funding for home adaptations.

One place, one budget, one system (focusing on place-based care and redesigning urgent and emergency care):

  • Place-based care developed rapidly in 2017/18, looking at new models of care delivered across population clusters of 30-50,000. This has included improvements in primary mental health services in an inner city cluster, integrated respiratory services, a new frailty model and a rural frailty and dementia pilot.
  • Proposals for urgent and emergency care are being developed to describe a network of strong, joined-up services to manage and co-ordinate care so that only the sickest patients need emergency department care. The ethos is simpler access to advice, support and services if needed, the right care in the right place, leading to reduced waiting times and less duplication. Subject to consultation, a new model of care would be implemented in 2020/21

Reducing unwarranted clinical variation: The optimising medicines programme, focusing on reducing waste and prescribing the most cost-effective medicines, delivered savings of £3.5 million in 2016/17 and £4 million in 2017/18 whilst also introducing clinical pharmacists into general practice to support a reduction in polypharmacy (patients taking multiple medications, sometimes unnecessarily) and reducing side effects for patients.

Developments across the four enabling programmes (primary care strategy, workforce, estates and a local digital roadmap) have included:

  • Improved access to GP services across all 16 clusters, improving patients’ ability to book evening and weekend appointments. This is providing an additional 40,000 appointments per year.
  • Delivery of a comprehensive primary care workforce strategy and the development of innovative new roles such as practice-based clinical pharmacists, community frailty and dementia nurses, urgent visiting paramedics and mental health practitioners. Quality improvement programmes have also been delivered for general practice to ensure staff are being trained up for future service needs and ensure technology opportunities are maximised.
  • Significant progress in the primary care infrastructure plan in 2017/18, with a number of primary care premises progressing redevelopment plans and two schemes delivering in full. Four further schemes will be complete in 2018/19 resulting in many more patients and staff benefitting from an improved care environment.
  • Mental health services leading the way in the use of the single Joining Up Your Information record. The shared care record will support the delivery of the urgent and emergency care model.