Milton Keynes CCG Strategic Plan

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1 Milton Keynes CCG Strategic Plan

2 Introduction Milton Keynes CCG is responsible for planning the delivery of health care for its population and this document sets out our goals over the next three years. Our mission statement is: We will openly work with you to plan and buy services that are high quality and provide you with the best health outcomes and experiences while achieving value for money for our local community. We will listen and we will improve the health and well-being for everyone in Milton Keynes We carry several important principles at the heart of our decision making which include: We will work in a fair and inclusive way to support to the most vulnerable to access health care We will commission safe, high quality services for all Clinicians will lead our commissioning decisions This document sets out how we will shape health care delivery in Milton Keynes for the future, describing the important changes we will achieve and how we will make our plans a reality. Milton Keynes is a vibrant town which is expanding rapidly. The population currently stands at 264,000. The birth rate for Milton Keynes is higher than average and we have a growing ethnic diversity which is particularly noticeable within the school age population. At the same time we are living longer and as we age we are more likely to succumb to multiple long term conditions such as diabetes and respiratory illnesses. All of this means that demand upon our health and care services is increasing. Economic migration is a factor of modern life too as families move to improve their lifestyle and choices. As a result some of our traditional support networks have eroded resulting in a greater reliance upon professional help and guidance. This has fundamentally affected the public s interaction with health services and it is important to develop a plan for delivery which addresses changing patterns of need. This strategy has been developed to deliver that change. How will we improve the health and wellbeing of the people of Milton Keynes? Firstly, we need to understand the needs of our population through the development of a Joint Strategic Needs Assessment (JSNA). Working with the Local Authority, we use demographic and other data to describe the big picture of current and future health and wellbeing needs, paying particular attention to the wider determinants of health e.g. housing, educational attainment and poverty. The JSNA is a key reference document that informs the CCG s strategic commissioning work plan. Working closely through the Health & Wellbeing Board, overarching joint goals are agreed with the Council. Effective partnership working is central Milton Keynes CCG is a membership organisation comprising the 28 GP practices that serve the population of Milton Keynes. Together, Board members, employees and patient representatives work to deliver the Milton Keynes CCG Strategic Plan

3 Group s commissioning intentions. 1 We also work very closely with our Local Authority commissioners this includes some joint commissioning arrangements 2 and also public health advisers How will things be different? There are major changes which impact significantly upon the way Milton Keynes CCG commissions for the future and these offer an opportunity to think very differently about the delivery of health care: Decisions will be taken by clinicians Financial resources will be significantly constrained going forward The provider landscape in Milton Keynes is changing Across the system there will be an increased focus on prevention - keeping people fit and well through simple lifestyle changes will, over time, produce significant benefits for individuals and also reduce requirements for health care over time. This is a long term strategy which will run in parallel with more immediate changes. As part of this strategy the CCG will work with its providers to ensure that every person using our services is offered simple lifestyle advice and are signposted towards support and prevention services we will make every contact count. 3 Screening of the population to help detect and treat illness will continue to be an import aspect of commissioners work. There will be further roll-out of health checks to reach those who are not yet unwell but whose risk factors for long term conditions e.g. diabetes are increasing. Reducing reliance upon health services through early intervention is an important step; however, this alone will not significantly reduce demand for hospital care. We must focus more of our efforts and resources within the community if we are to effect lasting change. We will implement a comprehensive primary care strategy in order to build the capacity and resilience within the community and effect lasting change. See page 8 for an overview of the strategy. The provider landscape in Milton Keynes is changing: - We are about to launch 3 important AQP services which should bring further plurality of providers. - An increasing number of traditional secondary care services are being provided in primary care therefore bringing care closer to home for Patients - Our local community and mental health services organisation is likely to be acquired by our local acute foundation trust. This represents a real opportunity to create a true integrated care organisation with fully integrated services. - In order to remain sustainable, our local acute trust is in active discussions as part of an Acute Services review about creating areas of specialism across each of the 5 trusts and potentially not providing all services from one site in the future. 1 Commissioning Intentions are the priority plans agreed annually to deliver change 2 Joint commissioning arrangements mean that we have created a jointly managed team of commissioners to deliver services against a pooled budget 3 Making Every Contact Count is a national objective for the NHS Milton Keynes CCG Strategic Plan

4 Milton Keynes Health & Social care System current state Milton Keynes CCG has a delegated budget of 262m for 2012/13. The GP registered population is 264,000 and patients are served by 28 practices. There is a single district general hospital and the Local Authority is virtually co-terminus with the CCG. There are already well established joint commissioning arrangements for mental health, learning difficulties, intermediate care services and community equipment services which are managed through our Joint Commissioning Board. Public Health colleagues are based at Milton Keynes Civic Offices. We have introduced a programme management approach to the commissioning of care divided into five discrete areas: unplanned care, planned care, long term conditions, children s & maternity and mental health & learning disabilities. GP leads are supported by commissioning managers to convert our plans for high quality and cost effective services into delivery. Performance The CCG s current position on performance is described within our Integrated Strategic Operating Plan. The main areas requiring focus are A&E waiting times and the 18 week maximum waiting time from referral to treatment. A&E waiting times of 4 hours or less for 95% of those attending was not achieved at our local acute provider in the final quarter of 2011/12 and they have continued to struggle in the first quarter of 2012/13. The CCG continues to be supportive with initiatives to stem demand to and improve efficiency in the department whilst applying contractual levers when appropriate. The sustainability of the A&E department is a concern given national recruitment problems for doctors and work within the south east midlands region is underway to strengthen and improve the quality of service delivery for the future. 4 Patient flow through the hospital has been audited 5 and is affected by a lack of systematic focus on discharge planning. In order to manage the daily admission rate the hospital opened 17 escalation beds earlier in 2012 which have been continuously in use. Outside of the hospital there are jointly provided health and social care community services with a single management structure these arrangements have been in place for ten years and have a good track record of supporting timely discharge from the hospital. The pressure of unplanned admissions can affect the trust s ability to treat all elective patients and some delays and cancellations of treatments have occurred. In terms of treating patients requiring surgery within the 18 week referral to treatment time there are pressures within key specialties including orthopaedics and urology. Demand management initiatives have been factored into the annual activity plan for the providers and these form part of the CCG s QIPP plans. Local joint Mental Health services are being redesigned into ageless services that deliver more effective, proactive services that are more closely aligned with PbR clusters and more fit for the future. A bed review to measure capacity of services has been conducted and a not fit for purpose unit is being closed. IAPT 4 This is the Healthier Together programme and is referred to later in this document 5 Audit of all inpatients across acute and community was undertaken in March 2012 Milton Keynes CCG Strategic Plan

5 services have been rolled out across all 28 of our practices and are seen as a key enabler for managing demand in mental health services in the future. Finance The CCG has to look at innovative ways to provide the same level of services for a growing population with roughly the same budget. There will be a slight year on year increase in funding; however, as we are living longer - and often with more than one health problem - this means the budget has to stretch further. We call this making efficiency savings so that we save in some areas to re-invest that money in more care. We are looking to improve the Quality of services through Innovation and also to increase our Productivity whilst an important parallel work stream around the Prevention of ill-health should over time reduce demand for health care. We call this our QIPP saving which amounts to 18m for 2012/13. Similar savings are required by the local hospital acute hospital foundation trust which has cost improvement plans amounting to 7.5% savings on its budget this year. The local community and mental health provider also has to make savings of 4%. CCG QIPP plans are running behind target and additional recurrent or non recurrent schemes will be required in order to deliver a balanced budget this year. The CCG has identified that it will need to save 10m in each of the next 4 years to re-invest in new areas of care. In order to deliver this level of savings, the CCG will be required to think radically differently about how care can be delivered rather than staying with the traditional model of care that the public is familiar with. One example would be the greater use of technology to support care delivery and also to reduce the need for face to face consultations on every occasion. Quality The CCG plays an important role in the monitoring of the quality of services provided. The local acute foundation trust has had support from the Care Quality Commission during 2011 which included paediatric and orthopaedic reviews. These were subsequently followed up in 2012 by the commissioner s quality team to ensure action plans had been satisfactorily completed. Following a thematic review of CQC visits it was noted that the hospital has made considerable effort in rectifying or improving all areas identified during the visits. In other areas of quality there have been no issues relating to the delivery of cancer services at our local provider during The CCG has agreed robust quality schedules and CQUIN 6 targets within provider contracts which support the delivery of high quality services Next steps to address the increasing demand for healthcare As already described, it will require a fundamental change in our approach to the way we deliver services in order to meet future expectations for safe, high quality services. We believe this has to be underpinned by a greater focus on assessing and treating within the community. This will include quick access to first level 6 Commissioning for Quality & Innovation (CQUIN) is a quality premium designed to encourage providers to improve service quality. Targets are monitored and payment is made against level of achievement Milton Keynes CCG Strategic Plan

6 advice for simple conditions to reduce reliance on expensive A&E services; creating time for informed decision making around choices of care to help patients to understand the outcomes and benefits that they can expect to experience following treatments; as well as providing greater follow up after consultation and treatment within primary care to reduce outpatient spend where this provides little benefit for the patient. Our approach to these changes will be immediate i.e. within the next two years and also incremental leading to a much more ambitious strategy which we will implement over the next 10 years. Both are described in more detail on the following pages. Our single most important piece of work is to transform primary, community and social care to better meet the needs of local people. This will be the focus of the CCG s efforts through to Our primary care strategy is described on page 8. Changes we intend to implement by 2014/15 If we are to be successful in managing demand for health care services within the resources available then there has to be a multi faceted approach to achieving success. There are several areas requiring focus and these include: Ensure all referrers are aware of the limited funded capacity available in elective care and uniformly apply appropriate thresholds for accessing treatment Create clinical assessment and triage within the community using consultant input to maximise effectiveness and create a learning culture that supports GPs and patients in their decision making Expand access to primary care for on the day requests including telephone triage plus minor injuries and ailments Support greater integration of IT systems to enable timely transfer of patient information Create a GP home visiting service to work with paramedics, community nursing and social care teams in order to assess and treat patients in their home without onward transmission to hospital when appropriate Further expand the end of life service to support people within a home setting during their last days Increase access to psychological therapies (IAPT) providing rapid access to low level support for those with mild to moderate mental health issues including those living with long term conditions These are some of our immediate plans and we have also developed a 10 year local health strategy which identifies 6 programme areas to focus upon in order to close the projected financial gap, address the quality challenge and build organisational capabilities 7. The programmes are described overleaf. 7 McKinsey were commissioned by the three CCGs in NHS Milton Keynes and Northants PCT Cluster to develop our 10 year health strategy Milton Keynes CCG Strategic Plan

7 PRELIMINARY We have identified 6 programmes for MKN to close the projected financial gap, address the quality challenge and build organisational capabilities Transform out of hospital care Introduce case management and integrated care Improve commissioning of elective care Transform acute care Implement prevention programmes Build organisational capabilities Transform the model for providing care in non-acute settings through Focusing on consistent adoption of best clinical practice Carrying out a lean transformation of GP and community services Setting up a hub and spoke system for GP practices For the elderly, those with long term and mental health conditions, specifically Develop a patient registry of those with the conditions Assess the risk of each patient and determine their needs Adopt clinical protocols amongst providers that are jointly understood Give patients integrated, pro-active care plans that vary according to risk and need Ensure that well-coordinate, planned care happens across settings of care Use multi-disciplinary case conferences for a very small number of complex cases Continuously assess and improve performance Ensuring maximum health gain for pounds spend on elective care, by Developing clear pathways by agreeing guidelines for commissioning elective care Developing decision aids and decommission procedures with little marginal benefit Using thresholds, incentives and other commissioning tools Transform acute care by Setting clear standards for acute care and supporting a reconfiguration strategy for the acute service landscape Putting in place better contract mechanisms to improve quality outcomes Partnering with providers to enable them to drive cost improvement programmes Strengthen programmes for reducing smoking and obesity rates to lower risk of critical long term conditions Strengthen awareness campaigns and detection programmes for conditions where recorded prevalence is deemed to be lower than estimated Build a leading-edge organisation through Use of contracting to improve performance management Developing staff capabilities through training and development Introducing area-wide PMO function to run transformation efficiently Building IT systems to support hub-and-spoke approach and integrated care 2 NB All three CCGs within the Milton Keynes and Northants PCT Cluster jointly commissioned McKinsey to develop our 10 year strategy. Milton Keynes CCG Strategic Plan Page 7 of 11

8 How will we achieve this? We believe that the greatest benefits can be achieved by working to deliver 3 strategies: transforming primary care, aligning general practice, community and social care services creating a truly integrated acute, community & mental health organisation re-organising acute services around areas of specialism Primary Care Strategy Successful transformation will be underpinned by safe, high quality, resilient general practice which acts as the patient s care navigator. Interoperability of information systems will be essential to allow timely sharing of information on individual patient care. This will include the ability to share information between practices, social and community care as well as hospitals. Increasingly practices will work proactively with disease registers and risk tools to keep patients well and away from urgent care. It will provide resilience in general practice to support the significant changes required in order to conclusively reduce demand for secondary care services. Given the long history of joint commissioning and joint provision within Milton Keynes we are confident that we can achieve this. There is potential to use the new technologies to interface much more quickly with patients and users rather than the traditional appointment based service that is currently offered. Sharing of information across Practices will become easier and primary care services will be more accessible when our Practices have all standardised on a single primary care IT system. Using more , telephone, skype or telehealth services to provide rapid assessment and advice is important and will be the norm for younger generations that are very familiar with social media. We have already introduced neighbourhoods of practices which work together to review quality and performance. These are the building blocks upon which we wish to develop further support networks - using education and clinical audit as tools to improve care. Clinical dashboards for urgent care will be introduced for general practice during Improving quality is an important driver for the CCG - we have made important strides through the Quality MK programme. Spearheaded by GP champions we have developed and embedded into our day to day business as commissioners a mix of ways of working and skills that place clinicians in the driving seat and enable the system to be more responsive to patients and the public, and better able to adopt innovation in line with best evidence. We recognise that to embed change requires an investment in time and we intend to develop the Quality Improvement facilitator role which is a trusted and knowledgeable resource working within primary care to advise, support and embed new ways of working. This will complement the roles already well established around prescribing. The move towards neighbourhoods will support further whole system working for the frail and vulnerable aligning more specialist nursing and care resources across a geographical patch brings efficiencies for all organisations. This is an important outcome that we would wish to see achieved; particularly in how we can further support care homes and access the skills of hospices in conjunction with community nurses to ensure end of life is managed sensitively and well within a homely setting wherever possible. Milton Keynes CCG Strategic Plan Page 8 of 11 V0.2 Jeannie Ablett 10/08/12

9 We will develop the strategy in line with the proposals described in Deloitte s review: 8 Integrating Acute, Community & Mental Health Services A managed transfer of our local community and mental health services to our local acute trust presents us with an opportunity to shape a truly integrated care organisation where the limitations of organisational 8 Deloitte: Primary Care Today and Tomorrow improving General Practice by working differently. (pg 19) Milton Keynes CCG Strategic Plan Page 9 of 11 V0.2 Jeannie Ablett 10/08/12

10 boundaries are removed. Staff will be more transportable between acute and community settings, hand offs between services are reduced, duplication is removed and patient experience is improved. Acute Services Review (Healthier Together) 5 acute trusts within reasonable range of the CCG are working with Commissioners to establish optimum portfolios of services that deliver centres of excellence for service specialisms and redesign remaining services such that Trusts are sustainable for the long term. The commissioner led programme board will commission transformational change through integrated pathways across organisational sites in order to maximise access to clinical excellence for patients. How will we know we have been successful? We will continuously review the services we commission; listening to our service users to ensure that we are providing safe, high quality services. We will receive regular feedback from the net promoter surveys 9 to understand where providers are offering service excellence and to focus on areas requiring improvement. We will also work with our Patient Participation Groups, LINks MK as well as our Advisory Forum to understand where we should investigate further. Our approach will be Outcomes based in order to achieve real improvements in care delivery across the system. The five domains from the NHS framework are described below and will be our driver towards successful commissioning for the people of Milton Keynes. 9 Introduced by the DH these are regular surveys of patients and staff assessing whether they would recommend their services to friends and family Milton Keynes CCG Strategic Plan Page 10 of 11 V0.2 Jeannie Ablett 10/08/12

11 Milton Keynes CCG Strategic Plan Page 11 of 11 V0.2 Jeannie Ablett 10/08/12

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