NHS Norwich CCG Operational Plan and

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1 NHS Norwich CCG Operational Plan and Commissioning NHS care for the people of Norwich 1

2 Release: V17 Final Date: Table of Contents Page 1 Introduction 4 2 National Background and Context NHS Five Year Forward View NHS Mandate NHS Outcomes Framework CCG Improvement and Assessment Framework 5 3 Local Background and Context Demographic Profile Key Challenges CCG Commissioning Intentions Programme Management Office (PMO) System leadership Norfolk and Waveney Sustainability and Transformation Plan Norwich New Model of Care 10 4 Priorities for 2017/18 and 2018/19 (delivering the must dos ) Norfolk and Waveney STP Finance Primary Care Urgent and Emergency Care Referral to treatment times and elective times Cancer Mental health People with learning disabilities Improving Quality in Organisations 31 5 Other Key Priorities Diabetes Continuing Care Maternity Children and Young People Seven Day Services Winter 2017/ Personal Health Budgets 37 2

3 5.8 Wheelchair Access Better Care Fund 38 6 Key Enablers in Delivering Value Estates Strategy Digital Norwich Contracting Communications and Engagement 41 7 Governance and Risk Management Governance Managing Conflicts of interest Key Risks and Issues Monitoring of Plan Delivery 45 8 Appendices 45 3

4 1 Introduction The Operational Plan for and is a high-level plan commission health services for the population of Norwich and contribute to the implementation of the Norfolk and Waveney Sustainability and Transformation Plan (STP). The Operational Plan describes how Norwich CCG will: Implement the Five Year Forward View to drive improvements in health and care Maintain financial balance and delivery of control totals Deliver core access and quality standards in line with the NHS Constitution Deliver ambitions for transformation in the six clinical priority areas: mental health, dementia, learning disabilities, cancer, maternity and diabetes 2 National Background and Context The development of this plan is informed by: National NHS policy and guidance, in particular: Delivering the Forward View: NHS planning guidance 2016/ /21 The NHS Constitution The NHS Mandate Benchmarking and evidence resources such as the Commissioning for Value data pack 2.1 NHS Five Year Forward View The aspirations of the NHS Five Year Forward View (5YFV) put continued emphasis on seeking greater efficiency and finding better ways to maintain and improve services for our patients. It sets out a vision for how the health service needs to change to promote health and wellbeing, prevent ill health and have a more engaged relationship with patients, carers and the public. This includes stimulating the development of new models of care, supported by innovative use of resources, workforce and technology. The 5YFV states that the NHS needs to address: Closing the health and wellbeing gap Driving transformation to close the care and quality gap Closing the finance and efficiency gap Norwich CCG has fully embraced the direction established in the 5YFV. This Operational Plan sets out how delivery of this national strategy will be pursued during 2017/18 and 2018/19. 4

5 2.2 NHS Mandate The Government s mandate to NHS England sets out the direction and objectives for the NHS through to These are underpinned by specific deliverables that are core to delivering the 5YFV and ensuring a sustainable health and care system. Clinical Commissioning Groups are required to play their part in delivering the mandate. Table 1 outlines the Government s Mandate to NHS England 2020 goals. Table 1 The Government s Mandate to NHS England 2020 goals 1 Through better commissioning, improve local and national health outcomes, particularly by addressing poor outcomes and inequalities. 2 To help create the safest, highest quality health and care service 3 To balance the NHS budget and improve efficiency and productivity 4 To lead a step change in the NHS preventing ill health and supporting people to live healthier lives. 5 To maintain and improve performance against core standards 6 To improve out-of-hospital care 7 To support research, innovation and growth 2.3 NHS Outcomes Framework The NHS National Outcomes Framework supports the Government s desire to improve integration of services. It is structured around five domains, which set out the high-level outcomes that CCGs should aim to improve. They include: Preventing people from dying prematurely Enhancing quality of life for people with Long Term Conditions, including mental health illnesses; Helping people to recover from episodes of ill-health or following injury; Ensuring that people have a positive experience Treating and caring for people in a safe environment. 2.4 CCG Improvement and Assessment Framework In 2016, NHS England published a revised assurance framework for CCGs. Using this new Improvement and Assessment Framework (IAF), CCGs receive an overall rating of outstanding, good, requires improvement, or inadequate. In July 2016 the CCG was rated as Good. CCGs also receive an annual assessment in relation to four key aspects of their function and responsibility: Better health Better care Sustainability Leadership The framework also includes six clinical priority areas: Maternity Mental health Dementia Learning disability Cancer Diabetes 5

6 A number of performance metrics underpin the IAF and are used to assess the CCG s performance. These cover areas such as efficiency, core performance, use of technology and prevention. During 2017/18 and 2018/19, the CCG will continue to focus on maintaining and improving performance against the measures set out in the framework. 3 Local Background and Context NHS Norwich CCG is responsible for commissioning many NHS services within the CCG area, serving a population of about 217,000 people. These services include acute hospital care, mental health, community health, Continuing Healthcare, ambulance services, NHS 111 and out of hours primary care. The CCG has jointly commissioned GP services with NHS England in 2016/17.NHS England directly commissions pharmacies, dentists, opticians and some specialised services. NHS Norwich Clinical Commissioning Group CCG is clinically-led: the 23 GP practices in Norwich form the membership of the CCG (see Governance ) and NHS doctors and nurses set the local health strategy and advise on clinical matters, working with a small team of experienced NHS managers, some of whom are clinicians by background. The CCG will be allocated a total funding of 241.8million in 2017/18 for programme costs (to commission local health services). The amount allocated to the CCG for its running costs is 4.5million (less than 2% of total resource). 3.1 Demographic Profile Like the rest of Norfolk, Norwich has experienced a growth in population and like the rest of England it has experienced an unprecedented increase in demand for NHS services. The number of registered patients in general practice in the CCG was approximately 217,000 persons of all ages in 2016/17 (49.8% male and 50.2% female).there are 23 member general practices in Norwich CCG. Practice list sizes range from around 3,000 persons to 19,000 persons, with an average list size of 9,500 persons. The population and demographic profile of Norwich is distinctly different to most other parts of Norfolk and Waveney, for example around 70% of the population is of working age, well above county and national rates. Norwich also has large proportions of younger people (particularly 20 to 29 year-olds) in the population compared with the county rate. Finally, Norwich has lower proportions of children and older people particularly in comparison with Norfolk as a whole. Norwich has the highest number and proportion of people belonging to ethnic minorities in the county. The resident population is projected to see much larger increases in the working age population over the next 20 years. 3.2 Key Challenges The key current challenges that Norwich CCG faces during 2016/17 relate to the delivery of a number of NHS Constitution standards by local NHS providers: 6

7 Table 2 Key Challenges Area Key Performance Challenges Mitigating actions Norfolk and Norwich University Hospitals Trust (NNUH): East of England Ambulance Trust (EEAST) Norfolk Community Health and Care (NCH&C) Norfolk and Suffolk Foundation Trust (NSFT) IC CCG Accident & Emergency (A&E): Activity increase when compared to last year and 4 hour waits standard not being met despite performance being in the high 80%s. Cancer 62 day: Performance increased when compared monthly, but still under trajectory Referral to Treatment Times (RTT) 18 weeks: Performance flat lining at a constant 86%. Agreed trajectory not being met, uncertain as to delivery by January Trust breaching most of the national timing trajectories. Integrated Community Services for Children with Disability and/or Additional Specialist Healthcare Needs (DASH) Outpatients trajectory of 92% is not being met across the central Norfolk Commissioners (North Norfolk CCG, South Norfolk CCG and Norwich CCG). The Improved Access to Psychological Therapies (IAPT) trajectory of 50% is not being met on a local basis due to the complexity of individuals contacting the service. Improving performance for calls answered within 60 seconds. Improvement of urgent home visiting (NQR12) Improving dementia diagnosis rate to 67% Revised System Wide Recovery Plan in place to focus on performance stabilisation and achievement of 95% target. Implementation of Best Practice Prostate Pathway. Review of capacity and processes for Urology Theatre capacity. Remedial Action Plan in place. Remedial Action Plan in place to correct and achieve 92% standard. Detailed analysis is being undertaken for all transports in each locality to try and understand the reasoning behind stabilising activity and breaches in response times. A Remedial Action Plan and trajectory in place but due to be revised due to a significant change in the consultant workforce. A Remedial Action Plan is in place and Norfolk and Suffolk Foundation Trust (NSFT) project compliance with the target by February Formal Recovery Trajectory in place to deliver contractual performance and support to recruit and retain call handlers. Remedial Action Plan to be agreed in relation to urgent home visits (NQR12). Action Plan in place. 7

8 Over the period of this plan, the key challenges facing Norwich CCG are expected to be: Maintenance of NHS Constitution standards at a time of constrained resources in the NHS Delivery of financial balance both for the CCG and for the Norfolk & Waveney health & social care system Supporting the implementation of the Norfolk & Waveney STP Facilitating the development of a new model of primary & community care in Norwich to deliver transformation. 3.3 CCG Commissioning Intentions The CCG is a partner with other central Norfolk CCGs in a collaborative commissioning arrangement with local providers. In line with the STP all five Norfolk and Waveney CCGs have developed a single set of commissioning intentions and are working in a collaborative way to reduce inequalities. This should also help release limited commissioning and clinical capacity to realign towards re-designing pathways and meeting the challenges to the system as set out in the STP. The Commissioning Intentions, published in September 2016, provide details of the key initiatives and changes that the CCG expects to implement in 2017/18, setting out how the CCG will implement its vision of system reform and redesign, and deliver against its clinical priorities. The full document can be found in Appendix B. 3.4 Programme Management Office (PMO) The purpose of the PMO is to support the delivery of the work Programme for Norwich CCG by providing information to enable oversight, analysis and assurance. The PMO provides full traceability from strategic plans to the investment in delivering new capabilities and the realisation of benefits. Project delivery and governance is supported via the PMO through the implementation of agreed standardised processes. The CCG manages the PMO in alignment with the Central CCGs (NHS North Norfolk, NHS South Norfolk and NHS Norwich CCG s). To support this, the CCG is compiling the Norwich CCG Programme of Work, which lists all portfolios, programmes and projects that the organisation is managing. 3.5 System leadership Norfolk Health and Wellbeing Board The Health and Wellbeing Board is aimed at helping to improve the health and wellbeing of people in Norfolk. The Board is responsible for producing the Health and Wellbeing Strategy for Norfolk based on the evidence of the Joint Strategic Needs Assessment (JSNA). It is also responsible for driving, promoting and encouraging integration, particularly between health and social care to improve care, save money and give patients a better experience. The Board brings together local organisations in Norfolk including councils, Clinical Commissioning Groups, Healthwatch Norfolk, the voluntary sector, Norfolk Constabulary and the Police and Crime Commissioner. 8

9 3.5.2 Norfolk Chief Officers Group The Norfolk Chief Officers Group is the operational leadership group for the health sector in Norfolk. Its membership consists of the Chief Officers and Chief Finance Officers from each CCG, and the Director of Adult Social Care from Norfolk County Council Joint Commissioning Committee The central Norfolk CCGs, covering North Norfolk CCG, Norwich CCG and South Norfolk CCG, have collaborative commissioning arrangements in place whereby each CCG acts as Coordinating Commissioner for key portfolios such as Community, Mental Health and Acute. The Joint Commissioning Committee (JCC) was established to strengthen these arrangements within central Norfolk. The purpose of the Committee is to make timely joint decisions on strategic and key operational issues to support the Coordinating Commissioner in the discharge of their duties, and crucially support and foster clinical ownership of the process, regardless of coordinating CCG arrangements. Great Yarmouth and Waveney CCG and West Norfolk CCG have recently been invited to join the JCC meetings. Further consideration is being given to expanding the JCC to cover the Norfolk and Waveney Sustainability and Transformation Plan (STP) area Joint Contracting Executive The Joint Contracting Executive (JCE) was established to strengthen contracting arrangements within central Norfolk and covers the North Norfolk CCG, Norwich CCG and South Norfolk CCG. The purpose of the Executive is to ensure that the joint strategic commissioning priorities of the central Norfolk CCGs, as set out by the JCC are delivered through the setting of appropriate contracts and contract management actions. Great Yarmouth and Waveney CCG and West Norfolk CCG have recently been invited to join the JCE meetings. 3.6 Norfolk and Waveney Sustainability and Transformation Plan In Norwich, the transformation of services will be aligned with the Norfolk and Waveney system vision to ensure: Services look at people as a whole person and outcomes which are important to the person are what matter in their care. People will receive good care any time, any day, with the aim of safely keeping them at home where possible and appropriate. People and organisations who care for individuals talk to each other with one liaison for an individual s care who is easy to get hold of. The system recognises an individual s time is precious and visits are arranged recognising this. A trusting relationship is developed between an individual and the services who see them. You can read more about the Norfolk and Waveney Five Guiding Principles of the Norfolk & Waveney STP STP and give us your views The Norfolk and Waveney STP has five guiding principles: and insights at: Preventing illness and promoting wellbeing Care closer to home Integrated working across physical, social and mental health Sustainable acute sector Cost-effective services uk/ingoodhealth/ 9

10 3.6.2 Areas of key impact Norfolk and Waveney STP workstreams have identified areas where they can best positively impact the health and care outcomes of our population and these align to the following system priorities: Sustainable physical and mental health, social care and prevention services out of hospital Reducing acute activity, including A&E attendances, non-elective (NEL) admissions and inpatient length of stay (LoS) by establishing integrated locality or place based teams responsible for physical, mental and social care Improved management of planned care to meet national waiting time standards, and reduce variation and demand Adaptive and sustainable workforce 3.7 Norwich New Model of Care Over the last 12 months the GP practices within Norwich CCG have been working more closely together under the direction of a Norwich New Models of Care Leadership Board. In November practices voted formally to work as an alliance, under the banner OneNorwich. The New Models Leadership Board and Norwich CCG have been developing a programme of integration of care services across Norwich, in line with its stated strategic vision to deliver; an improvement in our populations health and well-being through affordable, integrated, individualised, high quality health and care; available to all that need it and primarily delivered through integrated community primary care teams This programme is in line with the 5YFV, as well as the key aims and objectives set out in the Norfolk and Waveney STP. The programme supports the re-design of care around the health of the local population, focusing on prevention and increasingly integrating community health and social care around localities Overview and Core Principles Norwich CCG is committed to delivering a Multi-speciality Community Provider (MCP) in line with the key principles set out in the New Models of Care Guidance (July 2016). The MCP will combine the delivery of Primary Care and community-based services; it will also incorporate a wider range of services and specialists whenever it is the best thing to do. The aims of the MCP are: OneNorwich will implement this system of accountable care via care hubs of integrated teams, with the inclusion and active support of general practice and local partners. The MCP will focus on preventing ill health, redesigning care to improve the health and well-being of people, achieve better quality of care, reduce avoidable hospital admissions and elective activity, and unlock more efficient ways of delivering care. Bringing together health and social care professionals, alongside local support organisations to improve the lives of the people in greater Norwich. Offering care that wraps around the person to respond to the holistic needs of the patient and carer whether wellbeing, health, social and/or emotional. Flexible model able to respond to both planned and unplanned needs. Keeping people out of hospital and as close to home as possible when safe to do so. 10

11 Preventing illness and promoting wellbeing by targeting lifestyle risk factors (e.g. alcohol, obesity) to secondary prevention preventing unnecessary escalation to higher acuity care settings. Reducing demand at the acute hospital front door and assist discharge to maintain capacity within the acute system. People are supported to live with maximum independence, with improved access to primary and community care, supported by the third sector. Figure 1 Possible Norwich New Model of Care 4 Priorities for 2017/18 and 2018/19 (delivering the must dos ) In 2016/17, NHS England described nine must do priorities, which remain the priorities for 2017/18 and 2018/19. The following sets out the key actions the CCG will take in 2017/18 and 2018/19 to deliver these priorities locally. This section is supplemented by Appendix A which outlines each priority area and summarises the key milestones, the anticipated impact of actions and how successful delivery will be measured with regard to planning trajectories. 4.1 Norfolk and Waveney STP The Norfolk and Waveney STP articulates the challenges to the Norfolk and Waveney area as a result of competing pressures. These include: Significant financial savings required over the next two years to achieve the statutory financial targets. It is estimated that nationally allocated funding in Norfolk alone will reduce by 58m over the next three years. 11

12 Challenges to implementation of primary care at scale and shifting care out of hospitals and closer to patients homes. An ageing population, meaning that by 2025, the number of adults over the age of 75 will have grown by 38%. Workforce recruitment and retention, particularly in light of the ageing GP workforce in the area. Information Technology (IT) connectivity and changes to the way healthcare is delivered due to rapid changes in drug and other technologies. The Norfolk and Waveney system set out five guiding principles, central to the design and delivery of the transformed services. To deliver this transformation the STP programme structure has been established around four delivery workstreams, three enabling workstreams and three supporting workstreams (see Table 5). These workstreams have evolved since the submission on October 21 st 2016, but each workstream has planned solutions to deliver the 5YFV and improve patient and service user outcomes. Each solution will have measurable objectives, which when summed across the STP programme will deliver the key STP outcomes. Table 3 STP Workstreams Delivery workstreams Enabling workstreams Support workstreams Prevention and Good Health in Communities Demand Management Mental Health Acute Services Workforce Estates ICT Contracting Communications and Engagement Finance and BI 12

13 4.1.1 Milestones for delivery of the Norfolk and Waveney STP All workstreams have identified critical success measures and key performance indicators. These will be used to track progress of STP delivery. System-level metrics have been identified which will cut across workstreams, giving a uniting influence and allowing workforce at all levels to buy into our transformation. By 2021 the Norfolk and Waveney system ambition is to: Have reduced the gap in life expectancy across the county through targeted intervention Have a sustainable, integrated primary care model which meets locally defined minimum standards and is easily accessible to all Reduce A&E attendances and emergency admissions by at least 20% vs do-nothing forecast Reduce emergency acute bed days by at least 35% vs do-nothing forecast Have a safe and sustainable acute service capable of meeting key access and quality standards, including waiting times, the emergency care standard, and cancer 14, 31 and 62 day standards Provide physical, mental and social care through integrated place or locality based teams who work together to help the most vulnerable people manage their physical and mental health better and remain in their community Achieve parity of esteem between physical and mental health In Norwich CCG, the STP solutions will be delivered through robust, stretching plans and the development of the Norwich New Model of Care (MCP). The Norfolk and Waveney STP sets out a series of key principles and challenges to ensure financial balance by 2020/21 across the system. The Norwich model will highlight these as key deliverables against which resources can be released for investment to allow the programme of transformation to develop. It is recognised that some of this may require pump-priming and therefore it is essential there are clear business plans linking investment to directly impact the Norwich element of the following targets (Norwich is about 20% population of total STP footprint). 4.2 Finance Norwich CCG has a successful track record of delivering its financial targets, such that at March 2016 the CCG had a cumulative surplus of 3.4m (1.4% of funding). This represents 0.9m more than was required to deliver the NHS England expectation of 1% cumulative surplus; this excess surplus is to be returned to the CCG across 2017/18 and 2018/ Background In 2016/17 the CCG is on target to deliver an in-year breakeven position, which will maintain this cumulative surplus of 3.4m as at March 2017, but is experiencing pressures: cost growth with Acute providers (despite activity being below plan for both planned and unplanned admissions) significant national increases in cost of NHS Funded Nursing Care increases in the price of Continuing Healthcare packages. These pressures are mitigated by underspends in other areas and the release of reserves, some of which are non-recurrent. 13

14 4.2.2 Funding growth In 2017/18, the CCG will receive a total allocation of 246.8m, which includes recurrent growth of 2.3% in the allocation for programme (commissioning) spend. In 2018/19 the CCG will receive a further recurrent uplift to programme allocation of 2.2%, giving a total of 252.1m Financial Plan summary The 2017/19 financial plan delivers the CCG s control totals as set by NHS England, which brings the CCG back to a cumulative surplus of 1.0% by the end of the period as shown in the table below: Description 2017/ /19 m m Cumulative surplus b/f In-year control total (= return of excess surplus from previous years) Cumulative surplus c/f Cumulative surplus c/f 1.2% 1.0% The plan currently assumes no receipt of centrally held national transformation funding, as the CCG awaits further details on the bidding process. This is consistent with the approach taken in the Norfolk & Waveney STP. A summary of the 2017/19 financial plan is shown below in Figure 2. This illustrates that the CCG faces a challenging savings target in each year (3.9% in 2017/18 and 3.0% in 2018/19) and therefore requires delivery of a robust Quality, Innovation, Productivity and Prevention (QIPP) plan. This plan also reflects agreed contract settlements for 2017/19 with the CCG s main providers, including the impact of new national acute tariffs (HRG4+). 14

15 Figure 2 Summary of CCG Financial Plan Description 2017/18 Plan m 2018/19 Plan m Funding Recurrent Programme Allocation Non-Recurrent Programme Allocation Return of Excess Surplus from Prior Years Running Cost Allocation Total Funding Expenditure Acute Commissioning Mental Health Commissioning Community Commissioning Continuing Healthcare Prescribing / Primary Care Other Programme Expenditure / Reserves Running Costs Total Expenditure before savings Surplus / (Deficit) before savings QIPP requirement to deliver control total 2017/ / Total QIPP Surplus / (Deficit) after savings Annual Savings (QIPP) requirement as % of CCG Allocation 3.9% 3.0% Delivering Business Rules Whilst developing the financial plan, the CCG has adhered to NHS England business rules as detailed in the planning guidance. The above plan therefore reflects: Delivery of a cumulative surplus of at least 1% in both 2017/18 and 2018/19; Holding a 1% non-recurrent spend reserve, of which 0.5% is uncommitted and will be held as a risk reserve, the remaining 0.5% is earmarked for non-recurrent investment in both Primary Care and the STP to pump-prime new initiatives; Investment of 3 per head of population to support the implementation of new Models of Primary Care in line with the GP Forward View; Establishment of a 0.5% contingency to manage in-year pressures and risks; Delivery of the Mental Health Investment Standard (i.e. spending on Mental Health is rising in each year by at least the level of uplift in CCG recurrent allocation). 15

16 4.2.5 Activity Planning Financial and activity planning have been produced together to ensure consistency and both reflect agreed contract settlements. Acute activity plans for 2017/18 have been developed as follows: using agreed forecast outturn figures for 2016/17 as a foundation; adjusting for some clearance of non-recurrent waiting list (RTT) backlogs; however this does not address the full extent of RTT backlog which is currently being assessed as at December 2016; applying realistic growth estimates based on historical trends and agreed with local providers as part of STP discussions and contract negotiations; adjusting for the impact of demand management plans and other QIPP schemes. The activity impact of 2018/19 QIPP schemes will be developed further during 2017/18. The current acute activity plan is summarised in Figure / /18 RTT 2017/ / / / /19 Forecast Backlog QIPP Annual Annual Growth Growth Outturn Clearance Schemes Plan Plan Total GP Referrals (General and Acute) 39,710-1,760 (3,164) 38,306 1,695 40,001 Total Other Referrals (General and Acute) 28,343-1,255 (446) 29,152 1,294 30,446 Consultant Led First Outpatient Attendances 53, ,370 (3,610) 53,225 2,359 55,584 Consultant Led Follow-Up Outpatient Attendances 98,344 2,185 2,754 (3,134) 100,149 2, ,953 Total Elective Admissions 22, (1,084) 23, ,788 Total Non-Elective Admissions 19, (942) 19, ,580 Total A&E Attendances excluding Planned Follow Ups 49,904-2,769 (2,103) 50,570 2,804 53,374 Figure 3 Acute Activity Plan QIPP Norwich CCG has developed a range of productivity initiatives to deliver the challenging QIPP targets required in 2017/18 and 2018/19. These align with the overall strategy detailed within this document and also align with STP planning assumptions. The CCG is increasingly looking to deliver QIPP schemes in conjunction with other local CCGs within the STP footprint. A summary of the proposed QIPP schemes is available at Appendix C. All QIPP schemes will have individual project documentation with key deliverables and milestones for delivery. Those schemes that have been embedded within 2017/19 acute contracts are also reflected in the activity plan in Figure 3 above Key Financial Risks The financial plan outlined above includes funding for a number of anticipated cost pressures. However there are significant risks to delivery of the financial control totals in the following areas: clearance of RTT waiting list backlogs at the NNUH, which are currently being assessed in conjunction with the NHS Improvement Emergency Care Intensive Support Team. If capacity exists to deal with this work, it could result in a significant non-recurrent cost pressure; delivery of a QIPP programme totalling 9.7m; constraining acute activity & cost growth within the contracted financial envelope. 16

17 4.2.8 NHS RightCare The NHS RightCare programme is a methodology for quality improvement that helps the CCG improve population-based healthcare by reducing unwarranted variation and focusing on value. It is comprised of key tools such as the Commissioning for Value packs and the NHS Atlas Series. Norwich CCG is using the RightCare toolkits to support its planning process and early identification of value improvement opportunities. The latest Commissioning for Value data pack was published in October 2016 and is available at: A summary of Norwich CCG s key opportunities for improving value is set out in Figure 4. Figure 4 Summary of RightCare Opportunities for CCG These opportunities are being examined and systematically reviewed by the CCG and will be reflected in the further development of the CCG s QIPP programme of work. The CCG is proactively rolling out the approach to ensure that it becomes embedded in future planning and supports local commissioning decisions. Working with partners across Norfolk & Waveney as part of the STP, the initial focus is expected to be on reviewing pathways for Cancer, Circulation (Coronary Heart Disease), Diabetes and Respiratory. 4.3 Primary Care Norwich CCG recognises that primary care plays a critical role in the prevention of ill health and the management of people with long term conditions. As a result, primary care is central to the Norwich New Model of Care, in keeping with the principles of the 5YFV Progress against the General Practice Forward View For many people, the GP practice is an entry point to NHS care. In 2015/16, Norwich s GP practices members and the Local Medical Council met to discuss the extreme pressures they face and how some of the new models of care set out in the 5YFV could work in Norwich. This enabled all member practices to understand and explore the opportunities and requirements set out in 5YFV, and as a result, Norwich CCG appointed an independent provider to lead further development and a New Norwich Model of Care Leadership Board 17

18 was established. Membership of this board is made up of GPs, Practice Managers, other Clinical staff, administrators and representation from the CCG. The board is tasked with taking forward the changes set out in the 5YFV, development of General Practice at scale and acting as the voice of Norwich general practice. It provides a governance structure to develop, deliver, communicate and engage on projects through a General Practice hub and cluster model. In May 2016 the board appointed a transformation manager to support and lead a OneNorwich alliance programme to develop a new model of care in Norwich. The first part of this programme has created a single voice of general practice in Norwich, by bringing Norwich GPs together and forming OneNorwich. This Alliance will represent their collective interests as well as those of their patients, whilst allowing individual practices to maintain their autonomy. The OneNorwich vision draws upon much of what has been learned from Vanguard pilots elsewhere in the country and is also fully in line with the evolving themes in the sustainability and transformation plans for Norfolk: That for our patients, no decision about me, should be made without me must lie at the heart of our plan We can redesign primary care services in Norwich so all of the current care providers work much closer than ever before We can create a Norwich primary care that enables patients to live their lives by living well, whatever their stage of life Investment Norwich CCG is committed to ensuring local investment meets or exceeds minimum required levels. In order to deliver this, Norwich CCG has: ring-fenced 3 per head which will be used to support the development of the Norwich MCP model (totalling 652k in investment over the 2 years of this plan); agreed the principles for reinvestment of the Personal Medical Services (PMS) funds and appointed a project manager to develop business cases for projects related to the sustainability of general practice in Norwich; agreed that where clear business cases are developed, these may be considered for investment on an invest to save basis; Workforce The Norwich New Model of Care (MCP) will assist with managing workload to deliver safe, effective patient care, providing increased primary care access on a sustainable basis, help GPs to create management protocols and care plans to best manage patients at home for as long as possible, and reduce patient admission rates. In order to achieve this, a project workstream has been established to focus on tackling workforce issues and protect Norwich s future workforce supply. This workstream includes plans to address the sustainability and quality of general practice workforce and workload issues. The workstream s objectives include: 18

19 Increasing the skill mix / integration Think Whole Workforce Integrating Commissioning HR and back office functions Leadership and organisational development at a system level. The workstream will undertake key actions aimed at increasing the number of doctors working in general practice, investment in training practice staff and stimulating the use of online consultation systems where appropriate. This will include undertaking: workforce analysis survey of GP practices. options appraisals to introduce new roles within general practice and across community (including mental health) and primary care skill mix analysis and development of proposals for new roles staff training needs analysis analysis of future workforce requirements for the Single Point of Access The CCG has also put systems in place to monitor changes implemented under this year s contract with the acute trust. This are aimed at reducing bureaucracy for GPs and aligned with Making Time in General Practice. This approach aims to: ensure the sustainability of general practice in Norwich by implementing the General Practice Forward View, including the plans for Practice Transformational Support and the ten high impact changes recognise the pivotal role of primary care in developing the sustainability of general practice, improved integration and responsive patient care. A local primary care group has been set up as part of the Norfolk and Suffolk Workforce partnership. The group is focused on supporting the adoption and spread of best practice through Community Education Provider Network (CEPN) collaboration; influencing decisions on how Health Education England (HEE) resources are targeted in primary care and leading programmes of work to deliver these; supporting workforce planning, recruitment and retention, new role development and new ways of working to deliver STP priorities; work as a system to meet national and regional priorities such as the General Practice Forward View. The CCG currently have an application underway for funding to support a post that will develop this network for Norwich, South Norfolk and North Norfolk Improving Health in Care Homes A single cohesive project focusing on service provision to Care and Nursing Homes enables primary care to play its role in implementing the framework for improving health in care homes and implements the CCG s Commissioning Intentions for Care Homes. The project includes several areas of work across social care provision, primary, community and secondary health care. The project has utilised a partnership working approach to work locally with the NHS and the care home sector to develop new shared models of in-reach support, including comprehensive geriatric assessments, medication reviews, and rehabilitation services. The project s objective is to complement the Norwich New Models of Care Programme and support the national ambition for delivering primary care at scale. The Care Homes Programme Board has oversight of all work being done with the care home sector in Norwich, while linking to the wider STP footprint initiatives. 19

20 4.3.5 Norwich New Model of Care It is anticipated that an MCP will combine the delivery of Primary Care and community-based services by incorporating a wider range of services and specialists in care hubs of integrated teams. It is envisioned that the model will also incorporate some acute services that can be delivered in the community. This approach is supported by partners, (heath providers, local authorities, voluntary sector and patient representatives) from across the local health and care system, through the YourNorwich New Model Board, which has overseen the programme development for the last two years. Figure 5 shows the model set out as a potential basis for development of an MCP in Norwich. CCG 2-5 Year Vision for GP Practices OOH / Urgent Care Social Care Acute Local Authority / Housing Specialist MH CAMHS Figure 5 CCG 2-5 Year Vision for GP Practices The key elements are as follows; Preventing illness and promoting better health. The Healthy Norwich programme is a partnership between NHS Norwich CCG, Norwich City Council, Broadland District Council and Norfolk County Council Public Health to support wider health improvement programmes and develop community assets. Care closer to home/integrated working across physical, social and mental health. Coordinated through the YourNorwich programme, it includes initiatives to manage admissions and support discharge aligning community and social care community teams with GP practices. Support to primary care. In recognition of the pivotal role of primary care at practice, locality and Norwich-wide level in developing improved integration and responsive patient care, the CCG has focused on working with practices through the OneNorwich Alliance programme. This is developing through the direction of the new Norwich Leadership Board (OneNorwich Alliance) to develop an MCP model of delivery. Collaborative commissioning. Alignment of commissioning intentions and plans with other Norfolk CCGs, working with joint clinical networks to develop and clinically assure pathways and ensuring consistency and continuity wherever possible. 20

21 4.3.6 Healthy Norwich Healthy Norwich aims to improve the health and wellbeing of people living in Norwich. As a Healthy City (recognised by the UK Healthy Cities National Network), the CCG is committed to working together on improving people s physical and mental health and wellbeing. The programme also focuses on the social determinants of health, ensuring everyone has a good start in life, greater employment prospects, better housing conditions and good transport facilities. An overriding programme objective is to prevent and detect major chronic illness that affect the Norwich population. In the remainder of 2016/17, the CCG will use the Right Care approach to identify and target such opportunities. Once projects are scoped, they will be added to the CCG s work programme in 2017/18 and 2018/19. The Healthy Norwich key work programme objectives and targeted interventions for are outlined in Table 4. Table 4 Healthy Norwich Programme Programme objectives Reduce obesity and prevalence of diabetes and its impact on residents and the local and wider health system. Reduce occurrence of smoking and alcohol related harm Targeted interventions Diabetes Prevention Programme New Tier 3 Weight Management service will commence April Daily mile in primary schools Reducing sugar consumption secondary school children & young people Smoke free locations (building on the positive smoke free parks project in 2016) The CCG commits to leading discussion with Healthy Norwich stakeholders during early 2017/18 with a view to agreeing a project that will contribute to the STP measure of reducing alcohol specific admissions and addressing alcohol related harm To support health improvements in the wider population of Norwich The CCG intends to initiate project(s) to improve self-care and ownership of health through peer support and patient activation. The CCG will undertake a project during that will focus on take up and maintenance of breast feeding due to the positive impact on health for the baby and mother. With the support of Norfolk Community Foundation, Healthy Norwich has successfully made a number of grants from its two new funds for These funds are Mental Wellbeing Innovation Fund and the Innovation to Support Sustainable Healthy Communities Fund. 2017/18 is year 2 of a Local Quality Incentive Scheme with Primary Care with a focus on asthma and COPD. 21

22 Improve Social Determinants of Health Wider roll out of the social prescribing pilot in Lakenham. Evaluation of Promoting Independence two year pilot with Age UK Norwich to improve the health, wellbeing and independence of frail older people with two or more long term and reduce their use of hospital and other health care services. Optimisation of the existing online directory ( to help local people, doctors and nurses find services in Norwich provided by voluntary organisations and also to support and promote the valuable and vital work of local voluntary organisations. This will develop to become a key tool for the MCP. Optimisation of the work that district councils do with regard to their responsibilities for Home Improvement Agency (safe & warm housing), Early Help Hubs and Disabled Facilities Grants YourNorwich The CCG is continuing to make efficiency savings to ensure it maintains, transforms and improves core services. YourNorwich is a comprehensive programme to transform and integrate services at a local level in Norwich, by working closely with partners including Norfolk County Council, NHS providers and voluntary organisations. The programme seeks to develop services from a patient perspective and GP practice, community and locality perspective. YourNorwich aims to integrate and strengthen local health and care services with a particular focus on older patients and those with long term conditions, who will be helped to stay safe and well at home rather than require admission to hospital. In order to achieve this, the programme focuses on harnessing the power of community assets including local voluntary organisations. There are four major elements of YourNorwich: Table 5 Your Norwich Programme Programme Objective Specific interventions GP Localities Helping GPs work together in four city clusters in Norwich, each with about 50,000 patients. Each locality could develop shared Primary Care services for older and more vulnerable patients if they wished to. Integration Building mental health, community nursing, therapy, and social care services around the same localities meaning more care is provided closer to people s homes. It will ensure patients receive joined-up services based around their needs, rather than based around traditional organisational boundaries. Technology Harnessing new ways of providing care and making the NHS more efficient, and bringing modern information and 22

23 communication systems to your local NHS services Communities Providing more support for self-care, carers, voluntary organisations and communities to deliver support to people locally. The CCG has guaranteed to maintain funding of at least 500,000 a year for the voluntary sector and increase that where it can. Norwich CCG with its partners has made considerable progress in developing a range of programmes, projects and initiatives designed to further integrate care at a local level. These are entirely consistent with the direction of travel and key objectives of the STP. The next stage of the process, drawing all the various elements into a single coordinated programme, is a major challenge. A draft work programme has been produced by the CCG and the OneNorwich Leadership Board, and is now being considered and prioritised (including consideration of the STP success measures) into a two-three year plan. Implementation of the New Norwich Model of Care (NNMoC) will be overseen by the current Your Norwich Programme Board. It is intended that over time the Terms of Reference for this Board will change, moving from a commissioner to a Provider led Board. The proposed work streams for the NNMoC are outlined in Table 6. Table 3 Norwich New Model of Care Programmes NNMoC Programmes Prevention & Wellbeing (see Healthy Norwich) Primary, Community & Social Care (single team based around GP practices) Specific projects and interventions Targeted Intervention Addressing social determinants of health Single Point of Access for services within the MCP Admission Avoidance & Supported Discharge a 24/7 integrated health & social care response Enhanced Primary Care:- o Hub based services unplanned 7 days / extended hours; diagnostics; clinical observation; urgent care, pharmacy services and social care. o Hub based services planned diagnostics; outpatient clinics (diabetes & dermatology); minor surgery and pharmacy services. o Locality based services supporting those with complex needs and/or who are vulnerable identification of population cohort through risk stratification and frailty assessment; care planning; holistic care supported by health and social care and voluntary sector Multi-Disciplinary Team working. o Locality based services - planned services long term conditions and wound care management; drug administration; phlebotomy; outpatient clinics (diabetes & dermatology). Enhanced Care in Care Homes Roll out of the Bowthorpe Care Village pilot with a view to improving health and wellbeing of residents in care/nursing homes and reducing 23

24 unplanned activity. Projects will include using technology to facilitate information sharing and education of care/nursing staff and optimising the support provided to homes and residents through delivery of a MDT style enhanced care. Primary Care at Scale To create one voice for primary care and implement initiatives that will support sustainability of primary care services. Mental Health Dementia Embedding MH into communities and primary care Rehabilitation and Reablement Supporting people with MH co-morbidities. Other workstreams Information Communication Technology (ICT) Governance Finance, Contracting & Performance Communications & Engagement The work of OneNorwich will underpin the transformation of community and primary care services in Norwich and therefore enable delivery of significant elements of the CCG s QIPP programme. 4.4 Urgent and Emergency Care The provision of a sustainable urgent and emergency care service remains a key priority going into 2017/18 and beyond. Commissioning of acute care and resilience of the urgent and emergency care system is led by North Norfolk CCG with the active participation of Norwich CCG, who lead the Pre- Hospital Improvement Board and the Unplanned Care Clinical Network. Whilst considerable progress has been made over the previous two years in slowing the rate of non-elective growth, significant pressure still remains on the system. Solutions to achieve this will be based on the agreed Norfolk and Waveney STP guiding principles, our system s overarching priority of keeping me at home and will be consistent with the wider strategy as set out in the Urgent and Emergency Care Review. Consistent with the 5YFV, the priority remains on the sustainable delivery of the four hour A&E standard and the five improvement areas of the A&E improvement plan that accompanies it. The solution to a sustainable model of care lies both in the management of patients prior to attendance at a Provider (i.e. the typically transformational change) and then what happens to them should there not be any alternatives than secondary care. The primary aim to the management of patients prior to referral is to identify those whose care can be provided in an out of hospital setting and thus minimising onward transfer to 999 and Acute Care. The specific intentions we have for affecting this change involve: 24

25 Norwich CCG leads the development of the integrated clinical hub model on behalf of the system (as highlighted in the Urgent Care Review) to manage 111 and 999 calls both in and out of hours. This will be supported by GPs to support multidisciplinary clinical assessment and ensure people are directed to and treated by the most appropriate services including access to primary, social and mental health care. In turn, this will deliver a reduction in the number of 999 calls resulting in transportation to an A&E department. The development of Single Points of Access into Providers in order to manage demand, effect clinically appropriate access and aid flow through to discharge and recovery applicable to all Providers including secondary care and mental health. The new operating model will support a reduction in conveyances by appropriate signposting to alternate pathways via the Emergency Clinical Advice and Triage centre within EEAST emergency operations centre (EOC) and utilising the mobile specialist paramedic staff as a mobile community health service, treating patients in their own home or community. The development of a Supported Care service focused on providing support to patients to enable them to be care for in their own home, preventing the chances of emergency admission and a potential resulting stay in a community inpatient unit. Building on the 2016/17 Frailty CQUIN, CCGs wish to focus on the identification of the pre-frail and align services to support such patients and carers to minimise risk of escalation. For patients that do attend secondary care the focus will be on front end streaming and coordinated care. This will involve two stage management of patients presenting at A&E with primary care front end operating during weekends to triage and treat minor injuries and illnesses and redirection of patients to the out of hours service where appropriate. Norfolk and Waveney CCGs will work with Providers to implement the five areas from the A&E improvement plan Norfolk and Waveney CCGs will comply with national guidance and work with Providers to implement the five areas from the A&E improvement plan: 1. Streaming at the front door to ambulatory and primary care. This will reduce waits and improve flow through emergency departments by allowing staff in the main department to focus on patients with more complex conditions. 2. NHS 111 Increasing the number of calls transferred for clinical advice. This will decrease call transfers to ambulance services and reduce A&E attendances. 3. Ambulances Dispatch on Disposition (DoD) and code review pilots; HEE increasing workforce. This will help the system move towards the best model to enhance patient outcomes by ensuring all those who contact the ambulance service receive an appropriate and timely clinician and transport response. The aim is for a decrease in conveyance and an increase in hear and treat and see and treat to divert patients away from the ED. 4. Improved flow must do s that each Trust should implement to enhance patient flow. This will reduce inpatient bed occupancy, reduce length of stay, and implementation of the SAFER bundle will facilitate clinicians working collaboratively in the best interests of patients. 5. Discharge mandating Discharge to Assess and trusted assessor type models. All systems moving to a Discharge to Assess model will greatly reduce delays in discharging and points to home as the first port of call if clinically appropriate. This will require close working with local authorities on social care to ensure successful implementation for the whole health and care system. 25

26 For those patients who do require further care, a more sustainable solution needs to be in place that does not result in patients defaulting to A&E. For those patients who do require further care, a more sustainable solution needs to be in place that does not result in patients defaulting to A&E departments. Commissioners focus will be on establishing more integrated alternatives to A&E that provide access to same day urgent care and ensure a clinically appropriate response by ambulance services to 999 and with access to timely and clinically appropriate secondary care treatment as required. The specific intentions we have for affecting this change involve: Working with EEAST to develop an operational model in order deliver the clinically appropriate response (hear and treat, see and treat or convey) that is integrated across the health system. Implementing the NNUH A&E Front Door Redesign model to ensure access to the appropriate clinical intervention, including transfer into secondary care. Fully embedding the new contract for delivery of the Norwich GP-led Walk in Centre and develop to support both planned and unplanned care models. Reviewing current services for provision of out of hours primary care to identify options for aligning with the integrated model and improving most effective use of that resource. Whilst consortium contracting arrangements for ambulance services may previously have worked on the large scale with which they work at the moment, Commissioners are very keen to move to a model that is less centralised, better reflects the needs of the local population and is integrated with all the other local system changes we expect to see. Norfolk and Waveney will actively explore ways in which we can achieve more local influence and control over how ambulances services fit within our local system and drive better outcomes for our population. 4.5 Referral to treatment times and elective times Similar to unplanned care, the focus of the 5YFV (and hence the Norfolk and Waveney STP) is on recovering and maintaining the constitutional standards specifically RTT performance and Cancer. RTT performance remains a challenge in relation to the RTT 92% target, particularly due to the backlog. The review of the Intensive Support Team acknowledged the need to take a system wide approach to bridging the demand and capacity gap and this is reflected within the objectives of the STP. There are two strands to this work; first, getting the backlog down (this includes demand management measures); second, addressing the long term sustainability by balancing demand and capacity. In 2017/18, we will work with Providers to balance demand across the system and utilise the capacity available at JPUH (James Paget University Hospital) and QEH (Queen Elizabeth Hospital). Indeed, work is already underway to review capacity across the Provider base with this in mind. Equally, we will work with Providers to improve internal efficiency, recognising that there are aspects of this which require solutions from CCGs. As well as the balance of demand across Providers, our QIPP programme for 2017/18 will continue to focus on supporting our Providers in managing demand into secondary care. We will continue to monitor and challenge primary care variation with a focus on reducing this where it is unwarranted. The STP focuses heavily on the need to shift activity out of hospital and this will be facilitated through our QIPP programme alongside our Partners. We will continue to focus on supporting our Providers in managing demand into secondary care 26

27 In recognition of the above, QIPP programmes will focus on the NNUH, working with clinicians in each directorate to understand and scope opportunities for pathway design. The CCG will adopt the RightCare approach in doing this and is an active participant in the roll out of Wave Two areas. The CCG has already begun to scope the areas in which an STP approach to RightCare would be beneficial (e.g. cancer) but also the areas in which a local approach may be required. Further details on the QIPP approach are detailed within the financial section. The CCG actively promotes patient choice and already commission a number of community based services, including Audiology AQP and a streamlined community MSK and Physiotherapy service. We will continue to work closely with GPs to educate around the different providers through a peer review process and to encourage use of the e - referral system which empowers the patient to make choice of providers. Through the Norwich New Model of Care we will be looking at a model of hub and spoke services over the next two years to offer additional choice within the community setting, for example: Potential hub services for consideration include Urgent care services; Extended hours e.g. access to out of hours appointments; Diagnostics; Minor surgery; Outpatient clinics the first specialties to be considered will be dermatology and diabetes redesign may require a change in service delivery by both the acute and community Provider; Clinical observation; Pharmacy. Potential cluster services for consideration include Community Mental Health & Wellbeing; Locally Commissioned Services with Primary Care; Outpatient clinics; Community Nursing & Therapy; Social care. Potential transfer of service delivery of minor surgical procedures from the acute to the community settings. The CCG has developed an Elective Demand Management Plan to address the challenges to referral to treatment times and elective times (please see Appendix D). 4.6 Cancer The commissioning vision, aims and objectives for cancer care in Norfolk and Waveney are aligned to the new National Cancer Taskforce report Achieving World Class Outcomes: A strategy for England DH , the national performance indicators for cancer waiting times, Right Care and the new Quality Premium for cancer. Cancer care shall be provided and commissioned as part of the East of England Strategic Clinical Network for Cancer (EOE SCN) and as part of the forthcoming EOE Cancer Alliance. Norwich CCG will continue to work with Providers to achieve world class outcomes and the sustainable delivery of core cancer standards. Recognising the predicament that local services are in, the CCG expects Providers to work closer together as a way to sustain delivery and quality of care provided. Specific intentions for how this will be achieved include: Norwich CCG will continue to work with Providers to achieve world class outcomes in cancer Continuing to support the integrated care pathways project at the NNUH and James Paget University Hospital including survivorship, holistic needs assessment and risk stratified pathways across all Providers. The implementation of the national cancer taskforce recommendations. Reviewing the feasibility and potential implementation of supportive cancer care and chemotherapy administration in the community, building on the transfer of work into the community that has already taken place. Supporting the roll out of evidence based best practice cancer pathways. Supporting general practice and working with Public Health England to improve earlier cancer diagnosis and prevention. 27

28 Clinical service review of local cancer services in Great Yarmouth and Waveney. Implementation and monitoring of the national quality of life measure for all local cancer patients once it has been published nationally. Implementation of the local cancer dashboard in line with national guidance. Prevention, Early Diagnoses and Improved Treatment of Cancer Cancer is one of six clinical priority areas and the current baseline assessment of cancer highlighted that the CCG s performance needs improvement. Two of four key measures relate to increasing earlier diagnosis and survival rates. Specific work to improve our performance will include: Focus on prevention initiatives and projects included in the CCG s Wellbeing and Prevention Programme (New Norwich Model of Care), this includes projects that promote healthy weight, healthy lifestyles and smoking cessation Working with STP partners to undertake a pathway review for Upper GI and Lung with a focus on prevention Optimising screening uptake across the national cancer screening programmes Working with STP partners, in particular public health, regarding public information campaigns to raise the awareness of risks and symptoms Ensuring referrals to secondary care are in line with the new NICE referral guidelines Cancer has been identified as a priority to review using the RightCare methodology. Norfolk & Waveney CCGs have met to review the data within the Commissioning for Value Pack and have agreed areas for further investigation, prior to holding a clinically led Optimal Design Event across providers and commissioners in March Recommendations from this workshop will form part of a programme of work that will be addressed either at a STP footprint, or focused on NNUH footprint or at a specific CCG level. The areas for further scrutiny are: Review of pathway (both elective and non-elective) for Upper GI and Lung. For lung pathway review to include specific focus on prevention schemes such as smoking cessation and weight management. Optimise screening uptake, with particular focus on hard to reach population. Deep dive to understand what is driving the variation in elective activity for skin cancer although will be linked to variation seen for excision of skin lesions. Prescribing of hormone therapies and immunosuppressants Increasing diagnostic capacity which will include review of the radiology workforce to support sustainability Promotion of shared decision making regarding diagnostic process and also the treatment options available 4.7 Mental health Demand for mental health services across all ages continues to rise. In order for the system to better support this whole system change is needed ensuring that future provision sees mental health care embedded within future delivery models. A key challenge in achieving this is in continuing to ensure that mental health services are able to provide the best care possible during a period of and system change. The CCG is committed to ensuring delivery against the objectives and standards within the Five Year Forward Plan for Mental Health (February 2016). This is reflected within the Norfolk and Waveney STP and the system wide commissioning intentions for

29 This will ensure that the future community mental health service will be embedded within an integrated service approach that is focused on delivery within and/or aligned to Primary Care and enables a preventative approach across all ages that supports a reduction in need for urgent and crisis care interventions. Outcomes: In line with the Five Year Forward for Mental Health, the next two years will see: By 2018/19 at least 19% of people with anxiety and depression are accessing appropriate therapies (IAPT). By April 2019 at least 32% of children with a diagnosable mental health condition are able to access evidence based provision. Improved detection and management of dementia, ensuring compliance with and maintenance of performance against the national dementia diagnosis rate of 67% By the end of 2018/19 at least 53% of people with aged between 14 and 65 experiencing first episode of psychosis will receive a NICE compliant service within two weeks of referral. A reduction in out of area placements A reduction in suicide rates by 10% against the 2016/17 baseline 95% of children and young people receiving treatment for eating disorders within four weeks for routine cases and one week for urgent cases. Increased capacity to support people of all ages in crisis. Improvements in the physical health of people with mental health needs. Improved pathways for children, young people and adults with neurodevelopmental conditions such as ASD and ADHD. Improving Access to Psychological Therapies (IAPT) The expansion of the IAPT service, planned for commencement in April 2017, will focus on the development of Primary Care and Secondary Care services aligned to long term conditions. Core to this proposition will be the integration of physical health, mental health and parity of mental health with physical health. Many disease pathways such as Diabetes, Chronic obstructive pulmonary disease and Irritable Bowel Syndrome are exacerbated by mental health conditions and admissions to inpatient settings are double the average length of stay when a mental health condition co-exists with a physical health condition. In order to improve outcomes for patients, the service will embed IAPT practitioners and the philosophy of IAPT into Primary Care. This will ensure that patients with long term conditions are encouraged to access the IAPT service where clinically appropriate. It is envisioned that a practitioner will be based within a cluster practices, some of which will come under MCP arrangements. Within Secondary Care, the service will be linked with long term outpatient services to reduce the number of outpatient consultations and reduce the likelihood of admission. The CCG has also been running a pilot with Job Centre Plus in Norwich whereby a Wellbeing practitioner is based in the Job Centre and offers assessments and training for staff. In addition, there is a national funding pot that the CCG are currently bidding for in order to embed employment advisers in the Wellbeing Service (Primary Care Mental Health Service). 29

30 The current Wellbeing Service in Norfolk, like many nationally, has evolved tremendously and now sees patients who are more complex and severe than the recovery rate was originally designed to measure. As a result, a locally enhanced care pathway (ECP) has been developed to sit alongside the core IAPT pathway. Patients will receive the same service as before but those on the ECP will not be measured against the recovery rate. Norwich Mental Health Action Plan Norwich CCG is fully committed to ensuring an equal focus on improving mental health as physical health and that patients with mental health problems do not suffer inequalities as a result. In order to deliver the Mental Health Forward View (MHFV), Norwich CCG are currently developing the following actions and milestones. Table 4 Milestones for Development of MHFV Embedding MH into communities and primary care Rehabilitation & Reablement Training/Workforce development/awareness raising Information and Accessibility Physical Health Multi-disciplinary triage for mental health referral to ensure the right care is received in a timely manner. Work with partners to scope a Wellbeing Walk In Hub to act as a focal point for prevention services and navigation into community assets. Align Wellbeing (IAPT) service to MCP model To develop complex needs MDT s in Primary Care To explore Social Prescribing Models Effective MH liaison for primary care Work with partners to scope an evening café to offer an alternative resource and improve people s wellbeing out of hours Assess the support needs of vulnerable women who have experienced sexual assault and / or domestic abuse and identify appropriate interventions Work with existing mental health providers to offer training and awareness for primary care staff to improve early identification of mental health problems and subsequent support for these people. To develop a tiered training support offer for MH. Development of targeted online resources (eg. Podcast, different languages etc) Additional online resource (eg Self Help Materials/Guided workshops) Mental Health Support for people with LTC's Peri-Natal Mental Health target Improve Physical health screening and advice/sign posting for people with Serious Mental Illness (SMI) (eg. Smoking cessation) 30

31 Dementia Diagnosis The CCG has formulated an over-arching dementia action plan. A particular focus is bespoke support for specific practices, to improve dementia diagnosis rates. As at October 2016 the diagnosis rate for the CCG is 61.6% (where the dementia diagnosis rate = number of patients on dementia register / estimated prevalence x population estimate). The national ambition is 67%. Dementia Post Diagnostic Support The CCG is developing a tiered Dementia Support Service to support and enable families and people with dementia from peri-diagnosis to post bereavement, offering case management to patients in receipt of Continuing Health Care. The service will be work across services to ensure effective navigation and utilisation of services for people. Our Integrated Commissioning Team was involved in the commissioning of a new social care Flexible Dementia pilot service for Norwich, providing dementia respite opportunities, initially as part of a countywide pilot. Subject to full evaluation, it enabled 25 people with dementia to remain at home rather than go into respite care. 4.8 People with learning disabilities The CCG will continue to work in partnership in to deliver the ambitions of the LD Transforming Care Programme and ensure people with learning disabilities needs are met. Norwich CCG will Work in partnership with South Norfolk CCG (coordinating commissioner) to deliver the Transforming Care Partnership Plans with Norfolk County Council, Suffolk County Council and other key stakeholders. The plan will align with STP ambitions by enhancing community provision for people with learning disabilities and/or autism. A key challenge for this work is the lack of suitable community housing to discharge individuals to. This is being addressed with key actions in the Transforming Care Partnership Board plan. 4.9 Improving Quality in Organisations The CCG is working with partner organisations within the STP to deliver the health and care needs of the local population. In order to support this, Norwich CCG has robust processes and used a variety of intelligence and data, to monitor and evaluate the quality and patient safety of all the services we commission. This includes, but is not limited to reviews of: Serious Incidents, Never Events, Quality Issue Reports, NHS Safety Thermometer, Complaints, Patient Experience, Workforce and Performance data Supporting organisations to implement plans to improve quality of care, particularly for organisations in special measures It does so by working with NHS providers to ensure that learning and recommendations from national guidance, external inspections and enquiries are embedded within practice to ensure that patients receive evidence-based, safe and effective care. Norwich CCG actively works with other local CCGs, health and social care partners such as NHS England, the Care Quality Commission, Monitor and Norfolk County Council to monitor and support providers in delivering the highest standards of care. The CCG also works with the coordinating commissioners for local provider services, recognising the equal part the CCG plays in monitoring the quality and safety of services it commissions. 31

32 4.9.2 Drawing on the National Quality Board s resources to measure and improve efficient use of staffing resources to ensure safe, sustainable and productive services The CCG holds regular Clinical Quality Review Meetings with local providers to discuss quality and safety issues. The CCG also holds a monthly Quality and Patient Safety Committee where detailed discussions regarding the quality and safety of services are discussed, risks identified and mitigated. Risks are captured within the Quality Directorate Assurance Framework and escalated to Governing Body as appropriate. The CCG Governing Body receive monthly Consolidated Quality Report summarising the level of assurance for our providers and actions being taken. Norwich CCG has access to dedicated Safeguarding Adults and Children s teams, along with the other four CCGs across Norfolk and Waveney. The CCG works closely with both teams to access expert support and advice in matters relating to safeguarding to ensure that vulnerable people are appropriately supported and cared for within all the services we commission. Both teams work closely with their respective Norfolk Safeguarding Adults and Children s board to ensure that learning from serious case reviews is embedded within local practice. In addition, we have a dedicated Infection Prevention and Control team who supports and advises the CCG on national standards and recommendations to be embedded within our Provider organisations Improving Quality in Care Homes The CCG has worked with GP practices to align a practice to each care and nursing home in Norwich, making it easier for the care homes and each practice to develop effective communications and working relationships. The service includes weekly ward rounds by a GP and/or nurse with a focus on prevention. The CCG has also worked in partnership with Norfolk County Council to ensure that there is integrated health and social care services within the new Bowthorpe Care Village site. The Care Village is developing exemplar health and social care services for end of life care, dementia and falls. Norwich Practices Limited (NPL) is providing a primary care surgery run primarily by senior nursing and Healthcare Assistant (HCA) staff with access to GP and specialist support, for example partners in the Ambulance Trust, Out of Hours and 111, Primary, Community and Secondary Care. Norwich CCG will continue to promote integrated working between health and social care partners to ensure care home residents receive consistent quality of care. 5 Other Key Priorities There are a number of other key national priorities which the CCG is committed to delivering against in 2017/18 and 18/ Diabetes Norwich CCG is planning to redesign the community diabetes service into an enhanced primary/community care diabetes services. This work will be informed by the development of the MCP and may include shifting some diabetes services from the acute into hub/spoke arrangements with primary care integration. In order to enable transformational change, the CCG also intends to roll out a new diabetes prevention service that provides targeted intervention and education for patients to either prevent or delay the onset of diabetes. 32

33 Norwich CCG also has the opportunity to improve outcomes in Primary Care diabetes management by focusing on: Reducing obesity in adults and children HbA1c Blood pressure Cholesterol levels Retinal screening 8 Care Processes The Diabetes redesign pathway will focus on: Prevention of diabetes by building on the newly launched Diabetes Prevention programme Targeting improved delivery of diabetes 8 Care Processes in Primary Care Clustering of diabetes management in Primary Care to reflect Norwich New Model of Care Super six specialist diabetes being seen with N&NUH Trust Improving uptake of structured education; Ensuring everyone with diagnosed diabetes is recorded on GP practice diabetes registers Increasing the percentage of people registered with diabetes who receive the NICE key processes of diabetes care Increasing the percentage of people registered with diabetes who achieve NICE defined treatment targets for glucose control, blood pressure and blood cholesterol Understanding the rates of acute and long term complications (disease outcomes) for people with diabetes Table 8 Diabetes Deliverables and Milestones Deliverables Year 1 Deliverables Year 2 Deliverables Milestones Increase percentage of people supported to reduce their risk of diabetes through the Diabetes Prevention Programme. Measurable reduction in variation in management and care for people with diabetes. % of people with T1 & T2 on structured education " "% people supported to reduce their risk of diabetes through the Diabetes Prevention Programme. Measurable reduction in variation in management and care for people with diabetes. % of people with T1 & T2 on structured education " 33

34 5.2 Continuing Care Norwich CCG is the coordinating commissioner for Continuing Healthcare. In 2016/17 the CCG implemented a Project Plan to deliver NHS Standard Contracts signed with all Nursing Home Providers, Domiciliary Care Providers and Residential Care Providers. The CCG is committed to improving the value of the existing NHS Continuing Care (NHS CC) system in Norfolk over the next two years. This is intended to secure the following outcomes: Ensure NHS CC services are delivering improved outcomes for patients Ensure NHS CC services are secured in a way that delivers improved quality for patients Ensure NHS CC services are secured at improved expenditure rates for commissioners The programme of work encompasses a number of local measures as well as Pan-Norfolk Transformational measures for NHS CC and NHS Continuing Healthcare (NHS CHC). This builds on the work undertaken in and The Implementation of Contracts for all Nursing Homes, Residential Homes and Domiciliary Care providers of NHS funded CHC will be an ongoing area of work as the procurement will be reopened periodically in order to provide further opportunities for providers to join the framework. Table 9 Continuing Care Programme Ref Deliverable Stage 1 Local Measures A1 A2 A3 A4 Review of Individual Patient Placements Review of local arrangements for agreeing and funding Section 117 Placements Quality Assurance of NHS CHC Eligibility Reviews and High Cost package reviews Review of NHS CHC Fast Track Service provision Pan-Norfolk Transformational Measures B1 Implementation of Contracts for all Nursing Homes, Residential Homes and Domiciliary Care providers of NHS funded CHC Project idea identified Stage 2 Build high level project plan Stage 3 Project execution Stage 4 Project closure 01/05/ /10/ /11/ /03/ /05/ /03/ /06/ /06/ /05/ /10/ /11/ /12/ /04/ /03/ /04/ /07/ /01/ /03/ /06/ /09/

35 B2 B3 B4 Implementation of integrated CHC Service Delivery provision (including case management) Implementation of Discharge to Assess pathway Implementation of Children and Young People s (NHS CC) contracts 01/06/ /01/ /03/ /06/ /09/ /10/ /11/ /02/ /01/ /10/ /04/ /02/ Maternity Following publication of the national Maternity Services Review, the Trust and central CCGs undertook a self-assessment of its performance against the standards within. This led to the production of an action plan which is being implemented. The CCG has equally recognised the findings and aspirations within the Better Births report. The CCG is currently working with Dame Cumberlege to trial new models of care designed to offer more personalised care to women with continuity in carer. By breaking down barriers across organisations and providing more multi-disciplinary working, care should become safer in turn. A key element of this new model will be better support for post and perinatal mental health where Norfolk CCGs are represented in the national working group. 5.4 Children and Young People The CCG will ensure the development and delivery of children and young people s services by working in partnership across the Norfolk and Waveney STP footprint. This will include developing joint commissioning approaches across Norfolk and Waveney s CCGs, Norfolk County Council and other partners. Norwich CCG will work to align commissioning of services for children with Special Educational Needs and Disability (SEND) and their families and overall, improve outcomes and patient experience for children and young people. Reducing Unplanned Paediatric Acute Admissions The CCG will work with STP partners to reduce unplanned paediatric admissions to hospital by ensuring that children and young people s health needs are effectively supported before the need for an emergency admission arises. The focus of this work will be to ensure the achievement of improved health outcomes for all children and young people. The impact of this work will be a reduction in the rate of emergency hospital admissions against 2015/16 and 2016/17 data. Looked After Children effective support before the need for emergency admission The CCG has contributed to the development of a new Norfolk model for delivering health services to Looked After Children. This has been developed jointly by health commissioners, care commissioners and providers. The model includes GPs undertaking assessments and recruitment to the GP role is now underway. Our aim for the future is to operationalise the full model and establish a county wide dashboard that would provide a picture on the health and wellbeing of Looked After Children; this will involve collating data from various sources and providers. 35

36 5.5 Seven Day Services Everyone Counts: Planning for Patients 2013/14 first signalled that the NHS would move towards providing routine services seven days a week. The 5YFV (published in 2015) also set out seven-day working across the NHS as a key requirement. In recognition of the considerable impact this will have on GP practices already under enormous pressure, the CCG convened a summit of its Membership to discuss how best to deliver the 5YFV ambitions and ensure the sustainability of primary care. The option of an MCP was preferred by practices as a vehicle to integrate a range of NHS services. Nationally, the roll out of seven day services is required by 2020 in all hospitals across all ten standards. The NNUH is participating in the regular self-assessments of its provision against the 10 clinical standards identified by NHS England with the results of the next assessment being due to Commissioners in November The results of the most recent self-assessment demonstrate that job planning does make provision for consultant led ward rounds every day of the week in the majority of surveyed departments (76%). An average of 30% of patients are assessed by a suitable consultant within 14 hours of arrival, and 17% of patients are made aware of their diagnosis, management plan, and prognosis within 48 hours of arrival. There is no significant difference in weekend performance. An average of 5% of patients can access consultant directed diagnostic testing within 1 hour for patients with critical needs, and 2% within 12 hours for patients with urgent needs. Patients do have access to consultant directed interventions 7 days a week in all departments. An average of 34% of patients on AMU, ASU, ITU and other high dependency areas are seen and reviewed twice daily. ITU achieves 100%. Only ASU has a significant reduction over the weekend. Once transferred to a general ward from an acute areas, an average of 15% of patients were reviewed as part of a consultant delivered ward round at least once every 24 hours. There was a significant reduction over the weekend. 10% of patients were made aware of review done by consultants in high dependency areas and made aware of status and changes to their management plans. These results appear to show that NNUH falls short of achieving equivalent levels of 7 day service for acute patients compared to other acute trusts in England and in our region despite making relatively good provision for 7 days per week care in terms of consultant ward rounds in most specialities, and 100% availability of consultant led interventions 7 days per week. This survey exercise was performed independently of the clinical teams by the coding department using only information that could be gained from the medical notes of each patient. The survey was performed in a highly diligent manner with full submission of data for 282 patients so that for instance a ward round would only be labelled as compliant with the standards if the consultants name was clearly legible and if the time was clearly recorded. For future surveys (beginning in September) individual divisions will ensure clinical input so that the results we record accurately reflect the extent of the seven day service we provide. For some standards cross-referencing with other professionals notes and other systems (e.g. RIS) will be required. 5.6 Winter 2017/18 The CCG, in conjunction with other local NHS and social care partners, will build on the planning undertaken for Winter 2015/16 and 2016/17 by developing the central Norfolk System Winter Resilience Plan further for 2017/18. The development of this plan will be led by the central A&E Delivery Board. This is anticipated to include key mitigation in relation to the following service areas: 36

37 Acute hospital capacity Delayed Transfer of Care Norfolk and Norwich University Hospital Delayed Transfer of Care Norfolk Community Health and Care Social Care (including housing & wider Local Government) Ambulance Service Primary and Community Services Mental Health and Learning Disabilities Escalations and Communications 5.7 Personal Health Budgets Personal Health Budgets (PHBs) have been in development since the publication of Choice in Health and Social Care, (Department of Health). In 2015/16, a PHB smallscale patient pilot offered PHBs to a small cohort of Norwich and South Norfolk patients with type 2 diabetes. NHS Norwich CCG is fully committed to expanding its local offer for PHBs and Individual Patient Budgets (IPBs) beyond adults eligible for Continuing Healthcare and children receiving continuing care. Work in has focused on expanding PHBs and exploring IPBs with people with learning disabilities. The table below sets out the proposed strategy for achieving further expansion of the local offer for PHBs over the next two years. Table 10 Deliverables for Expansion of Local PHB Offer 2017/18 Deliverables Quarter Milestone Expand PHB offer to Q1 Initial scoping meeting NHSE & NCHC wheelchair users Q2 Viability assessment undertaken Q3 Project plans drawn up and agreed Q4 Working group formed with OT colleagues Expand PHB offer to Q1 Residents with CHC identified residents with Q2 Viability assessment undertaken learning disabilities Q3 Project plans drawn up and agreed Q4 Working group formed with LD colleagues Explore a range of Q1 Develop reporting for current process options for Q2 Agree current savings delivered to CCG management of PHB Q3 Analyse savings for different users for LTC residents Q4 Agree and procure provider Have 72 people on Q1 Establish regular reports on usage PHB Q4 CCG PHB Policy ratified 2018/19 Deliverables Quarter Milestone Have 144 people on Q1 Establish regular reports on usage PHB Q2 Identify other cohorts suitable for PHB Q3 Link in to national trials in other areas of health Q4 Regular networking with colleagues for opportunities 37

38 5.8 Wheelchair Access The CCG will work towards achieving two key deliverables in relation to wheelchair access: Halve the number of children waiting 18 weeks for a wheelchair by quarter four of 2017/18 Eliminate 18 week waits for children for wheelchairs by the end of 2018/19 Table 11 Deliverables for Wheelchair Access Year 1 Deliverables: Milestone: Key actions: Produce Project Initiation Documentation (PID) to achieve 2017/18 target Half the number of children waiting 18 weeks for a wheelchair 30th June st March 2018 Year 2 Deliverable: Milestone: Key actions: No children waiting more than 18 weeks for a wheelchair 31st March 2019 Task & Finish Group established to produce PID to understand current performance and scope plan to achieve target. Implementation of PID and project execution phase. Put processes in place to ensure target achievement is business as usual. Project closure phase. 5.9 Better Care Fund The Better Care Fund (BCF) forms part of the NHS Mandate. This requires local areas to formulate joint plans for integrated health and social care, and set out how a pooled budget will be used to facilitate closer working between health and social care to provide consistent, joined up and high quality services for everyone. Locally, the work of the Integrated Commissioning team and the YourNorwich project is aligned to the Better Care Fund (BCF) for Norfolk. The BCF is a key mechanism for the delivery of integration in Norfolk million of the CCG s planned spending including YourNorwich and other integrated care projects accounted for Norwich s share of the Better Care Fund. 6 Key Enablers in Delivering Value 6.1 Estates Strategy Norwich CCG has established a OneNorwich Estates workstream including representatives from GP practices. This supports delivery of the Norfolk and Waveney STP and the 5YFV and will continue to evolve with delivery driven through partnerships with providers, local authorities, NHS England and NHS Property Services Limited. A key initial priority is to identify the longer term capacity needed for primary and community care in Norwich, building on work already done within the central Norfolk Strategic Estates Plan. This will then enable a review of primary care estate in Norwich and the establishment of a strategy to align with the new models of care under development. In the short term, the CCG has successfully secured funding from the Estates & Technology Transformation Fund (ETTF) to support more immediate needs for extensions to a number of practices. 38

39 6.2 Digital Norwich Norwich CCG is committed to using information management and technology to support people in Norwich to live healthier lives and better manage their own care, to effect transformation of services and enable integration of health and social care. The CCG is working with partners across Norfolk to deliver the plans within the Local Digital Roadmap Connected Digital Norfolk and Waveney which sets out a three year journey towards becoming paper-free at the point of care and two year plans for progressing universal capabilities. Three ambitions shape the vision: digitally enabled individuals, connected quality care, and innovation through technology. Informed by the Digital Maturity Index Assessments, the plan builds on the good practice in primary and community care and with the Ambulance Trust, digital pathology systems in the acute hospitals and community trust mobile working. However, there are significant gaps and under-investment in technology in secondary care compared to the national position and work is underway to improve the digital infrastructure and interoperability, such as better uptake of SystmOne and investment by the mental Norwich CCG is committed to using information management and technology to support people in Norwich to live healthier lives and better manage their own care health trust in a new clinical information system. The key aim of the LDR is to implement a shared EPR by 2020 but this requires significant investment. Underpinning this work is the safe sharing of patient records, with mandatory data sharing agreements to be in place across the system, compliance with the new Data Security Standards, Consent and Opt-Outs, encouraging communication with patients on their options around consent to share records, ensuring minimum of level 2 compliance with the IG Toolkit, promotion of Cyber-security, continued use of the NHS Number and adherence with legislation. The Information Governance Leads across the Norfolk & Waveney footprint are leading this as part of the LDR. We continue to require our providers to deliver on LDR priorities through our commissioning and contracting processes, including through our local contracts enforcing the terms of the NHS Standard contract and digital transformation and through CQUINS. Norwich CCG has established an IT Workstream with the Norwich GP Alliance, linking closely with the LDR programme, as a fundamental enabler for the new models of care and development of our MCP, as well as local implementation of the STP. The focus of the workstream is to facilitate digital interactions between primary and secondary care and is described more fully in our GPFV Plan. Initiatives are outlined below. e-prescribing Our aim is for all prescriptions to be sent using the national Electronic Prescribing Service (EPS), unless the patient asks for a paper prescription. We are working with our Medicines Management team to increase the uptake of EPS and to ensure transfer of repeat prescriptions electronically by March 2018, with 80% transmitted by March e-referral Norwich GP practices are able to make all referrals electronically, however the issue is with bookable slots with providers. The CCG is addressing this through contractual mechanisms and through the LDR to identify root cause. 39

40 Interoperability and transmission of healthcare information Interoperability, through the optimised use of SystmOne is the key priority area for the IT workstream of the OneNorwich GP Alliance. Through contractual mechanisms and through the LDR, the CCG is ensuring compliance with the terms of the NHS standard Contract on interoperability. Across the footprint, 100% of consented patient records have been uploaded to the spine and all providers are viewing SCRs. Already the majority of Norwich practices and community trust uses SystmOne which has SCR viewing embedded and we are working with the acute hospital to enable the SystmOne viewer. Child protection information is currently recorded in SystmOne by health visitors and school nurses. Palliative care info shared by SystmOne viewer. Work is underway via the LDR to structure hospital clinic letters structured to Academy of Medical Royal Colleges headings. We aim to have all discharge summaries sent electronically from all acute providers to the GP within 24 hours. Although all GP practice systems are capable of receiving electronic communications, acute systems are not. As the hospital systems are upgraded, electronic messaging will be enabled. Risk stratification Norwich practices have been utilising the NELCSU NELLIE risk stratification tool for over two years. Through the IT workstream with OneNorwich GP Alliance, we are optimising the use of this tool, along with health and social care partners to reliably identify those patients at risk of complications and/or early deterioration to prevent unnecessary hospital admissions. Patient OnLine Services The CCG is working with the OneNorwich GP Alliance and with NHS England to ensure these requirements are implemented. This includes ensuring better wifi access and the development of the OneNorwich website and portal with the aim of digitally enabling our citizens to interact with services online and facilitate self-care. We will promote the use of Skype/facetime technologies for patients to interact with clinicians and similarly work with care homes on smarter options. All Norwich practices have already enabled the record access, repeat prescriptions and online booking. Telehealth The CCG has invested in Telehealth and tele monitoring to underpin its key transformation projects, including support for the Norwich Escalation Avoidance Team (NEAT). The CQUIN with NCH&C for 2016/17 has facilitated the use of tele monitoring in the heart failure service and this will be rolled out for 2017/ Contracting Contractual mechanisms and payment mechanisms need to evolve to better reflect, and encourage, wider changes within the system, including those outlined in the Joint Commissioning Intentions. Commissioners and Providers have agreed contracts for two years ( ) in line with national guidelines. Our ambition is to move away from the heavily transactional and narrowly focused way of contracting to something that is simpler, focused on outcomes and not organisationally constrained. In order to comply with national timescales, Commissioners have taken a pragmatic approach to the contract process, agreeing contracts with individual 40

41 providers, but will continue to explore options for contracting beyond existing organisational boundaries. CCGs continue to work more closely together in the current Coordinating commissioner arrangement, such that each main provider will hold one contract with all Norfolk and Waveney Commissioners from April Commissioners will continue to seek regular assurance over the quality of services being provided. The Clinical Quality Review Meeting (CQRM) for each main contract will monitor service delivery of standards throughout the year, using all contract levers available to us to ensure standards are met. We will do this by ensuring that the quality of services against the CQC standards and/or performance remedial or recovery plans is embedded within contract quality schedules. The expectation will be that contractual standards will be delivered as business as usual with improvement plans in place if that is not the case. The Commissioners expect and will seek from Providers that quality and safety are embedded within their culture. 6.4 Communications and Engagement Norwich CCG is committed to being open and engaging in order to harness the knowledge and experience of clinicians, patients, carers, citizens, local voluntary and independent sector community partners and local authority partners. The CCG does this by adhering to the Six Principles for engaging people and communities. This involves working on the wider development of plans with a number of groups at both a local and strategic level; for example: Norfolk Carers Council for Norfolk Broadland Youth Advisory Group Pan-Norfolk CCG colleagues Health Overview Scrutiny Committee Healthwatch Norfolk Deaf Connexions Bridge Plus The CCG is committed to co-producing and engaging with stakeholders, patient representatives, communities, carers and individual patients on the areas outlined in Table 12. To support this, the CCG has established a Patient and Community Advisory Group (PCAG), whose role is to support co-production and engagement. Table 12: Key Areas of Engagement for Norwich CCG Area Development of the MCP (Norwich New Model of Care) Specifically The development of the hub and cluster model for services. The review of Locally Commissioned Services (LCS) Development of HomeWard Review of community IV therapy service Norfolk and Waveney STP Delivery on the six principles of engagement for the STP and plans going forward 41

42 7 Governance and Risk Management Norwich CCG has robust process in place to ensure good governance across the organisation. All staff must comply with the CCG s policies, including the requirements for managing conflict of interests. 7.1 Governance Norwich CCG continues to review and build on its robust governance arrangements to ensure we focus our commissioning resources to deliver our ambitions and vision, meet our financial challenges and support our transformation agenda. The governance framework ensures that responsibilities are clear, that there are effective processes for monitoring and acting on a range of information about quality, performance and finance and that statutory duties are successfully discharged. We are establishing appropriate governance frameworks to support the new models of care work, our move to full delegation of primary care commissioning and working with partners across the Norfolk & Waveney STP footprint to support accountable decision making within a new system. The STP will be underpinned by a Memorandum of Understanding (MoU) that cements the partnership and defines the relationship, shared values and behaviours and system assurance needed to effectively implement our plans. Figure 6 shows the relationship between the CCG membership, Governing Body and its committees and working with our health and social care system partners. 7.1 Managing Conflicts of interest The CCG has robust systems and processes in place to identify and manage potential conflicts of interest in line with the revised statutory guidance on managing conflicts of interest for CCGs, including policies, training, Conflicts of Interest Guardian, register of interests and processes for reporting breaches. The annual internal audit of conflicts of interest management will provide further assurance on the level of compliance with the statutory guidance. 42

43 Figure 6 Norwich CCG Governance Structure 7.2 Key Risks and Issues The CCG follows a proactive, systematic process for identifying, evaluating, mitigating and escalating risk in relation to risk appetite. The Governing Body monitors the CCG s risk management arrangements and reviews the risks to delivery of its strategic priorities as recorded in the Governing Body Assurance Framework (GBAF). The GBAF provides the CCG with a comprehensive and effective method for the identification and focused management of risk across Norwich CCG and the wider system. Through the GBAF, the CCG Governing Body and Members gain assurance that risks are being appropriately managed throughout the organisation. Significant risks to delivery of our plan are shown in the chart below: 43