Kingston s Clinical Commissioning Group, Adult Social Care and Public Health Services. Integrated Operating Plan 2015/16

Transcription

1 Kingston s Clinical Commissioning Group, Adult Social Care and Public Health Services Integrated Operating Plan 2015/16

2 CONTENTS Page 1. Introduction 3 2. Quality and Patient Safety 4 3. Voice and control for people in Kingston 5 4. Children and Young People 6 5. Integrated Health and Care Services for Adults 7 6. Mental Health 8 7. Primary Care 9 8. Urgent and Emergency Care Cancer Prevention and Treatment Services End of Life Care Socially Excluded and Disadvantaged Groups Health and prevention Integrated Commissioning of Health and Adult Social Care 15 Appendix 1 How this plan addresses the priorities in The Forward View Into Action 18 Appendix /16 Kingston CCG and Adult Social Care Budgets 19 Appendix 3 Kingston CCG 2015/16 Quality, Innovation, Productivity and Prevention (QIPP) programme 20 summary Appendix 4 Supporting Documents 21 Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 2

3 1. Introduction Kingston Clinical Commissioning Group (the CCG) and the Royal Borough of Kingston (the Council) are continuing to develop ways in which to collaborate on commissioning for the benefit of the population of Kingston. This plan brings together priorities that Kingston s CCG, Adult Social Care and Public Health have identified into a single document for the first time. These priorities are derived from previously published documents such as the Joint Strategic Needs Assessment (JSNA), the Health and Well Being Strategy and the CCG Commissioning Intentions. This plan should be read alongside these and the other documents listed in Appendix 4. The priorities identified in this plan are deliberately described at a high level so that the document acts as an easy reference guide for our population, partners and staff. The delivery of the priorities is supported by detailed plans. Delivery is monitored by the Collaborative Leadership Team that brings together CCG, Adult Social Care and Public Health directors. The original plan covered the period 2014/ /16. This version of the plan has been updated for 2015/16 to ensure that it reflects the priorities identified by our population and partners and national policy drivers including the Care Act and the NHS Five Year Forward View We welcome any feedback on the document please to communications@kingstonccg.nhs.uk Tonia Michaelides Chief Officer, Kingston Clinical Commissioning Group Sue Redmond Interim Director of Health and Adult Services, Royal Borough of Kingston upon Thames Jonathan Hildebrand Director of Public Health, Royal Borough of Kingston upon Thames Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 3

4 2. Quality and Patient Safety Aim: To achieve visible leadership in quality improvement across health and care commissioning and provision, embedding the learning from the Francis, Berwick and Winterbourne reports into local services Continue to contribute to the regular health & social care quality information sharing meeting, led by RBK and aligned with providers, using SBAR (Situation, Background, Assessment and Recommendation) tool Maintain mature relationships with providers include 15 steps (quality from a patient s perspective) and walk rounds Focus attention on lower value contracts with providers to develop and improve quality reporting Be an active member of the London Quality Surveillance Group and work collaboratively with other CCGs and Local Authorities on issues of quality and patient safety Ensure requirements and good practice in Adult and Children s Safeguarding are rigorously applied (ref Care Act 2014) Extend the use of focused user outcome measures to all Adult Safeguarding investigations Reduce the number of Health Care Acquired Infections being reported by our providers Ensure the 6 action areas and 6 Cs behaviours of Compassion in Practice are rolled out across providers Continue and expand the current projects to improve medicines safety optimisation in care homes Improve access and sharing of data across health and social care Deliver the London Quality Standards and equivalent in line with the trajectories set out in the SW London 5 year strategic plan Establish a culture where health and care providers raise their own concerns with commissioners which triangulate with other information to enable intelligent decision-making and appropriate action Kingston CCG s Integrated Governance Committee receives quality reports from all health and care commissioned providers Commissioners gain assurance from providers against a set of agreed standards and early warning systems are in place Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 4

5 3. Voice and control for people in Kingston Aim: To ensure that the voices of patients, carers and the wider population are central to the development and delivery of both their own health and care and the health and care services provided in Kingston Develop a joint engagement strategy across health and care commissioning to ensure service user engagement throughout the commissioning cycle, in order to drive improvements in service quality Ensure that the insights of people in Kingston and frontline staff, derived from the voice of the customer project, inform health and social care commissioning Ensure providers involve patients in the root cause analysis arising from any Serious Incident Integrate learning from complaints and feedback into practice Continue to commission Kingston Voluntary Action to disseminate health and social care information and support and contribute to the development of local strategies Support people with long term conditions to have personal health budgets Keep the Joint Strategic Needs Assessment (JSNA) under development and ensure that it incorporates the views of patients and the public by adhering to the 'Principles of Community Voice' guidance Ensure women have the opportunity to discuss options for birth, including choice of place of birth, reflecting the commitments in the SW London 5 year plan A measured improvement in service users experience of health and care services Real involvement of patients and carers in the development of individual care plans and wider service planning and development Feedback is used to inform commissioning processes Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 5

6 4. Children and Young People Aim: Children and Young People are able to access the right service in the right place and the right time and have a positive experience of care Continue to identify opportunities for collaboration and joint commissioning with the Local Authority and schools, and through the work of the South West London Commissioning Collaborative Embed the new statutory duties of the Children and Families Bill and expand the offer of Personal Health Budgets Review the transition pathways for vulnerable young people requiring ongoing care into adulthood Support the full implementation of the Healthy Child Programme and the arrangements to transfer of commissioning responsibility for Health Visiting to the Local Authority from NHS England Review the provision of Speech and Language Therapy, Occupational Therapy and Physiotherapy in the community Review the health arrangements in place for Looked After Children and ensure the recommendations of the most recent CQC inspection and Serious Case Reviews are implemented Identify approaches to ensuring that children and young people are involved in the design and delivery of local services Children and young people have a positive experience of care, feel empowered in decisions about their care or treatment and have improving levels of health and wellbeing Support children and young people to achieve their full potential Improve the experience of transition for those service users moving between children and adult services Collaborative working across professions and integrated commissioning Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 6

7 5. Integrated Health and Care Services for Adults Aim: To improve choice, outcomes and experience of care for vulnerable adults, people with long term conditions and the frail elderly within our population Under the leadership of the Health and Wellbeing Board, develop and deliver the Kingston Coordinated Care programme that will o Support the development of active and supportive communities in which people are enabled to stay healthy and well, living independently as part of thriving and resilient communities o Develop truly customer-centred care that supports people with complex needs to achieve the best possible quality of life and the goals that matter to them with an increased focus on prevention, proactive care and self-reliance The Kingston Coordinated Care programme includes developing and implementing an Active and Supportive Communities strategy that will focus on o Customers and communities having a voice and being able to influence and engage with decision making o Appropriate access to universal services and provision in the VCS for all, particularly socially excluded and more disadvantaged groups and people at risk of ill health o Supporting people with existing health and social care needs to maintain as much independence in their lives as possible o Creating a more co-ordinated and extensive information and advice provision that supports resilience. The provision of information and advice by a voluntary and community sector alliance will be piloted during 2015/16 in preparation for commissioning a service for 2016/17 The programme also includes Improving Care for People with Complex Needs by o Delivering the nationally mandated Better Care Fund to improve the integration of services for people with complex needs, reduce unnecessary hospital admissions and delayed discharges. o Designing a new model of care and operating model for people with complex needs o Commissioning and contracting for the new operating model and transitioning to a new provider landscape Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 7

8 The scope of the programme is currently being defined and it will include, or align with the following priorities: o Develop an approach to the provision of short term beds as part of the Older and Vulnerable People s Housing Strategy o Review and refresh the Learning Disability Strategy to inform commissioning o Pilot assessments for carers by Kingston Carers Network o Implement the changes brought in by the Health and Social Care Act o Strengthen care management in the integrated team as part of Kingston at Home o Extend seven day decision-making and care provision, including the delivery of the clinical standards for seven day working o Roll-out Kingston Health Passport to provide an interoperable digital health record for all Kingston registered patients Improved outcomes for people in Kingston, as defined by them Improved staff effectiveness and experience A system focused on keeping people healthy and well, on self-reliance and on community resilience Care is provided in the most appropriate and safe setting with fewer inappropriate admissions to hospital and care homes and timely and coordinated transitions out of hospital Reduced duplication, fragmentation, complexity and waste in service delivery A viable and sustainable health and care system Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 8

9 6. Mental Health Aim: Improve mental health and wellbeing, extend local mental health services and support for carers, and provide effective mental health commissioning leadership for a wider area Continue to be fully engaged and committed to the No health without mental health programme and to addressing patients physical and mental health needs Translate the requirements of the Five Year Forward View and Mental Health Crisis Care Concordat into practice Divert targeted secondary care patients into effective crisis services and enhanced primary care mental healthcare services Increase partnership working by fostering strong relationships with local authorities and the third sector Increase engagement and co-production with service users, carers and provider services Provide a Psychiatric Street Triage Service to working with the police offering interventions and advice to ensuring triage to the right service Increase the range of services available in primary care by achieving 100% coverage of the Kingston population by GPs with the mental health diploma and implementation of a GP-led Community Dementia Service Implement a 24/7 Liaison Psychiatric Service in Kingston Hospital Implement 24/7 Crisis and Home Treatment Teams which meet the national staffing level guidance Develop crisis beds/housing for people who are undergoing a mental health crisis but do not require an acute admission Develop a dementia friendly community Improve timely access to services by ensuring providers maintain rigorous standards for follow-up; providing a crisis helpline and reducing waiting times from first referral Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 9

10 Kingston will achieve the national diagnosis rate for dementia The Liaison Psychiatric Service will result in improved service user experience, greater support to patients with dementia, reduced waiting times in A&E and reduced lengths of stay By reducing the number of patients in secondary care services we will improve the quality of care to those in CMHTs Pilot Street Triage services have demonstrated decreased use of Section 136 and inappropriate attendance at A&Es Achievement of the new waiting time standards for people entering a course of IAPT, penetration and recovery targets Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 10

11 7. Primary Care Aim: Support primary care in core provision and in tackling new requirements, seek to assure quality and consistency in patients experience and establish a longer term plan for primary care in Kingston Continue to provide support and funding to general practices for the further development and implementation of care planning and care coordination for higher risk patients. Learn from experience and other evidence and seek to replicate good practice widely with the aim of increasing proactive and preventive interventions As part of Kingston s Better Care Programme enable general practice to develop its central role in multi-disciplinary and multi-agency working. Support continued improvement in the already close working between general practice and community health services and increase the involvement of hospital specialists, social care and mental health professionals Explore the potential for a programme of work to improve GP Access Increase the capability across general practice in specific priority areas including mental health and cardiovascular disease In the light of SW London, London-wide and national strategies for primary care transformation, develop a local strategic development programme for primary care which will include primary care workforce (especially nursing), estates and IT so that local primary care is well placed for future changes and challenges Implement the joint level of primary care co-commissioning via a joint committee with the other SW London CCGs and NHS England. Prepare for the delegated level from April 2016 Support the further development of federated working between general practices across Kingston through Kingston GP Chambers. Enable this organisation to play a central role alongside other major local providers in shaping and introducing new models of care A clear strategic development programme for primary care with specific short term priorities identified and pursued An increasing emphasis on proactive and preventive intervention for particular patient groups Development of primary care staff, infrastructure and organisations Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 11

12 8. Urgent and Emergency Care Aim: To build on the achievement of the Kingston Systems Resilience Group in actively engaging all key partners in the development and implementation of a whole system plan Ensure cross-system plans and services are in place early to ensure systems resilience Procure an integrated GP Out of Hours and NHS 111 service Develop and implement local alternatives to A&E attendance. Potential options include improving access to other timely advice and support; an urgent care front end at Kingston Hospital; GP-led health centre provision; an urgent care service at Surbiton Health Centre Evaluate the Co-Responder pilot in which a paramedic and a community nurse respond to category C 999 calls and embed the learning Enhance the NHS 111 Directory of Services to signpost service users to right services not just A&E Review and refresh the membership of the Systems Resilience Group to ensure it functions as an effective Urgent and Emergency Care Network; assure the delivery of the 5 key elements of the national Urgent and Emergency Care Review; assure the provision of high quality, seven day urgent and emergency care services outside hospital Improved patient satisfaction with Kingston s urgent and emergency care services Reduce patients reliance on A&E to gain access to urgent treatment Achievement of outcome measures associated with urgent and emergency care including the 4 hour A&E waiting time target Increase choice and access to urgent care services An integrated GP Out of Hours and NHS 111 service Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 12

13 9. Cancer prevention and treatment services Aims: Ensure a comprehensive range of cancer prevention and treatment services are in place, and ensure they are fit for the future. Review cancer prevention and treatment services in light of the London Cancer Strategy Continue to commission and provide prevention services Work with the South West London Commissioning Collaborative and NHS England to ensure a full range of cancer treatment services are in place and accessible for Kingston residents and waiting time targets are met Further enhance public awareness of issues around cancer, including the potential benefits and harms of lifestyle choices; early warning signs and symptoms of cancer; how to access services for diagnosis, treatment and support. Increase early detection rates with the help of enhancing clinical knowledge and skills and enabling directly accessible diagnostic tests e.g. flexible sigmoidoscopy, colonoscopy, non-obstetric ultrasound for low risk, not no risk of cancer patients. Improve patient experience of cancer services, especially at the primary / secondary care interface Reduce variation in secondary care Implement living with and beyond cancer best practice including provision of recovery packages (holistic needs assessments and care plans, treatment summaries; health and well-being events) and managing the consequences of anticancer treatment. Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 13

14 10. End of Life Care Aims: Continue to improve provision and coordination of end of life care services, enabling an increasing number of people to die in their place of choice Implement Kingston s End of Life Care Strategy Continue to promote partnership working, ensure comprehensive service information is shared across health and social services, champion joint education programmes Continue to provide 24/7 provision for end of life care patients within the community setting through collaboration between the community health provider and third sector including hospices Develop and implement pathways that support people to die in the place of their choice Increase the number and proportion of people who die in the place of their choice Reduce the number of palliative care patients dying in hospital Improve care through the sharing of care plans or records across organisations building on CoordinateMyCare and the Kingston Health Passport Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 14

15 11. Socially Excluded and Disadvantaged Groups Aim: People who are disadvantaged or socially excluded have similar opportunities for good health and wellbeing as the wider population in Kingston Develop and implement a localities strategy to provide targeted initiatives in disadvantaged areas and to disadvantaged population groups in Kingston Continue to undertake participatory needs assessments to provide a detailed understanding of local needs and assets Implement the Joint Refugee and Migrant Strategy and commission the provision of 1:1 advice, information, and support sessions for refugees and asylum seekers. Pilot health improvement activities for homeless people including support for those experiencing mental ill health, the homeless or vulnerably housed Deliver the CCG s obligations in relation to the Armed Forces and Veteran Health. These include responsibility for commissioning all secondary and community services required by Armed Forces families where registered with NHS GP Practices and services for veterans and reservists when not mobilised commissioning bespoke services for veterans, such as veterans mental health services Increased engagement with and improved health and wellbeing of people who are disadvantaged or socially excluded Seek, receive and act on feedback from these groups, and increase the range of intelligence available to commissioners to inform future planning and commissioning Universal services are more sensitive and responsive to the specific requirements of these groups within our population Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 15

16 12. Health and Prevention Aim: An accessible range of information and opportunities that promote health and wellbeing and prevent illness, suited to the varying needs of Kingston residents Specify and tender for a range of early intervention and support services with the independent / voluntary sector, to include services such as case finding and combating isolation for older people, support to manage personalisation / personal health budgets, support to carers and mental health prevention Continue to upscale obesity prevention and physical activity promotion services and focus on increasing utilisation of these services by men Support London wide health improvement initiatives including Healthy Schools and the Healthy Workplace Charter Promote our tobacco control and smoking cessation services by both discouraging people (including young people) to take up the habit as well as providing a range of service to support people who want to quit smoking Ensure there is a high level of awareness of the issues regarding shisha use Promote safe and sensible drinking and provide education around illegal substances and substance misuse Deliver the Health Check programme, ensuring that it targets disadvantaged populations within Kingston Undertake a review of local sexual and reproductive health services Prepare for the transfer of commissioning responsibilities for children s public health services for 0 to 5 year olds from NHS England to the Council Ensure that the adolescent health link workers programme is fully embedded in local schools Review the range of self-care and self-management provided and develop a plan fit for future ambitions Establish demonstrator projects for clinical coaching Explore opportunities for using Council assets to promote health and wellbeing e.g. libraries, parks and green spaces Continue to maximise the impact of the Annual Public Health Report Tender for early intervention and support services let, achieving better use of available resources, simplification of commissioning arrangements and clearer and increased provision Increase uptake across the full range of health promotion and disease prevention services available Increase the coverage of the Health Checks programme Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 16

17 13. Integrated Commissioning of Health and Adult Social Care Aim: To improve the alignment, effectiveness and efficiency of health and social care commissioning, with the aim of ensuring seamless provision and best use of resources Bring commissioners from health, and adult social care together in a single leadership team Increase the level of funding pooled between health and adult social care and formalise this in a section 75 agreement Test a joint commissioning approach for the VCS with the appropriate governance, lines of accountability and risk strategy that will inform the establishment of a joint commissioning unit. Use the opportunity to re-commission community health services to develop a shared specification for health and social care support for people with complex needs to be commissioned from 1 April 2016 and delivered in an integrated way by providers Lead the development of a workforce strategy to support the culture change we wish to achieve in which all staff are focussed on the needs to people in Kingston Establish an organisational development programme to foster a culture of collaborative and cross boundary working to support the integration of the respective teams and support the health and wellbeing of staff eg by participation in the Mayor of London s Healthy Workplace programme Consolidate and better align staff development arrangements Develop and implement plans to improve information sharing, specifically to ensure the NHS number is the primary identifier; for electronic prescribing; for the provision of online services for patients; for electronic discharge summaries; for electronic elective referrals and interoperable digital records. Foster an innovation culture, to enable and enhance integrated working and optimise commissioning Align the Adult Social Care and CCG saving plans Improved patient and service user experience particularly where they require both health and social care services Optimise the commissioning capacity in Kingston, with an efficient, motivated integrated commissioning team streamlined where appropriate Ensure the resources spent on services by the CCG and RBK are used in the most effective way possible, optimising value for money Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 17

18 Appendix 1 How this plan addresses the priorities in The Forward View into Action The Forward View into Action Joint Operating Plan Section 2.2 Quantified ambition to reduce health and healthcare inequalities 10 and Appendix Improve outcomes for health and wellbeing 11 and Appendix Actions to improve staff health and wellbeing Expand personal health budgets Work with LAs and schools for children with special educational needs Review choice for women using maternity services Carers Co-creating new models of care 5, Primary care fund Prime Minister s Challenge Fund Establish urgent and emergency care network Progress in implementing the clinical standards for seven day services Mental health NHS number as primary identifier Electronic prescribing Online services for patients Electronic discharge summaries Electronic referrals Interoperable digital health records Workforce strategy 12 Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 18

19 Appendix /16 Kingston CCG and Adult Social Care budgets A3.1. Kingston CCG s budget for 2015/16 can be found here: A3.2. The Royal Borough of Kingston s Adult Social Care budget for 2015/16 can be found here Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 19

20 Appendix 3 Kingston CCG 2015/16 Quality, Innovation, Productivity and Prevention (QIPP) programme summary Scheme title Scheme summary Net funds released for reinvestment k Acute contract management Containing the contract funding sums and careful management of quality and 1234 Expansion of Kingston at Home and Kingston Coordinated Care programmes NHS continuing care performance across our portfolio of commissioned hospital provision. Expansion of the community rapid response services, better alignment and integrated working between community health and social care services, strengthened specialist clinical support (esp. to GPs). Continued work in primary care around risk stratification, care planning and multi-disciplinary working (supported by the national avoidable unplanned admissions directed enhanced service ). Impact of 2014/15 investment in community respiratory services, mainstreamed in 2015/16 contracts. All expected to improve access, coordinated and proactive care in out-of-hospital services, reducing demand for unplanned / emergency hospital services. Impact of investment in 2014/15 and again for 2015/16 to increase capacity enabling timely reviews of NHS funded continuing care packages. A specific, targeted programme has been initiated which started to identify quality improvements and efficiencies towards the end of 2014/15, which will carry through and extend throughout 2015/16. Urgent care Implement the planned walk-in centre at Surbiton Hospital for the 2 nd half of 2015/16. Expectation is that this will help contain A&E attendances at hospitals. GP referral support Review arrangements in GP practices and provide additional support to ensure best practice in GP referrals, optimise use of services out-of-hospital, ensure appropriate quality for patients and reduce unexplained variability in referral rates. Other non-acute areas Technical change re. previous non-recurrent transitional fund and sale (and elimination of rental charges) or disused community estate. Prescribing Practice support pharmacists continue to work with every individual GP practice (26) to optimise prescribing for both quality and cost. CCG running costs National requirement for CCGs to reduce management costs by 10% in 2015/16. Achieved through some rationalisation of posts and tight budget management Total funding released for reinvestment Note that QIPP targets to release funding are after growth funding (e.g. for inflation, demographic change, increasing cost base etc.) has been allocated to contracts / providers. Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 20

21 Appendix 4 Supporting Documents Document title Joint Strategic Needs Assessment Joint Health and Wellbeing Strategy Annual Public Health Report for Kingston 2014 Mental Health and Wellbeing in Kingston Health and Wellbeing Board Commissioning Mandate for Mental Health Kingston CCG Commissioning Intentions for 2015/16 South West London Draft 5 Year Strategic Plan Better Care Fund plan Kingston s CCG, Adult Social Care and Public Health Services Integrated Operating Plan 2014/ /16 Five Year Forward View The Forward View into Action Links ssessment %20final%20draft.pdf report al%20draft%2017th%20january% pdf %20%20SWLCC%20draft%205%20year%20strategic%20plan_CCGs_FINAL.pdf %20-%20Integrated%20Operating%20Plan% %20Final%20v4.pdf Kingston s CCG, Adult Social Care and Public Health Integrated Operating Plan 2015/16 DRAFT 22/5/15 PC edit Page 21