Governing Body Meeting - Agenda

Transcription

1 MEETING HELD IN PUBLIC Governing Body Meeting - Agenda GP/GB/ April 2013, Gujerat Centre, South Meadow Lane, Preston PR1 8JN 2.00pm pm 1. Welcome and introductions Apologies for absence Mr P Richardson Information 2. Declarations of interest Mr P Richardson Information 3. Minutes of Governing Body meeting 21 March 2013 Mr P Richardson Review GP/GB/ Matters Arising Mr P Richardson Information GP/GB/ Standing Items 5. Chair s Update Mr P Richardson Information 6. Chief Officer s Update Mrs J Ledward Information GP/GB/ Items for decision 7. Delivery Plan Mrs J Ledward Approval GP/GB/ Financial Position April 2013 Mr I Crossley Approval GP/GB/ Performance Report April 2013 Mr I Crossley Approval GP/GB/ Questions from the Public Mr P Richardson Discussion Items for assurance 11. Quality Improvement Committee Minutes 13 March 2013 Any Other Business 12. Any Other Business Mr D Noblett Information GP/GB/ Date, Time and Venue of next meeting 27 June 2013, 2.00pm 4.00pm, The Lantern Centre, Vicarage Road, Fulwood, Preston PR2 8DY Agenda NHS Greater Preston CCG Governing Body Meeting 25 April 2013

2 MEETING HELD IN PUBLIC Agenda NHS Greater Preston CCG Governing Body Meeting 25 April 2013

3 GP/GB/ Governing Body Meeting - Minutes 21 March 2013, The Lantern Centre, Vicarage Lane, Fulwood, Preston PR2 8DY at 12.30pm Present In attendance Mrs Anne Bowen Governing Body Nurse Dr Ann Bowman Chair and Clinical Lead Dr Steve Cairns Secondary Care Doctor Mr Iain Crossley Chief Finance and Contracting Officer Dr Brigid Finlay Clinical Lead Dr Manjit Jandu Clinical Lead Mr Sam Jones Lay Member Audit and Finance Mrs Jan Ledward Chief Officer Mr David Noblett Lay Member Patient and Public Involvement Mr Paul Richardson Lay Member Governance Mr Mike Barker Head of Constitution and Governance Mrs Louise Giles Head of GP and Stakeholder Engagement Dr Anthony Sudell Consultant in Public Health Medicine Mrs Anne Whittle Governing Body Secretary Members of the Public Ms Anne Corcoran Member of the Public Mr John Corcoran - Member of the Public Ms Sharon Coyle AstraZeneca Ms Alison Dixon - Abbott Diabetes Care Ms Hayley Summerville Ramsay Healthcare Ms Faye Wilkinson Abbott Diabetes Care GPGB/13/03/01 Welcome, Introductions and Apologies for Absence Dr Bowman welcomed everyone to the meeting and included an especially warm welcome to members of the public at this first meeting in public for NHS Greater Preston Clinical Commissioning Group (CCG). Apologies for absence were received from Dr Richard Parry, Clinical Lead and Mr Alan Stedman, Head of Quality, Strategy and Outcomes. GPGB/13/03/02 GPGB/13/03/03 Declarations of Interest There were no declarations of interest made within the meaning of Section 8 of the Group s Constitution. Minutes of the CCG Governing Body meeting held on 17 January 2013 The minutes of the previous meeting held on 17 January 2013 were agreed as an accurate record, subject to alteration of principal to Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 1 of 8

4 principle to be amended. GPGB/13/03/04 Matters Arising from the minutes of the previous meeting There were no matters arising from the minutes of the previous meeting. Dr Bowman expressed sincere thanks and best wishes on behalf of the Governing Body to Dr Parry for his hard work and commitment to the CCG over the last two years up until his resignation from the end of March GPGB/13/03/05 Chairs Update Dr Bowman updated the Governing Body with a presentation describing CCG s development to date, how the CCG is pursuing early priorities and building key partnerships and the CCG s key areas of focus. The key points were as follows: Developing the CCG The development programme is being progressed to ensure that the organisation works together in the most effective and efficient way and to ensure that it has the right skills in place and training needs identified. Following Dr Parry s resignation, an election process has been undertaken and Dr Sandeep Prakash, who was elected as Clinical Lead will take up this role with effect from 1 April Peer Groups continue to develop to share best practice and educational needs. The CCG structure is now fully recruited to. Pursuing Early Priorities A draft annual plan for is on the agenda for members to provide comment, and a patient and public involvement strategy is also being developed. Commissioning for Quality and Innovation (CQUIN) schemes are being established to reflect quality and patient experience and service redesign initiatives are starting such as the referral gateway scheme, Atrial Fibrillation (AF) screening to assist in the prevention of strokes, additional GP surgery appointments to address the seasonal pressures and a GP visiting scheme. Dr Bowman described how these initiatives will improve services, such as time spent by community staff (including mental health) to better support patients with long term conditions. Work is being undertaken to provide more specialist care for patients with dementia where needed. Other initiatives include improving access to Attention Deficit Hyperactivity Disorder (ADHD) service, a local enhanced scheme for diabetes services, improved anticoagulant services and access to MRI scans and urgent care. Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 2 of 8

5 Building Key Partnerships The CCG is working with senior colleagues from provider organisations and an initial meeting was well received from Local Authority colleagues in efforts to understand their needs. Meetings continue with Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire Care NHS Foundation Trust and Lancashire County Council through the Clinical Senate to drive programmes of work forward. Next Steps The Commissioning Support Unit (CSU) is now 75% recruited to and will provide commissioning support to the CCG when it becomes a statutory body from 1 April This will support and develop commissioning at practice level. Resolved That the Governing Body received and noted the Chairman s presentation on the development of the CCG as a commissioning organisation. GPGB/13/03/06 Chief Officer s Update Mrs Ledward presented a report on CCG progress since the last Governing Body meeting. The key issues identified to members were as follows: The CCG had been confirmed as authorised without conditions and that the thanks for the Governing Body and Membership should be extended to all those involved in that achievement, in particular Mrs Louise Giles and her team. That Lancashire Teaching Hospitals NHS Foundation Trust, and all health care providers including community and social care have experienced severe winter pressures and that partners have worked collaboratively to address some of the pressures. The consultation on dementia services ended on 25 February 2013 and a copy of the response from the CCG was submitted. The national Staff Survey results for 2012 can be accessed on the Department of Health website and the CCG will be working with providers to ensure that the health economy addresses any areas of concern as part of its approach to quality. New legislation around Special Educational Needs is being proposed to ensure that local authorities, health and care services work collaboratively to increase provide support to children with special educational needs and their families. The publication of the Mid Staffordshire Report is being debated heavily by the Quality Improvement Committee to ensure that lessons are learnt and that patients are at the heart of everything the CCG does. Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 3 of 8

6 The emergence of new national guidance around the Emergency Planning Framework, which means that collaborative work between the CCG and partner organisations, is now starting to happen and that CCGs need to commit resources and put in place on-call arrangements despite the funding for such issues being transitioned to other organisations. The national development of a Friends and Family Test, which the CCG will work closely on in the future. The launch of a review of Urgent and Emergency Services in England and that the details remained unclear at this stage but the CCG will need to follow progress in relation to this review given its work around unplanned care locally. The progress of the Vascular Services Review was disappointing to see and one that the CCG will need to be mindful of going forward. Resolved: That the Governing Body noted the update provided by the Chief Officer. GPGB/13/03/07 Clinical Commissioning Group Business Cycle Mr Barker presented a report which proposed amendments to the CCG business cycle using the frequency of meetings set out in the constitution in order to improve the flow of information through the Governing Body and its sub-committees. Members provided comments on the proposed new dates including 11 meetings per year in total, with 6 formal and 5 informal / development meetings. Members accepted the proposed changes and requested that the business cycle be reviewed after 12 months. Resolved That the Governing Body approved the proposals in the paper for the business cycle to be implemented from 1 May GPGB/13/03/08 Register of Interests Mr Barker presented the above paper to provide assurance to the Governing Body that principles and procedures are in place to minimise, manage and register potential conflicts of interests which could be deemed or assumed to affect the decisions made by those involved in the CCG. Mr Barker explained that the Audit Committee had recently approved the policy for Conflicts of Interests. A register of interests for Governing Body members which stated the current declarations of interest of members was appended for information. Resolved That the Governing Body noted the Register of Interests of its members and approved this register be published for public viewing. Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 4 of 8

7 GPGB/13/03/09 CCG Corporate Policies Mr Barker presented a paper which explained the need for key governance and policy documents to be in place to ensure that the CCG starts on a sound legal footing as it takes on its statutory obligations from 1 April Mr Barker explained that the Remuneration Committee has now approved a number of HR policies which the CCG needs to have in place from 1April Members accepted that the Audit Committee had provided scrutiny around this work and is satisfied with the corporate governance and risk management frameworks in order to meet the needs of the organisation from 1 April 2013 and that this was a good start for the organisation and will be reviewed quarterly. In relation to the Corporate Governance Framework, the Audit Committee was satisfied with this and members recognised that further development is required over the next few months. The Audit Committee had also welcomed the Risk Management Strategy and Policy. Resolved That the Governing Body (i) Formally ratify the Corporate Governance and Risk Management Frameworks, including the Risk Management Policy and noted that further development work is required in both areas which will be overseen by the Audit Committee; and (ii) Noted the policies already approved by the Remuneration Committee and those already approved by the Audit Committee. GPGB/13/03/10 Planning Framework (i) Delivery Plan 2013/14 Mrs Ledward presented the draft delivery plan for NHS Chorley and South Ribble CCG for the year ahead and asked Governing Body members to provide comment and express any concerns which they feel about the document. Comments were received as follows: Mental health has only been allocated half a page yet is a major part of people s well being Members would welcome some narrative to explain how the various themes were chosen and include timescales for delivery Could be more understandable for reading as some areas contain a lot of detail Primary care strategy requires more detail Helpful document and could be adopted to produce the more public facing prospectus in May 2013 Should acknowledge the role of voluntary organisations and Local Authorities as integral to patient care Should acknowledge engagement with provider organisations throughout (e.g. LCFT for mental health services and that Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 5 of 8

8 Blackburn with Darwen CCG is the lead commissioner for mental health) Should include aspirations to provide 24/7 care and implications on secondary care organisations through national directives Resolved That the Governing Body note the progress made in the development of a draft delivery plan for and its comment be incorporated into the plan prior to final approval at its next meeting. (ii) 2013/14 Financial Budget Mr Crossley presented for approval the financial budget for for the CCG for both health care and running costs. Mr Crossley highlighted the key issues since the CCG received its financial allocation for its population. Mr Crossley explained that the CCG financial allocations have been developed with the National Commissioning Board and that the allocation needs to match the risks the CCG is aware of, and that some significant risks are emerging around allocations and therefore signing of contracts. This has led to the delegation of the budget to Mrs Ledward, Mr Crossley and Mrs Louise Giles who will continue to look at expenditure until the CCG has a better understanding of these risks. In the meantime, regular reports and forecasts will be brought to the Governing Body. The CCG cannot yet confirm its investment proposals until the financial risks to the organisation are understood. It was recognised, however that much investment has already taken place in the last year with regard to sharing of best practice through initiatives such as the referral gateway and prescribing savings schemes. Mr Barker advised that the CCG has already made an early level of savings, and that his is an excellent starting point for the new organisation. Resolved That the Governing Body noted the financial risks and approved the financial plan and budget. GPGB/13/03/11 Questions from the Public Mr Barker referred to this meeting being the first meeting in public (i.e. not a public meeting) and asked members to consider at what point they feel it appropriate to receive any questions from the public. Comments received included: Members welcomed people to attend and for the Governing Body to provide any answers to questions received Questions received at the time of the meeting may not be answered if the depth of knowledge and expertise was not available at the meeting Some members felt at the right point of time for stimulating members of the public to ask questions Members could refer people to the delivery plan where Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 6 of 8

9 appropriate as this will affect people in Preston Consider to propose local debate before the meeting Whether members should take questions from the floor Could submit questions in advance to allow Governing Body members time to provide answers at the meeting Whether to allow time on the agenda to provide answers to questions from the previous meeting Accepted to take questions before the meeting and for the Secretary to note questions from the floor Would need to consider how Health Watch links into questions from the public Governing Body members are committed to ensuring that members of the public including voluntary, community and faith sectors have a voice in CCG plans to improve patient care. It was noted that Governing Body papers will be available at least four working days prior to meetings and that the Secretary will provide papers for those who we know will be attending Resolved That future meetings of the Governing Body should include questions form the public and that those questions should be taken at the end of the business to be transacted and prior to receipt of the committee minutes. GPGB/13/03/12 Quality Improvement Committee Minutes Mr Noblett presented for information the minutes of the joint Quality Improvement Committee meeting held on 13 February Mr Noblett highlighted that the Governing Body will receive regular reports in relation to the CQUIN schemes to provide assurance of the delivery of improved quality of care from provider organisations. Resolved That the Governing Body note the minutes of the joint Quality Improvement Committee meeting. GPGB/13/03/13 Audit Committee Minutes Mr Jones presented for information the minutes of the joint Audit Committee meetings held on 1 February and 1 March Mr Jones reported that the Audit Committee continues to meet jointly with Chorley and South Ribble CCG s Audit Committee, with shared Chairmanship from himself and Mrs Linda Chivers. Mr Jones advised that this joint working is proving well so far and it was accepted that the Committees will need to meet separately at some point in the future. Mr Jones reported on discussions held on 1 February 2013 when concern was expressed around the capability and capacity of the CSU to deliver support services, and the significant risk to the CCG in achieving its objectives if it fails. Mr Jones reported that internal and Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 7 of 8

10 external auditors and counter fraud services have been appointed. Mr Jones also reported that the Audit Committee continued to discuss the concerns around the CSU delivering support services at its meeting on 1 March2013, and that governance policies have been agreed. An internal audit plan has been agreed for the first quarter of The remainder of the year s internal audit plans would be agreed at the next Audit Committee meeting. Resolved That the Governing Body noted the minutes of the joint Audit Committee meetings and endorsed the Audit committee s view that lay members should be more actively engaged with the Membership Council activities. GPGB/13/03/14 Delivery and Finance Committee Minutes Dr Bowman presented for information the minutes of the joint Delivery and Finance Committee meetings held on 24 January, 7 February and 21 February Dr Bowman was pleased to report on recent progress at practice level with regard to: (i) The development of the Reporting Analysis and Intelligence Delivering Results (RAIDR) Tool. The scheme will go live from 1 April 2013 and provide more real time data to better inform practices of referral activity and support work such as the risk strategy and to improve long term conditions; (ii) The Referral Gateway is being piloted by some practices and will be rolled out soon. Some members expressed a wish to see a demonstration of the Referral Gateway and it was agreed to arrange a visit to one of the practices involved in the pilot. Both of these initiatives were welcomed by Governing Body members. Resolved That the Governing Body noted the minutes of the joint Delivery and Finance Committee meetings. GPGB/13/03/15 Any Other Business There was no further business to discuss. Date and time of next meeting: 25 April 2013 Venue to be confirmed Signed as an accurate record. Date... Minutes of CCG Governing Body Meeting 21 March 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 8 of 8

11 GP/GB/ Matters Arising Date Action Lead Status 21 March 2013 There were no matters arising from the meeting held on 21 March 2013 Date Action Lead Status 16 January /01/06 Chief Officer (designate) update GP IT Services an update to be brought back to the next meeting Mrs L Giles Green Matters Arising NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 1 of 1

12 GP/GB/ Part 1 Part 2 Report Title Written by Presented by Purpose of the paper Governing Body Meeting Chief Officer s Report 25 April 2013 Jan Ledward, Chief Officer Jan Ledward, Chief Officer This paper provides an update from the Chief Officer on the CCG s progress since the last meeting of the Governing Body. Key issues The paper outlines a number of areas which will impact upon the CCG as a consequence of national direction and intervention. These are evident within the paper but for reference include: Commissioning of GP Out of Hours services; LES schemes; and GP IT Services. The paper also outlines a series of national developments in areas such as the Quality Premium Scheme and national generic commissioning policies and frameworks. Actions required by Governing Body Members The Governing Body is asked to note the report. Chief Officer s Report NHS Greater Preston CCG Governing Body Meeting 25 April 2013

13 Chief Officer s Report 1. Authorisation 1.1 The Clinical Commissioning Group (CCG) is now a statutory body assuming our full responsibilities as set out in the Health and Social Care Act Authorisation was just the first step on our commissioning journey of continuous improvement. The CCG will have big challenges ahead to create an NHS fit for purpose and a culture of care and compassion. Our values and purpose is to deliver, and improve outcomes and experience for patients, and the role of the commissioning system must be absolutely focused on ensuring quality today whilst leading the transformation of services for tomorrow. 1.3 Clinical Commissioning Groups have a wide range of functions set out in legislation to enable them to achieve these aims, whilst demonstrating appropriate accountability, financial probity, governance and cooperation. The Functions of CCGs, which sets out a summary of the core duties and powers, is available on the NHS England website, All CCGs in Lancashire have now all met all the criteria for authorisation. The NHS Commissioning Board, at their sub-committee on 22 March, removed all outstanding conditions from CCGs in Lancashire. 2. NHS England Direction to CCGs On Primary Care Service Commissioning 2.1 The NHS Act 2006 (as amended by the Health and Social Care Act 2012) enables NHS England (previously NHS Commissioning Board) to direct CCGs to commission certain primary care services on its behalf. NHS England has opted to do this in areas where it believes local decisions about primary care services will add most value, and in respect of financial and other reporting. NHS England is directing CCGs in accordance with these powers in the following areas: a) GP Out-of-Hours services (except where GP practices have not opted out ). b) Local Enhanced Services for primary medical services and primary ophthalmic care (agreed prior to 1 April 2013 by PCTs for which responsibility is transferred to NHS England). 3. GP Information Technology Services 3.1 CCGs have now received confirmation from NHS England that GP IT services must be commissioned in accordance with NHS England s guidance Primary medical care functions delegated to CCGs: Guidance and Securing Excellence in GP IT services: Operating model. The CCG Chief Finance & Contracting Officer is our senior manager lead for this area and will take matters forward accordingly. Chief Officer s Report NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 1 of 4

14 4. Pharmaceutical Services Remuneration 4.1 NHS England is also required to make determinations with respect to apportionment to CCGs of pharmaceutical services remuneration. This relates to the costs that arise from the provision of pharmaceutical services in response to the patient presenting a prescription written by a prescriber under primary medical services, to a pharmacy or dispensing appliance contractor, this will be apportioned to the CCG of the prescriber. 5. Managing Conflicts of Interest 5.1 NHS England has also published further guidance in respect of managing conflicts of interest to which the CCG must have due regard. It incorporates and updates previous guidance into one consolidated piece of guidance and covers both statutory requirements and best practice, together with templates and other supporting material. The CCG will review current policy in respect of the guidance and adjust its own governance systems and processes accordingly if required. This work will be overseen by the Audit Committee. 6. Seasonal Pressures 6.1 The local health economy is still under significant pressure. The CCG has agreed with all stakeholders to conduct a whole system review of the winter period in order to learn lessons, address any deficiencies in our system and incorporate this into a new escalation plan for the health economy in time for next winter. The CCG is currently looking at framework agreements to identify appropriate suppliers to support this work. 7. NHS England Business Plan 2013/ NHS England has published their first three year business plan. It sets out how they will work to support the NHS commissioning system to put patients at the centre of care and deliver improved outcomes. The plan includes an 11 point score card to measure progress. Two of these measures take precedence over all others: Satisfied patients. Satisfied staff. 7.2 Other measures include: Preventing people from dying prematurely. Enhancing quality of life for people with long term conditions. Helping people recover from episodes of ill health following injury. Ensuring people have a positive experience of care. Treating and caring for people in a safe environment, and protecting them from avoidable harm. Promoting equality and reducing inequalities in health outcomes. NHS Constitution rights and pledges (incl. key service standards). Becoming an excellent organisation. High quality financial management. Chief Officer s Report NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 2 of 4

15 7.3 A copy of their two page summary is attached. A full version of their plan is available on the NHS England website (address as above). 8. Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 8.1 The government has published Patients First and Foremost their initial response on behalf of the whole health care system to the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. It details the key actions required to ensure that patients are the first and foremost consideration of the system and everyone who works in it and to restore the NHS to its core values as set out in the NHS Constitution. 8.2 There is a call to action for every individual and organisation within the health care system to reflect and consider how the lessons of the Inquiry are understood and responded to locally. The CCGs Quality Improvement Committee will consider this report further and set out their response for the Governing Body in due course. 9. Putting Patients First 9.1 NHS England reported to their April Board their strategy for putting patients and the public at the heart of everything it does. The paper included a range of initiatives and plan, one of which is the Friends and Family test. From 1 April the Friends and Family test will be implemented for all providers of NHS care for inpatient and A&E services. The test asks the standard question How likely are you to recommend our ward / A&E to friends and family if they needed similar care or treatment? The first data from this test will be published for Quarter 1 of 2013/14 in July 2013; trusts are being encouraged to publish local data prior to this. 9.2 The test will be rolled out to maternity services from October. Further guidance will be issued by NHS England on the planned rollout of this test to cover all NHS services and a similar test for staff. 10. NHS England s Generic Commissioning Policies 10.1 NHS England has published a number of interim generic policies, ensuring fair and consistent decision-making across its direct commissioning function. The 14 policies cover all aspects of NHS England s direct commissioning responsibilities including specialised services, primary care, screening, military and offender health. The policies, agreed by the Clinical Priorities Advisory Group (CPAG), set out NHS England s approach on a variety of funding issues including Individual Funding Requests; access to treatments for patients moving between different sets of commissioners and services providers, and the process that NHS England will adopt for implementing guidance produced by the National Institute of Clinical Excellence (NICE) Other policies include the Ethical Framework for Priority Setting and Resource Allocation which sets out a fair and consistent approach to decision-making. The policies are being adopted on an interim basis to enable NHS England to carry out further engagement with patients, carers and the public over the next 6-12 months Chief Officer s Report NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 3 of 4

16 in refining and agreeing final versions. NHS England plans to bring together a steering group which will lead development of the policies, working in partnership with a range of stakeholders. This group will test the principles on which the policies are based and will revise them, where appropriate, in order to make them more accessible. This transparent approach to policy development reinforces NHS England s commitment to ensuring that patients and carers are at the heart of the planning and development of NHS services. 11. Final Quality Premium Guidance Published 11.1 Final guidance has now been published which confirms that the maximum amount payable to CCGs in 2014/15 for improving outcomes against the national and local measures will be 5 per head of population. The guidance also confirms that CCGs will have flexibility to decide how best to use money earned from the quality premium, provided that it is spent in ways that improve patient care or health outcomes. The guidance also clarifies that NHS England is committed to include a national measure on mental health in the 2014/15 quality premium. The final guidance can be found at: Mrs J Ledward Chief Officer April 2013 Chief Officer s Report NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 4 of 4

17 Putting Patients First: The summary NHS England business plan for 2013/ /16 Purpose Our goal is high quality care for all, now and for future generations. This plan sets out how we will improve quality and secure the best possible outcomes for patients and best value for taxpayers. 2013/14 is a critical year for the NHS. The Francis report demonstrates the tragic consequences when standards of care fall woefully short. This is why we in the NHS must, and will, put patients at the heart of everything we do. The overarching theme of the Francis report is clear: a fundamental cultural change is needed in order to put patients at the centre of the NHS. Good staff support and management is fundamental to culture, and directly impacts on patient experience. The whole of the business plan is oriented towards supporting this cultural change. The NHS England scorecard Patients and the public are entitled to know how we are doing. We are committed to transparency and will introduce an 11 point scorecard for our priorities and how these will be measured. Two measures stand above the others as touchstones of our success: direct feedback from patients and their families; and feedback from NHS staff. We know that understanding the satisfaction of service users and staff will tell us how well we are delivering quality where it matters, and how we can improve. Priority Scorecard measurement 1 Satisfied patients Net score of positive versus negative feedback (scale -100/+100) 2 Motivated, positive NHS staff Net score of positive versus negative feedback (scale -100/+100) 3 Preventing people from dying prematurely: Outcomes Framework Domain 1 4 Enhancing quality of life for people with long term conditions: Outcomes Framework Domain 2 5 Helping people to recover from episodes of ill health or following injury: Outcomes Framework Domain 3 6 Ensuring people have a positive experience of care: Outcomes Framework Domain 4 7 Treating and caring for people in a safe environment; and protecting them from avoidable harm: Outcomes Framework Domain 5 Progress against Improvement areas Progress against Improvement areas Progress against Improvement areas Progress against Improvement areas Progress against Improvement areas Promoting equality and reducing inequalities in health outcomes Progress in reducing identified health inequalities on all indicators for which data are available 9 NHS Constitution rights and pledges, including delivery of key service standards The proportion of people for whom NHS England meets NHS Constitution standards 10 Becoming an excellent organisation Staff survey results, 360 degree feedback 11 High quality financial management Actual spend versus budget

18 Our operating model We shall achieve these outcomes by using the eight components of our operating model to ensure that the commissioning system is in the best possible place to make a difference for the people of England: a. Supporting, developing and assuring the commissioning system b.direct Commissioning: NHS England directly commissions specialist services, primary care, public health services, dental services, armed forces health services and offender health services c. Emergency Preparedness d.partnership for quality e. Strategy, research and innovation for outcomes and growth f. Clinical and professional leadership g.world class customer service: Information, Transparency and Participation h.developing Commissioning Support We are open and transparent. We are accountable and we take individual and collective responsibility for our actions. We act with integrity and we are transparent about the decisions we make, the way we operate and the impact we have. We are inclusive. We work in partnership with patients and clinicians, the public and our partners because we get the very best outcomes when we work together with common purpose. We are relentless for improvement. We believe we can always do better for patients and will challenge and seek challenge. We share ideas and knowledge and take risks because we believe in innovation and learn from our mistakes. We listen and learn. We believe everybody has the right to a good idea and to be listened to carefully and thoughtfully. We respect and support each other, building trust to encourage everyone to give their very best. What we stand for: We are committed to achieving better outcomes for all in the right way: We put people first. Everything we do is directly connected to our purpose of improving outcomes not a process, not an organisation, not a profession but the person who needs the NHS to care for them. We make informed decisions. We listen to the people and communities we serve, we look at the insight and evidence and we measure our outcomes, so that our decisions are objective and we understand their impact.

19 GP/GB/ Part 1 Part 2 Report Title Delivery Plan Written by Presented by Purpose of the paper Governing Body Meeting 25 April 2013 Jan Ledward, Chief Officer Jan Ledward, Chief Officer Everyone Counts: Planning for Patients 2013/14 was published by the NHS Commissioning Board in December It outlines the incentives and levers that will be used to improve services from April 2013, the first year of the new NHS, where improvement is driven by clinical commissioners. The CCG has developed its own local plan for delivering health care services in 2013/14. This paper is the final version of the plan which was presented in draft form to the Governing Body in March 2013, and reflects the comments and amendments of the Chair, Governing Body and lead Clinicians. Key issues It is now critical that the Governing Body reaches a final position on the Delivery Plan. Actions required by Governing Body Members The Governing Body is requested to approve in full this, the final version of the Delivery Plan , so that we can move forward to publishing our prospectus by 31 May Delivery Plan NHS Greater Preston CCG Governing Body Meeting 25 April 2013

20 Delivery Plan

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22 CONTENTS Foreword... 1 Executive Summary... 2 Introduction... 4 Strategic aims... 5 Core values... 6 The Needs of the Population (Case for change)... 7 Demography... 7 Burden of Disease... 8 What the population told us How we have listened What the CCG was told Greater Preston CCG Plan on a Page Quality at the heart of everything the CCG does Improving quality through learning from others Assuring the CCG and public that high quality services are being delivered by service providers.. 15 Commissioning high quality services National CQUINs Local CQUINs The Quality Premium for CCGs Improving outcomes, reducing inequalities NHS Outcome Framework Domain Prevention Health Care Acquired Infections (HCAIs) NHS Outcome Framework Domain NHS Outcome Framework Domain NHS Outcome Framework Domain NHS Outcome Framework Domain Patients Rights: the NHS Constitution Eliminating long waiting times Ambulance performance Eliminating mixed sex accommodation... 26

23 Reducing cancelled operations Choice and the information to exercise it Military Veteran Health Health Visitors NHS services, 7 days a week More transparency, more choice Rehabilitation services Major trauma NHS More Responsive Care: Urgent and Emergency Care Mental Health Dementia Primary Care Care Home Liaison and Intermediate Care Teams Hospital Liaison Services CCG Priorities for 2013/ Reducing inappropriate admission Long term conditions Diagnostics The case for change Reducing inappropriate and unnecessary admission to hospital Elective admission rates Long term conditions Rebalancing the health economy Working to reduce elective admissions Primary Care Key developments this year Collaborative commissioning Contributing activities that will help deliver the CCGs priorities Organisational development Commissioning Support Joined up local planning The agreed priorities for the Clinical Senate Listening to patients and increasing their participation... 60

24 Ensure that there is a culture of innovation Personalised budgets Clinical Programmes Facilities and Estate Management Productivity and efficiency transformation priorities Peer Review Mental Health Medicines Management Workforce Financial Planning Allocations Summary Baseline Assumptions Expenditure Profile /14 Investments Admissions Avoidance Primary Care Initiatives Winter Planning Urgent Care Medicines Management Running costs Strategic Reserve Risks and Uncertainties CQUIN (Commissioning for Quality and Innovation) Schemes National CQUIN Schemes Local CQUIN Schemes Key Performance Indicators (KPIs) Collaborative Commissioning Appendix 1 Milestone Trajectory Appendix 2 Delivery Timelines Appendix 3 NHS Outcomes Framework... 81

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26 FOREWORD Welcome to our first Annual Operating Plan produced by Greater Preston Clinical Commissioning Group (CCG). It reflects our visions and values, and responds to the priorities identified by our constituent practices and the wider clinical community. The NHS reforms have placed clinicians absolutely at the forefront of improving healthcare commissioning and in Greater Preston now we are fully authorised without any conditions we are determined to grasp this challenge and to improve services and outcomes for our population. This plan reflects and builds upon our three five year integrated plan and sets out the work we are undertaking in collaboration with our partners in neighbouring CCGs and local and District Councils. Our annual plan is a key document for everyone in Greater Preston - patients, member practices, providers, partners, the Governing Body and staff team. It is also a key document for those who hold us to account, specifically the NHS Commissioning Board Authority. It sets out: What we want to achieve our vision and target outcomes How we plan to do it our mission, our values, actions and financial resources; Who will lead, manage and be engaged - our clinical leaders, partners, patient groups and staff; When we will deliver improvements. It is a live and responsive plan based on needs identified in our Joint Strategic Needs Assessment and created with involvement of GP member practices, patients, providers and the local Health and Wellbeing Board. We have a strong foundation to build on the general health of the population of Greater Preston is good but we also face some big challenges. There are seven areas in our community which are amongst the most deprived areas in the country and the link between deprivations and ill health has been well made. Our plan includes a series of activities to begin addressing these health inequalities. We believe this plan reflects a way in we can do this in a truly transformational way, with a clear clinical focus and added clinical value. As you read this I hope that you will be both inspired and assured that our organisation has patient involvement,safety, quality, clinical leadership and engagement running through its veins, and that we are driven by a relentless commitment to improve services and health outcomes for the people we serve. If you have any comments, please do get in touch. Jan Ledward Chief Officer Dr Ann Bowman Chair & Clinical Lead 1

27 EXECUTIVE SUMMARY We are pleased to share the first Greater Preston CCG annual plan. Our Plan describes our establishment as a new organisation. From April 2013, Greater Preston Clinical Commissioning Group (CCG) has become the statutory body responsible for commissioning local health services. Greater Preston CCG is responsible for commissioning (planning and buying) the majority of local health services, apart from primary care services (GPs, prison primary care services, dentists, opticians, pharmacists), specialist services (such as special heart and renal services) and public health services (such as obesity and alcohol). Our annual plan describes the priorities and actions we will deliver on during and sets out, in detail, how we plan to tackle the challenges facing our local health economy as we continue to develop and grow our organisation within In the following pages we outline our starting point, our ambitions and our plans for realising them. The plan is more than a strategic statement of intent; it is also a detailed document that contains milestones to be achieved each month during the coming year. We will be using this plan regularly to review progress and keep track of our achievements. At the year-end we will produce an annual report outlining what has been achieved against the plan. This integrated plan sets out a high level strategy for ensuring delivery of operational targets and financial balance for Greater Preston CCG. It reflects our development over the past two years and our ambition for the future. It outlines our overall vision and priorities for the long term and importantly how we will set out to deliver these during 2013/14. In developing this commissioning plan the CCG has first considered the NHS Operating Framework, the Outcomes framework and nationally available tools that benchmark local performance against other CCGs. It has also taken advice from public health regarding our local health needs, and we have consulted with GP practices in our area with regard to which services are working well, which are not and may need redesign or decommissioning and where there are gaps in service provision. What you will see over the next year as a result of this delivery plan 2 Our performance against the NHS Outcomes Framework will continually improve, as set out in this document, and this information will be published on our website; Demonstrable evidence of our contribution via collaboration including the Health and Wellbeing Board to improvements against public health, children s and social care outcomes frameworks. Patient experience surveys carried out in services that we commission will show an improving trend and this will also be published on our website;

28 Information will be routinely published around the clinical commissioning group achieving financial balance each year. Wider based community services locally and reduced duplication; Improved access to services and reduced waiting times; Reduced admissions to hospital by avoiding unnecessary admissions; Each of our general practices will have a patient participation group and the number of people joining these will increase; An ownership scheme that will commence with more opportunities for local people to contribute to decision-making particularly via our website. Services that are integrated so that patients do not feel bounced from one organisation to another. Improved support to adopt healthier lifestyles. 3

29 INTRODUCTION The opportunity for local general practitioners to lead Clinical Commissioning was established by the Health and Social Care Act GPs in this locality came together to form the Greater Preston Clinical Commissioning Group (CCG). The CCG was authorised without conditions on 18 th January 2013 by the NHS commissioning Board, and has taken on all its statutory functions from the 1 st April Greater Preston CCG is made up from the district of Preston and surrounding communities. This includes the following practices situated in the district of South Ribble, Ribble Valley and Wyre (January 2012) where 20 per cent of the CCG population is located: St Fillans Medical Centre, Longton Health Centre, St Mary s Health Centre, Riverside Medical Centre and Lostock Hall Medical Centre, Gt Eccleston Health Centre, Berry Lane Medical Centre and Stonebridge Surgery. The CCG comprises of 34 GP member practices and it represents a population of , with a higher than national average population in the age range. 56% of practices in the area are single handed. 56% The percentage of single handed practices Our health outcomes compared to other similar areas are not as good as you would expect or want. This plan sets out what we intend to do about this during the financial year 2013/14. The CCG is accountable for in excess of two hundred and forty four million pounds worth of expenditure on health care services. In setting strategic priorities and prioritising the investment of NHS Greater Preston CCG commissioning resources the CCG will work in a joint arrangement with NHS Chorley and South Ribble CCG. As both CCGs are commissioning health services from the same providers, mainly Lancashire Teaching Hospitals which provides prominently acute care, Lancashire Care Foundation Trust providing community and mental health services and an independent sector hospital Ramsey Healthcare, NHS Greater Preston CCG has established a joint agreement with NHS Chorley and South Ribble CCG to ensure alignment and clarity of expectations. This includes a joint commissioning committee and lead commissioning arrangements across the two CCGs where individual CCG decisions and priorities are shared to check for alignment. We have a strong history of collective working with neighbouring NHS commissioners. All eight Lancashire CCGs have committed to supporting the establishment of a Lancashire Wide Commissioning Network to support the work of CCGs. We already have shared programmes in place with Lancashire CCGs and we are working with local authorities to consider what opportunities might accrue through developing a public health function across Lancashire. The network will also provide a mechanism for collaboration with respect to our other important collective working arrangements, including Lancashire wide approaches, shared programmes, sharing best practice, discussing common issues and our partnership working within Lancashire. 4

30 As a CCG we are responsible for commissioning: Emergency and urgent care services for anyone present in our geographical area A range of services to meet the reasonable needs of the people we are responsible for, such as services provided by district general hospitals, mental health providers and community services Improving the quality of acute-based, community-based and mental health services, as well as primary care. This plan is developed and informed by the Joint Strategic Needs Assessment (JSNA) for Lancashire, the Lancashire Health and Wellbeing Strategy, the Greater Preston Health and Wellbeing plan and views of the local GPs, stakeholders, the public and patients. Nationally defined targets govern the overall thrust and strategic direction within which we will deliver improved outcomes for Greater Preston, and demonstrate improved performance in respect of system reform, quality, and access to care, within our financial allocation. Our key, national directions, which can be found on the National Commissioning Board website, are: NHS Mandate NHS Outcomes Framework NHS Constitution Strategic aims Following extensive consultation the CCG drew up a set of strategic aims during These cover: Rebalancing the Health Economy We will target our resources on the major causes of ill health to improve outcomes for our patients but doing so at an appropriate cost so our resources across the health economy are deployed to deliver best value. Health Improvement We will utilise our own commissioning responsibilities and work with partners across the public, private and voluntary sector to protect good health and prevent ill health be ensuring evidence based practice at the appropriate scale. Communication / Relationships We will not achieve our goals without working closely with individuals, communities and other partner organisations. Fostering and maintaining effective partnerships that improve outcomes for patients and communities is an essential and key component of our plan. Effective Commissioning We will commission services that demonstrate value for money for our population and improve the quality of healthcare and outcomes and reduce inequalities. We will maintain a robust system of financial control with our 5

31 clinical leads overseeing effective management of resources including the delivery of our QIPP programme. Integration We aim to commission and manage effective integrated care pathways in partnership via our local clinical senate, local health and wellbeing boards and other appropriate partnership structures. Our goal of developing integrated care is to reduce duplication, improve coordination across settings and to structure services so they are patient focussed to improve outcomes. Core values As a new organisation it is important that we define values that guide us in the way we make decisions and how we work. We have therefore worked with our staff, members and partners to establish our values outlined below. Collaboration we will work effectively with the public, patients and partner organisations to achieve our vision and aims; Respect we will be an organisation that values its staff and the population it serves; Listening we will listen and value the views of local people, putting patients at the heart of everything we do; Openness and transparency local decision making and local accountability. How we will explain and make decisions. Effectiveness ensuring clinically led, locality focused, evidenced based services that deliver best outcomes for our population. 6

32 THE NEEDS OF THE POPULATION (CASE FOR CHANGE) Demography NHS Greater Preston CCG is made up of 34 GP practices serving primarily the local authority areas of Preston but with GP practices covering populations in Fylde, Ribble Valley, South Ribble, West Lancashire and Wyre. The CCG has a registered population of approximately 212,000 people, although it covers a geographic area containing 217,000 residents. The graph below shows the variations across the CCG registered population. Almost a third (30%) of the CCG population resides in deprivation quintile 1, the most deprived level in the country, although conversely over a fifth (22.5%) live in the least deprived areas (quintile 5). The majority of the population (59%) live in the lower three quintiles. Registered population of NHS Greater Preston CCG The population of the CCG is increasing; by the year 2022 it is forecast to increase by around 8,000 people to approximately 220,000. The biggest increase will occur in the age group for both genders and also in the over 55 age group. The health of people in Preston is generally worse than the England average. Deprivation is higher than average and 6,965, roughly 7,000, children live in poverty. Across the locality there are many variations between the most and least disadvantaged areas in terms of life expectancy, mortality rates and the number of people living with limiting long term illnesses. These inequalities lead to Preston men who live in the least deprived areas expecting to live over twelve years longer than men in the most deprived areas, and for women the difference is over nine years. Over the last ten years all-cause mortality rates have fallen to 537 per 100,000 population, but early death rates from cancer have risen to 110 per 100,000. This is now on a par with the England average of per 100,000, although it remains lower than the average for the North West of 121 per 100,000. 7

33 Early death rates from heart disease and stroke have fallen but are still worse than the England average, with a rate of 90.2 per 100,000 against 67.3 per 100,000 for England. Almost 19% of year 6 children are classified as obese, while 55% of pupils spend at least three hours on school sport per week, both of which are close to the England average. Levels of teenage pregnancy are higher than the England average, although this will include births to teenage married mums. Levels of adult smoking (24%) are higher than the England average (20.7%). Rates of road injuries and deaths smoking related deaths smoking related deaths and hospital stays for alcohol related harm are higher than the England average. Burden of Disease Statistical data shows that in comparison to the rest of England there is significantly lower recorded prevalence for nine conditions in the local population (marked in green in the diagram below). This could reflect poor identification of those in the local population suffering from these conditions or the local population does indeed have a lower prevalence. QoF registers and Modelling of Disease Prevalence Conversely there is a higher than England average recorded prevalence for nine of the disease groups in the local population (marked in red on the above diagram), which could point to over recording of the conditions in general practice or that there is a genuine higher prevalence for these disease areas. 8

34 Estimated prevalence of COPD is significantly higher than the England average with a CCG prevalence of 3.23% compared with an England prevalence of 2.90%. Recorded prevalence of asthma and depression are both significantly higher than the recorded England average. This could be due to a genuinely higher prevalence locally or better than average recording of these conditions within the CCG. For a number of conditions the QoF recorded number relative to the estimated prevalence is significantly lower in statistical terms. This may indicate that practices are under recording these conditions, and also that hard to reach groups are possibly not being included, particularly as the majority of practices have significant populations within the most deprived cluster groups. The above diagram shows that hypertension appears to be under recorded locally. The estimated local prevalence of hypertension is 23.7%, while practices have only recorded prevalence of 12.7%. However, as can be seen from the England average, this is the case across the country. 9

35 WHAT THE POPULATION TOLD US The views and opinions of the local population and those involved in some of our work have been vital in helping develop a plan that will deliver the best healthcare for our community. The CCG puts patients, carers and the public at the heart of everything it does. The CCG has actively sought feedback from patients, the public and local partners, through a range of mechanisms outlined in the table below. How we have listened Who The population Local Community Groups Member practices local How Through interactive surveys at events such as at the local health Mela, the development of the CCG Ownership Programme and customer care queries By attending meetings with voluntary sector organisations such as: CVS, Local Improvement Network (Links) and Third Sector Lancashire Through workshops, membership councils, peer groups, practice manager meetings and through the development of Patient Participation Groups The Senate Clinical Bringing together clinicians and managers from across local health and social care services What the CCG was told Patients, carers and the local population have said that they want to be involved in the work of the CCG. The top three themes in the feedback received from patients and the local population are: 10 To see and experience an improvement in the overall quality of care. To receive more knowledge and information to help them manage their own health conditions or self-care. To see a reduction in waiting times including making it easier to book an appointment with their GP. They also told us that it was very important that we prioritised our plans as follows: Cancers and tumours Urgent care Community services Heart disease

36 Our healthcare delivery partners, voluntary and third sector organisations said they wanted much more engagement with us through: Involvement in discussions about how our environment is changing, Sharing how our organisation is developing and the emerging governance and membership arrangements Increasing transparency and working more collaboratively. In response to our delivery partners, we have developed mechanisms to facilitate increased levels of meaningful engagement, helping us to understand and strengthen our partner relationships and demonstrate strong clinical leadership. We have received positive feedback on our approach to engagement, as shown by a number of direct quotes from our stakeholders. We will continue to put patients, carers and the local population at the heart of our work by: Keeping patients, carers and our population involved searching for feedback, listening and acting upon it. 11

37 Involving children and young people in developing services and making decisions about their health. Involving staff in how we change and improve services and our systems and processes. Building and strengthen partnership working, particularly with the third sector Being open, honest and acting with integrity. Taking into account the needs of the population and what people have told us, we produced an Integrated Commissioning Plan 2012/2017. This plan set out the core values that the CCG will work to and its strategic aims for the five year period. These are outlined overleaf in our Plan on a page. 12

38 Greater Preston CCG Plan on a Page 13

39 QUALITY AT THE HEART OF EVERYTHING THE CCG DOES The CCG is a quality driven organisation. Clinical and service quality should be of the highest order for our residents. Improving quality through learning from others It is clear from the national reports on Winterbourne View Hospital and Mid Staffordshire NHS Foundation Trust that in those particular hospitals, care fell below the standard expected. It is incumbent on the CCG as a key commissioner of health care that it assures itself that care is of the highest order in organisations that it holds contracts with. Additionally, it has a statutory role to continuously improve quality in primary care. The Mid Staffordshire NHS Foundation Trust Public Enquiry report by Robert Francis requires health organisations and health regulators to look carefully at a range of issues. For commissioners, the key issue is to ensure that there is in place sufficient monitoring of a variety of aspects of care to enable a commissioner to recognise and intervene when things may be going wrong. The CCG will therefore in response to the Francis report: reassess its own internal quality strategy, including taking into account all the key recommendations of the Francis report aimed at CCGs develop a quality strategy across the health economy with its key partners Greater Preston CCG, Lancashire Teaching Hospitals FT, Lancashire Care FT and Lancashire County Council. These partners meet monthly as the Clinical Senate Underpinning these new strategies will be the Chief Nursing Officer's '6 Cs'. These are Care, Compassion, Competence, Communication, Courage and Commitment. These apply to all clinical staff, not just nurses. They should be in place in order to ensure that not only are high quality treatments delivered but also that a high quality of care is sustained. A key issue to be dealt with during is the actions required following the Winterbourne View Hospital review. The aim is to transform care for this group of patients. The following is an extract from the government s response to the review: We expect to see a fundamental change across Learning Disability services and our plan for 2013 is summarised as follows: all current placements will be reviewed by 1 June 2013, and everyone inappropriately in hospital will move to community-based support as quickly as possible, and no later than 1 June 2014; by April 2014 each area will have a locally agreed joint plan to ensure high quality care and support services for all children, young people and 14

40 adults with learning disabilities or autism and mental health conditions or behaviour described as challenging, in line with the model of good care set out at Annex A; as a consequence, there will be a dramatic reduction in hospital placements for this group of people and the closure of large hospitals; a new NHS and local government-led joint improvement team, with funding from the Department of Health, will be created to lead and support this transformation; we will strengthen accountability of Boards of Directors and Managers for the safety and quality of care which their organisations provide, setting out proposals during Spring 2013 to close this gap; CQC will strengthen inspections and regulation of hospitals and care homes for this group of people. This will include unannounced inspections involving people who use services and their families, and steps to ensure that services are in line with the agreed model of care; and With the improvement team we will monitor and report on progress nationally 1. The requirements of Winterbourne review have major implications for the type of care provided to our population who have learning disabilities. As commissioners we will respond by making sure that we reflect on this report and ensure learn the lessons and incorporate this into our planning and service improvement effort. All current placements are being reviewed in line with the timeline set out above. In the medium to long term we will work with the collaborative commissioning team to ensure that we have a co-ordinated approach to Learning Disability across Lancashire. Assuring the CCG and public that high quality services are being delivered by service providers The CCG will ensure that it has appropriate monitoring systems in place, and use a variety of benchmarking information and guidance to initially assess and gain assurance when reviewing the levels of quality in our providers. Assurance can be gained regarding quality of care through the following: NICE Clinical Commissioning Group Outcomes Indicator Sets Provider safety dashboards. National quality dashboards and benchmarking information Monitoring of Never Events, and Serious Untoward Incidents (SUI) management including provider root cause analysis. 1 Transforming Care: a national response to Winterbourne View Hospital pages

41 Understanding improvements to care provision that can be made following analysing positive or negative local events, for example Mid Staffordshire review / Winterbourne View Hospital report.. Reports detailing areas of concern as a result of trends analysis. Introducing the Friends and Family test, reflecting on the outcomes and instigating necessary change Other avenues include patient feedback (covered elsewhere in the plan), patient and staff surveys undertaken by providers, complaints made to providers and soft intelligence from patients seen in primary care who have had contact with provider services. Patient feedback to primary care staff is particularly important and provides the CCG with a backcloth against which to lay all the other quality information it has access to. Commissioning high quality services The CCG as a commissioning organisations have a statutory duty to commission interventions which have been recommended by the National Institute for Health and Clinical Excellence (NICE) in a Technological Appraisal. Any commissioning will be underpinned by a set of principles where services and interventions are deemed to be effective, appropriate, cost effective and ethical. As part of our assessment of cost effectiveness, we will review our main providers Cost Improvement programmes for quality and efficiency. We have instigated within the contracting arrangements a process to understand their cost improvement programmes. This is described in the Finance section later in the plan. In addition, the CCG will, on occasions, undertake visits to providers in particular where quality indicators or patient feedback suggests further detailed investigation is required. One way of incentivizing improvements in quality of care is through the use of CQUIN payments in contracts with providers. A sum of 2.5% of the value of each contract is set aside and only paid if the provider can show that it is meeting agreed improvements in quality. These improvements are carefully documented and measured. CQUINs come in two forms national ones and local ones. 16

42 National CQUINs Lancashire Teaching Hospital FT Friends and family test Ensure that patient feedback through the friends and family test is collected and acted on National safety thermometer Complete and use the safety thermometer to improve safety for patients Dementia Improve diagnosis rates and identification of dementia in admitted patients and ensure high quality care is given to these patients and their carers VTE To reduce avoidable death, disability and chronic ill health from venous thromboembolism (VTE) Ramsay Health Care Friends and family test Ensure that patient feedback through the friends and family test is collected and acted National safety thermometer Complete and use the safety thermometer to improve safety for patients Dementia Improve diagnosis rates and identification of dementia in admitted patients and ensure high quality care is given to these patients and their carers VTE To reduce avoidable death, disability and chronic ill health from venous thromboembolism (VTE) Lancashire Care FT Community contract Not applicable to community service contracts, but see local CQUIN scheme below National safety thermometer Complete and use the safety thermometer to improve safety for patients Not applicable to Community service contracts Not applicable to Community service contracts Local CQUINs Lancashire Teaching Hospital FT Ramsay Health Care Lancashire Care FT Community contract Outpatients Improve patient experience in outpatients Care of the Elderly Achieve quality mark for elder friendly hospital wards Alcohol Screening, brief intervention and referral Smoking cessation Support to patients Dementia Supporting carers Person centred planning Signed agreed care plans for each patient 17

43 Lancashire Teaching Hospital FT Diagnostics Improvements in time to get tests done and reporting times to patient and GP End of Life Improvements in education and care planning and reduction in number of patients on and end of life pathway that die in hospital Advancing Quality participation in a programme of work on agreed clinical areas of work measuring and monitoring improved outcomes Ramsay Health Care Lancashire Care FT Community contract Person centred planning Improvement in patient experience and goal planning Friends and family test Introduce test to agreed schedule Improve quality of care Implementation of quality dashboards at individual and team level All national and local CQUIN schemes have detailed reporting and payment schedules in place. The Quality Premium for CCGs NHS England will reward clinical commissioning groups for improvements in the quality of services they commission and for associated improvements in health outcomes and reducing inequalities. There are a series of pre-qualifiers including the requirement to manage within its total resources envelope, but as importantly, providers used by the CCG will have to meet the NHS Constitution rights and pledges for example four hour waits in A&E, maximum 18 week wait from referral to treatment etc. The four key national measures are: 18 Reducing potential years of lives lost through amenable mortality Domain 1 of the NHS Outcomes framework Reducing avoidable emergency admissions combination of measures from Domains 2 and 3 of the Outcomes framework Ensuring roll out of the Friends and family test Domain 4 of the outcomes framework Preventing health care associated infections Domain 5 of the outcomes framework Three local measures had to be nominated reflecting the Health and Wellbeing Boards priorities. The CCG chose to link these to its own main priorities. These are:

44 1. Avoidable admissions Reduction in unplanned hospital admissions for asthma, diabetes and epilepsy in Under 19s - 10% reduction on previous year What we will do to achieve this. A project will be implemented to ensure that patients in these groups are given the appropriate support and care to ensure that hospitalisation is the last resort. 2. Long term conditions Reduction in the average length of stay for patients with primary diagnosis of dementia of 0.9 days (equivalent to a 7% reduction in length of stay on previous years) What we will do to achieve this. Dementia is one of the key parts of our Long term conditions programme of work that will be undertaken during The dementia part of the programme includes clear plans to reduce the length of stay in hospital for this group of patients 3. Diagnostics Reduction in the number of first outpatient cardiology attendances of 932 (equivalent to a 20% reduction in the number of first attendances on previous years) What we will do to achieve this. Outpatient referrals will be triaged by a cardiology consultant using the information in the referral letter who will then assess whether it is appropriate for the patients to be managed by their GP or to be referred into the cardiology department. The CCG will monitor progress on these measures throughout the year as part of its performance management system. The measures related to the NHS Constitution will be measure through the contract monitoring system as they are written into relevant provider contracts. 19

45 IMPROVING OUTCOMES, REDUCING INEQUALITIES The NHS Outcomes framework which is published by the NHS Commissioning board and is based on the Mandate agreed between the Commissioning Board and Department of Health. It provides the NHS with a national framework and methodology for measuring improvement in outcomes over time. There are 5 domains set out in the outcomes framework. For each of the five domains there are a series of measures that CCGs need to demonstrate improvement in and how continuous progress will be achieved. The NHS Commissioning Board makes it clear in its planning guidance for 2013/14, Everyone Counts, this year is a foundation year. CCGs should aim to maintain performance across all measures and target improvement in priority measures. The NHS Outcome Framework is included in full at Appendix 3 of this Plan. NHS Outcome Framework Domain 1 The CCG will be working in partnership with Public Health England to achieve improvements in the health of the population in line with our first strategic objective: Prevention To ensure that the CCG uses its influence to improve preventative activity that helps keep our community healthy and promotes wellbeing. Lancashire County Council has Public Health responsibilities and its own outcomes framework against which to monitor performance. However, the two outcome frameworks are aligned and, locally through the Lancashire Health and Wellbeing Board and the local District Health and Wellbeing structures, the CCG will work collaboratively to improve outcomes in this domain. The CCGs impact and work with colleagues in all sectors on prevention (NHS Outcome Framework Domain 1) is laid out in the table overleaf. This shows that the main areas of impact will be on Health Inequalities and premature deaths. The CCG will collaborate with other health care partners in delivering the programmes of work set out overleaf. Timescales are still to be finalised. 20

46 Respiratory (COPD) Cancer Cardiovascular disease Health inequalities Local Health Challenge Description What we plan to do Life expectancy for both men and women is lower than the England average Across the locality there are many variations between the most and least disadvantaged areas in terms of life expectancy, mortality rates and the number of people living with limiting long term illnesses These inequalities lead to Preston men who live in the least deprived areas expecting to live almost nine years longer than men in the most deprived areas, and for women the difference is almost seven years Continue to ensure clinical priorities are aligned to areas of health inequality. In particular, within elective (planned) care, long term conditions, mental health, and learning disabilities Maintain work with all GP practices to reduce unwarranted variation in referrals and with hospitals to reduce the variation in intervention rates Maintain a rolling programme of clinically led service reviews Premature deaths Premature mortality, associated morbidity and health inequalities across the area Premature mortality, associated morbidity and health inequalities across the area Contributing factor on mortality and admission to hospital Develop local enhanced services and direct access to diagnostics Implement integrated community service models Make improvements along the stroke pathway, including TIA Improve uptake of cancer screening Programmes Promote interventions to raise awareness of signs and symptoms of cancer Roll out an admissions management nursing and residential home scheme across the area Integrate health and social care teams, ensuring better coordinated services and better outcomes for patients 21

47 Health Care Acquired Infections (HCAIs) Greater Preston CCG is committed to reducing healthcare associated infections (HCAI) and improving patient safety. We will pursue a zero tolerance approach to unavoidable serious infections and poor infection prevention practice across the health economy. C.difficile cases from October 2011 to September 2012 show that there were 61 cases of infection. There is a requirement to reduce this by 21% or, to a maximum of 48 cases during % The target percentage reduction in C.difficile cases The objective for MRSA bacteraemia is zero avoidable infections and the CCG will support the post infection review of all cases to determine whether cases were avoidable and ensure lessons are learned to prevent reoccurrence. To reduce the risk of avoidable HCAIs, Greater Preston CCG will: Gain assurance and monitor providers in relation to infection prevention outcomes and on-going quality improvement. Perform a post infection review on all MRSA bacteraemias (according to national guidance) and root cause analysis on cases of CDI (as a minimum), working collaboratively with all relevant organisations to identify lessons and monitor actions to improve practice across the health and social care economy. NHS Outcome Framework Domain 2 The CCG has put in place a major programme of work covering a wide definition of long term conditions (including COPD, diabetes and asthma). It also includes one of the CCG s major priority areas of dementia. The CCG will also prioritise reducing unplanned hospitalization for under 19s asthma, diabetes and epilepsy. We will drive progress on the outcome measures, and make a priority of reducing time spent in hospital, support for carers and improved diagnosis rates. Specific plans are included in the section headed CCG Priorities later in the Plan. NHS Outcome Framework Domain 3 Domain 3 of the Outcomes framework covers a wide variety of issues. Specifically, this CCG will be focusing on two areas, as measured by patient reported outcome measures (PROMs): 1. recovery from stroke, and 2. total health gain as experienced by patients on three specific operations, i. hip replacement, 22

48 ii. knee replacement, and iii. groin operations In addition, the CCG is planning a significant rehabilitation review programme that will contribute to this domain. NHS Outcome Framework Domain 4 The initial investigation on Mid Staffordshire NHS Foundation Trust identified failure to listen to, and take action on, patients, carers and staff concerns about poor quality care and safety issues despite being raised repeatedly with the organisation. The second report by Robert Francis QC published in February 2013 reaffirmed these findings and made recommendations that we need to act upon. The CCG feels that it is vital that it knows more about what our patients think of the services we commission and act on that information when reviewing and commissioning services. We recognise a particular responsibility to ensure that the voice and views of currently under-represented groups are sought out and listened to. Therefore the CCG will work with providers to put in place mechanisms for systematically capturing timely patient and carer feedback and comments, as well as developing plans to gather public insight on local health services. Providers will be monitored closely against the National Commissioning for Quality and Innovation (CQUIN) scheme entitled Friends and Family Test as well as the National Patient and National Staff surveys. Early warning systems are in place to identify concerns relating to the quality and safety of services. The CCG will ensure that appropriate action is taken in response to those concerns. NHS Greater Preston CCG will work closely with all providers of healthcare services to ensure patient privacy and dignity is improved through 2013/14. NHS Outcome Framework Domain 5 This outcome domain is vitally important to the CCG as it allows it to be explicit about the need for a safe environment and protection from harm being a high priority as a measure of the quality of care. Greater Preston CCG aims to commission secure safe, sustainable, high quality health care for its population. It understands that sometimes patients do suffer avoidable harm and that there is a need to take action to ensure this does not happen again. The CCG has robust procedures in place for reporting and investigating incidents. Health care providers are required to demonstrate that lessons are identified and learned through the investigation of incidents and then shared across the health economy. The monitoring of incidents provides assurance that there is a reporting culture within organisations and that providers appropriately report and grade 23

49 incidents at all levels of severity, learning lessons from these adverse events. Sharing of these reports with the commissioning organisation supports transparency in provider organisations. The CCG will continue to develop and enhance the exception profiling of our providers, utilising the data from National Quality Dashboards, regulators and other external agencies, ensuring that the exceptions to quality and safety are known and risks mitigated through contractual mechanisms and early warning signs of failing providers are identified. Clinical quality is monitored and assurance provided to the CCG Governing Body through the Quality Improvement sub Committee. The CCG is a member of the Lancashire Quality Surveillance Group which will systematically bring together different parts of the health economy, to share a view on risks and consider opportunities to coordinate actions to drive improvement between organisations. 24

50 PATIENTS RIGHTS: THE NHS CONSTITUTION Eliminating long waiting times Greater Preston CCG are committed to ensuring people have quicker access to services and are committed, through delivery against the NHS Constitution patient rights, to the achievement of the targets for waiting times: that no patient will wait for longer than 18 weeks and locally at Lancashire Teaching Hospitals we have agreed a maximum referral to treatment time of 36 weeks. In addition, Greater Preston CCG will continue to: Comply with best practice guidance and report to their Governing Body the reasons for patient breaches classified as choice, complexity and capacity. Analyse on a monthly basis all patients reported as waiting over 35 weeks. Review all planned waiting lists monthly to ensure compliance with Department of Health policy, and Ensure 18 week delivery is sustainable by monitoring the current pathway wait for surgical patients and reducing the diagnostic or outpatient waits as appropriate linking into the CCG priorities. Ambulance performance Ambulance services are commissioned collaboratively on a North West basis by NHS Blackpool; they act as lead commissioner and monitor performance for ambulance services for all Northwest CCGs. National standards are being applied across the North West Ambulance Service NHS Trust (NWAS) for response times. The current contractual commitment is for NWAS to achieve the target on a Northwest basis. Performance over the past 12 months suggests a significant reduction in turnaround times. Initiatives in place to improve performance are part of the work of the urgent care provider partnership. This group is developing improved pathways for patients, appropriate direction of patient care based on needs to the most appropriate provider (not just hospital) and integrated urgent care services. NWAS pathfinder protocol has been initiated for COPD which will allow direct referrals from NWAS to GPs, thereby avoiding inappropriate A&E attendances. Alternative pathways for patients with long term conditions using advanced care plans are being developed as well. Links are being made with urgent care provider partners and NWAS to look at pathways for patients with falls to assist in providing alternative solutions and options again to avoid in appropriate admission to hospital. The CCG is working with Lancashire Teaching Hospitals to introduce a triage nurse to support rapid handover from ambulance crews and the hospital. This will ensure 25

51 that patients being brought to hospital receive that rapid handover and are seen and assessed within a timely manner. There is a new requirement for compliance with turnaround monitoring via the Hospital Arrival Screens (HAS) screens in A&E. Where hospital staff do not complete their required tasks on these screens there is a financial penalty to be paid. These penalties are also to be administered where turnaround times exceed 30 minutes. This process will be administered by the lead commissioner. Turnaround times and HAS screen compliance reports are fully monitored. Updates are available on a weekly basis and NWAS are able to report daily performance against these standards on request. Any penalties will be used to reinvest in the service. Eliminating mixed sex accommodation NHS Greater Preston CCG has is place a contract monitoring structure for all providers, within which quality monitoring is key. Major contracts have a specific interface group that review the quality and safety of health care provision. The elimination of mixed sex accommodation is a standard agenda item for assurance and discussion at every meeting. All providers are required to submit and publicise their declaration in relation to the elimination of mixed sex accommodation and the CCG uses evidence from patient surveys, established and agreed governance associated with reporting breaches and walk-around methodology to both provide assurance, but also understand where risks exist and what providers are doing to mitigate these. Reducing cancelled operations The reduction in cancelled operations has been identified as a priority issue for the CCG. We are undertaken benchmarking and trend analysis to highlight areas of concern. The CCG recognises a systematic approach, underpinned by robust contracting is required to support the improvement. The CCG accepts that there will always be a number of cancelled operations. However, we will focus on minimising this number and seek assurances from providers regarding staffing arrangements, mitigation plans, improved resilience and service planning. The CCG is currently establishing a feedback system, whereby issues with providers picked up by GPs and other stakeholders can be easily raised with the CCG and these concerns systematically addressed. This system should help the CCG to spot patterns and add value to contract and quality review meetings. Choice and the information to exercise it NHS Greater Preston CCG has developed a strategy to fulfil its responsibilities which includes a plan for improving patient choice and increasing the availability of information to inform that choice. 26

52 This patient choice strategy will be an important step in the development of an improved outcomes health system for the people of Greater Preston. It will promote improved customer satisfaction with the services we commission and improve quality and outcomes for our population. It will ensure that services we commission are personalised to the needs of patients and delivered in the most appropriate environment. This strategy is based on sharing information with the public to help them make decisions about their own clinical needs. We will work with constituent practices to support the offer of choice to patients so that they have a choice of hospitals to which they can be referred. We will also work with local providers to enable named consultant teams, where appropriate, to be accessible on their directory of services. The CCG will retain a focus on ensuring patients receive a choice of secondary care provider and promote the use of national resources, such as NHS Choices, to support informed choice. The CCG will also work with its member practices to ensure choice is offered via the Choose and Book system where referrals are subject to Any Qualified Provider (AQP). Military Veteran Health The CCG recognise the importance and value of the Armed Forces. This recognition extends not just to those that work in the Armed Services but also their families and veterans, and especially the injured and the bereaved. Greater Preston CCG is working collaboratively across the North West with regard to the Military Veteran (MV) agenda. The table below shows our actions to date and our planned activity over the next 12 months. What we have done to date Hosted a primary care clinical engagement and awareness event across the North West sector on 6 February 2013 and March 2013 that focused on the health issues affecting MVs, an introduction to the Community Covenant and understanding what services are available for MVs. Targeting a variety of community venues distributing leaflets to raise awareness. Development of a business card of services which will be distributed to GP practices for GPs to distribute to clients. Next Steps Promote attendance at the clinical engagement event in March in order to raise awareness of the health needs of Military Veterans and their families across the whole community. Attendance at local events at Fulwood Barracks raising awareness of health services Monitoring of identification of Military Veterans in primary care: There is a need to ensure that Military Veterans in the Greater Preston area are identified and appropriately coded on the health data systems so that take-up and suitability of the services on offer can be promoted and monitored. 27

53 What we have done to date Greater Preston CCG has extended the Military Veteran Improving Access to Psychological Therapies (IAPT) service for a further 12 months to the end of March This service offers specific psychological therapies tailored to Military Veterans and their family s needs. Next Steps Military Veterans IAPT: Continue to monitor the service on a quarterly basis Across the region a multi-agency working group has been established to support the Military Veterans agenda and also signed the non-statutory Community Covenant which supports the Military Covenant. This is currently being considered across the Lancashire CCG Network. Co-ordinating a Lancashire approach to commissioning of services for Military Veterans: Consideration is being given to establishing a local task and finish group to take the Military Veterans agenda forward in Greater Preston which would also consider signing-up to the Community Covenant. Health Visitors The commissioning of health visiting is led by the National Commissioning Board. However, the CCG will ensure the Health Visiting Service specification is incorporated into the contract for community services. The CCG will ensure that our provider capacity and capability is adequate and where necessary agree improvement plans. The relationship between the area team and the CCG will be crucial in this area, as the health visitor role will be integral to the development of the integrated neighbourhood teams. The CCG will continue to proactively monitor the quality and performance of the Provider providing health visiting services, to ensure any risk to provision external to the specific service line (that may impact upon it) is identified. The CCG is committed to continue to support the Early Years Agenda through representation on the Children s Trust Board and the Health & Wellbeing Board. Delivering our strategy for safeguarding vulnerable children is a priority for the CCG. NHS services, 7 days a week The ambition of the CCG is that patients will have: far more personalised healthcare, 28

54 the support they need to navigate the health care system, access to care 24 hours a day 7 days a week, at the appropriate level and location, pro-active management of their conditions, and greater support and guidance to manage their own health care issues. The CCG will develop plans to move towards routine services being available seven days a week. This will be essential to offer a much more patient-focused service and will also offer us the opportunity to improve clinical outcomes and reduce costs. Our key standards include: Hospital inpatients should be reviewed by an on-site consultant at least once every 24 hours, seven days a week, unless it has been determined that this is not necessary for the patient. Consultant-supervised interventions and investigations along with reports should be provided daily if the results will change the outcome or status of the patient s overall care before the next normal working day. This should include interventions which will enable immediate discharge or a shortened length of stay. Support services both in hospitals and in the primary care community setting should be available daily to ensure that the next steps in the patient s treatment, as determined by the daily consultant review, can be taken. It also acknowledges that it is outside its scope to look in detail at community services. These are entirely consistent with our principles which include: The right patients should receive the right treatment at the right time. Investigations should only be undertaken if needed. They should be based on evidence and should not replace a considered and informed clinical assessment. The choice of surgical intervention should be appropriate to the condition of the patient and to its severity. Patients, rather than clinicians or commissioners, should be able to choose their treatment for a non-urgent disorder, having been provided information on a variety of alternatives from multiple sources. As part of all our transformation programmes across the CCG we will be exploring 7 day availability with providers. The CCG is convinced that seven day routine service provision will offer us the opportunity to both drive up outcomes and reduce cost. A forum will be established to examine ways in which to improve access to seven day care with a report expected in autumn Diagnostics, urgent and emergency care will be the areas of focus in the initial stage of the forum's work. 29

55 More transparency, more choice NHS Choices will publish consultant-level data across a range of conditions such as adult cardiac, orthopaedic and urological surgeries by summer There will be a contractual obligation for all providers to publish their information from 2014/15 to enable comparison. This will be regularly reviewed routinely by the CCG s Quality Committee. The CCG has extended choice in community services for Audiology. In the next 12 months we are looking to extend any qualified provider (AQP) for a number of services including ENT and Dermatology. All services where choice has been extended have been published on the national map ( The CCG will keep this map updated to reflect extended choice plans and implementation through the Commissioning Support Unit. The CCG intends to review the impact of Community AQP in 2013 to assess quality and financial impact on services and patients. The CCG plans to explore an AQP framework that incorporates multiple primary care based services, which may include diagnostics in response to policy guidance to extend direct access to accelerate cancer diagnosis. This will expand choice for primary care services. We will retain a focus on ensuring patients receive a choice of secondary care provider and promote the use of national resources such as NHS Choices to support informed choice. In September 2012 Greater Preston CCG, working with Chorley & South Ribble CCG, implemented a web-based Integrated Care Gateway software application which will enable the establishment of a referral gateway for all GP referrals in order to make more effective use of primary and secondary care. The overall objective is to deliver savings through more effective use of secondary care; the referral gateway will facilitate the following: Clinical triage of GP referrals by GPs supported by administrative systems to enable the tracking, recording and gathering of data in relation to referrals. Management of appropriate referrals by primary/community services or advice and guidance provided to referrer. Reduction in number of interventions of limited clinical priority carried out. Development of a central point for the receipt and administration of all GP referrals. Use of Choose and Book centralised booking service to meet constitutional requirement to offer choice. Implementation of a single referral form for all GP referrals to secondary care (excluding two week wait urgent referrals). Improvement in quality of referrals; including consultant to consultant referrals Increased use of provision of real-time referral and patient tracking information for GPs. 30

56 Identification of GP educational needs. Rehabilitation services Greater Preston CCG, in partnership with Lancashire County Council, Lancashire Teaching Hospitals and Lancashire Care Foundation Trust has reviewed the approach to rehabilitation in Greater Preston. The overall aims of the Programme, (linking to the Long Term Conditions programme), are as follows: to identify opportunities for reducing health inequalities, supporting people to regain life skills and control, enabling them or their carers to be experts in their own care and avoid care solutions which foster dependence, supporting people to remain within their own homes for as long as possible. to support people to maintain their independence and find the solutions to do the things that matter to them. to achieve significant gains in terms of service quality, patient outcomes and productivity together with increased partnership working with both private sector and voluntary and community sector organisations. The aims of the Programme are to achieve the following outcomes: identify opportunities that will drive forward innovation and the delivery of high quality services develop recommendations for a service model which will provide value for money, underpinned by the philosophy of care closer to home and will achieve: - reduced demand on packages of care and admissions to long term care, - identify opportunities for disinvestment for health and social care through redesign, and recommend a model of rehabilitation, to commission for the future, which reflects the changing needs of our population and which embraces an integrated, whole systems approach. Major trauma 2013/14 will see the development of the Major Trauma Centres (MTCs) based at Lancashire Teaching Hospital. Patients with trauma will be taken to the designated centre in Lancashire bypassing other local emergency departments in order to receive optimum care in the most appropriate setting. NHS 111 NHS 111 is a new national service. It is a telephone advice line and signposting service for patients with unscheduled health problems which require assessment but which are not serious as to require a 999 call. The Service will be available 24 hours a day, 365 days a year to respond to people s health needs. 31

57 The service is intended to provide a consistent assessment at the first point of contact and route customers to the right NHS service first time, without the need for the caller to repeat information. The service provider will have a call handling system with support software which links automatically into a comprehensive local directory of service. NHS 111 was implemented as a pilot across Greater Preston in It has now been rolled out nationally and will become the gateway to the urgent care system. It will direct people to the most appropriate service for their needs, underpinned by well-developed local pathways of care. NHS direct has been awarded the contract in this area from 1 st April More Responsive Care: Urgent and Emergency Care The CCG works in partnership with Chorley & South Ribble CCG and Lancashire Teaching Hospital and partners to ensure high quality urgent care services are delivered to patients. One of the key priority areas for the CCG in 2013/14 is to realign our current urgent care service provision on the existing Royal Preston Hospital site. Our ideas include creating a single clinical care triage facility within the scope of the Urgent Care Centre at the front of the hospital. The proposal is to develop an Urgent Care Model that aims to improve patient outcomes and experience, through speedy clinical resolution of care, and minimising inappropriate investigations and admissions, building on the existing model. The achievement and maintenance of the A&E 4-hour standard is seen as an indicator of urgent care performance across all providers and not only as an indicator of quality in A&E. Urgent care performance is monitored by the CCG and also by the Area Team. The CCG is leading a whole system wide resilience and escalation plan, to respond to operational difficulties across our health system at times of pressure, for example during winter this year, we dealt with delayed transfers of care from hospital, waiting times in accident and emergency, ambulance delays, medical outliers, unplanned ward or home closures and the need for escalated beds. The key elements of the escalation plan will seek to ensure: Clear identification of the need for escalation of service provision Key organisational triggers and contacts Potential risks have been identified and contingencies have been put in place Provision of high quality patient services are maintained through periods of pressure The service maintains satisfactory performance levels throughout pressure periods Processes are in place to meet the reporting requirements of Boards and Governing Bodies. 32

58 A clear communication plan is in place to support the escalation plan informing service providers, public and patients of necessary changes to service. The escalation plan will bring together the seasonal plans for all organisations. It will be based on best practice from existing updated plans taking in to account the change of ownership to CCGs. The CCG will ensure that the seasonal planning process is integrated with other CCGs, where appropriate, ensuring that important local operational relationships are maintained. Our plans for ambulatory care (care delivered on an outpatient basis) include: Establish ambulatory care assessment clinics across the top 10 identified conditions to ensure one-stop rapid assessment and treatment as an alternative to hospital admission. Crisis response services and alternatives to hospital admission A range of initiatives have been developed giving GPs access to beds in residential care, Increased ability to spot purchase additional intermediate care beds. In collaboration with all our providers, improvements to the current service will cover a range of opportunities including: Pick-up after falls where previously an ambulance would have attended A re-ablement service that will deliver crisis response 24/7 Extension of the current Rapid Response Service / telephone access to consultants for both primary and secondary care Mental Health Commissioning and provider organisations are collaborating to provide integrated physical and mental health provision. This approach to integration has prioritised 3 key themes: shifting settings of care better adherence to care plans for people with long term conditions better mental health treatment in acute hospitals. Across the three themes, the focus of the approach is to improve patients mental and physical health, reducing the reliance on inpatient care and promoting primary and self-care. Locally the CCG, in collaboration with Lancashire Teaching Hospitals and Lancashire Care, are introducing a model of care that, for example, includes a 24/7 psychiatric liaison service, which will enable better identification and treatment of mental health in A&E and on hospital wards. Through better identification and treatment times, patients will be enabled to access the appropriate care pathways more quickly. 33

59 As well as this initiative, we are focusing the commissioning arrangements on improved access and treatment for people with mental health issues. Across the national mental health performance indicators, delivery of Improving Access to Psychological Therapies (IAPT) is variable in terms of referrals into the service against prevalence. IAPT was established in 2006 and as a result, significant gains have been made in terms of increasing the availability of evidence-based therapeutic interventions for people with common mental health problems. We are working with Lancashire Care Foundation Trust to review the current service provision and to identify future patient needs. The aim of this review is to provide equitable, efficient, evidence based collaborative primary care mental health service that adopt a recovery based and personalised approach to enable patient to achieve their optimum level of health and wellbeing and in which patients are central to and active participants in their care. The service aims to be innovative, in maximising service delivery, forging links and partnerships with existing community assets. These include third sector providers, volunteers and independent organisations. Dementia Dementia is a key priority for the CCG. Dementia will affect more people and their families in the future; people with dementia have lots of complex needs and often have physical health problems too. There is no cure for dementia, but with better treatment, early diagnosis and support for people and their families they will have a better quality of life. People with dementia are disproportionate users of some of the highest cost elements of the health and social care system (nursing and residential care, acute services). A radical and targeted approach to reviewing services and supporting people with dementia is needed as there is going to be a significant population change. The demographic change over the next years will impact enormously on the numbers of people projected to have dementia across the area. The table below details the impact of this locally: Projected increase in the numbers of people with dementia to % difference England 607, , , , % Chorley 1,124 1,270 1,560 1, % Preston 1,281 1,374 1,525 1, % South Ribble 1,262 1,446 1,675 1, % 34

60 In addition to the significant increase in the number of people with dementia, the current level of diagnosis across Greater Preston is currently only at 49%. This means that approximately 1,200 patients may not be receiving the treatment they need as diagnosis is critical in giving access to treatment, support and appropriate pathways of care. Lancashire Care foundation trust recently undertook a full public consultation on Dementia services within Lancashire. The outcome of this consultation has now been published. The key actions the CCG now need to take forward are: CCG and local authority commissioners work in partnership with LCFT to undertake a technical appraisal of the options for the specialist dementia unit location CCG and local authority commissioners develop solutions to the access and travel issues raised in the consultation and ensure that these are put in place at an appropriate level, to meet need before the dementia inpatient unit is open CCG and local authority commissioners work with LCFT to address the critical issues and concerns that were raised during the consultation, with particular regard to supporting people and families living with dementia across the whole care pathway and ensuring appropriate access to memory assessment services, before the dementia inpatient unit is open. The CCGs work programme for dementia includes: Primary Care Deliver an in-reach model of Memory Assessment Services to Primary Care settings this will mean that GPs will provide this element of the pathway delivered within your local GP surgery. Supported by Dementia Liaison Advisors provided by the Alzheimer's Society within practices. Support for families and carers help with planning care, holding difficult conversations and end of life planning. Care Home Liaison and Intermediate Care Teams Improving Care Home Liaison and crisis response through Intermediate Support Teams with significant investment. Improving and enhancing current team capacity. Reducing the level of prescribing where possible. Improving the quality of care within a nursing and care home setting. Improving the response to community carers at risk of reaching a breaking point in their ability to deliver on-going support. Reducing admissions to secondary acute services and long term care support by sustaining people within their current homes. 35

61 Hospital Liaison Services Improving specialist support for staff and patients in hospital. Ensuring community services are in place to address needs once discharged. Reduced re-admissions to hospital. As a result of the Dementia programme we expect improvement in the following: Improved cognitive function, Reduced incidence of stroke, Reduced length of stay when patients are admitted to secondary care, Lower admissions and re-admissions to secondary care, both specialist and general acute services, Reduced or delayed reliance on long term care support. 36

62 CCG PRIORITIES FOR 2013/14 We believe that we will have the greatest impact on health and reducing health inequalities by focusing on three clinical areas that are outlined below. This judgement is based on our local Joint Strategic Needs Assessment, the views of local GPs and other senior clinicians and the responses we have received from the general public and local community groups. We have chosen the following areas of focus which we believe will have the greatest impact on health, health inequalities and quality of services that link to our strategic objectives. The following section describes why these themes have been prioritised and outlines how these areas will be addressed in our plan. By focusing on these areas during the CCG expect to see: Reduced admissions activity to hospital by avoiding unnecessary admissions (all age) by 10%; Reduced lengths of stay in hospital (where appropriate all age) by 2 days; Reduced levels in non-elective activity (where appropriate all age) by 5%; Reduction in elective care by 5% Provision of quality services that are patient focussed but offer value for money in primary, community and secondary care (all age). Reducing inappropriate admission The CCG needs to avoid in appropriate admissions to hospital in order to enable the most sick and needy to have that facility available to them when needed. Long term conditions The CCG needs to ensure that those which chronic long term conditions are supported appropriately and effectively and that their carers get the support they need to ensure as good a quality of life that can be expected (we include Dementia within this priority) Diagnostics The CCG needs access to diagnostic tests and results available in a timely manner and to be of high quality. CCGs have been invited to nominate three local priority areas for improvement in outcomes by the NHS Commissioning board. Achievement of measureable improvement in these areas will form part of the payment to the CCG under the quality premium incentive scheme. The CCG has prioritised areas that reflect the key priorities laid out in its plan. In this way, the CCG will remain focused on a few key priorities in year one. 37

63 Greater Preston has therefore, nominated the following measures under each of the priorities of Admission avoidance, Long term condition and Diagnostics. This section outlines the case for change for each of these priorities and what we plan to deliver in 2013/14. The case for change Reducing inappropriate and unnecessary admission to hospital If the CCG is to realise its ambition in the medium to long term to deliver care closer to home we need to understand the reasons for admission to hospital and start the work now on changing how we deliver care safely and effectively in alternative settings. The aims of this priority are to: reduce over reliance on the secondary sector, improve support in the community for those who would benefit from care closer to home (this links to the long term conditions programme). understand the reasons for and take action on the relative high rate of planned admission to hospital for the residents of Greater Preston. This will necessitate a review of the evidence base for treatment, implementing the appropriate care pathway; including prevention, having access to the right diagnostic services, onward referral criteria and admission thresholds for individual specialties. It will also include the need for responsive aftercare, medication, treatment and support options. 10% The target percentage reduction in unplanned hospitalisation for asthma, diabetes and epilepsy in Under 19s Specific target Outcome indicator Unplanned hospitalisation for asthma, diabetes and epilepsy in Under 19s. We will measure this priority by the reduction in the numbers of unplanned hospital admissions during 2013/14. Delivery will be through a specific project aimed at improving the hospital / community interface and supporting these patients at home wherever possible. This priority area links to the recently published national pledge on improving health outcomes for children and young people 2. Specifically, ambition four states: Services will be integrated and care will be coordinated around the individual, with an optimal experience of transition to adult services for those young people who require on-going health and care in adult life. 2 Better health outcomes for children and young people, NHS Commissioning Board and other national bodies (Academy of Medical Royal Colleges, Faculty of Public Health, CQC, RCN et al February

64 Evidence so far suggests that the CCG presently relies on a model of care that places a lot of reliance on the hospitalisation. This evidence for this is set out below. The CCG has one of the highest rates of admissions in the country for planned care particularly general surgery and orthopaedics. Elective admission rates The chart shows the range of total elective (ordinary and daycase) admission rates per 1,000 population for CCGs across England (in blue). The rate for this CCG is in red and other CCGs in its ONS cluster are shown in yellow. The rates are standardised for age and sex. The chart shows that in 2011 this CCG had 166 elective admissions per 1,000 population compared to a median of 116 in its ONS cluster and the national average of 123. When you also consider the cost of this activity, it becomes an obvious place for the CCG to review to realise significant opportunities to invest in alternative care pathways. The table on the right shows that there appears to be significant opportunity to reinvest resources in primary and community services, with potentially up to 7,844 more admissions than the England average in Further analysis of this activity needs to be completed to understand fully our pathways and the opportunities to change treatment options. 39

65 The work programme to support this priority for 2013/14 is as follows: Use of a referral gateway including triage and tier 2 services; Development of a speciality review project team and revised orthopaedic pathways and independent review of tier 2, assessment and treatment centre (ATC) and clinical assessment services Continued practice peer review of referrals; Referral audit Development of tier 2 services, such as neurology and gynaecology Procurement of an ENT service Improved access and reporting times for diagnostics. It can be seen from the above list that many of our programmes of work interlink as for example a key improvement area that will improve our performance in admissions avoidance is access to diagnostics. Improved access to diagnostics will also benefit the Long term conditions programme and in the longer term support care closer to home. Admission avoidance is an agreed priority with our main providers via the Clinical Senate. The Clinical Senate is a forum where all these parties come together and focus on achieving benefits for patients. Long term conditions The phrase Long Term Conditions is used to describe those patients who have illnesses that require consistent and appropriate support to manage their condition over time. They often have complex needs and require a range of support. In the past many of these patients would have simply been admitted to hospital for stabilisation / management of their illness when they have an exacerbation of their condition or something triggers an acute phase of their illness. A national GP survey between April 2010 and March 2011 identified that 46% of Preston, Chorley and South Ribble residents who responded reported having a long standing health problem, disability or infirmity. (Source: NHS Information Centre). Locally, demographic projections indicate a 65% rise in the number of people over 65 by 2035, with a projected 172% increase in the age 85+ population as shown in the chart below. Population projections in the 65+ age group in Preston, Chorley and South Ribble 40

66 There is evidence that hospitalisation of these patients is not always the best for them, nor is it necessarily the best use of resources. The work by the national team on Long Term Conditions led by Sir John Oldham identified three main areas to focus on: Risk stratification of patients Developing integrated health and social care teams Encouraging and supporting self-care The CCG has a significant number of residents living with long-term conditions such as diabetes, hypertension, COPD, coronary heart disease and asthma. One of Greater Preston s priorities is managing long-term conditions to extend both the quality of life and reduce health inequalities for the local population. The aims of this priority area are: To develop a single point of access to acute and community care for patients with long term conditions To oversee the implementation of a risk stratification model within GP practices To implement a wide range of self-care and self-management resources To implement integrated health and social care neighbourhood teams To review and remodel rehabilitation provision across the health and social care economy Integrating care is arguably the most important change that will happen in Greater Preston in the next three years. The CCG will support the development and extension of the current Integrated Care Model. In 2012/13 the CCG agreed an outline model of integrated care and case management as part of the Long Term Conditions improvement programme across all partners including the local authority. The work programme for long term conditions is organised to enable local geographic areas to implement an evidence based system of community based services to support patients. The programme is designed to facilitate and enable local health economy teams to deliver change at pace, in a measured and supported way. There are a number of specific conditions such as diabetes, dementia, mental health and end of life where we have singled out for special attention but are included in the overall work programme, the details of these are outlined below. The Long Term Conditions programme is generic in approach; key elements of the programme are as follows: Risk Profiling The concept of identifying at-risk patients is to enable primary care teams to plan interventions to minimise and/or prevent emergency admissions. Identifying those at risk helps to identify patients quickly and to focus on and prevent deterioration of their conditions (which could result in an emergency admission). It is also anticipated that targeting help to those at the lower end of the risk stratified 41

67 population may prevent further deterioration in their health, improving both quality and quantity of life, and reduce some of the current inequalities in health presently seen across the Greater Preston area. In identifying the patients at high risk, our aspiration is that the patient s quality of care is enhanced, their experience of services is improved, and their health does not deteriorate to such a point that they need to be admitted to hospital. The CCG has commissioned a software tool called RAIDR to support the identification of patients which has a risk stratification dashboard and incorporates the LACE tool, which is the element of the software that is used to identify patients who are also at risk of readmission to hospital. Shared decision making and self-care The CCG is implementing a shared decision making model to establish and enhance the relationship between clinicians and patients and to change the consultation experience so that both parties share knowledge and expertise as equal partners. This allows patients and their clinician to reach informed decisions about care and treatment, including the choice to manage their health themselves through selfmanagement Integrated Neighbourhood Care Teams We are working in partnership with all out providers to develop extended community teams which will provide multi-disciplinary, integrated and streamlined care closer to a patient s home. They will offer a comprehensive and pro-active case management support service on a 24/7 basis. The aim of the teams is provide support in the community reducing the need for emergency admission to hospital when this is not required. It will also enable patient to be discharged from hospital as soon as they are medically fit, increase rehabilitation provision and enable patients to manage their conditions in their own homes. The teams will have close links with social services and share boundaries with social services care management teams, facilitating joined up care. The teams will be aligned to local GP practices and work closely with primary care. They are also supported by more specialist teams who work across the patch such as the respiratory team and specialist therapists. Rehabilitation Locally we recognise that excellent rehabilitation services can significantly improve patient outcomes, speed up hospital discharge and reduce re-admission rates, thus contributing to the more efficient use of NHS resources. We do not currently have a comprehensive picture of the range, cost and availability of services across our health economy. Surgeons, physicians, nurses, therapists, social workers and others often fail to recognise their own roles as agents of rehabilitation, despite their crucial importance in securing good rehabilitation outcomes. Our services are not joined up meaning patients do not always receive timely, coordinated and sustained interventions to maximise their rehabilitation. 42

68 As part of the Long Term Condition Programme we have set up a local programme to review all our rehabilitation facilities including step up / step down care as well as our local community hospitals. Anticipated benefits and outcomes: Improved quality of end of life care in acute hospitals and community settings Prevention of inappropriate acute hospital admissions of care home residents in the last 12 months of life Reduction in unplanned admissions in the last 12 months of life Reduction in hospital bed day usage in the last 12 months of life Reduction in inappropriate tests and interventions Prevention of inappropriate hospital deaths Delivery of patient choice at end of life Increase in the number of individuals able to die in their usual place of residence Improve skills of health and social care workforce Increase in the number of patients on GP supportive care registers Increase in the number of patients on the pathway improving care in the last days of life Improvement in communication between primary and secondary care regarding patients approaching the end of life Improved communication to support transfers between care sectors Improved supported for families and carers to care for relatives in community settings Improved quality of services Integration of health and social care services for End of Life services The importance of support for carers Carers have told us that it is important to them to be and feel included in our plans and we are committed to implementing the four priority areas identified by the Government s Carers Strategy Refresh (2010), 'Recognised, Valued and Supported'. We are committed to ensuring that carers in Greater Preston: Are identified and recognised Supporting those with caring responsibilities to identify themselves as carers at an early stage, recognising the value of their contribution and involving them from the outset both in designing local care provision and in planning individual care packages. Realise and release their potential Enabling those with caring responsibilities to fulfil their educational and employment potential Have a life outside of caring Personalised support both for carers and those they support, enabling them to have a family and community life Are supported to stay healthy Supporting carers to remain mentally and physically well 43

69 Diabetes Across the CCGs we will undertake a redesign of diabetes services to enable us to provide an excellent standard of care closer to home and ensure that we have a service fit for the future given that the diabetes population is set to rise from 4.86% to 5.88% in The service redesign will be via a new local enhanced scheme with primary care that will ensure patients are seen by the most appropriate person in the most appropriate place. By April 2014, GP practices across the CCGs will be working towards treating all but the most complex patients in primary care. Patients will have access to a truly seamless service. Blood tests, retinal screening and podiatry will all be available in primary care together with insulin management, so patients will not have to wait for multiple outpatient appointments. The specialist team of consultants and diabetes specialist nurses will be advising and supporting practices so any concerns about a patient s condition can be dealt with quickly. This will reduce the number of hospital referrals freeing up specialists to be able to see those patients that need to see a consultant or specialist nurse more quickly. Evidence shows this will improve access to specialist services. The additional benefits are that it improves the skills of both primary and specialist care clinicians. As for patients it will mean you can receive ongoing routine treatment in the community quickly when needed, improve outcomes and should also: End of Life Improve communication between primary and secondary care Reduce waiting times for access to routine and specialist treatment Provide additional services such as care planning and structured education to improve quality of life Give equitable access across the CCG to highly skilled professionals Improve quality of diabetes care in all GP practices with support from the specialist teams. End of life care is delivered in all care settings, across both health and social care by a multidisciplinary range of professionals, support workers, families, carers, friends and volunteers. In order to support individuals at the end of life to achieve a good death in the place of their choice all parts of the health and social care system need to communicate well, have a consistent language and understanding of death and dying, and have the necessary confidence and expertise to deliver high quality end of life care. We know many patients die in hospital not their usual place of residence or where they chose to be at the end of life. The aims of this priority area are as follows: Improved quality of end of life care in acute hospitals and community settings Prevention of inappropriate acute hospital admissions of care home residents in the last 12 months of life Reduction in unplanned admissions in the last 12 months of life Reduction in inappropriate hospital bed day usage in the last 12 months of life 44

70 Reduction in inappropriate tests and interventions Prevention of inappropriate hospital deaths Delivery of patient choice at end of life Increase in the number of individuals able to die in their usual place of residence Improve skills of health and social care workforce Increase in the number of patients on GP supportive care registers Improvement in communication with patients and their families as well as between primary and secondary care regarding patients approaching the end of life Improved communication to support transfers between care sectors Improved support for families and carers to care for relatives in community settings Improved quality of services Integration of health and social care services for End of Life services The CCG believes that improvement in peoples experience of end of life care can only be systematically delivered if all constituent parts of the health and social care system are communicating well with each other. It is also important that the patient, their carers and families understand and respect the wishes of their loved ones, friends and relatives and accept their patients preferences, are confident and competent to play their part in improving end of life care and understand the fundamental elements of what constitutes quality end of life care and a good death. The CCG is working with its health and social care partners to implement an End of Life strategy to support the work required to deliver the above. The strategy outlines how we will continue to work and support current projects that are already making significant progress in the quality of end of life care and also identifies new initiatives that will further enhance the quality of our services for both patients and their carers. The CCGs End of Life work programme includes the following: Dementia The Six Steps Programme providing education to staff of care/nursing homes Development of 24/7 community palliative care nurses Development of an End of Life CQUIN with our main acute provide Lancashire Teaching Hospitals Foundation Trust to include the Gold Standards Framework (GSF) and Advance Care Planning (ACP) Development of GP Champions Whilst we have described some of what we are doing to improve Dementia services in section 6 above, more detail in respect of the CCGs work programme for Dementia is described here. We want to build on the on-going work currently being undertaken across health & social care to re-shape services. This will be in line with the 17 objectives within the National Dementia Strategy Living Well with Dementia (DH 2009). We know dementia will affect more people and their families in the future; people with dementia have lots of complex needs and often have physical health problems 45

71 too. We know that there is no cure for dementia, but with better treatment and support people and their families we can improve the will have a better quality of life of people with dementia, their families and carers. The aims of the dementia programme are: Improving public and professional awareness and understanding of dementia; Good quality information for those diagnosed with dementia and their carers; Enable easy access to care, support and advice following diagnosis; Development of structured peer support and learning networks; Improved quality of care for people with dementia both in community service provision and in general hospitals; Delivering comprehensive hospital liaison services The appropriate use of antipsychotic medication for people with dementia. The Time for Action report makes several recommendations, mainly that people with dementia should receive antipsychotics only when they really need them, and that reducing their use in this group should be a priority for the NHS. Closing the diagnosis gap, initiating treatment, training for carers and people with dementia and on-going support post diagnosis Improving the infrastructure of care home liaison Improving crisis response to people with dementia Working with voluntary and community groups to provide services to support The anticipated outcomes include: Delay or avoid admission to long term care support Reduce the incidence of stroke Improve cognitive function Reduce length of stay when people are admitted to secondary care The CCG work programme for dementia includes: Delivery of an in-reach model of Memory Assessment Services to Primary Care settings this will mean that your GPs will provide this element of the pathway delivered within your local GP surgery Supported by Dementia Liaison Advisors provided by the Alzheimer's Society within practice Support for Families and carers help with planning care/difficult conversations/end of life planning Improving Care Home Liaison and crisis response through Intermediate Support Teams with significant investment Increasing the current capacity Reviewing the level of prescribing Improving the quality of care within nursing and care home setting Improving the support to community carers at risk of reaching a breaking point Reducing admissions to secondary acute services by providing long term care support and sustaining people to remain within a familiar environment 46

72 The CCG has proposed the following improvement trajectory to cover the next two years as shown in the table to the right. The CCG has believes that dementia and its effect on individuals, their families and the community at large is so important, it has nominated dementia as one of its local priority areas. As a consequence we have to nominate a second improvement measure for this illness to have it qualify as a measure for the CCG Quality Premium payment. The second measure nominated is to reduce length of stay in hospital for patients with the primary diagnosis of dementia (down by 0.9 days from just over 13 days). Such an improvement will have a positive impact on the patient and their family as well as help the CCG to progress its priority to reduce reliance on hospital beds for care. This is especially so during winter when the need to more access to medical beds is required, The CCG will work with all providers to reduce medical outliers, length of stay, improve bed utilisation and work with patient and families to be able to be confident and informed about the best place for loved ones to be cared for. Specific target Outcome indicator 2 - Health related quality of life for people with long term conditions. The indicator we will use to measure progress is to reduce hospital length of stay by 0.9 days from its current level of just over 13 days. This is addition to the national target to improve the rate of diagnosis of dementia. Any reduction in hospital length of stay will only be achieved by the whole health economy working together. We believe the approach we have adopted will ensure improvements in care for patients with dementia, by ensuring more support in the community, proactive support in residential care and when in hospital, support and advice for carers. Our investment in this project will impact on the whole dementia pathway. Improvements in access to Psychological therapies (IAPT) A second national priority and an area we are currently implementing with Lancashire care Foundation Trust is Improving Access to Psychological Therapies (IAPT). An enhanced IAPT service has been commissioned by the CCG in 2012/13. Currently the workforce is in training that will continue until October Full service roll-out, with a fully trained staffing compliment is expected by April 2014 when a substantial increase in activity is expected in terms of access rates. 47

73 The CCG currently experiences long waiting times for this service. The service specification is currently being redesigned in order to improve waiting times and linking into community and third sector organisations. Further work is planned to ensure appropriate psychological therapy provision for people with co-morbidities of mental health and long-term conditions. This will be an integral part of the local IAPT provision and Integrated Teams. Our plan is to achieve as a minimum, the access rate set out below during the coming year: Greater Preston Access rates to psychological therapies 2013/14 The number of people The number of people who have who receive psychological depression and / or anxiety disorders (local therapies estimate based on Psychiatric Morbidity Survey) Proportion % Diagnostics Presently, whilst waiting time targets for diagnostics are generally met, there is scope for improvement in the timeliness and quality of the reports on these tests. Any improvement in the time to turn reports around will reduce anxiety for patients and thereby improve the patient experience of local services. Diagnostic reports are vital to ensure high clinical quality as the earlier the diagnosis, the more chance there is of starting treatment to affect the cause of the illness. In many cases earlier intervention can lead to a further reduction in those needing to be admitted to hospital. The NHS Commissioning Board has asked acute providers to implement 7 day working for diagnostics during In that respect our programme of work will align well with that being undertaken by our main provider, Lancashire Teaching Hospitals Foundation Trust. The aims for this priority are: To increase the range of direct access diagnostic tests available to primary care teams To improve the timeliness of reporting of all diagnostic tests To instigate a programme to develop increased primary care direct access to diagnostic tests The CCG is interested in improving diagnostic utilisation on specific patient pathways and have already secured direct access diagnostic testing in a number of therapeutic areas for example, MRI scans for knees. Plans will be developed to consider and prioritise tests for care pathways being developed in the long term condition management programme. Improvements in 48

74 diagnostic access and the patients pathway for diagnostic treatment in hospital have the potential to secure significant improvements in quality and patient experience. Access to appropriate diagnostics when required, rather than when it is next available is a key contributor to improving the quality of care and outcomes for patients. There is a national requirement of 6 weeks from time of referral to the test taking place. However it is appreciated that the majority of tests take place within a matter of weeks. The CCG recognises that it is equally important for a review of the results to be undertaken in a timely manner, actions taken as soon as possible and results being shared with appropriate clinicians (general practitioner) in a timely fashion. It is for this reason that the CCG has decided to develop a local improvement priority as part of the CQUIN measures on: improving the time from when the test is undertaken to it being reviewed improving the time from the review to the results being sent to the patients GP Wider GP engagement will be necessary in order to define the scope and prioritised tests/scans for the diagnostics programme. It may be possible to identify a number of quick wins that can be secured in-year via contract variations, whilst working on larger changes that will be negotiated as part of the 2014/15 contracts. The work programme priorities are set out in the table below: Programme phases Timescales Outline business case April 2013 Project governance April 2013 Project management April 2013 Stakeholder engagement March July 2013 Service specification End Aug 2013 Commissioning intentions Mid Sep 2013 Develop procurement strategy if required End Sep 2013 (parallel process with negotiations with local provider) Negotiation with local provider Mid Sep end Oct 2013 Market sounding - if required By end Sep 2013 Contract agreement Feb-Mar 2014 New services go live April 2014 The CCG anticipate delivery of the following outcomes: Ensure a high quality, safe and compliant service Improve effectiveness and timeliness of services Improve the experience of diagnostic services for patients Improve affordability Improve value for money Minimise complexity of operation (for stakeholders) 49

75 REBALANCING THE HEALTH ECONOMY The key principle underpinning strategy of the CCG is utilising its resources in the most effective and efficient manner. There is evidence that compared to other CCGs we spend more in the secondary sector and subsequently less on community and primary care. In effect, we are presently reliant on a comparatively expensive mode of care where admission to hospital appears more the norm than in other parts of the country. The evidence takes into account the relative deprivation and age structure of the population, by comparing the CCG with similar CCGs in terms of socio-economic groupings across the country. The following two charts, for example, show the position for Greater Preston with regard to elective admission rates and access rates by specialty. On both, we are a significant outlier particularly in some specialties. Elective Admissions 2011/12 Greater Preston Elective Admissions 2011/12 Greater Preston 50

76 The cost of this apparent misbalance can be seen in the table to the left. This shows the excess cost to the whole health economy of when compared to the average cost across England. The whole health economy figures have been included as both Greater Preston CCG and Chorley & South Ribble CCG use the same acute providers for the majority of their acute care. (Lancashire Teaching Hospitals Foundation Trust and Ramsey). At the same time, the demographics are changing and over the next few years the proportion of elderly will increase and this will bring pressures on the hospital system unless the work defined in our priority areas for the coming year, admissions avoidance, long term conditions and diagnostics is undertaken. Working to reduce elective admissions A number of initiatives will be implemented this year with the aim of putting sustainable pathways in place to safely reduce the level of elective admissions. These include: Orthopaedics review aimed at improving Tier 2 / ATC and extended scope physiotherapy (ESP) services. A clinical consultant-led review covering all admissions (elective and non-elective) referred by GPs or others, for trauma or orthopaedic procedures and treatments aimed at reducing the reliance on hospital-based interventions. Report Analysis and Intelligence Delivering Results (RAIDR) System. Identification and case management of patients. Integrated Referral Gateway. Streamlining referrals through a standardised pathway management system. GPs with special interests (GPwSI). Primary care based specialists triaging referrals and treating patients who may otherwise be admitted into secondary care. Dementia - improving care home liaison and crisis response through Intermediate Support teams. Teams delivering care home liaison and intermediate support (intensive, crisis response) - shift from hospital to community based delivery of services. Key outcomes include: - improving the quality of care within nursing and care home settings through case-related advice, training and support on improved approaches for people with dementia. - reducing admissions to secondary acute services and long term care support by sustaining people within their current homes. 51

77 The CCG will also be investigating and analysing why there is a significant difference in the patient reported outcomes for hip, knee and groin operations. The CCG is in the lower quartile of its cohort. This will take place early in the year with an action plan agreed with our providers in place by the end of June Linked to this priority is the work that is to be undertaken developing a clinical strategy for Lancashire. The CCGs across Lancashire have agreed to work with the Area Team of the NHS Commissioning Board to realise this development during the 2013/14 Locally, there will be a need to bring several strands of important work together to achieve the production of a strategy that starts to articulate the need for change across the health economy to meet the needs of our population in the future. The CCG recognises the need for the following sub strategies: primary care strategy urgent care strategy (as described above) secondary care strategy (linked to the Lancashire wide clinical strategy) Engagement with Local Authorities and voluntary sector and their contribution to improving health and well being Any proposals to rebalance the health economy will lead to significant service change. The CCG will therefore need to ensure that it fulfils its duties with regard to engagement and consultation. Whilst there is a duty to engage and consult the CCG wants to talk to the public, patients and their families about their expectations and needs for health care in the future and what any potential changes might mean for them. Public engagement will be at the heart of what the CCG does and we are committed to innovative approaches to helping with our engagement activities. Primary Care Greater Preston primary care services have achieved much over the last few years; the CCG want to build on these successes. We recognise that as a CCG our success is dependent on our ability to transform primary care, increasing capacity. This is because a key requirement of the CCG success is the ability to move care out of the acute hospital setting. Within this year we plan to describe a major programme of transformational change which will require commitment and/or investment by all parties involved in the commissioning and delivery of primary health care services. Its aim is to improve quality, capability and productivity further, and to create capacity within primary care. Going forward our plan is to engage with the member practices to understand what is required of primary care through the CCG core business, and how we can strengthen inter-practice relationships. We recognise there is an opportunity for practices to start to work together to reshape their own business. Our vision for GP practices and other primary care services is that they will work more in a federated, networked model of primary care, enabling all of the Greater Preston population to have a similar range and quality of service. 52

78 As the demands on general practice increase we need to plan for the future to create a long- term, dynamic foundation on which to grow and build to ensure we keep the best attributes of local general practice whilst demonstrating the best attributes of a sustainable primary care. Key developments this year. Productive General Practice (PGP) Improving general practice productivity will help GPs to continue to deliver high quality care whilst meeting increasing levels of demand and expectations. PGP offers an opportunity for practices to release time, improve quality and cut costs at the same time. NHS IQ have commissioned accredited delivery partners to offer the product nationally; it consists of a license and assisted implementation Programme to ensure GPs have the right support to make the changes to their practice working. The CCG wants to invest in GP practice productivity and hopes to maximise the benefits of any investment by using a phased approach to implementation with practices at a locality level, thereby enabling them to share better practice across the locality at the same time as looking closely, and on an individual basis, at their individual processes and productivity. RAIDR All GPs have the RAIDR software available to them. The CCG now wants to ensure GPs gain the maximum use of the system and will support data analysts to work with GPs to extract and interpret the data available from the system. It is expected that this will lead to better informed GP practices. With a clearer understanding of pathways, referral rates and patient profiles the CCG can work with GPs to achieve improvements in: Demand management Effective management of patients with LTCs and co-morbidities Patient care Peer review process Practice engagement The Integrated Referral Gateway The integrated referral gateway is a decision support system that assists GPs to standardise referrals. Roll out of the system commenced at the beginning of March 2013 and is being carried out on a practice by practice basis. Clinical feedback to date has been consistently positive; it is quicker and easier to triage within the integrated referral gateway than previous ways of working Dr Bob Bennett Practices are currently able to refer Tier 2 service and hospital referrals through the gateway. Going forward, urgent referrals as well as community service referrals will go through the gateway to further streamline the referral process for practices. 53

79 Development of Integrated Neighbour Teams As part of the Long Term Conditions programme, the CCG will be developing integrated neighbourhood teams (INTs). This is discussed in more detail in the section on Long Term Conditions. Many people who receive both health and social care support have to cope with several sets of professionals coming to see them, asking similar questions and assessing them for many of the same conditions and problems. Most of these people are living with one or more long term condition and many are elderly. In some parts of the country health and social care teams have begun to work together in a more integrated way. They have found that this more streamlined, joined-up approach often results in services which patients and carers say are better for them and fewer people ending up in hospital or in long term residential care. Our ambition is to have integrated health and social care teams covering our CCG by It is envisaged that these teams will provide community services such as podiatry, phlebotomy and physiotherapy. GP Education & Training The CCG has developed a twelve month programme of Protected Education Time (PET) events. This programme covers a wide range of learning workshops and is offered to all GP membership practices. The CCG has established peer group meetings at which GPs work with their peers to develop understanding and share best practice on a range of current issues. A full timetable of scheduled meetings has been agreed by the membership. Practice Indicative Budgets For a number of years, GPs have had financial responsibility for their own prescribing budgets. Building on the learning from this, we will work with GP practices to identify services that GPs could be responsible for commissioning locally, to ensure high quality and improved outcomes for their patients. Dementia support The CCG is developing plans for a local dementia service within GP surgeries to deliver quality dementia care to our residents. This service will ensure delivery of earlier and improved diagnosis rates and improved post diagnostic support and reviews. Quality dementia care is a national and local priority and GPs have a crucial role in ensuring their early concerns about memory problems are detected and responded to, and not mis-attributed to the symptoms of old age, and also that early signs of young-onset dementia (people under 65) are recognised. Currently a local dementia shared care pathway is being developed to describe partnership working between GPs and Lancashire Care Foundation Trust. Its implementation will ensure every dementia patient within the CCG locality will 54

80 receive the same level of care regarding assessment, diagnosis, medication management and disease management from their GP practice. GP locum support To support and enable GP practices to deliver against the CCG priorities, we are developing a business case to provide a pool of GPs who can provide: locum cover to increase capacity for GPs to take on other initiatives, backfill for clinical leads, resource for 24/7 urgent care service (front ending A&E), enhanced succession planning for primary care in general, backfill to facilitate additional training opportunities to become GPwSIs, support to practices in specialist fields to level-up quality, support, analysis, training and education based on intelligence from RAIDR and the gateway, support for dementia work. The CCG expects this initiative to deliver: Reduced admissions to hospital Improved primary care quality Better succession planning GP productivity initiatives implemented faster, better. COLLABORATIVE COMMISSIONING The CCG is part of a network of 8 CCGs across Lancashire that are working together to commission services where there is a need to work collectively to commission and contract for a service which is delivered across Lancashire as a whole. It is also a mechanism for enabling greater equity of service provision across a wider geographical area. The detailed work programme for 20123/14 is presently being developed. One of the key areas linked to work to be undertaken by the collaborative commissioning team on behalf of the CCG is the commissioning of Learning Disability services. The response to the government s final report on the Winterbourne View Hospital investigation will be considered by the collaborative commissioning team to ensure we incorporate the learning from this review and transform care for those patients affected by learning disabilities. We expect to see a fundamental change across Learning Disability services and our plan for 2013 is summarised as follows: all current placements will be reviewed by 1 June 2013, and everyone inappropriately in hospital will move to community-based support as quickly as possible, and no later than 1 June 2014; by April 2014 each area will have a locally agreed joint plan to ensure high quality care and support services for all children, young people and adults 55

81 with learning disabilities or autism and mental health conditions or behaviour described as challenging, in line with the model of good care set out at Annex A; as a consequence, there will be a dramatic reduction in hospital placements for this group of people and the closure of large hospitals; a new NHS and local government-led joint improvement team, with funding from the Department of Health, will be created to lead and support this transformation; we will strengthen accountability of Boards of Directors and Managers for the safety and quality of care which their organisations provide, setting out proposals during Spring 2013 to close this gap; CQC will strengthen inspections and regulation of hospitals and care homes for this group of people. This will include unannounced inspections involving people who use services and their families, and steps to ensure that services are in line with the agreed model of care; and With the improvement team we will monitor and report on progress nationally 3. The requirements of Winterbourne review have major implications for the type of care provided to our population who have learning disabilities. As commissioners we will respond by making sure that we reflect on this report and ensure learn the lessons and incorporate this into our planning and service improvement effort. All current placements are being reviewed in line with the timeline set out above. In the medium to long term we will work with the collaborative commissioning team to ensure that we have a co-ordinated approach to Learning Disability across Lancashire. 3 Transforming Care: a national response to Winterbourne View Hospital pages

82 CONTRIBUTING ACTIVITIES THAT WILL HELP DELIVER THE CCGS PRIORITIES Organisational development The CCG is committed to the development of its services and staff so that people choose it both as a workplace and as a provider of services. Our Organisational Development (OD) Strategy sets out our plans for the management and development of our organisation and workforce over the next period. It complements the CCG s Integrated Plan and supports the achievement of our strategic objectives by ensuring our workforce is equipped with the right skills and values to be effective in the new business culture of this CCG. The development of the CCG provides an opportunity to build the necessary capacity, skills and competencies required by the new organisation together with the opportunity to access new expertise that exists in our practices whilst recognising and wishing to retain and develop many of the excellent staff from the former PCT. The CCG s OD priorities for 2013/14 can be summarised as follows: Developing our organisational capability, capacity and core competencies and culture Developing our leadership, in particular governing body and membership Delivering on key operational performance Delivering our strategic plan for a more effective model of care The priorities have been derived from the outcome of the CCG self-assessment toolkit and from issues identified as part of internal team discussions and CCG development days. The OD Strategy is designed to be a dynamic and responsive document which will be will be considered, further developed and amended on an on-going basis in light of feedback received and as a result of the learning obtained during the CCG s journey towards Authorisation and beyond. The strategy is supported by an implementation plan which articulates the key actions to be taken to achieve the priorities identified. We view 2013/14 for the CCG as an important one in which we will establish a credible organisation with the business acumen and skilled individuals working within appropriate organisational structures that meet our organisations objectives. We believe this approach has a number of advantages over other methods of service provision: We will benefit from a very experienced and technically capable team used to dealing with all aspects of the NHS and when drawn from an existing pool of talent, we will benefit from people who have a track record of successful stewardship of public resources. We will benefit from a seamless transfer of responsibilities from the PCT to the CCG with the lowest possible risk as we will have access to people who understand the historical and legacy issues that will be invaluable to the CCG as we set and start to deliver our operating, financial and performance strategies. 57

83 We will benefit from a pool of talent that understands the market issues facing the CCG and can proactively support the development, procurement and successful implementation of new clinical pathways and service redesign. We will benefit from retaining a locally based operation ensuring that there is personal contact with the GP leadership community and GPs in general on a regular basis, which will allow us to respond far more quickly to the needs of the population. We have only retained in-house those functions we consider to be core, enabling our business and operating model to be delivered in line with our design principles. A range of support services will be purchased from the Lancashire Commissioning Support Unit (LCSU), especially for those high-volume, transactional elements of work that can be undertaken more efficiently and effectively using LCSU resources and systems. Commissioning Support Discussions have been on-going throughout 2012/13 with the LCSU on which functions will be undertaken within the CCG, bought from LCSU or are a shared make or buy with other CCGs. It is crucial in 2013/14 that the CCG assures itself of the quality of all of the products and services that the CCG buys, undertakes or shares. The CCG is fully aware that it cannot devolve accountability and must ensure it is an intelligent customer of all products it is buying in from the CSU. Thus when put into the context of our overall organisational development programme we have three phases of work which re as follows: Set up : up to March Having already built the organisational structure and recruited the people, this period will focus on us building a shared sense of vision and purpose. In this phase we will also put in place some basic systems and processes, in particular, in the areas of corporate governance. Establishment : from April 2013 to March During this phase, whilst we will have filled all our posts in our core structure, we will also be reengineering certain functions, and building and developing our core capabilities. We will also be bedding in, testing and developing our systems and process, and establishing ourselves in the reformed health system. Maturity : from April 2014 onwards. During the maturity phase we will have our end state structures in place, and we will have completed a full business year cycle with our systems and processes in place. Joined up local planning The CCG is a full member of the Lancashire County Health and Wellbeing Board. It participates in the Joint Strategic Needs Assessment (JSNA) process that helps both the County Council and associated health organisations focus on what needs to improve in the local population with regard to health and social care. Initiatives 58

84 include a Long Term Conditions programme and a Dementia programme that transcend health and social care organisations. It is important that we work alongside the Health and Wellbeing Board as they are a key partner in our collective effort to improve outcomes for the population. The Health and Wellbeing Board has produced a strategy and in this it has set out four priority areas for 2013/14. They are: 1. New and expectant families Our plans around unplanned admissions for Under 19 s for asthma, diabetes and epilepsy will support this priority 2. Mental health and wellbeing Our plans on Mental Health acute services, IAPT and Dementia support this priority 3. Long term conditions (LTC) We are committed to the economy wide programme of work on LTC 4. Improve the health, wellbeing and independence of older people Three of our key programmes of work will have impact on this priority (LTC, Dementia and Diagnostics) Our plans will contribute directly to improvement in all of the above areas. In our first year as an operational CCG we will look to build on the progress already made in working with key partners to improve service delivery. Greater Preston and its partner Chorley & South Ribble CCG have combined with its two main key providers (Lancashire Teaching Hospitals FT and Lancashire Care FT) as well as the County Council to form the Clinical Senate. The aim is to work collectively to improve the quality and effectiveness of services that require partners to work together. The agenda therefore is focused mainly on areas where integration of services will bring benefits to patients. The agreed priorities for the Clinical Senate 1. Long term conditions 2. Dementia 3. Admission avoidance The programmes of work on Dementia and Long term conditions are reported regularly to the senate. 59

85 Listening to patients and increasing their participation NHS Greater Preston Clinical Commissioning Group has underlined its commitment to making patients an integral part of the health service, by placing increased emphasis on their input to the work of the CCG Our aim is to ensure that patients, public and staff are engaged with commissioning decisions at every level from the individual s involvement in his or her own care to statutory engagement through bodies such as HealthWatch. The CCG will listen to and respond to patient feedback, and continually work with providers to implement lessons learned to improve patient care and experience, and fulfil all legal duties related to Equalities and Engagement. Patients are central to the health service, and increased importance is being placed on their participation and contribution to the work carried out by Clinical Commissioning Groups through the government s health reforms. Our Clinical Commissioning Group has committed itself to closer partnership working with patients to improve commissioning, and to ensure that services meet the needs of our population. This includes distinct types of participation which are defined as patient engagement in self-management of their conditions, and patient involvement in the commissioning process. To this end, changes have already begun. We now have drafted a Patient and Public strategy and established a Participation Working Group. Improved structures have already been put in place to provide greater opportunity for patients to become involved in commissioning. This includes locality-wide patient groups, practice-level patient groups, and the opportunity to sit as lay members within working groups on developing specific clinical areas for the Clinical Commissioning Group. The CCG will develop inclusive relationships with users so that we have a clear and up-to-date understanding of the views, needs and preferences of the communities that we commission for. The national mantra of no decision about me without me applies to every aspect of the patient/professional interface, from individual treatment choices to major system redesign and commissioning of services. The CCG has appointed three lay members to the Governing Body, with one having specific responsibility for public engagement, to ensure we hear the patient voice and to ensure that the governing body receives assurance that we engage and involve the public in commissioning decisions, priorities and plans. The CCG will: 60 Engage with the public throughout the process of pathway review and or redesign Ensure good representation of the whole population when public engagement is required Provide evidence that the views of the public are included in the shaping of services and decisions

86 We encourage patients, carers and the public to champion the outcome and describe a positive experience of the services we commission The CCG will ensure more relevant data is recorded and collected to inform commissioning decisions and thereby drive improved outcomes. This will also enable better monitoring of those outcomes. The NHS number should become the primary identifier across all providers in 2013/14 to support the development of the care.data system for health and social care pathways. Clinical data will be collected from GP practices for 2013/14 to assist with outcomes evaluation. Mechanisms will be put in place to capture real time patient and carer feedback. Patient experience is seen by the CCG as a key arbiter of all NHS services. The CCG will ensure that appropriate systems are in place to capture the views and experiences of patients, service users and carers. This will include use of local and nationally coordinated patient surveys, but also a range of additional approaches or sources that are locally relevant, such as the use of real-time feedback collected at the point of care (SMS texting, Patient Experience Trackers, kiosks), use of complaints data and Patient Reported Outcome Measures (PROMS). The CCG is developing a range of population based indicators to assess local health care needs including inequalities plan and commission services work with local authorities to improve public health monitor access to, quality and outcomes of health care services Provider-based indicators to: plan and commission services monitor access to, quality and outcomes of health care services manage contracts and pay-for-performance identify poor performance and take steps to address it Ensure that there is a culture of innovation Innovation and the adoption of best practice are vital in transforming health care. The CCG is working together with partners in several key ways to ensure that it keeps a focus on innovating and adopting best practice. It is a member of the Academic Health Science Network (AHSN) for Cumbria, Cheshire, Lancashire and Merseyside and will play a key role in making it a success as patients will benefit from the research, knowledge and role the AHSN can play in improving health locally. Medicines management input to the CCG will be provided by CSU. The offer includes production of a horizon scanning document to support a systematic process to track NICE Technology Assessments and an Innovation Scorecard has been 61

87 developed. A Lancashire wide Medicines Management Board has been created that includes primary care, community care and secondary care. A key aim for them is to produce a Lancashire formulary to ensure that we have consistency across the county and improve prescribing practice through the use of a formulary. Telehealth and telecare will be considered as part of the CCG s long term conditions programme. Investment in this area will be reinforced by the need for providers to meet the pre-qualifiers for two particular CQUIN areas: digital first and 3 million lives. Both of these initiatives are highlighted in Innovation, Health and Wealth as areas in which service delivery can be transformed. We expect our providers will be able to meet these pre-qualification requirements. There is, however, some evidence emerging that telehealth and telecare may have limited effectiveness, and should be considered as supplementary to other primary care delivery methods. The CCG will closely monitor the evidence of effectiveness of tele-based services, and flex its plans to ensure it commissions them at an appropriate level. Personalised budgets Evidence from pilot work around the country and in particular in the North West of England has shown that personalised budgets for patients can have a positive impact on their life and improve their experience of care. The CCG therefore intends to build a programme of work around personalised budgets. This work will be carried out in a co-ordinated fashion with our colleagues in social care. This work will be focused initially on those patients requiring specific and specialised care packages. Our long term aim is to broaden this initiative to include other patients. Clinical Programmes The CCG has a range of clinical programmes of work. They are all aligned around our key priorities of Rebalancing the health economy, admission avoidance, long term conditions and diagnostics. At the same time, we have commenced an organisational development programme that is focused around ensuring ownership (accountability) and delivery or programmes are aligned. Our programmes of work therefore have been set out below as to whether they should be owned and managed at either: GP practice level (or cluster of GP practices) care pathway level the CCG as a whole 62

88 This model of working is demonstrated in the following diagram: The CCG will be developing this model of working (the operating model ) during 2013/14. Facilities and Estate Management Our analysis has shown that we are overly dependent upon hospital-based services, compared to similar CCGs. To allow us to move care outside of hospital and provide services to improve health and well-being in the local community, we need to develop a strategy to improve our premises and community facilities. Our vision, supported by GP practices, partner organisations and patients, is for the delivery of high quality services from local practice premises which are welcoming, with a broad range of clinical staff and facilities available to meet the needs of the local population. In the longer term we wish to provide access to a broader range of diagnostic and therapeutic services in purpose built buildings which are easily accessible and which serve as a focus for a range of community activities, not necessarily just a space for the provision of health services. Patients should be able to experience a more seamless service where the primary, secondary, voluntary sector and social care are more integrated, offering a wider range of services at a single point of contact. The services provided will support the aim of avoiding unnecessary admissions to, or attendance at, hospital or facilitate earlier discharge from hospital. During 2013/14 we will work with the Local Area Team and other partner organisations to map our current estate infrastructure and develop a long term strategy for transforming our care environment. 63

89 PRODUCTIVITY AND EFFICIENCY TRANSFORMATION PRIORITIES Greater Preston CCG is working with Chorley & South Ribble CCG to ensure there are robust financial and governance processes in place to commission services that demonstrate best value for the public purse, whilst meeting the health needs of the area. This section describes in more detail the work streams which underpin delivery of the productivity and efficiency plans. Growth has been factored into the financial plan to reflect the anticipated impact of demographic changes. However, significant progress has been made during 2012/13 to control the patient flows into, in particular, secondary healthcare settings. Activity growth is expected to slow during the year and then stabilise as alternatives to hospital admission are progressively introduced. Historic growth trends have been between 2-4% annually over the last 3 years; as explained, this is expected to slow during 2013/14. However, it is unrealistic to expect demand to slow immediately and activity will be funded non- recurrently by drawing down reserves held by the National Commissioning Board; the expected activity profile is illustrated below and the overshoot of activity is expected to cost 2.4m non-recurrently in 2013/14: Our approach to identifying a savings plan has been to adopt the model used by the National Commissioning Board in understanding technical and allocative efficiencies: 64

90 Technical cost efficiencies are achieved in provider services to maximise value for money and have four key components: Driving acute provider productivity through reducing variation in productivity Driving non-acute provider productivity, community services, mental health, learning disabilities and primary care providers Optimising supply chain procurement and reducing drug costs Estates optimisation and utilisation Allocative efficiencies are achieved by using our resource allocation to best effect through: Optimising spending across disease areas and care pathways; in particular reducing procedures of limited clinical value and targeting cost effective interventions. Ensuring compliance with standards and enforcing contracts. Shifting care into more cost effective settings through enhancing self care and chronic disease management Local health care transformation in unplanned care and shifting care from hospitals into community settings. Increased prevention interventions. As explained above, the CCGs do not have the recurrent investment funds which have been available in the past to invest in new services. The funding implications of strategic initiatives have to be identified from the following funding sources: Reducing costs in current service budgets and re-deploying resources to other health priorities where appropriate Utilising non-recurrent funds to pump prime schemes and to cover double running costs during service re-design Stopping or reducing less effective services where appropriate and redeploying the resource in to other health priorities Each service provider is expected to identify efficiency savings of 4% in 2013/14 and these funds are then available to the CCG to invest in further service development. Clinical leaders of CCGs are expected to make their own assessment of these cost improvements and be satisfied that services are safe for patients with no reduction in quality. Greater Preston CCG, working in partnership with Chorley & South Ribble CCG, will ensure through the contracting process that it has carried out a clinicallyled quality impact assessment of all cost improvement schemes undertaken by providers. In addition to the provider productivity improvements, Greater Preston CCG, and Chorley & South Ribble CCGs have a joint plan to improve commissioning efficiency by 9.2 million. Benchmarking data from many sources including, Better Care Better Value; Standard Admission Rates; Programme Budgeting, alongside audit data and other reports such as High Impact Changes in Innovation and Wealth have been used to provide evidence where these efficiency savings can be targeted. 65

91 The savings work streams support the plan priorities of rebalancing the health economy, admission avoidance, long term conditions, diagnostics and improving the quality of primary care: The delivery of the savings plan will be monitored through a robust performance framework at Governing Body level. Achievement of the savings plan is vital for both CCGs as they become statutory bodies and need to be in a strong and sustainable financial position. Greater Preston CCG has chosen the following transformational priorities which it believes will have the greatest impact on health, health inequalities and quality of services that link to our strategic objectives described earlier in this plan. Peer Review There is significant variation in referral rates, A&E attendance rates and emergency admission rates for GP practices with similar demographics across the CCG. The peer review programme has two guiding principles, firstly that the review should result in a benefit to the practice and the CCG and secondly, that this is not about blame and recognises that there are many reasons why referral and activity levels differ. The impact of the work to date has been that clinicians have learned more about each other and a culture of trust developed; and the rate of referrals growth has reduced; growth was 4% between 2010/11 and 2011/12 compared to growth of 9% in 2008/09 and 10% in 2009/10. Mental Health The CCG works closely with other CCGs across Lancashire in this area and have developed an innovative approach to integrated care in mental health. These plans have been highlighted previously in the plan, but will ensure that we are focusing the commissioning arrangements on improved access and treatment for people with mental health issues. Additionally, the national initiative on IAPT will also impact on services available to those with a mental illness. Medicines Management The CCG will further develop the long term aim of prescribing that is evidence based, best practice, rational and cost effective in order to improve clinical outcomes and patient safety within the agreed financial budget. The primary care prescribing uplift has been set at 2.4%; offset by an efficiency saving of 4.0%. 66

92 WORKFORCE Implementing the new models of care will have significant impacts on providers workforce. Changing the settings of care (centralising specialist services, localising routine medical services, integrating care between primary and secondary care) will require significant planning. There will be a wide consultation programme to ensure plans for all providers are considered as part of the whole picture. The national, regional and local priorities, and our productivity and efficiency plan and new models of care set out in this document, all have a significant impact on the providers workforce. We will be putting plans in place to implement changes such as: Understanding and delivering the training requirements to support the new models of care this is particularly relevant for those groups who will play a more central part in delivering the new models of care, such as non-medical professions and community services. New roles to support the new models of care, such as GPs with a special interest in emergency medicine, end-of-life care or gynaecology need to be further developed. This would enable a more primary care-led model of care linking in to our strategic objectives. Increasingly, there will need to be a movement of more staff from the hospital to the community to support out-of-hospital models of care. There will be a need to support staff making this transition as well as more developed career structures for community consultants in both elective and emergency care. In order to secure the delivery of the new models of care, better use of workforce incentives, including individual-level incentives linked to outcomes, need to be explored and strengthened. Workforce has been recognised as a significant enabler and our annual operating plan will begin to set out the workplace aims for some areas, such as in the planned care pathway and for primary care. Within our plans the ambition by the end of 2014/15 is to: Create integrated multi-disciplinary teams across primary, secondary and social sectors Re-skill staff to enable them to deliver the new models of care effectively Enable the community to play an oversight role and enforce consistent, high quality delivery of care Manage talent and ensure robust processes are in place for hiring, replacing, and retaining necessary skills Provide strong support for on-the-job training and development Develop the use of action learning 67

93 FINANCIAL PLANNING Allocations Each CCG receives a financial allocation for its population and has a duty to provide services in the most effective way without exceeding the available resources. As anticipated in the Integrated Commissioning Plan, it has been confirmed by the National Commissioning Board that CCGs will receive limited growth for the foreseeable future. Consequently, all future investments in healthcare improvements will need to be more than matched by corresponding reductions in expenditure through improved efficiency. The challenge for all CCGs over the coming year will be to achieve our financial duties and maintain the quality of our services whilst delivering significant cost reductions. The financial strategy underpinning this operational plan has been generated in accordance with the financial principles set out by the National Commissioning Board for 2013/14. Summary 68

94 The CCG has received a recurrent allocation (Resource Limit) of 244.9m, excluding 5.0m of Running Costs, and is planning to achieve a net surplus of 3.1m equivalent to 1% of recurrent (programme) allocation. No Quality Premium payment to the CCG has been assumed as this will not be received until 2014/15, should it be payable. The CCG Plan already meets the minimum 2% recurrent surplus target, and delivers the 1% in-year surplus requirement detailed in the national planning guidance, Everyone Counts, Planning for Patients 2013/14. In addition, following the same guidance, the CCG has set aside 2% of its recurrent funding to be spent nonrecurrently and primarily to manage system risks, such planned expenditure being subject to approval by the Lancashire Area Team. The minimum nationally mandated Contingency has been built in at the required level of 0.5% of revenue ( 1.2m). Nationally mandated planning assumptions for inflation (2.7% 5.5m) and efficiency savings (4% 6.3m) have been included, giving a net tariff adjustment (reduced costs) of -1.3%. Non-recurrent CQINN payments of 4.0m have been assumed, which are in line with national planning assumptions, but which will be ultimately dependent on agreed provider contract values, these will only be payable if core/minimum standards within the contract are achieved by the provider. In line with national requirements, and CCG principles, the CCG has identified a realistic cash-releasing cost savings plan of 4.8m for the year to support the overall delivery of longer-term cost savings targets. As a result, and due to its strong recurrent position, the CCG does not require achievement of this to deliver its required financial position. Baseline Assumptions All CCGs have received an increase in the baseline allocation of 2.3% for 2013/14. The planning assumptions, including inflation and efficiency requirements for CCGs, are set nationally by the National Commissioning Board. The CCG baseline allocations have been made by the National Commissioning Board and mirror the commissioning expenditure profile inherited by the CCGs from the former primary care trusts Hospital healthcare inflation has been agreed at a negative1.3%, net of an efficiency target of 4%. 69

95 The hospital tariff has been set to reflect the national efficiency targets. Last year an additional 2.5% of the contract value was set aside for quality and innovation schemes; this will be available again during 2013/14. The national assumption for non-hospital care is also negative 1.3%, net of an efficiency requirement of 4%; this has been applied to other budgets and the 30% marginal tariff for non-elective admissions will continue. Modelling of the coding and tariff changes resulting from the 2013/14 Payment by Results guidance indicates that the CCG will need to invest a further 1.5m (net) for all provider services on standard tariffs. However, further detailed review is on-going as provider contract negotiations continue. As in previous years, the financial regime for non-elective activity is to continue in 2013/14. The principle of keeping resources locally will be maintained, and plans have priced all activity at 100% of tariff. The 2012/13 forecast outturn assumes that nothing will need to be paid to the Area Team (NHS Commissioning Board), and that as a result of managing coding changes together with accurate contracted thresholds, it is not anticipated that anything will be paid over in 2013/14. Expenditure Profile 70

96 2013/14 Investments 1. Admissions Avoidance The plan provides for on-going development and support of the Integrated Referral Gateway and the RAIDR systems across both Greater Preston and Chorley and South Ribble. Initial investment was made in both projects in 2012/13, to cover capital costs and physical implementation. Further funding this year will see the development of those systems to ensure full benefits are achieved. 2. Primary Care Initiatives The plan assumes both Greater Preston & Chorley & South Ribble CCGs will seek to pool as much financial risk as possible. However, it also envisages investment at a local level to address key local priorities in community and primary care services. At this stage of the planning process it is difficult to assess the exact cost of these local initiatives. The financial plan sets aside 1 million for Greater Preston. 71

97 3. Winter Planning Urgent Care A winter plan for 2013/14 has been developed and a reserve of 1.1million has been set aside to cover the cost of supporting both acute and community services over the winter period. 4. Medicines Management The GP prescribing budget has been increased to reflect the current trends in prescribing growth and the need for to meet the increasing demands of dementia patients. Running costs The combined running cost allocation for both Greater Preston & Chorley & South Ribble CCGs in 2013/14 is 9.3m. This is split between direct running costs of the shared management team and commissioning support costs. Strategic Reserve The NHS Operating Framework requires CCGs to ensure that 2% of recurrent funding is only committed on a non-recurrent basis. This reserve will be held by the local Area Team of the National Commissioning Board with CCGs required to submit business cases to access the funding. The financial strategy assumes the CCG will bid for, and receive this funding in full to be used non-recurrently. The first call on this reserve will be to fund the nonrecurrent activity within the secondary care sector as the wider impact of the alternatives to hospital admission take effect. The National Commissioning Board financial guidance requires CCGs to plan for a minimum 1% surplus for 31 March 2014.This is additional to, and separate from the 2% recurrent reserve. The mandated 2% recurrent ring-fenced for non-recurrent purposes amounts to 4.8m, planned expenditure detailed below: 72

98 Risks and Uncertainties The allocation to CCGs has been based on a detailed analysis of NHS Central Lancashire s baseline position in July The methodology used was based on a set of national principles with local factors overlaid. These were agreed across local commissioning organisations to ensure consistency in treatment. The underlying assumption which underpins the whole plan is that the allocation and the baseline are equally matched As policy develops and the former primary care trust activity and performance trends are better understood, there is a potential for a disconnect between the allocations and the financial demands against them. These may arise from either accountability shifts, or from unforeseen pressures. For instance we have already seen a shift in accountability and resources from CCGs to the National Commissioning Board in respect of Specialised Commissioning, yet the precise nature of the change as it affects CCG contract setting and the financial flows that follow are far from clear. The Legacy transfer from the former Primary Care Trust has identified and provided for 6.7m of continuing care restitution claims; this is based on an extrapolation of 10% of total claims. The final cost in 2013/14 may exceed this provision. There are a number of other key variables which may impact on the financial outlook: Further growth in secondary care activity in excess of planned levels. Changes to the national Payments by Results tariff. Potential financial impact of reductions in centrally funding budgets. Growth in costs of both continuing healthcare and learning disabilities. The CCG will mitigate potential planning risks by pooling the financial resources of both CCGs; where this is appropriate. CQUIN (Commissioning for Quality and Innovation) Schemes The CCG is committed to ensuring that CQUIN schemes are in place for all organisations that meet the nationally mandated pre-qualification criteria. The maximum amount payable for CQUIN schemes, under the terms of the NHS Standard Contract, is 2.5% of the contract value for all services commissioned. National CQUIN Schemes Of the total funds available for CQUIN, 20% is set nationally for 2013/14, and is aimed at ensuring delivery of improvements in the following: Friends and Family test Improvement against the NHS safety Thermometer (excluding VTE) Improving dementia care (FAIR) 73

99 Venous Thromboembolism 95% patients being risk assessed and achieve locally agreed goal for no. of VTE admissions that are reviewed through RCA. The CCG is committed to including, and proactively monitoring, the achievement of all Providers with regards to the national CQUIN schemes and these will be monitored and managed as per the contract governance used for the local schemes (see below). Local CQUIN Schemes The remaining 80% of the funds available for CQUIN are for locally developed schemes. The CCG can demonstrate a process, aligned with organisational governance for the identification, prioritisation and development of local CQUIN schemes with our Providers. The Clinical Directors will be fully involved in the development and monitoring of the outcomes of CQUIN schemes. There is a clear governance structure within the organisation to ensure that the CQUIN schemes are aligned to the CCG s strategic priorities. The CCG will continuously map potential ideas for CQUINs into existing workstreams/clinical programme areas and in collaboration with other local CCGs, with shared providers and the Providers themselves, work to generate a long list for detailed work-up during the end of quarter 3 each year. The CCG supports detailed negotiations with its Clinical Directors and providers during early quarter 4 each year to enable a suite of local CQUINs to be agreed and signed-off in line with the contract. CQUIN domain development meetings are carried out throughout January to agree the outcomes, measures, content and monitoring. The development meetings are attended by both commissioners and providers specialists from those areas. The CCG has already entered into detailed discussions with Providers to identify areas of risk and agreed assurance mechanisms for the following areas where relevant: 3millionlives: The use of tele-health/ tele-care technologies. The CCG will ensure that the trajectory set is appropriate (through reviewing planning assumptions) and in line with the Commissioning Strategy (through reviewing scope, trajectory and model of provision); IOFM (Intraoperative Fluid Management): Trajectories for technology are in place and are consistent with NHS Technology Adoption Centre guidance. The CCG will ensure that the provider plan, including the baseline assessment, is appropriate and in line with NTAC. Child in a chair in a day: The CCG will undertake a service review in line with the local commissioning strategy. International and commercial activity: The CCG has supported the development of a NHS CQUIN to support the exploitation of commercial intellectual property through the AHSN in Providers. 74

100 Digital First: The CCG will ensure it works with Providers to establish trajectories for 2013/14 which correspond to needs and priorities for the local health economy. Carers for people with dementia: The CCG has aligned additional local CQUIN schemes to support the assurance required in relation to care of people with dementia. The assessment of provider plans and their interrelationship with other schemes and initiatives, including discharge information, will be planned in a systematic way to ensure an integrated view of care for this vulnerable group and their carers. The CCG will ensure that each CQUIN is monitored with the appropriate expertise through CCG staff, Clinical Directors. All national and local CQUINs are monitored and challenged throughout the year through the established Clinical Quality Leads meetings with attendees include GPs and Quality Leads from the CCGs and providers. CQUINs will only be paid where providers meet the minimum requirements of high impact innovations. Key Performance Indicators (KPIs) The CCG will continue to comply with the terms of the NHS Standard Contract in invoking, as and when necessary, performance clauses and applicable penalties to providers for all nationally set indicators. In addition to the nationally determined quality and performance indicators, the CCG continues to support the approach across Lancashire CCGs to establish a supplementary common set of performance indicators. Indicators established in the 2012/13 Contract are currently under review. In the acute contract these covered the following themes: Health care acquired infections (MRSA and E Coli bloodstream infections) A&E attendances and admissions relating to DVT and cellulitis Available appointments on Choose and Book Nutritional assessments using the Malnutrition Universal Screening Tool for patients over 60 years old Delayed transfers of care being managed to minimal levels Dementia patient care focussing on staff completion of basic awareness training, efficient discharge and carer involvement Reporting and recording of serious incidents Stroke patient care focussing on patients receiving care within designated stroke beds and wards Discharge letters Early access to maternity services. From a community service perspective, a standard set of KPIs was developed across Lancashire in 2012/13 for inclusion within contracts. The CCG will continue to work with its main community service provider in developing information reporting systems to populate all current indicators which will remain in 2013/14. The themes of the performance indicators are: 75

101 Health and well-being - focussing on stop smoking cases including expectant mothers; alcohol intake screening; chlamydia testing in 15 to 24 year olds; eligible girls receiving the HPV vaccination; nutritional assessments; Children and families - focussing on breast fed infants; height and weight checks for 4-5 year olds; weight management programmes for obese children; health visitor levels; looked after children assessments; Rehabilitation use of valid assessment tools; End of life care focussing on personalised care plans and pathways to support preferred place of care; Access managing appointment waiting times, cancellations and DNAs; Personalised care plans. In addition to the above, the CCG has local performance indicators for the intermediate care service managed by the community provider which supports the urgent care pathway reforms. Collaborative Commissioning The CCG will collaborate with other Lancashire CCGs to determine the commissioner requested services of its main acute provider (Lancashire Teaching Hospitals NHS Trust) and community provider (Lancashire Care NHS Foundation Trust) as part of contract discussions. Commissioner requested services are those which are to remain available even if a provider is in serious financial difficulty. It is anticipated that this will as a minimum support the Lancashire Emergency Preparedness Resilience and Response proposals. 76

102 APPENDIX 1 MILESTONE TRAJECTORY 77

103 78

104 Initiative Impact Lead Estimated completion date Enablers 70 79

105 APPENDIX 2 DELIVERY TIMELINES Key priority area Initiative Impact Lead Estimated completion date Enablers 80

106 APPENDIX 3 NHS OUTCOMES FRAMEWORK 81

107 GP/GB Part 1 Part 2 Governing Body Meeting 25 April 2013 Report Title Financial Position April 2013 Written by Presented by Purpose of the paper Matt Gaunt, Head of Finance Ian Crossley Chief Finance & Contracting Officer The paper sets out for Governing Body the financial position as at April 2013 and provides an update on financial issues, the latest budget position and aspects of financial governance. Key issues The Governing Body became statutorily responsible from 1 April for ensuring its expenditure does not exceed the budget allocated from NHS England for 2013/14 and for ensuring expenditure on administrative running costs is below the specified allowance. The CCG has established financial procedures and systems to ensure the Governing Body that it can effectively manage its resources and ensure honesty and transparency in their use. The nationally defined Integrated Single Financial Environment for CCGs is now operational and a bank account is in place with the Government Banking Service. The Governing Body approved the financial budget for 2013/14 at the March meeting; however, the first financial reports will not be available until May, consequently, this report concentrates on the development of the financial governance and risk management arrangements. A number of significant delays in the resolution of NHS England commissioning arrangements have arisen which mean that it is not yet possible to conclude NHS provider contracts and co-commissioning arrangements; these are being taken forward by the Local Area Team on behalf of Clinical Commissioning Groups Actions required by Governing Body Members The Governing Body is asked to note the financial update and the risk assessment. Financial Position April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013

108 Financial Position April Introduction 1.1 The Governing Body became statutorily responsible from 1 April for ensuring its expenditure does not exceed the budget allocated from NHS England for 2013/14 and for ensuring expenditure on administrative running costs is below the specified allowance. 1.2 The CCG has established financial procedures and systems to ensure the Governing Body that it can effectively manage its resources and ensure honesty and transparency in their use. The nationally defined Integrated Single Financial Environment for CCGs is now operational and a bank account is in place with the Government Banking Service. 1.3 The Governing Body approved the financial budget for 2013/14 at the March meeting; however, the first financial reports will not be available until May, consequently, this report to the Governing Body concentrates on the development of the financial governance and risk management arrangements. 2. Purpose 2.1 The purpose of this paper is to update the Governing Body on the actions following last month s budget paper and provide an update on financial governance matters; in particular: a. The 2013/14 budget setting process; b. Progress on establishing co-commissioning risk share arrangements; c. Provider contract agreements; d. Financial risk assessment; e. Financial governance and the introduction of the Integrated Single Financial Environment (ISFE). 3. Update on 2013/14 Budget Setting 3.1 The CCG s healthcare budgets have been set within the overall funding envelope of 244.9million and will deliver 1% surplus in year and 2% underlying or recurrent surplus. The financial planning assumptions around inflation, efficiency and growth are consistent with the NHS England s financial framework. 3.2 The CCG s running cost allowance is set nationally at approximately 25 per head of population. This is consistent with the national aim of reducing system wide running costs by one third. Financial Position April 2013 NHS Greater Preston CCG Governing Body 24 April 2013 Page 1 of 6

109 3.3 The 2013/14 budgets agreed in March are summarised in the following tables: Greater Preston CCG Summary Running Costs m Running cost allowance 5.0 CCG pay costs 1.3 CSU SLA (running cost element) 1.9 NHS Property Services re -charge 0.4 Other non -pay 0.4 Additional support costs 1.0 Total costs The budget setting process will be concluded following contract sign-off, and budget accountabilities and the financial authorisations will be more closely aligned to match clinical commissioning responsibilities. 3.5 Practice level budgets have been prepared for prescribing expenditure and further work is being undertaken to develop practice level commissioning; particularly, and where possible, to identify where GP practices can directly influence hospital or community activity. 4. Agreement of Co-commissioning Risk Share Arrangements 4.1 CCG plans have been built on the assumption the opening CCG budgetary commitment mirrors its share of the former Primary Care Trust s budget commitments and that the CCG allocation correctly reflects this position. However due to timing issues and complexities inherent within the change process, significant disconnects between CCG baseline allocations and expenditure commitments have arisen in the commissioning of specialist services. 4.2 To mitigate these allocation issues, NHS North of England proposed that commissioners work collaboratively with each provider within the framework of one collective contract encompassing both specialist and CCG activity. This collaborative framework should allow risk sharing between commissioners to counteract differences between the value of actual baseline activity performance and resource allocations. In year risk sharing data should also form the basis for any 2014/15 allocation corrections by NHS England. 4.3 The principle of a collaborative framework has been agreed across the Lancashire health economy by the Area Team. However practical difficulties remain in evaluating the extent of financial risk within individual CCG and Trust contracts, due to information coming from multiple sources with inconsistent bases of preparation. Financial Position April 2013 NHS Greater Preston CCG Governing Body 24 April 2013 Page 2 of 6

110 4.4 Considerable work has been done across CCGs, Trusts and the Area Team on the mechanics of adjusting allocations to reduce the financial risk for all commissioners. However, the Area Teams across the North West of England have yet to confirm how this will be done or the mechanism for agreeing any adjustments with individual CCGs. 5. Update on Provider Contracts 5.1 The CCG has four main contracts that account for the majority of its healthcare expenditure. These are Lancashire Teaching Hospitals, Lancashire Care Mental Health, Lancashire Care Community and Ramsey Healthcare. Of these, only the Ramsey Healthcare contract has been finalised and signed to date. 5.2 Provisional agreement has been reached with the NHS providers where Chorley and South Ribble & Greater Preston are the lead commissioners. However, as agreed by the Audit Committee these contracts will only be signed once the cocommissioning risk share arrangements referred to above have been finalised. Other contracts for acute services, led by other CCGs, impacted by these arrangements are similarly affected. 6. Financial Risk Assessment 6.1 There is still a high level of uncertainty as the new commissioning arrangements become established. In order to attempt to quantify the level of financial exposure arising from these uncertainties, an assessment of the financial risks facing both CCGs has been prepared. These have been classified as planning and operating risks and are set out in following table: Financial Position April 2013 NHS Greater Preston CCG Governing Body 24 April 2013 Page 3 of 6

111 6.2 The planning risks largely relate to the transfer of resource from CCGs to NHS England for the commissioning of specialist services; this was raised last month with the Governing Body. In addition the CCG incorrectly received an allocation for dental services, which are commissioned by the Lancashire Area Team rather than the CCG. The Area Team with direct commissioning responsibility for Specialist Commissioning has proposed corrections to misallocations which total 2.9m for the CCG. There is an expectation that this correction will be received as a one-off settlement of allocation issues through the co-commissioner risk share arrangements; however this has yet to be formally proposed. 6.3 The operating risks were flagged in last month s report on the financial budget. The principle risk relates to acute activity with Lancashire Teaching Hospitals Foundation Trust. The financial plan anticipates a slowing of activity growth over the next 12 months; however the extent and rate of the reduced growth presents a financial risk which has been assessed as 2.3m for Greater Preston CCG. 6.4 Acute contract prices are expected to reduce by 1.3% on 2012/13, if prices fell by half this value (0.65%) the CCG would face a financial risk of 0.7m. 6.5 The CCGs mitigation strategy for contract performance issues is to access the 2% non-recurrent funds that are held by the Area Team and have been formally requested but not yet approved. 6.6 Growth in continuing care and individual packages of care is assumed in the plan at 10%, this is in line with historic growth which has ranged between 9-11% since 2009/ The GP practice level prescribing plan is based on a primary care prescribing uplift of 2.4%, offset by an efficiency saving of 4.0%. The improvement this represents would lift all GP practices into the top quartile of best prescribing practice. The medicines management team indicated a less challenging level of improvement would generate a 0.4m shortfall to the prescribing plan. 6.8 Risk mitigation is assumed will be through the use of 2% non-recurrent funds and the 0.5% winter pressures contingency fund. These contingencies are sufficient to meet all the operating risks identified at this stage however would reduce the funding available for pump-prime initiatives or local CCG priorities. 6.9 In addition to the quantifiable financial risks, uncertainties remain over the precise accountabilities, funding and expenditure arrangements of the following areas: 6.10 GP IT costs this is funding that is held and managed by the Area Team. Across Lancashire the Area Team is holding 6.5m of allocations from NHS England to meet GP IT requirements. The Area Team has not decided how these costs will be allocated to individual CCGs nor given guidance on which costs should be met from this fund NHS Property Services the CCG will be recharged occupancy costs for the premises it operates from. A provision within the running cost budget has been made of 0.4m. We have had no confirmation of the actual charge or basis on which it will be calculated. Financial Position April 2013 NHS Greater Preston CCG Governing Body 24 April 2013 Page 4 of 6

112 6.12 Local Enhanced Service (LES) schemes NHS England has transferred existing contracts held by the former primary care trust to the Area Teams, although accountability still remains with CCGs. At this stage there is still uncertainty as to which organisation will be involved in the administration of LES contracts and the CCGs have not been advised to take any action to progress LES payments. 7. Financial Governance 7.1 The new financial ledger system, the Integrated Single Financial Environment (ISFE) was implemented nationally on the 1 st April. Provider payments in April have been made based on estimated or proposed contract values; these have been processed through the ISFE and were paid in week commencing 15 th April. 7.2 The finance team will use the April month end as a test for ISFE functionality and month end processes. At this stage in the year there is no meaningful contract or activity information so no formal monthly accounts have been produced. It is expected the first monthly management accounts will be issued for May and these will be presented to the June Governing Body meeting. 7.3 The CCG bank account with the Government Banking Service has been established and the first monthly tranche ( 19.1m) of the CCGs financial allocation was paid into the account on the 2 nd April. 7.4 The former Primary Care Trust (PCT) 2012/13 financial position has been completed and the PCT will achieve its forecast control total. The process of assigning the assets and liabilities of the PCT to successor bodies is now underway. The CCG will take accountability for any long term liabilities; the most significant being the provision for continuing care restitution claims. 7.5 The PCT has made a provision of 11.4m (subject to audit approval) for continuing care restitution claims, Chorley and South Ribble and Greater Preston CCGs can expect to become accountable for between 8-9m of these claims. While there remains some risk in this transfer of accountabilities; it is expected the provision will be sufficient to meet the expected liabilities. 7.6 The CCG has established clear audit arrangements; Grant Thornton UK LLP will audit the accounts of Chorley and South Ribble and Greater Preston CCGs for four years, starting with the accounts to 31 March Audit North West has been appointed to provide internal audit and counter fraud services to Chorley and South Ribble and Greater Preston CCGs for a period of 12 months from 1 April Conclusion and Next Steps 8.1 Budgets have been established and governance mechanisms are in place to enable the Governing Body to meet its statutory responsibilities; to operate within the budget allocated from NHS England for 2013/14 and to ensure expenditure on running costs are below the specified allowance. 8.2 There remain uncertainties in resolving allocations issues and this has delayed the contractual cycle. The Area Team are in the process of resolving these issues. The principle financial risks associated with these issues are largely understood and a Financial Position April 2013 NHS Greater Preston CCG Governing Body 24 April 2013 Page 5 of 6

113 financial risk assessment has been prepared. Mitigation is in place for all operational risks so far identified; however if they all arise, our flexibility to implement local initiatives will be reduced. 8.3 There are uncertainties over the precise role the CCG is expected to play in respect of GP IT, Property Services and LES contract payments and clarification in respect of these is expected shortly from the Area Team. 8.4 The CCG is working, with support from Area Team and Co-Commissioners, to: Agree provider contracts for 2013/14; Agree co-commissioning arrangements and risk mechanisms across the Lancashire health economy and North Region to mitigate financial allocation issues 9. Recommendation 9.1 The Governing Body is asked to note the financial update and the risk assessment. Matt Gaunt Head of Finance April 2013 Financial Position April 2013 NHS Greater Preston CCG Governing Body 24 April 2013 Page 6 of 6

114 GP/GB/ Part 1 Part 2 Governing Body Meeting 25 April 2013 Report Title Performance Report April 2013 Written by Presented by Purpose of the paper Iain Crossley, Chief Finance & Contracting Officer Iain Crossley, Chief Finance & Contracting Officer This paper updates the Governing Body on progress against the key performance targets in the Delivery Plan and proposes a reporting format for the coming year. Key issues This performance report sets the scene for performance and quality monitoring of the targets set out in the Delivery Plan for the coming year. It describes the local and national indicators and provides an overview of current performance where this is available. At this stage, it is not possible to provide a comprehensive update on actual CCG performance as current commissioner datasets used to monitor progress are still only available at former Primary care Trust level. However, from April 2013 many of these indicators will start to be collected at Clinical Commissioning Group level and the first actual reports will be available from May onwards. The report outlines where future reports could be expanded as further information becomes available and suggests additional areas where performance monitoring could be enhanced to improve understanding of the influences affecting the health economy. The Governing Body is asked to comment on the style and content of the report so it can be amended to more closely reflect performance on key priorities. Actions required by Governing Body Members The Governing Body is asked to note the content of the report and comment upon the style and format. Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013

115 NHS Greater Preston Clinical Commissioning Group Performance Report April 2013

116 Contents 1. Introduction 2. Quality Premium 3. Local Planning and Priorities 4. NHS Outcomes Framework 5. NHS Constitution 6. Quality Monitoring 7. Primary Care 8. Activity Analysis 9. Next steps Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 2 of 13

117 1. Introduction 1.1 April 2013 marks the start of a reformed health service where there is a greater emphasis on local decision making based on the specific needs of the population. This first performance report for 2013/14 aims to set the scene for performance and quality monitoring for the coming year so that we are able to ensure we are on track to deliver our commitments to our population. 1.2 This year our priorities focus on: Reducing inappropriate admissions to hospital, particularly for younger people with asthma, diabetes or epilepsy Better support for people with long term conditions Improving diagnostics 1.3 Nationally defined targets govern the overall strategic direction within which we will deliver improved outcomes for our population and demonstrate improved performance in respect of system reform, quality and access to care within our financial allocation. Our key national directions are: NHS Outcomes Framework NHS Constitution 1.4 We are still developing our approach to performance reporting but as a minimum will ensure future reports include the following: 2. Quality Premium Progress against delivery of the measures included in the Quality Premium Quality monitoring including CQUIN reporting, essential standards compliance at site level (updated as and when CQC reviews take place for all providers) and patient safety Performance against key local and national priorities Analysis of referrals to highlight areas of changing demand and demand pressures Activity and financial performance against contract plans and exception reporting Delivery of Quality, Innovation, Productivity and Prevention (QIPP) plans. Progress around the primary care work programme Areas of concern will be highlighted and assurance provided of the actions being taken to address any issues. 2.1 The Quality Premium is intended to reward clinical commissioning groups (CCGs) for improvements in the quality of the services they commission and for associated improvements in health outcomes and reducing health inequalities. 2.2 The premium will reflect the quality of the health services commissioned by the CCG in 2013/14 and will be paid in 2014/15. It will be based on four national measures, all of which are based on measures within the NHS Outcomes framework and three local measures. NHS England may withhold payment of the quality premium in cases Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 3 of 13

118 of serious quality failure or if the CCG fails to manage within its total resource envelope. 2.3 The national measures are: Reducing potential years of lives lost through amenable mortality Reducing avoidable emergency admissions Roll out of the Friends and Family Test and improving patient experience of hospital services Preventing healthcare acquired infections 2.4 The local measures are based upon the local priorities identified by the CCG and agreed with the Area Team. Future reports will track progress against each of the Quality Premium measures. 2.5 The diagram below details the overall distribution of quality reward: 3. Local Planning and Priorities 3.1 Our delivery plan outlines our strategic aims, vision and priorities for 2013/14. The local priorities that will be part of the quality premium are: Priority 1: Reducing inappropriate admissions 3.2 The CCG acknowledges the requirement in reducing both inappropriate and unplanned hospital admissions. The reduction of such admissions would enable services to work more efficiently, having a positive impact on inpatient waiting lists as well as potential financial investment opportunities in alternative care pathways. Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 4 of 13

119 3.3 Our work programme during 2013/14 to support this priority, as detailed within the delivery plan, is as follows: Use of a referral gateway including triage and tier 2 services Development of a specialty review project team and revised orthopaedic pathways. Independent review of tier 2, ATC and clinical assessment services Practice peer review of referrals Completion of referral audits Development of tier 2 services such as neurology and gynaecology Procurement of an ENT service Improved access and reporting times for diagnostics 3.4 In addition to the monitoring of the above programme, continued development of referral analysis and referral audits alongside monitoring of specific pathway developments will be performed in order to monitor the progress being made. 3.5 Within the NHS Outcomes Framework a specific target for this area is the reduction of unplanned hospitalisation for asthma, diabetes and epilepsy in under 19 s. The CCG target for 2013/14 is a reduction of 5% from baseline. 3.6 This indicator, embedded within the 2013/14 Outcome Frameworks will be performance monitored on a monthly basis. Priority 2: Long Term Conditions The Diagnosis of Dementia 3.7 Building on the on-going work currently being undertaken across health and social care to re-shape services, the CCG recognises that earlier diagnosis of dementia enables timely access to pathways of effective intervention. Better treatment and support for families can improve the quality of life for people with dementia. 3.8 The work programme during 2013/14 to support this priority, as detailed within the delivery plan is as follows: Delivery of an in-reach model of memory assessment services to primary care settings Supported dementia liaison advisors provided by the Alzheimer s society within practice Support for families and carers Improving care home liaison and crisis response though intermediate support teams Increasing current capacity Reducing the level of prescribing Improving the quality of care within nursing and care home settings Improving the response of the community careers Reducing admissions to secondary acute services and long term care support by sustaining people within their current homes Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 5 of 13

120 3.9 Our plan is to increase the diagnosis rate for dementia from 54% to 57%. The performance of this priority area will be regularly monitored throughout the year to evidence the progress being made In addition to the improvement trajectories, the CCG has also set targets to reduce hospital length of stay for dementia patients by 7% working to provide further support within the community and proactive support in residential care and when in hospital Regular monitoring for this specific improvement trajectory will identify progress being made. Priority 3: Diagnostics 3.12 The aims for this priority are: To increase the range of direct access diagnostic tests available to primary care teams To improve the timeliness of reporting of all diagnostic tests o Where diagnostic tests are requested by GPs, results to be sent electronically to practices, thereby avoiding unnecessary delay. o Where diagnostic tests are organised by the hospital, any relevant results to be communicated to GPs via the discharge summary, or otherwise electronically in a timely manner. To instigate a programme to develop increased primary care direct access to diagnostic tests 3.13 The CCG is interested in improving diagnostic utilisation on specific patient pathways and have already secured direct access diagnostic testing in a number of therapeutic areas for example, MRI scans for knees. The CCG is also developing a Tier 2 cardiology service delivered through GPs with special interests (GPwSIs) Our plan is to reduce the number of first outpatient cardiology appointments by 932 (equivalent to a 20% reduction on 2011/12). To achieve this, outpatient referrals will be triaged by a cardiology consultant using the information in the referral letter who will then assess whether it is appropriate for the patients to be managed by their GP or to be referred into the cardiology department. Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 6 of 13

121 4. NHS Outcome Measures 4.1 The NHS Outcomes Framework is set out into five domains. The indicators within each of these areas of framework will be used to track the progress of individual CCGs. These five domains are: Domain 1 Domain 2 Domain 3 Preventing people from dying prematurely Enhancing quality of life for people with long term conditions Helping people recover from episodes of ill health or following injury Effectiveness Domain 4 Ensuring that people have a positive experience of care Experience Domain 5 Treating & caring for people in a safe environment and protecting them from avoidable harm Safety 4.2 Indicators will be monitored on an annual, quarterly or monthly basis against plans/baselines where applicable. 4.3 As part of the planning guidance released in December 2012, CCGs were provided with an outcomes benchmarking support pack to help them understand their current position on outcomes. This information represents the baseline position against which CCGs progress in improving outcomes will be monitored. 4.4 Figure 1 below is the summary outcome indicator chart for Greater Preston CCG. This benchmarks the CCG against other CCGs in the same ONS cluster group. Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 7 of 13

122 Figure 1: Summary Spine Chart Greater Preston CCG Performance Report April 2013 NHS Greater Preston CCG Governing Body Meeting 25 April 2013 Page 8 of 13