HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG

 
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
HEALTHY
 LIVERPOOL
 THE BLUEPRINT

NOVEMBER 2015
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
A full copy of the Healthy Liverpool    Email: healthyliverpool@liverpoolccg.nhs.uk
Strategic Direction Case is available   Tel:     0151 296 7000
at www.liverpoolccg.nhs.uk              Twitter: @HealthyLvpool

Alternative formats are available
on request.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
Healthy Liverpool: The Blueprint   1

CONTENTS
      Introduction by Nadim Fazlani,               10   Urgent and Emergency Care Programme 34
      Chair, NHS Liverpool CCG and
1                                             2
      Katherine Sheerin, Chief Officer,            10.1 Urgent and Emergency Care aims                35
      NHS Liverpool CCG
                                                   10.2 Why change?                                   35
2     Healthy Liverpool vision                4    10.3 Delivery                                      35
                                                        Plan overview                                 41
3     The case for change                      6
                                                   11   Hospitals Programme                           42
4     Healthy Liverpool outcomes               9
                                                   11.1 Hospital aims                                44
5     Healthy Liverpool programmes            10   11.2 Why change?                                  44
                                                   11.3 Delivery                                      45
6     Healthy Liverpool design principles     11        Plan overview                                 50

7     Living Well Programme                   12   12   Supporting transformation                     51

7.1   Living Well aims                        13   12.1 Patient and public engagement                 51
7.2   Why change?                             13   12.2 Workforce                                     51
7.3   Delivery                                14   12.3 Estates                                       51
      Plan overview                           17   12.4 Finance                                       51

8     Digital Care and Innovation Programme   18   13   Conclusion                                    53

8.1   Digital aims                            19   14   Outcomes                                      54
8.2   Why change?                             19
8.3   Delivery                                19
      Plan overview                           23

9     Community Services Programme            24

9.1   Community Services aims                 25
9.2   Delivery                                25
9.3   Community Model of Care                 26
      Plan overview                           33
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
2

    1   INTRODUCTION
                                                                                      Nadim Fazlani, Chair,
                                                                                      NHS Liverpool CCG

                                                                                      Katherine Sheerin,
                                                                                      Chief Officer,
                                                                                      NHS Liverpool CCG

        In November 2014 NHS Liverpool Clinical Commissioning Group published
        Healthy Liverpool: Prospectus for Change. This document was the culmination of work
        which began in the summer 2013, when we embarked on Healthy Liverpool in response
        to the Mayoral Health Commission. The Prospectus outlined our vision for the future of
        health and care services in the city, and the principles on which change would be based.

        The Mayor’s Health Commission set out a           We have engaged with primary, community
        vision for an integrated health and social care   and social care providers to agree a
        system for Liverpool, with prevention and self    compelling vision and new model for community
        care at its core, for which Liverpool CCG has     services, which will be the cornerstone
        a mandate to lead and deliver, working in full    of Healthy Liverpool’s transformational,
        partnership with all parts of the health and      whole-system changes.
        care system, along with patients and public.
                                                          The CCG has already approved significant
        In the 12 months since The Prospectus was         investment to realise our ambitions for Liverpool
        published, a huge amount of work has taken        to become the most active city in the country,
        place, involving partners across the health       and to drive digital care and innovation.
        and care system.
                                                          Alongside intensive and sustained clinical
        In July 2015, 120 senior clinicians and           engagement, we have continued discussions with
        leaders from 15 organisations gathered for        the people of Liverpool. Throughout the summer
        the Healthy Liverpool Clinical Assembly for       people had the opportunity to provide their views
        Hospital Transformation, where a landmark         on our “case for change”, and will soon be asked
        agreement to work together towards a              to get involved in informing detailed plans for
        “Single-Service, City-Wide Delivery” model        Healthy Liverpool projects and programmes.
        around a Centralised University Hospital
        Teaching Campus was reached.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
Healthy Liverpool: The Blueprint   3

This document – The Blueprint - sets out how     pieces of work, which you will read about in
we will deliver transformational change across   this document.
five areas:
  L iving Well                                  The publication of The Blueprint represents
  D igital Care and Innovation                  a key point in our five-year journey. We now
   C ommunity Care                              have a clearly defined programme to deliver
  U rgent and Emergency Care                    ambitious and measurable transformation with
  H ospital Services                            targets formed by extensive engagement from
                                                 clinicians, leaders, patients and the public,
Within individual programme areas we are         and are moving to full mobilisation to deliver
already seeing implementation of significant     the aims and ambitions of Healthy Liverpool.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
4

    2   HEALTHY
        LIVERPOOL VISION

        Like many health economies, Liverpool faces
        significant system-wide challenges including:
        The need to improve      Tackling inequalities   Ensuring that the
        clinical standards       and improving           city is able to
        and reduce variations    health outcomes.        maintain a clinically
        in quality and access.                           and financially
                                                         viable health and
                                                         care system which
                                                         is sustainable for
                                                         the long-term.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
Healthy Liverpool: The Blueprint   5

Liverpool will have a health and social care
system that is person-centred, supports people
to stay well and provides the very best in care.

The findings of the 2013 Mayoral Health   NHS Liverpool Clinical Commissioning
Commission concluded that such is         Group, as the body responsible for the
the extent of the poor health outcomes    vast majority of health commissioning
of the people of Liverpool, and the       in the city, took up the challenge of
relentless pressures on budgets and       delivering the recommendations of the
resources, that only a whole-system       Mayoral Health Commission. Healthy
and comprehensive approach to the         Liverpool will realise this vision for
transformation of health and care could   improved health and wellbeing and a
successfully address these challenges.    sustainable health and care system.
The Commission’s vision was for an
integrated health and social care
system for Liverpool, with prevention
and self care at its core.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
6

    3                  THE CASE FOR CHANGE

POOR HEALTH

                   0                                                             HIGH

                                                                                CANCER
                                                                              MORTALITY

                                                                                  LOW

30% of people in Liverpool live with   93,000 people in Liverpool are         Liverpool has one of the highest
one or more long-term conditions.      affected by mental health issues.      cancer mortality rates in the country.

HEALTH
INEQUALITIES

                                                                              You are 2.5 times more likely to die
The difference in life expectancy      Men in Liverpool live 3.1 years less   of cardiovascular disease if you
between areas of the city can vary     and women 2.8 years less than the      live in Picton ward than if you live in
by more than 10 years.                 England average.                       Mossley Hill ward.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
Healthy Liverpool: The Blueprint   7

The case for change is compelling.     Within our health and care system           Although some lifestyle improvements
As a city, we experience amongst       there remain unacceptable levels of         have been achieved, such as reducing
the highest levels of poor health      variation between services, and access      smoking rates, poor lifestyles remain
                                       to services needs to be improved.           a major challenge and this is the
and health inequalities – both                                                     biggest issue we face as a city. These
within the city and compared to        Improvements in medicine mean that          challenges are represented visually:
the rest of the country.               we are living longer, but not necessarily
                                       living well in our later years.

 AGEING
 POPULATION

                                                                                                     +10.7%

 By 2021 there will be 9% (5,700)
 more people living beyond the age      Almost 26,000 older people have             By 2021 there will be a 10.7%
 of 65 with the biggest growth in       a long-term illness that limits             increase in the number of people
 those aged 70-75 and 85+.              their day-to-day activities a lot.          living with dementia.

 ACCESS AND
 VARIATION

                                                        LEARNING
                                                        DISABILITY
                                                      AGED UNDER 50
                                                      PREVENTABLE

                                                                                    The number of people with diabetes
 The number of patients with Chronic    People with a learning disability are       receiving the recommended care
 Obstructive Pulmonary Disease          58 times more likely to die before the      processes to manage their condition
 offered rehabilitation varies          age of 50 and 4 times more likely to        varies between 20% and 80% depending
 between 24% and 79% in the city.       have a preventable cause of death.          on where they live in Liverpool.
HEALTHY LIVERPOOL THE BLUEPRINT - NOVEMBER 2015 - Liverpool CCG
8
                             3         THE CASE FOR CHANGE, CONTINUED

LIFESTYLE

                                                                                                      86%

Over half of adults in Liverpool are       An estimated 11,300 people in          86% of people in Liverpool are not
overweight or obese.                       Liverpool drink at high risk levels.   active enough to maintain good health.

424 deaths could be prevented each
year by 30 minutes of activity per day.    25% of adults in Liverpool smoke.
Healthy Liverpool: The Blueprint          9

        4                            HEALTHY LIVERPOOL
                                     OUTCOMES
                                     We have set ambitious targets for change, which require Healthy Liverpool
                                     to be bold in its plans and for the whole health and care system to come
                                     together with a common cause, to transform services and to inspire and
                                     empower many more Liverpool people to improve their own health and wellbeing.
                                     More detailed information on outcomes is available at the end of this document.

                                      HEALTHY LIVERPOOL
                                      OUTCOMES FOR
                                      TRANSFORMATION:
                                                                                                                     An increase from 65% to 71%
                                                                          To deliver a 24.2% reduction               in the measurement of the
                                                                          in avoidable mortality                     quality of life for people
                                                                          (years of life lost).1                     with long-term conditions.2

                                      A 15% reduction in avoidable
                                      emergency hospital admissions.      To deliver a patient experience            To provide a community-based
                                      Equivalent to a reduction of 1659   in our hospitals that puts us in           care experience that puts us in
                                      emergency admissions by 18/19.      the top 10 of CCGs nationally.             the top 5 of CCGs nationally.

                                      A CLEAR SET OF
                                      MEASURES OF SUCCESS
1. ‘Potential Years of Life Lost’    FOR HEALTH AND SOCIAL
   (PYLL) is a count of the
   number of years between            CARE INTERVENTION                   Reduction in the number of
   the age a person under             HAVE ALSO BEEN                      permanent admissions to                    Increase the % of patients
   75 dies and the age of 75.
   These are summed for               DEVELOPED:                          residential and nursing care               still at home 91 days after
   the population who die                                                 homes from 767.3 to 612.9                  discharge to reablement
   in a 12 month period and                                               per 100,000 people by the                  services from 78.9% to 83%
   reported as a rate per                                                 end of 15/16. Equivalent to                by the end of 15/16. Equivalent
   100,000 patients. A higher
   rate means more people                                                 a reduction of 87 permanent                to an extra 196 people still at
   die younger. Liverpool is                                              admissions to care homes.                  home 91 days after discharge.
   going to reduce this value
   by 24.2% by 18/19.

2. ‘This is a measure of the
    average EQ-5D score for
    people responding to the
    GP survey. EQ-5D asks
    patients to score themselves
    1-5 against 5 questions
    relating to quality of life,
    mobility, self-care, usual        Reduction in the number of
    activity, pain/discomfort,        delayed transfers of care from                                                 Based on expected prevalence
    depression/anxiety. A %
    between 0-100 is attached to      2664.5 per 100,000 population                                                  levels, increase in recorded
    each response combination,        to 2602.7 per 100,000                                                          cases of dementia from 54% in
    100 being good and 0 being        population by the end of 15/16.                                                July 2013 to 70% by March 2016,
    poor quality of life. The %
    reported is the average           Equivalent to a reduction of        Increase in the levels of                  equivalent to finding an extra
    score for people responding       214 delayed days in hospital.       carer-reported quality of life.            912 people with the condition.
    to the survey.
10

     5   HEALTHY LIVERPOOL
         PROGRAMMES
         The changes planned in Liverpool are substantial and represent significant
         transformation in the way health and social care is organised and delivered.
         This transformation also extends to key enablers including workforce, estate,
         technology, systems and finance.

         A new model of care will transform the whole         Community Care: Improving capability
         health and social care system in Liverpool            and capacity in primary care, community
         leading to improving outcomes for patients and        care and social care
         new ways of working. Five core transformation        Urgent and Emergency Care: Developing
         programmes have been established:                     robust and effective rapid response services
           L iving Well: Supporting people to become         Hospital Services: Ensuring our hospital
           healthier and more active                           services are the best they can be
            D
             igital Care and Innovation: Ensuring all our
            services make best use of developing
           technologies

         Six clinical areas have been prioritised,           The delivery of these priorities will
         informed by where we believe we can                 ensure that people in the greatest need
         make the greatest impact in transforming            receive the best care and support.
         services and health outcomes.                       The priority clinical workstreams are:

          MENTAL HEALTH                       HEALTHY AGEING                    LONG-TERM CONDITIONS

          CHILDREN                            LEARNING DISABILITIES            CANCER
Healthy Liverpool: The Blueprint   11

6   HEALTHY LIVERPOOL
    DESIGN PRINCIPLES

    The Healthy Liverpool                 Person-
    model of care has been                centred
    informed by a core set
    of design principles:

    Proactive       Eliminating          Local care
                     avoidable            where
                     variation            practicable,
                     in quality           central when
                                          necessary

    Improving        Integrated           Making
    access           across health,       the best
    to services in   social care and      use of digital
    the community    the voluntary        technology
                     sector
12

     7              LIVING WELL
                    PROGRAMME

                    Leading an active life is one of the single most
                    powerful actions we can take as individuals to
Dr Maurice Smith,
Living Well         improve and maintain our overall health and
                    wellbeing, and yet so many of us are living
Clinical Director

                    sedentary lives.
                    “This isn’t an issue unique to our city – inactivity   activity. We hope to use these findings to
                     has become a global epidemic – but we’ve              help spark a social movement around being
                     made tackling it a cornerstone of Healthy             active. We want to help people find a realistic,
                     Liverpool, because the potential benefits             sustainable approach which suits their lifestyle.
                     of raising physical activity levels are huge.         It doesn’t need to involve hitting the gym or
                     For example, we know that it offers us a real         running a marathon – anything which gets you
                     opportunity to improve outcomes for diseases          moving more on a regular basis is important.
                     such as diabetes, heart disease and cancer,           Even using the stairs instead of the lift can
                     which all present major challenges locally.           make a difference.

                    “We’re working to understand more about what           “It’s about embedding physical activity into
                     will inspire the population, on both a group and       the fabric of our daily lives, so that we can
                     individual basis, to engage in daily physical          all start to reap the benefits of moving more.”
Healthy Liverpool: The Blueprint     13

                       Our vision is for Liverpool to be the most active
                       Core City in England by 2021, inspiring and enabling
                       people who live and work in Liverpool to be active
                       every day for life.
                       Our aim is that by 2021 an additional 1 in 3 of           We will work with the city’s schools to
                       us - 118,000 people in Liverpool – will be doing           embed activity as a core part of school life,
                       at least 30 minutes of activity, one day a week.           not just as a PE lesson.
                       This would equate to at least 80% of the                  We will work with the city’s employers to roll
                       Liverpool adult population undertaking a level             out workplace activity programmes to enable
                       of activity that will be beneficial to their health.       people to get active during their working day.

                               LIVING WELL AIMS                                       WHY CHANGE?
                        7.1                                                     7.2
                               Living Well is central to the success of               Physical inactivity has become an epidemic
                       Healthy Liverpool and is built upon two objectives:     and is now perceived to be the greatest threat
                        T o prevent people falling into ill health, through   to our physical and mental health. Only 14% of
                         supporting them to adopt positive lifestyles;         people in Liverpool are doing enough activity
                        P romoting self care; supporting and                  to benefit their health. Half of the population of
Our aim is that by       empowering people with long-term conditions           Liverpool do not take part in any regular sport
2021 an additional      to better manage their health, in partnership          or active recreation in a typical week.
1 in 3 of us –          with clinicians and carers.
118,000 people in                                                              According to Sport England, the health
Liverpool – will be    The Living Well priority for Healthy Liverpool over     cost of physical inactivity in Liverpool is
doing at least 30      the next two years is to increase physical activity     currently £10.8m per year, based on five of
minutes of activity,   levels for a substantial number of people who           the most common conditions - diabetes,
one day per week.      are either currently inactive or moderately active.     breast cancer, colon cancer, coronary
                                                                               heart disease and hypertension.
                       We have a set of ambitious objectives:
                        W
                         e aim to create a large-scale social movement        If we were able to surpass our ambitions
                        in Liverpool, with people in the city getting active   and get every adult in the city to undertake
We want the             for their own benefit, but also driven by a collective 30 minutes of activity a day for at least five
inactive to become      sense of pride around Liverpool aiming to become       days a week we estimate this would prevent:
active; the semi-       the most active major city outside London.                424 deaths a year;
active to become        W
                         e will be using existing expertise and                  146 coronary heart disease emergency
more active;            creating new community assets to support                   admission a year;
and the active          people with activity programmes, mentoring                2,452 new diabetes cases;
to maintain their       and other forms of support to encourage people            55 cases of breast cancer;
activity levels.”       to get active.                                            43 colorectal cancer cases.
                        W
                         e will be investing in physical assets, in both
                        indoor and outdoor environments, to maximise           Our ambition to get people active enough to
                        the potential for physical activity and sport.         realise health benefits requires a significant
                        W
                         e will deliver schemes to encourage mass             step-change, with many more people valuing
                        participation in physical activity schemes,            activity as an intrinsic part of daily life. Therefore
                        including supporting major events, ongoing             the key aims of the strategy are to enable the
                        programmes and a large-scale social marketing          inactive to become active; the semi-active to
                        campaign to motivate and inspire people to             become more active; and the active to maintain
                        get active.                                            their activity levels.
                        W
                         e will integrate physical activity and
                        sport into health care, as a prescription for
                        better health.
14
                             7      LIVING WELL PROGRAMME, CONTINUED

                      When we refer to physical activity, this doesn’t     The aim is to launch this campaign in May
                      have to mean joining a gym or participating in       2016, but we will also carry out work in 2015/16
                      sport. The activities that will make a difference    which raises awareness of the compelling
                      include: walking; active travel, such as getting     benefits for getting active - improving health
                      off the bus a stop early; taking the stairs rather   and saving lives.
                      than the lift; gardening; dancing; chair exercise;
                      swimming; cycling and even housework.                Living Well Champions
                      Doing more of these everyday things will             In order to achieve the desired step-change
Inspiring people to   make a difference.                                   activity across all parts of the city, we will
integrate activity                                                         develop a network of champions who can
into daily life.”           DELIVERY                                       empower and support people and groups. This
                       7.3
                            The aim for Liverpool to be the most           includes targeting people who work for the NHS,
                      physically active Core City is a long-term           the city’s largest employer. The NHS has made
                      aspiration. However, over the next two years         a commitment to set a national example in the
                      we have set ourselves realistic but stretching       support it offers its own staff to stay healthy,
                      targets, which are underpinned by nearly             including helping them to be more active.
                      £3 million new investment.
                                                                          We will also be investing in champions and
                      Over the next two years (2015/6 and 2016/17)        projects designed and delivered through a
                      the programme will:                                 network of voluntary organisations that
                                                                          understand the particular needs of their
                      Year 1: Engage 10,000 people in the city, resulting communities and the areas of the city they
                      in at least an additional 5,000 people undertaking work in. This will in part be delivered through
                      at least 30 minutes of activity, one day a week.    Liverpool CCG’s Community Grant scheme.

                      Year 2: Engage 30,000 people, resulting in an        Quality indoor and outdoor environments
                      additional 15,000 people undertaking at least        We will be investing in schemes to improve
                      30 minutes of activity, one day a week.              access to quality indoor and outdoor assets,
                                                                           to maximise opportunities for people to access
                      The key deliverables designed to achieve these       a range of activities and sport. This will be
                      targets are:                                         achieved through developing a number of
                                                                           Liverpool City Council-led initiatives, including
                      Insight and Social Marketing                         Access to Schools; Open Spaces and Parks;
                      The objective is to inspire people to value and      and Lifestyles centres.
                      integrate physical activity into daily life by
                      encouraging a Liverpool social movement.             Mass Participation
                      This will be supported by a large-scale social       Alongside the city-wide campaign to generate
                      marketing campaign, media and commercial             a social movement for activity, we will be
                      partnerships, to: raise awareness of the             delivering mass participation activity schemes,
                      compelling benefits of physical activity; motivate   focused for the first two years on maximising
                      people to take action; and to let them know what     walking and cycling opportunities. These
                      support is available, both in terms of structured    schemes will be consumer-focused and will
                      programmes and ‘do it yourself’ activity.            incorporate incentives to motivate people
                                                                           and families to participate. Planned mass
                      Bespoke behavioural insight has been                 participation schemes include:
                      commissioned to provide local intelligence and
                      to understand motivations and barriers at an         Active Travel – Embedding a ‘moving’ culture
                      individual, community and city-wide level. This      into the lives of Liverpool residents, encouraging
                      insight will inform a bold and Liverpool-centric     people to walk and cycle over other forms of
                      campaign to create and sustain a city-wide           transport. This is arguably the most practical,
                      social movement to get and stay active.              sustainable and cost-effective way to increase
                                                                           physical activity on a daily basis.
Healthy Liverpool: The Blueprint    15

                   Beat the Streets – A scheme designed around a         Back to Sport Programme – A city-wide
                  ‘real world walking game’ concept where people         programme offering people opportunities to
                   compete for points by walking or cycling around       return to sport, using existing local facilities
                   their local area: to work, to school or as part of    and clubs. This programme will be supported
                   a daily routine. As part of the challenge, schools    by Sport England and the 12 national governing
                   and businesses will compete to accumulate the         bodies of sport that are currently designing a
                   most points, which brings a range of rewards.         bespoke offer for Liverpool. The sports are:
                   Beat the Streets is designed to ‘nudge’ people to     athletics, badminton, boxing, cycling, football,
The activities     try walking and cycling for a period of six weeks,    gymnastics, hockey, golf, netball, rugby union,
that will make     at the end of which it is anticipated that a          swimming and tennis.
a difference       significant proportion will continue to incorporate
include walking    regular walks and bicycle rides into their daily      Community Grants – the CCG’s Community
and cycling.”      lives. This programme has evaluated well              Grants programme will be enhanced to
                   elsewhere in the UK. The concept will be              include a specific physical activity element
                   tested initially in the north and east wards of       to support local groups to provide sustainable
                   Liverpool, which have some of the country’s           activities based on local needs and interest.
                   lowest levels of physical activity.
                                                                         The programme will also look at how
                  Bounts – A scheme that rewards residents for           physical activity can be embedded into
                  making positive lifestyle choices. Bounts is like      clinical pathways, and extensions to the
                  airmiles for physical activity, using an app to        School Sport Pathway Programme.
                  check-in at healthy venues like gyms, or with
                  instructors and coaches outdoors. People build
                  up points which can be redeemed for rewards.
                  Again, we will test this concept for Liverpool.
16
                                  7         LIVING WELL PROGRAMME, CONTINUED
CASE STUDIES

               ACTIVITY       ‘Active Me’ is an inclusive sports programme aimed   A few weeks later Ann-Marie had made new
                               at disabled people in Liverpool who experience      friends and had already attended a number
               FOR BETTER      barriers to physical activities and sport.          of weekly sessions. She gained in confidence
               HEALTH                                                              while improving her fitness at the same time.
                              Ann-Marie, 32, first attended the Active Me          With the support of the activator running the
                              project in April 2014, with her then support         sessions she embarked on the Walk for Health
                              worker. Anne-Marie was morbidly obese                scheme, where twice a week she took part in a
                              and spending a lot of time alone. Her mental         3 to 5k walk, and was given the opportunity to
                              health issues meant she was relying on               understand the importance of preparing and
                              anti-depressants to face each day.                   cooking healthy meals.

                              The first time Ann-Marie attended an Active          To date Anne-Marie has lost five stone in
                              Me session, she was very anxious and shy.            weight. She cooks and prepares healthy meals,
                              Ann-Marie was encouraged to attend the               has reduced the amount she smokes and is an
                              next week’s session where activities would           active gym member. She also no longer requires
                              be broken down into smaller chunks, so               a support package.
                              that she felt more confident joining in.

               ACTIVITY ON    Exercise for Health is a GP referral scheme          house - but since coming here I have made
                              for people living with long-term conditions.         some great friends and now we all have
               PRESCRIPTION                                                        a laugh and a social after our workout.
                              Bill, 82, who takes part in activities at
                              Lifestyles Garston, said: “After starting            “I go out feeling great and ready to take
                              the scheme with instructor Wendy, I was               on any challenge put in my way. Since I
                              given a programme to suit my needs.                   have joined Lifestyles Garston, my life has
                                                                                    changed for the better. I feel much fitter
                              “When I first started the scheme I felt               and am enjoying life.”
                               down - I didn’t always want to leave the
Healthy Liverpool: The Blueprint       17

LIVING WELL PROGRAMME
PLAN OVERVIEW
VISION AND OUTCOME AMBITION

‘A health care system in Liverpool that is person-centred,
 supports people to stay well and provides the very best in care.’
 Improved Health                             Deliver First                                Delivering a
 Outcomes                                    Class Services                               Sustainable System

LIVING WELL OUTCOME DOMAIN
                           Liverpool will be the most active Core City in England by 2021 by increasing
                                    participation in physical activity and sport (PAS) by 30%

   Increased population               Increased access to              Enablers to activate                 Activity is integrated
 awareness of the benefits             quality indoor and             networks of expertise                 into healthcare and
    of activity and mass             outdoor environments                                                    schools pathways
  participation in schemes
         and events

        Insight and               Access to Schools Initiatives      Enterprise Start-up Fund               Activity Pathway for
      Social Marketing                                                                                  Primary and Secondary Care
                                     Community Facilities              Sponsorship Capacity
 Wellness Incentive Schemes          Capacity Programme                    Programme                       School Sports Pathway
                                                                                                                Programme
  Back to Sport Programme            Open Space and Park              Community Grant Fund
                                      Spaces Programme                                                           Exercise for
                                                                                                                Health Scheme
    Workplace Wellbeing                                                  Active Liverpool
         Scheme                     Lifestyle Fitness Centre            Development Team
                                          Programme                                                                 Mamafit
     Walk and Cycle for                                              Sports Development Team
      Health Schemes

   Major Sporting Events
  and Legacy Programmes

       Futures Scheme

Principles   Population approach, Person-Centred: Co-creation, Collaboration, Engagement: Access to Physical Activity Opportunities

Enablers     Digital Care, Estates, Proactive Care, High Quality Primary Care, Community Engagement, Workforce
18

     8               DIGITAL CARE
                     AND INNOVATION
                     PROGRAMME

                     We’ve been focused on the benefits of digital innovation
                     for a number of years now, and Healthy Liverpool
Dr Simon Bowers,
Digital Innovation   gives us an opportunity to realise the enormous
                     potential that technology can bring to both local
Clinical Director

                     health services and the people who depend on them.
                     “Further roll out of assistive technology will        health and social care, ensuring that a
                      support even greater numbers of people to            patient’s information can be accessed by
                      maintain their independence and take control         all of the professionals who look after them.
                      of their lives. They will join thousands of          This has major benefits for speeding up
                      residents across the city who have already           diagnosis, improving safety, and delivering
                      benefited from devices to monitor their health,      a better experience for patients.
                      make everyday life simpler, and help them stay
                      in touch with family and carers.                   “If we are to realise the Healthy Liverpool vision
                                                                          then the way in which we access, deliver and
                     “However, while technology offers exciting benefits experience care services must be different.
                      for the individual, it is also a fundamental part   Technology will be at the heart of this change,
                      of our plans for the health system to work more     and in Liverpool we’re leading the way in
                      collaboratively. For example, it will provide us    harnessing digital tools to make joined-up,
                      with the means to integrate records across          person-centred care a reality.”
Healthy Liverpool: The Blueprint      19

                       Our vision is that by 2020, we will support better
                       health for people in Liverpool by maximising the
                       benefits of digital technology and innovation.
                             DIGITAL AIMS                                    will help empower them to take better control
                        8.1
                             Our aim is to be one of the top ten             of their health and wellbeing, confident in the
                       most digitally advanced health and social             knowledge that this information will be made
                       care economies in Europe by 2020. We will             available only to those practitioners involved in
                       transform the way services are delivered              their care, with appropriate safety, monitoring
                       through a step-change in the use of digital           and governance in place.
                       technology and innovation.
                                                                             Technologies that allow the monitoring of
                       Digital services in Liverpool have been at            patient vital signs, assist diagnosis, and
                       the leading edge for several years through            state-of-the-art sensors to detect specific
                       existing programmes such as iLinks and More           cells in the blood stream will form a new set
                       Independent (Mi). Our achievements include:           of tools that allow clinicians to gain access to
                       scaling up of electronic patient record sharing,      clinical data faster, enabling proactive care.
                       moving from 1 million shared records from
                       2008-2014 to 5.5 million in the last 12 months;                 DELIVERY
                                                                              8.3
                       and one of the largest deployments of telehealth                Delivery of the digital care and
Our aim is to be one   in a single health economy in Europe, with 2,000      innovation services of the future is based
of the top ten most    patients using this technology.                       around four connected themes:
digitally advanced                                                             I ntegrated Health and Social Care Records
health and social      Our ambition is to empower people to take                P erson Held Record
care economies in      control of their own health and wellbeing,                A ssistive Technology
Europe by 2020.        while ensuring professionals have access to               P redictive Analytics
                       the information they need to use technology to
                       deliver safe and efficient ‘seamless’ care. We        Integrated Health and Social Care Records - iLINKS
                       envisage a connected health and social care           Integrated records will enable Liverpool health
                       economy supported by integrated systems that          and social care practitioners to view information
                       empower people to make the right choices in           relevant to the person they are caring for safely
                       an innovative, efficient, safe and secure way.        and confidentially. Whether people are being
                       We will enable the use of smartphones and             treated by their GP, in a community-based
                       other personal devices to open up better self         service or in hospital, their shared digital care
                       care for people in a way that is convenient and       record will be accessible 24/7, with appropriate
                       complements other elements of their lives.            permissions and consent. This will save people
                                                                             being asked for information repeatedly, meaning
                              WHY CHANGE?                                    that a person only has to tell their story once.
                        8.2
                             The use of digital technology allows us to      It will also ensure that individual preferences
Digital health
                       deliver health and care services more efficiently,    about resuscitation, mental capacity and end of
records will enable
                       more quickly and to achieve better outcomes.          life care are understood by all practitioners caring
people to take
                       Patients and professionals alike experience           for them. Liverpool has led the way nationally in
more control
                       duplication in the health and social care system,     information sharing; we will build on these solid
of their health.
                       with paper-based recording and computer               foundations by truly integrating electronic health
                       systems across care providers making                  and social care records at scale.
                       communication particularly difficult, and in some
                       cases impossible. For professionals, access to        Person Held Record
                       shared information across care settings will          The person held record will enable people
                       be enormously beneficial, providing clinicians        to take real control of their health, providing
                       with access to clinically significant information     the means for truly person centred care. It will
                       at the point of care, improving efficiency and        support data sharing and integration between
                       reducing costs and associated duplication.            health and social care providers, people and
                                                                             their circles of care. Liverpool is in a unique
                       For individuals, the ability to view and contribute   position, working with the Cabinet Office, to
                       to their own person held record and care plan         create a new identity authentication scheme,
20
         8         DIGITAL CARE AND INNOVATION PROGRAMME, CONTINUED

     which links social identities to an NHS                  will lead the identification, evaluation and
     identity so that the right information can               adoption of new technologies in Liverpool
     be confidently shared.                                   with a real focus on innovation.

     This project will utilise the digital ‘marketplace’      Predictive Analytics
     to provide access to apps created by digital             Predictive analytics is at the forefront of
     innovators in response to public need, enabling          data science, using multiple sources to define
     the CCG to support innovation at pace without            health and care issues. Profiling risks at a
     needing to drive or fund this innovation directly.       population and individual level, to predict care
                                                              trends, will enable us to plan and allocate
     Assistive Technology                                     resources most effectively. For example risk
     Assistive technology enables people to live              stratification models allow patients most at
     more independently in a variety of ways, by              risk of emergency hospital care to be identified
     deploying technology to support diagnosis,               so we can provide proactive care and avoid
     monitoring and self care. The programme                  preventable issues.

     DIGITAL
     SERVICES                                     BILITY AND INFRASTRU
                                           RO PERA                          C TU
     MODEL                                E                                     RE
                                     INT
                                                    A ND W  ORK F OR CE D
                                               RITY                      E VE
                                          M ATU                               LOP
                                      A L                                         ME
                                   I T              GO VE RN A NC E                  NT
                                DIG

                                                AND                 PER
                                                                       SON
                                             LTH RDS
                                            A O                            HE
                                          HE REC
                                            E
                                                                                    LD
                                    AL D
                                SOCI RATE
                                         R

                                                                                       RE
                                       CA

                                                                                         COR
                                     G
                                 INTE

                                                                                            D
                                ASS

                                                                                             CS
                                                                                            Y TI
                                 IS T

                                                                                          AL
                                   IV E

                                                                                    AN

                                        EC
                                                                                   IV E
                                        T

                                             HN
                                                  OL O                        CT
                                                         GY         PR   E DI
Healthy Liverpool: The Blueprint             21

A NUMBER OF DIGITAL OUTCOMES
HAVE BEEN IDENTIFIED ACROSS
A 1-5, 5 AND 10 YEAR PERIOD:
                                                                      Person Held Record, apps
                                                                      and self care support all
                                                                      available from one place.
                                                 1-5                  They can choose the app
                                                                      and support that they want
                                                YEARS                 and share their information
                                                                      and plans with whoever
Practitioners have access to appropriate                              they choose. Liverpool
information 24/7 through class-leading iLinks                         citizens can access online
information exchange and interoperability.                            records and content using
                                                                      a nationally recognised
                                                                      and secure digital identity.

                                                                      Assistive technology
                                                                      deployed at scale
                                                                      and integrated with
                                                                      personal technology
Apps and digital services are key to                                  to maintain self care
the delivery of all services supporting
self care.                                       5-10                 and prevention activity.

                                                YEARS
Using a Liverpool based cloud
computing centre, data from
around the region will be analysed                                Advanced sensors, designed
by data scientists to understand                                  and manufactured in Liverpool
and predict when care will be                                     are enabling early detection
needed, how it will be needed and                                 and management of diseases.
identify those requiring intervention
before the health need arises.

                                                                      A single, integrated care
A ‘virtual’ hospital service                                          record across the Liverpool
across Liverpool providing                                            health economy.
access to specialist care
at any site in the secondary
care infrastructure.
                                                 10+
                                                YEARS
                                                             Transformation of NHS services
                                                             towards predictive. Changing lifestyles
Digital services are the first
                                                             and utilising precision medicine
contact for all non-emergency health
                                                             techniques to dramatically reduce
services providing initial advice,
                                                             unplanned care and long-term
triage and appointments at the
                                                             condition prevalence.
appropriate care setting.
22
                                  8         DIGITAL CARE AND INNOVATION PROGRAMME, CONTINUED
CASE STUDIES

               USING          75 year-old grandmother, Win Cumine, suffers             if something went wrong and I ended up
                              from arthritis, limiting her mobility and leaving        stuck at home with no way of calling for
               TECHNOLOGY     both her and her family worried about what would         help. But now I know that all I need to do is
               TO SUPPORT     happen if she were to have a fall. This all changed      press the button on my wristband and help
               INDEPENDENCE   with the help of care technology, and she is now         will be there, 24-hours a day. It’s given me
                              able to live more independently and confidently          tremendous peace of mind. I don’t need to
                              in her own home.                                         feel isolated and worried anymore, because
                                                                                       of the helpline.
                              Win uses an intercom system that connects to a
                              helpline. A button is housed on a wristband that “Just because you’re getting older or have
                              she wears in her bungalow, which, when pressed, a health problem, you don’t have to give up,
                              connects to a friendly voice that’s ready to help. feel isolated, or trapped in your own home. The
                                                                                 technology is there to use. I’ve recommended
                              Win says: “It’s made a huge difference. My         it to lots of my friends. It’s so easy to use –
                              family and I were concerned what might happen nothing complicated, just peace of mind.”

               REDUCING       Dave Haslam’s life changed when he was diagnosed         The technology has improved Dave’s
                              with COPD (chronic obstructive pulmonary disease).       understanding and helped him come to terms
               HOSPITAL       It left him tired, breathless and constantly coughing.   with his condition. He’s delighted how effective
               ADMISSIONS     He was also very worried and didn’t really               and easy to use it is. He says: “It really couldn’t
                              understand what was happening to him.                    be simpler to use. It is really easy to understand.
                                                                                       It really works – it’s brilliant!”
                              The 67-year old grandad was referred to have
                              health technology installed in his home and he            Dave has spent far less time in hospital (he
                              says it has made the world of difference. The             estimates by as much as 60%) and says:
                              gadget works with existing technology to send            “Knowing that someone who really knows what
                              key health information through to a team of               they are doing is keeping an eye on me is great.
                              health professionals, who monitor his condition.          I’ve only been in hospital twice this year, which is
                                                                                        a huge improvement. It’s made a huge difference
                                                                                        to our lives, and I would recommend it to anyone.”
Healthy Liverpool: The Blueprint        23

DIGITAL CARE AND INNOVATION PROGRAMME
PLAN OVERVIEW
VISION AND OUTCOME AMBITION

‘A health care system in Liverpool that is person-centred,
 supports people to stay well and provides the very best in care.’
 Improved Health                                Deliver First                                  Delivering a
 Outcomes                                       Class Services                                 Sustainable System

DIGITAL CARE AND INNOVATION OUTCOME DOMAINS
     Preventing                 Enhancing quality            Delaying and           Ensuring that people          Prevention of ill health,
  people from dying                  of life             reducing the need for         have a positive              health protection
    prematurely                                            care and support          experience of care              and maintaining
                                                                                        and support                 healthy lifestyles

 Integrated Health and Social           Person Held Record               Assistive Technology                  Predictive Analytics
    Care Records - iLINKS

 iLINKS Information Sharing                Digital Identity                 Telecare Service                  Proof of concept Design
 Framework Implementation                                                                                        and Mobilisation
                                         New App testing and               Telehealth Service
    Proactive Audit System                  integration                                                        Intelligence pathway
                                                                                                                   development
                                                                         Digital Health Trainers
   Digital Interoperability          AT and App Support Helpline
          Roadmap                                                                                           Multi-sector data transfer
                                                                        New sensor development
                                                                                                           and information governance
                                      Digital Skills Development
 Digital Maturity Framework
                                                                      Tech Skills Syllabus/Training           Data aggregation and
                                      Digitise existing material
                                                                                                                common structure
   Health and Social Care
                                                                       Digital Community Support              standards/agreement
        Integration
                                       Health Innovations Hubs
                                                                       Intelligence and Evaluation         Pseudonymisation at source
  Electronic Correspondence
                                          Tech Equality and
                                            Accessibility                                                   Stakeholder development
        Infrastructure                                                  Test Bed and Cross HLP
                                                                           Digital Initiatives
                                     N3 Aggregation, Cloud and
                                                                                                           Programme access pathways
     Technology enabling               SME App Framework
        Community and
       Hospital settings                                                                                    Ethics and dissemination

             Utilising Digital to manage own care; Right information, right place, right time; Information exchange across
Principles
             Health & Social care; Technologically enabled workforce; Identification and mobilisation of ‘State of the Art’

Enablers     Information Governance, Digital Maturity, Workforce Development, Interoperability and Infrastructure
24

     9              COMMUNITY
                    SERVICES
                    PROGRAMME

                    Liverpool has some fantastic community services,
                    providing crucial care for our population, but a
Dr Janet Bliss,
Community           fragmented and illness-focussed approach is
                    holding us back from making the kind of impact
Services Clinical
Director

                    we want – and need – for the city’s people.
                    “Our model for the future brings together the      health and wellbeing. This reflects a growing
                     many different pieces of care which happen        consensus that we must prioritise efforts to
                     outside of our hospitals into a single, person-   prevent ill-health in the first place, rather
                     centred system, with integrated planning,         than simply managing the end results.
                     commissioning and delivery, which is easier to
                     navigate for both professionals and patients.     “At the heart of the community model is recognition
                                                                        that although we plan services for the population,
                    “We will take an increasingly proactive role,       we deliver them to individuals; care should be
                     which recognises the importance of prevention      holistic and allow us to address people’s overall
                     and empowers individuals to manage their own       needs, rather than just their specific conditions.”
Healthy Liverpool: The Blueprint   25

                     Our vision for community services: “Making the
                     most of our city’s assets to deliver the best in
                     community-based care and support, to improve the
                     health and wellbeing of the people of Liverpool.”
Transformation       Improving health outcomes in Liverpool and             The alignment and integration of care for children,
of community         creating a sustainable healthcare system for           young people and adults is a key aspect of this
services is          the city will require a fundamental shift from the     new model of care, recognising the impact that
already underway.”   current hospital-centric model to one which is         transition to adult support can have on people.
                     focused on prevention and community-based care.        The model also recognises that services need
                                                                            to be designed and personalised to meet the
                     This will require a major change in the way            specific needs of children, young people and their
                     that people in Liverpool are supported to              families, due to the crucial impact that early
                     manage their health, and the way that community years have on life chances.
                     services are delivered. At present, while we
                     have some excellent services, they are too                    DELIVERY
                                                                              9.2
                     often fragmented, lacking integration across                  Our transformational programme for
                     health, social and voluntary agencies and              community care encompasses all care services
                     focused on specific conditions that an                 that are provided outside of a hospital setting,
                     individual may have, rather than holistic care.        including services provided by health, social
                                                                            care, education, housing and the voluntary,
                     Health interventions alone will not deliver the        community and independent sector. It includes
                     major improvements in health outcomes we need all age groups, from pre-conception and birth
                     for people in Liverpool. We must make the most         through to end of life.
                     of the many community-based assets we have,
                     if we are to be successful in improving outcomes. At the core of the community model is a
                                                                            proactive approach to health, wellbeing and
                                    COMMUNITY SERVICES AIMS                 care delivery. It will mean that for the first
                       9.1
                                    We will create a new system of          time there is a clear, overarching direction
                     community-based care which meets the                   for community service delivery, focused on
                     needs of people, both clinically and socially,         the needs of the whole population – children
                     taking into account the wider impact on                and adults – and sensitive to the particular
                     families and carers. We need to create a               needs of each neighbourhood community.
                     new system of community care where:
                        People are empowered to manage their own           Further improvements will be realised in
                               health and care;                             phases over the next 1-2 years, with others
                         The social model of health will be delivered      taking 3-5 years and beyond, due to their
                               alongside the medical model;                 dependency with planned longer-term changes
                          Care is integrated in commissioning and delivery in hospital services.
                               across health and social care;
                           Care planning takes into account the impact
                               and dependence on families and carers;
                            Services enable proactive care, targeted
                               at people most at risk of poor outcomes;
                             Care is provided closer to people’s homes
                               and is designed to support people to remain
                               independent and in their home environment;
                              People are supported to return to their
                               home environment, as soon as possible,
                               following admission to hospital.
26
            9     COMMUNITY SERVICES PROGRAMME, CONTINUED

            COMMUNITY MODEL OF CARE
      9.3
            The transformation of community
     services is segmented into four components:
       Community Care Teams
       Specialist Clinical Integration
       Neighbourhood Collaborative
       Managing Complex Needs

     COMMUNITY
                                                              ENABLERS
     MODEL OF
     CARE
                                                           B O UR H OO D D E L I V E R Y
                                                 NE IG H
                           L                                                                             AC
                         TA                                                     SPEC                        C
                                              MS                                     IAL
                    GI

                                                                                                               ES
                                            EA                                    ‘CAR IST C
                  DI

                                                                                                                S
                                           T
                                        RE OR’                                         E C LIN
                                      CA DO                                               LO I
                                                                                            S
                                        NG
                                                                                              CA TO
                            WR Y
                        ‘NO UNIT

                                                                                                L I HOM
                                                                                                ER
                              O

                                                                                                   NT
                                                          ERED TO SELF C
                           M

                                                        OW
                                                                                                     EGR E’
                        COM

                                                      P                  AR
                                                    EM                     E
                                                                                                        ATIO
                                                                                                            N
                                                        CARERS

                                                                                                                        WORKFORCE
       ESTATES

                                                     INDIVIDUALS
                                                       FAMILIES
                      N E I G H I S IN
                        ‘M A X

                                                                                                              E’
                                                                                                   LN EEDS
                                                                                                         A BL
                               BOU G
                               IM

                                                                                                 VU E X N
                                                                                                     ER

                                                           P R E V E N TIO N
                                  R H C OM

                                                                                                   L
                                      OO

                                                                                              MP

                                        CO                                                        O
                                         D

                                      MU L L A                                                 G C TH
                                                                                                  E

                                        NI B O R                                           I N
                                                                                        AG        G
                 PR

                                           TY      A
                                              A S S TIV E                        M A N R T IN
                                                                                                                    T
                 OA

                                                                                                                EN

                                                                                        P O
                                                   E TS’                         ‘ S UP
                  CT

                       VE
                                                                                                            EM

                                                                                                               AG
                      I

                            CA                                                                             G
                                 RE                                                                     EN

                                             HIGH
                                                    - Q U A L I T Y P R IM A R Y C A R E
Healthy Liverpool: The Blueprint   27

                                 Community Care Teams                                   needs, providing support such as benefits
                                ‘No wrong door’                                         advice and Healthy Homes assessments.
                                 Liverpool was one of the early pioneers of
                                 integrated care in the North West, bringing            Risk stratification data will be used
                                 together primary care, community, social care,         systematically to identify people who would
                                 mental health and secondary care clinicians            benefit from integrated care and more proactive
                                 to deliver care across neighbourhood-based             intervention, supporting them to retain
                                 teams.3 This has already established robust            independence, be in more control of their health
  Integration of                 systems and data flows from all general                condition and addressing their key risk factors.
  community nursing,             practices within the city; live operational delivery
  social care and                in neighbourhood teams and multidisciplinary           We have already established an approach to
  mental health                  teams working together. However this                   risk stratification that uses data from general
  teams will be fully            infrastructure is varied across the city.              practice and secondary care to predict risk of
  operational in 2016.                                                                  emergency admission to hospital. This data
                                We will establish Community Care Teams                  allows for systematic identification of people
                                within each of the city’s 18 community                  and more targeted interventions, including use
                                neighbourhoods, with ‘core’ community teams,            of specialist resources.
                                which include General Practitioners, Practice
                                Nurses, Social Workers, Community Nurses,               Similarly, for children and young people, the
                                Community Mental Health Nurses, Health                  Early Help agenda is being implemented across
                                Trainers and Pharmacists, along with other care         the city as a multi-agency response to ensure
                                professionals, voluntary organisations and              that children and families can benefit quickly
                                agencies that may be involved in delivering             from the support that they need. The delivery of
                                care, including Health Visitors and School Nurses.      Early Help, alongside other services such as the
  Early help for                                                                        Multi-Agency Safeguarding Hub (MASH) offers a
  children integrated           Key services will be co-located, within                 comprehensive and risk-based response to need.
  across health                 neighbourhood bases, to support integration
  and social care.              and multidisciplinary team working. The                 Building on the More Independent (Mi) Liverpool
                                integration of community nursing, social care           programme, we will work in partnership with
                                and mental health teams will be fully operational       the local authority to scale up the use of
                                in 2016. These teams will be key to breaking            assistive technologies, including telehealth
                                down barriers to co-ordinated care, delivering          and telecare services, targeting support for
                                a ‘no wrong door’ approach with clear points            older people and people living with COPD,
                                of access into the care system, ensuring                heart failure and diabetes.
                                access to the right care professional without
                                being passed around the system.                         Local evaluation of the impact of telehealth
                                                                                        demonstrates that for people with a high risk
                                Addressing poor outcomes for people with                of hospital admission, the adoption of telehealth
  Introducing a new             mental health issues will be a key priority             support has led to a 23% reduction in hospital
  model of extended             for our Integrated Care Teams, recognising the          admissions.
  access to primary             connection between mental, emotional, social
  care in addition              and physical health. Significant numbers of             We will scale up the use of assistive
  to the services               people with long-term or complex conditions             technologies, remote monitoring and clinical
  provided by the               also have an underlying mental health                   support, reviewing the impact of large-scale
  city’s 93 practices.          condition and experience high levels of                 deployments elsewhere in Europe. This up-
                                premature mortality and inequality of care.             scaling will also include increasing the current
                                                                                        level of service operating 8am-6pm Monday
                                A common assessment will be the norm for                to Friday, to a seven-day-a-week service.
                                people who need it, with single care plans
                                in place, available to all relevant care                A cornerstone of community service provision is
                                professionals, via shared care records, with            primary care. We will introduce a new model of
                                people holding their own Personal Health Record.        extended access to primary care in addition to
                                                                                        the existing services provided by the city’s 93 GP
                                Care Teams will adopt a proactive approach              practices. New locality hubs will be established
                                which targets people at increased risk of               to deliver 7 day services in primary care, giving
3. K
    ings Fund (2014). System
   Leadership. Lessons and      poor outcomes, alongside taking action in               greater access to routine and urgent care.
   learning from AQuA’s         the context of their social circumstances and           General practice remains the bedrock to our
   Integrated Care Discovery
   Communities.
28
                                      9        COMMUNITY SERVICES PROGRAMME, CONTINUED

                                  new model, as this is where the vast majority        Specialist Clinical Integration
                                  of people receive care and support. We will         ‘Care delivered closer to home’
                                  continue to build on the major improvements          Care will be provided in a community setting,
                                  in outcomes delivered over the past five             closer to people’s homes, unless hospital care
                                  years through the Liverpool General Practice         is necessary.
                                  Specification. Eliminating unwarranted
                                  variation in provision and standards will be        A key focus will be on supporting people
                                  a top priority, contributing to our ambition to     with long-term conditions, where there is
                                  reduce health inequalities within the city.         considerable opportunity to reduce the need
                                                                                      for hospital-based care.
                                  The role of community pharmacy has become
                                  more central over the past few years through        Significant progress has already been made
                                  initiatives such as the Care at the Chemist         on diabetes care management and plans are
                                  scheme. We will continue to enhance the critical    in place to do the same for COPD, heart failure
                                  role pharmacy plays in supporting people to         and cancer. Other opportunities include
                                  self care, by giving pharmacy a stronger role       gynaecology and musculoskeletal conditions.
                                  in the management of long-term conditions,
                                  and access to urgent and emergency care.4          There is an opportunity to realise a significant
                                                                                      reduction in outpatient appointments delivered
                                  When people do require a hospital admission,        currently within hospital settings. In addition
                                  the Community Care Team will work closely with to providing more specialist clinics in community-
                                  hospital teams to plan for discharge, with people based settings, we will also utilise digital
                                  discharged as soon as it is safe to do so. We will technologies such as virtual clinics, using tools
                                  build on the successful development of the new      such as clinical video consultation.
                                  frailty unit at the Royal Liverpool Hospital and
                                  learn from successful approaches elsewhere.        We will maximise the use of the community-
                                                                                      based estate available within Liverpool, taking
                                  Effective and cohesive reablement arrangements full advantage of the significant investment made
                                  will be introduced, with timely assessment and      within the city in neighbourhood health centres.
                                  deployment of community equipment and a single
                                  integrated health and social care community         Managing Complexity
                                  reablement team in place to support people to      ‘Supporting the vulnerable’
                                  remain in their home.                               One of Healthy Liverpool’s key priorities is to
                                                                                      narrow the inequality gap within the city. We will
                                  A new approach to community-based beds will         target support towards key groups who currently
                                  be adopted, ensuring that there is a cohesive       experience high levels of inequality in health.
                                  approach for people who need bed-based
                                  support, from hospital acute care through to       The Healthy Child Programme (HCP) is an early
                                  long-term residential care. A new model for         intervention and prevention programme that
                                  people in care homes will be put in place, with     lies at the heart of universal services for children
                                  greater provision of ‘step-up’ beds for people      and families. Failure to meet the needs of
                                  who need support but do not require specialist      children and young people stores up problems
                                  hospital beds.                                      for the future of the child; the community model
                                                                                      can play a key role in preventing escalation of
                                  The vital role that domiciliary care services play need into hospital-based or specialist services.
                                  in supporting people to retain their independence
                                  will be strengthened through increased             A key initial focus will be to design better
                                  integration with Neighbourhood Care Teams;          services to support the homeless population,
                                  the introduction of a new jointly commissioned      people with severe mental illness and people
                                  contract in 2015; and working collaboratively       with complex alcohol problems. Data clearly
                                  with services such as Ambulance and GP Out of       demonstrates that these groups experience
                                  Hours, to reduce the need for hospital admission. significantly poorer outcomes than the general
                                                                                      population and high levels of premature
                                                                                      mortality; high use of emergency care; and
                                                                                      poor access to services, including screening.
4. N
    HS England (2013).
   Improving Health and Patient
   Care through Community
   Pharmacy – A Call to Action.
Healthy Liverpool: The Blueprint   29

                                       Neighbourhood Collaborative                         Self Care and Empowerment
  The Healthy                         ‘Maximising community assets’                        There is considerable evidence that empowering
  Lung Project will                   We are clear that in order to improve health         people to take more control over their health and
  improve detection                    and wellbeing in Liverpool we will need to          conditions will lead to reduced mortality, lower
  of lung cancers and                  deliver a ‘social model of health’ that addresses   emergency admissions and better quality of life.5
  identify COPD at                     the broader influences on health, social,
  an earlier stage.                    cultural, environmental and economic factors.      Focusing initially on long-term conditions we will
                                                                                          equip people and professionals with the tools,
                                      We have much to be proud of already within the      techniques, resources and confidence to deliver
                                       city with a strong legacy of innovative approaches this approach to self care and management of
                                       such as More Independent (Mi) Liverpool, Healthy conditions. The Healthy Liverpool self care model
                                       Homes and Social Inclusion Teams. The CCG has has already been rolled out to support people
                                       continued this legacy and has commissioned a       with diabetes and COPD.
                                       range of non-medical support including Benefits
                                      Advice on Prescription, the Community Grants        Peer support models have proved successful
                                       programme and Liverpool Active City.               in Liverpool, including health trainers and
                                                                                          community champions. We will scale-up their
                                       Building on the strong relationships established   use as part of a social model of support. A new
                                      with housing associations in Liverpool we           service specification for health trainers, including
                                      will seek to maximise opportunities for joint       a review of capacity and function, will be
                                      working, delivering the key objectives of the       introduced in 2016.
                                      ‘Healthy New Towns’ programme.
                                                                                          Early Identification and Intervention
                                      A number of enablers will support the delivery of Screening, diagnosis and vaccination rates
                                      the Healthy Liverpool community model of care:      in Liverpool often lag behind other areas of
                                                                                          the country, impacting on outcomes including
                                       Prevention and Wellbeing                           mortality and quality of life. There is high
  New Centres for                     To achieve improvements in health and               variation in take-up across the city, impacted
  Wellbeing will                      wellbeing we need to raise awareness of             by factors such as deprivation, disability
  be established.                     the opportunities and risks of lifestyle            and ethnicity.
                                       behaviours, including physical activity,
                                       smoking, alcohol and social isolation.             Liverpool has some of the highest levels of
                                                                                          mortality in the country, so tackling cancer is
                                       Support services available in communities,         a major priority for Healthy Liverpool. We are
                                       such as smoking cessation, benefits and            introducing programmes to improve early
                                       housing advice, mental health, reducing social     diagnosis of cancer, which will include the
                                       isolation and improving emotional wellbeing        national ‘Be Clear on Cancer’ programme;
                                      will be fully utilised and clear information        Cancer Research UK bowel screening
                                       promoted to the public and care professionals      intervention; primary care based audit of
                                      through the ‘Live Well Liverpool’ directory and     pathways and significant event analysis of
                                       information portal.                                emergency presentations, along with increased
                                                                                          support for screening programmes to reduce the
                                      We will establish new Centres for Wellbeing,        variation in screening rates across GP practices.
                                       providing locality-based hubs designed to
                                       provide people, carers and families with           Priority is being given to lung cancer, for
                                       access to resources and support. A key focus       which mortality in Liverpool is almost double
                                      will be support for children and families, with     that of England. The ‘Healthy Lung’ project
                                       early years development and family resilience      will focus on early detection of lung cancer
                                       a major priority area.                             and COPD, aiming to raise awareness of
                                                                                          respiratory health within communities,
                                      We will build on developments such as the           targeting neighbourhoods with high mortality
                                       Liverpool Community Grants programme,              rates and high-risk groups. Through this
                                       designed to support community groups in            approach we aim to detect between 140-153
                                       providing wellbeing initiatives. Joint work with   lung cancers and identify COPD at an earlier
5. NHS National Institute for        the local authority and the voluntary sector        stage – an estimated 6,000 people in Liverpool
    Health Research (2015). A
    rapid synthesis of the evidence   will also focus on sustainability of this sector    have undiagnosed COPD.
    on interventions supporting        in light of austerity measures.
    self-management for people
    with long-term conditions.
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