Appendix 4.1. SUPPORTING PAPERS: None. RECOMMENDED ACTION: The Governing Body is asked to: NOTE and COMMENT on the content of the attached paper.

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1 Appendix 4.1 MEETING: Haringey Clinical Commissioning Group Governing Body Meeting DATE: Wednesday, 1 February 2017 TITLE: Alignment of Sustainability and Transformation Plan and Haringey CCG Local Priorities LEAD DIRECTOR Rachel Lissauer, Director of Commissioning AUTHOR: Lyndsey Abercromby, Assistant Director of Commissioning CONTACT DETAILS: Rachel.Lissauer@haringeyccg.nhs.uk SUMMARY: This paper considers how the local priorities as identified by the Governing Body align with initiatives identified in the North Central London Sustainability and Transformation Plan (STP). It can be seen that in many areas there is a clear alignment and that the work currently underway locally and as part of the Haringey and Islington Partnership will put us in a strong position to deliver the aims of the STP. It also highlights that some aspects of the STP, such as the focus on planned care pathways, are not explicitly reflected in our local plan on a page although they are the focus of considerable local work. There are also areas of particular focus seen in the STP, for example Care Closer to Home Integrated Networks (CHINs) and Quality Improvement Support Teams (QISTs), where the CCG will want to direct greater energy in order to ensure successful delivery of these initiatives. SUPPORTING PAPERS: None RECOMMENDED ACTION: The Governing Body is asked to: NOTE and COMMENT on the content of the attached paper. Objective(s) / Plans supported by this paper: This paper considers how the CCGs local priorities align with the Sustainability and Transformation Plan. Audit Trail: Papers relating to the STP have been considered previously by the Governing Body. The diagram on page 5 has previously been considered at a Governing Body Seminar. 1

2 Patient & Public Involvement (PPI): This report is for information only. The STP is informed by prior patient and public involvement carried out by CCGs, Councils and providers. Further engagement opportunities for comment on the STP will be developed. Equality Analysis: Not applicable for this report. Equality Analysis will be a vital part of ensuring the STP delivers improvements across the diverse population of North Central London. Risks: None specifically identified as originating from this paper. Resource Implications: Successful deliver of the STP impacts on the amount of money local areas receive from national funds. 2

3 Alignment of Sustainability and Transformation Plan and Haringey CCG Local Priorities 1. Introduction Sustainability and Transformation Plans (STPs) are plans developed across health and care economies to address three key gaps over next 5 years: the health and wellbeing gap, the care and quality gap and the financial gap. Locally, the North Central London (NCL) STP has presented an opportunity for CCGs, local authorities and providers across Barnet, Camden, Enfield, Haringey & Islington to develop a local plan for an improved, more sustainable, health and care system. Our financial gap is significant. Our current spend on health and care services in NCL is approximately 2.5bn. Health commissioners and providers were already approximately 120m in deficit in 2015/16. In the next 5 years, if nothing changes, this will rise to nearly 900m deficit by 2020/21. The STP sets out a range of interventions that, as CCGs and provider organisations, we have collectively identified will lead to significant improvements in wellbeing and quality and will reduce our financial gap. Successful delivery of the STP is a pre-requisite for NCL to access national transformation funding. Our NCL Sustainability and Transformation Plan (STP) was submitted to NHS England in October The successful delivery of this plan and any additional NCL wide initiatives will require effective leadership and ownership across health and social care and from both providers and commissioners. It will require leadership and delivery at both an NCL and a local level. Further information about the NCL STP is available on our website at This paper considers how Haringey CCGs existing local priorities align with STP priorities, and provides a brief update on work currently underway on each priority and any additional work that may be required. 2. Haringey CCG Local Priorities Within 2016/17 we have set in place a range of organisational changes in order to position ourselves to work more effectively across systems. The Governing Body has previously reviewed plans for changes in commissioning arrangements across North Central London and has approved the establishment of an NCL wide commissioning hub to deliver centralised acute commissioning, performance, contract management and oversight as well as progressing development of NCL wide strategy. Through the Wellbeing Partnership, Haringey and Islington CCGs and Councils are working closely together and with our main acute and mental health trusts as a way of ensuring that our local delivery is genuinely integrated. Our partnership shares a strong local focus on the wider determinants of ill health; maintaining health and wellbeing and improving efficiency across health and social care. Haringey and Islington CCGs are also bringing our management teams together in order to strengthen our local commissioning structure and capacity. A large number of functions will remain commissioned locally: joint commissioning of health and social care; out of hospital support, mental health and community services. 3

4 At a time of increasing system-working, it is important that we check that there is alignment between Haringey s local priorities and the broader STP objectives. Haringey CCG, together with Islington CCG, will retain responsibility for delivery of the key interventions set out within the STP. So this paper considers how far we are currently positioned to deliver on both our local priorities and the aims of the STP. The diagram on the following page outlines the mission, values and aims of Haringey CCG and the key projects / areas of focus in 17/18 at a Haringey level. This diagram was shared with Governing Body members at a seminar in November 2016, where it was agreed that the local objectives were still supported, and reflected where the CCG should be focusing its efforts, specifically for residents and patients in Haringey. 4

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6 3. Alignment of STP and Haringey CCG Local Priorities To deliver on the STP vision and achieve the triple aim as set out in the Five Year Forward View (to increase health and wellbeing; meet the highest standards of care and quality; and improve productivity and efficiency), the strategic framework underpinning the STP has been established with 4 aspects. This section considers how the CCGs local priorities align with the STP aspects, summarises recent progress and outlines plans for 17/18. a) STP prevention goals: Much of the burden of ill health, poor quality of life and health inequalities in NCL is preventable. We will increase our efforts on prevention and early intervention to improve health and wellbeing outcomes for our whole population, which will reduce health inequalities, and help prevent demand for more expensive health and care services in the longer term. This aspect is supported by 3 Haringey local priorities: Prevention and early help (hypertension & Atrial Fibrillation) Improved hypertension detection and management has been identified as a key priority for improving health and reducing health inequalities in both Haringey and Islington. Both boroughs have been working closely with primary care to improve detection of hypertension through incentive schemes with primary care and quality improvement approaches. In Haringey, key developments include the piloting of AliveCor, a mobile device which detects Atrial Fibrillation (AF). Although this has resulted in improved detection of hypertension, we feel that more needs to be done to identify undiagnosed people in deprived communities, through routes other than traditional health settings. We plan to achieve this through partnership working with local community and voluntary sector organisations, taking advantage of their well-established community links and infrastructure, and a bid to the British Heart Foundation Blood Pressure Award Programme is currently being progressed. Childhood obesity A wide range of work has been undertaken on childhood obesity. The London Association of Directors of Public Health undertook a sector led improvement programme focussing on child obesity last year. Haringey participated in this and are now participating in the recently devised task and finish groups to help take the recommendations forward e.g. healthy vending machines and how London can become a breast feeding friendly city. Haringey has also been heavily involved in the Great Weight Debate, a conversation with Londoners about whether they think childhood obesity is an issue we should be focusing on and what we could do to support families to lose weight or maintain healthy weight. A Tottenham school was chosen to make the video for this. Over 100 families have participated in Henry, an early intervention and prevention programme. In addition, work has been undertaken strengthening our brief interventions approach (Making Every Contact Count, MECC) in primary care, to make it more routine, as we know this is one of the most effective means of promoting physical activity. The new MECC e-tool launched autumn 2016, aims to make sure that interactions between Haringey frontline workers (from across the public and voluntary sector) and local people are used to raise the issue of healthy lifestyles, promote the benefits of healthy living and signpost to further support. The tool complements the existing face to face training days, and a MECC pathway will also be developed to support professionals. 6

7 In the future, we want to reduce obesity so that Haringey falls below the England average (year 6 overweight and obesity). There is also work underway to increase the number of healthy schools (aiming to achieve 50% bronze, 25% silver, currently have achieved 50% bronze and silver currently at 23%). Transformation plans for school nursing and health visiting have been developed and are being implemented. Supported self-management and the diabetes prevention programme In supported self-management, as part of the Better Care Fund, Haringey is funding a Promoting Independence Programme. Included in the programme are two selfmanagement support programmes, one for people with diabetes called the Diabetes Self- Management Programme and another for people with long term conditions other than diabetes called the Expert Patient Programme (both of these programmes have been funded through the Better Care Fund since spring 2016). These services mirror services delivered in Islington. In March 2016, Camden, Islington and Haringey CCGs and Local Authorities were selected by NHS England to rapidly roll out the Pilot Diabetes Prevention Programme (DPP), a national initiative to support patients with non-diabetic hyperglycaemia (pre-diabetes) to prevent the onset of diabetes. NHSE commissioned the service and provided 57,500 funding in the first year only to the three boroughs. This funding has been used to introduce a Local Incentive Scheme (LIS) to support the generation of referrals from GP practices. 18 GP practices have signed up to the scheme to date, leading to 250 referrals. One of the main goals of the Haringey and Islington Wellbeing Programme is to increase the focus that we give to prevention across both the CCG and the Local Authority. Through 2017/18 we have worked together with public health and the council to map our existing preventative interventions. We have identified a gap for Haringey in the degree to which we commission primary care to provide case finding and early help, building on the success of the locally commissioned service for AF and stroke. Within the Wellbeing Partnership there is a strong ambition to upscale and share good practice across Haringey and Islington as well as embedding a preventative approach into the re-design that we are doing for diabetes/cvd, frailty, MSK and mental health. b) STP service transformation goal: To meet the changing needs of our population we will transform the way that we deliver services. This involves taking a population health approach: giving children the best possible start in life; strengthening the offers and provision in the local community to ensure that where possible care can be provided out of hospital and closer to home reducing pressure on hospital services; rethinking the relationships between physical and mental health to ensure that mental health care is holistic and person-centred; and, reducing variation in services provided in hospital. Social care plays a key role in service transformation. The majority of Haringey CCGs local priories support the service transformation aspect of the STP, which covers a variety of different elements. The best start in life The STP outlines a range of proposals in relation to giving children the best start in life which are in line with the direction of travel that we have been following in Haringey. Since 2015 our public health team, with Whittington Health has delivered the healthy child programme, ensuring that all children receive health visiting reviews antenatally, at 6-8 7

8 weeks and at one and two years. In 2017/18 we will be carrying out a full review of our children s community services. Demands on this service are increasing as a result of the development of the universal health visiting service and we need to work with the service on how best to provide an effective early response. In 2016/17 we have commissioned successful allergy clinics that have had a positive impact in reducing general paediatric outpatient referrals (leading to a QIPP saving of 73,000 in the first 6 months of 16/17); we have run learning together clinics that have provided opportunities for joint working between GPs and paediatric consultants and have begun to explore ways of improving management of asthma both in primary care and in schools. We have continued to implement the CAMHs strategy with a focus on the provision of early intervention (tier 2) support and out of hours and crisis prevention. The Haringey and Islington Wellbeing Partnership will allow Haringey to put children s needs at the forefront of our commissioning. We plan to focus particularly on reducing smoking in pregnancy and childhood obesity; continuing our work around the management of long term conditions in children; focusing on reducing avoidable emergency attendances for children; ensuring our children s community services are able to meet the demands on them and scaling up our efforts to reduce the boundaries between primary care and secondary care in paediatric services. We will also have a focus on early identification and support for people with learning disabilities; on working jointly with Islington wherever possible to meet the needs of people with learning disabilities and on the transition for children and young people between children and adults services. It is therefore likely that our local commissioning for children and young people will be closely in line with the aims of the STP. Health and healthcare closer to home Within the STP the focus on health and healthcare closer to home is on scaling up out of hospital care, particularly for people with long term conditions as well as on reducing variation in the quality of primary care and on enhanced integrated community care. This cuts across all three of the local Haringey aims and encompasses a range of our project areas. Our work to develop seven days a week, eight till eight working, primary care hubs and federation development support the STP aims of providing care closer to home. In 2017/18 we will continue to embed extended access ensuring that patients are seen when they need to be and can be routinely redirected from the emergency department. The measures that we are taking to embed joint commissioning with the local authority further support the STP aims of ensuring that we can reduce our reliance on acute care. In 2016/17, we have developed a section 75 in order to align our budgets for learning disabilities, children with complex needs, adult continuing health care and integrated care and we are moving into lead commissioning arrangements which is an important step towards looking together at how we meet growing demand and increase our efficiency: reducing the different assessment processes and referral systems that service users sometimes experience. We also have in place teams that aim to significantly improve the process for people leaving hospital and to work pro-actively with vulnerable people in our community to reduce hospital attendances and admissions. We have an effective re-ablement service that is supporting the coordination of care for people leaving hospital. On the preventative side we have Rapid Response and locality teams, multi-professional teams that work pro-actively 8

9 with people who are at risk of hospital admission. The work of these teams is likely to become increasingly important as we look to improve the degree to which primary and community services work together to support people s care out of hospital. Over the next year we will move further developing care closer to home, as set out in more detail in section 4 below. Mental health In Mental Health, the local priorities around the recovery (enablement) model, the mental health primary care model, employment partnerships with Department of Work and Pensions and joint commissioning with the local authority all contribute towards the Mental Health STP goal. The CCG is actively involved in the development of NCL bids in relation to the STP mental health Workstream. Bids are being submitted that would support increased psychological input for people with long term conditions and for psychiatric liaison services in general acute hospitals. Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) are developing a new service structure which will support the delivery of the goals, particularly through better interfaces with primary care, integration with community and voluntary sector services, and a needsled, flexible model better able to provide holistic care. Urgent and emergency care The focus within the STP on urgent and emergency care is largely on reducing variation in the way that emergency services are provided. As such, our role locally is likely to be focused on ensuring that the model of care offered to people in Haringey, for example their ability to access seven day community services, is consistent with the overall offer in North Central London. More robust and comprehensive community and primary care service are expected to alleviate pressure on urgent care services. Locally, services such as rapid response will support us to manage the demand for secondary care services, as well as other prevention and early intervention services, some of which are detailed elsewhere in this paper. All should ultimately mean local people are less reliant on crisis services and that overall health improves. Optimising the planned care pathway The STP sets out a plan for re-design of elective pathways across a range of specialties. These include orthopaedics; urology; general surgery; colorectal surgery; ENT and gynaecology. It also sets out a plan to explore consolidation of specialities. Locally, this is linked to our aim of making best use of resources. It is in line with the way that we run our QIPP programme but is likely to mean that there is a change in focus, with more NCL-wide direction and delivery of this pathway re-design alongside our locally process. c) STP Productivity goal: In order to ensure sustainability, we will focus on identifying areas to drive down unit costs, remove unnecessary costs and achieve efficiencies. For providers, this includes implementing recommendations from the Carter Review and 9

10 working together across organisations to identify opportunities to deliver better productivity at scale. The productivity element of the STP is largely being led by provider organisations, and none of Haringey CCG s local priorities fall into this area. There is work being undertaken locally that does contribute towards the deliverables in this aspect, including the NCL Joint Formulary Committee and NCL Medicines Optimisation Network developing and implementing decisions on use of new drugs, ensuring the effective use of medicines for patients across the STP through clinical guidelines and pathways and working towards a joint formulary across all care settings. d) STP Enablers goal: We will focus on delivering capacity in key areas that will support the delivery of transformed care across NCL. This includes digital, workforce, estates, and new commissioning and delivery models. Two of Haringey s local priorities align with the enablers aspect of the STP. These are workforce (Community Education Provider Networks - CEPN) which supports the Health and Workforce initiative, and Primary Care Estate which supports the health and care estate initiative. Locally, the work of CEPN is increasingly aligning with the CEPN in Islington. Working to ensure that Primary Care estate is fit for purpose. 3 Estates and Technology Transformation Fund bids were successful in 2016 and work is progressing to complete business cases for each sites: Wood Green, Tottenham Hale and Green Lanes. Work is also progressing to articulate the type of estate which will be prioritised for redevelopment to ensure that primary care can accommodate the new ways of working described elsewhere in this paper. Summary This section has considered how Haringey CCGs local priorities align with the STP. There are a small number of local priorities that have a stronger emphasis on building strong local services that support health improvement. These priorities are largely the creation of the Haringey & Islington Wellbeing Partnership, a form of Accountable Care Partnership and the development of level 3 commissioning. There are also some aspects of our commissioning work in the CCG, such as the transformation of elective care pathways that are featured within the STP but are not explicitly mentioned as a local priority. Our expectation is that this area of work will be a significant focus within 2017/ Areas requiring further development It can be seen that the majority of the CCG local priorities align with STP initiatives, largely supporting the prevention, care closer to home and mental health aspects of service transformation. There are however some areas where the STP details specific interventions to be implemented, such as Care Closer to Home Integrated Networks (CHINs) and Quality Improvement Support Teams (QISTs). 10

11 The development of CHINs are a specific intervention detailed in the STP, attracting a high level of focus. CHINs may be virtual or physical, and will most likely cover a population of c.50-80,000 people. They will be home to a number of services including the voluntary and community sector to provide a more integrated and holistic, person-centred community model, including health and social care integrated multi-disciplinary teams (MDTs), care planning and care coordination for identified patients. While there is alignment with local CCG priorities (for example CHINs are also a local CCG priority) further focus in these areas will be required to deliver the scale of change required by the STP. For Haringey to implement this model, it is likely that a number of existing schemes would be incorporated into CHINs, including both core community services and locality teams. Locality teams are forerunners of the CHINs model. However these on their own are not taking significant costs out of the system and further work is needed to explore how these can be developed further. For CHINs to be successful it is essential for them to be established so that existing services and people are working differently, and that they are not an additional level to current structures. Quality Improvement Support Teams (QISTs), which will provide hands-on practical help for individual GP practices to ensure a consistent quality standard and offer to all patients are another key specific intervention detailed in the STP. While the CCG has been undertaking a range of quality improvement work, this has not been to the same scale as that proposed in the STP. Consideration is currently been given as to how both CHINs and QISTs could develop in Haringey, and it is suggested that both need to be key local priorities if we are to meet the requirements of the STP. 5. Delivery of Local Priorities: The Haringey and Islington Wellbeing Partnership Our Wellbeing Partnership, bringing together Islington and Haringey commissioners, local authorities, health and care providers and GP Federations is well positioned to support local delivery both of the STP and our local initiatives. This partnership currently has a focus on; o seven priority population based groups or clinical pathways and how these could be developed together to deliver better outcomes; as well as, o a strategic approach to establishing a potential Accountable Care Partnership (ACP) across Islington and Haringey delivering place / population based health and care. The STP assumes that delivery of care is increasingly place-based with responsibility for improving outcomes of care and driving good value services being shared between organisations. However there is no specification about how this local accountability should be taken forward. Across Haringey and Islington providers and commissioners are working together to set out a structure that allows for shared decision making and shared delivery of service improvement. This will be articulated in a Partnership Agreement between organisations. Our expectation is that there is an iterative process in which the Wellbeing Partnership is both delivering on the aims of the STP, whilst also providing a test-bed for work that then also informs work at an NCL level. 11

12 6. Conclusion This paper has considered the local priorities as identified by the Governing Body, and how these align with STP initiatives. It can be seen that in many areas there is a clear alignment. However, some of the terms used to describe these priorities may benefit from being standardised with the terminology used in the STP. We have also seen there are areas highlighted in the STP, for example CHINs and QISTs, where the CCG will want to direct greater energy in order to ensure successful delivery of these initiatives. Going forward, if we are to ensure Haringey and Islington CCGs are fully engaged and successfully deliver the STP workstreams, we will need to ensure we develop our local structure and delivery teams are in line with the STP structure proposal. In addition to this, we recognise that the STP does not currently encompass all those areas of health and care where we believe we can make significant improvements, such as some of the workstream areas already established in our Wellbeing partnership programme; children and young people and learning disabilities. Some of the work done in these additional areas are likely to feed back into the STP in time. 12