An Integrated Plan for Commissioning Specialised Services for Wales 2014/ /17

Transcription

1 An Integrated Plan for Commissioning Specialised Services for Wales 2014/ /17 Technical Document Status Final Version Number 2.0 Publication Date 18/03/14 To ensure equitable access to safe, effective, and sustainable specialised services for the people of Wales. WHSSC is a joint committee of the seven Local Health Boards in Wales, which has the delegated responsibility for commissioning specialised services on their behalf. 1

2 Table of Contents 1 Executive Summary An Integrated Plan for Commissioning Specialised Services WHSSC Finance and Policy Context Strategic Context Integrated Plan Development of the Plan Transforming the Commissioning of Specialised Services The WHSSC Commissioning Cycle Health Needs Assessment Commissioning Intentions Evidence Based Policy Development Looking to the Future - Commissioning Specialised Services Collaborative Commissioning Integrated Commissioning Commissioning through Coproduction Service User Focused Commissioning A Model for the Future Key Priorities for Service Priorities for Delivery of Tier 1 Priorities Implementation of Joint Committee Decisions Equity of Access to Specialised Services Quality, Safety, Outcomes and Patient Experience Sustainable Services Repatriation Business Cases Monitoring Quality and Performance Key Performance Indicators Provider Visits & Site Assessments Audit, Quality and Outcomes Commissioning Plans for Financial Plan Agreement of Financial Planning Principles Detailed Financial Modelling and Options Appraisal Financial Tables Summaries Financial Tables Commissioner Splits Key Risks Risks to the Financial Plan Service Planning Programme Maps Local Health Board Developments - impacting on WHSSC services Further Risks to the Plan Risks to Delivery and Mitigating Actions Monitoring, Delivery and Assurance Monitoring and Delivery Assurance

3 Three Year Commissioning Plan for Specialised Services 2014/ /17 1 Executive Summary The Integrated Plan for Commissioning Specialised Services for Wales 2014/ /17 has been structured to support the delivery of the NHS Wales Specialised Services Strategy i.e. to ensure equitable access to safe, effective, and sustainable specialised services for the people of Wales., and to ensure that the planning of specialised services is consistent with the Institute for Healthcare Improvement Triple Aim to: Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and Reduce, or at least control, the per capita cost of care. A key feature of this plan is the integration of: 7 Health Board plans for commissioning local services (collaboratively along the patient pathway); and Provider plans (Health Boards, NHS Trusts in Wales and England) As well as: Quality (including patient experience and outcome) Activity volume (to meet agreed targets) Finance (including cost and affordability) The plan highlights the key priorities for specialised services for Welsh patients over the next three years, together with the financial implications, and key risks to delivery. The plan is underpinned by detailed work plans (annex i) for each of the programme areas, and a three year financial plan (annex ii). In addition to setting out the priorities and work plan for WHSSC over the next three years, the plan also describes the WHSSC commissioning process, and sets out a model for transforming commissioning through the adoption of: Collaborative Commissioning Integrated Commissioning Commissioning through Collaboration 3

4 2 An Integrated Plan for Commissioning Specialised Services 2.1 WHSSC The Welsh Health Specialised Services Committee (WHSSC) is a Joint Committee of the seven Health Boards in Wales, and they have delegated responsibility to plan specialised and tertiary services on the LHB s behalf. Specialised and tertiary services are those provided by a relatively small number of specialist centres, to populations greater than 1 million people. These services are typically high cost and low volume. The aim of WHSSC is to ensure that these services are planned and secured from providers that have the appropriate experience and expertise; are able to provide a robust and sustainable service; are safe for patients and are cost effective for NHS Wales. Diagram 1 NHS Wales - Health Boards 4

5 2.2 Finance and Policy Context The financial environment in NHS Wales is very challenging and difficult decisions will need to be made about the use of NHS resources, including in relation to specialised services. Within this context it remains essential to set a realistic and deliverable plan that recognises the current position and re-aligns budgets appropriately to enable an improved understanding of financial risk and improves governance arrangements. It must be recognised that the health policy context in England continues to diverge from Wales, and the recent reorganisation has resulted in significant changes in the way that specialised services are commissioned in NHS England. This divergence will be increasingly apparent to the public and will impact directly on Welsh patients treated in England. In the above context, it is essential that: Plans for specialised services are developed in close liaison with LHB and regional level planning for non-specialised services; Decisions and choices in relation to specialised services, affecting both individuals and services, are consistent in terms of consideration of risk, impact and value with decision making in other services; and Divergence with policy and practice in England is carefully managed. The following context is important in developing a full understanding of the WHSSC position and the demands arising from the interaction of NHS Wales and NHS England: Relative access rates to specialised services remain lower than the English population. The nature of these gaps were extensively reported in 2013/14 and work is underway to update the comparison but indications are that gaps have not closed. The WHSSC work programme for 2014/15 will include further detailed engagement with Health Boards to explore these differences as part of developing a longer term plan on commissioning specialised services. Overall spending on specialised services is significantly less than in England with a headline difference now up to 25% to 30%. The English system continues to target additional growth resources to specialised services with growth planned for 2014/15 of 4.4% and a 5

6 further 5.9% for 2015/16. In addition to this commissioners benefit from a planned 1.5% price deflation in 2014/15 increasing the headroom for service demand and development. In this context the overall provision gap is therefore likely to grow. English waiting times are generally significantly shorter than in Wales and referrals to English providers will generally be treated well within the current Welsh maximum waiting times standards. The anticipated English financial framework for payment by results will include value for net price deflation inflation. However, many of the contracts with English providers continue to experience net demand growth which to date has been in excess of any price deflation. This plan assesses these risks on a contract by contract basis. The financial plan sets out a comprehensive assessment of the likely position for 2014/15 and includes a risk assessment of the additional risk facing Health Boards for the year but which require further consideration or approval. The financial plan includes provision for growth over and above the 2013/14 outturn position which will be subject to further detailed scrutiny before being released to the provider. All business cases for development have been rejected in the process so far and are included in the risk assessment section. It is important to emphasise that each new business case still under consideration will need to be signed off individually through the established governance process of Management Group consideration and Joint Committee approval. 2.2 Strategic Context Together for Health A Five Year Vision for the NHS in Wales, focuses on delivery and aspires to services best suited to Wales, but comparable to the best anywhere. This aspiration applies to specialised services, where it is possible to make comparisons, particularly with services in other parts of the UK. NHS Wales Specialised Services Strategy - the seven Health Boards in Wales have agreed this strategy in order to: ensure equitable access to safe, effective, and sustainable specialised services for the people of Wales. The strategy also aims to raise awareness and understanding of specialised services and to ensure that specialised services help meet the Institute for Healthcare Improvement Triple Aim to: 6

7 Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and Reduce, or at least control, the per capita cost of care. 2.3 Integrated Plan The Integrated Plan for Commissioning Specialised Services for Wales 2014/ /17 sets out an integrated commissioning plan for specialised and tertiary services for the population of Wales for the next three years. The aim of the plan is to not only integrate with Welsh Government priorities and Health Boards planning intentions, but also to integrate across a series of wider dimensions including quality and patient safety, finance, and service sustainability. An integrated commissioning plan for specialised services differs from other integrated delivery plans as it must integrate: 7 Health Board plans for commissioning local services (collaboratively along the patient pathway) Provider plans (Health Boards, NHS Trusts in Wales and England) As well as: Quality (including patient experience and outcome) Activity volume (to meet agreed targets) Finance (including cost and affordability) The diagram below illustrates how the plan integrates across the patient pathway. 7

8 Collaborative and Integrated Commissioning across the Patient Care Pathway Integrated Patient Pathway Home G.P. Local Hospital Specialised Service Highly Specialised Service IHI Triple Aim Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and Reduce, or at least control, the per capita cost of care WHSSC 2013 Diagram 2 The Integrated Plan 2.4 Development of the Plan The process for developing the plan was agreed by the WHSSC Management Group in November This involved the issuing of commissioning intentions for specialised services for the next three years to Welsh commissioners and providers, as well as meeting directly with each Health Board in order to: Agree national priorities for specialised services Clarify impact of local plans on specialised services Identify opportunities for repatriation Assess progress in implementing Joint Committee and Management Group decisions The responses received from the Health Boards were analysed and used to develop the plan for each of the six programme areas within WHSSC. 8

9 A copy of the draft plan was issued to Welsh commissioners and providers for review and comment on the 18 th December The final document will reflect any further responses received, and will be issued on the 17 th January 2014, in order that in can be included in the submissions of the Health Boards and NHS Trust to the Welsh Government on the 31 st January

10 3 Transforming the Commissioning of Specialised Services 3.1 The WHSSC Commissioning Cycle The WHSSC Commissioning Cycle is designed to facilitate a transformational rather than transactional process, to reflect the integrated nature of health service commissioning and delivery within NHS Wales. The core aim is to integrate quality and risk management, performance and volume, and finance. There are four stages within the cycle: Health Needs Assessment o Assessment of need; o Review of current service provision; and o Evidence appraisal o Determining priorities. Service Planning o Management of risk; o Pathway and provider development; and o Developing commissioning policies and service specifications. Procurement & Contracting o Identification of Key Performance Indicators; and o Implementing contracts with providers. Performance Management and Review o Management of contract performance by providers; and, o Seeking public and patient views 10

11 Diagram 3 WHSSC Commissioning Cycle Consideration of issues of Equality and human rights will be embedded across the four stages of the cycle as appropriate and in accordance with the Public Sector Equality Duty. 3.2 Health Needs Assessment To support the 3 year cycle of the Specialised Services Plan, key information analysis will be conducted on epidemiology, clinical service evaluation and evidence appraisal. Stage 1 1. Rare Diseases epidemiology, related genetics and screening, laboratory and clinical demand analysis linked directly to the work needed for the Welsh Rare Diseases Plan. This analysis includes defined clinical conditions and diseases managed through immunology, haematology, paediatric subspecialties, oncology, neurology and endocrinology 2. Relate the epidemiology specific to the clinical services covered in Year 1 of evidence appraisal and prioritisation and the current epidemiological work with Public Health Wales on the appraisals in progress now for Year 2 to service planning to support needs assessment. Stage 2 3. Further analysis on need for complex pathways for diseases and conditions requiring cross-border referral including highly specialised services for Rare Diseases 11

12 4. Calculation of need/demand volumes for Specialised Service Interdependencies within Wales and across to England. This Includes: Low frequency clinical events (disease/interventions) including trauma related head injuries and burns (moderate/severe) Designated Specialised Services which link in higher volumes to disease pathways: cardiac and renal as well as posture and mobility services. 12

13 3.3 Commissioning Intentions The Integrated Plan for Commissioning Specialised Services for Wales 2014/ /17 will be underpinned by the Institute for Healthcare Improvement Triple Aim: Improving patient experience of care (including quality and satisfaction); Improving the health of the population; and Reducing the per capita cost of health care The plan reflects the impact of commissioning decisions made by the Joint Committee on the 2012/13 and 2013/14 Commissioning Plans. It also reflects the implications of delivering against the Tier 1 priorities in specialised services: Setting the direction Dignity in care Quality in care Mortality rates Access Unscheduled care Cancer Stroke Efficiency and productivity Resource utilisation The plan has been drafted on the assumption that level of funding available from Health Boards will continue in line with the 2012/13 outturn position, and that there will be no additional funding available to meet inflationary or service pressures. WHSSC are fully engaged in the work on shift to the left, and will work closely with Health Boards to explore the potential benefits in collaborative commissioning across the whole pathway of care. WHSSC will also build upon the existing work with service users and stakeholders to identify more opportunities for coproduction within specialised services. WHSSC will continue to work closely with Welsh providers, in order to ensure that where it is clinically appropriate and cost effective, activity in England can be repatriated back into Welsh services. In addition WHSSC will work with Health Boards in developing referral management over the next three years, with the 13

14 objective of ensuring that all referrals into English services are managed in accordance with the agreed pathways of care. The following principles for the transfer of service to and from WHSSC have been agreed with Health Boards: Non Specialist Services, contracted for by WHSSC on behalf of Health Boards, will be provided for in the WHSSC plan at the level established for the 12/13 baseline. Therefore, all growth, pressures and opportunities will need to be considered and provided for in individual Health Board plans. Specialist Services funded directly by Health Boards will be provided for at 12/13 baseline within Health Board plans. Therefore all growth, pressures and opportunities will be considered within the WHSSC plan. 3.4 Evidence Based Policy Development Evidence based policy development is the model used by the Programme Teams to develop commissioning policies and service specifications. There are two types of evidence used by Programme Teams in policy development practical and empirical. Practical evidence includes local intelligence, benchmarking data and expert clinical and service user advice. Empirical evidence comprises published clinical and cost effectiveness data relating to the specific technology or treatment. Diagram 4 Evidence Based Policy Development The collection of empirical evidence is supported by the Evidence Assessment and Appraisal process which runs continuously through the year. This process has six core stages, as described overleaf: 14

15 15

16 1. Identification of need for policy and / or service specification Programme Teams are responsible for monitoring and identifying the need for policy development. The need for a policy and / or service specification can arise from a number of factors, including: Development of a new technology or treatment Use of an existing technology or treatment for new indications Increased demand for an existing technology or treatment Political interest in new or existing technologies and treatments This process is ongoing, and will occur throughout the commissioning cycle. 2. Evidence Appraisal Once the need for policy development has been identified, the Medical Directorate are responsible for undertaking a detailed appraisal of the published evidence relating to the technology or treatment. The Medical Directorate uses a highly structured methodology, which takes account of the clinical and cost effectiveness of technology or treatment. The Medical Directorate is supported in this work by the Clinical Evidence Reference Groups and the Prioritisation Panel. The final product incorporates: Detailed and summarised appraisal of the evidence. Assessment of Clinical and Cost effectiveness. Recommendation for implementing or not implementing the technology or treatment, including detailed access criteria and outcome measures. 3. Policy / Service Specification Development The Programme Team are responsible for taking forward the outcomes of the evidence appraisal, in order to develop a Commissioning Policy or Service Specification. This stage includes the following processes: Structured consultation with service users, service providers (Clinicians, Managers NHS Wales and NHS England), and the third sector; Equality Impact Assessment assessment of the access criteria on service users with protected characteristics; 16

17 finance, activity Impact assessment in both the WHSSC and Health Board services; Triple Aim assessment assessment of the policy against Together for Health and the IHI triple aim principles; Shift to the Left assessment assessment of the impact of policy on collaborative commissioning; Coproduction assessment assessment of the opportunities for coproduction of the commissioning policy. The culmination of these processes is the development of the Commissioning Policy or Service Specification, and a detailed covering paper which addresses all of the key issues central to implementation. 4. Approval The Commissioning Policy is submitted to the WHSSC Management Group or Joint Committee for consideration and approval. 5. Implementation Following approval at the WHSSC Management Group or Joint Committee, the Programme Team will liaise with the service to ensure that the Commissioning Policy or Service Specification is implemented in line with the timeframe specified in the covering paper. 6. Monitoring and Auditing Following implementation, the Programme Team is responsible for working with the service to audit compliance with the Commissioning Policy or Service Specification, and to ensure that the service provides regular monitoring reports on the clinical outcomes of patients who receive the treatment or technology. This will include the submission of monthly key performance indicator reports, as well as presentation of the outcome data at formal audit days and the WHSSC Quality and Patient Safety Committee. The diagram overleaf shows how the six stages link together to support the delivery of evidence based policy development. 17

18 Evidence Based Policy Development Structured Consultation (NHS, Service Users, Third Sector) Equality Impact Assement Activity & Financial Assessment (HB & WHSSC) Identification of Need Policy +/- Service Specification Evidence Appraisal Recommendation inc Proposed Access Criteria & Outcome Measures Triple Aim Assessment Policy / Service Specification Development Draft Policy / Service Specification & Impact Assessment Joint Committee Approval Final Policy / Service Specification Implementation Audit Compliance Monitor Outcomes Shift to the Left Assessment Coproduction Assessment Diagram 5 Evidence Based Policy Development Process 18

19 3.5 Looking to the Future - Commissioning Specialised Services The integrated nature of NHS Wales has enabled and empowered Health Board, through WHSSC, to develop a transformational approach to commissioning. Over the next three years there are a number of emerging themes which will continue to transform the current model for commissioning specialised services. These are: Collaborative Commissioning Integrated Commissioning Commissioning through Coproduction Collaborative Commissioning Over the last few months the collaborative commissioning programme has developed further. For specialised services commissioning there are a number of potential advantages including: The sharing of good practice and developmental work, including benchmarking, evidence appraisal, commissioning improvement projects, etc. Identifying opportunities for collaborative commissioning across the whole patient care pathway Developing consistent approaches to cross border commissioning and the management of individual patient funding requests Integrated Commissioning The plan has been developed to reflect the integrated nature of commissioning across NHS Wales, in particular the relationship between developments at a national level which impact on local services and developments at a local level which impact on national services. The key developments within each of the Health Boards which will impact on specialised services are outlined in annex iii. Diagram 2 illustrates how collaborative and integrated commissioning work in order to ensure that there is an integrated approach to commissioning across the whole of the patient care pathway Commissioning through Coproduction Coproduction is an emerging theme in the planning and delivery of public services, it is defined as the..means of delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their 19

20 neighbours. Where activities are co-produced in this way, both services and neighbourhoods become far more effective agents of change. 1 Over the next three years, there will be an increased focus on the development of coproduction as a key commissioning methodology. This will offer a number of opportunities to develop a more effective commissioning framework through: Transforming services through the introduction of new resources from within the community Promoting effective patient and public participation in the commissioning cycle Developing services around individuals in order to reduce the demand for acute health services Challenging assumptions of service users as passive consumers of care The move towards a coproduction model for commissioning specialised services, will present a number of challenges for commissioners, providers and service users across the commissioning cycle, as it will require a significant change in culture and working practice for commissioners, providers and service users. Therefore, this model will be piloted across a number of specialised service areas initially, in order to assess the benefits of application to the planning of specialised services Service User Focused Commissioning A Model for the Future It is envisaged that over the next three years, the combination of these three models will facilitate a move towards to a transformed approach to commissioning which is based on an equal and reciprocal relationship between service users, providers and commissioners. This is illustrated in the diagram overleaf. 1 The Challenge of Coproduction, NESTA, December

21 4 Key Priorities for Diagram 6 Service User Focused Commissioning 4.1 Service Priorities for Each Programme Team has identified the key priorities within it s workplan for the next three years. However, there are ten high profile priorities which are core to the delivery of this plan. These include: No. Service Priority Triple Aim 1 Cardiac Surgery Improved outcomes for Improving the cardiac surgery health of the including reduction of population mortality on inpatient waiting list. 2 Cardiac Surgery Achievement of 26 week referral to treatment time, and phased introduction of component waiting times. 3 Thoracic Surgery Increased access to thoracic surgery to 21 Improving the health of the population Improving the health of the

22 improve outcomes for lung cancer. 4 Liver Surgery Improve outcomes for lung cancer. 5 Posture and Mobility Achievement of 26 week referral to treatment time. 6 CAHMs Tier 4 Strengthening the local services to reduce out of area referrals 7 Cardiac Services Implementation of Heart Disease Delivery Plan. 8 All Reduction of non specialised activity in NHS England providers. 9 All Ensure embedding of prudent healthcare including enforcement of INNUs and contract exclusions. 10 All Commissioning for improved outcomes. population Improving the health of the population Improving patient experience of care (including quality and satisfaction) Improving patient experience of care (including quality and satisfaction) Reducing the per capita cost of health care Improving the health of the population Reducing the per capita cost of health care Reducing the per capita cost of health care Improving the health of the population 4.2 Delivery of Tier 1 Priorities WHSSC will continue to work with providers in NHS Wales and NHS England in order to ensure that Tier 1 priorities are achieved, including: Setting the direction Dignity in care Quality in care Mortality rates 22

23 Access Unscheduled care Cancer Stroke Efficiency and productivity Resource utilisation Over the next 12 months there will be a particular focus on ensuring that the following services achieve 26 weeks RTT: Neurosurgery Plastic surgery Wheelchairs Following the outsourcing initiative undertaken in Cardiac Surgery in South Wales, the focus will be on a phased approach to introducing component waiting times for Cardiac Surgery. 4.3 Implementation of Joint Committee Decisions WHSSC will continue to take forward the implementation of decisions made by the Management Group and Joint Committee (annex iv) 4.4 Equity of Access to Specialised Services Work will continue over the course of the next three years to develop clear access criteria and commissioning policies for specialised services, as well service specifications to set out what service users can expect from specific specialised services. In addition WHSSC will continue to develop and strengthen the existing clinical gatekeeping arrangements, to ensure that there is clarity at all levels about the appropriate referral pathways for each service. 4.5 Quality, Safety, Outcomes and Patient Experience WHSSC will continue to build on the improvements in the measurement of quality, safety and patient outcomes and increasing the number of service specific multi centre audit events. 23

24 4.6 Sustainable Services WHSSC will continue to build and develop referral management arrangements for specialised services, including cross referrals from secondary care services in NHS England, and to ensure services are commissioned from centres with sufficient expertise and volumes to demonstrate good patient outcomes. Referral management arrangements have been established for the following areas: Eating Disorders Services Gender Dysphoria Assessment and Surgery Services Neurosurgery Specialised Paediatric Services 4.7 Repatriation As in previous years, WHSSC will continue to work closely with provider Health Boards to review and identify opportunities for repatriating specialised services activity from NHS England. The following areas have been identified for progression in 2014/15: Bone Marrow Transplant and Haemophilia patients from Liverpool to North Wales Stereotactic Radiosurgery Service in Sheffield to Velindre Fetal medicine from Bristol to Cardiff Reprovision of neonatal cots Paediatric cochlear implant surgery As outlined in the commissioning intentions, all potential opportunities for repatriation will be reviewed in a systemic approach, in order to ensure that it is clinical appropriate and cost effective to repatriate. The following areas have been identified as potential opportunities for review in 2014/15 Paediatric orthopaedic surgery into South Wales. As part of the development process, Health Boards were asked to identify opportunities for repatriation using a standardised template. These templates were then used to identify the current level of activity that could be repatriated and assessed against the IHI Triple Aim by the relevant programme team. Only one area was identified as a possibility for repatriation brachial plexus. Following assessment it has been concluded that level of historic activity did not match the demand 24

25 outlined in the proposal, and as such it would there would not be sufficient resources available from repatriation to offset the development of a service in ABMU. 4.8 Business Cases Programme Teams have undertaken an assessment of the following five business cases against the IHI Triple Aim: All Wales Lymphoma Panel (Tier 1) Cleft Lip and Palate (Deferred from 2013/14) Cystic Fibrosis Infrastructure (Deferred from 2013/14) Sentinel Lymph Node Biopsy (Deferred from 2013/14) 68 Ga DOTA PET Scanning in the Management of Neuroendocrine Tumours in South Wales The assessments were issued to Health Boards for review and comment, and the responses are set out in annex v. 25

26 5 Monitoring Quality and Performance The quality and outcomes high level framework is now in place within Welsh Health Specialised Services. This high level dashboard will provide re-assurance to the WHSSC Executive Team and Joint Committee on the quality of services being commissioned for, and on behalf, of Wales. Data is now being received from our provider organisations, which is starting to be entered onto the dashboard. Each provider has a single dashboard which then feeds into an organisational dashboard for board assurance. One avenue being explored is trying to migrate to an electronic system. Healthcare Evaluation Data (HED) is a system developed by University Hospital Birmingham which allows monitoring and evaluation of quality data. A presentation has been made to the Quality and Patient Safety Committee around this system which they were very keen to take forward. 5.1 Key Performance Indicators Key performance indicators have been developed for the following areas: Wheel chair and posture & mobility service Gender Dysphoria service Cystic Fibrosis service Home Parenteral Nutrition Clinical Immunology Over the next three years, it is planned that key performance indicators will be developed for all of the services commissioned through WHSSC, with regular monitoring and reports to the Health Boards. 5.2 Provider Visits & Site Assessments The Head of Nursing, in line with the contracting meetings, has visited a number of providers to meet with their Nurse Directors and members of the quality teams. These visits have been a great opportunity to build a relationship with our providers. During the visits, The Head of Nursing has been introducing the earlier mentioned Quality and Outcomes framework to the quality teams within the provider organisations. 26

27 Following each visit, a report will be compiled detailing the standards of the clinical areas visited and a brief summary of the meeting with the Nurse Director. 5.3 Audit, Quality and Outcomes Throughout 2013, there have been a number of specialist multiprovider service focused audit days, which have focused on quality and outcomes, these include: Adult Cardiac Services Child and Adolescent Mental Health Cochlear Implants IVF Paediatric Cardiac Services Renal Specialised Rehabilitation The outcomes of these events have been reported to the WHSSC Quality and Patient Safety Committee. Over the next years, there will be a further series of audit days for the above services, and in addition further events are planned in the following services: Clinical Immunology Deep Brain Stimulation Posture and Mobility (Wheelchairs) Prosthetics Thoracic Surgery 27

28 6 Commissioning Plans for There are a number of national delivery plans and strategies which impact on specialised services over the next three years. The table below shows the relationship between these strategies and each of the programme areas. Mental Health (incl CAMHS) Women & Children Neuro LTC Cancer & Blood Cardiothoracic EU Directive Y Y Y Y Y Y Together for Health Y Y Y Y Y Y NHS Wales Planning 26/11/13 Y Y Y Y Y Y Guidance Achieving Excellence - 23/07/13 Y Y Y Y Y Y Quality Delivery Plan Delivering Local Health Care 22/11/13 Y Y Y Y Y Y Accelerating the pace of change NHS Wales delivery 24/05/13 Y Y Y Y Y Y framework and Future Plans Working differently working 17/05/12 Y Y Y Y Y Y together Setting the Direction 27/07/10 Y Y Y Y Y Y primary and Community Services Strategic Delivery Programme Public Information Delivery 26/07/12 Y Y Y Y Y Y Plan UK Rare Diseases Strategy 22/11/13 Y???? Organ donation and????? Y Y Y transplantation Delivery Plan Renal Disease Delivery Plan????? Y Liver Disease Delivery Plan In preparation Y Respiratory Disease Delivery Consulting Y Plan Neurological Conditions Consulting Y Y Delivery Plan Together Against Stroke 05/12/12 Y Y Delivering End of Life Care????? Diabetes Delivery Plan 26/09/13 Y Y Eye health care delivery plan 18/09/13 Arthritis and Chronic musculoskeletal conditions 02/09/13 Y Strategic Vision for Maternity services 17/07/13 Y Delivery Plan for the Critically Ill 19/06/13 Y Heart Disease Delivery Plan 11/04/13 Y Together for Mental Health 26/02/13 Y Cancer Delivery Plan 13/06/12 Y Renal 28

29 The commissioning plans for are set out in thee distinct themes, in line with the Institute for Healthcare Improvement Triple Aim : 1. Improving the health of the population 2. Enhancing patient experience of care 3. Reducing, or controlling the per capita cost of care The key priorities for the six programme areas are set out in annex i. 29

30 7 Financial Plan The financial plan will be comprised of two main components: Agreement of financial planning principles Detailed modelling of plans and options As part of the continuous improvement of the planning process WHSSC this plan is backed by a supporting document which sets out the detailed assumptions and basis behind all key changes from year to year. This detailed document includes the justification for assumptions regarding the continuance of trends on contract lines that have either under or over performed. 7.1 Agreement of Financial Planning Principles In order to deliver a plan that matches as closely as possible to a flat cash aspiration there is a requirement for greater clarity from Health Boards around the range of actions that are permissible. The planning process has engaged Health Boards in a discussion around reducing uncertainty in terms of what is permissible to include in the plan regarding efficiency, price reduction and disinvestment. The planning principles underpinning this final plan are based on the following key components: Price deflation at this point there is no clear consensus in favour of a price deflator. In order to reduce uncertainty this plan has therefore been constructed on the basis of a flat cash position for Welsh providers. However, for English providers the published price deflator has been fully incorporated. Efficiency the adoption of a flat cash position for Welsh providers means that there is an underlying efficiency improvement equivalent to actual unavoidable pay and price inflation valued at an estimated 2%. However, WHSSC do not expect specialised services to be subject to additional local cost reductions over and above the funded flat cash position. It is essential that specialised services, funded by all Health Boards, are appropriately protected. If there is any local disinvestment WHSSC must be consulted in advance and any benefits appropriately shared. WHSSC will be increasing attention to ensuring that service levels are maintained at funded levels. Disinvestment WHSSC will be specific with providers regarding any disinvestment that arises from a commissioning decision, the basis of that decision and the expected funding flows and timescales. 30

31 7.2 Detailed Financial Modelling and Options Appraisal The financial modelling process includes: Baseline assessment based on rolling projections from the 2013/14 monthly financial positions. Evaluation of recurrent and non-recurrent components. Accounting for existing Joint Committee decisions. Assessing new demands and service trends. Evaluation of the limited number of business cases that have been requested all business cases have been assessed as not recommended at this point and are detailed in the further risk table. Evaluation of the impact of prioritisation on demand management; avoidance; criteria and disinvestment. Opportunities for external price reduction, procurement benefits and repatriation. Evaluation and modelling of requirements for Welsh provider efficiency and price reduction. Further Options for disinvestment. The attached tables (annex ii) show the provisional positions pending the detailed work set out above. The key points from the tables are summarised below: The net increased funding required excluding ambulance services is 13.8m New service pressures and growth in demand represent an increase of 3.3m Net savings from prioritisation are 0.2m. However, in addition to this prioritisation has avoided a range of potential pressures valued at over 4m in the 2013/14 plan. New savings from procurement, system efficiency and cost reduction are estimated to be 4.3m including over 1.3m from high and medium secure services, and 1.6m in enzyme replacement therapy. Net forecast pressures from new risks are estimated to be 1.7m including cardiology growth, cardiac surgery outsourcing, home parenteral nutrition and liver services. 31

32 Financial Tables Summaries 32

33 7.4 Financial Tables Commissioner Splits 33

34 8 Key Risks 8.1 Risks to the Financial Plan Service Planning Programme Maps The service planning programme maps set out the priorities that WHSSC will be working on throughout the coming three years. These have been considered as part of the financial plan and the following schemes have been identified in terms of financial risks which have not been included within the finance tables. a. Delivery of Ministerial Priorities. Cardiac Surgery this plan includes the costs that have been committed to date from outsourcing that will flow into 2014/15. In addition the plan includes a provision, pending full business case evaluation, for the 1m requested by CVUHB to return contract performance to 1,064 cases. The significant additional cost of decreasing the surgical component waiting time is noted as a risk at this point and is not for consideration in this plan. The cost of outsourcing cardiac surgery to deliver RTT performance in relation to contract volume underperformance has been picked up by CVUHB in 2013/14 strictly on a without prejudice basis. The residual cost of outsourcing provisional included in the 2014/15 plan will need to be subject to further agreement as to distribution to individual Health Boards. This will need to occur as part of deciding on the wider strategy for cardiac surgery capacity. With the exception of the above mentioned no other business cases have been received for tier 1 targets. Therefore, it has been considered by programme teams as part of assessing baselines. Cochlear Implants BCU and Cardiff and Vale has identified a pressure in their cochlear services. The specialist planner is currently working through capacity and activity plans to establish what the pressure is for 14/15 ongoing. Indicatively, it is suggested that collectively this could be in region of 250k this is not currently included in the plan until the work is refined and validated and represents an investment choice. Hepatology and Liver surgery - A ministerial priority has been identified in relation to Hepatology and Liver surgery. WHSSC is awaiting proposals from the provider in terms of the two consultant posts required including job plans. It was also 34

35 mentioned in the Cardiff and Vale provider pressures letter, but did not contain any financial values. Indicatively, an increase in activity to fund two consultant posts may cost in the region of 250k. The financial plan includes provision for a hepatologist given the nature of the undertakings given to date by the provider. However, the plan does not include additional funding for a surgeon as the current contract currency already meets all liver surgery costs at full unit cost based on an agreed benchmark price. b. Delivery Frameworks It is assumed that the delivery frameworks will need to be considered in context of the current resource levels. c. Improving Equity of Access Revascularisation: Access to PPCI in North Wales - This scheme specifically related to the BCU Health Board and is being considered by their Board before finalisation of recommendations. Therefore, this has not been included as part of the financial plan. It should be noted, that the financial risk to this being agreed is in the proximity of 1m. Revascularisation: variation in PCI treatment times for ACS (NSTEMI) - similar to PPCI, this indicates a potential opportunity. However, this has not been included as part of the financial plan as the cash releasing savings is limited despite the economic model of reducing bed stays is clear. Thoracic Surgery: ensuring equity in access to resection for cancer and to surgery for non-malignant indications. For South East Wales, the provider has not identified this as a cost pressure and therefore on balance, this has been omitted from the plan. It should be noted that the level of overperformance in 13/14 is forecast to be in the region of 100k. Neuropsychiatry - Increased access for North Wales residents - impact of WCFT development - would pose a financial risk should any North Wales patients present. To date, WHSSC hasn't experienced any individual requests to fund this service in North Wales; however, the newly opened unit in the Walton may attract more referrals. 2-3 patients accessing this service would carry a financial risk in the region of 150k. 35

36 Clinical Immunology - Improved access for North Wales residents - implementation of service specification - the impact of this is unknown and is still being worked through. Cochlear Implants for Adults - this relates to a service issue in BCU Health Board as there is an agreed gap in the number of cochlears that should be provided which has also contributed to delays in waiting times. There is a financial gap to this. This hasn't been included in the plan as it's currently being considered as part of the WHSSC Specialist Planner and Evidence Evaluation Team. In addition, there are some opportunities in relation to the delivery for wider populations thus being self funding. SBRT/SRS is initially funded in the first year from repatriation monies currently invested into the Sheffield contract. The business case currently estimates increased costs in years 2 and 3 by 275k and 403k respectively providing all the indications and the activity identified in the business case occurs. This is currently not included in plan for future years as WHSSC is currently working with the provider to re-profile these costs. In addition, there have been delays in implementation and therefore, the entire funding in these years may not be required fully. d. Horizon Scanning All programme areas are participating in the Evidence Evaluation process. The nature of this process does not easily allow for an evaluation of the future financial impact, until specific schemes have been worked through. However, unless otherwise specified in the financial plan, the financial tables are assuming these schemes would be cost neutral overall. This is not without risk/opportunity and any further risks need to be condidered in the context of affordability. The Cancer Programme Team has identified a future pressure in BMTs in South Wales. The extent of the pressure is to date unknown, however, WHSSC is working with the provider to refine these pressures and look at any potential efficiency gains from e.g. service redesign to limit any future financial pressures. e. New Commissioning Policies The following commissioning policies are deemed to have a financial impact that WHSSC will work through as and when the policies become available to formulise. The financial risks should be noted in terms of affordability in future years: 36

37 Revasularisation in stable coronary heart desease - the financial impact of this policy is now yet known and is being worked through as the policy progresses. Bariatric Surgery - has been considered as part of the financial plan ICD/CRT - the financial impact of this policy is now yet known and is being worked through as the policy progresses. f. Shift to the Left Low back pain - this may pose a financial opportunity to WHSSC if the adoption of the English service specification is supported. This has not been included as part of the financial plan as the Welsh clinical support to date has been limited. This service is currently being conisdered by Evidence Evaluation. g. Key Clincial Risks Wheelchair (BCU) - 180k has been provided to the BCU Health Board directly to improve access to wheelchairs. This is not included as part of the plan due to the income being directly accounted for by the Health Board. This will be monitoring via the on-going contracting frameworks. WHSSC will continue to review the deployment of income for wheelchairs as part of the review of wheelchair provision project to ensure that resources have been deployed to purpose. h. Contracting Issues Walton Centre Foundation Trust - WHSSC currently benefit from intense negotiation deals with the Walton Centre. However, it should be recognised that in the coming three years, the discount received via favourable marginal rate, will not continue. This will be reduced by at least 50% in 14/15 and then by 100% in 15/16. It is hopeful that WHSSC can work with BCU Health Board in relation to the neurology elements of the contract to minimise future overperformance and therefore the risk of not receiving this benefit. This has been considered as part of the financial valuation in 14/15 and the overall growth proposed in future years. 900k has been identified as a potential pressure going into next year. Details of this is unknown and has therefore hasn t yet been included. WHSSC will converse with BCU to agree the strategy around what is included. Neonatal care - A current gap in the current system has been identified as part of the Neonatal network and the Women and Childrens Specialist Programme Team. It is assumed that the funding for this service is provided for within the resources of the plan; however, the contracting arrangements for this service will need to be revised to ensure resources are deployed correctly. 37

38 i. Transfer of Services/ Transfer of Resources The services included in the transfer of services/resources are deemed to be neutral on transfer Local Health Board Developments - impacting on WHSSC services WHSSC Programme Teams have assessed the impact of local developments on the WHSSC services. Overall, the response has been limited and therefore, there is a risk that all developments which may lead to an increase in WHSSC activity or decrease have not been identified. It should be noted that this exercise has only taken place in Wales. The following schemes have been identified as repatriation schemes and will therefore need to be undertaken within the current resources, unless individual Health Boards agree to invest individually. BCU Repatriation of PCI from LHCH EBUS repatriation from LHCH BMT repatriation from Christie IHBD repatriation from RLBG Bariatric surgery potential to transfer of service from Salford to Chester Development of North Wales Neurology service PET development in North Wales (from The Christie) Hwyel Dda Explore options for delivering cardiology, including angioplasty Neonatal - Strengthen service in Carmarthen ABMU Neonatal - increased capacity Paediatric oncology - shared service arrangements Cystic Fibrosis - offer additional services in Swansea Cwm Taf Repatriation of ICDs from CVUHB Aneurin Bevan Centralisation and consolidation of ABHB Breast Surgery Services Development of radiology repatriation plans 38

39 Development of ABHB capacity to potentially repatriate cardiology services e.g. PCI, Complex Devices The following services identified by Health Boards have been considered as part of the financial plan is therefore provided for in the plan as far as possible: Wheelchairs RTT and expansion of access criteria across Wales - a project group will be set up in 2014/15 to review the expenditure in ALAS services. This is an area that has been identified for review due to the need to expand and achieve RTT. In the medium term, WHSSC is suggesting that due to the historic funding arrangements of providing this on a block contract basis, there is a need establish what is currently being provided before Health Boards are requested to review any further funding. Consistently Health Boards whom have responded has identified Neonatal services as an area of development. WHSSC has agreed a way forward on this service with the Management Team and methods of implementing this are being reviewed. The current status of this project is that funding is already assumed to be within the system, however, deployment of the funding in relation to the cot day activity remains to be agreed. In addition, AB and BCU have both mentioned developments to be undertaken to reduce the amount of out of area placements in Tier 4 CAMHS services. The work of the Network will be taken into consideration whilst implementing any proposals. This would generate future opportunities to Health Boards, however, in the medium, the costs of out of areas placements pose a significant financial risk and the likelihood of these placements in the short term remains high. Therefore, this risk has been assessed as part of the financial plan Further Risks to the Plan The Cardiac Surgery at Cardiff and Vale business case has now been received which WHSSC is currently scrutinising. The new recurrent pressure detailed in the business is 3.29m ( 1.64m in 14/15). The Director of Finance of WHSSC is currently arranging meetings with Health Boards to go through the detail of the case. In addition, there are fundamental information requests outstanding with the provider, in order for WHSSC to form a view. Thus as per the original pressures letter, only 1m of this pressure is currently included in the plan. Eculizumab for AHuS patients The NICE Highly Specialised technology (HST) process began the appraisal for Eculizumab in Atypical Haemolytic Uraemic Syndrome (shus) in Dec NICE will circulate the consultation on their draft Final 39

40 Appraisal determination (FAD) in March/April) Although a positive or negative decision is not binding on NHS Wales there will be considerable pressure to conform to the decision in NHS Wales. The anticipated patient numbers eligible for this indication and treatment are 7 14 patients per annum at expected costs of 250, 000 per patient per annum. The estimated financial risk to the plan million. The Specialist Planning Teams in WHSSC continue to work on the work plans for the coming years. It should be noted that whilst the financial plan includes those included in Version 1, this may change as the final version is produced. An area that has already been identified as a financial risk is Thoracic surgery. This has close links to the cancer network and the ability identify patients early enough for lung resection. For South Wales, the potential risk based on a population analysis is 700k whilst the risk for North Wales is still being worked through. The ALAS project is due to conclude in December with a report to the Minister setting out the costs to the service of uplifting all artificial limb provision in line with that received by war veterans. If a decision is made to uplift provision, there will be a significant cost pressure in excess of 1 million, it is not possible to quantify the exact value at this stage although this will become clearer over the course of the ALAS project and updates will be provided to the Health Boards via MGM and the Joint Committee. 8.2 Risks to Delivery and Mitigating Actions 40