Quality and Place. Our Strategy Transforming health together. Our Strategy

Transcription

1 Quality and Place Transforming health together Our Strategy Our Strategy Autumn 2017

2 Our Values At Bridgewater, our PEOPLE values shape how we deliver our NHS services in your local community. We are: Person centred: We believe in putting people in control, coordinating and delivering services to achieve the best health and care outcomes Encouraging innovation: We want to encourage and embrace new ideas to learn and deliver creative and pioneering improvements in community care Open and honest: We aim to behave in a way that develops relationships based on mutual trust and respect Professional: We recognise and value the contribution of our staff and seek to ensure they have the skills to deliver outstanding care Locally led: We strive to continually develop our knowledge of the communities we serve and work in partnership to respond to local need Efficient: We look to use resources wisely to ensure our services provide value for money and we are a sustainable organisation in the future. We are Bridgewater People 2

3 Contents 1. Foreword Context...5 Bridgewater at a glance...5 Health priorities in our boroughs...6 Influences and risks...9 Future opportunities and challenges...10 How we have developed our strategy Our response: Quality and Place...13 Driving up quality...14 Focusing on place Enabling strategies...21 New service models...21 Continuous improvement...23 Communication and engagement...24 Service line management...26 Technology...27 Workforce transformation...28 Data and information...30 Estate and infrastructure Financial and investment plan Strategic change programme Measuring success and reporting progress Abbreviations

4 1. Foreword Colin Scales Harry Holden The National Health Service (NHS) was created in 1948 steeped in a set of values as important today as when it was founded, free at the point of use and available to everyone based on need, not ability to pay marks its 70th anniversary and these values resonate as strongly today as they did back then, despite increasing demand, an ageing population and a growing complexity of long-term conditions and disease. Demands and pressures are becoming bigger than ever meaning there is a constant challenge to shift healthcare from high-cost, reactive bed-based care to care that is preventive, proactive and closer to people s homes, with a focus on communities and their assets. The pressures facing us and every NHS organisation are greater than they have ever been with clinical and financial sustainability the major challenges as we strive to deliver high quality, financially viable clinical services against a national backdrop of increasing demands and reduced funding. Our strategic objectives make clear our aspiration; they are to: Deliver high quality, safe and effective care which meets both individual and community needs. Deliver innovative and integrated care closer to home which supports and improves health, wellbeing and independent living. Deliver value for money, be financially and commercially successful. Be a highly effective organisation with empowered, highly skilled and competent staff. In 2014, The Five Year Forward View (FYFV) was published by NHS England setting a vision for new delivery models which integrate local health and care provision, tailored to local communities, with holistic person-centred care at the heart of service design and delivery. The introduction of Sustainability and Transformation Plans (STPs) are enabling health and care organisations within an area to develop, improve care, reduce health inequalities, manage their money and work jointly on behalf of the people they serve. They are the chosen vehicles for delivering NHS England s Forward View ambitions. As a Trust, we are taking this opportunity to refresh our thinking and reassert the strategic challenge this changing health policy poses, which includes moving NHS activity away from hospitals to community services in preparation for borough-focused integrated care. As STP ambitions centre on tackling gaps in health, wellbeing, care, quality, funding and efficiency, the proposals in the FYFV seek to support by empowering local people to develop new care models whilst using resources more effectively. They include a commitment to a greater priority on prevention, self-care and working across health and social care systems with our partners to deliver holistic person-centred care. The pace and effectiveness of change in NHS organisations is set by the agility and ability to adapt not only to new ways of working but also mindset. As we move forward into future place-based systems of care, collective leadership and thinking is crucial to our success along with valuing the importance of local people s voices. This is a challenge we embrace, underpinned by a desire to create an approach which responds to needs of local people. Our services operate successfully across many communities in a number of boroughs but to ensure our Trust develops at the pace required we must continue to work with local people and partners across all sectors including the third and voluntary sectors. Therefore, the centrality of staff, people and partnerships will be at the heart of everything we do. The priorities and commitments outlined in this strategy are based on the delivery of high-quality healthcare, investing in our staff and developing collaborative relationships in our boroughs to ensure sustainability across our health and care systems. This strategy articulates why we exist, where we are heading, the expectations and priorities laid upon us. Put simply, we must be single-minded in our ambition to be outstanding and to be an organisation for which people love to work and work with, and one from which people know they will receive great local care. Colin Scales Chief Executive Harry Holden Chairman 4

5 2. Context Bridgewater at a glance Bridgewater service delivery map - October 2017 We are an expert NHS Foundation Trust provider of out of hospital care and one of the largest UK employers of healthcare staff in community settings. Our mission is to improve local health and wellbeing in the communities we serve and we are working with our commissioners and partners to bring more care closer to home to ensure a more sustainable NHS for current and future generations. We provide high-quality community and specialist services to 1,304,500 people living in: Bolton Halton Oldham St. Helens Warrington Wigan Borough Community Dental Network (providing services in all of the above areas (except Oldham) plus Bolton, Tameside, Trafford, Glossop, Stockport and Western Cheshire) The majority of our services are delivered in patients homes or at locations close to where they live, such as clinics, health centres, GP practices, community centres and schools. We also provide health and justice services in a number of prison settings in the North West. As a provider of both mainstream and specialist care, our role is to focus on providing cost-effective NHS care by keeping people out of hospital and supporting vulnerable people throughout their lives. We aim to bring more care closer to home this means providing a wider range of services in community settings to keep people healthier for longer and developing more specialist services to support people to live independently at home. We employ 3,021 staff and have an income of around million which comes from our commissioners, who include Clinical Commissioning Groups (CCGs), NHS England and local authorities. 5

6 Context - Health priorities in our boroughs The population of the North West is living longer and health is improving for many, but not all. As a whole, the North West of England fairs worse compared to the England average for many of the health indicators described in the Public Health England profiles. While a number of these indicators are improving, some are getting worse. Only Warrington records any scores that are better performing than the national average as shown in the diagram below. Headline health issues in our boroughs Lower than the national average of 79.5 for males and 81.2 for females for all our boroughs except Warrington. Life Expectancy Mortality Rates Higher than the national average for cardiovascular disease and cancer in all our boroughs Smoking-related deaths are higher than average for all our boroughs. Smoking prevalence in adults is higher in all areas except Warrington. Smoking Physical Activity Percentage of physically active adults lower than national average of 57% in all areas exept Warrington Hospital stays for alcohol related harm are higher than the national average in all boroughs. Alcohol Diabetes Excess weight in adults is higher in all boroughs. Only Warrington has an under 18 conception rate below the national average. Some boroughs are significantly higher. Conception Information taken from various sources. Latest available figures used in all cases.

7 Key health needs, priorities, population growth and life expectancy in our boroughs Health needs Commissioning priorities Population growth Life expectancy Bolton Heart disease Stroke Maternal and child health Mental wellbeing Childhood obesity Self harm Physical activity Alcohol harm Falls Social isolation Fuel poverty Housing Employment 5 years Lower than average predicted increases in the number of people in Bolton. For those in the most deprived areas of the borough compared to those in the least deprived is: 10.2 years lower for men 10.4 years lower for women Halton Deprivation and child poverty figures Obesity in adults and children Diabetes and cancer related deaths Smoking related deaths Integrated health and social care Harnessing transformational technologies Practice based services Providers working together to deliver improvements in health and wellbeing 1.5% Population growth expected over next five years. For those in the most deprived areas of the borough compared to those in the least deprived is: 11.9 years lower for men 9.3 years lower for women Oldham Supporting people to take more control over their lives, increasing levels of community engagement and so reducing levels of behaviour that are a risk to good health Best Start - improving school readiness through integrated service delivery Work and Health - increasing productivity through health in the workplace Ageing Well Find and Treat programmes 5.2% Population growth expected over next five years. For those in the most deprived areas of the borough compared to those in the least deprived is: 11.1 years lower for men 9.8 years lower for women St Helens Alcohol specific admissions for under 18s Obesity and diabetes in adults Under 18 conceptions Smoking related deaths Giving every child the best start in life Tackling alcohol misuse Promote good mental health and wellbeing Early detection of long term conditions 3.2% Population growth expected over next five years. For those in the most deprived areas of the borough compared to those in the least deprived is: 11 years lower for men 10.5 years lower for women Warrington Breastfeeding initiations Excess weight in adults Alcohol related admissions Cardiovascular deaths Smoking related deaths Growing healthy communities Promoting healthy lifestyles Promoting healthy ageing Improving child health and wellbeing Improving healthy life expectancy Delivering high quality systematic healthcare 6.8% Significant population growth expected over next five years - nearly twice the national average. For those in the most deprived areas of the borough compared to those in the least deprived is: 12.1 years lower for men 8.3 years lower for women Wigan Addressing wider determinants of health and improving outcomes Targeting support on patients with a higher dependency on health services Shift delivery of services from in-hospital to out of hospital Low levels of physically active adults Alcohol related hospital admissions Smoking related deaths Breastfeeding initiations Cardiovascular deaths 6.4% Population growth expected over next five years. For those in the most deprived areas of the borough compared to those in the least deprived is: 11.5 years lower for men 10 years lower for women 7

8 Deprivation levels and population growth Figure 1 - Deprivation levels in Bridgewater's boroughs High deprivation levels are linked to health inequalities, worklessness and high incidences of life-limiting and risky health behaviours, such as smoking and high alcohol intake. Populations in some areas have over ten years less life expectancy than others nearby. In determining the need for community services across our wide geographical footprint, we must understand our current and future population demographics, and the level and acuity of demand this will pose on our services. It will also help us to understand how we need to expand and diversify our service provision to meet the likely conditions and morbidities our population will face. Table 1 below shows borough population changes by age group and gives an overview of the expected population growth to The total estimated population for our footprint across our six key boroughs (Bolton, Halton, St Helens, Warrington, Wigan and Oldham) as at midpoint of 2017 was 1.36 million and 2.76 million for our total Bridgewater geographical footprint. By mid-2022, the population of our six key boroughs is projected to rise to 1.38 million. This represents a growth of 2.1% from which is less than the national average (3.5%) but above the North West average (1.9%). Table 1 - Borough current population profile and future population growth Source: 2014 Subnational Population Projections for Local Authorities and Higher Administrative Areas in England 8

9 Context - Influences and risks The Trust will be exposed to many external influences and risks which will drive the way services are delivered in years to come. Close monitoring and review will be needed and undertaken to ensure alignment to local system changes and health policy. The analysis below illustrates the key external influencing factors and risks that the Trust must consider and be able to adapt to in delivering this strategy. Political Economic Increased financial challenge for the Trust Future commissioning arrangements i.e. role of Joint Commissioning Boards and Strategic Commissioning Functions (SCF) Lack of coordination across clinical and political leadership when setting commissioning strategies Patient choice and NHS constitution Impact of integration with and across social care Minority government and confidence and supply agreement Rate of economic recovery Post Brexit impact Risk to sustained transformation programme within current resources Continued impact of reduced funding, ambitious Cost Improvement Programme (CIP) and Quality, Innovation, Productivity and Prevention (QIPP) targets combined with increasing levels of inflation Fragmented commissioning budgets across health, social care and wider public services Increasing demands e.g. ageing population and long-term conditions Reduction in Local Authority provision of Social Care services Sociological Technological Demographic changes and impact i.e. ageing population People dependent on services for their long term health and social care needs; services don t fit around their lives Poor deprivation scores across all boroughs Increased emphasis on community based preventative healthcare/self-management Increased choice for where care is received e.g. in community, at home etc Growing culture of assertive consumerism with increasing expectation New IT solutions: People powered technology e.g telehealth/telemedicine Alignment and sharing of information across IT platforms Greater access to the internet, apps and remote assessment Availability of new drugs to support conditions and disease Diagnostic/service capability i.e. opening up opportunities for delivery of more services/diagnostics outside the acute hospital sector Innovation to support care delivery and staff mobilisation e.g. Electronic Patient Records (EPR), agile working Home/office security and reliability Maintenance hardware/communications network/software Legal Future organisational legal status i.e. Accountable Care Organisations (ACOs) / Accountable Care Partnerships (ACPs) EU Working Time Directive impact Changes due to reversion to UK law Regulatory environment i.e. regulatory checks, CQC, NICE guidelines, governance etc. Potential future changes to staff terms and conditions Changes to drug and equipment licensing between EU and UK Environmental Estates i.e. expectations and requirements Investment in smart buildings control systems Lack of space for co-location of services Corporate responsibility to environmental factors e.g. carbon footprint, recycling etc. Increasing utility costs 9

10 Future opportunities and challenges Populations are growing with people living longer creating unprecedented demand on NHS services. With increasingly high expectations of NHS services by all and the complexity of local people s health, we know the real test this poses today and can foresee the serious challenges for all health and social care in the future. Much more is now expected of us on all fronts set against a backdrop of rising costs and the need to continually invest in innovation and technology. Without radical change to the way we and the health and social care system works, we know that as demand and costs rise we will be clinically unsustainable and financially unviable. Partnerships and collaboration in a place-based system of care presents a key opportunity for ourselves and others to come together to tackle these increasing pressures. It means all NHS, Social Care and Third Sector partners working differently as we pursue the greater good of serving our populations. It will require the involvement of all to encourage and support more integrated approaches to physical, mental and social wellbeing. Crucially, services will need to be collectively redesigned across service boundaries whilst enabling systems of care and leadership to evolve rapidly. However, with no blueprint for how this should be done, there will be many barriers to overcome to ensure all parties can mutually agree on a way forward. Opportunities to learn from others ahead of us in this process will offer insight and ways into how this can be done which we can subsequently adopt. Relationships in place offer huge opportunities and benefits as we develop our journey into place-based care systems particularly those within our communities. In all boroughs, we have a real opportunity to contribute to creating asset-based areas. This can be achieved by developing strong and inclusive communities focused on what individuals, families and communities can, or could do, with the right support, rather than focusing exclusively on failings and problems. As such, we must uncover what can be created as a whole and as partners. We will see individuals and communities as positive assets and not just disabilities, conditions, diseases or simply problems. Commissioning moving forward will present additional opportunities in both our relationships and the way we are commissioned to deliver services in the future. As both strategic and integrated commissioning is introduced, we should see an end to short-term contracts and the introduction of performance measures which are jointly owned and shared. For example, in the FYFV Next Steps acute hospitals, local authorities and community services are encouraged to work together as a system jointly owning the challenge of freeing up acute hospital beds. As a system, all parties will be responsible for this outcome and Trusts like Bridgewater will play a vital role. Commissioning decisions taken at a locality level by a single, small and strong Strategic Commissioning Function would be a key enabler to achieving this type of system working. This is evolving in the review of commissioning across Greater Manchester (GM). Principally, we know there will be opportunities for different types of conversations with our partners and commissioners and we welcome this. Accountable Care Systems will provide a platform to move away from cyclical tendering and competition to one of increased collaboration and partnerships due to the way we see commissioning changing in the future. With a more strategic role for Commissioners in the coming years, ACSs will take on in part both a commissioning and providing function and will be expected to have an in-depth understanding of communities, risk stratification and prevention. Incentives to do this should be aligned so that activity is delivered for the system as a whole with a rebalance of health resources. Indeed, we will be seeking sustained investment in frontline community services in order to deliver health changes. For our staff, we need to acknowledge that this is a time of change when they might be unsure of future expectations. Therefore, we must listen, support and continually engage so our staff are very much part of this journey. The strategic priorities set out in this strategy and the effective delivery of these will ensure we are ready to embrace the opportunities. Contracting and funding in the short term, is unlikely to change and whilst we recognise that there needs to be a transition to population budgets, the challenge for us is to continue to work together through the existing barriers to develop integrated health and social care services. 10

11 Context - How we have developed this strategy In developing our strategy we have listened and involved staff, governors, local people, partners and communities in all our boroughs and have used the nationally acclaimed National Voices and their six principles (figure 2) as the organising framework for doing this. We have done so because we recognise that developing a new collaborative relationship with local people, carers, third sector and our communities is crucial to our success and is fundamental in how we deliver integrated community-based services in the future. Taking this inclusive approach and involving people in creating our strategic direction is vital to harness creativity and ownership for health and care delivery at a borough level as we continue to adapt to the changing landscape of health and social care. By engaging in this way, we understand and recognise that whilst people do not have to be involved in every aspect, it is important to respect and acknowledge that people have a voice. Figure 2 - National Voices six principles For those that preferred to engage in other ways, we also created an online conversation over a 24/7 platform for adults and young people and visited local people in their community setting e.g. schools, colleges, Children s Centres, GP surgeries and local events. The engagement programme was designed by staff, engagement champions, governors and local people and set out to understand each borough s responses to a series of strategic questions focused on how community services are developed now and in the future. The questions also considered how Bridgewater could adapt at both a borough and system level. A multi-channel approach to communication and engagement was created to develop a variety of listening and feedback opportunities across each of the boroughs. Three clear questions The face to face and online engagement exercises focused on three key questions in relation to individuals, their friends, family, community connections and the health and care partnerships across boroughs and asked: 1. How can Bridgewater make sure that community healthcare for you and your family is the best it can be? 2. What could Bridgewater do to be a stronger part of the community in the future? 3. How could Bridgewater join up and work better with the hospital, local council, mental health services and the voluntary sector? By focusing on these three elements we were able to identify those things that mattered most in each borough and were able to get under the skin of the critical issues people specifically cared about. Place Based Conversations During the summer of 2017, our staff, local people, carers, health and care professionals, partners and community-based leaders came together in each borough as part of a Big Conversation to influence and shape the development of our strategy. Concentrating on and talking about what people cared about locally was meaningful in many ways to understand the differences in help, care and support available in our boroughs and how experience depends not only on where you live but what part of the system you come into contact with. 11

12 Ensuring there was sufficient opportunity to give feedback, ask questions and listen to these stories was critical in the design of these events and this was positively felt through the event evaluation with 100% of attendees agreeing or strongly agreeing that that was the case. 98% of participants said they felt that the conversation design was just right. Staff, public and community perspectives were intentionally brought together as a borough rather than separating out contributions from different groups because as we look forward to future accountable care systems, what we do and how we do it in place is paramount. The insight and intelligence gathered at each event has been presented collectively as a story of future healthcare delivery and resulted in a better understanding, new connections and a network of collaborators in our communities. It is important to emphasise the difference in this approach from our previous engagement efforts. Collective leadership has been promoted at every level from our public governors, strategy leads, communications team, innovation team and clinical leads. Learning from each other and hearing what works, in order to build public and community engagement as a core activity for the organisation, is an important feature of the work we have embarked upon. Furthermore, our governors have been with us every step of the way, relishing the inclusivity of this approach; whilst we have all benefited from their experience, local knowledge and connections made. The benefit of governors as critical friends throughout this process has been invaluable as they have guided us with the voice of local people helping to identify the best ways and means to speak back. Governors will continue to work with us developing engagement opportunities to build relationships in our boroughs as well as helping us deliver this strategy. They will also play a part in holding the Trust to account for delivery. Public and community engagement is a key strategic priority and is central to our strategy development. It will become the norm and be part of our everyday work, not a periodic collection of views and will be an integral part of our success in adapting and developing to meet the challenges in health and social care. 6 place-based events 4 staff events Online responses college roadshows social media = Over 500 responses from people to help shape our strategy Key themes people told us about were: Better Engagement; prevention; technology; coordinating care with other partners. 12

13 3. Our response - Quality and Place Our analysis indicates that the Trust operates in a diverse and challenging environment supporting a range of communities and their differing needs and is working closely with stakeholders in each of the different health economies to develop sustainable services. Whilst there is an expected level of variation between their approaches, at their core the focus so far has been on: 1. Empowering and educating patients, service users and carers to make informed decisions about their health. 2. Developing services that have the patient at the centre of the care process. 3. Developing integrated services that deliver the right care, first time. The challenge for the future in every health economy in which we operate is to reduce the costs of care. This has a particular focus on preventing unnecessary hospital admissions, reducing duplication and fragmentation and joining up health and social care. In order to achieve this, there is a stated strategic commissioning intent in every local health economy to shift care out of hospital into community settings Our assessment indicates that there are a set of four key themes for the Trust to focus on and progress: Our intent is to be an outstanding and sustainable community healthcare organisation where we are: Trusted: staff love to work with us and people love their care. Connected: staff are empowered to provide the best possible care and people are encouraged to take control of their wellbeing. Respected: relationships are developed and nurtured so that we are the partner of choice. Inspired: creativity and learning are embraced so we are always fit for the future. In pursuit of that vision we have identified four strategic ambitions: Strategic ambition High Quality Collaborative & Innovative Being Sustainable Confident, Engaged People Delivering high quality, safe and effective care which meets both individual and community needs Delivering innovative and integrated care closer to home which supports and improves health, wellbeing and independent living Delivering value for money, be financially viable and be commercially successful Being a highly effective organisation with empowered, highly skilled and competent staff. Our strategy can be summarised simply in the following diagram. Key theme Drivers 1. Place Based Organisation Nature of competitive landscape dictates that not all providers can continue providing all services (lots of services with low volumes). 2. Collaboration Clear collaboration opportunities identified at place-based level as well as at functional level to strengthen our service offer and delivery 3. Quality Ongoing need to reduce unwarranted variation in every borough in which we operate Systems are shifting to focus on quality improvement driven by national policy focusi 4. Trust Brand & Reputation Nature of competitive landscape dictates that differentiation will be key Increased importance of patient choice and feedback Stakeholder knowledge as accountable care models develop. 13

14 6. Strategic priority one Driving up Quality Ensure a zero harm approach that drives the Trust s culture Our big quality idea is to reduce unwarranted variation in care by ensuring a zero harm approach that drives the trust's culture. This is a significant and stretching challenge that will involve three core paradigm shifts: 1. Training staff to adopt a person-centred approach to reporting of harm, supporting the development of patient safety improvements. 2. Increasing skills and capacity to analyse and interpret data at team, service and Trust-wide levels to support a culture of shared learning from incidents. To achieve this we are setting ourselves a triple aim outlined below - focused on patient safety, clinical effectiveness and patient experience. We will embed and use national strategies and frameworks for all clinical staff to drive improvement in the quality of patient care and outcomes. By adopting these frameworks we will make 10 commitments to help us focus on narrowing the three gaps identified in the FYFV to address unwarranted variation and help demonstrate our triple aim outcomes. 3. Promotion of what good quality healthcare looks like in each service and celebrating success in delivering good outcomes. 14

15 The 10 commitments are 1. We will promote a culture where improving the population s health is a core component of the practice of all clinical and care staff 2. We will increase the visibility of clinical and care staffs' leadership and input in prevention 3. We will work with individuals, families and communities to equip them to make informed choices and manage their own health 4. We will be centred on individuals experiencing high-value care 5. We will work in partnership with individuals, their families, carers and others important to them. 6. We will actively respond to what matters most to our staff and colleagues 7. We will lead and drive research to evidence the impact of what we do 8. We will have the right education, training and development to enhance our skills, knowledge and understanding 9. We will have the right staff in the right places at the right time 10. We will champion the use of technology and informatics to improve practice, address unwarranted variations and enhance outcomes. The key elements of our triple aim are: 1. Patient Safety Patients will receive care and treatment that is safe and does not put them at risk of harm that could have been avoided. Staff must have the qualifications, competencies, skills and experience that keep patients safe and free from harm. We will achieve this by: Reducing the number of moderate harms and above. Increasing the number of near miss reporting. Being open with every patient that receives harm and apply Duty of Candour for patients that have received a moderate harm. We will enable this by: Providing ongoing education and training around risk management principles and methodology. Providing ongoing Duty of Candour training. Providing incident and risk reports to teams so they can use their data for quality improvement work. Providing quarterly lessons learned newsletters to disseminate across the Trust. 2. Clinical Effectiveness We want to provide the highest quality services that are viewed as excellent by all. We also want to provide effective services with the right outcomes for our patients. Clinical effectiveness is thinking critically about what you do, questioning whether it is having the desired result and making a change to practice if required. It is based on evidence of what is effective in order to improve patient care and experience. Clinical effectiveness is about doing the right thing at the right time for the right patient and is concerned with demonstrating improvements in quality and performance: The right thing (evidence based practice requires that decisions about health care are based on the best available, current, valid and reliable evidence). In the right way (developing a workforce that is skilled and competent to deliver the care required). At the right time (accessible services providing treatment at the point of need). In the right place (location of treatment / services). With the right outcome (maximising health gain and use of resources). 15 "We want to provide the highest quality services that are viewed as excellent by all."

16 We will achieve this by: Developing our quality processes to ensure that the gains we have made in improving services are monitored and maintained Embedding processes to facilitate an evidencebased approach to clinical delivery Ensuring effective and efficient use of resources that will improve outcomes by standardising practice and reducing any unwarranted variations in care Taking corrective action where necessary and monitoring outcomes. We will enable this by: Developing the Trust quality dashboard Developing a framework of quality indicators at team level to monitor quality assurance Providing a refreshed approach to Quality Visits Developing an annual clinical audit plan to ensure clinical effectiveness is being appropriately measured and monitored incorporating NICE quality standards Delivering against contractual quality standards including the Commission for Quality and Innovation (CQUIN) payment framework Developing systems and processes that will drive innovation and quality improvement in clinical services and delivery.eg. Medicines Management and End of Life care Participating in national initiatives that aim to reduce harm and variations in care including falls, pressure ulcers, venous thromboembolism and catheter-associated urinary tract infections Implementing Clinical Supervision framework to support staff development Supporting the aim of preventing avoidable deaths by reviewing all deaths and where it is found that lessons can be learned, sharing them across the organisation Participating in national initiatives and also developing local systems to monitor clinical staffing requirements. 3. Patient Experience We understand that how healthcare is experienced can be just as important as what treatment people receive and that enhancing patients' experience can positively influence outcomes. We aim to develop a culture of partnership working; improving patient and carer involvement and engagement; listening and learning from their experiences in order to continue to develop services that are of the highest quality, where the slogan nothing about me without me is truly reflective of the way we work and communicate at every level of our organisation. We will achieve this by: Providing opportunities for patients and public to be actively involved within the Trust Using patient surveys and promote the use of the Friends and Family Test to understand what service users think about the services we deliver and use the results to improve care Promoting a culture where patients are encouraged to share any questions and concerns Ensuring we have effective mechanisms to respond and resolve complaints. We will enable this by: Providing education and training e.g. Duty of Candour Producing patient experience reports Providing a forum i.e. the Complaints Group with active patient representation to oversee and monitor the complaints handling process within the Trust Presenting patient stories at Trust Board meetings Ensuring shared learning from complaint outcomes are disseminated throughout the Trust. 16 "We understand that enhancing patient experience can positively influence outcomes."

17 7. Strategic priority two Focusing on Place Internal integration organised by place The next five years will be a time of change for the Trust and the whole of the NHS as we look to become part of an Accountable Care System (ACS) in each of the boroughs we operate. In an ACS, local NHS organisations, often in partnership with local authorities, work together in an integrated health and care system with collective responsibility for resources and population health. Accountable Care Organisations (ACOs) are similar to an ACS i.e. an organisation of healthcare providers that agrees to become, or is committed to becoming, accountable for the quality, cost, and overall care of a group of patients in a given place. However, despite the similarities, the major difference between an ACS and ACO is the development and introduction of a single contract with a single organisation for population health in an area. In mid-2017, the first designated ACSs were announced nationally with the potential for more coming together in the near future. In relation to ACOs, no single model or exact organisational form currently exists although some NHS and Social Care colleagues are progressing well and are further along than others e.g. Greater Manchester (GM) and Northumberland. Locally, across our boroughs, we are seeing an alignment of the vision and values that will underpin the delivery of accountable care and population health. The challenge for Bridgewater is to prepare ourselves now by organising ourselves in place developing borough structures, delivery and partnerships. Delivering integrated community services through place-based systems of care as part of an ACS presents a real opportunity for Bridgewater to demonstrate the Trust s significant strategic, clinical and operational experience and commitment to joining up health and social care delivery across our boroughs. In some boroughs, Bridgewater will be involved in more than one system of care i.e. GM and Cheshire and Merseyside (C&M) due to the wide geographical spread of services. This will create an additional challenge of managing capacity and effectiveness across systems. Therefore, it is important to work together with partners to find sensible and intelligent ways of achieving this as clinical and service integration matters initially rather than organisational integration. Moving forward we know across GM that all localities have already produced locality plans which describe how health and care will become more integrated, creating the conditions for the development of ACSs or ACOs. Using our experience In Wigan, the Healthier Wigan Partnership (HWP) has been established and is moving quickly, by April 2018, to develop a formal Alliance which will strengthen and formalise relationships between providers. Bridgewater has played its part in shaping the governance to support this new Alliance, which will, when launched, begin to operate as if managing a pooled health and care budget. Rather than being prescriptive on organisational form, partners across the system will use local insight and understanding of what could work in a place and how practically partners can work together to tackle shared local health and efficiency challenges. 17 We are therefore in a unique position to share our experience and learning from GM to help accelerate the concurrent development of ACSs in Cheshire and Merseyside.

18 Figure 4 below describes the focus needed to deliver a population-based health system. To tackle these growing challenges requires a fundamental shift across the system to one not centred on hospitals but on integration at every level focused in the community promoting self-care and prevention. It will demand a new way of commissioning as well as strong relationships and collaboration amongst clinicians along with accelerated system frameworks such as shared care records, access to data and joined up risk stratification processes. In addition, a new way of commissioning between our Local Authorities and Clinical Commissioning Groups is needed with shared health outcomes, budgets and longer-term contracts to encourage all agencies to work better together as a system. New commissioning outcomes must focus on what is important to people and genuinely develop meaningful people based outcomes. Figure 4 - Focus on population health based systems (King's Fund 2015) Transforming out of hospital care Community services play a large role in NHS activity across our boroughs meaning we are well placed to move more care from hospitals closer to people s homes, changing reactive care to prevention based on earlier intervention. The case for transforming out of hospital care is clear, as the NHS can no longer afford to use existing models of care. Without a fundamental change to current systems, there will be insufficient resources to meet future demand as the health needs of people in our boroughs continues to change and more are living longer. Intervening earlier, coordinating care and improving the community services we deliver is the best way to transform the health system, so it moves away from one dependent on hospital services with unnecessary admissions. A core part of the vision described in the FYFV involves acute hospitals, primary, community and social care becoming more closely integrated in the face of rising demand and shrinking resources. It also seeks to ensure better prevention and care closer to home with care delivered as a result of better conversations with people. National Voices is a coalition of charities that stand for people being in control of their health and care and regard these better conversations as care planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes. Increased person-centred coordinated care develops from these conversations and is not about processes or frameworks; it s about people viewed as equal partners involved in the planning and delivery of their care, in line with their preferences and needs. Key priorities required to achieve this are: We will keep a real focus and importance on people and place and what needs to be devised locally with insight and knowledge from those who know what will work across boroughs. We will localise delivery and structures in boroughs across our workforce where reasonable and centralise where necessary. We will support positive risk-taking and permission-based working, with our staff liberated to demonstrate innovation and creativity on a daily basis sharing our learning across the Trust. Responding to the challenges described in the FYFV, NHS England established 44 footprints which mirror the route people take to access local care systems and each has developed STPs. Bridgewater is an active partner in this delivery and ambitions and is working closely with and supporting the workstreams developed in both the Cheshire and Merseyside and Greater Manchester local delivery plans. Going forward, Bridgewater will continue to work together to make the FYFV a reality with long-term sustainability in our boroughs and to ensure we remain an active partner in the development and delivery of these local plans. 18 "This requires a fundamental shift across the system to one not centred on hospitals but on integration at every level focused on the community."

19 For example, Ambulatory Care Sensitive Conditions are those conditions where effective joined-up community care and case management can help prevent the need for hospital admission e.g. chronic obstructive pulmonary disease (COPD), cellulitis and urinary tract infections (UTIs). As such it presents a real opportunity to target a joint response in people s homes and communities as it is known that over 50% of the required reduction in emergency admissions could be managed through more streamlined and integrated pathways of care. Potential savings (based on average PBR tariff) are forecast to be 14.8m by 2021/21, an average of 3.7m per annum. Our approach to leading on the delivery of these savings in Warrington, Halton and St Helens (and also making a contribution in other towns) will be to establish the core components of an out of hospital model and secure the necessary investment in each borough in order to deliver the strategic shifts from current hospital-based activity to the community. Whilst the financial drivers demonstrate a huge incentive for such change, the motivation for providing better quality treatment and care across health and care providers is an even greater incentive. Uncoordinated healthcare services fail people in many ways. They lack ownership and understanding for the whole person, are condition specific and contain fragmented processes including poor communication between providers and people resulting in disjointed services. Our community model of care Figure 5 describes the essential key components needed to drive a high performing and fit for purpose health and care system that delivers a joined-up, person-centred, asset-based and resilient approach. Partners across each of the boroughs along with Bridgewater have a wealth of experience, knowledge and expertise in developing out of hospital services which aligns with each of the four quadrants in the model of care. In future community services will be closely connected to all parts of the health and social care system and no longer delivered in silos as Bridgewater becomes involved at an earlier stage in the treatment and care of local people in their journey through the system. Partners must work better together to provide support at home and earlier treatment in the community to prevent people needing emergency care in hospital. Recognising the need for the whole system to come together, sign up and share the outcomes of delivering out of hospital care, we see ourselves as a key lead for developing this across our boroughs. Figure 5 - Our Community Model of Care 19 "Over 50% of the required reduction in emergency admissions could be managed through more streamlined and integrated pathways of care."

20 To support this priority: We will encourage our staff to be positive, courageous and accountable in the way they deliver their services to local people. We will drive continuous improvement and innovation creating joined-up services that offer an alternative to hospital stay to deliver better health outcomes and value for money. We will work in partnership to develop integrated services wrapped around primary care and reduce the complexity of services to ensure we meet the needs of individuals in our boroughs. We will play a lead role in redesigning pathways of care working in partnership to develop multidisciplinary teams to proactively manage high-risk patients. We will support the prevention plans and priorities of our boroughs within GM and C&M and contribute to self-care/management approaches and a reduction to health inequalities by keeping people healthier for longer. Specialist Services Our specialised service portfolio Dental and Health & Justice - will remain important to us. Place based working will impact these areas much less than our other service portfolios and we will therefore focus on three objectives in relation to these functions: We will keep a real focus and importance on people and place and what needs to be devised locally with insight and knowledge from those who know what will work across boroughs. We will localise delivery and structures in boroughs across our workforce where reasonable and centralise where necessary. We will support positive risk-taking and permission-based working, with our staff liberated to demonstrate innovation and creativity on a daily basis sharing our learning across the Trust. The core of what we will do in relation to these specialist services will be ensuring an effective clinical service delivery strategies are in place for each business operation. Our service line management programme will help to identify areas for redesign and improvement within each of these two business operations. 20 "We will support positive risk-taking and permission-based working, with our staff liberated to demonstrate innovation and creativity."

21 4. Enabling strategies 1. New service models Asset-based delivery Improving the health of our local communities requires changes in behaviours and living conditions across our boroughs. It also means that accountability for population health is spread widely across these communities, not concentrated in single organisations or within the boundaries of traditional health and care services. Across all boroughs, we know that there are a wealth of undiscovered and untapped assets, skills and experience. To underpin our clinical delivery model we will adopt Asset Based Community Development (ABCD) - a different and influential approach to developing communities and the people in them. We will focus on the assets within communities, rather than its deficit and what s missing as a basis for development. These will include the skills of local people and volunteering, the insight of local community groups and associations, the use of community buildings, outdoor spaces and the appreciation and understanding of the idiosyncrasies, cultural and religious norms in a given community. Asset-based practice will help us promote and strengthen the influences that support good health and wellbeing, protect against poor health and inequalities and helps sustain the health of local people and their communities. Taking this approach will support the design and delivery of future models of care, devolution and the need for problems and solutions to be resolved locally as well as supporting financial sustainability due to the increasing demand for healthcare services. We know partners in some of our boroughs have already adopted an asset-based approach to prevention, self-care and how they deliver services in communities e.g. The Deal in Wigan. As a Trust, we must understand our contribution to this asset-based approach and work with partners to maximise and share volunteers as community assets to help local people reduce their reliance on health and social care services. We will do more by working together in place, reducing red tape and enabling things to happen. We will go further, working with our staff to understand and identify ways local people can contribute and how we can help them become part of the Bridgewater family not as substitutes for our highly skilled staff but as partners in our local service delivery. We will treat our volunteers as equals with a vital contribution to make to their own health as well as the health, care and wellbeing of our boroughs. In essence, we will work in new ways which will mean taking risks and breaking away from the normal operating roles as we become more innovative and agile in our approach. As a result, we will contribute to increasing people s ability to look after their own health, be independent and create stronger and more connected communities. Initiatives to support this priority include: We will work with partners and local people building on the progress of our partners (Community Connectors, Community Knowledge Workers, Practice-Based Community Link Workers and Wellbeing Officers) to understand the range of assets and resources across our boroughs developing trust, robust partnerships and collaboration opportunities for future integrated service delivery. We will train and support our staff to have a different conversation with patients and local people based on the promotion of their strengths and assets and those within their community. We will work with our partners, local people and communities connecting people with community solutions and contribute to the development of community capacity across our boroughs. 21

22 We will work in partnership to promote the Trust s volunteering function and develop our approach to Patient Partners contributing to an increase in level and diversity of volunteering effort in our boroughs. With our staff we will identify roles to maximise and share the use of volunteers as community assets to help local people reduce their reliance on health and social care services. Prevention, self-care/management approaches By integrating a range of wider health and care support, including the voluntary sector and community capital, we know the needs of local people and communities can be more effectively addressed. We are ideally placed to support the prevention agenda and delivery programmes emerging from the Cheshire and Merseyside STP and the Greater Manchester Plan and has much to offer local people and communities. By closer working with our boroughs, we will ensure services are designed around the emerging needs of our boroughs and their health challenges. Our workforce is a sizeable asset and is ideally placed in the heart of local communities as part of our teams or as a resident themselves. Across Cheshire & Merseyside, three STP prevention schemes have been prioritised and will be delivered at a locality level including Alcohol Harm Reduction, High Blood Pressure and Antimicrobial resistance whilst in Greater Manchester the focus is on starting, living and ageing well with more people looking after themselves and each other. We will work with our partners to develop our contribution to these and other borough priorities. In delivering services directly to local people, our staff are highly skilled and can promote public health self-care messages to those they come into contact with, to encourage them to make positive changes in their lives. It is recognised that levels of health literacy across our boroughs is poor and so we will contribute to improving population health literacy by increasing practitioner awareness of the challenges faced by people. In doing this, we will mobilise the entire patient facing workforce towards a contribution to better health for all. We will ensure patients, families and carers are involved in discussions about their care in doing so eroding the notion of health professionals doing to or for people. In Warrington, the Expert in Me network promotes shared decision making and aims to raise awareness of the importance of good health and care conversations in a conversational style which encourages and enables people to be fully involved in decisions about their health and care. Our partners in Warrington e.g. Warrington CCG, Health Watch, North West Boroughs Healthcare NHS Foundation Trust, voluntary and community sectors, individuals, peer support groups and the Local Authority are all part of this innovative network. There is a strong and growing body of evidence that shared decision making approaches as exemplified in the Expert in Me delivers a better patient experience, involvement for patients and staff and self-management of people s illnesses and conditions. Person-centred coordinated care is fundamentally based on collaborative and respectful partnerships between people, families, professionals and organisations. It is not a series of tick-box type, fixed requirements such as co-location, buildings and sharing of data, as it requires much more in its approach to fundamentally shift the culture, attitude and power base for people and ourselves. Initiatives to support this priority include: We will support people to be in control of their own lives and contribute to borough initiatives to encourage people to become more health literate, self-monitor and manage their treatment and care. We will promote health and healthy lifestyles in our day to day interactions with local people contributing to the prevention agendas in our boroughs. Staff will be trained and supported to deliver preventative messages and signposting in their boroughs to change behaviours that have a positive effect on the health and wellbeing of individuals and communities. We will develop person-centred approaches in our clinical delivery e.g. shared decision making and invest in training our clinical front-line building on existing programmes in our boroughs e.g. Expert in Me. 22 "Person-centred coordinated care is fundamentally based on collaborative and respectful partnerships."

23 Enabling strategies 2. Continuous Improvement Quality, wellbeing, finance The NHS Five Year Forward View (FYFV) is the national plan for improving services in the NHS in England. It set out a vision for how NHS services need to change to meet the needs of the population, and argued that the NHS needs to make improvements in three main areas: 1. Improving quality of care. 2. Improving the broader health and wellbeing of the population. 3. improving financial efficiency. Since then, sustainability and transformation plans have been developed across England to provide more detail on the local changes needed to make this vision a reality. These plans are intended to be the delivery plans for the FYFV. The plans are broad in scope, proposing changes in all parts of the NHS by They also call for major improvements in NHS efficiency typically at well above the rate of improvement achieved in the recent past. A national framework to guide action on improvement capability building and leadership development in NHS services in England has also been launched. Our CQC inspection made clear that we need to drive up and then maintain standards of care. In addition, the current climate means we need to focus on improving quality - safety, effectiveness and experience of care - and delivering better-value care. Quality improvement in our Trust will mean the use of methods and tools to continuously improve quality of care and outcomes for people and it will be at the heart of our plans for redesigning services as we believe that there are many opportunities for the Trust to deliver better outcomes at lower cost (improving value). To deliver the changes that are needed to sustain and improve care, we will need to move from pockets of innovation and isolated examples of good practice to organisation-wide improvement. A major focus will be on the development of our first ever Continuous Improvement Strategy during 2018/19 We are making ten commitments to support the establishment of continuous improvement within the Trust, which include: 1. We will ensure quality improvement is a leadership priority for the board. 2. We will ensure shared responsibility for quality improvement with leaders at all levels. 3. We will develop the skills and capabilities for improvement. 4. We will have a consistent and coherent approach to quality improvement. 5. We will use data effectively. 6. We will focus on relationships and culture. 7. We will enable and support frontline staff to engage in quality improvement. 8. We will involve patients, service users and carers. 9. We will work as a system partner. However, the potential benefit will be even greater when quality improvement techniques are applied consistently and systematically across the organisation. 23

24 Enabling strategies 3. Communication and Engagement Engaging our communities We need to up our game to transform how and what we need to communicate with our stakeholders including our own staff, local people, partners and the wider community. Much of the feedback when setting our strategy is consistent with the general direction set out by the FYFV, including the need for more focus on communications to support the development and delivery of place-based integrated health systems which support genuine involvement of local people. At the same time we must not lose sight of our responsibilities as a statutory body to ensure clear Trust-wide communications for our community of staff, local people and stakeholders which clearly set out expectations, accountabilities and priorities. The financial demands on the NHS mean that budgets have been scaled back for communications in recent years, but as we enter into a period of unprecedented pressure and change, never has the requirement for clear, planned and co-ordinated communication been so great. The dichotomy posed by the need for a global Trust-wide approach in parallel with a specific borough focus to communications in multiple boroughs is likely to prove challenging. The specific actions which will be identified in the strategy delivery plan will require investment. Moving away from our traditionalist approach by creating new conversations and relationships in each of our boroughs means we also need to invest in communications and engagement to build collaborative relationships with local people, members, carers and partners. During this time of enormous and unprecedented change, building relationships and increasing Trust visibility will be more important than ever. In order for this strategy to be clear and understood by all of our staff, partners and people it is crucial that we work together to design a compelling narrative that can be shared in meaningful ways across Bridgewater. To do this, we will work with local partners to design the narrative to help understand the rationale, see the benefits and understand their contribution to the delivery of a locally owned plan. Part of this narrative will describe the anticipated patient experience, outcomes and importance of appropriate clinical interventions and how they will contribute to more efficient, clinically sound person focused approaches described in this strategy. In line with the local STP approaches, it will also be crucial to strengthen and improve the close working relationships between internal communications staff, organisational development staff and human resource partners across boroughs. Engagement will mean listening, empowerment, involvement, co-production, consultation and research. It will involve a process of working together with people, carers, governors and other partners to design and develop services and the Trust s future plans. Feedback across our boroughs was consistent - engagement is a key priority and so it will be the responsibility of everyone working in the borough to engage by creating and strengthening relationships rather than the sole responsibility of our dedicated communications and engagement resource. However, we will need to add dedicated resource and expertise to these efforts. This will support staff in the boroughs bolstering efforts to develop a wide range of relationships and connect staff, local people and organisations together in our borough specific and facing relationships. Therefore, Bridgewater s approach to engagement and relationship development will go far beyond just consulting local people, partners and communities. It will lie at the heart of the services we provide and will be central to service delivery in our boroughs. By investing in all relationships to promote collaboration and integrated working the Trust s profile and visibility will increase along with improved quality and service delivery and better coordination of engagement across our boroughs. 24

25 We have six key communication priorities: 1. Implementing a revised operating model so that communications is an integral support function for a borough-focused operational management model. 2. Developing our partnerships with all borough stakeholders to design bespoke borough communications and marketing plans. 3. Raising the profile of the Trust through face to face, traditional and digital channels. 4. Developing whole borough approaches to communication within each borough which support greater integration of services. 5. Focusing internally on promoting our strategic priorities, key objectives and goals for each year and keeping staff up-to-date on progress. 6. Supporting the greater integration of health and social care services - playing an integral role in supporting system-wide evolution of ACSs and ACOs. We have six key engagement priorities: 1. We will engage widely and in its fullest sense, realigning and creating dedicated resources for developing, managing and coordinating new and existing member, community, voluntary sector and delivery partner relationships in each of our boroughs. 2. We will work to develop ways and means to create the capacity to build relationships in each borough. 3. We will work strategically and in partnership with the voluntary, community and social enterprise sector, large organisations and small groups in each of our boroughs. 4. We will support our communities and engage with our membership, local people and communities. 5. We will gather insight and intelligence to shape borough specific delivery plans. 6. We will work with our local partners to design the narrative that will help everyone to understand the rationale, see the benefits of our proposed approach and understand the rationale for our service developments. 25 "We will support our communities and engage with our membership, staff and local people in those communities."

26 Enabling strategies 4. Service Line Management Ensuring sustainable services The pressures facing us and every NHS organisation are greater than ever and year after year we are doing more and going further to adapt and meet these challenges. There is now an underlying consensus about how care needs to change to 'future proof' the NHS and ensure we are fit for the future. To enable the development of service line strategies and ensure a consistent approach we will need classify our portfolio of services during 2018/19 against the following areas and identify high-level strategic options: During 2017/18 we have started a programme of work, designed to support our operational services take a detailed analysis of individual service lines to test for long-term sustainability and where necessary develop plans to address any areas of weakness. We will use the Monitor sustainability tests to ensure the strategies are developed to deliver services which are clinically, operationally and financially sustainable, and which provide a high-quality experience for our patients. The underpinning demand and activity projections to support our strategic analysis will be jointly agreed with our commissioners and we will continue to engage with key stakeholders to inform and challenge our analysis and strategic options. Perfromance MAINTAIN ENGAGE GROW/ ADOPT IMPROVE It should be noted that we have reviewed service contracts that could potentially be divested from so as to minimize loss. We have compiled data for all operational units and developed a series of hurdle criteria. As part of our planning process, we will commit to running a clinical service options review which will explore opportunities to collaborate, leverage technology and integrate services to create a viable portfolio of services. Specifically it will explore opportunities to collaborate, integrate pathways of care and further service transformation opportunities (both clinical and non-clinical) in the Trust using a SWOT analysis with each of the Operational Units; test opportunities with external stakeholders such as commissioners and acute Trusts as appropriate; and finally tested service viability options within the Trust. It will also mean: Importance Considering how the Trust s resource allocation needs to be revised to better reflect commissioner income streams between and within contracts Considering on what footprint would the Trust need operate to be most effective and efficient Clarifying what type of services does the Trust want to be in the business of providing. Focusing on retaining services in our core boroughs consistent with the emerging ACPs. We will empower senior managers to make the difference and changes needed to support them to maintain those standards. We will also engage positively with our commissioners to address these challenges. 26

27 Enabling strategies 5. Technology A digitally enabled organisation The Trust will commit to a digital roadmap and provide the vision for a digital enabled transformational system change to support ITenabled pathways of healthcare. The focus will be on four themes: 1. Clinical Systems and Interoperable electronic patient records (EPR). 2. Patient-focused digital technology. 3. Cyber Security and protection. 4. Back Office Systems. We will use digital technology to transform how people engage with services, drive improvements in efficiency and care coordination, and help people manage their health and wellbeing. Clinicians and frontline staff will be involved in designing and rolling out new technology as part of digital delivery. This will prevent a narrow focus on cost savings and going paperless as the aim is to improve outcomes, efficiency and patient experience. This will empower people to contribute to improving the quality of their own health and wellbeing. We will commit to eleven digital priorities: 1. Implement an electronic patient record in each service/locality. 2. Continue the roll-out of agile working solutions across clinical and corporate services. 3. Engage with common dataset share initiatives, such as DataWell, so our clinical staff can access health records from partner organisations. 6. Continue to be part of national community and social care initiatives. 7. Develop robust information governance processes. 8. Maintain a robust Cyber Security policy. 9. Plan to migrate all clinical and specialised systems into cloud services. 10. Move back-office systems and applications into a secure high available virtualised data centre. 11. Encourage continuation of the IT Skills Development Network to develop staff and support the Trust digital strategy. Initiatives to support this include: We will work with strategic partners to support further innovation and solutions that put the Trust at the forefront of delivering the five-year digital agenda and strategy. We will also work with our clinical teams to educate and support the use of innovative technology solutions enabling new methods of care delivery and service innovation e.g. Podcasts, Skype, virtual clinics, text, dedicated apps, online service access, social media engagement (Facebook and Twitter) and online support groups. We will also develop wider technology-based solutions with telehealth providers to offer people the opportunity to manage some of their conditions such as self-serve, appointments, consultation and results. 4. Collaborate and develop Care Record projects across wider health and social care organisations. 5. Implement leading-edge technology-enabled care such as telehealth and digital home initiatives. 27

28 Enabling strategies 6. Workforce Transformation Developing our people People are our greatest asset and developing our staff to deliver the care models required in the future is a key enabler for this strategy. Workforce planning The skill mix and age profiles of the workforce have remained relatively stable over recent years but it will need to change to reflect and respond to local demand and productivity. Populations continue to grow and as activity increases the workforce will need to respond to meet this future demand. Our workforce planning approach will focus on the borough-based plans that set out the intentions for the delivery and development of services over the next five years. During 2017/18 we have developed following eight guiding principles: 1. Planning at directorate, clinical reference group and borough and service-level. 2. Population-centric workforce modelling. 3. Service transformation. 4. Greater clarity on roles and accountability in the delivery of people s care. Headcount in the Trust as at 31 August 2017 was 3,021 staff, which equates to 2,505 whole time equivalents (WTE). The key activities over the first two years of this strategy will include: Working collaboratively with the STP plans as a key driver in the wider health economy and these will be regularly reviewed in respect of capacity and skill mix. Actively working as part of place-based systems development to ensure our workforce planning is current, flexible and receptive to the new partnership roles we adopt. Continuing to undertake capacity and demand modelling with key services. Significantly reducing reliance on temporary workforce through permanent recruitment to longstanding and newly established vacancies. Reducing staff sickness through support for staff health and wellbeing, effective absence management and revised staffing profiles. 5. Environment and Information Management and Technology strategies to support flexible and motivated workforce. 6. To support service transformation and accountability on roles and delivery of care not about how we have always done things. The right balance of skills to deliver efficient and effective care. 7. Recruitment and retention plans and workforce shortages within the financial envelope. 8. Succession plans and talent management i.e. grow our own. 28

29 Organisational development A significant challenge for the Trust moving forward is ensuring that the workforce is appropriately skilled and is flexible enough to respond to changes in service delivery, particularly in light of the drive towards more community-based services and integrated multi-disciplinary teams. Our key organisational development priorities will include: A Staff Engagement strategy which embodies and drives greater alignment to the organisational values. This will be a key driver to enable us to organise ourselves in place with 40 Staff Engagement champions from all areas of the Trust. Continued implementation of the Listening into Action programme. Handling the inevitable change that leading out of hospital care will bring by preparing staff and giving them appropriate change management tools e.g. Lean methodologies (Productive Community Services programme) including bespoke Kaizen rapid improvement events. Using our own asset-based approach to staff so that they feel valued with a sense of personal responsibility for their own wellbeing. There are also numerous informal opportunities that our senior leadership team, corporate managers and clinical leaders will take to engage and interact with frontline clinical staff to deliver this strategy. Leading at the Speed of Trust programme will be used as our behavioural framework as we seek to distribute leadership power to staff and teams wherever expertise, capability and motivation sits across our boroughs. We will define the leadership, management structures and processes essential to supporting the cultural changes to thrive in future accountable care models. We will support a realignment of services as our external partnerships begin to change e.g. partnership working with Primary Care. A set of core competencies/behaviours will be developed to form the foundation for a new Talent Management Framework and work has started during 2017/18 to build on this further. Developing our leadership capacity Development activity will be undertaken to build an organisation-wide understanding of the principles and skills needed to manage adaptive change effectively. As place-based structures are created and lessons learned through a participative change process, these insights will be embedded in a sustained way into the Trust s way of working. A key component of this work will be to ensure leaders not only understand their role but are also enabled and developed to give their best. Future leadership development and talent management will underpin any change initiatives and be clearly aligned with this strategy. To ensure we hold a strong position in future healthcare systems across our boroughs we will need to be agile to capitalise on the opportunities as they emerge. Therefore, we will focus on workforce morale by developing a positive and supportive work environment. Improvement and change come about through vision, opportunity, inspired action, passion, innovation and celebration, not just project management; budget reviews, reporting relationships, compliance, and accountability to a plan. Both sets of actions are crucial, but the latter alone will not guarantee success in a complex, everchanging NHS world. We will ensure we have leadership programmes available to staff at all levels of the organisation; including our own, bespoke Leadership Development programme designed to ensure that staff have the skills to deliver health services in the 21st century. 29 "We will ensure we have leadership programmes available to staff at all levels of the organisation."

30 Enabling strategies 7. Data and Information Supporting performance Effective performance management will become even more critical. It is key that all staff within Bridgewater recognise that they have a responsibility to manage performance and ensure alignment between clinical and nonclinical contractual performance activity, people, finance and quality. It is vital that we operate within a suitable performance management system with strategically aligned indicators which enable the Board to assess performance against targets and necessary action to address current and future performance. It is also paramount to demonstrate the quality and value of our delivery to the commissioners of our services. We already have a comprehensive performance management framework as a key internal control. We also have associated processes to performance manage operational activities, support service improvement, cost reduction programmes, budget setting processes, and business planning. In addition, we have developed a set of supporting metrics and outcomes measures to create a picture of quality, financial and operational performance and to support any service level intervention. However, there is a need to significantly up our game. We need to develop the culture of the organisation to embrace the use of information and the need for effective performance management. This will be achieved through an increased use of broader business intelligence including outcome measures, providing wider insight beyond headline metrics. In light of this, the role of the corporate information and performance team and the provision of information will be reviewed and developed in line with this future vision. This will support the organisation to understand its performance, profitability and organise its services in a way which benefits patients and delivers efficiencies for the trust. This will need to be supported by new technology and a state of the art data warehouse. We have identified seven priorities for delivery over the life of this programme: 1. Ensure we use data and information better. 2. Seek to use data better to facilitate the identification of variance promoting positive variance and reducing or eliminating harmful or inefficient and unnecessary variance. 3. Review our data infrastructure and systems and processes with a view to streamlining and enhancing wherever possible. 4. Review skills and capacity to intelligently analyse data at team, service and Trust-wide levels. 5. Review our performance management processes to support decision making and the identification of areas of risk to the delivery of plans. 6. Develop appropriate and meaningful performance dashboards at team, services, locality and Trust Board levels. 7. Invest in new technology-driven systems and data warehousing. Service Line Reporting will become the foundation upon which Service Line Management will be introduced. 30

31 Enabling strategies 8. Estate and Infrastructure The right space for care The Trust has acknowledged that property and the built environment is an important part of delivering high quality services to the communities across the boroughs we serve. Property also represents a significant cost. It is important therefore, that during these challenging financial times we ensure that as much of the local public budget as possible is spent on frontline service delivery. We also recognise that to achieve the ambitious strategic plans around integrated health and social care requires better delivery systems, more shared and effective use of the public sector estate. The vision for an integrated health and social care system networked across boroughs physically and conceptually, horizontally and vertically, can only be achieved with the supporting infrastructure. Therefore, we will continue to contribute to the local Strategic Estates Groups (SEGs) and sign up to the following overall key assumptions and enablers: One public sector estate. Optimal utilisation. Shared occupancy. Appropriate rationalisation. High standard for delivery of services. Hub and spoke/clinical network model. An Estate strategy helps health economies to turn properties into flexible assets that can support changing services. It has an important role to play in enabling change, delivering savings, reducing running costs and ensuring that all investment is properly targeted. Every strategy is different, depending on local circumstances and the complexity of the estate. However it is an overarching community asset which will be: responsive to change; take account of demographic trends; increase specialisation; support integration of health and social care; provide care closer to home; support technological advances and new ways of working. Within the context of the Trust, the estate is more commonly referred to as the Environment. We define the Environment as: The sustainable clinical and non-clinical physical estate and surrounding conditions including factors such as noise, parking, equipment etc." Clinical estate is defined as any environment where people receive or use a service and non-clinical estate is defined as any environment used by staff, including associated travel. With support from One Partnership, we are developing an updated Environment strategy which looks towards 2021 and beyond. Six estates priorities include 1. Our Space: a) The space occupied supports the delivery of the relevant Operational and Strategic Plans b) The space occupied is within a multi-stakeholder, co-located premise which creates opportunities for integration. c) The space occupied could be re-modelled/adapted without incurring significant capital costs. d) The space occupied is generic/flexible space that can be used by a range of services and teams. e) The space occupied is occupied at optimum level. 2. The premises are in a safe and accessible (parking) location for service users and staff and the site is secure. 3. Annual operating costs are at optimum levels. 4. Rationalisation (disposal) and re-investment of associated capital/revenue savings. 5. Land release for housing in line with the One Public Estate (OPE) initiative. 6. Lease length and security of tenure aligned with service contracts. 31

32 5. Financial and Investment Plan In common with other NHS providers, the Trust submitted a two-year financial plan to NHS Improvement in December 2016, which was subsequently updated in July The two-year plan is the basis on which the five-year forecast has been developed consistent with this strategy document using the assumptions detailed below. This base case forecast has been remodelled to include the effect of expected activity growth due to an ageing population and delivering a proportion of the additional out of hospital activity identified in the Cheshire and Merseyside STP and in the Wigan locality plan on the financial position of the Trust. It also includes additional CIP requirements. In addition, there is an expectation that the Trust delivers a surplus in each of the five years. Five year forecast Base Case - Table 1 describes our planning assumptions for the next five years which are taken from the national planning guidance: The base case also includes the following assumptions: 1. STP funding ends after 2018/19 2. There are no further contract losses or gains 3. CIP is calculated in order to recover the Trust s cash position due to historic deficits and generate cash to fund capital expenditure. 4. The 2017/18 control total of 523k deficit is achieved. Table 2 below shows the effect of rolling the current two-year plan forward assuming no further contract losses or reductions. It also includes a level of CIP sufficient to recover the Trust s cash position and generate cash to fund future capital expenditure. 32

33 Key assumptions for this base case are: 1. CIP is 4% in 2018/19 and reduces to 2% by 2022/ Level of CIP is linked to recurrent savings delivery and delivery of budget 3. The surplus generated for each year will be utilised to recover the Trust s cash position due to historic deficits and generate cash to fund capital expenditure 4. The base case does not generate an investment fund to deliver the strategy. Financial Scenario Planning Scenario 1 - Activity Growth Model This scenario builds on the base case and is termed our Activity Growth Model. The ONS population projections by borough have been used as the basis for uplift of activity for future years within the Trust. Each borough was further stratified by children s and adult services. The projected population estimates from were then used to calculate a percentage increase (or decrease) in each borough and age group. This allowed an age and area specific uplift to be applied to current activity levels. The year on year activity uplift has used actual activity for as the basis. The model assumes that the additional costs incurred are fully covered by additional income which also includes a small element of profit. Table 3 describes the impact of population growth on the Trust s financial position. In summary the total CIP reduces from 2.9m to 2.8m by The level of CIP is linked to recurrent savings delivery and delivery of budget. The Activity Growth Model would not generate an investment fund to deliver the strategy. 33

34 Scenario 2 - Out of Hospital Care Model Our second scenario is termed the out of hospital care transfer and strategy investment model. It builds on base case plus scenario 1. Cheshire and Merseyside STP have identified circa 10.2m of non-elective and A&E activity that can be moved out of hospital and delivered within a community setting. This will generate additional income which we have assumed to be 60% of the Commissioner tariff savings for the activity and this has been factored in from mid The additional income has been modelled to produce a 5% surplus. This model includes a CIP requirement of 3% which is an increase on the previous scenarios and this is to generate headroom and financial resource to invest in delivering the strategic enablers described in this strategy. Income increases from 143.4m in 2018/19 to 147.5m in 2019/20 reflecting the additional funded activity. In summary additional income from the out of hospital model facilitates an investment fund of 11.3m to support the delivery of the strategy and CIP year on year is 3%. 34

35 Cost Improvement Programme The Trust has developed CIP plans for the two years to 2018/19 as part of the Fit for the Future initiative. However, no plans exist beyond that point and focus must shift from year to year schemes to a more transformational approach to meeting cost saving targets. Capital Expenditure Planned capital expenditure over the five year forecast period has been forecast. Capital expenditure plans are outlined in the table below with a focus on home loan and medical equipment and IT infrastructure investment. Summary As can be seen from the financial models above, the Trust is facing significant financial challenges in the five years following the current financial plan. Ignoring costs arising from additional activity, in each scenario, there is still a need to find 12.8m in cost savings and/or income generation to ensure the Trust recovers its cash position and has financial resilience to fund future capital expenditure. This is against a backdrop of minimal NHS income inflationary uplifts and an ever increasing pressure from local authorities to bridge funding gaps. In the previous sections we have identified a number of strategic priorities for the Trust - one of these is our leadership in developing the out of hospital model for each of the boroughs where we are the leading provider of community services. System-wide investment in out of hospital services will be essential for us to create the resources necessary to fully deliver our strategy as well as the future sustainability of our place-based partnerships. 35

36 6. Strategic change programme With a focused programme of transformation and efficiency, the Trust is financially viable but there are risks which will create additional challenges for the Trust and therefore, the Trust Board will need to consider what strategic change would look like in the medium to longterm. As a consequence, the Trust will continue as a standalone entity seeking to achieve greater efficiency and reduce losses over the lifetime of this strategy. However, the Trust also recognises the changing nature of the environment and it is clear that NHS England and NHS Improvement want to tear up silos between primary, secondary and community services. Locally our commissioners are united behind a common set of principles reduce the reliance on acute-based care in favour of the development of new systems that integrate care, make it more convenient to access for people and lower the per capita costs. We are already working on such developments and we will continue to support that with a view to achieving most activity deflection back into community settings. However, many of our CCGs have identified the intent to establish new networked models of care based on the development of a new community infrastructure. As a Trust we too are serious about reducing the cost of care and better managing services in a way that ensures they are safe, high quality, integrated and sustainable in the long term this is what we believe is our core purpose. "The trust will continue as a standalone entity...exploring opportunities for collaboration" So recognising the likely need for strategic change indicated through all of our LHE assessment and analysis, during 2018/19 we will start to consider our strategic options. On that basis the Board will develop a process which enables it to consider a range of options and the feasibility of each option. However, we recognise that progress to prosecute strategic change depends on wide scale support outside of the Trust and thus is dependent upon a variety of factors outside of the Trust s control. The development of a robust case for change would be required and we would need to work with our commissioners on the development of this throughout the period. We envisage that this will lead to the development and/or exploitation of clinical network models/hub and spoke arrangements federated service models/alternative service provision and we will start by exploring opportunities across community service providers. Exploring collaboration The Trust will continue to explore potential opportunities for collaboration (partnership / joint venture) with other providers as this will still be important to achieve further efficiencies, improve the quality of services provided to patients and ensure clinical service stability resulting from ever increasing pressures from sub-specialisation. We recognise that it is inherently difficult to implement collaborative opportunities without a strong programme infrastructure aligning people and organisations behind joint goals. Therefore, we will establish this infrastructure during 2018/19. 36