Wandsworth Clinical Commissioning Group. Commissioning Strategy Plan 2012/ /15

Transcription

1 Wandsworth Clinical Commissioning Group Commissioning Strategy Plan 2012/ /15 goes here November 2011 FINAL (V0.12) 22 November 2011 Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 1 of 89

2 Contents 1. Clinical Commissioning Group Chair Foreword Our Vision, Values and Strategic Goals Approach Governance Planned governance to support delivery Engagement Equality & Diversity Case for Change Population demographics Key health issues for the Wandsworth population Quality position Financial position Key Strategic Initiatives (Commissioning Priorities) Key strategic initiatives (commissioning priorities) Local Commissioning Group (LCG) Priorities Opportunities and Focus Areas for Service Redesign New opportunities Previous CSP initiatives Measuring success Enablers Incentives Information, Information Technology and Communications Workforce Estates Delivery Impact Patient impact Provider impact Financial impact Sustainable Commissioning Implementation High level milestones for the delivery of the opportunities (2012/13) Risks Glossary Appendices Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 2 of 89

3 1. Clinical Commissioning Group Chair Foreword This Commissioning Strategy Plan (CSP) sets out how we intend to deliver improvements in the health of Wandsworth people and how we will ensure that local services are transformed through partnership working with patients, the public, Local Authority and provider organisations. Wandsworth Clinical Commissioning Group (CCG), in collaboration with the people and communities of Wandsworth, aspires to commission high quality services, driven by real need, clear goals and budgetary transparency, ultimately producing visible improvements in outcomes and patient experience. NHS Wandsworth has a strong history of maintaining financial control; however, there is a clear recognition by Wandsworth CCG of the scale of the current and future financial challenge. The CCG has a central role in delivering savings and cost-effectiveness to ensure continuing financial balance on a recurrent basis. We also have a responsibility to ensure we invest to support service transformation, which will secure both health gains and improved outcomes and efficiencies. Our objectives at this stage build on those that have been the focus of the PCT and will be subject to continuous review and development as the CCG becomes more embedded over time. We have worked with our staff, clinicians, partners and local communities to review our vision, goals and values. The CCG is an emerging organisation and there will be more work to ensure that our vision is shaped and shared by our partners and stakeholders. In developing this Plan, we have refreshed the existing CSP ( ) and looked to the period 2012/ /15. The refreshed CSP demonstrates our continued focus on the needs of the population, as evidenced by the Joint Strategic Needs Assessment (JSNA). Our strategic goals are borne out of these needs as follows: Reduce health inequalities through helping people to live longer and healthier lives, particularly those living in Wandsworth s most deprived communities; Support young people to take control of their own health earlier, so they continue to make healthier choices throughout their lives; Educate people about mental wellbeing, sexual health, drugs, alcohol and obesity. Help prevent and diagnose earlier and improve services; Improve access, quality and choice of service provision across all care pathways and in appropriate settings; Improve the quality of life of people living with long term and complex health conditions and their carers by improving the quality, range and choice of services and giving them information to better manage their own health. The Department of Health White Paper: Equity and Excellence: Liberating the NHS, published in July 2010, is clear that there will be a fundamental shift in responsibilities and budgets for commissioning NHS healthcare and services. Wandsworth CCG, as an early adopter of the CCG model, has Pathfinder status and from 1 st October 2011 has been one borough-wide Wandsworth Clinical Commissioning Group (CCG) composed of three Local Commissioning Groups (LCGs); Wandle LCG, Battersea LCG and West Wandsworth LCG. We have maintained and built upon the strong existing local knowledge, joint working and governance arrangements in the three Locality Commissioning Groups. Active engagement Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 3 of 89

4 and delivery will occur at this level in the CCG as we feel that the existing forums are effective and trusted by the constituent practices. Clinical commissioning through this structure provides us with the best opportunity to ensure that we maximise clinical engagement in the challenges we face, drive clinical wisdom into the commissioning process and embed a local focus in our plans. Our continuous work to engage and consult with local communities and partners over the last year has shown us that we are moving in the right direction. We are determined to ensure that through this ambitious but achievable Strategic Plan we will deliver the improvements to health and wellbeing that our population needs and deserves. Dr Nicola Jones Clinical Commissioning Group Chair 2. Our Vision, Values and Strategic Goals The following Vision, Values and Goals were reviewed in partnership with our staff, clinicians, partners and local communities for our previous Commissioning Strategy Plan (CSP) Wandsworth Clinical Commissioning Group (CCG) is committed to the implementation of the vision, values and goals and will continue to refine and develop these with our partners and key stakeholders as the CCG is established over the next 18 months. Our Vision To transform the health of people living and working in Wandsworth. We will work with local people, communities and our partners to deliver high quality services that are patient centred, safe and innovative. We want all our local communities to be ambitious about their own health and to challenge us to commission the best possible care in the best possible environments within our resources. Our Values In partnership with patients, staff, key clinicians and partners we have developed our values to underpin our commissioning approach: outward looking, focussed on high quality outcomes, based on honesty and integrity, trustworthy and open, person centred and listening, collaborative, innovative and professional. Our Strategic Goals Reduce health inequalities through helping people to live longer and healthier lives, particularly those living in Wandsworth s most deprived communities Support young people to take control of their own health earlier, so they continue to make healthier choices throughout their lives Educate people about mental wellbeing, sexual health, drugs, alcohol and obesity. Help prevent and diagnose earlier and improve services Improve access, quality and choice of service provision across all care pathways and in appropriate settings Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 4 of 89

5 Improve the quality of life of people living with long term and complex health conditions and their carers by improving the quality, range and choice of services and giving them information to better manage their own health Section five of this plan outlines the strategic initiatives that have been agreed to address the above goals, in line with the key health issues identified in the recent Joint Strategic Needs Assessment (JSNA), described in section 4.2 below. Section six of this plan provides an overview of recent achievements to date against the initiatives outlined in our previous CSP ( ). It also summarises the actions to be taken forward under each strategic initiative for the period 2012/13 and Joint Strategic Needs Assessment (JSNA) This plan has been developed in line with the priorities defined in the 2010 Joint Strategic Needs Assessment (JSNA). This plan will also feed into the Joint Health & Wellbeing Strategy (JHWBS), as it is developed from 2012, in line with our approach to joint commissioning, The purpose of the JSNA is to provide an agreed record of the key health needs of the Wandsworth population, and to guide the CSP to address these needs. The JSNA represents a summary of much more detailed work that has been undertaken in Wandsworth. It is underpinned by a core data set defined in statutory guidance, and by needs assessments which have been undertaken in relation to various client groups and localities. Much of this background material is available on the Joint Strategic Needs Assessment web site: 3. Approach 3.1 Governance The Department of Health White Paper Equity and excellence: Liberating the NHS sets out the direction for empowering clinicians to innovate and improve local health services. By April 2013, PCTs will be replaced by Clinical Commissioning Groups as the main local commissioning statutory body. In order to test assumptions Pathfinders have been established nationwide, typically mirroring PCT boundaries. Wandsworth became a Pathfinder in 2010/11 and from October 1 st 2011 was given the status as an emerging CCG and took on delegated responsibilities (via the Borough Managing Director, as Responsible Officer) for a significant proportion of the NHS Wandsworth budget along with its commissioning priorities and resources. Over the coming months, the emerging CCG will undertake a series of comprehensive steps to authorisation to ensure that the required governance systems are in place to commission healthcare safely; that we are financially viable; and that we harness the potential of local clinicians to shape local health services. We aim to be a fully authorised CCG by April The CCG encompasses the same boundary as the PCT and has one borough-wide Clinical Commissioning Group (Wandsworth CCG), composed of three Local Commissioning Groups (LCGs): Wandle LCG, Battersea LCG and West Wandsworth LCG. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 5 of 89

6 Figure 1: Wandsworth CCG structure Wandsworth CCG West Wandsworth LCG Battersea LCG Wandle LCG The CCG Committee meets in public every month as the accountable committee for delegated responsibilities and is chaired by the elected clinical lead. This Committee will be responsible for ensuring commissioning priorities are delivered. In developing this CSP, we have focussed on the high-level needs of the population, as evidenced by the JSNA, and we are working in partnership with the Local Authority and Public Health to identify how best to address those needs. The Plan has been developed, and regularly reviewed, with the support of the Wandsworth Management Team, which include clinical leads from the three LCGs. Drafts of the Plan have also been shared with the LCGs for comment. A CSP Workgroup was also established to plan the CSP refresh and monitor its development. The group includes leads from Commissioning, Finance and Public Health (NHS Wandsworth). 3.2 Planned governance to support delivery NHS Wandsworth and the CCG, in collaboration with our partners in the public, the Local Authority, community organisations and the wider NHS, look to a future of high quality services driven by real need, clear goals and budgetary transparency, ultimately producing effective implementation and visible outcomes. To ensure that the health and wellbeing needs of the population are met well and in a timely fashion - an ethos, the RAPIDE methodology, is emerging. RAPIDE will instil a can do, open and honest culture throughout the organisation and its partners. The application of this methodology has, at its heart, high quality commissioning with effective engagement and the promotion of excellence whether through innovation, hard work or demonstrable effectiveness. Rapid Actions Promoting Improvement/Innovation Delivery Engagement The principal vision of the emerging CCG is to improve the health and well-being of the population of Wandsworth. We will achieve this by developing an approach to Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 6 of 89

7 commissioning which drives clinical insight into the decision-making process and is informed by patient views. There are a number of key enablers which are focussed on the successful engagement of GPs, other clinicians and the public. Local GPs will be supported to lead work-streams and develop effective relationships with the Local Authority, Public Health and other key stakeholders. This approach will facilitate the development and delivery of plans to be informed by input from patients and the public and which will be designed to improve outcomes. See Appendix 1 for further detail on our planned governance to support delivery. Wandsworth Health & Wellbeing Board (WHWB) and the JSNA The Wandsworth Health and Wellbeing Board (WHWB) represents all stakeholder interests from across Wandsworth. The agenda for the WHWB is directed by the JSNA. The JSNA sets the priority areas for the NHS, Adults Social Services and Children s Services and directs subsequent commissioning plans. The priorities reflected in the CSP align with those reflected by the HWB. The JSNA has ongoing engagement with stakeholders to continually state priorities and reflect community needs. Locality Commissioning Groups (LCG) Each LCG has engaged with its Board, comprising of constituent practices, to sense check priorities contained within their individual Locality Delivery Plans (LDPs) local plans to address local needs. This will become part of a yearly cycle, with quarterly updates on progress discussed at each Board meeting, with a yearly refresh (in line with the overarching CCG CSP refresh). Where work is delivered on a pan-wandsworth level, there is ongoing involvement of locality Clinical Leads in ensuring that the views of their locality are represented and that services are tailored to the specific population. 3.3 Engagement CSP Engagement Since the development of the previous CSP in 2009, we have analysed evidence from Patient and Public Involvement (PPI) activity on an ongoing basis to ensure that the CSP reflects the views of Wandsworth patients and residents. We have taken the CSP to specific community and PCT patient health groups, such as Wandsworth Lesbian, Gay, Bisexual and Transgender (LGBT) Forum and the Wandsworth Youth Health Jury, to describe the CSP and request feedback on what they want to see reflected in it. An Engagement Schedule was developed for the drafting of this CSP refresh. We have engaged with key local stakeholders through existing forums where possible, during the developmental stage (October and November 2011). Our Commissioning Intentions for the period 2012/13 were also developed during the same period as the CSP refresh. A full copy of these can be found on the PCT s website. GPs We have engaged with LCG clinical leads via the CCG, which has received drafts of the Plan as it has evolved, for review and approval. Drafts have also been shared with the three LCGs for comment. Drafts of the Commissioning Intentions for 2012/13 are also being shared with the CCG. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 7 of 89

8 London Borough of Wandsworth (LBW) The Local Authority is represented on the CCG Committee and drafts of the Plan have been shared at that meeting for comment. Health & Wellbeing Board We have shared drafts of the CSP with the Wandsworth HWB Board. Providers We will continue to have further discussions about the Plan and our Commissioning Intentions (2012/13) with our key providers. Patients and the Public The JSNA key priority areas and an extract of the draft CSP have been shared with Wandsworth patients, carers and voluntary sector organisations at a large patient/public event held in early November to enable them to comment on the JSNA and strategic priorities. We have also shared this information with locality-based patient groups as well as other PPI groups, e.g. Thinking Partners and Wandsworth LINk, to gather feedback on the priorities for the CSP. LINk is also represented on the CCG Committee and has received full draft copies of the CSP between October and November. Local MPs The Borough Managing Director will update our local MPs during their regular meetings. Other Clinicians An overview of the JSNA and CSP key priority areas has been shared with St George s clinicians and managers Wandsworth CCG and Patient and Public Involvement (PPI) The CCG is one of five pathfinders for PPI nationally and the only one within London. The CCG s intention is clear about the need to engage openly and honestly with patients and communities and to find creative ways to engage them in developing commissioning processes. We are developing a CCG PPI Strategy which will drive future PPI within Wandsworth, including the development of future CSPs. The main priorities outlined in the strategic plan were shared at a local forum event in September 2011, attended by 85 patients who were asked to contribute. PPI is an on-going process. We will continue to plan and capitalise on opportunities to obtain the views of our patients on our priorities and direction of travel. As the CSP is a refresh and update plan, we will continue to collect and collate evidence from our involvement activities. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 8 of 89

9 In addition to our work with the CCG, we will continue to: develop the Expert Patients Programme in Wandsworth, which is a key component in self management of long term conditions; develop our successful patient communication approach using the Customer Relationship Management System (CRM); support initiatives with the online PPI resource centre tool; build closer working relationships with Wandsworth Local Involvement Network (LINk), the Health and Wellbeing Partnership and Wandsworth Local Authority. develop an approach to service redesign which ensures that patient insights are built into design and commissioning 3.4 Equality & Diversity Equality and Diversity continues to play a pivotal role in the development of the CSP. This year, with the new Equalities Act in place, there is a public sector duty requiring statutory authorities to promote equality. In order to support compliance with the Equality Act, we will be implementing the Equality Delivery System (EDS), developed by the NHS. Our approach will be to engage with our Thinking Partners Group which will partner NHS Wandsworth in grading our quality performance and help us identify future outcomes. This ties in closely with the developing work around PPI and the CCG consortium. Our Thinking Partners Group will continue to meet to support and advise the CCG on the approach to health in Wandsworth and specific projects requiring Equality and Diversity input. The EDS process will result in the CCG publishing evidence of current performance, plus an action plan for improvement to help us meet the Act s requirements. The Joint Health Inequalities Strategy (JHIS), currently under development, will detail how the NHS and the Council will work closely together to reduce the variations in health within Wandsworth through community empowerment and addressing the wider determinants of health, such as education and employment. The JHIS and the CSP are inter-related and mutually dependent, with a consistent focus on key borough priorities, such as children in the early years and long term conditions, and an emphasis on joint working between the NHS, Local Authority, members of the public, service users and the third sector. 4. Case for Change 4.1 Population demographics Population Wandsworth has around 132,000 [1] dwellings, which are home to a population of over 290,000 [2] residents. The largest increase in population by 2030 is projected in the 45-49, and year old age groups. However, in practice, Wandsworth is also a borough which experiences high levels of population turnover year on year. The turnover statistic is 30% (Source: GLA, DMAG, between and within Wandsworth ). This creates particular issues for NHS services. For example, there is a large cohort of patients who never register with a GP or access healthcare except for emergency services. Provision of prevention and screening services is challenging where there is a high turnover of patients. [1] 2009 Housing Strategy Statistical Appendix [2] 2009 Round GLA Demographic Projections (SHLAA) Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 9 of 89

10 Primary care experiences a high patient turnover, which can impact negatively on the ability of continuity of care to deliver health gains. Data collection can be difficult in primary care when patients move frequently. Although actual numbers remain small, the number of people aged 90 or over is projected to increase significantly by 2030, particularly for males. The proportion of households that are couple households (married and cohabiting) is projected to decrease over the next 15 years, whilst the number and proportion of lone parent households is set to increase. On average, there are 2.2 people per household in Wandsworth and the average household size is projected to decrease to 2.1 persons by The population of the borough is set to increase to over 330,000 by 2030 [6]. The Vauxhall/Nine Elms/Battersea Opportunity Area has been identified as an area of potential major change. It includes the redevelopment of Battersea Power station and the American Embassy, with an additional two stops for the Northern line. It is expected to result in 20,000 new jobs, over 10,000 new homes, and 25,000 new residents by Within the scope of this CSP the latest planning figures indicate that by 2015 an additional 3000 people will have moved into the area. Issues to be considered will include collaboration with LBW to create a new community that promotes the health of its residents, provides the required health and social care services, and maximises the health benefits to the wider community of new employment opportunities. The demographics for Wandsworth therefore require specific services and access opportunities, particularly for the younger population, but also to respond to the needs of an older, less affluent population not moving from the Borough. The highly skilled professional population will be health literate and will demand high quality services. Opportunities for prevention initiatives need to be matched to the highly mobile lifestyle of this population and prevention initiatives will need to capitalise on the latest communication technology. For our elderly population, keeping healthy whilst maintaining wellbeing and independence, are priorities for Wandsworth health borough team and the LBW. Age and gender The age structure of residents is uniquely skewed towards the young, with the year old age group representing 48% of the population compared to 27% nationally and 36% in Greater London [3]. This is further exemplified by the fact that one person households account for 38% of all households in Wandsworth. Wandsworth has a greater proportion of highly skilled workers than London and fewer lower supervisory and semi-routine workers [4]. Rates of unemployment are generally low compared with London. [6] 2009 Round GLA Demographic Projections (SHLAA) [3] 2008 Mid-Year Estimate (revised May 2010), Office for National Statistics Population Estimates [4] 2001 Census, Office for National Statistics Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 10 of 89

11 Figure 2: 2011 Wandsworth age and gender distribution Source: GLA 2008 Round of Demographic Projections LOW The current residential population estimates for Wandsworth shown in Figure 2 indicate that the Borough has a higher proportion of residents than either Inner London or London as a whole between the ages of 20 and 44. The effects of this are lower proportions of residents between the ages of 5 and 20. The Wandsworth profile is more similar to Inner London than London, and is not expected to change significantly by The biggest percentage change expected in the Wandsworth population is a 1,000 increase in the 5-9 age group. This is a 12% increase from 2011, compared to 9%, and 12% increases in Inner London, and London respectively. Ethnicity Wandsworth is home to a diverse range of communities and 20% of the borough s population is non-white, compared with 31% in Greater London and 12% nationally. [5] In 2011, 78% of the population are estimated to be White (230,000), black African, Black Caribbean, and 'Other' ethnicities are the next highest groups each with approximately 3.6% of the population (each 10,700). Up to 2015, the largest change expected in the population will be an increase of just over 5000 people in the White ethnic group. The next largest group is the 'Other' ethnic group with an increase of just under 1,500. Black Caribbean represents the third largest change with a drop of 500 people. [5] 2007 Mid-Year Estimates by Ethnic Group (experimental), Office for National Statistics Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 11 of 89

12 Figure 3: 2011 Wandsworth ethnic population estimates Source: GLA 2007 Round Ethnic Group Projections Disability Estimating the extent of disability in a given population is complicated by the definition to be used, and the care and support a person with a disability requires. The number of severely disabled people under the age of 65 receiving a Disability Living allowance payment can be used as a crude measure and an obvious underestimate of the number of people with a disability. The allowance has two components: a care component - for people who need help with personal care and are likely to go on needing that help; and a mobility component - for people who have walking difficulties and are likely to continue to have those difficulties. In May 2010 there were 6,600 people receiving the allowance in Wandsworth, 60% of which were aged between 45 and 65, exactly the same proportion as recorded for the whole of London. Sexual Orientation The numbers of people who are Lesbian, Gay, Bisexual or Transgender (LGBT) in the UK is unknown and only estimates exist. However, the Office of National Statistics (ONS) estimates that the percentage of LGB people in the UK is 1.5%. This would represent 6,600 people in Wandsworth. Due to Wandsworth s close proximity to central London and its closeness to social gay areas of London (Clapham) and because of Wandsworth s social demographics, this figure is again likely to be higher than the average for London [1] [1] The latest detailed figures show that gay people are much more likely to be in managerial or professional occupations 49% compared with 30% for straight workers - and better educated, with 38% holding a degree. Their age profile is also much younger than the rest of the population, with 66% under the age of 44 and 17% aged 16 to 24. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 12 of 89

13 The CCG engages with the LGBT population via the Wandsworth LGBT Forum. Set up in 2005, its overall aim is to improve the lives of LGBT people living, working and studying in Wandsworth In addition, the CCG is a member of the Stonewall Diversity Champions programme. Carers Within the age range, an increasing proportion of the population will assume caring responsibilities for a person with a long term illness or disability. Carers save the UK economy an estimated 119billion with the care they provide. Caring is based on preexisting relationships with the cared for person, therefore the pressures of caring often have a detrimental effect on the health and well-being of the carer. There are around 19,000 carers in Wandsworth. In October 2009 a Carers Strategy was launched to improve the way in which carers needs were met. A real-time survey at the launch found that 45.2% of the carers participating felt themselves to be less physically healthy than people of the same age who were not carers, and 67.1% felt themselves to be less emotionally healthy. In 2009/10 the proportion of carers, who were reviewed by Adult Social Services and provided with a service as a result, was 15%, which placed Wandsworth in the bottom quartile of London Boroughs (England 26%). Provisional figures for 2010/11 indicate an improvement to 26.5% due to investment in systems and processes linked with the implementation of Self-Directed Support. Identification of carers remains a priority in order to promote independent living. This is particularly an issue for mental health service users where the role of the carer can more easily remain hidden. Health status Statistically, Wandsworth residents are not expected to live as long as their counterparts elsewhere in London. Males are expected to live 76 years and females 81 years, whereas male Londoners as a whole can expect to live 77 years and females 82 years. A boy born in Latchmere is expected to live for 72 years: 8 years less than a boy born in Thamesfield (Source: LHO, ONS mortality ). The Standardised Mortality Ratio (SMR) is a measure that assesses one value against another taking into account age and sex differences within each population. The based SMRs for Wandsworth indicate mortality in line with England, both across all causes of death (5,013 deaths) and for cancer (1,311 deaths), whereas rates of mortality in London are generally better than England. Although not statistically significant the SMRs for Wandsworth are worse than England for under 75 mortality (1,837 deaths) and circulatory disease (1,683 deaths). The level of suicide and undetermined deaths in Wandsworth is relatively low compared to England; Wandsworth (SMR 70, 53 deaths), London (SMR 88, 1,705 deaths). (Source: NCHOD ) Within circulatory disease, the under 75 mortality Directly Standardised Rates (DSR) from heart disease in Wandsworth is lower at 38 per 100,000, than London (40) and England (39). For stroke the under 75 mortality DSR in Wandsworth is higher at 15 per 100,000, than the rate in London (13) and England (13). Source: NCHOD 2007/2009). Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 13 of 89

14 Two targets for under 75 mortality were set out under the White Paper Our Healthier Nation for circulatory disease and cancer. These were set with another measure called DSR, which, although laid out differently, still address the age and sex differences in the underlying populations. The circulatory target of 99 (DSR) has already been reached with a actual of 85 (DSR). The cancer target of 107 (DSR) has not yet been reached, with a based actual of 124 (DSR). Attendance rates at hospital are indicative both of the absolute level of need within the community as well as the effectiveness of community based services in providing treatment without the need for hospital admission. The attendances rates for outpatients, and emergency admissions in Wandsworth is lower than for London, but A&E attendances are higher than London (Table 1). The DSR for outpatient attendances and admissions for mental health conditions in Wandsworth is higher than for London and England, suggesting that mental wellbeing remains a key issue for Wandsworth. Table 1: Hospital Care 2009/10, Directly Standardised Rate per 1000 population. Activity Wandsworth Rate (Value) London Rate England Rate Outpatient Attendances 1209 (405,673) Accident and Emergency 344 (126,648) attendances Emergency admissions 69 (21,610) Admissions for alcohol 1489 (3,375) related* Mental Health harm outpatient 35 (12,468 ) attendances Mental Health admissions 2.1 (792 ) Source: NHS comparators 2009/10, *Local Alcohol Profiles England 2008/ Key health issues for the Wandsworth population The 2010 JSNA is available online and represents a strategic level analysis of key issues for the health and care of the Wandsworth population. NHS Wandsworth is responsible for the commissioning of health services and population facing health promotions, and ill-health prevention initiatives. The JSNA collates all health needs assessments conducted in Wandsworth and presents a series of key messages for health and care that deserve particular attention. The context for the CSP is set by two over-riding themes. (a) There are significant geographic variations in health within Wandsworth. In general, the more affluent parts of Wandsworth also have the best health outcomes. The gap in life expectancy between the most and least affluent areas in Wandsworth is 7.5 years, with Latchmere being the ward in which residents have the shortest life expectancy. The greatest single cause of variations in life expectancy is coronary heart disease, accounting for over one year of the life expectancy difference between the most and least affluent areas. (b) Wandsworth has higher than expected rates of premature mortality from circulatory disease and cancer. Between 2006 and 2008, the standardised mortality rate amongst Wandsworth residents aged under 75 from both cancer and circulatory disease was above both London and national averages, for both males and females. The mortality rate for cancer was of particular concern, with the previous decline in the Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 14 of 89

15 mortality rate ceasing in 2003, and subsequent years showing a slight upward trend amongst both males and females. The 2010 JSNA details nine further specific areas for further analysis and action. (c) Childhood obesity is a major concern. Over one in five children (21.4%) in Year 6 in Wandsworth primary schools in 2009/10 were obese. This is just below the London average (21.8%) but significantly above the national average (18.7%). (d) Wandsworth still has a high teenage pregnancy rate. Although the teenage pregnancy rate in Wandsworth has decreased faster than the London and national averages over the past ten years, it remains above the London and national averages, and higher than the rate in boroughs with the most similar population profiles. (e) There are high rates of sexually transmitted infections. In 2010, there were acute sexually transmitted infections per 100,000 population in Wandsworth well above the London average of and more than twice the national average of The rate of Chlamydia infection in the population aged was 3,053.7 per 100,000 population above the London average of 2,506.8 and the national average of 2, (f) Alcohol-related hospital admissions have risen sharply. Between 2005 and 2009 the rate of alcohol-related hospital admissions amongst Wandsworth residents rose by 36%, from 1,260 per 100,000 to 1,719 per 100,000. This reflects the trend across London, where admission rates increased by 41%, and nationally, where there was a 35% increase. (g) There is a high level of mental health needs in Wandsworth. The estimated rate of depressive episodes in Wandsworth is 37.6 per 1,000 population aged 16-74, significantly above the overall rates for London (35.2 per 1,000) and England (25.0 per 1,000). Likewise, the estimated rate of all neurotic disorders in Wandsworth (200.1 per 1,000 population) is significantly higher than the overall rates for London (182.1 per 1,000) and England (165.7 per 1,000). The proportion of Wandsworth patients on the primary care mental health register for schizophrenia, bipolar disorder and other psychoses (8.2 per 1,000 population) is significantly higher than the national average (7.5 per 1,000) but significantly below the London average (9.3 per 1,000). However, the mental health register is not adjusted for age and is dependent on the comprehensiveness of GP records, so it can only be regarded as giving a partial view of mental health needs. (h) Carers may have unmet health and support needs. A survey at the launch of the Wandsworth Carers Strategy in 2009 found that 45% of the carers participating felt that they were less physically healthy than people of the same age who were not carers. In 2008/09 the proportion of carers in Wandsworth who were reviewed by Adult Social Services and provided with a service as a result was 15 %, below the rates for London 21% and England 23%. However, there has subsequently been a rapid increase in the proportion of Wandsworth carers receiving a service, reaching 27.8% in 2010/11. (i) There is a high rate of excess winter deaths. Between 2005 and 2008 the death rate in Wandsworth in the winter months (December to March) was 22.5% higher than that Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 15 of 89

16 in other months of the year. This is greater than the differential across London (13.0%) and nationally (15.6%). This equates to a total of 571 excess winter deaths in Wandsworth over this five year period. The largest numbers of excess winter deaths were due to ischaemic heart disease, flu and pneumonia. Factors that may contribute to this include a low uptake of flu immunisation that is below the London and national averages and (at the 2001 census) a higher proportion of people aged over 65 in homes without central heating (18.78%), compared to London (13.54%) and England (11.57%). (j) The mortality rate from accidental falls is high. The mortality rate from accidental falls in Wandsworth between 2006 and 2008 was 7.88 per 100,000 population significantly higher than the rates for Inner London (3.71 per 100,000), London (2.65 per 100,000) and England (3.73 per 100,000). Over the past five years, there have been rising trends in the number of Wandsworth residents admitted to hospital both for hip fractures and for non-hip fractures. (k) Enabling the over-75s to maintain their independence remains a significant challenge. In 2010, there were around 11,300 people aged 75 or over living in Wandsworth, which is expected to reduce slightly to 11,000 by Just over 5,000 people aged over 75 live on their own, and the proportion of people in this age group living alone is expected to rise. Of the approximately 30,000 people raged over 65 who are registered with Wandsworth GPs, over 12,000 have a long-term limiting condition, 5,000 were unable to manage at least one mobility activity, and 2,000 required support to live independently. 4.3 Quality position The CCG is committed to improving health and health care for the local population through pursuing excellence in the quality and efficiency of commissioned services. A quality strategy is being drafted, drawing together existing work, and will guide future developments. It is due to be completed by the beginning of next year (2012). The four key objectives that will be addressed at every stage of the commissioning cycle are: 1. To ensure that services being commissioned are safe, personal and effective. 2. To ensure the right quality mechanisms are in place so that standards of patient safety and quality, are understood, met and effectively demonstrated. 3. To provide assurance that patient safety and quality outcomes and benefits are being realised, and recommend action if the safety and quality of commissioned services is compromised. 4. To promote the continuous improvement in the safety and quality of commissioned services. The last year has seen some real improvements in healthcare services across the borough. Clinical Quality Review Group (CQRG) Findings Clinical Quality Review Groups (CQRG) are a good monitoring framework to review and scrutinise the quality of a service commissioned. Frequency will be determined by size and complexity of service. Within Wandsworth we are currently engaged with two key groups, St Georges Hospital and South West London and St. Georges Mental Health Trust. As Wandsworth residents access services outside of these providers, a formalised link, or development of a review process for the services needs to be established. E.g.: Chelsea and Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 16 of 89

17 Westminster hospital currently has a CQRG- but no information about the quality of care is provided to the Wandsworth borough team. The quality of all these services together with national, pan London and locally available data (including surveys) will then be considered in a quality of commissioned services sub group of the CCG Performance against targets for 2010/11 Overall, performance in 2010/11 was strong, with improvements or sustained performance seen in a number of areas. For example, CCG has achieved targets set in: childhood obesity (10% of reception year children are obese compared to a target of 12% and 21% of year 6 children are obese compared to a target of 22%); diabetic retinal screening, which we failed to achieve in 09/10 (100% of diabetics were offered screening); smoking cessation (1,351 quitters compared to a target of 1,287); NHS Health Checks (16% of eligible people offered screening); There were improvements in most areas of acute care, with the quality of stroke care, 18 weeks non-admitted, A&E wait times and cancer waits targets, all being achieved. We also achieved a strong performance in mental health targets such as Child & Adolescent Mental Health Services (CAMHS), Crisis Resolution and Early Intervention. Finally, we were successful in achieving our Healthcare Associated Infections (HCAI) targets which were particularly challenging in 2010/11 and there has been an improvement in London Ambulance Services (LAS) performance in 10/11 (achieving both elements of Category A calls). However, we underperformed at year end against indicators such as: 12 week maternity waits (86% against a target of 90%) Breastfeeding prevalence (72% against a target of 76%) Chlamydia screening (26% against a target of 35%) 18 weeks admitted (83% against a target of 90%) Childhood immunisation (achieved 3 out of 7 indicators) Cervical screening coverage (68% for year olds and 74% for year olds) Teenage pregnancy rates (47 compared to a target of 32). These indicators will continue to be monitored in 2011/12, and improving performance in previously underperforming areas has been identified as a key priority for the CCG. Indicators will be reviewed and strengthened to reflect the quality of the service to compliment the performance using NICE quality outcome indicators where available, and developing locally agreed ones where not. We have detailed action plans in place to improve all of our performance measures, which are monitored regularly at our Performance Steering Group (attended by target leads and representatives from each of the locality commissioning groups). In order to further sustain improvements, we have developed a GP engagement plan, which provides funding for each GP practice to identify performance leads to improve performance against a number of key indicators. This ensures that we have engagement in performance improvement from the front line of primary care. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 17 of 89

18 St George s Healthcare NHS Trust, Tooting The CCG works closely with the Acute Commissioning Unit (ACU) to oversee performance at our local Trusts. In some cases (e.g. Chelsea and Westminster NHS Trusts) this involves working with ACUs in other sectors to identify and resolve issues. Our main provider, St George s Hospital, performed well overall in 10/11, and achieved key quality indicators such as Healthcare Acquired Infection rates, A&E waiting times, cancer waiting times and percentage of women initiating breastfeeding. However there were some areas of performance concern such as the number of admitted patients waiting longer than 18 weeks, mixed sex accommodation and discharge summaries sent out within 24 hours. The Trust has actions in place to improve performance in these areas in 11/12 onwards, and these are monitored by the CCG and ACU regularly. As our main provider, we work particularly closely with St George s Hospital. Some of the key areas that the CQRG have worked on trust-wide include: Paediatric out of hours clinical cover Quality/safety of maternity services Overview of SGH serious incidents and learning Quality of discharge letters Reviewed care of patients with pressure ulcers Improving the quality of care for patients requiring emergency surgery as per best practice guidance. South West London & St Georges Mental Health NHS Trust Although there are examples of good performance and improvement in many areas, the Trust had a mixed record of delivering services to good standards of quality and safety during 2010/111. Some significant improvements in patient experience were reported during 2010/11, with the implementation of the Improving Access to Psychological Therapy programme in primary care and qualitative improvements in inpatient services in Wandsworth being notably successful. Significant improvements also occurred in key quality indicator areas for community services including 7-day follow up, Crisis plans, delayed transfers of care and gate-keeping by Crisis and Home Treatment teams. However, in some areas of clinical effectiveness, in particular in Wandsworth, Care Programme Approach Reviews, the Trust has struggled to meet targets. A major area of concern Trust-wide also lies with patient experience, with community service user ratings continuing to be poor and waiting-times for Child and Adolescent Mental Health (CAMHS) Tier 3 and Psychological Therapy in particular, remaining stubbornly long. Remedial Action Plans are in place. Key issues that the Mental Health Trust CQRG is working on include: Overview of serious incidents and learning Inpatient quality and experience Monitoring implementation of CQUINs Engaging other key stakeholders in quality issues Audit of anti-psychotic medication for dementia Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 18 of 89

19 Other Commissioned Services The Transforming Community Service programme has meant that our provider arm, Community Services Wandsworth (CSW) merged with St George s NHS Trust from 1 st October A number of our challenging Key Performance Indicators (KPIs), such as breastfeeding and childhood immunisations, are delivered or supported by CSW. CSW also report a number of quality measures to us on a regular basis. We will continue to have quarterly contract management meetings with CSW to monitor and improve performance against quality and productivity. Better Services, Better Value: the case for change for health services in south west London In addition to the Borough priorities identified below, there is South West London (SWL) Cluster-wide work looking at the Cluster-wide strategy, Better Service Better Value (BSBV). The focus of this programme is ensuring that we have high quality, safe and good value acute services into the future. There are a number of clinical working groups comprising doctors from both hospitals and general practices and patient representatives, to look at the patient journey and models of care in the following: 1. Planned care 2. End of life care 3. Urgent, unscheduled and emergency care 4. Maternity and newborn care. 5. Children s services 6. Long-term conditions Several Wandsworth GPs are involved in (or lead) these programmes. The CCG supports the work of the BSBV programme. Ongoing plans will reflect the recommendations as they emerge between now and 2014/15. We will take incremental steps, year on year, to invest in enhanced capacity and service quality in those areas identified as priorities in the case for change. We will also ensure that local plans dovetail with the outcomes of BSBV and that plans are mutually supportive Patient Experience We are committed to using the information we gather from patients to help us improve the quality of services we commission. This includes information from patient surveys, PALS queries and other PPI activities. We also review learning from Serious Incidents and Complaints to identify particular concerns about quality or patient experience and address this with providers through contractual routes. Wandsworth Patient Advice & Liaison Service (PALS) In 2010/11 the Wandsworth Patient Advice and Liaison Service (PALS) reported that the key queries/issues raised by patients about their experiences predominantly relate to areas around Access within GP practices and General Dental Practitioners. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 19 of 89

20 Main issues include: improving access, waiting times and information on how to access service required; Patient Pathways; including registration with GP and removal from GP list; Finding a dentist and NHS dental charges; Referral enquiries. Other queries/issues raised related to commissioning enquiries which were dealt with directly by NHS Wandsworth, including: NHS policies and procedures; Assisted Conception funding and specialist funding; Referral enquiries; Immunisation enquiries BCG and HPV vaccinations. Results of the GP Patient Survey We regularly monitor the results of the GP Patient Survey. The aggregated results for 2010/11 showed that Wandsworth performed at, or better than, the England average in: Ability to see a doctor fairly quickly (78% compared to average of 79%); Ability to book ahead for an appointment with a doctor (71% - same as average); Ease of getting into surgery buildings (98% - same as average); Satisfaction with opening hours (80% - same as average); Recommending GP surgery to someone (83% - same as average). However, our patients raised concerns in the following areas: Below England average for ease of getting results on the phone (29% compared to average of 36%); Frequency of seeing preferred doctor (68% compared to average of 73%); Rating of doctor asking about symptoms (85% compared to a average of 88%); Rating of doctor treating patient with care and concern (81% compared to average of 84%); Practice nursing (e.g. rating of practice nurse taking problem seriously 61% compared to average of 70%, rate of practice nurse listening to the patient was 68% compared to an average of 76%); Out of hours (OOH) care (e.g. 48% know how to contact OOH provider compared to average of 62%, 63% found it easy to contact OOH provider compared to an average of 78%, 47% rate the care received by OOH provider as good compared to an average of 63%). There will be a new GP patient survey issued twice a year in 2011/12 and we will continue to monitor our performance against this Care Quality Commission (CQC) Inpatient Survey The Care Quality Commission (CQC) publishes surveys relating to provider organisations. According to the 2010 inpatient survey, our main provider, St George s, scored about the same as other Trusts in the 10 overall sections. The detailed results were: Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 20 of 89

21 Table 2: St.George s Hospital survey results St George s Hospital Section in survey Score Comparison with other Trusts Questions about the emergency department 7.6/10 About the same Questions about waiting lists and planned 6.5/10 About the same admissions Questions about waiting to get a bed on a 7.7/10 About the same ward Questions about the hospital and ward 7.9/10 About the same Questions about doctors 8.5/10 About the same Questions about nurses 8.2/10 About the same Questions about care and treatment 7.6/10 About the same Questions about operations and procedures 8.4/10 About the same Questions about leaving hospital 7.0/10 About the same Questions about overall views and experience 6.7/10 About the same Similarly, the maternity survey of 2010 asked specific questions about maternity services: Table 3: St.George s Hospital maternity survey results St George s Section in survey Score Comparison with other Trusts Care during pregnancy 7.9/10 About the same Labour and birth 7.6/10 About the same Staff during labour and birth 8.2/10 About the same Care in hospital after the birth 6.7/10 About the same Feeding the baby during the first few days 5.3/10 Worse This indicates that, on the whole, our main provider is rated average for a number of quality indicators as reported by our patients. Where particular issues have been raised, (e.g. infant feeding support), the CCG will continue to work closely with our providers and the Acute Commissioning Unit (ACU) to improve performance. Survey results for our other main providers can be found on the CQC website: Financial position NHS Wandsworth (NHSW) ended 20010/11 as planned with a surplus of 12.3m. This surplus has built up over a number of years through sound financial planning. The surplus has been established to protect Wandsworth patients from an anticipated tough financial climate in future years, to ensure investment into patient care for Wandsworth patients is protected. NHSW utilised its 2010/11 growth to fund inflation and anticipated increases in activity. After funding existing commitments NHSW was able to invest approximately 5.4m in to specific Commissioning Strategy Plan initiatives and high priorities. NHSW recognised that there were a number of risks, particularly associated with key NHS policy initiatives nationally and locally that could impact on its 2011/12 financial Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 21 of 89

22 performance. As a result we have made provision to manage many of these risks through making adequate investment in service level agreements and through existing reserves and provisions to manage these pressures in year. For 2011/12 NHSW is forecasting that it will meet its proposed revised surplus of 14.5m and its current year to date position and most likely scenario planning indicates this can be achieved. NHSW s acute spend increased significantly in month 6 and is likely to increase further over the winter months. This increase was partly expected and we have sufficient reserves to cover the impact. However, this has significantly reduced our 2011/12 reserves overall and we need a cautious approach to spend to the end of the year. Wandsworth has a QIPP target of 7.086m and we are confident that this will be achieved. We have identified new QIPP schemes during the year to mitigate slippage in existing schemes. There are some key financial challenges within our position. Our capital programme is reliant on the sale of Putney Land, and we will not have certainty about completion until December In 2012/13, NHSW is expected to move from a forecast surplus of 14.5m (2.7%) to a surplus of 8.2m (1.5%). The 1.5% 2012/13 surplus target will be confirmed when the overall SW London Cluster financial position is more certain. It is essential that our underlying recurrent and non recurrent position is understood. This will ensure our investment plans do not jeopardise our underlying financial position going forward. Section 8.3 explains NHSW s underlying position and the investment approach required to maintain underlying recurrent balance. 5. Key Strategic Initiatives (Commissioning Priorities) 5.1 Key strategic initiatives (commissioning priorities) In response to the key health issues, as identified in Joint Strategic Needs Assessment (JSNA), the CCG has approved a number of key strategic initiatives (commissioning priorities) for the health and healthcare of the local population, below. These initiatives will be supported by the Quality, Innovation, Prevention and Productivity (QIPP) transformational programme. a) Prevention, screening, early diagnosis and awareness initiatives b) Sexual Health c) Substance Misuse (drugs and alcohol) d) Children s Services e) Urgent Care/Older People f) Long Term Conditions g) Mental Health h) Borough Specialised Commissioning Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 22 of 89

23 a) Prevention, screening, early diagnosis and awareness initiatives Relation to JSNA priorities: (a) Significant geographic variations in health within Wandsworth; (b) High rates of premature mortality from circulatory disease and cancer; (i) High rate of excess winter deaths; (j) High mortality rates from accidental falls. Prevention initiatives are intended to change behaviour that may lead to ill health or premature death. Screening initiatives are intended to detect disease earlier before the development of clinical signs and symptoms. Awareness initiatives empower people to take control of their own lives, inform them of health risks, symptoms of conditions or diseases and available services. There are many separate initiatives all with measures of success, a few examples include: Prevention: smoking cessation, childhood immunisations, NHS health checks Screening: cervical screening, maternal and newborn screening. Early diagnosis: clinical stage of cancer at diagnosis. Awareness: smoking in pregnancy, or breastfeeding uptake, healthy eating, physical activity. b) Sexual health Relation to JSNA priorities: (d) High teenage pregnancy rate; and (e) High rate of STIs. Implementation of Integrated Service for Reproductive Sexual Health and Genito- Urinary Medicine Services (GUM) to enable a plurality of tests and services to be made available to patients that attend either service. Development of a primary care sexual health model. Achieving a reduction in teenage pregnancy and high numbers of positive Chlamydia screens will be two measures of success. c) Substance Misuse (drugs and alcohol) Relation to JSNA priorities: (f) Sharp rise in alcohol-related hospital admissions. To increase the numbers in effective treatment and planned exits. To reduce alcohol related hospital admissions. d) Children s Services Relation to JSNA priorities: (c) Childhood obesity. Delivering the Children & Young People s Plan (CYPP): Increase patient facing time with health visitors and school nurses. To embed the principles of safeguarding children throughout locality groups. To build upon existing weight management services for children and families. To achieve 75.7% breastfeeding prevalence at the 6-8 weeks check and increase the percentage of women who initiate breastfeeding to 95%. To increase all childhood immunisation and seasonal flu immunisation uptake rates, and to ensure all GP practices have a standard call / recall mechanism. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 23 of 89

24 To deliver on the Children s and Young Persons Plan (CYPP) in collaboration with Children s Social Services, other Council departments and key stakeholders. To reduce the number of children without a GP. e) Urgent Care/Older People Relation to JSNA priorities: (i) Excess winter deaths; (j) Mortality rate from accidental falls; and (k) Enabling the over 75s to maintain their independence. To reduce emergency admissions for patients at risk of admission by admittance to a community ward for more specific monitoring in the community. NHS Wandsworth and WLA to jointly specify an aligned intermediate care and reablement service by April To re-align intermediate care into an accessible, admissions avoidance service. This is an immediate priority given Dawes House (16 ICT beds) is to close due to withdrawal of other services on the site and the physical condition of the site and an interim arrangement is to be put in place. Reduce A&E attendances during practice opening hours by providing same day access to primary care. To specify and commission the Out Of Hours contract from July To commission a primary-care lead Urgent Care Centre to migrate the existing Walkin Centre along with enhanced primary and community services to reduce inappropriate attendances and mitigate short-stay admissions. A programme on referral management is reviewing options to reduce outpatient attendances. To refocus the falls management and bone health pathway from secondary care intervention to primary/community care prevention and mitigation. To improve End of Life Care services by measuring and reviewing quality of services. Collaborate with Social Services on the case-management of patients with a high health and social care need. Improve services and care to people with dementia and their carers. f) Long term conditions Relation to JSNA priorities: (b) Higher than expected rates of premature mortality from circulatory disease and cancer; (h) Carers unmet health and support needs; (i) High rate of excess winter deaths; (k) Enabling the over 75s to maintain their independence. Supporting the development of models for Long Term Conditions (LTC) which: support self management; reduce the need for secondary care attendances; deliver nurse or consultant led clinics in the community; strengthen primary care services; prevent ill-health wherever possible. This priority will see pathway development for Cardiovascular Disease (CVD) and Stroke, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Asthma, Sickle Cell Disease and Dementia. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 24 of 89

25 Carers : Carers support to be embedded into new care pathways for all long term conditions Primary care staff to receive carer awareness training and ongoing engagement with carer support services. Carers to be fully engaged in the process of hospital discharge Carers should have access to breaks. g) Mental health Relation to JSNA priorities: needs. (g) High level of mental health needs; (h) Carers unmet The key outcomes are to develop primary care mental health resources and effective primary care pathways, and where appropriate, develop mental health initiatives in partnership with local communities and third sector organisations. Two particular initiatives have been prioritised: Embedding recently agreed changes to the Community Mental Health Teams (CMHT) and crisis intervention services, which have been funded to provide additional capacity. Reducing the waiting time for Improving Access to Psychological Therapies (IAPT), and to ensure the service reaches hard to reach groups, such as Black and Minority Ethnic groups, people with Learning Disabilities, carers and isolated older people. Measures of success include the achievement of a number of mental health indicators related to IAPT, Crisis Resolution, Early Intervention in psychosis and reduced admissions and re-admissions to acute inpatient care. h) Borough Specialised Commissioning Continue to improve the rehabilitative pathway for Forensic patients through effective care management. To ensure regular reviews of Continuing Care patients, use of joint health and social care funding, where appropriate, and achieving value for money within the provider market in collaboration with council commissioners. i) Supporting initiative: QIPP QIPP is a large scale transformational programme for the NHS, to improve the quality of care the NHS delivers whilst making efficiency savings which will be reinvested in frontline care. Wandsworth needs to deliver approximately 12.5 million of savings in 12/13, and the CCG is committed to ensuring quality and prevention initiatives form part of our approach. 5.2 Local Commissioning Group (LCG) Priorities Many of the above strategic initiatives need to be delivered at a locality level to address the variances in health across the borough. LCGs have therefore identified important priorities for their local population to address inequalities in health and these are described below. There are three levels of LCG priorities: Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 25 of 89

26 Wandsworth-wide priorities (Level 1) Local priorities have been defined by the JSNA key priorities, and with national targets form a comprehensive range of Wandsworth wide priorities. In conjunction with the LCGs, Public Health priorities include: CVD prevention including NHS Health checks. Smoking cessation. Cancer prevention, screening, awareness and early diagnosis. Teenage pregnancy. Chlamydia screening programme. Reducing late diagnosis of HIV. Mental health and well being. Childhood immunisation and flu immunisation. Obesity and weight management services. Physical activity services. Improving the health of older people including falls prevention, prevention of excess winter deaths. Community development and outreach services with Health Trainers. Substance misuse, including alcohol The management of LTCs and their complications, including diabetes, cardiovascular and cerebrovascular disease. Locality-led action (Level 2) It is proposed that one LCG takes the lead on particular workstreams for all other LCGs. Locality specific action (Level 3) LCGs have identified local needs and developed priorities and workstreams based on these needs. LCGs have developed Local Delivery Plans (LDPs) which detail the actions to address these priorities. The table at Appendix 2 provides a summary of the current LCG priorities for 2010/11 as well as recently identified focus areas for delivery. These priorities are due to be refreshed. Table 4 below illustrates how the different levels of plans and priorities discussed above map across from Borough to LCG level. It should be noted that some particular JSNA key messages may span a number of strategic initiatives, e.g. the unmet health and support needs of carers. The table below provides a snapshot of the ongoing priorities and actions from 2010/11 as well as recently identified focus areas for delivery. These will be reviewed annually. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 26 of 89

27 Table 4: Link between Borough and LCG plans and priorities Help people to live longer and healthier lives, particularly those living in Wandsworth s most deprived communities Goals JSNA priorities Strategic Initiatives Public Health/LCG Wandsworth-wide priorities (summary) Significant geographic variations in health within Wandsworth High mortality rate from accidental falls High rates of mortality from CVD and cancer High rate of excess winter deaths Prevention, awareness, early diagnosis and screening initiatives; CVD prevention including NHS Health checks Smoking cessation Cancer prevention, awareness, screening and early diagnosis of cancer Maternal and newborn screening LCG Actions (Levels 2 & 3) (Pan-Wandsworth and locality specific) West Wandsworth Battersea Wandle Falls Support young people to take control of their own health earlier, so they continue to make healthier choices throughout their lives Childhood obesity. Children s Services - Delivering the Young People s Plan Chlamydia screening programme Childhood immunization Childhood Obesity Teenage pregnancy TB Ready for schools pack Educate people about mental wellbeing, sexual health, drugs, alcohol and obesity. Help prevent and diagnose earlier and improve services. High rates of sexually transmitted infections. High teenage pregnancy rate Alcohol-related hospital admissions High level of mental health needs Carers unmet needs Sexual Health Substance misuse Mental Health Reduce late diagnosis of HIV Substance misuse including alcohol Mental health and wellbeing Obesity and weight management services Physical activity services Community development and outreach services with Health Trainers Sexual health teenage pregnancy and Chlamydia screening Mental health Dementia Educational Event HIV screening Improve access, quality and choice of service provision across all care pathways and in appropriate settings. High mortality rate from accidental falls. Enabling the over-75s to maintain their independence Urgent Care/Older People Borough Specialised Commissioning Flu immunisation Ageing well Urgent Care (QMH) Shift of Care (QMH) Practice/District Nursing 24 hour ECG Heart failure nurses review Phlebotomy and Anticoagulation Improve the quality of life of people Carers unmet health and support Long term conditions Falls prevention living with long term and complex needs health conditions and their carers by improving the quality, range and High rate of excess winter deaths choice of services and giving them information to better manage their Enabling the over-75s to maintain Prevention of excess winter deaths own health. their independence Management of Long Term Conditions Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) and their complications, including diabetes, Page cardiovascular 27 of 89 and cerebrovascular disease. Supported self management Pain management Cardiac rehab Sickle cell COPD Managing community same day urgent care in practices Diabetes Cardiovascular disease Dementia Educational Event

28 6. Opportunities and Focus Areas for Service Redesign 6.1 New opportunities The following opportunities (i.e. strategic initiatives) and focus areas for service redesign have arisen from the JSNA 2010 and the identified priorities, as described above. The new commissioning priorities and their associated initiatives and opportunities are described below including information about the progress to date and plans up to These initiatives have also been mapped back to headings used in the previous CSP to illustrate how they build on previous CSP priorities. There are, however, a number of other initiatives described in the previous CSP which are not picked up within the newly identified commissioning priorities. These initiatives have been added below together with descriptions of progress and any further actions planned up to 2015, or whether these actions have been completed Prevention, screening, early diagnosis and awareness initiatives - previously identified as Staying Healthy in the previous CSP Prevention, screening, early diagnosis and awareness initiatives are designed to promote health, reduce inequalities and tackle the key causes of mortality and preventable disease. These initiatives are not exhaustive; other initiative areas in the CSP will also contain examples of health promotion, for example sexual health and children s services. Strategic Initiative Achievements to date 2011/12 Prevention, screening, early diagnosis and awareness initiatives Targeted health promotion Delivered obesity programme in deprived wards and high risk groups. Health Trainer outreach work to 250 people Exceeded the smoking cessation target, and implemented a Locally Enhanced Service to negotiate targets at GP and Pharmacy level. Targeted areas of high smoking prevalence and increased access to the stop smoking service. Trained providers to improve capacity to deliver on Stop Smoking targets, and improved information systems, to improve the efficiency of service provision. Cancer awareness and earlier diagnosis A Cancer Awareness survey was undertaken with 835 responses from members of the public Appointment of a GP Facilitator to work with primary care, Pilot with pharmacy for lung and bowel cancers Support the existing cancer screening programmes for Bowel breast and cervical and identify additional services. Recognised as one of the top early implementers of the NHS Health Check Programme. Since the start of the programme in 2009 over 17,000 NHS Health Checks have been undertaken. Universal BCG pilot launched for all children soon after birth. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 28 of 89

29 Outstanding Actions to date (2011/12) New Initiatives 2012/13 Achieved the diabetic retinal screening target Implemented the Abdominal Aortic Aneurysm Screening Programme. Development of Public Health CQUIN with community services. Development of Stop Smoking Mental Health CQUIN. Piloting of a combined physical activity and intensive stop smoking programme Develop Atrial Fibrillation patient screening and treatment optimisation programme to be implemented by March 2012 Increase Smoking cessation services in pharmacies Ensure patients that smoke receive support in hospital and after discharge from St George s, and SW London & St. George s Mental Health Trust. To complete the development of a Joint Tobacco Control Strategy with the Council Develop and implement a Joint Health Inequalities Strategy Implement Falls Prevention and Bone Health Strategy Health Needs Assessment and action plan for the frail elderly in care homes Health Needs Assessment and an action plan for excess winter deaths NHS Health Checks Development and procurement of a Community Outreach function. Pilot with Community Pharmacy. Consider procurement of an Intensive Lifestyle Intervention Programme. Implement Your Personal Best physical activity programme for people with long term conditions in primary care Produce and implement the Active Wandsworth Strategy for and capitalise on the opportunities of the 2012 Olympics Develop and implement an action plan with the Local Authority for the NICE CVD prevention and Type 2 Diabetes prevention guidelines. Implementation of the London TB Model of Care within Wandsworth Improve coverage of Abdominal Aortic Aneurysm and diabetic retinal screening Implement initiatives with GPs and the public to improve cancer awareness and early diagnosis. Support health promotion in HMP Wandsworth and delivery of all Public Health programmes such as smoking cessation, and NHS health checks Formal procurement of Physical Activity Services to support an increase in the service provision. Implement a primary care Stop Smoking Model Develop a Stop Smoking referral pathway with St Georges Implement Stop Smoking programmes in schools Development of workplace health initiatives to improve the health of the NHS workforce Work with partners in South West London to harmonise the system of Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 29 of 89

30 remuneration and data capturing for the Stop Smoking service Implementation of the new Cardiac Rehabilitation commissioning guidelines in 2012/13 to ensure improved consistency, quality and access by patients to cardiac rehabilitation services across Wandsworth. Potential Investment requirements Implement cancer awareness initiatives. Implement obesity strategy. Recruit a health promotion practitioner at HMP Wandsworth to help assess, deliver and sign post prisoners to appropriate services. Screen for TB in high risk individuals in primary care ( 80k) Promote diabetic retinopathy screening (DRS) and abdominal aortic aneurysm (AAA) in the community and general practice ( 15k) Implement NICE prevention guidelines for CVD and Diabetes. Implementation of national cardiac rehabilitation commissioning guidance ( 600k). Implementation of Your Personal Best initiative. Implementation of Active Wandsworth Strategy and workplace health initiatives Sexual health Strategic Initiative Achievements to date 2011/12 Sexual Health 34% reduction in teenage pregnancy rates since o Action plan in partnership with the Local Authority HIV pilot projects to reduce late diagnosis. o Increased testing in GP including at registration and at A&E in St George s. o Cluster and pan London prevention and support services including helplines, and outreach work with specific group and communities. Maintained coverage of Chlamydia screening at significantly reduced cost. o Increased GP engagement and involvement from other core services with the aim that they provide the majority of tests completed. o Included Gonorrhoea in a joint test; this increases the value of the test to the young people with no additional cost to Wandsworth. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 30 of 89

31 Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential investments or disinvestment requirements Continue and stabilise current trend of reducing teenage pregnancy rates. Refresh and formalise the sexual health specialist service integration model for Reproductive and Sexual Health (RSH) and Genito-urinary medicine (GUM) services. Review the provision of Sexual Health Services within primary care. Review value for money and effectiveness of HIV services provided by groups of PCTs within and across London. Review condom distribution scheme. Review service level agreement with termination of pregnancy providers. Continue work focused on reducing repeat terminations among those aged 19 and under by providing contraceptive advice and treatment, including LARC. Scope and develop a sexual health QIPP programme. Review HIV pilot projects to monitor effectiveness at reducing late diagnosis. Consult and implement the sexual health specialist service integration model. Scope integrated sexual health LES in GPs and implement if appropriate. Scope tiered sexual health LES for pharmacies and implement if appropriate. Develop action plan for long acting reversible contraception through general practice in line with NICE guidelines. Discuss with neighbouring PCTs advantages of a joined up commissioning model for some aspects of sexual health. Scoping and development of an action plan with the Local Authority to map out new Public Health and Council responsibility for sexual health. Development of a commissioning and delivery plan with the Local Authority for sexual health. Implement, and monitor sexual health QIPP interventions. Investment ( 148k for 2 years) is required for teenage pregnancy posts to sustain the progress that has been made. Investment may be required to sustain HIV work begun in GP practices. Implementation of the integrated sexual health tariff may impact the overall commissioning budget for sexual health. Investment may be required to continue and potentially increase the role of the nurse involved in the work to reduce repeat terminations. Investment may be required to implement aspect of the sexual health QIPP programme once the plan has been developed. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 31 of 89

32 6.1.3 Substance Misuse - previously identified as Drugs & Alcohol Harm in the previous CSP Strategic Initiative Achievements to date 2011/12 Outstanding actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential investments or Substance Misuse Drugs progress In 2010/11 the Drug & Alcohol Action Team (DAAT) has undertaken a major redesign and procurement of its tier 2 and 3 drug and alcohol treatment services Informed by a comprehensive stakeholder audit and service review the process was driven by four key objectives: Ensure more people can access effective drug and alcohol treatment Increased emphasis on recovery Improved access to effective treatment for alcohol misuse Ensure best value for money Delivering a significant contribution to the PCT s QIPP savings Increase primary care based treatment Improve GP access to training and specialist support. The DAAT has also led on the procurement of inpatient treatment services for drug and alcohol misuse on behalf of the south west London sector. This procurement was driven by a requirement to maintain current levels of provision but within a context of improved quality and value for money. The outcome of the procurement process is the award of two contracts. Alcohol progress Commissioning of a dedicated alcohol liaison team in St Georges Hospital Commissioning of an intensive case management project for alcohol misuse Strengthen stop smoking support within DAAT services Priorities for the future Deliver an effective multi-agency alcohol harm reduction programme Pilot screening, access to interventions & brief advice in general practice. Targeted strategies for adults who are at higher risk To include adults with long term mental illnesses, offenders, street drinkers and rough sleepers. Develop pathways and protocols for improving prevention, early intervention and treatment of alcoholic liver disease. Increase treatment capacity/quality of services for alcohol dependent adults Increase access to treatment for alcohol use disorders within a primary care setting See Below Further investment will be required to deliver this priority area. Alcohol QIPP programme being developed by DAAT. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 32 of 89

33 disinvestments required An early indication is that approximately 700k investment required for different elements including Licensing (licensing framework, enforcement work and mystery shoppers), Family Recovery programme; interventions in primary care and acute settings; in mental health interventions, to improve community engagement, tackling street drinking and training of young people Children s Services - previously identified as Delivering the Children & Young People s Plan in the previous CSP The following priorities have been developed for the Children & Young People s Plan (CYPP) for the period Several Health Summit meetings (held between June September 2010), involving all of the partner agencies in Wandsworth, were used to develop the priorities outlined below. Partner agencies include Children s Services (WLA), the Voluntary Sector, NHS Wandsworth and service users etc. CYPP Priorities 1. More children and Young People develop emotional resilience and achieve positive mental health and well-being throughout childhood. 2. More children and Young people physical resilience to enjoy good health in Childhood. 3. More children and young people feel and are safe in the community. 4. More children and young People identified as vulnerable and safe at home and the community. 5. Fewer children experience significant harm and those who do so are enabled to remain safely within their families and communities. 6. More children and Young People achieve good standards and achieve better than expected progress at all stages of their education. 7. More children and young People enjoy and engage with their education. 8. More children and young People develop positive and lawful behaviour. 9. More children and Young People develop confidence and life skills through enjoyable purposeful activities. 10. More children and Young People are active and responsible citizens confidently engaged in influencing and developing their community. 11. More families achieve economic security and stability and fewer children live in poverty. Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date Children s Services School Nursing and Health Visiting services review group was set up in July A call/recall pilot for childhood immunisations completed and is being rolled out to all GP practices to improve immunisation rates. Plans underway to procure a community based Weight Management service to reduce childhood obesity with a specific focus on high risk / vulnerable children and families. Human Papilloma Virus (HPV) vaccination awareness raising DVD produced and an evaluation has been planned. Evaluation of BCG Pilot in progress Immunisation needs assessment and equity audit in progress Development of Tier 2 Child & Adolescent Mental Health Service (CHAMS) preventative and Early Intervention services. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 33 of 89

34 (2011/12) Action plan to improve school based immunisations (HPV, School leaver booster). Review smoking cessation contract with provider services. New Initiatives 2012/13 To roll out CAMHS training across Wandsworth universal services Develop CAMHS Tier2 Services across Wandsworth with the Local Authority Collaborative working with GPs and Community services to improve uptake of all childhood immunisations Provision of a universal BCG Immunisation service for all babies in Wandsworth. Initiatives to reduce obesity in children, particularly those in year 6. Develop Wandsworth Breastfeeding Strategy and implementation action plan. Commission services to reduce the inequalities in vision screening for pre-school children. Review Community Paediatric Service at St George s to maximise opportunities for integration with community and Local Authority services. Implement Stop Smoking programme in schools and promote Smoke free homes Implement initiatives to reduce number of children without a GP. New initiatives (2013/ /15) Potential investments or disinvestments required To identify and address inequalities in service provision and access to childhood immunisations. To develop an Advice and Consultation Service during for CAMHS Tier2 Services across Wandsworth with the Local Authority. To review the Breastfeeding Strategy and implementation Develop capacity to provide commissioning support to LCGs Implement changes to Health Visiting Service in response to the Health Visitor Implementation plan. Explore integration of children s Community and Continuing Care teams. To be confirmed after review of services in CAMHS, Paediatrics, School Nursing and Health Visiting. To source additional 35K to commission universal BCG vaccination during To continue to invest 99K for another year ( ) to reduce the inequalities in childhood immunisation uptake. To source 6K to reduce inequalities in the provision of school leaver booster vaccine for 2011 onwards. To invest 30k to reduce inequalities in children s eye screening. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 34 of 89

35 6.1.5 Urgent Care/Older People a) Urgent Care Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential investments or disinvestments required Urgent Care Admissions avoidance projects, e.g. a mobile admissions avoidance GP to prevent short-stay admissions in patients needing an 'urgent' home visit have been successfully evaluated and combined with the evolving Community Ward clinical pathway model. This has facilitated the Community (nee Virtual) Ward project to be radically expanded following learning from the various projects, i.e. identified the correct clinical model to meet needs. Ongoing evaluation and monitoring of the Community Ward. Urgent Care (high-level commissioning strategy aims for ) Outcomes we will deliver: Reduce short-stay emergency admissions on multiple patient cohorts, through targeted whole pathway interventions and recurrent funding, e.g. falls prevention. Reduce emergency admissions in specified Long Term Conditions through the continued development of the Community Ward that places Multi-Disciplinary Team management at its core through close working between community nursing services, primary, secondary and social care. Reduce A&E attendance rates during core GP hours (i.e. 08:00-18:30) through each Local Commissioning Group working with member practices to internally develop systems for improved call handling / responsiveness for patients wanting a same-day appointment. Reduce A&E attendance rates outside core GP hours (i.e. 18:30-08:00) via not only an Urgent Care Centre at St George s (will also support the above objective) but also through commissioning an Out of Hours service that will link up community urgent care clinics and other OOH services into a seamless continuity of care for patients. Reduce future emergency re-admissions within 28-days through developing an integrated Re-ablement service Strategy with the Local Authority. These will be monitored via an Urgent Care Strategy Group with key local partners. Review urgent care services at Queen Mary s Hospital. Implement the Re-ablement Strategy to reduce re-admissions and to support the Community Ward in preventing admissions. Pending Community Ward evaluation, we would seek to reduce acute contract values accordingly. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 35 of 89

36 b) Older People Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) New Initiatives 2012/13 Older People Falls and bone health Implementation of the Falls action plan with stakeholders is underway. Further work on development of the falls pathway and costing the Falls Strategy is ongoing Health care needs of older people (based on findings of the JSNA) A residential and care home residents Needs Assessment and an excess winter deaths Needs Assessment are underway. Intermediate care and re-ablement Implementation of a range of measures to more closely align health and social care services. A completed joint needs assessment for re-ablement and intermediate care. A summary outline strategy document agreed by NHSW and Wandsworth Social Services. Community ward The Virtual Ward and WHEISP pilots have been integrated to form the Community Ward ; aimed at admission avoidance. Mental health Joint review of all services for older people with mental health conditions completed in January Older peoples health needs Completed needs assessments on residential and care home residents and excess winter deaths will inform strategies to address findings. Expected benefits include reductions in winter mortality and improved quality of care to care home residents Intermediate care and re-ablement maximising independence and keeping people at home for longer Development of joint strategy for re-ablement and intermediate care with stakeholders leading to a joint commissioning plan in Implement an immediate interim solution for intermediate care beds due to significant issues with the current building, and for the longer term undertaking an assessment of future requirements. Older adults mental health Based on the recommendation of the review plan to implement a new model of care for older people with mental health concerns The new model will have the following elements: a Single Community Mental Health Team (CMHT) for older people, centralise Wandsworth Older People s Mental Health Beds in Wandsworth Borough, health input to Borough Older People s Day Services, Intensive Home Treatment Team, Challenging Behaviour Service and Memory Assessment Service. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 36 of 89

37 New initiatives (2013/ /15) Potential investments or disinvestments required Develop and implement an action plan to deliver the local Dementia Strategy - including the implementation of the new model of care. Conduct soft market testing for intermediate care bed-based service and procurement. Investment in Falls Plan will be needed on a spend-to-save basis, to be determined by outcome of costing of falls plan. Level of investment determined by outcomes of care homes and excess winter deaths Needs Assessment. Additional investment for memory assessment clinics. Level to be determined by options appraisal Long Term Conditions - previously identified as Long term conditions/disease management in the previous CSP We aim to reduce the proportion of people with undiagnosed long term conditions and to improve early diagnosis so as to prevent further progression and development of complications. In addition, we want to improve the quality of clinical care that patients receive across all levels of care through the use of evidence-based shared guidelines and protocols and ensure patients are treated in the appropriate place. Joint working groups, comprised of primary and secondary care clinicians, Public Health and service users, are leading significant service and pathway redesign of diabetes, COPD, sickle cell disease and cardiovascular disease. Patient self-management, self-care and education (also known as Tier 0 ) is a key priority and will form part of every Long Term Condition (LTC) pathway/service redesign initiative. a) Long Term Conditions Strategic Initiative Achievements to date 2011/12 New Initiatives 2012/13 Long term conditions Successful pilot on Atrial Fibrillation in Primary Care Development of prescribing guidelines for COPD and Asthma NHS Health Checks Programme - 12,000 health checks completed in 2011/12. The diabetes pathway has been reviewed and redesigned Review of heart failure NHSW have developed a Community Ward model that will support patients with long term conditions Increased capacity of pulmonary rehabilitation Expert Patients Programme (EPP) in place across Wandsworth. 90% implementation of the Learning Disability DES New integrated community service developed for people with learning disabilities and challenging behaviour Diagnostic pathway for adults with Autism has been designed a) COPD Development of an integrated model of COPD care which will be implemented in Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 37 of 89

38 Ongoing initiatives 2012/13-15 Earlier identification of undiagnosed COPD Reduction in variation and Improved management in general practice Multi-disciplinary specialist care in the Community Specialist nurse-led Exacerbation/Recurrent Exacerbation Management Improved pathway to create seamless service across primary and acute services. b) CVD Implementation of the new NICE guidelines on the clinical management of primary hypertension in adults. This will be an Invest to Save initiative with the purchase of 24 Hour Ambulatory Blood Pressure Monitors for use in primary care. c) Asthma Completion of Asthma needs assessment. Development of paediatric and adult asthma care pathways, supported by, evidence-based shared guidelines and protocols, agreed referral and discharge criteria Reduction in emergency admissions, A&E attendances and length of stay Improved self management d) Transition and Adult Sickle Cell Pathway Development of a model of care for adults Sickle Cell Disease, to include transition programme for young people, individualised care plans, improved self management. Joint protocols will be developed between community services and acute services. Reduction in emergency admissions, A&E attendances and length of stay, improved self management, improvement management and diagnosis in primary care. Improved GP engagement and management of Sickle Cell Disease Centralisation of current SGH haemoglobinopathy services to one site. e) People with Learning Disabilities and Autism Reduction in unnecessary hospital admissions Implementation of assurance systems for private sector placements Implement Action Plan in response to 2011 Learning Disability Performance Assessment Systems implemented to ensure identification of autism in adults and provision of relevant services Ongoing initiatives Implementation of the national Your Personal Best physical activity programme for people with long term conditions in primary care The delivery of disease specific education and training for the primary care Piloting of shared IT systems to improve communication To increase and continue: o pharmacy-led medication reviews o delivery of non-invasive ventilation in the community o The use of Tele-health equipment for patients with LTCs Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 38 of 89

39 New initiatives (2013/ /15) Potential investments or disinvestments required o support to facilitate self-management/care in the home, in particular development of personal care plans for patients on disease registers Jointly commission (with social care) communication support service for stroke patients with aphasia Reduce health inequalities for People with Learning Disabilities (LD) through provision of health checks and reasonable adjustments in primary care and to improve safety and quality of care of people with LD in hospital To improve collection of information on risk and disease registers To improve the provision of services to transient populations who often exhibit high levels of LTCs The Improvement of data management and shared data systems across health and social care settings People with long term conditions will be able to access advice, support and treatment in a wide range of care settings including primary and community care. Greater support for self management through supporting patients of all ages, health and social care professionals To be confirmed during the development of future models of service. Investments may be required on a spend-to-save basis. Haemoglobinopothy services will require significant investment including 200k for development of a single site. b) Carers (Long Term Conditions) Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) New Initiatives (2012/13) New initiatives (2013/14- Carers (Long Term Conditions) Carer support was implicit in last year s plan, and no specific initiatives were identified. However the following work has taken place during the last year. Funding for the Crossroads respite breaks service made nonrecurrent. Carers included as a target group for the Locally Enhanced Services for GP and pharmacy flu immunisations. GP Carers Awareness Training delivered to a number of practices in NHS Health Checks are currently being promoted to carers. A rolling programme of GP Carers Awareness Training needs to be resumed. An up-to-date version of the Wandsworth Carers Guide is required. A funding request has been submitted. Enhanced support for young carers Carers support initiatives will be embedded into new care pathways across all care groups to ensure they receive the appropriate support and are working in partnership with health care professionals to deliver appropriate care. The action plan for the Wandsworth Strategy for Carers and Young Carers is currently being refreshed this will determine new initiatives Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 39 of 89

40 2014/15) in 2013/14 & 2014/15. Potential Investment required for commissioning of GP Carers Awareness investments/dis Training exact level to be determined. investment 30k investment required for updating the Wandsworth Carers requirements Guide. Potential investment required to develop support for young carers exact level to be determined Mental Health - previously identified as Mental Health Strategy in the previous CSP Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) Mental Health Maintaining Wellbeing through Mental Health Promotion The production of the Mood Manager DVD, Books on Prescription, mental health First Aid training and Living and Learning courses. Early Intervention and Self- Management The scope and size of the Psychological Therapy and Wellbeing service (IAPT) has trebled, with over 4,000 patients treated and nearly half in recovery. Over 300 people have been supported back to work. The review of CMHTs, and important initiatives to support recovery, have been implemented. Improving the Acute care pathway, Safety and Quality of care Further WPCT investment in Crisis and Home Treatment services, the development of single-sex wards, environmental improvements, improved staff development and training, consultant-led multidisciplinary in-patient teams, a reduction in unnecessary admissions and bed utilisation. Reduce health inequalities and improve access to services Completion of the BUTS (Bengali, Urdu, Tamil and Somali) project, providing engagement and translated mental health resources and the IAPT roll-out of the co-production model with nine community and Black and Minority Ethnic (BME) organisations. Open access and selfreferral systems have also been implemented and adjustments made to services for those with special needs e.g. Learning Disabilities. Established a mental health smoking cessation CQUIN. Two Stop Smoking advisors have been appointed and supported by the public health stop smoking service. Maintaining Wellbeing through Mental Health Promotion Publication of an updated Mental Health Promotion Strategy and Action Plan, completion of the suicide prevention audit and programme of mental health First Aid training, expansion of the books on prescription scheme, developing a new mental health promotion strategy for the prison and working with business to improve mental health in the workplace. Early Intervention and Self-Management Implementing the outcomes of the further trial of the on-line Big White Wall mental wellbeing service, completion of stage 2 of the Co- Creating Health project, improvements to waiting times for the Psychological Therapy and Wellbeing service (IAPT) and extending the service to children and young people. Implementation of more Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 40 of 89

41 New Initiatives 2012/13 New initiatives (2013/ /15) Potential Investments streamlined processes for self directed support and recovery for the majority of service users. Improving the Acute care pathway, Safety and Quality of care Modifying care pathway to secure more integrated response with primary care. Continuing improvements in compliance with Care Quality Commission (CQC) standards and patient experience continue to occur on inpatient wards. The Trust is commissioned to deliver a range of quality improvements via the CQUIN process. Reduce Health Inequalities and improve access to services Outstanding actions include the development of a multi-lingual version of the Mood Manager DVD and continuing the programme of community mental health development in partnership with the borough s BME communities and increasing access to IAPT services for Older People and People with Learning Disabilities (PLD) Improving the Acute Care Pathway, Safety and Quality of care Cluster-wide quantification of need for inpatient provision for adults and older people, including the need for single-sex wards. QIPP programme of reconfiguration of inpatient services for older adults. Further investment in Crisis Resolution and Home Treatment team (CRHT) remains outstanding for 2012/13. Another major QIPP initiative involves the review of forensic and other high cost out of area private sector placements and working in partnership with the SWLSTG Trust to develop further step down accommodation from medium and low secure services on the Springfield Hospital site. Implementation of the London-wide Models of Care programme, including further work to redesign the acute care pathway and reduce unnecessary admissions and A&E presentations, Further review and reconfiguration of adult inpatient services as part of a major QIPP project. Implement proposals for more rapid responses to the acutely unwell and in crisis, and changes to the management and treatment of those with a long-term mental health condition, through further development of an integrated pathway between IAPT, CMHT and primary care. Some pump-priming ( 50k) required for further investment in selfmanagement initiatives 200k for implementation of on-line psychological therapy service. 170k additional investment in CRHT service from existing budgets Borough Specialised Commissioning a) Continuing Care for patients To ensure the robust implementation of the Department of Health's NHS Continuing Care Guidance 2009 which highlights the legal position, "Where a person has a primary health need and is therefore eligible for NHS Continuing health care, the NHS is responsible for providing all of that individuals assessed needs." Based on the above, Wandsworth will commission quality care to meet the needs of the individual, whilst ensuring competitive rates are applied. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 41 of 89

42 Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential investments or disinvestments required Continuing Care (Borough Specialised Commissioning) Merged Continuing Care services for Richmond & Wandsworth thus enabling a streamlined approach to clinical and commissioning services. Delivering greater clinical oversight across the Boroughs, including the implementation of a more structured process of assessments and monitoring. Reassessing and re-commissioning of Continuing Care patients, in particular those with high cost, complex packages of care, to ensure quality and value for money. Implement a pilot programme for Personal health budgets which will focus on quality and gives patients more control and choice. Volume discounts are currently being negotiated with nursing home provider which is expected to deliver a cost savings. Ensure responsive packages of care are commissioned that reflect the assessed clinical needs of patients whilst delivering quality and value. A consistent market management approach of nursing home placements, through contract negotiations. Actively engage with the London Procurement Programme to ensure quality and value for money. Continued review and re-commissioning of existing services to meet the clinical assessed needs of individuals Refocus the care pathway so that provision of care includes a more patient focused approach including personalisation for patients with complex care needs. Implementing a more structured approach for provider to a performance and quality monitoring framework Ensure continuing care assessments are completed within national timeframes providing clinical and financial clarity. Work in line with the relevant legislation following the emerging CCG. Continuation of QIPP programme will require additional non-recurrent investment of approximately 180k for full year effect. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 42 of 89

43 b) Forensic Mental Health Secure Forensic Mental Health Services will be commissioned by the NHS Commissioning Board from April However, it will be important to ensure good interface with local commissioning structures as patients discharged from secure settings will return to locally commissioned health services Strategic Forensic Mental Health (Borough Specialised Commissioning) Initiative Achievements to date 2011/12 There has been a particular focus on reviewing Wandsworth s forensic mental health patients in out-of-area treatment placements. Each patient in a medium secure hospital can cost up to 200,000 per annum and there was concern that patients were not being reviewed frequently or thoroughly enough and therefore not identified for appropriate move onto accommodation. Towards the end of , a suitably qualified clinician was seconded to the Borough to begin the process of patient reviews. The majority of patient moves out of medium secure hospital settings require careful risk assessments and Ministry of Justice approval and the process therefore takes time to come to fruition. However, there has been clear progress which has materialised in and the Borough is confident that it will exceed its QIPP plan forecast for forensics in Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential investments or disinvestments required In collaboration with the other SW London boroughs, Wandsworth decommissioned SWL and St George s Mental Health Trust s low secure Ellis Ward on the Springfield site. It is due to close by December Wandsworth had seven patients in Ellis Ward and the PCT is likely to realise approximately 250k of savings though further clarity on the care needs of those patients is required. In collaboration with the MH Trust, commissioners are attempting to redesign the local care pathway for forensic mental health patients with a greater emphasis on step down accommodation, so that patients can move out of both medium and low secure facilities. The review work will continue into and beyond as there is a continual requirement to review patient placements and ensure that the local care pathway is developed and local services are responsive to the needs of the Wandsworth forensic population. It is likely that the rate at which patients will be identified as ready to move, and resulting savings realised, will slow down over time as many placements are long term and treatment slow. There are on-going discussions with the MH Trust about the development of new step down services on the Springfield site. The precise model of care is being developed and we are anticipating that it will be open for business in early None planned None identified at the current time. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 43 of 89

44 c) HMP Wandsworth Health services at HMP Wandsworth will be commissioned by the NHS Commissioning Board from April However, it will be important to ensure good interface with local commissioning structures as offenders discharged from custody will return to locally commissioned health services. HMP Wandsworth (HMPW) is a category B prison with an operational capacity of 1,665 places, the largest in the UK. It takes male remand and sentenced prisoners aged 21 years or older. The prison population at HMP Wandsworth is young, with the majority of prisoners aged between 21 and 39 years (64.0%), and 14.0% of prisoners aged over 50 years. The largest single ethnic group within the prison is white (57.0%). Black Caribbean prisoners form the second largest group (9.2%). More than half of prisoners are sentenced. Among those sentenced, half have sentences of less than 4 years, with 21.0% having sentences of less than a year and 19.8% of prisoners have sentences of 10 years and above. Many of the needs of prisoners are the same as those of any population of adults. Prisoners therefore need to be able to access the full range of services, ranging from informal primary care through to highly specialised interventions, which are available to adults in the community. Strategic Initiative Achievement s to date 2011/12 Outstanding Actions to date (2011/12) HMP Wandsworth (Borough Specialised Commissioning) After a number of re-organisations of healthcare services at the prison, there has been relative stability in CSW/St Georges provides primary care and substance misuse services, sub-contracting podiatry and chiropody to independent providers. Secondary mental health services are commissioned from SWL & St.George s MHT and dentistry is provided by an independent organisation Tooth and Mouth. There are currently 18 inpatient beds across 2 inpatient units; 12 being dedicated mental health beds and the remaining 6 for acute physical health needs. Plans are in place to open more inpatient beds. A HNA was conducted recently by Public Health. It concluded that Reception health screening, second day health assessment processes, chiropody, optometry, sexual health services, secondary mental health care, substance misuse and inpatient care work reasonably well. However, it found that there were currently few chronic disease management clinics and no Hepatitis B immunisation programme. There were long waiting times to see a GP or a Dentist and there was no diabetic retinal screening or NHS Health Checks being offered to eligible prisoners. Primary mental health services needed to be strengthened. The electronic patient record system SystmOne was not being used effectively by staff. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 44 of 89

45 New Initiatives (2012/13) New Initiatives (2013/ /15) Potential investments or disinvestmen ts required The key commissioning priorities for will be to: Improve health promotion including smoking cessation, NHS health checks, bowel cancer screening, AAA screening diabetic retinal screening, regular assessment of lifestyle risk factors and implementation of the Prison Health Promotion Action Plan improve access to primary healthcare services by opening a Walk-in Centre. This will be staffed by Advanced Nurse Practitioners and supported by GP s. extend the opening of the second day health assessment centre to ensure that the increasing number of new prisoners arriving every evening at the prison can be properly health assessed the following morning. extend the number of inpatient beds to better cater for the health needs of the population. work in collaboration with the Drug and Alcohol Action Team to review the range of psychosocial interventions currently offered and ensure full integration with clinical drug and alcohol services in the prison. improve access to dental services ensure that healthcare providers are making full use of IT systems to report accurately on activity and outcomes. Implement the recommendations of the health needs assessment Provision of chronic disease clinics and management programmes Staff recruitment drive to fill all vacant and temporary posts. Develop the primary care mental health service. Develop services for prisoners with Learning Disabilities. CSW/St.George s have indicated serious cost pressure for additional GP sessions and nursing cover and new investment will be required. Awaiting costs. 6.2 Previous CSP initiatives There are a number of other initiatives from the previous CSP ( ) which are not picked up in the newly identified Commissioning Priorities. We have provided an update on these initiatives below as well as any further actions required Shift of Care - previously identified as Polysystems and primary/community service redesign in the previous CSP. This is an important ongoing initiative. Strategic Initiative Achievements to date 2011/12 Shift of Care The GP Led Health Centre (GPLHC) at Clapham Junction opened on 1 April 2010 and it is now offering walk in services and extended hours. The refurbishment of Bridge Lane was completed in March 2011 and it is now being used for the delivery of a two year pilot community based ophthalmology service. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 45 of 89

46 The GP Federation covering Battersea, Central Wandsworth and Balham, Tooting and Furzedown provides the community dermatology pilot that went live on 4 April Existing primary care estates (GP practices and St John s Therapy Centre) are being utilised for the delivery of the shift of care programme. The GP Clinic at Queen Mary s Hospital opened in February 2010 and it is now offering routine and urgent/walk-in primary care services. The specification is to be reviewed in the context of the emerging urgent strategy. Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential Investments/ disinvestment requirements Changes to the primary and community service hubs and networks and primary/community service redesign since the last Cluster and PCT CSP: Plans to extend coverage of community ultrasound at four sites did not go ahead due to lack of capacity within primary care estates. GP Federations are now delivering dermatology and are about to commence delivery of orthopaedics. Plans for gynaecology, rheumatology and paediatrics are being developed. Partnership working arrangement between secondary and primary care Agree priorities for delivering Gynaecology, Paediatrics and Rheumatology pathways through partnership work between primary and secondary care practitioners. Develop seventeen QMH Rapid Diagnostic Packages (RDPs) designed by acute and primary care in 2011/12. GP Federations to lead on the development of gynaecology, rheumatology and paediatrics pathways in collaboration with commissioners. Roll out of Chronic Obstructive Pulmonary Disease pathway will lead to better management of patients in primary care. Roll out of rapid diagnostic packages at QMH will lead to financial savings and improved patient experience. Roll out of shoulder and hypertension pathways. The Borough strategy for delivering shift of care is underpinned by utilisation of primary care estate within the four primary, community service hubs and networks namely Battersea, West Wandsworth, Balham, Tooting and Furzedown. Increase utilisation of Queen May s Hospital. Commissioning gynaecology, rheumatology and paediatrics pathways Redesign of Gynaecology, Paediatrics and Rheumatology, and implementation of RDPs, will require capital and revenue investment exact level to be determined Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 46 of 89

47 6.2.2 Maternity Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential Investments/ disinvestment requirements Maternity Significant improvement in both initiation and prevalence of breastfeeding at 6-8 weeks from birth Picker survey conducted at SGH demonstrated high concern over staff conduct. Issues being address through Task Force with remedial results reported to SGH management team and Maternity Services Liaison Committee (MSLC). Antenatal and postnatal services delivered within two designated integrated Children s Centres Health promotion strengthened on key topics e.g. use of Folic Acid, smoking cessation, maternal and infant nutrition, healthy lifestyle promotion of breastfeeding, through dissemination of 40,000 leaflets to frontline health services (Pharmacies, GP practices/health centres, maternity units). All women (and partners) now routinely asked smoking status at booking Group set up July 2011 to review School Nursing and Health Visitors in Wandsworth Wandsworth Breastfeeding strategy under development Promotion of home birth through the launch of the Rainbow Home Birth team Continue work to improve the 12 week maternity booking. Support the Better Service, Better Value project and take forward any resulting borough level recommendations Improving the uptake of healthy vitamins Universal distribution of healthy vitamins to pregnant women and newborns Promotion of direct access to antenatal booking Take forward recent NICE guidance relating to maternity Wandsworth Breastfeeding strategy will be completed and an action plan formulated based upon the recommendations Health Visiting Service currently under review. Envisaged there will be major changes in the service in response to the Health Visitor Implementation plan The CCG to continue to work with the ACU to improve the quality of maternity clinics with particular focus on the maintenance/improvement of community clinics and long term plans to address the challenging workforce and capacity issues in the hospital delivery unit K investment into healthy vitamins distribution to be taken from Maternity Matters budget Recruitment of short/medium term project manager to focus on 12 week maternity booking Recruitment of two breastfeeding coordinators (Band 6) within the Health Visiting Team. Part of Health Visitor Implementation Plan Other significant investment may be required in response to the Health Visitor Implementation plan Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 47 of 89

48 6.2.3 End of Life Care The focus of the End of Life Care (EOLC) workstream continues to be to increase numbers of patients cared for and dying in their preferred place of care, often their own home. This means ensuring clinicians in all settings have the knowledge and skills to identify EOLC patients and ensure that their care is high quality, planned, co-ordinated and wherever possible addresses their wishes and choices. Strategic Initiative Achievements to date 2011/12 Outstanding Actions to date (2011/12) New Initiatives 2012/13 New initiatives (2013/ /15) Potential investments or disinvestments required End of Life Care Reduction in hospital deaths (ONS 2010 figures); Increase in deaths in usual place of residence (ONS 2010 figures); Roll-out of the patient-held Yellow Communication Book; Roll-out of a Community Care Pathway for care of the dying; Integration of the St Georges Discharge Home pilot project; Development of a Direction of Travel EOLC strategy document. Continue with core EOLC system activities to focus on achieving preferred place of care and reducing hospital admissions at EOL: On-going support to GPs with EOLC; On-going support to Nursing Homes and Residential Homes/Extra Care Housing with EOLC; Ongoing work with the acute sector to improve EOL patient care; Ongoing focus to identify EOL patients with non-cancer diagnosis. Greater focus on prevention of inappropriate admissions of EOL patients to hospital (in-and out-of-hours providers); Review of nature of EOL patient continuing/care packages; Develop action plan for addressing equality/diversity EOL needs. Development of audit framework for EOLC patient pathways; Supporting care of more complex EOL patients in the community. Potential for further investment in community services to support the care of more complex EOL patients in the community rather than hospital setting exact level to be determined Supporting initiative: Quality, Innovation, Prevention and Productivity (QIPP) Delivery - previously identified as Supporting Initiatives: demand management and cost saving initiatives in the previous CSP The QIPP programme was developed in 11/12 to support the NHS in delivering efficiency savings without compromising care and quality. Therefore, the projects for demand management and cost savings originally identified in the Commissioning Strategy Plan ( ) have been superseded by the QIPP programme. Some of the original projects borne out of the strategic initiatives remain. Some have changed or have a different emphasis. Additional projects were added in 2011/12 in line with new priorities. The QIPP plan was developed by the PCT and GP commissioner clinicians to address the clinical and financial challenges facing the sector. Quality, Prevention and Productivity were Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 48 of 89

49 the key drivers. A number of projects were identified to deliver 7.1m of savings. These are listed below and mapped against our priorities. Table 5: 2011/12 QIPP schemes mapped to commissioning priorities Strategic initiative Preventative Initiatives Sexual Health Substance Misuse Children s Services Urgent Care/ Older People Long Term Conditions Projects contributing to QIPP Cost Savings (either identified through the CSP or through later scoping exercises) Falls Prevention Reviewing of sexual health Local Enhanced Services (LES s) Case management of alcohol dependent adults who are frequent users of A&E services. Re-procurement of DAAT services to create an integrated service and patient pathway Further Opportunities under development A more comprehensive Falls programme is in development in conjunction with the Local Authority. Cost savings as a result of fracture avoidance and its associated treatment and care costs will be part of this scoping exercise. Resigning and improving primary care sexual health services Exploring options with the Local Authority to expand this project for example, by including other hospitals in the sector or by expanding the patient groups involved, and prevention of alcohol abuse. No specific schemes identified that will produce QIPP cost savings (in either 11/12 or 12/13). Community Urgent Care - reducing To continue and expand in 12/13. admissions to A&E for a range of conditions by supporting and managing patients within their own home. Diabetes shift the management of stable patients into community settings To continue the service and to improve the management of foot care. Mental Health Package of Care Assessment Assessment of packages of care to ensure patients are still eligible and that the package is still appropriate. Continue assessment programme Review inpatient services across SWL Review adult rehabilitation services Better Service Better Value Pelvic Floor Clinic redesigning current consultant led service to use a nurse consultant. Queen Mary s - redesign of pathway of care and booking systems, generating clinical efficiencies that will reduce the cost base, in return for increased activity to improve hospital Continue programme. No new schemes identified to date but existing schemes to continue and to be developed to full potential. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 49 of 89

50 utilisation with reduced overheads for the provider per appointment. End of Life No specific schemes identified Exploring opportunities to reduce A&E admissions from care homes. Demand Management Cost savings initiatives Reducing GP Referrals through referral management system Challenging use of High Cost Drugs and Devices and procedures of limited clinical value. Forensic Placement Assessments Medicines Management Use of cost effective medicines. Dental contract reduce cost of enhanced rate UDAs GP List Cleansing Decommissioning a small number of local pilots Contract renegotiations (Mental Health, Drugs & Alcohol) Continue programme Continue programme Continue programme Continue Programme The programme incorporates a number of separate initiatives such as use of ScriptSwitch, moving from branded to generic products, and reviewing medicines to replace with more cost-effective alternatives. Continue Programme Continue Programme No new schemes identified Contract renegotiations for Community Dentistry and Home oxygen The CCG has taken the lead in developing QIPP programmes for 12/13 onwards. Detailed plans are in development for 12/13 when our savings target is 12.5 million. Although a number of schemes have been identified, we have identified three large change programmes to focus on: Falls, Alcohol and Sexual Health. The detailed work for these programmes will be scoped out in the next few months (and savings quantified) but the focus will be on improving quality and prevention in these areas, which will result in an improvement in productivity. The table below summarises the individual projects already identified and their planned and actual savings delivery for 2011/12. This will be supplemented by additional schemes over the next few months as further work is undertaken. We anticipate that plans will evolve over time as we gather more data and consult with patients and the public over individual areas of work. The figures given below will therefore change as plans evolve. Table 6: 2012/13 QIPP schemes QIPP Plans / /2013 Scheme Strategic initiative Plan Forecas t / actual carrie d over New * 000's 000's 000's 000's GP List Cleansing Mental Health Contract (2% reduction) Total General QIPP programme Mental Health Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 50 of 89

51 Forensics QIPP Plans / /2013 Scheme Strategic initiative Plan Forecas t / actual carrie d over New * 000's 000's 000's 000's Estimated Drug Savings 2011/12 Continuing Care (mitigation) Community Urgent Care Commissioning/VW Falls Management Borough Specialised Commissioning General QIPP programme Borough Specialised Commissioning Urgent Care/ Older People Total Urgent Care/Older People Dental contract UDA General QIPP adjustment programme High Cost Drugs / General QIPP Devices programme Sir Jules Thorne Urgent Care/ Court Older People Mental Health HCP Mental Health DAAT : Drugs And Substance Misuse Alcohol / Cost Savings RSH Sexual Health Sexual Health Dawes House / Ronald Gibson House Effective Commissioning Contingency Returns Private Osteopathics Urgent Care/ Older People General QIPP programme General QIPP programme General QIPP programme Talking Therapy Mental Health Choose and Book Smoking Cessation - Cease Smoke Free Homes Smoking Cessation - Reduce Tobacco Control Spend GP Referrals General QIPP programme Prevention initiatives Prevention initiatives General QIPP programme Queen Mary's RDP s General QIPP programme Diabetes Long Term Conditions Alcohol Admissions Substance Misuse Pelvic Floor Clinic General QIPP programme Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 51 of 89

52 QIPP Plans / /2013 Scheme Strategic initiative Plan Forecas t / actual carrie d over New * 000's 000's 000's 000's Home oxygen General QIPP programme Total Immunosuppresants Diabetic Podiatry Community Dental figure to be confirmed Review Nurse Tariff figure to be confirmed Prostrate Follow up figure to be confirmed Savings still be scoped though new projects and programme expansions/developm ents identified as future opportunities General QIPP programme Long Term Conditions General QIPP programme General QIPP programme Long Term Conditions Total Planned Total Actuals/ Forecast Over performance/(shortf all) *This column represents expansions to existing schemes and new schemes to the programme Measuring success There are a number of Key Performance Indicators (KPIs) aligned to the commissioning priorities/initiatives which will support the measurement of their success. These indicators may change following the publication of the Operating Framework and the NHS Outcome Framework and we will adapt our Performance Management Frameworks accordingly. The specific target levels for existing indicators for 2011/12 onwards will be set as part of the Operating Planning process from January 2012 onwards. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 52 of 89

53 Table 7: Commissioning priorities, aligned KPIs and performance against KPIs for 2010/11 Commissioning Priorities / Initiatives Prevention, screening, early diagnosis and awareness initiatives Sexual Health Substance Misuse (drugs and alcohol) Children s Services Urgent Care / Older people Long term conditions Mental Health Measures of Success (KPIs) Target 2010/11 Achievement against target 2010/11 Breast Screening (Age Extension & 70-73) 8.0% 29.8% Breast cancer screening (Women aged 50-73) 70.0% 64.2% Bowel Screening 60% 39.6% Cervical Screening - Women aged screened within the last % 68.0% years Cervical Screening - Women aged screened within the last 5 75% 74% years Cervical Screening results within two weeks 98% 92.27% Diabetic retinopathy screening 95.0% 100.0% NHS health checks 10% 16.24% Four week smoking quitters 1,287 1,351 All cause mortality female All cause mortality male CVD mortality - Under Cancer urgent referral to first outpatient appointment waiting times 93% 95.70% Cancer mortality - Under GUM Access 100% 99.66% Chlamydia positive tests New New Chlamydia percent screened 35% 26.4% Under 18 conception rates Drug misuse numbers in effective treatment Health visitor numbers (FTEs) New New Breastfeeding at 6-8 weeks prevalence 75.70% 72.30% Breastfeeding at 6-8 weeks coverage 95% 96.20% Immunisation age 1; All 3 doses of DTaP/IPV/Hib 93% 91.2% Immunisation age 2; Hib/MenC booster 92% 87.8% Immunisation age 2; All PCV booster 90% 95.2% Immunisation age 2; One dose of MMR 95% 82.4% Immunisation age 5; All 4 doses of DTaP/IPV/Hib 90% 86.7.% Immunisation age 5; Two doses of MMR 95% 82.4% Immunisation girls age 12-13; HPV three doses 90.0% 76.9% Childhood obesity (Reception) Coverage 89% 92% Childhood obesity (Reception) Prevalence 11.70% 10% Childhood obesity (Year 6) Coverage 89% 92% Childhood obesity (Year 6) Prevalence 21.93% 21.40% A&E wait times and quality measures 95% 97.4% Urgent GP referrals for suspected Cancer 93% 95.70% Referrals for breast symptoms (Cancer not suspected) 93% 96.40% Ratio of Excess winter deaths (2006/2009) N/A 24 Fractured neck of femur admission rates (DSR per 100,000) 2010/11 N/A 53.3 Mortality rates from accidental falls (DSR per 100,000) 2007/09 N/A 6 Emergency Readmissions New New Patients with Diabetes above HbA1c 7.0 New New First definitive Cancer treatment within one month 96% 99.40% Subsequent Cancer drug treatment within one month 98% 100% Subsequent Cancer surgery treatment within one month 94% 97.40% Subsequent Cancer radiotherapy treatment (from December 2010) 94% 98.40% within one month People with long term conditions feeling independent and in control New New Stroke patients 90% of time on unit 80.0% 93.4% Four week smoking quitters 1,287 1,351 Emergency admissions for long term conditions New New Early intervention of psychosis Crisis resolution home treatment Care programme approach follow up New New Psychological therapy patient numbers as % of population with New New depression Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 53 of 89

54 Overarching measures of success Previous CSP initiatives Psychological therapy patient numbers as % referrals New New Admitted patients seen in 18 weeks 90% 82.83% Non admitted patients seen in 18 weeks 95% 96.87% Patient Experience Survey Average Score New New RTT 95 th percentile for admitted patients New New RTT 95 th percentile for non admitted patients New New RTT 95 th percentile for patients on incomplete patients New New RTT median waiting for admitted patients New New RTT median waiting for non admitted patients New New RTT median waiting for patients on incomplete pathways New New Choose and Book 90% 23% Maternity: 12 week maternity wait, initiation of breastfeeding 90% 86.30% End of Life Care: Proportion of people who die at home New New The expected impact of not meeting targets. Each of our strategic priorities has a number of related indicators which we monitor on a regular basis. Improving performance against process measures and outcomes is a key goal of the CCG, and we have a number of processes in place to ensure that this is delivered. Progress against targets will be monitored on a regular basis and where any variance from trajectory is identified, action will be taken to improve performance. The governance structures of the CCG allow for performance concerns to be escalated to the Wandsworth Management Team and for high-level scrutiny and support to be provided to ensure that issues can be resolved. SWL Cluster has instituted a regular performance meeting where the Borough team update on performance and finance. This is a requirement for the CCG to receive delegated responsibilities, and so is an important stage of authorisation. 7. Enablers 7.1 Incentives The key enablers required, locally and regionally, to support the implementation of the opportunities above are provided below GP Federations The Battersea Community Interest Company, Wandsworth Integrated Healthcare and Balham, Tooting and Furzedown (BTF) Integrated Healthcare will be merging to form a single federated entity on the 1st April Building on the shift of care work on Dermatology, we will continue to work with the Battersea, Central Wandsworth and Balham, Tooting and Furzedown (BTF) GP federations and GP Commissioners to take this programme forward through the 2 years pilot period. GP Federations have also indicated that orthopaedics will be delivered in primary care and acute settings in 2012/13. We will also continue to work to strengthen the Information Governance, Estate and Information Technology capacities of GP Federations to deliver the shift of care from secondary care services. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 54 of 89

55 7.1.2 Quality Outcome Framework (QOF) Quality and Productivity indicators The development of primary care led care pathways for community Virtual Wards, Chronic Obstructive Pulmonary Disease, Shoulder, Falls Management and Hypertension under the QOF Quality and Productivity Indicators Programme in 2011/12, provides real opportunities to improve the management of patients in the primary care setting and avoid inappropriate use of outpatient referrals and avoid emergency admissions. We will continue to work with GP commissioners, GP Federations and secondary care services to explore options for managing the over performance of outpatient activity with continued focus on service redesign, developing the GP Referral toolkit and shift of outpatient activity with the highest volumes from secondary care Commissioning for Quality and Innovation (CQUIN) CQUIN was introduced in April 2009 as a national framework for locally agreed quality improvement schemes. It enables commissioners to reward excellence by linking a proportion of healthcare provider s income to the achievement of local quality improvement goals. The framework aims to embed quality within commissioner-provider discussions and to create a culture of continuous quality improvement We will continue to drive improvements in health outcomes for patients by building on achievement in previous years, with Public Health input. There will be a particular focus on shifting towards indicators that deliver the QIPP and strengthen the interface between primary and community services. The percentage value of CQUIN is nationally set. In 2011/12 the value was set at 1.5% of provider contract value (unchanged from 10/11). Although the 2012/13 value has not been confirmed it is likely to remain at 1.5%. In previous years there have been nationally mandated CQUINs, for example, in acute care. In 2011/12 these were improving patient experience (based on Trust patient survey performance) and reducing impact of Venous Thromboembolism (VTE). The 2011/12 nationally specified CQUINs were equivalent to 20% of the overall CQUIN value. Again, the expectation is that nationally specified CQUINs will continue at a similar level in 2012/13. Therefore, there remains approx 80% of CQUIN value where targets can be set at a more local level agreed between local commissioners. South West London (SWL) ACU coordinated CQUIN agreements last year for sector acute trusts providing a shortlist of recommended CQUINs for commissioner decision. Experience has shown that the CQUINs which worked the best were ones which were developed locally with Trust and GP clinical buy-in. The process for confirming CQUINs for 12/13 has now started and the intention is to further develop those schemes which worked well in 11/12 to build in further stretch where this would benefit patients, and to develop new CQUINs which are congruent with SWL case for change e.g. management of the frail elderly, improved management of long term conditions etc. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 55 of 89

56 St George s Healthcare, including Community Services Wandsworth (CSW) A. Acute CQUINS for 2011/12: Reduce avoidable death, disability and chronic ill health from Venous Thromboembolism (VTE) Patient Experience personal needs Decrease the number of Out of Intensive Care Unit (ICU) Cardiac Arrest calls. End of Life Care (acute) Alcohol misuse Outpatient experience Urinary Catheter Pressure Ulcers Medicines Management The total CQUIN value for the NHSW contract with SGH (excluding QMR), is 1,763,569 B. CSW division St George s Promotion of breastfeeding. School leaver booster (SLB) uptake by increasing uptake in schools where SLB uptake falls below 90%. Increase in the percentage of parents of eligible year 8 girls in Wandsworth who consent to HPV. Immunisation offer and extra sessions of HPV immunisations in state and independent schools where the uptake of HPV immunisations is below 90%. Increase the proportion of adult patients on the haemoglobinopathies team caseload with a care plan in place (which includes identification of and signposting/ referral to disease specific self-management programmes). Increase the proportion % of children defined as overweight or referred to weight management or activity programmes identified and agreed by NHSW. CSW specialist respiratory nurses in post during 2011/12 who have received at least level 1 smoking cessation training. Increased proportion of COPD patients with smoking status recorded as well as referred to smoking cessation services. Urgent Care (Falls / Palliative Care / Short-stay admissions / delayed transfers of care) Pressure ulcers Sickle Cell case management plans Breastfeeding Long-term condition management for COPD Mental Health CQUINs There are five mental health CQUINs as follows: 1. Venous thromboembolism: VTE risk assessment of all adult inpatient admissions. 2. Physical Health: linked to chronic disease management and medicines reconciliation within care plans. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 56 of 89

57 3. Patient experience: based on responses to questions in community and inpatient surveys. 4. Recovery: self-defined recovery goals included within CPA. 5. Smoking cessation: number of smokers who set quit dates. The total value of Wandsworth CQUINs is 581,800. Queen Mary s Hospital, Roehampton (QMH) CQUINs There are 11 QMH CQUIN indicators that have a total value of 570,000. These are: Venous thromboembolism: VTE risk assessment of all adult inpatient admissions. National Patient Survey Reasons for Catheterisation Catheter Protocol Pressure Ulcers-assessment Pressure Ulcers-Educational and Awareness Pressure Ulcers-Equipment OP-Hospital Cancellation and first and follow-up appointments OP-Hospital Cancellation of C&B appointments OP-Choose and Book slots Rapid Diagnostic Pathways (RDPs) Local Enhanced Services (LES) Wandsworth Local Enhanced Services have been developed in response to challenges in delivering care closer to home, shift of care and public health interventions. The key priorities are as follows: Increase practice productivity by aligning the provision of existing Local Enhanced Services to the delivery of the GP Practice Commissioning Engagement Scheme. In preparation for transition to commissioning arrangements in April 2013, review of Local Enhanced Services to ensure their effectiveness, value for money and strategic fit. Incorporate the Once for London Pan London Operating Principles for Primary Care Enhanced Services in future commissioning of LES. PBC LES 2011/12 will be focusing on falls management and GP referrals that would inform the delivering of QIPP initiatives Supporting Self Management Underpinning a number of our strategic goals is the need to increase self management in a number of areas, building on the Co-Creating Health model that has been developed in mental health and also maximising the benefits of the Expert Patient Programme. A Wandsworth-wide supporting self management strategy will be developed, which will include patient facing skills training, healthcare professional training as well as possible training for social care professionals. Patient education to support self management is core to all the long term conditions workstreams. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 57 of 89

58 7.1.6 Promoting Patient Choice Any Qualified Provider (AQP) is an initiative to widen the choice of providers available in certain service areas. In summary the process is that: Providers qualify and register to provide services via an assurance process that tests providers fitness to offer NHS-funded services. Commissioners set local clinical pathways and referral protocols and thresholds which providers must accept Referring clinicians offer patients a choice of qualified providers for the service being referred to Competition is based on quality, not price. Providers are paid a fixed price determined by a national or local tariff (based on national guidance) NHSW has selected musculo-skeletal physiotherapy (for head and neck) to pilot the roll out of the Any Qualified Provider (AQP) initiative to commence in April The aim of the programme is to provide greater choice of a range of accredited providers. Wider engagement will be undertaken as the programme starts to be rolled out to other areas. Further work is being undertaken to assess the likely impact of this initiative on existing contracts. 7.2 Information, Information Technology and Communications South West London Cluster Informatics Strategy and Services SW London PCTs have been working together to define and deliver a Cluster-wide informatics (Information Management and Information Technology) strategy since April The Informatics Strategy delivers services across a number of different layers, as depicted in the diagram below. These layers enable a number of informatics services to be delivered to a range of customers as described in the informatics services catalogue. These services are driven by existing and future customers and are designed to meet the needs of both commissioners (current and future) and providers (in particular GPs and Community providers) as well as fulfilling the IT related statutory responsibilities of the PCTs. The key principles that underpin the informatics strategy are: Fit for purpose services delivered by the strategy must meet the needs, and exceed the expectations, of existing and future customers. Competitive the price of services (and therefore the cost) must be competitive and maximise Value for Money (VfM) in order to retain existing customers (both commissioners and providers) and maximise market share in the future. Innovative solutions and services must be innovative to ensure a competitive edge and to maximise return on investment. Flexible and scalable infrastructure, systems and services must be flexible to meet local requirements and scalable to meet increasing demand. Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 58 of 89

59 Open architecture appropriate systems must be open architecture to enable the flexibility to accommodate local solutions within the overall technical architecture (e.g. ability to plug in local analytical tools and solutions, such as risk stratification, to the Cluster provided data warehouse). Single source, single entry data must, wherever possible, be collected or entered once from a single source. Quality quality is imperative in everything we do including; accurate and timely data, robust, resilient and secure infrastructure, efficient and effective processes and methodologies and fit-for-purpose systems and services. Integration and interoperability infrastructure, systems, data, information and services must be joined up to enable sharing of holistic datasets that support the integrated nature of commissioning and care delivery. Security and governance systems and data must be secure and only accessible to those that have a right and a need to access or process that data adhering to all the principles and requirements of information governance. Organisational development the strategy recognises that there is a significant organisational development, change management and benefits realisation dimension in maximising Value for Money and return on investment in IT and information systems and services. Patient Centric while focused on meeting the needs and requirements of the direct customers, the services must also be designed with significant consideration for the patient and service user 1. 1 SW London Cluster Informatics document (Nov 11) Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 59 of 89

60 Wandsworth CCG Commissioning Strategy Plan 2012/ /15 (FINAL v0.12) Page 60 of 89