1. Blueprint PrinciplesBenefitsRequirements Whole system approach, esp. for smoking, alcohol and obesity Co-ordinated campaigns across health, social care, general public work, with consistent messages Consistent prioritisation across all agencies avoiding fragmentation of efforts Campaign team Including wider system levers in plan: Health education Environmental health improvements Housing eligibility and maintenance Trading standards Licensing Standards and specifications for health and social care contracts Community development support Holistic approach that tackles underlying causes for ill-health Co-ordinating team to reach out to all agencies and to drive for consistency of programmes People encouraged and supported to take greater responsibility for their health and healthy choices People become true partners in care: manage parts of pathways themselves, take part in active prevention and make healthy lifestyle choices Campaign to increase people’s willingness to take on responsibility for own care (culture change) Suitable information content and communications channels Enhanced capacity of communities and individuals to support themselves and each other Greater awareness of health (physical and mental) and social needs and more looking out for each other in community (neighbours and volunteers helping) Education/campaign team Information materials Volunteer and informal carer support Health and Wellbeing System 1

2. Blueprint PrinciplesBenefitsRequirements People are supported to take greater responsibility for their own care People become true partners in care: manage parts of pathways themselves, take part in active prevention and make healthy lifestyle choices People willing to take on responsibility for own care (culture change) Suitable, easily accessible information Accessible, responsive and reliable support 24/7 when questions and issues arise Incentives (?) People are fully informed and take part in planning their care Avoiding unnecessary and ineffective care People take more of their own care decisions Easy access to easy-to-understand information Access to up-to-date care plans and care records People make earlier decisions about their own EoL care Earlier discussion on EOL patient preference with reduction of excessively aggressive treatments Info about EOLC service options Cultural acceptance of “natural” death 24/7 responsive and reliable support service for crises People are supported to stay at home and independent for longer Reduce avoidable hospitalisations Ability to receive treatments that otherwise would have needed hospital (greater convenience for patients) 24/7 responsive and reliable support service for crises Supported housing and domiciliary care enables people to stay in their homes longer Avoid unnecessary admissions for “social” reasons Healthier homes (e.g., less cold/damp, less falls risk) Well co-ordinated social/domiciliary care services Local community and voluntary organisations provide more support to people and carers Support at home by neighbours and volunteers Support within the community by volunteers Overall greater awareness of “look out for each other” Culture of helping each other Info/education for volunteers and community at large Self and Informal Care 2

3. Blueprint PrinciplesBenefitsRequirements Comprehensive New Primary Care responds 24/7 Receive and respond to all calls 24/7 Deals with most calls, refers on only few Call handling protocols Call centre Sufficiently senior clinicians (e.g., GPs) on call Practice clusters that offer diagnostics and other extended services Diagnostics (imaging) in the community Some specialist services in community More therapies in community Suitable facilities (within some GP practices or community centres?) Easier access 24/7 Someone within NPC responds always Single phone number Call handling protocols Universal electronic record system All professionals can access same records Data protection protocols Access to suitable IT system MDT-teams based around health centres, or community hospitals All professionals work as a team with good communications Shared record and care plan MDT processes Risk profiling and proactive outreach to people at risk of deterioration People at high risk of developing condition targeted for prevention People at risk of deteriorating proactively contacted and treated Risk stratification tool Processes and team capacity to respond New Primary Care (1/2) 3

4. Blueprint PrinciplesBenefitsRequirements OOH is integral part of New Primary Care OOH run by/integrated with GP practices (by cluster?) Call handling protocol and call centre Access to GP records (IT systems) Adequate staffing levels (if GP and community staff deliver part of OOH) Dedicated processes for scheduled and unscheduled care Unscheduled care does not disrupt scheduled care and is expecting patients Dedicated practice capacity for unscheduled care Population health is part of NPC’s responsibilities Primary prevention and health education has greater role in practices Active working with Public Health NPC ‘owns’ their patients along the entire pathway Named ‘lead’ clinician for patients who remains involved and in control Clinical governance for lead clinicians Communications protocols for ‘lead’ NPC can access intermediate care GP can admit into intermediate care beds Intermediate care beds Clinical governance Integrated assessments One single needs assessment for health and social care Suitable joint protocols and skilled staff Care coordinators for patients with complex needs Dedicated/named professional help patients navigate the system Skilled care coordinators Access to specialist opinion without referral GP/lead clinician can ask specialists opinion without referral Clinical governance “On phone” specialists New Primary Care (2/2) 4

5. Blueprint PrinciplesBenefitsRequirements 111 call centre gives helpful advice and is supported by GPs Advise people on self-care Discuss with people at what point to seek further help Qualified and sufficiently senior staff answering phones Call centres and call management protocols Clinical governance Call handlers know what local services are available and when Call handlers can direct people (and potentially GPs/lead clinicians) to available services Process to keep directory of services up-to-date and manageable See-and-treat by paramedics in the field Default for urgent but not emergency care is to be provided in patients’ homes with expanded range of services Access to medical records and care plans MCS are integrated part of NPC team (same care protocols/processes and medical records), or at least integrated operationally MCS clinicians are part of a care team, rather than just the “urgent care” provider who ties people over MCS clinicians may still be employed by another agency (e.g., ambulance service) to operate efficiently on a larger scale) Processes to keep Paramedics/MCS clinicians involved Integrated care records Designed and formally agreed protocols and processes Mobile Clinical Services 5

6. Blueprint PrinciplesBenefitsRequirements Enhanced assessments and diagnostics en route Start more care en route Qualified staff Protocols and clinical governance Suitable equipment Same universal care protocols Urgent care protocols the same regardless of care setting Agreed, standardised protocols Access to universal medical records All care professionals have access to universal records all the time Suitable record system Conveyance can be to GP practice, or other community-based care setting A&E is not automatic destination but patients could be taken to GP practice Urgent care services outside of A&E Clear protocols for triage More patient transport provided by volunteer and community support teams More non-urgent patient transport to be provided by others than ambulance Suitable transport organisations/capacity Urgent Transfer Services 6

7. Blueprint PrinciplesBenefitsRequirements Separate processes of scheduled and unscheduled care More efficient scheduled care without “disruption” by urgent cases Urgent cases “expected”, not an add’l “burden” Large enough provider units to keep both scheduled and unscheduled care areas above critical mass Concentration of highly specialised services in larger centres For services that are only needed infrequently or are highly specialised greater travel distance is acceptable Sufficient capacity at specialist centres Specialist centres at still acceptable distance Hospital-based urgent care is integrated with NPC and mobile services Patients seen at A&E are advised to seek local help first Adequate NPC-based urgent care capacity Clear arrangements between specialists and NPC about hand-offs, clinical responsibility and risk Specialists and GPs work as one team with one lead clinician Clinical governance Quality monitoring Clear protocols Ongoing monitoring and rapid learning to adjust care supply to demand Provider capacity responds to demand, rather than supply inducing demand Close intelligent activity monitoring Contractual flexibility Hospital-based MDTs facilitate care handover to NPC and use universal medical records All care is provided by default in NPC, even ongoing specialist input Adequate expertise and capacity in NPC to take on care New Secondary Care (1/2) 7

8. New Secondary Care (2/2) 8 Blueprint PrinciplesBenefitsRequirements Health promotion role with full access to support services From hospital people can be referred to prevention and health promotion services Referral protocol Responsive prevention and health promotion service and capacity Proactively link physical and mental health Psych liaison services at hospitals Psych liaison service Shared understanding when patients should be referred GPs and consultants adhere to standardised referral guidelines Agreed referral guidelines Clinical governance Agreement between West Kent specialists and tertiary care about referral criteria and how to access tertiary advice without referral Secondary care consultants can access tertiary advice without referral Tertiary advisory service Clinical governance Coordinated and simplified care for patients with complex needs Multiple treatment protocols are pulled together into a synthesised, as-simple-as- possible care plan Competent clinician who can synthesise treatment regimens into one simplified care plan

9. Blueprint PrinciplesBenefitsRequirements Information sharing protocols as first step towards universal medical records Allow all care professionals access to real- time patient record and care plans from anywhere Data sharing protocols Suitable record system Remote access to such system Improved communications and relationships amongst professionals of different organisations Fast and responsive back-and-forth communication between care professionals involved in an individual patient’s care Communications platform Availability of care professionals to respond rapidly Greater use of electronic communications Greater shift away from paper letters and faxes to electronic transmissions Communications processes Clear risk management agreements Commissioners and providers are incentivised to keep patients well and to reduce overall care costs Funding model that incentivises best outcomes at minimum costs Culture of personalised care, collaboration and joint ownership of effectiveness of care Genuine and universal prioritisation of quality of care at minimum costs Shared culture and incentives Enabling systems and processes 9