Liverpool: A Comprehensive Approach to Health and Equality, Lecture notes of Business

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One Liverpool: 2018- 2021

The Long and Winding Road to a Healthier Life

Contents

• Contents
• 1 Introduction
• 2 Our Challenges
  • 2.1 The System Challenge
  • 2.2 The Financial Challenge
  • 2.3 Our Environment
• 3 Healthy Liverpool Legacy
• 4 Our Vision, Aims and Objectives
• 5 Our Strategy – One Liverpool
• 6 Radical Upgrade in Population Health and Prevention
• 7 Integrated Community Services
• 8 Acute and Specialist Services Sustainability
• 9 National Service Improvement Priorities
  • 9.1 Primary Care
  • 9.2 Mental Health
  • 9.3 Cancer
  • 9.4 Urgent & Emergency Care
• 10 High Impact Priorities
• 11 Delivering the CCG’s Core Responsibilities
  • 11.1 Integrated Commissioning
  • 11.2 Our Commitment to Quality
  • 11.3 Managing Risk
  • 11.4 Delivering for Today - 2018/19 Operational Plan
• 12 Financial Sustainability
• 13 Enablers
• 14 Next Steps
• 15 Conclusion......................................................................................................
• 16 Appendices.....................................................................................................

2 Our Challenges

Liverpool faces a number of challenges in our efforts to improve health and services. A review of Liverpool’s Joint Strategic Needs Assessment (JSNA) has given us a fresh understanding of health and wellbeing need in Liverpool, providing essential insight to inform our plan.

A Growing and Ageing Population Liverpool is resurgent after many years of economic decline; yet high levels of deprivation endure in parts of our city and people still die younger than in other parts of England.

Liverpool has a relatively young population when compared to the rest of the country, with an average age of 37.7 years compared to 39.8 years for England.

There are around 484,600 people living in Liverpool, a 9.7% increase in the population since 2001, representing a welcome shift in the long term trend of population decline. In April 2016, there were 514,630 people registered with a Liverpool GP, an increase of 7.1% (34,280) people over the last ten years. Projections suggest the increase in the number of Liverpool residents will continue to increase, with an estimated population of 510,000 by 2030. Although our population is growing, it is doing so at a lower rate than many other areas. Over the next ten years plus, the largest population increase is predicted in people aged 65 and over (27.1%), which presents a challenge for the local NHS and social care, with an expected increase in health issues affecting older people, including long term conditions, cancer, dementia and injuries due to falls.

Deprivation and Inequalities Liverpool is one of the most deprived areas of the country, with more than 4 out of 10 people living in the 10% most deprived neighbourhoods in England. Deprivation is strongly associated with poor health outcomes, from childhood through to old age. We know that people in our more deprived communities begin to experience poor health and require care from a much younger age, leading to significant health inequalities between Liverpool and the UK as well as within our city, where the difference in life expectancy is 10 years between the poorest and most affluent wards. Liverpool is a diverse city and people can experience inequality in health, access to healthcare and quality of health services. For example, people with a learning disability on average die 20 years younger than people without a learning disability. We have a collective responsibility to tackle discrimination and advance equality.

Health and Wellbeing A review of the health of our population tells us:

 There were 4,500 deaths in Liverpool in 2016, 1000 of which were attributable to smoking  1,800 of these people died young  1,000 of these deaths were preventable  Our biggest killers are cancer (30%), Cardio-Vascular Disease (20%), Respiratory Disease (15%)

People in Liverpool live shorter lives than the national average, and spend a greater proportion of their life living with disability and poor health. Measures for healthy life expectancy - not just whether years are being added to life, but life added to years - highlight that our population spend a quarter of their life living in poor health.

Healthy life expectancy for men in Liverpool is 57.4 years, and 57.7 years for women. As our older population grows, our main challenge will be to achieve significant improvements in healthy life expectancy – keeping more people well for longer.

The main diseases that rob people of healthy years of life in Liverpool are poor mental health, cardiovascular and respiratory disease

Source: Public Health Epidemiology team, Liverpool City Council

Long Term Conditions The majority of diseases that impact on years of healthy life in the city are long term conditions (LTCs).The number of people diagnosed with LTCs in Liverpool is above national levels for cardiovascular disease (CVD), respiratory disease, diabetes, dementia, cancer and kidney disease. We also know that these figures understate the true extent of the situation, with many people undiagnosed.

Mental Health In Liverpool, over 66,000 people have a mental health condition, with depression, anxiety and serious mental illness depriving many of a good quality of life. Deprivation contributes considerably to poor mental health. For individuals and their families it can mean disrupted lives, limited life opportunities, financial hardship, poor education and employment prospects and social isolation.

Children and Young People Children and young people represent 33% of Liverpool’s population. The Liverpool Joint Strategic Needs Assessment (JSNA) tells us:

 There were 5.2 infant deaths per 1,000 live births in 2014-2016, significantly

higher than the England rate.

 One in seven mothers smoke at the time of the delivery, compared with one in

nine nationally.

 Only 54% of Liverpool mothers initiated breastfeeding and only 32% were

breastfeeding 6-8 weeks after the birth of their baby, compared to national figures of 74% and 43% respectively.

 Liverpool has a high rate of A&E attendances for children aged 0-4 years, 60%

higher than England.

 One in four of our children aged 4-5 years were either overweight or obese.

 Only 6 out of 10 Liverpool children have a good level of development at the end of their school reception year, compared with 7 out of 10 nationally.

Too many of the city’s children face a difficult start in life. We know that adverse experiences in early life often shape a child’s future, leading to a greater risk of social, emotional and cognitive impairment, influencing negative health behaviours, a higher risk of disease/disability and earlier death.

Traditionally, the focus by the NHS has been on improving clinical care. Whilst this remains a priority, it is clear that we need to do a lot more to tackle non-medical issues. This has also been a consistent message from the public through previous engagements.

2.1 The System Challenge Liverpool has a diverse and complex health and care system, with eight NHS provider trusts including 2 large adult acute hospitals within 5 miles of each other, a children’s acute trust, a women’s acute trust and four specialist trusts, located in the city but serving the wider region. The key partners within the Liverpool health and social care system are:

 Liverpool City Council

 NHS Liverpool CCG

 92 General Practices

 Urgent Care 24

 Mersey Care NHS FT

 Liverpool Community Health NHS Trust (transacting to Mersey Care, April 18)

 Alder Hey Children’s Hospital NHS FT

 Royal Liverpool Broadgreen University Hospital NHS Trust

 Liverpool GP provider organisation.

 University Hospital Aintree NHS FT

 Liverpool Heart and Chest Hospital NHS FT

 Liverpool Women’s Hospital NHS FT

 The Walton Centre NHS Foundation Trust

 North West Ambulance Service NHS Trust

 3,055 voluntary sector organisations; 1,332 of which are registered and some 1,723 are ‘below the radar’ organisations.

There is significant variation in quality and duplication in services, both clinically and non-clinically. We also have a complex commissioning system and a large, but fragmented voluntary, community and social enterprise (VCSE) sector.

Over the last five years our health and social care system has been on a journey of change and integration, driven by the need to address significant challenges in delivering better care and improving clinical standards. We have made good

progress on this journey but in the next three years a further step change is needed in order to achieve better outcomes.

2.2 The Financial Challenge The Liverpool health and care system is facing increasing financial challenge with both commissioner and providers experiencing significant pressures.

From a commissioner perspective, LCCG has experienced a difficult recent period, needing to deliver increased levels of cash releasing savings (£13m and £26m, in 2016/17 and 2017/18) in order to deliver its financial targets. Social care and prevention has also been impacted by reductions in central government funding to Liverpool City Council, with overall funding reduced from £523.7m in 2010/11 to £246m in 2019/20, representing a real terms reduction of 64%. The current NHS provider financial position is expected to further deteriorate when the 2017/18 picture is declared over the next few weeks.

Whilst the CCG ‘resource’ allocation is expect to rise to £918.3million by 2020/ (from £888.1million in 2018/19) based on current allocation growth assumptions, NHS and social care budgets are subject to on-going pressure from increasing demand, new treatments, innovation and increasing costs. An initial estimate of the Do-Nothing gap for the North Mersey System was estimated at £352m over a 5 year period and current financial performance would indicate broad alignment with those trajectories.

In order to support transformation, NHS commissioners and providers across Liverpool (and the neighbouring areas of Sefton and Knowsley) came together to ‘ Act as One’ by agreeing fixed price contracts for 2017/18 and 2018/19, in order to share the risk of managing increased demand and to support a shared plan to find longer term transformation solutions. This two year all-system deal is testament to the strong collaboration that has developed in our health system, with providers and commissioners collaborating to address the challenges we will face in the years ahead. Our aim is to build upon this trust to agree joint approaches to making best use of resources beyond 2018/19.

This partnership approach to addressing financial pressures is also demonstrated by the pooling of NHS and Council budgets within the Better Care Fund, to maximise the impact of our joint resources at the interface of health and social care. Liverpool health and care commissioners are currently exploring the opportunities that could arise from further integration of commissioning.

3 Healthy Liverpool Legacy

Healthy Liverpool was the CCG’s five-year transformation programme to transform health and services in the city. The programme was established to enact the recommendations of the Mayoral Health Commission^3. Healthy Liverpool’s vision was to improve the health of people in the city; supporting more people to stay well for longer and providing the very best treatment and care when needed. A review of has been undertaken to understand its impact in improving outcomes and to identify lessons learnt to inform how we can effectively plan and deliver well in Liverpool.

The review of outcomes undertaken indicates that Healthy Liverpool has been successful in achieving a range of clinical service improvements, particularly programmes which have held back demand for hospital services. We have had less success in tackling the long term challenge of premature mortality and reducing health inequalities, with preventable mortality continuing to increase, and the inequalities gap as wide as ever.

Now is the time to build upon the system collaboration and maturity that has developed through Healthy Liverpool and to use this learning and the good progress we have made as springboard to go further and faster in achieving system integration and better outcomes for our city.

4 Our Vision, Aims and Objectives

The vision for One Liverpool is a whole-system vision for all partners with a role to play in delivering our objectives:

Partners in Liverpool will come together to create a ‘One Team’ ethos and a place-based system change for better health, reduced inequalities and maximising the impact from our shared resources

Our Aims

One Liverpool has three transformational themes:

• A radical upgrade in population health and prevention
• Integrated community services, bringing communities to life
• acute and specialist services sustainability

(^3) http://liverpool.gov.uk/media/8680/healthcommissionerport2.pdf

Outcome Ambitions

We will continue to strive for ambitious improvements in health outcomes for the people of Liverpool. Our ambitions are to:

1. Reduce Avoidable and Early Deaths
2. Increase Healthy Years of Life
3. Reduce health inequalities
4. Improve Quality of Life and Ability to Self-care
5. Reduce Demand for Hospital Services
6. Establish Seamless, pro-active care; integrating services across health and social care
7. Improve the delivery and experience of care
8. Achieve parity of esteem between mental and physical health
9. Ensure children have a good start in life
10. Ensure a financially sustainable health and care system for the city

System partners are working together to set measurable targets for our shared outcome ambitions, some of which are already set through the operational planning process and others soon to be determined. The measures we will use to measure success are:

Outcome Measure Ensuring children have a good start in life

Improving the infant mortality rate

Improving levels of school readiness with a higher percentage of children with a good level of development Improving levels of childhood obesity (ages 10-11)

Reducing premature mortality from Cancer, CVD and Respiratory Disease and improving healthy life expectancy

Improving the healthy life expectancy rate

Improving the premature cancer mortality rate

Improving the premature CVD mortality rate

Improving the premature respiratory mortality rate

Reducing health inequalities Reducing the gap between Liverpool and England for the key premature mortality indicators

Achieve parity of esteem between mental health and

Increasing the proportion of people with a Mental health condition receiving a list of physical checks

 We will simplify complexity: improving access to the right care in the right place and providing care navigation for people who need it.

 We will plan for the right care in the right place: delivering more hospital- based services in our communities.

 We will maximise community assets: making full use of the rich and diverse assets that exist in our city neighbourhoods, recognising that health and wellbeing is influenced not only by health and care services, but also social, cultural and economic factors.

Values

We propose a set of core values to guide our conduct and interactions with each other, with staff and people:

 Accountability: We will accept responsibility for our actions. We will make decisions through evidence and sound systems and processes, and we will deliver our intentions.

 Equity: We will be fair in our interactions with patients, public, staff and partners.

 Integrity: We will act with honesty and transparency in all our actions. We are committed to a teamwork environment, where everyone is valued, encouraged to contribute and recognised for their efforts.

 Listening: We will actively listen and act upon feedback from our communities, staff and partners.

 Collaborative: We will ensure our partnerships are positive and constructive, in the pursuit of shared goals.

 Progressive: We encourage innovation and continuous improvement in all services.

 Value: We will target our resources in the most effective way to ensure maximum value. We will tackle inappropriate care; address unwarranted variation in clinical practice and use evidence of to find better ways of delivering care and support services for specific patient groups

5 Our Strategy – One Liverpool

Despite having excellent community and hospital services, a thriving VCSE sector and high quality social services, we are not solving the city’s intractable health challenges; particularly preventable deaths and years of healthy life, and we are not making inroads into health inequalities.

We know that individuals and families with the most complex needs experience multiple interventions from different services and agencies and yet all too often remain trapped in repeating cycles of intervention. People’s lives and associated health problems are increasingly complex and require services to work together in order to be effective, but all too often individual organisations offer services in isolation.

Health and social care organisations in Liverpool have a unique opportunity to create a ‘One Team’ ethos and a place-based system change to achieve better health outcomes, uniting primary care, social care, community, physical and mental health services and the voluntary sector.

In addressing the challenge of health inequalities, our actions must be universal, but with a scale and intensity that enables us to tackle high levels of disadvantage in some parts of our city, informed by the principle of proportionate universalism^4.

In order to achieve this there’s a need for fundamental changes in how we commission and provide health and social care and we want to forge a new deal with wider partners and with our population.

We are working together to develop and implement the One Liverpool plan, which sets out how we will harness the collective influence and resources of the NHS, Liverpool City Council, the housing sector and other public partners, VCSE organisations and the people of Liverpool to pull in the same direction, working to a clear vision and aims to improve health and wellbeing.

 One Liverpool will be about Liverpool people and the place, above the needs of organisations;  One Liverpool will scale up our ambitions around prevention, early intervention and self-care;  One Liverpool will improve and re-shape primary, community and social services, building upon the Healthy Liverpool community model of care, as the cornerstone of place-based care;  One Liverpool will implement the vision for high quality, single services for our acute and specialist hospitals;  One Liverpool will find solutions to address the clinical and financial sustainability challenges we face as a whole health and care system.

(^4) http://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf

We also believe that a life-course approach is central to this aim, recognising that health outcomes in early childhood play a significant part in health outcomes in adulthood and older age.

Liverpool’s health and care system has a multitude of assets, including outstanding facilities and people who are passionate about delivering good care, but we are not maximising our collective potential to address the intractable health problems in our city. It is beyond the ability of any one organisation or sector to influence the wider determinants of health so we are calling for a much greater degree of integration. The role of Liverpool City Council is crucial, along with other public services, business, academia, and most importantly the people of Liverpool as engaged participants.

The One Liverpool approach to prevention will integrate the Liverpool Mayoral Inclusive Growth Plan, the aim of which is to harness the support of local businesses, employers and residents to maximise the value of the Liverpool Pound and to see the distribution of work, prosperity and opportunity spread more fairly. The Inclusive Growth Plan has six aims, all of which have the ability to positively impact upon the health of our population:

Our collective actions will include:

 Preventing ill health by delivering healthy public policies and changing behaviour to increase healthy lifestyle choices. Our ‘Health in all policies’ approach aims to

make every individual’s default decision healthy, including supporting parents to make healthy choices for their children.

 Developing a chronic diseases prevention programme which delivers prevention at scale.

 Developing an integrated pre-birth – 19 healthy child programme, incorporating a programme of action for the first critical 1001 days and working with partners to maximise school readiness. Our aim is for all our children to be safe, healthy, active and happy; that they have a voice and to demonstrate our ambition by becoming a UNICEF Child friendly City.

 Strengthening arrangements to protect the health of the population to prevent and control infectious diseases, including antimicrobial resistance; screening and immunisation; emergency preparedness and air pollution.

What do we want to achieve?

 To reduce health inequalities within the city, and between Liverpool and the rest of England

 To increase healthy life expectancy, and particularly amongst those with the poorest healthy life expectancy

 A measurable improvement in mental and physical health and wellbeing

 More people moving into economic activity and employment

 Reduction of avoidable spending on downstream NHS and social care services.

 A sustained reduction in the infant mortality rate, narrowing the inequalities gap within the city and between Liverpool and the rest of England

 Increase the proportion of children at a good stage of development for school

 Reduce the prevalence of obesity among children in Reception and in Year 6

Prevention needs to be everybody’s business and we have to find ways of resourcing and supporting up-scaled prevention programmes in the face of continued pressures in our health and care system. This will require creativity and a long term commitment to improving healthy life expectancy.

Our action now is to develop an integrated, One Liverpool population health plan which sets out our ambition; the measurable changes we want to achieve; evidence-based integrated programmes of delivery and how we will come together to do this.