Bristol CCG North Somerset CGG South Gloucestershire CCG. Draft Commissioning Intentions for 2017/2018 and 2018/2019

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1 Bristol CCG North Somerset CGG South Gloucestershire CCG Draft Commissioning Intentions for 2017/2018 and 2018/2019 Programme Area Key intention Primary and community care Sustainable primary care Implement the 10 high impact actions from the GP Forward View to ensure sustainable primary care for the Bristol, North Somerset and South Gloucestershire population. This will include: Learning from best practice models of care across the area. Ensuring that all services commissioned are in line with the GP Forward View and support the delivery of a more integrated model of primary and community care. Ensure that where there are gaps in service delivery these are commissioned in primary care where this is better for patients. Integrated primary and community care Work with providers, the local authorities and the voluntary sector to develop a model of multidisciplinary and integrated working with practices including other primary care providers such as pharmacists, mental health services, social care and services for those who would benefit from a nonhealth or social care response through social prescribing. As part of this model, ensure that all individuals receiving a funded care package in the community have a named case manager/care coordinator. Develop a BNSSG-wide care home model enabling a robust and sustainable care home and extra care housing support model. The aim is to ensure both the required capacity and quality within care homes for our population but also to ensure residents are only admitted as required to acute hospital. Implement a pathway of care for frail older people and those with dementia that ensures consistent

2 care across our health and social care system including rapid access clinicians in the community and comprehensive assessment on arrival at hospital. Work with hospital providers to bring specialist support into the community to provide more specialist rapid responses and avoid unnecessary hospital admissions, including key diagnostics, community beds and teams. Ensure a joint approach to the management of referrals into acute hospitals for planned care, including commissioning advice and guidance services, direct access to diagnostics for primary care and alternatives to outpatient appointments. Deliver community based alternatives to hospital outpatient appointments. Reduce length of stay and delayed transfers of care including developing consistent approaches using single assessments across BNSSG, and ensuring sufficient capacity in our rehabilitation, reablement and recovery services. Principles This will be underpinned in each area by use of joint funding mechanisms agreed within the Better Care Fund with the Local Authority in which the CCGs will expect to see greater use of risk share approaches and development of plan for integration by March The CCGs expect to work with providers to develop more flexible approaches to workforce and service delivery across organisational and geographical boundaries. Specifically, the model will require development of consistent approaches to 7-day working. Full utilisation of shared care records using the Connecting Care programme. Long Term Conditions, prevention and self-care The BNSSG CCGs have prioritised the development of a number of care pathways for the next two years. For each of these we expect to develop efficient and effective services that deliver value for the patient and the population. These pathways will be developed across the whole system including prevention. These include: Diabetes Stroke Respiratory Heart failure Dementia Musculoskeletal conditions Pain management

3 Liver disease and services for those with alcohol dependency Principles The CCGs expect to see the use of innovative approaches to self-care, including roll out of decision making aids for surgery, patient activations measures, digital technologies and texting to enable those with long term conditions to support their own care. The CCGs will work with providers to offer a coordinated approach to end of life care including use of care plans supported by technology, development of anticipatory prescribing, coordinated and robust community provision and a reduction in unnecessary hospital admissions, primary care demand and ambulance call outs. Personal health budgets will be tested within North Somerset and evaluated. Urgent Care CCGs will commission a single approach to care delivered to patients in need of urgent care. This will include: Effective and responsive NHS 111 service and primary care out of hours provision - a functionally integrated urgent care service, primarily through the establishment of a clinical hub, in line with recommendations from NHS England. A single point of access for BNSSG that provides professionals with one number to support access to rapid responses and crisis services, supporting the community. This will support coordinated discharge and access to rehabilitation, recovery and reablement services. This will combine health and social care professionals, using up to date IT to enable rapid response. Links from that single point of access to a joint front door at the acute hospital staffed by primary and acute care clinicians, enabling appropriate streaming of care and comprehensive assessment for frail older people. Achievement of the 4-hour emergency access standard through: o Admission avoidance and prevention: Ensuring community alternatives to hospital admission are easily accessible by patients and Primary Care and other healthcare professionals in their local communities. o Improving flow through hospitals by ensuring the patient journey through hospital is efficient and the patient is not subjected to any unnecessary delays. o Enabling discharge: Ensuring that patients are discharged as soon as they are no longer

4 in need of acute hospital care o Frail & elderly care: Ensuring there is holistic, multi-disciplinary end-to-end care for people living with frailty and complex conditions. Planned Care BNSSG CCGs will launch a transformation programme for musculoskeletal services to deliver improved outcomes, productivity, performance and patient experience A programme to support greater self care, including the use of decision making aids, and IT solutions to ensure that patients make informed decisions An effective and standardized approach to demand management across BNSSG, that supports healthcare professionals to manage requirements for elective care. Implement a range of solutions to modernize outpatient activity, including increased use of one stop clinics, implement protocols for consultant to consultant referrals, increase use of virtual consultations ( , skype, telephone) and direct access. Develop integrated system wide solutions for specific patient pathways (e.g. dermatology) where clinicians can work together across organizational boundaries to design services that meet the needs of patients in the most efficient way Mental Health Improve access to psychological therapies and meet the targets set out in the operational planning guidance including procuring a new model of care. Review rehabilitation pathway capacity to meet the needs of those currently living independently. Reduce admissions to psychiatric beds out of the area other than for the most specialised care. Provide local capacity and increase value of services to support those with specialist health needs, including provision of aftercare services for certain people who have been detained under the Mental Health Act, in line with section 117. Increase access to individual placement support for people with severe mental illness in secondary care services. Develop the following key pathways and services: Perinatal mental health and the development of greater community support for pregnant women or new mothers with mental health issues. Implement the personality disorder pathway. Develop services for those with autism by developing a social prescribing service. Ensure local provision for those requiring specialist Obsessive Compulsive Disorder (OCD) interventions. Increase resources to the primary care eating disorder service and reduce the current waiting times for this service to meet the eating disorders national target. Support and improve crisis response, including developing the street triage approaches.

5 Cancer Children s and Maternity Work with Public Health to develop a targeted approach to prevention which reduces the inequalities in life expectance by increased awareness of cancer, increased screening and improving diagnostics. Implement NICE guidance to achieve the required waiting time standards. Implement the living well with and beyond cancer strategy including professional education programmes, enhanced support for cancer survivors and commissioning a recovery package and measuring longer term quality of life. Deliver the objectives of the CCGs 5 year Emotional Health and Wellbeing Transformation Plan for Children & Young People Implement the children s urgent care action plan to reduce emergency admissions and length of stay

6 Learning disabilities Medicines Management in hospital. Ensure effective provision of inpatient mental health liaison for children. Ensure delivery of the health components of the childhood obesity strategy. Improvements to the following pathways for children with long term conditions including: Cerebral palsy Epilepsy Work towards a managed clinical network for maternity services to develop a single approach to maternity services across BNSSG. Work with Public Health to reduce rates of smoking and reduce stillbirth, neonatal and infant mortality working with providers. Improve physical health care & parity of esteem for people with learning difficulties To reduce dependence on care home placements and inpatient care for people with learning disabilities To continue to implement Transforming Care Optimise use of medicines by working collaboratively across all providers using evidence based practice to a shared plan. Establish an embedded pharmacist in acute services to ensure better management of high cost drugs, making the use of biosimilar (generic) drugs and pursuing joint IT to manage charges for CCG commissioned high cost drugs. Ensure that providers supply medication to patients as part of their outpatient care to improve patient experience. Enable community providers to take financial responsibility for the medicines which they supply ensuring they are able to prescribe in a cost effective manner. Support primary care to prescribe in a way that avoids unnecessary hospital referrals or admissions including: Monitoring Disease-modifying anti-rheumatic drugs (DMARD) therapy Initiation of parenteral therapies for type 2 diabetes Safe and effective monitoring of anti-coagulation therapy Continue to ensure that we review prescribing practice to ensure prescribing of items of good value Continue to tackle medicines waste including training of professionals and the public Commission the same prescribing support tool across BNSSG Ensure appropriate antibiotic prescribing

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