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2 VERSION CONTROL No. Description Author Date Status 0.1 Initial draft Anna Vigurs, Head of Draft Planning & PMO, NWS 0.2 Revised draft Anna Vigurs Draft 0.3 Revised draft following NW Surrey CCG Clinical Executive Seminar 0.4 Revised draft Additional narrative in Part 1; Part 2: Ambulance Collaborative; Part 3: NWS CCG Local CIs; Part 4: Digital technology; Part 4: Medicines management 0.5 Revised draft: Feedback from Sumona Chatterjee Inclusion of Part 1 Finance & QIPP Inclusion of Part 3 Local CIs from G&W & SD CCG. 0.6 Revised draft after Joint Executive Team on Revised Part 1 Finance and QIPP Part 2 Mental Health Part 4: Contracting; Procurements; Glossary updated Anna Vigurs Draft Anna Vigurs Sumona Chatterjee, Director of Commissioning, NWS Anna Vigurs Steve Abbott, IM&T Programme Director, Surrey CCGs Linda Honey, AD of Medicines Optimisation, NWS Anna Vigurs Sumona Chatterjee Karen McDowell, Chief Finance Officer, G&W Annette Keen, Senior Strategic Transformation & Commissioning Lead, G&W Warren Beresford, Acting Head of Planning, SD Anna Vigurs Vicki Taylor, Deputy Director of Finance, G&W Diane Woods, AD of Commissioning, MH Surrey CCG Collaborative Sumona Chatterjee and Rachael Graham, AD of Contracts, NWS Anna Vigurs Draft Draft Draft 0.7 Revised draft after Integrated Planning Group on Part 2: Mental Health updated Part 2: Learning Disabilities Anna Vigurs Diane Woods Kathryn Fisher Draft Page 2 of 140

3 Part 2: Carers Part 2: Safeguarding Part 3: Local CIs: G&W Update Part 4: Workforce updated Revised Part 1: Preventing Disease and Promoting Well-being 0.8 Revised Part 1: Financial Context & QIPP after feedback from NWS Clinical Executive on Inclusion of Part 2.6: Safeguarding Inclusion of Part 4: Digital Technology: Transition to Digital Data Landing Portal 0.9 Update of 2.2 Children and Young People Inclusion of 3.4 Local Commissioning Intentions: Surrey County Council Update of 2.6 Carers Update of 3.1: Local Commissioning Intentions: G&W CCG 1.0 Part 1: Inclusion of The Armed Forces Covenant Revision of 3.1: Local Commissioning Intentions: G&W CCG 1.1 Revision of Part 3.4: Surrey County Council Public Health: Smoking Cessation Revision of Part 3.1: Guildford and Waverley: Diabetes Revision of Part 4: Procurement for Surrey Downs 1.2 Update of Local CIs for G&W, NWS and SD: Primary Care sections: inclusion of Sepsis. Inclusion of Part 5: Engagement Feedback Anna Vigurs Annette Keen Sumona Chatterjee Ruth Hutchinson, Deputy Director of Public Health Jane Chalmers, G&W CCG Amanda Boodhoo, Surrey Wide CCG Deputy Director Safeguarding Steve Abbott Harriet Derrett-Smith, Interim Joint Head of Children s Commissioning Community Health Services Ruth Hutchinson and Phill Austen-Reed, Senior Public Health Lead Debbie Hustings, NHS Partnership Manager Carers Annette Keen, G&W CCG Debbie Hustings and Anna Vigurs Annette Keen Phill Austen Reed Gem Ryan, Senior Commissioning Manager Planned Care Jules Wilmshurst-Smith Anna Vigurs Anna Vigurs Draft Draft Draft Draft Draft Final Draft Page 3 of 140

4 Co-ordinating Author: Anna Vigurs, Head of Planning & Portfolio Management, NW Surrey CCG Approvals: This document has been submitted to the following: Name Date Version Joint Executive Team V 0.5 Joint Executive Committee V 0.7 North West Surrey CCG Clinical Executive North West Surrey CCG Governing Body Guildford and Waverley CCG Governing Body Surrey Downs CCG Governing Body Surrey Downs CCG Governing Body North West Surrey CCG Governing Body Guildford and Waverley CCG Governing Body V V V V V V V 1.2 Related documents: These documents will provide additional information. Ref no Title Version Guildford and Waverley CCG Operational Plan North West Surrey CCG Operational Plan Surrey Downs CCG Operational Plan Page 4 of 140

5 Surrey Heartlands Sustainability and Transformation Plan (1 st submission) Delivering the Forward View: NHS Shared Planning Guidance 2016/17 to 2020/21 NHS Operational Planning and Contracting Guidance Next Steps on the NHS Five Year Forward View, NHS England, March 2017 The Five Year Forward View for Mental Health, NHS England, February 2016 General Practice Forward View, NHS England, April 2016 Integrating care: contracting for accountable models, NHS England, Version 2, August 2017 Page 5 of 140

6 CONTENTS FOREWORD... 9 PART 1: INTRODUCTION AND OVERVIEW The Next Steps on the NHS Five Year Forward View Sustainability and Transformation Partnerships (STPs) and Devolution Surrey Heartlands Partnership for Health and Care Surrey Heartlands Devolution Joint Strategic Needs Assessment (JSNA) Preventing Disease and Promoting Well-being Long Term Conditions Promoting Independence Better Care Fund (BCF) Specialised Commissioning Financial Context and the Quality, Innovation, Productivity and Prevention (QIPP) Programme The Commissioning Landscape The Armed Forces Covenant PART 2: COLLABORATIVE COMMISSIONING AMBULANCE Service Integrated Urgent Care (IUC) Patient Transport CHILDREN AND YOUNG PEOPLE CONTINUING HEALTHCARE MENTAL HEALTH LEARNING DISABILITIES SAFEGUARDING CARERS PART 3: LOCAL COMMISSIONING INTENTIONS 3.1 GUILDFORD & WAVERLEY CCG Overview Financial Context and QIPP Urgent and Emergency Care Planned Care Page 6 of 140

7 Out of Hospital Care Primary Care Long Term Conditions Mental Health Quality Demand Management Medicines Management NORTH WEST SURREY CCG Overview Financial Context and QIPP Urgent and Emergency Care Planned Care Out of Hospital Care Primary Care Long Term Conditions Mental Health Quality Demand Management Medicines Management SURREY DOWNS CCG Overview Financial Context and QIPP Urgent and Emergency Care Planned Care Out of Hospital Care Primary Care Long Term Conditions Mental Health Children and Maternity Care Medicines Management SURREY COUNTY COUNCIL Overview Financial Context Commissioning Intentions Public Health, 2018/ Adult Social Care, 2018/ Page 7 of 140

8 Children Schools and Families, PART 4: ENABLERS Contracting Framework for New Models of Care Procurement CQUIN Digital Technology Estates Medicines Management Workforce PART 5: ENGAGEMENT FEEDBACK Background Our Engagement Objectives and Approach Summary of Feedback Urgent and Emergency Care Children and Young People Continuing Healthcare (CHC) Mental Health and Well-being Learning Disabilities Safeguarding Carers Cancer Diabetes Stroke Adult Social Care Guildford and Waverley CCG: Local Feedback North West Surrey CCG: Local Feedback Surrey Downs CCG: Local Feedback Impact of Engagement Evaluation GLOSSARY OF TERMS, ACRONYMS & ABBREVIATIONS APPENDICES Page 8 of 140

9 FOREWORD Our ambition is clear we want Surrey Heartlands to be a prosperous and healthy place with a high quality health and care system for our population that is sustainable for the long term. This year symbolises a significant milestone in taking the next step towards fulfilling our ambition. On 15 June 2017 Simon Stevens announced the signing of the Surrey Heartlands Devolution Memorandum of Understanding between NHS England, NHS Improvement, Surrey County Council and the three Surrey Heartlands CCGs (NHS North West Surrey, NHS Guildford and Waverley and NHS Surrey Downs) (the CCGs). The memorandum sets out the commitment of partners to the progressive implementation of devolution in Surrey Heartlands. The agreement establishes 2017/18 as a shadow year when work will be undertaken to establish new integrated commissioning governance arrangements across health and social care; to define the commissioning responsibilities that will be delegated / devolved to Surrey Heartlands; and embed (within local arrangements) an oversight and support function for local NHS activities. Placing health and wellbeing as part of the infrastructure of prosperity and aligning with wider work around education, skills, work and housing will help to secure the best outcomes for the people of Surrey Heartlands, while unlocking new opportunities to develop and strengthen partnership arrangements with academic and business partners. The plans to build a foundation of citizen leadership and personal responsibility, and to optimise the social capital of strong local communities, form the cornerstone for any meaningful solution. Devolution is an essential component to unlocking far broader changes, accelerating integration and more effective collaboration within the Surrey Heartlands Partnership. Next Steps: Delivering the next two years Based on local communities and patient flows, the health geography within Surrey currently splits three ways. Surrey Heartlands serves 850,000 people covering three CCGs, NHS Guildford and Waverley CCG, NHS North West Surrey CCG and NHS Surrey Downs CCG which together account for around three quarters of the overall Surrey population. Founded on strong relationships and joint commitment, the 2018/19 Commissioning Intentions incorporates the high level Surrey Heartlands Partnership plans as we embark on our journey towards greater health (mental and physical) and social care integration and placed based commissioning delivered at CCG level by local Accountable Care Systems. Page 9 of 140

10 We are however cognisant of the significant financial, capacity and clinical challenges our system faces which are set to get even more difficult over the next few years. The NHS Five Year Forward View set out why improvements were needed to deliver on our collective aim of better health, better care, and better value. This Commissioning Intentions refresh document provides an update on our journey towards realising these improvements and the local plans for the next two years to deliver the goals set out in the Next Steps on the NHS Five Year Forward View, March Surrey Heartlands remains resolute in its ambition to deliver the improvement priorities within the context of delivering financial balance. Improving Urgent and Emergency Care: Surrey Heartlands will take practical action to take the strain off A&E by working closely with our system partners in particular our Acute Hospitals, Community Service providers and Surrey County Council. In addition we intend to offer patients with less severe conditions more convenient alternatives, including a network of newly designated Urgent Treatment Centres, extended GP appointments, and more clinicians in an Integrated Urgent Care system which synergises the skills across the 999, 111, Community, Acute, Mental Health and Out of Hours providers. Improving Primary Care Extended Access: Plans to implement the GP Five Year Forward View requirements for extended access across Surrey Heartlands are well underway which is aimed at improving access during the working week, bookable appointments at evenings and weekends by March Improving Mental Health Services: Delivery of the Mental Health Five Year Forward View is well underway across Surrey. Achieving parity for mental health and improving the physical health of people with mental health are priorities. To achieve this, further integration of mental health services within new local models of care in Surrey Heartlands to create whole-person care that responds to mental health, physical health and social needs together will be sought. Helping Frail and Older People live healthier longer lives: Surrey Heartlands CCGs continue to roll out hubs to help frail and older people stay healthy and independent, avoiding hospital stays where possible. The establishment of Accountable Care Systems at the localities underpinned by the integration of services provided by Primary Care, Community health, Mental health and Hospital services, as well as more joined up working with the voluntary sector and Adult Social Care will be key to realising this objective. Page 10 of 140

11 Improvements in Cancer services: Surrey Heartlands CCGs will continue to develop plans to deliver improvements within areas of specific focus which include lung, upper GI (including pancreas) lower GI and urology ensuring there is alignment of the demand and capacity for diagnostics across these services. Financial Balance and QIPP: Working with our system partners we aim to implement a number of initiatives that seek to deliver system balance by operating efficiently, reducing variation and achieving better integration of services. Sustainability and Transformation Partnerships and Accountable Care Systems: In order to deliver these and our wider goals, in 2018/19 we will work to accelerate service redesign locally and the establishment of Accountable Care Systems. System Enablers: We also intend to focus on the necessary system enablers, namely our workforce, safer care, digital technology and estates with citizen engagement at the core of everything we do. These actions are described in more detail within this Commissioning Intentions refresh document. During January and February 2018, we engaged local people and our partners on our refreshed plans and priorities. This document includes the key areas of feedback which is being fully considered by the individual commissioning teams. A full response will be published by the end of May Matthew Tait Joint Accountable Officer Surrey Heartlands CCGs Page 11 of 140

12 PART 1: INTRODUCTION AND OVERVIEW The Next Steps on the NHS Five Year Forward View 1. The NHS Five Year Forward View set out why improvements are needed to deliver the triple aims of better health, better care and better value. The Next Steps on the NHS Five Year Forward View was published in March 2017 and focusses on what will be achieved over the next two years, and how the Forward View s goals will be implemented. Key priorities include: urgent and emergency care; primary care; improvements in cancer services; improvements in mental health services; accelerate service redesign locally, through Sustainability and Transformation Partnerships (STPs) and Accountable Care Systems; funding and efficiency; workforce; safer care; and technology and innovation. Sustainability and Transformation Partnerships (STPs) and Devolution 2. As part of implementing the NHS Five Year Forward View, health and care organisations have come together to plan services across wider geographical areas. Each area has developed a five year Sustainability and Transformation Plan (STP) to improve patient outcomes and ensure systems remain viable in the longer term. This is likely to mean significant transformation across the country. Surrey Heartlands Partnership for Health and Care 3. Health and care organisations serving the citizens of Guildford & Waverley, North West Surrey and Surrey Downs are known as Surrey Heartlands Partnership which is focused on transforming health and care and achieving financial sustainability. 4. Surrey Heartlands Partnership was created by our statutory heath and care organisations coming together to agree a Sustainability Transformation Plan (STP) for our population of 850,000 people, across seven boroughs, who receive health and care services across a range of multiple organisation and sites, with a combined health allocation of circa 1bn and combined social care and public health budget of circa 328m. STPs nationally are focussed on addressing the three 'Gaps' in the Five Year Forward View (the health and well-being gap; the care and quality gap and the funding and efficiency gap). Page 12 of 140

13 5. At the heart of our partnership is a commitment to work together as a system to transform public services and secure consistent, sustainable, high quality physical and mental health and care for the people of Surrey Heartlands for the long term. 6. Our shared partnership objectives are to: Improve health and social care outcomes. Drive integration of services and functions that improve quality and reduce health inequalities. Demonstrate public value. Increase citizen involvement in decision-making. Standardise best practice in health and social care through commissioning and provision, in order to secure improved outcomes, efficiencies and effectiveness. Achieve sustainable financial balance. 7. Working in this way presents us with an opportunity to plan on a different scale to achieve tangible benefits for patients and citizens and address the challenges we face as a system as well as organisationally. 8. Working to a single control total for aggregate income and expenditure across the CCGs, acute and mental health providers, community services, specialised commissioning, social care and public health budgets, partners have begun to work together on a cross system programme to design and agree a set of consistent clinical standards, address clinical variation and deliver citizen led service design and transformation across a number of clinical pathways. 9. Partners developed a Plan on a Page (October 2016). An update to this Plan on a Page is anticipated from the Transformation Board in December 2017: Page 13 of 140

14 10. The CCGs will continue to work within the Surrey Heartlands Partnership to develop proposals that: Develop primary and secondary disease prevention strategies at scale. Standardise pathways, thresholds and approaches to care across the whole health and social care, for major diseases, with reference to national and international standards, reducing the burden of inappropriate and avoidable acute care. This will focus on the STP clinical workstreams (above). Repatriate the delivery of appropriate care services, locally, supporting improved sustainability of acute healthcare infrastructure. Transform the system operating model through the development of new payment mechanisms to support the delivery of a single system control total across organisational boundaries. Achieve efficiency and improved economies by identifying opportunities for greater joint working across vulnerable clinical services, back-office infrastructure and areas of subject matter expertise that could be shared across the system to deliver transformational and organisational change such as delivery of the digital strategy. Page 14 of 140

15 11. The Prevention Plan developed and delivered by Public Health, the CCG and Borough Councils describes our joint priorities. The Prevention Plan forms part of the Surrey Heartlands Partnership plans. Surrey Heartlands Devolution 12. The Trilateral Agreement (Memorandum of Understanding) has now been signed by local partners (the three Surrey Heartlands CCGs and Surrey County Council), NHS England and NHS Improvement this sets out the formal commitment of partners to the implementation of a devolved health and social care system. Work is underway to implement the agreed governance structures (as we move to operate in a shadow form during 2017/18) and to identify and agree the commissioning responsibilities to be devolved / delegated to Surrey Heartlands from 1 April The devolution approach, which enables integrated commissioning across CCGs, NHS England and Surrey County Council, signals an important principle of place based autonomy and is a key element of a more integrated model for the commissioning and provision of healthcare focused on the key localities across Surrey Heartlands. It will also give access to, and control over, approximately 80m of transformation funding over the next four years. 13. Accountable Care System Programme: As a result of the progress made on devolution, Surrey Heartlands has joined a national group of health and social care systems looking to move at pace towards the establishment of accountable care systems. This will give the opportunity to work through some of the issues we are tackling including the integration of provider and commissioner governance, how to operate system financial control totals, and the effective engagement of the public and stakeholders with other areas with similar ambitions. Joint Strategic Needs Assessment (JSNA) 14. The Commissioning Intentions for Surrey Heartlands take account of local and social care needs as outlined in the Joint Strategic Needs Assessment (JSNA) and area Health and Social Care Profiles for Surrey. 15. The JSNA is an assessment of the current and future health and social care needs of our local community. It follows a life course approach which recognises that the conditions in which people are born, grow, live, work and age can lead to health inequalities. It is available here. Page 15 of 140

16 16. The 2017 Health and Care Profiles for Surrey provide an extensive set of information that describes the health and care needs of the population in each CCG area. They describe variation both within CCG areas and between CCGs, Surrey and England, providing a picture of where need is greatest and where resources may need to be focused. Where data are available, they also provide information on trends over time. The profiles for Surrey Heartlands CCGs are available here. Preventing Disease and Promoting Well-being 17. Prevention will be delivered through the Surrey Heartlands Partnership Prevention work stream. The vision for prevention in Surrey Heartlands places preventing ill health and disability at the heart of the health system. We will drive a fundamental shift towards prevention and early intervention across the life course. This will be through both the delivery of the prevention initiatives detailed within this work stream and by working alongside each of the clinical work streams to map and deliver opportunities to intervene upstream to improve and maintain people s physical and mental health. 18. The delivery of this vision will increase the number of years all Surrey residents live in good health and accelerate improvements in those currently experiencing the worst health. 19. As a Surrey Heartlands system, there are five objectives for our Prevention programme: Prevent the increase in child and adult obesity through system-wide place based and behaviour change approaches. Prevent the development of long term conditions through primary prevention programmes focussed on the major causes of ill health. Empower citizens to remain independent in their own homes by supporting carers, strengthening social networks and the generation of social capital. Improve health outcomes for people with long term conditions (LTCs) through a staged approach of early detection, support for self-care and robust and consistent management of LTCs. Improve the health of working people through the development of workplace health and wellbeing programmes. Page 16 of 140

17 Long Term Conditions 20. Earlier detection is important to prevent the development of long term conditions. Primary prevention programmes, focussed on the major causes of ill health will aim to improve health outcomes for people with Long Term Conditions (LTC) through a staged approach of early detection, support for self-care, robust clinical management of LTCs and the integration of psychological therapies. This will be realised through implementation of increased early detection of breast and bowel cancer, improved childhood immunisation and flu vaccination rates, integration of psychological therapies within LTC services, stroke prevention and reduction in the prevalence gap particularly for vulnerable groups for hypertension and diabetes. Providers should prepare for regular reporting of the identified KPIs. Promoting Independence 21. The commissioning intent is to empower citizens to remain independent in their own homes by supporting carers, strengthening social networks and social capital. The commissioning strategy includes promoting independence in older adults, mental wellbeing, reducing social isolation and enhancing falls prevention initiatives. Communities and individuals will be supported through Wellbeing coordinators and training to support self-care. Better Care Fund (BCF) 22. This Fund was established in 2013 to ensure a transformation in integrated health and social care and explicitly supports reductions in unplanned admissions and hospital delayed transfers of care. The CCGs continue to work with Surrey County Council to agree plans and deliver its requirements 1. Commissioners will develop future plans, including increasing the amount of pooled budget, in accordance with national guidance. Detailed programmes of work to support BCF will be shared in due course. 23. The Local Joint Commissioning Group brings together partners including CCGs, Surrey County Council, Districts and Boroughs to focus on joint priorities and delivery against the BCF aims and objectives within the financial envelope; aligning our resources to maximise impact and value. 1 Page 17 of 140

18 Specialised Commissioning 24. The scope of healthcare services commissioned by CCGs and that defined as specialised 2 commissioning is established by NHS England and routinely reassessed. CCGs participate with Specialised Commissioning in four main ways; engagement in planning and decision making, joint commissioning, delegation (transfer of functions) and devolution (services to local authorities). It is expected that a number of services and pathway elements will transfer to routine healthcare commissioning in the forthcoming business cycle. Our aspiration remains to grow the capacity and capability of local centres of excellence to respond to demand pressures and reduce overall costs to the commissioner. 25. The national transformation programme will facilitate the further integration of specialised commissioning within the broader healthcare system and care pathway planning. As part of the development of Sustainability and Transformation Plans, we will work closely with Specialised Commissioning to move towards place-based activity and spend data, at HRG level, across London and South regions. This will allow us to make substantive proposals for reshaping local services and develop an agreed trajectory for moving key priority pathways to shared, place-based commissioning arrangements. Financial Context and the Quality, Innovation, Productivity and Prevention (QIPP) Programme 26. The Trusts, CCGs, local GPs, Community Services, Mental Health Trusts and Surrey County Council share an ambition to integrate health and care services for the local population. The partners share a view that a new sector-wide model of integrated care, incorporating service and clinical pathway improvements, will enable the delivery of outstanding quality services for local people, and a step change improvement in productivity and efficiency. 27. Through working in partnership, our objective for the Integrated, Urgent and Planned Care Programmes is to ensure effective and efficient health and social care services are provided for the population of the Surrey Heartlands, with a resultant reduction in: Unnecessary hospital admissions, (elective and non-elective) Ambulance conveyances 2 Specialised services are those provided in relatively few hospitals, accessed by comparatively small numbers of patients but with catchment populations of usually more than one million. These services tend to be located in specialised hospital trusts that can recruit a team of staff with the appropriate expertise and enable them to develop their skills. Page 18 of 140

19 A&E attendances Duplication of services within the local economy Delays in discharging patients to the most appropriate care setting Integrating pathways to deliver efficiencies. 28. We recognise joint working and a mutual understanding of our challenges and priorities are a pre-requisite for the successful delivery of our respective efficiency targets, and are determined to work together effectively in 2018/19 to achieve these. 29. The organisations recognise that Service Transformation delivery is one of the key components of financial delivery and the return to recurrent financial balance. Service transformation across the system will maintain the following standards to ensure that all initiatives are: Co-produced with all relevant stakeholders, including patient, their families and carers Based on the needs of the patient, their family and carers Use the RightCare methodology, including preferred patient decision Undertake Quality impact assessment on all proposed transformations. 30. The organisations are committed to improving their capability to deliver services ensuring we all have processes and systems in place to identify schemes, comply with governance arrangements, ensure partnership with clinical leads and, importantly, ensure accountability is central to the delivery process. 31. The principles are: Transparency of clinical and managerial accountability for delivery and holding to account through the governance and performance framework All schemes have clinical, managerial and project leads All project documentation is in place for monitoring, managing and assuring on all aspects of the scheme The process for developing schemes includes clear milestones and measurable KPIs focused on outcomes Page 19 of 140

20 The savings values of schemes are robustly challenged to ensure they are, and remain, realistic A review and re-prioritisation of resources to reflect the organisations priority of improving the overall financial position whilst retaining good service quality. 32. The Principles and Objectives for QIPP delivery in 2018/19 are: To maintain and seek to improve patient safety and service quality To achieve savings targets in 2018/19 in the context of providing sustainable and high quality services across the system To roll out agreed schemes promptly whilst maintaining a new pipeline of ideas that can be developed and drawn upon as required To drive delivery of constitutional standards To provide transparent information across the organisations and to external stakeholders To manage risk across the organisations and across the range of programmes. 33. The organisations aim to demonstrate responsible use of resources by: Holding leads to account for delivery of the changes Constructive challenge process throughout the organisations Managing resources in accordance with statutory requirements and professional best practice Ensuring non recurrent resources are not used to support recurrent costs Ensuring best value for money and best use of resources in commissioning services - Utilising relevant benchmarking data, ie Rightcare. 34. All organisations are committed to delivering transformational service change. We all recognise we face a challenging agenda in 2018/19 and to be successful we must work closely together, strengthening the existing inter-organisation and external relationships to deliver our required efficiencies. 35. Key outcomes and metrics for the Service Transformation Programme are: Page 20 of 140

21 Improve outcomes for patients compliance with NHS Constitutional standards Achievement of all the relevant quality premium targets and associated income Achievement of best in class RightCare comparator ratings (or to an agreed improvement trajectory - year one of a five year improvement trajectory) Reduction of A&E attendances by most appropriate use of Urgent Care facilities providing care at the right setting and through development and implementation of the Urgent Care, Primary Care and Out of Hospital programme Reduction of primary care referrals through establishment of services in the community which would benefit from integrated pathways, working in collaboration with acute, community providers and Social Care Reduction of Consultant appointments and Surgical intervention for example through establishment of virtual clinics, patient education on self-care, prevention, patient decision aids etc. Reduction in overall CCG drug costs, where appropriate, through the implementation of the medicines optimisation programme Reduction in general and acute capacity available beds and bed days by improving flows in the system, integrated discharge and assessment services Reduction in excess bed days Reduction in ambulance conveyances through implementation of integrated Clinical Assessment Services (icas) between 999 and NHS 111. The Commissioning Landscape 36. The CCGs have a responsibility to consistently improve performance against a number of clinical and operational priorities, which are assured via an assessment framework. The framework seeks to use indicators that demonstrate how commissioned activities progress towards the triple aim of better health, transformed quality of care and sustainable finances. 37. The Government s Mandate to NHS England gives clear objectives and priorities for maintaining and improving standards across a range of performance measures and deliverables in support of this. The CCGs Improvement and Assessment Framework (IAF) focuses on six clinical areas: Cancer, Diabetes, Dementia, Learning Disabilities Mental Health and Maternity. All these clinical areas feature within our operational and strategic planning; to seek further improvements in all areas. Providers should prepare for regular reporting of the identified KPIs. Page 21 of 140

22 38. As we continue to focus on achieving the Mandate, the CCGs must continue to deliver and maintain key NHS Constitution Standards. The commissioners will continue to work with providers to achieve these standards and expects all recovery trajectories to be accomplished and form part of core business by 2017/ Working with providers the commissioners will continue to utilise the NHS RightCare Commissioning for Value analysis to inform decision-making for on-going prioritisation through improved understanding of the correlation between spend and demand, resulting in directing local improvement efforts to increase the value of the care we commission and the release of funds for innovation. 40. The CCGs expects to undertake a number of service reviews and incentives through CQUIN and Quality Premiums, which directly relate to these clinical areas and operational improvement requirements. The Armed Forces Covenant 41. The Armed Forces Covenant is a promise from the nation that those who serve or have served in the Armed Forces and their families are treated fairly. 42. CCGs are responsible for commissioning health services for veterans or reservists (when not mobilised), and emergency care, including A&E and ambulance services, for serving armed forces and families registered with Defence Medical Services (DMS) practices present in the CCGs geographic area. 43. The CCGs are working with the award winning SCC Surrey Civilian Military Partnership Board to take forward the Armed Forces Covenant within Surrey. The Board has two Task Groups, of which the Community Integration Task Group addresses issues around health and welfare, employment, education and housing. 44. The Surrey Health Armed Forces Champions Group is a sub-set of this task group which includes representatives from the all the Surrey CCGs (including Surrey Heartlands CCGs), Public Health and Social Care at Surrey County Council. During 2018/19 the SHP will demonstrate support by: Signing up and upholding the principles of the covenant Registering for the Defence Employer Recognition Scheme bronze award which states our intent to support defence personnel Be an active member of the Community Integration Task Group. Promoting Armed Forces Awareness Training Page 22 of 140

23 Promoting primary care registration of service leavers, reservists and those transitioning. Support Surrey Armed Forces Carers Support Service. Page 23 of 140

24 PART 2: COLLABORATIVE COMMISSIONING Surrey Heartlands will continue to commission services collaboratively where commissioning at scale delivers better opportunities for integrated clinical pathways, reduces variation and offers economies of scale. 2.1 AMBULANCE 999 Service Context 45. Commissioners and South East Coast Ambulance Service NHS Foundation Trust (SECAmb) are committed to working jointly in the delivery of safe and effective services for its population whilst creating sustainable services for the future aligned to SECAmb s strategic vision, Sustainability Transformation Plans (STPs) and Ambulance Response Programme (ARP). The system, however, faces unprecedented financial, capacity and workforce challenges in 2017/18 and this is unlikely to improve in 2018/19 without delivery of transformation plans and system efficiencies. Transforming the Service 46. Ambulance Response Programme (ARP): In terms of focus and value for money, joint consideration and discussion has taken into account the role of ambulance services in wider transformation of integrated urgent and emergency care pathways and the key function of the new national Ambulance Response Programme (ARP) which was published in August ARP aims to increase operational efficiency and improve focus on clinical need and outcomes through clinically focused performance measures. This will enable better allocation and distribution of resource and workforce through a new commissioning model to support the development of future models of care. 47. ARP Implementation: Commissioners and SECAmb are carrying out further work considering the impact of ARP and management of the new model; phase one of the roll out is mandated nationally to be implemented by SECAmb by 22 November National commissioning guidance on roll out of ARP has been published. The expectation is that no contract sanctions will apply for the remainder of 2017/18. A review and refresh of the programme is anticipated in Spring and a contract variation for year 2018/19. Page 24 of 140

25 48. Demand and Capacity Review: A joint Demand and Capacity Review is being undertaken to better inform commissioning a new model of care and SECAmb have committed to proactive work with associate CCGs to maximise system efficiency opportunities. Commissioners have committed to invest in undertaking Demand and Capacity modelling to support the delivery of ARP standards and future contracting mechanisms. Surrey Heartlands have invited SECAmb to bid for transformation funds relating to Integration and Transformation of Urgent Emergency Care. 49. STP Engagement: Commissioners continue to seek SECAmb s engagement in local discussions via Local A&E Delivery Boards (LAEDBs) and the Urgent Emergency and Out of Hospital Strategy workstreams across the four STP footprints in Kent, Medway, Surrey and Sussex (KMSS). Commissioners would like to set up a working group to explore transfer of conveyances requested by Healthcare Care Professionals from the 999 service to the Patient Transport Service (PTS) to ensure that resources are appropriately used. There is a need for collaboration on the Digital Roadmap and system-wide IM&T developments. There is also a need to review activity patterns following the introduction of SECAmb s new Computer Aided Dispatch system CLERIC. Commissioning a Safe Service 50. Commissioners and SECAmb remain committed in focusing on providing and maintaining a safe level of service. To support this, a number of actions have been agreed: Action Description Metrics Quality Impact Assessment (QIA): Focusing on Long Waits Triangulating information These are being developed to support the continued focus on patient safety, outcomes and experiences and agreeing what good looks like. This is being undertaken by SECAmb to be shared with Commissioners. Continued focus on key areas of risk to minimise long-waits in line with our role to commission safe service. It is important that triangulation of information Page 25 of 140

26 is undertaken with outcomes captured in Ambulance Quality Indicators (AQIs), CQC action plans, Unified Recovery Plan (URP), Ambulance Response Programme Plan (ARP) to monitor progress and offer support. Surge planning: This will include application of No Send, Immediate Handover Policy and consideration of See and Treat time limit. Commissioners and SECAmb will continue to expedite Trust internal and system wide efficiencies. Handover Delays Commissioners will provide direct support to working with SECAmb and NHSI on a Task and Finish Group for improving hospital handover delays and local improvement trajectories. Monitoring outcomes from Commissioners have also proposed a Investment number of areas for additional support. Existing and future investments will be reviewed through weekly SECAmb Executive oversight on performance and activity and weekly CCG monitoring on impact of investment. This will enable regular updates and assurance to associate CCGs and live review of progress and flexibility in changing focus if targeted hours are ineffective. Streamlined Governance Continue with streamlined governance arrangements in shadow form this year, with all parties considering a move to a single KMSS contract led by North West Surrey (NWS) CCG from 2018/19. Development of Local pathways Commissioners will continue with SECAmb to implement the outputs of the local workshops with Local A&E Delivery Boards Page 26 of 140

27 to develop alternative to A&E pathways Integrated Urgent Care (IUC) 51. The Urgent and Emergency Care Review led by Sir Bruce Keogh proposed a fundamental shift in the way urgent and emergency care services are provided, improving out of hospital services so that we deliver more care closer to home, reducing hospital attendances and admissions. A core element of this vision is the commissioning of a functionally integrated urgent care access, treatment and clinical advice service accordingly; a procurement programme has commenced to recommission the current NHS111 and GP Out of Hours services. The new service, the "Integrated Urgent Care Service", will be commissioned based upon the requirements of the NHSE service specification and latest available guidance. The new contract will go live on 1 April 2019 and will include a clinical assessment service along with the face to face treatment provision during the evening and weekends. Patients, public and stakeholders have participated in a comprehensive engagement campaign, and the feedback will be considered / incorporated into the final service specification. Further market/bidder engagement events will provide opportunities for the provider market and key stakeholders to comment and further develop the draft service specification prior to the final restricted tender process due to commence in January Greater integration of all elements of the urgent and emergency care system- including ambulance services, primary care (in hours and out-of-hours), urgent care centres, emergency departments and both community and hospital based services will enable the NHS to help people with urgent care needs to get the right advice in the right place, first time. We recognise that this requires cooperation between and within numerous organisations and services, and collaboration between clinicians and supporting staff and this continues to be a focus area and will a priority for development both now and over the course of the contract to be awarded. Patient Transport 53. Commissioners recognise the role of the Patient Transport Service as key to the success of the Out of Hospital Strategy and in particular the delivery of the locality hub model of care. We will seek to establish a working group to explore how patient journeys associated with attendances at locality hub settings may be rapidly established to support the development and expansion of the hub offer over the course Page 27 of 140

28 of the next year. In addition, this working group will take forward discussions with the 999 service regards the transfer and redirection of Health Care Professional (HCP) activity to the PTS service when it is clinically safe and appropriate to do so thus enabling the use of scarce resources in the most efficient and effective way. Page 28 of 140

29 2.2 CHILDREN AND YOUNG PEOPLE 54. These intentions are supported by the three CCGs and our partners in Surrey County Council. They will be led by the children s commissioning team hosted by NHS Guildford and Waverley CCG. These should be read in conjunction with Part 3.4 Local Commissioning Intentions: Surrey County Council. Commissioning Intention Description In-line with Devolution and STP aspirations, we will continue to seize opportunities to commission jointly across CCGs, public health, maternity and children s services Align, where possible, service delivery, workforce and key enablers including estates and digital platforms across Early Help (local Family Partnerships), STP and CFHS transformation programmes Ensuring women are able to make safe and appropriate choices of maternity care for them and their babies, through achievement of the Better Births and Local Maternity System Transformation Plan Elements of these programmes require aligning to ensure opportunities are realised. This may include: a. Aligning the Family Partnership Approach and Local Maternity Hubs b. Digital health records and a single approach to family health and early help assessment. Moving towards a single care record across health and social care. c. Using the principles of Making Every Contact Count to deliver key public health messages on healthy weight, smoking, substance misuse, mental wellbeing, breastfeeding, immunisations and oral health Priorities for delivery include: a. Deliver a new shared maternity information system across the SH organisational boundaries b. Develop community hub working, ensuring that community midwifery services wrap around local populations. c. Improve access to advice and information by developing a 24 hour maternity advice line and a localised maternity information app d. Expand birth choices available to all women, to include Page 29 of 140

30 Support our hospitals in effective management of acute and emergency care reducing unnecessary lengths of stay; including unplanned attendances for both mental and physical health emergencies. admissions for self-harm Develop better ways of engaging with all parents and families about their children s health, including helping families to understand how to support their children when they are unwell Through the joint commissioning arrangements agreed between Health and Surrey County Council, commissioning intentions will on-going focus on the key priorities set out within the the development of a Surrey Heartlands homebirth service e. Work to enhance prevention throughout the maternity pathway, with particular focus on MECC, immunisations, breastfeeding and obesity. Priorities include: a. Facilitate STP wide engagement to identify opportunities for innovation and development and enable service providers to influence commissioning strategy through the Surrey Heartlands Children s Working Group and the Surrey Heartlands Programme Board. b. Develop plans to support parents to develop skills to feel confident caring for their children at home when they are poorly, c. Work with Surrey Heartlands providers to streamline access to urgent care and advice. d. Develop and roll out standardised pathways of care for high volume conditions, reducing unwarranted variation and giving consistently high quality care to all. We will therefore continue to improve the way in which we engagement with children, young people, their families and carers to ensure their views are heard by services and also that they inform the future design and commissioning intentions. We will do this in partnership with the County Council and our local providers to ensure that groups who may struggle to have their voice heard are included within our processes. a. Work in partnership with Education and Social Care to integrate services to meet the needs of children and families closer to home and within their local communities b. Provide a welcoming single point of access and improved early identification and support for children with SEND. c. Improve the timeliness, suitability and quality of health Page 30 of 140

31 Surrey SEND Development Programme and the SEND Written Statement of Action Reduce inequalities in health for people with Learning Disabilities Continue to improve access to and scope of mental health services in-line with the new CAMHS contract commissioned from April 2016 and the Surrey CAMHS Transformation Plan. Decision will also be required to enact 2 year extension to the current CAMHS contract or to re-tender services. Champion more local and timely access to tier 4 CAMHS beds, through the delegated commissioning model led by SABP assessments to support those either being assessed for Education, Health and Care plans or those in receipt of a plan. Reduce the waiting times to access therapy services and developmental paediatrics and improve timely completion of medical advice for SEND. d. Improve the identification of need and timeliness of support for children and young people with SEND and their families. e. Continue to offer personal health budgets to eligible young people with SEND and families We will encourage uptake of the GP Annual Health checks and Health Action Plans at Transition for Young People aged 14 years +. We will also further our joint commissioning planning and delivery of services for people with a learning disability by bringing together colleagues from across the CCGs and adults and children s social care to scope where improvements and opportunities are required. The work is under-pinned by priorities given to us by CYP and their families, with services also shaped by their views and Surrey County Council s Joint Strategic Needs Assessment, with this work grouped into the following areas: Crisis care services Community Eating Disorder Service Our Transformation Plan Priorities available here. Supported the bid led by Surrey and Borders Partnership NHS Foundation Trust, to establish delegated commissioning responsibility, from NHS England Specialist Commissioning that will enable the delivery of a locally co-ordinated Tier 4 service across Surrey, Sussex and Kent. Subject to approval by NHS England, we expect the delegated serve to mobilise in the autumn of Page 31 of 140

32 2017. Improving public health outcomes for children and young people with a focus on prevention and early identification Ensure sustained delivery of the children s community health service transformation plan Reduce the gap in health outcomes for Looked after Children through achievement of the specified standards and effective partnership working CCGs will continue to support children with complex needs including further development of our offer in regard to personal health budgets, encouraging Preventing poor physical and mental wellbeing through robust population and targeted approaches is key to maintaining good outcomes in Surrey whilst helping to close the gap and reduce inequalities. We will ensure a continued balance between population and targeted service delivery a. Delivery of the expected benefits from the SPA and integration with the CAMHS One Stop. b. Achievement of the CFHS recovery plans for therapy services, jointly between the community health provider, CCGs and Surrey County Council. Ensuring a better experience and outcome for children and their families as well as earlier identification and support. c. Maximise benefits of the new public health workforce service model in line with Local Family Partnerships. d. Focus on required improvements to Community Developmental Paediatrician services and links within the CAMHS pathway. The CCGs commission the Looked After Children Health service that is responsible for ensuring the health and wellbeing of those children in Surrey s care and those that may be placed in the Surrey area. Working with the County Council we need to ensure that the statutory timeframes for initial and review health assessments are met and that this information is included within the relevant records for that child. We also need to improve our mechanism for reaching children placed out of county and for the provision of their health histories. Work closely with adult continuing healthcare to ensure that young people with continuing healthcare needs receive a seamless transition and that families are informed and supported during the process. We3 will continue to develop our PHCB approach for children with complex needs. Page 32 of 140

33 an increase in uptake Safeguarding is everybody s business and all staff will respond and act to raise safeguarding awareness and address any emerging issues These priorities are reflected within the safeguarding priority commission intention. 55. Full details can be found in Appendix 1. Page 33 of 140

34 2.3 CONTINUING HEALTHCARE 56. The main objective of Continuing Healthcare (CHC) Surrey hosted by Surrey Downs CCG is to comply with the National Framework for NHS Continuing Healthcare and NHS Funded Care (2012) and to assure the Clinical Commissioning Groups that they are meeting the requirements stipulated and evidenced in case law. 57. CHC is developing a 3 year strategy, which will be used to reinforce, articulate and guide the team to strengthen and focus on what matters aligned to the following principles: Quality, Integration, Workforce, Governance, Better value. 58. Commissioning Intention Transformation Strategy Operational contract efficiencies Home care/domiciliary care Personal Health / Integrated Personal Budgets Contracting arrangements NHSE Quality Premium Partnerships Ways of working Description Deliver year two of a two year transformation strategy. Operational contract efficiencies for better value and better outcomes for patients by negotiating individual packages of care. Improve home care / domiciliary care delivery with Surrey County Council. Expanding the Personal Health / Integrated Personal Budgets with integrated commissioning and support for CCGs in designing the Long Term Conditions budget process. Address system pressures through innovated contracting arrangements working with local partners. Working with system wide partners to focus on delivering the NHSE Quality Premium objectives. Develop partnerships for integrated health and social care commissioning of local services. Enhancement of paperlite ways of working. CQUINs Support providers to improve performance through 6 CQUINs: UTIs, Pressure Ulcers, Nutrition and Hydration, Falls Prevention, Flu Vaccination Update for frontline staff and Proactive and Safe Discharge. Quality Assurance Framework Continuous improvement through the Quality Assurance Page 34 of 140

35 Framework. End of Life Care Engaging with End of Life care specialists to support quality provision throughout the End of Life Pathway. Page 35 of 140

36 2.4 MENTAL HEALTH 59. In refreshing the 2017/19 commissioning intentions, the health profile of our population has been looked at with specific attention given to what this means for people s mental health. The key features are: There is a considerably higher prevalence of mental health problems than those receiving treatment so we need to increase identification and recording Approximately one fifth of our population is aged over 65 which means an increasing proportion of the population will be suffering from dementia, depression and long term conditions requiring additional psychological care needs The Surrey Heartlands area has a low level of Physical Health Checks undertaken in primary care for people with a serious mental illness which needs to be addressed to reduce the health inequality and mortality gap that currently exists We have a similar rate of mortality from suicide as England however recent published figures show that NWS CCG has a higher level than the England average. We need to increase our work and plans on suicide prevention and managing mental health crisis to prevent avoidable harm and distress. 60. The new models of care introduced by the NHS five year forward view (Forward View) create an important opportunity to improve on a number of the above areas and deliver whole-person care that responds to mental health, physical health and social needs together. Despite these positive steps, there is clearly more to be done to prioritise mental health in the development of our new of models of care and integration. 61. The review of these needs, CCG performance requirements and local service provision have led to the following mental health commissioning intentions: Page 36 of 140

37 Commissioning Intention Description Increasing Mental Health in integration Improving response to mental health crisis Ensuring that integrated care teams designed to support people with complex and ongoing care needs can make full use of mental health expertise, with mental health capacity and capabilities sufficient to meet the needs that exist. Making new forms of mental health support and local services commissioned a core component of enhanced models of primary care, so that primary care teams are better equipped to address the wide range of mental health needs in general practice, ensuring earlier identification and recording of mental health and to meet the physical health care needs and checks of people with long-term mental health problems. Further strengthening mental health components of urgent and emergency care pathways in accident and emergency (A&E) departments and elsewhere making public mental health and wellbeing central to population health management approaches, including through a focus on perinatal mental health, children and young people, where some of the greatest opportunities for prevention lie. We will be working with the Surrey IAPT providers to integrate the delivery of psychological therapies into the LTC services and increasing the number of people accessing the service. Further strengthening the crisis and home treatment pathway in attributing MHFYFV funding in 2018/19 to support the delivery of a 24/7 universal mental health crisis single point of access and overnight support service. To enhance the suicide prevention plan by ensuring Page 37 of 140

38 GP training is available and delivered on mental health and suicide prevention; and staff from acute hospitals and mental health trusts are supported to receive appropriate suicide prevention training and are aware of the group that have higher risk factors Increased numbers and quality of crisis contingency plans through the year to support the implementation and response at the point of crisis through the SPA. Continue to commission, monitor and embed the Safe Havens across the area jointly with Surrey County Council, ensuring that they remain a key element within the mental health crisis pathway. Perinatal Mental Health Services Continuity of the preparation work within our STP of this service is being planned. Bids have been prepared and are going forward both nationally and to the STP for funding of a STP wide specialist community perinatal mental health service for 2018/19. Dementia A Surrey Heartlands and East Surrey Dementia Strategy has been developed and will set out milestones through the year. The increase in dementia diagnosis and working towards a 6 week referral to treatment goal standards are planned. Work to ensure that the pathways for specialist dementia areas that are linked to alcohol acquired brain injury, Huntingdon s Disease and Parkinson s Disease and local pathways will take place. Mental Health Inpatient Facilities To work with Surrey and Borders Mental Health Partnership NHS Foundation Trust in ensuring that the business case for the new 24/7 mental health inpatient unit/s are agreed with stakeholders and meet the bed capacity need and requirements for efficient and effective mental health provision for all Surrey CCGs Mental Health Employment Support (IPS) Surrey CCGs will be taking part in a national pilot of employment advisors being embedded in IAPT Page 38 of 140

39 Mental Health Citizens Advice Service services and will support the providers with this work. The CCG collaborative will be working with a currently commissioned training placement provider to go to a self-sustaining model and be reducing the commissioned level of service in 2018/19 with a view to ending the contract at the end of 2018/19. A Prior Information Notice (PIN) is currently out on this service to inform whether procurement will be required. Page 39 of 140

40 2.5 LEARNING DISABILITIES 62. Commissioning Intention Learning Disability Mortality Review (LeDeR) Programme Dementia Strategy for Learning Disability Description Surrey is implementing the national programme of mortality reviews. Every death of a person with a learning disability will be reviewed to: Develop understanding of local health inequality To drive improvement in the quality of health and social care service delivery for people with learning disabilities. To help reduce premature mortality and health inequalities in this population. The programme is to roll out with active reviews going live from October People with Learning Disability have an increased prevalence of early onset dementia in particular in relation to specific genetic conditions ie Downs Syndrome. This has been refreshed and is the final stages for inclusion within the wider Dementia Strategy. The LD CQUIN with Surrey and Borders Partnership NHS Foundation Trust (SABP) will drive the development of early baseline assessment to enable timely diagnosis leading to robust clinical support. Transforming Care The National Programme for Transforming Care is a multi- agency response to deliver significant changes in community services that will enable support to be delivered to people with Learning Disabilities and/or Autism and Challenging Behaviour to enable care closer to home. Reduce inpatient admissions to Tier 4 Low /Medium Secure facilities or Assessment and treatment units. Intensive Support Team Multi agency response process is under development Page 40 of 140

41 /Crisis Response Care and Treatment Reviews (CTRs) Enhancement of the Community teams Annual Health Checks which will mobilise joint Health Social Care and private provider social care to provide wrap around support in the community. The adult team is in place and in the process of operational delivery. The children s service is in pilot phase. The reviews are for all people, both children and adults, under transforming care as follows:. Community CTRs: To mobilise enhanced care and treatment in the community. Blue Light CTRs: Rapid response to crisis to mobilise the least restrictive care and support In Patient CTRs: To review all people under transforming care during their hospital stay to reduce length of stay (LOS) and to support discharge. We currently have 5 people who have been in hospital for 5+ years who will require intensive Learning Disability specialist support to ensure they have a safe discharge and rehabilitation into the community. Work is underway to establish the service specification for this enhanced community support team that will be commissioned through money released for NHSE and CCG bed closures. Significant progress with the DES enhanced annual health check sign up by primary care and the establishing of the Primary Liaison service indicates we are now understanding who we have with a learning disability and the health needs of the population. The Joint Strategic Needs Assessment (JSNA) wants to look more in depth at the exact nature of health inequalities. The intention is to complete an audit of the health conditions of people on the Learning Disability register to establish any additional service requirements to inform future commissioning intentions This work will support the delivery of the NHSE directives regarding: Increasing cancer screening for people with LD Reducing premature mortality for people with LD Page 41 of 140

42 2.6 SAFEGUARDING 63. Surrey Heartlands principal philosophy is that safeguarding is everybody s business and all staff will respond and act to raise safeguarding awareness and address any emerging issues. This includes all commissioning intentions, services commissioned and contractual arrangements. The three Surrey CCGs incorporated within Surrey Heartlands will ensure that all provider organisations contracted by them provide assurance in relation to their safeguarding responsibilities and processes. Surrey Heartlands ensures that commissioned organisations have robust systems that safeguard children in line with section 11 of the Children Act (2014) and adults at risk in line with the Care Act 2014, including; clear accessible policy and procedure, safer recruitment, training and governance systems. 64. Commissioning Intention Commissioning Services Multi Agency Safeguarding Hub (MASH) Primary care Looked after Children CCG s Safeguarding Compliance Description Contracts with health providers will ensure delivery of both national safeguarding children priorities and the priorities of the Surrey Safeguarding Children Board, Health and Wellbeing and other local strategies, and Surrey Safeguarding Adult Board Contribute to the effective multiagency safeguarding arrangements delivered through the MASH. CCGs will monitor and support primary care in discharging their safeguarding responsibilities through training and audit. Ensure CCGs have a clear pathway for young people when they enter care and their transition into adult services by working with partners in creating an improved system for Looked after Children. CCG s have comprehensive and robust roles, systems and processes in place to protect and safeguard vulnerable children and adults and there is a safeguarding strategy and policies available. The CCGs safeguarding quality governance roles and committees Page 42 of 140

43 oversee reporting and monitoring of compliance with provider safeguarding requirements. CCG s compliance will be monitored and assurance given through the Safeguarding Assurance Framework. Page 43 of 140

44 2.7 CARERS 65. According to the Joint Strategic Needs Assessment (JSNA), Surrey has 115,216 carers and an estimated 14,700 young carers. Evidence shows that carers have poorer health outcomes than the non-carer population but that early identification of carers can improve their health and wellbeing. However, carers are not easy to identify and may not consider themselves to be carers. 70 percent of carers come into contact with health professionals and yet, of those, only 10 percent are identified, with GPs more specifically only identifying 7 percent. 66. Surrey has agreed 8 principles for carers in their Carers Memorandum of Understanding Together for Carers these reflect the duties under the Care Act & Children and Families Act to identify, assess and cooperate with the local authority. It is available here. 67. Our shared vision for carers means each service commissioned must be seen through the carers lens and reflect a partnership approach where Carer & stakeholder engagement and involvement at all levels can be evidenced throughout. 68. All services commissioned need therefore to have set procedures in place for the identification of carers and include carers in all Equality Impact Assessments. Carers must be integral in all core service commissioning. 69. This can only be achieved if staff are equipped and skilled to identify and support carers they come into contact with therefore staff should receive Carer awareness training including young Carer awareness training and this should be embedded in all providers training systems. 70. Carers need to be identified and offered support across our healthcare system. To do this, primary and secondary providers need to have systems and quality markers in place to achieve better outcomes for carers. All Providers should be using the Surrey Carers Prescription service our one stop shop social prescribing on line referral mechanism for carers. 71. This approach includes access to Carer breaks services, advice, information, support & advocacy and referral to local authority for carers assessments including young carers assessments. Page 44 of 140

45 72. Services which support emotional wellbeing including IAPT services need to ensure they meet carer outcomes. 73. Core service contracts need to consider how best they can support Carers by providing training and skills to equip carers to care in the community this should include managing medicines. 74. Providers can achieve better outcomes for carers by adopting best practice models such as unrestricted visiting times endorsed by Johns Campaign and Carers Passports services. Furthermore it is expected that new national GP quality markers for carers will be published in 2018 and these will need to be embedded locally. 75. Our universal offer to carers needs to be accessible to all members of the community including out of hours support for working carers. Our provider will pilot extended opening hours in Digital solutions such as e- learning tools are now included within our contract arrangements and available 24: Providers including NHS providers need to consider how they reach and serve carers from protected characteristic groups. We need to be able to compare outcomes for specific cohorts of carers to ensure all carers have access to the same level of support. This is especially true for those who care for someone with a stigmatised condition such as alcohol or substance misuse. Other marginalised groups include: Young and young adult carers Carers aged 85+ Mental health carers (including dementia) BAME Parent carers Armed forces Carers caring in EOL circumstances Carers juggling work with care 77. Supporting staff who juggle work with care is referenced in the NHS Five Year Forward View - therefore we need to promote Carer friendly employment practices. All contracts should include components which support staff carers. Page 45 of 140

46 78. Commissioning Intention Adult Carers Support Young and Young Adult Carers Support Giving Carers a Voice Manual Handling Benefit advice for carers Carers Direct Payments (Carers Breaks) Home based care flexible breaks service End of Life Carers Support Healios Support for carers of people with mental health Description Provides information, advice, advocacy and support to adult carers (of people from all client groups ) Provides support to young carers aged 5-18 years, many of whom would be at risk of harm without support. This includes one to one support and group activities as appropriate. Provides support and networking opportunities for carers aged 18 to 24 so young carers do not experience a cliff edge at age 18. (Responds to new Care Act requirements concerning young carers in transition) Carers campaigning and engagement programme also includes Because Carers Count Carers awareness training Support county wide for carers with safe moving and handling. Second tier benefits advice service for carers responding to cases referred by carers support (who do not have the expertise to provide benefits support) Making payments of up to 300 to carers to support them to have a break agreed by GPs Carers enabled to have short breaks of a few hours and sometimes overnight or at weekends. Replacement care provided to facilitate this Specially targeted breaks to support carers in end of life circumstances (where life expectancy is less than twelve months) Healios is seen as a best-practice online family intervention (FI) service, a form of psychological therapy, Page 46 of 140

47 for NHS community-based outreach mental health teams working with the person with mental illness and their carers and other family members. We will continue to commission this service subject to funds being available and evaluation of pilot evidencing impact. Page 47 of 140

48 PART 3: LOCAL COMMISSIONING INTENTIONS 3.1 GUILDFORD & WAVERLEY CCG Overview 79. In commissioning and sourcing provision of clinical services, the CCG will uphold the following principles and priorities and act to : Secure services which: Meet local health and social care needs, as identified through health and social care profiling and active citizen engagement, for the population within Guildford and Waverley CCG. Enable patients experience of access to care services and the care that they receive to reflect national and local standards for waiting times, quality and safety across all health care settings; irrespective of whether their needs are physical, mental health or social care needs. Enable patients to receive person centred care which addresses their health recovery needs by providing value added health interventions; support to stabilise conditions, acting to prevent avoidable complications and disease progression; promoting self-care and support for carers and preventing the development of avoidable diseases and ill health. Enable health inequalities, disease prevention and the promotion of wellbeing priorities as identified by health, Public Health and District and Borough Council to be addressed. Secure services from organisations that commit to: Organise and operate as one directing resources and efforts to achieve financial balance and sustainable services across the system: Working collaboratively to drive efficiencies, add value, improve effectiveness and health and social care outcomes; Removing duplication, unwarranted variation, standardising services across care pathways and for care groups in line with best practice; and Creating truly joined up seamless care for patients and carers across primary, community and hospital care to meet holistic physical and mental health needs. Page 48 of 140

49 Actively promote ways of working which enable staff, at all levels, to take every opportunity to embed patient education, teaching and adoption of self-care and health and well-being motivation strategies in order to support personal responsibility for self-care and healthy lifestyles for our patients and carers of today and tomorrow. Actively promote citizen, patient and carer involvement in decision making. Actively contribute to optimising the inclusion of voluntary, third sector and faith organisations in the delivery of services and the creation of social capital. Actively promote the wellbeing and development needs of staff to embed processes for continuous improvement in patient experience and health and social care outcomes for all. Financial Context and QIPP 80. The financial position in the Guildford and Waverley system remains challenged. A year-end deficit for 2017/18 in-line with the plan is expected; so G&W CCG will need to achieve its contribution towards the system control total to clear the deficit. 81. G&W CCG intends to deliver Joint Quality Innovation Productivity and Prevention (QIPP) plans in line with financial opportunities which arise from STP initiatives; as identified for the local health care system. 82. G&W CCG will also identify additional savings opportunities for the local system by developing collaborative QIPP schemes in partnership with provider organisations; using the mandated NHS 10 point efficiency plan 3 set out in the NHS Five Year Forward View (FYFV) as the framework to support the formulation of the system QIPP/CIP efficiency programme for 2018/ The CCG will strengthen its partnerships with its main providers using an Accountable Care Partnership to drive collaborative approaches to identifying and delivering cost reductions for commissioners (QIPP) and providers (Cost Improvement Savings - CIPs) to support delivery of financial across the systems; whilst working to the 10 point efficiency plan set out below: i. Free up hospital beds requires health and social care providers and commissioners to ensure patients who are medically fit to do so are discharged from hospital into social care and to community services without delays. 3 Page 49 of 140

50 ii. iii. iv. Reduce temporary staffing costs requires health providers to engage in capping hourly rates, using framework pricing agreements and using agency staff less; particularly medical locums and converting A&E locums into substantive posts. Using collective procurement purchasing power requires health providers to participate in the national contracted out products programme. Getting the best value out of medicines and pharmacy requires health providers and commissioners to engage in medicines optimisation, using RightCare opportunities, reducing waste, focusing on low clinical value prescribing and medicines available over the counter and increasing pharmacists time for clinical work and patient review. v. Reducing avoidable demand and meeting demand more appropriately - requires health providers and commissioners to engage in reducing unwarranted 4 variation in the number of people seeing a GP, being referred to hospital and receiving operations; using RightCare opportunities; increase health prevention strategies such as smoking and alcohol cessation, falls, stroke and obesity prevention and address avoidable demand for emergency care. vi. vii. viii. ix. Reducing unwarranted variation in clinical quality and efficiency requires providers to get it right first time; getting the right clinical decision maker involved at the earliest opportunity and ensuring the right patient receives the right care to the right quality to reduce admissions, length of stay, complications, litigation and improve outcomes. Rationalising estates, infrastructure and clinical support services infrastructure requires providers to participate in a review of NHS property assets. Reducing costs of corporate services and administration requires health providers and commissioners to rationalise back office functions and reduce running costs by streamlining areas of joint work and involving NHS Resolution 5 to provide earlier and closer support. Collecting income which is owed supporting providers to recover costs for secondary care. 4 Unwarranted variation means the increased levels of activity are not explained by clinical needs. 5 Formerly The NHS Litigation Authority Page 50 of 140

51 x. Ensuring financial accountability requiring health providers and commissioners to work to financial limits and utilise financial incentives; being subject to loss of incentives for noncompliance with key finical instructions. Urgent and Emergency Care 84. Commissioning Intention Develop an urgent and emergency care system which is responsive to demands for on the day, urgent and emergency care Description Identifying the local requirements for, and the optimum location of, an urgent treatment centre; rolling out standardised new Urgent Treatment Centres in line with national policy. Securing regular updates and disseminating information about out of hours services through the Directory of Services (DOS); supporting improved utilisation of alternative pathways of care in order to prevent unnecessary patient conveyances to hospital, for both physical and mental health conditions. This will be supported by additional clinical advice services as part of the pan Surrey Integrated Urgent Care procurement. Rolling out the provision of GP appointments in the evening and at weekends (called extended access to primary care) to 100% of the local population by September 2019; through collaborative working between practices; allowing direct booking of appointments and future compatibility with NHS 111 for those who need to see a GP. Develop an urgent and emergency care system which delivers core performance standards for this care setting Deliver and sustain national waiting times for patients accessing A&E within 4 hours (95%). Delivering nationally defined standards for ambulance handovers; providing support for ambulance crew Page 51 of 140

52 handovers by improving the quality and governance of handover processes and redesigning booking-in processes to overcome technological and human factors which are driving delays. Establishing an integrated discharge pathway to enable proactive management of medically optimised patients; reducing lost bed days due to delayed transfers of care (DToC) so that a patient s stay in hospital is no longer than is clinically necessary. For example, ensuring greater use of approaches such as Discharge to Assess so that patients can access planned support for recovery and independent living without delays. Establishing new ways of working to deliver the standard for 85% of Continuing Healthcare (CHC) full assessments to be conducted in the out of hospital setting to help reduce lost bed days. Undertaking a community hospital review to inform actions that enable the system to achieve improvements in flow and to optimise length of stay for local patients and those who reside out of area; helping to reduce lost bed days. Working collaboratively to develop the model and payment mechanism for ambulatory emergency care; by applying requirements from NHSE South and the commissioner guidance from the Ambulatory and Emergency Care Network. Develop an urgent and emergency care system which actively seeks to reduce attendance and non-elective admissions Developing an integrated frailty model of care which includes admission avoidance using a virtual team approach around proactive care in the out of hospital setting and in-reach GPs - focusing on managing frail and elderly patients in A&E to avoid admissions and expediting discharge supported by reablement services; avoiding over medicalisation of conditions which can result in patients experiencing diminished self-care, independence and independent living skills. Page 52 of 140

53 Removing barriers and improving the use of technology and information flows to: Ensure timely, effective and Information Governance compliant information sharing between the staff in A&E and in-patient departments, GP practices and / or community providers to optimise the prevention of unnecessary A&E attendances, non-elective admissions and readmissions across multiple care groups and care pathways; particularly frailty, older people, care homes, frequent attenders and end of life-care. Exploring opportunities to establish minor illness education opportunities for families of children where they are frequent users of GP and urgent care services. Exploring opportunities to develop a communication strategy with the children s and young people s workforce and education establishments, including preschools, about extended access in primary care and access to on the day urgent care for managing minor illness and to prevent seasonal peaks of high volume conditions such as respiratory disorders. Exploring opportunities for further development of locally commissioned services to support case finding e.g. for Atrial Fibrillation (AF) which can lead to strokes; and the Proactive Anticipatory Care Plans as strategies to reduce urgent and emergency care demand. Page 53 of 140

54 Planned Care 85. Commissioning Intention Develop a planned care system which delivers core performance standards for this care setting Description Deliver and sustain national waiting times for patients accessing elective care with Referral to Treatment (RTT) within 18 weeks (92%). Promoting GP peer review of elective referrals, including audit and structured education programmes involving primary and secondary care; moving away from traditional outpatient referrals and instead reviewing referral options prospectively, in real time, or retrospectively with other local GPs; and as part of formative clinical education to ensure optimal access to the right care pathway and the development of alternative options where gaps in services are identified. Exploring opportunities for further development of practice based locally commissioned services to support a shift in care to the closer to home setting; and exploring opportunities to increase health promotion and ill health prevention e.g. through additional incentives to support diabetes education; undertake more diagnostic tests such as ECGs and spirometry and exploring opportunities to optimise the provision of inter-practice services e.g. minor surgery (joint injections and skin lesions), ear suctioning and micro suction, phlebotomy / INR monitoring; using non-medical workforce models for delivery where it is clinically appropriate to do so. Develop a planned care system which actively seeks to improve patient outcomes from elective healthcare interventions Working with the Surrey Priorities Committee and providers to scope opportunities for reducing the risks from planned surgery through supported decision making and providing pre-operative fitness improvement or prehab through smoking cessation and weight loss Page 54 of 140

55 programmes and reviewing criteria for low priority and local threshold procedures (LPTP) to remove unwarranted variations and improve health outcomes. Using shared decision aids so that patients are able to fully understand outcomes of planned care and make informed choices known as supported decision making about the treatment options open to them versus continuing with current treatment plans. Enhancing GP access to online specialist support through Advice and Guidance (A&G) - accelerating the move away from traditional outpatient referrals and requesting advice and guidance i) in those specialities where patients do not access further healthcare interventions or ii) making a step change in clinical practice so that A&G becomes the first line option including mental health services; and in both cases with automatic progression to an outpatient clinic where it is clinically appropriate to do so. Creating truly joined up seamless care for patients and carers across primary, community and hospital care Transforming the way that follow-up models are delivered in clinically chosen specialties at the local acute provider. For example, supporting effective management of patient flare-ups for some conditions and enabling patient initiated follow-ups; using telephone follow-ups and / or group clinics for peer and clinical support which would work to improve patients management of their conditions and reduce waiting times for treatment. Standardising services across care pathways and for care groups in line with best practice; ensuring both the optimum setting of care and care that meets holistic physical and mental health needs. Page 55 of 140

56 Out of Hospital Care 86. Commissioning Intention To develop formal locality working within Guildford and Waverley GP practices To deliver an integrated approach to adult community services through Proactive, Intermediate and Place Based Care models Description To bring GP practices together to work in a formal locality model. This could include the provision of multidisciplinary care across a geographic area, the sharing of best practice, or the more formal sharing of back office functions. To accelerate the development of the GP Federation and the role of primary care in developing and delivering out of hospital services. Working with the newly appointed community services provider to develop integrated teams focused around localities of GP practices; establishing robust care coordination by creating a single point of access across multiple local agencies which responds effectively to the needs of the patient. Primary Care 87. Commissioning Intention Deliver high quality sustainable primary care at scale Description Explore opportunities for further development of locally commissioned services to support case finding e.g. for Atrial Fibrillation (AF) which can lead to strokes; and the Proactive Anticipatory Care Plans as strategies to reduce urgent and emergency care demand. Explore opportunities for further development of practice based locally commissioned services to support a shift in care to the closer to home setting; and explore opportunities to increase health promotion and ill health prevention e.g. through additional incentives to support Page 56 of 140

57 Commission additional capacity in primary care in line with NHS England s access requirements Develop a planned care system which delivers core performance standards for this care setting Sepsis (septicaemia) awareness and education diabetes education; undertake more diagnostic test such as ECGs and spirometry and explore opportunities to optimise the provision of inter-practice services e.g. minor surgery (joint injections and skin lesions), ear suctioning and micro suction, phlebotomy / INR monitoring; using non-medical workforce models for delivery where it is clinically appropriate to do so. Rolling out the provision of GP appointments in the evenings and at weekends (known as extended access) to 100% of the local population by September 2019, allowing booking of GP appointments and future integration with NHS 111. Exploring opportunities to accelerate the development of the local GP federation and establishing an organisational form with CQC registration so that it is not excluded from delivering provider functions. Working collaboratively with the responsible commissioner and STP colleagues in order to leverage the collective powers and resources of the commissioning architecture to support the delivery of sustainable and high quality core primary medical services; and subject to members vote and an authorisation decision, seek to take on delegated cocommissioning for primary care. We will use existing systems, processes and communication routes to ensure our healthcare professionals in primary care and out of hours services are aware of the risks, signs and symptoms of septicaemia (sepsis) and ensuring that this awareness is not lost in the future. Page 57 of 140

58 Long Term Conditions 88. Commissioning Intention Cancer Description The CCG recognises the importance of early diagnosis in improving cancer outcomes. We will build on improved communication between primary and secondary care, brought about by a CCG and Royal Surrey County Hospital cancer speed dating event. Together with our STP and Surrey and Sussex Cancer Alliance partners, we will take forward a number of recommendations that came out of a recent, local emergency diagnosis audit, including: Commissioning a vague symptoms clinic; and Increasing the availability of direct access diagnostic tests, where appropriate The CCG will also work on improved pathway development, such as risk stratified pathways for breast, prostate and cancer, and the development of an anaemia pathway. Diabetes The CCG is committed to improving support for people living with and beyond cancer. For example, we will introduce an Integrated Cancer Care Team pilot, supported by Macmillan, to drive forward the implementation of all elements of the Cancer Recovery Package, and the development of services to best support patients that are on stratified, open access follow up pathways. The CCG is investing in significant improvements in Primary Care Diabetes provision to improve delivery of the 3 NICE treatment targets, increase uptake of structured patient education services as well as investing Page 58 of 140

59 Stroke in improvements to diabetes inpatient care. The continuation of participation in the National Diabetes Prevention Programme (NDPP) will set and achieve goals for patients and support positive changes to their lifestyle through weight loss, improved diet and increased levels of physical activity. CCG are also working with the diabetes teams to develop an integrated diabetes service, in order to deliver streamlined services to people with diabetes across community and hospital services. G&W CCG and NWS CCG are committed to improving the outcomes for patients who suffer a stroke in our populations. The benefits of concentrating expertise and services on fewer sites makes a compelling argument. The Surrey Stroke Review recommended 3 co-located HASU/ASU across Surrey and the proposal for West Surrey is HASU/ASU at both Frimley Park Hospital (FPH) and Ashford and St Peter s Hospital (ASPH). In responding to the consultation the commissioners recommend that : NWS population is best served by a co-located HASU/ASU at St Peters Hospital, Chertsey in line with the original proposal. Further that bedded rehabilitation continues to be provided from Ashford Hospital while the stroke pathway is mobilised with increased early supported discharge (ESD) provision, that over a period of 2 years that ASPH consolidate stroke rehabilitation beds to a single site. Guildford and Waverley population will be best served by co-located HASU/ASU at ASPH, and HASU at FPH with a networked ASU in Royal Surrey County Hospital (RSCH). Further, that specialist bedded rehabilitation is provided from RSCH. Page 59 of 140

60 G&W CCG and NWS CCG are committed to ensuring that the stroke pathway delivers the improved outcomes for patients and that the hospitals providing the stroke services are sustainable for the future. In order to ensure that the pathways set out in this document are delivered, as modeled, the CCGs will establish a Surrey wide stroke oversight group which will include the commissioners and providers across Surrey to ensure that Surrey wide services are sustainable going forward and any interdependencies are identified and managed. The stroke oversight group will have a specific focus on ensuring the West Surrey pathway is delivered in line with the proposals set out in this document and will have a responsibility to address issues where they arise - taking remedial actions should they be necessary. The Committees in Common recommended the above as the outcome and CCGs response to the Surrey Stroke Review and feedback from the public consultation. Mental Health 89. Commissioning Intention Acute Liaison Service Description The CCG has commissioned a 24/7 liaison service for the past 2 years and, following a successful bid for transformation funding, we will be implementing core 24 standards for emergency care from April A programme board has been established with partners from Ashford and St Peter s Hospitals (ASPH), Royal Surrey County Hospital (RSCH) and Surrey and Borders Page 60 of 140

61 Dementia Safe Haven and Haven (Adults) (CYP) Partnership NHS Foundation Trust (SABP) to oversee and monitor implementation and delivery of agreed outcomes and KPIs. The programme board will also evaluate benefits realisation for continued investment in 2019/20. The Dementia Strategy has been developed with partners to ensure services are optimised for improved patient outcomes and experience. This will enable a shift of provision; to an increased out of hospital model with a focus on primary care and third sector provision. It is expected that the programme includes: Review Dementia and wellbeing advisor posts in primary care Scope community based memory service including memory clinics Revised model of inpatient provision Services provided to meet and go beyond national diagnosis rates Primary Care Dementia champions Implementation of Namaste care programme in care homes. The CCG will continue to promote the safe haven service for our residents and local partners e.g. police, A&E. We will continue to monitor a suite of performance indicators and evaluate the return on investment with our commissioning partners in Surrey. We will ensure the safe haven service is fully integrated within the crisis response services. The CCG will continue to promote the haven service for our Children and Young people. Key performance indicators will be monitored and an evaluation of the return on investment with our commissioning partners in Surrey will be undertaken. Page 61 of 140

62 Quality 90. We believe that the people of Guildford and Waverley are entitled to a high quality and safe patient experience in any of the healthcare services commissioned by the CCG. We will continue to listen to our patients and carers and work with all our service providers to achieve continuous improvement and reduce variation in the quality of their services. 91. Our quality duty is a statutory obligation and we consider we are well placed to assure people about the quality of the health services they commission. This is because we: Are a clinically led commissioning organisation Have in-depth knowledge about local health services and communities Involve local people in the design of healthcare services and receive and analyse their feedback Are dedicated to placing quality at the heart of commissioning activities Work in close partnership with other commissioners We will ensure learning from our quality and safety assurance processes are triangulated from a variety of sources to inform what high quality, safe and effective care looks like across Guildford and Waverley CCG. 92. We will ensure learning from our quality and safety assurance processes are triangulated from a variety of sources to inform what high quality safe and effective care looks like across Guildford and Waverley CCG. We will address: Patient Safety: By ensuring that the safety of patients is at the heart of clinical decision making and service planning and a commitment to reduce the incidence of avoidable harm including Never Events, pressure ulcers, health care acquired infections and falls. Also by improving patient safety by continually promote a positive culture where we learn from incidents to ensure the lessons that are learnt from incident investigations are effectively embedded across organisations. Innovation and Improvement: By promoting the use of high quality evidence-based practice across all commissioned services and supporting primary care in improving the quality of care provided to patients. Develop a learning culture that welcomes and promotes innovation and new ways of working. Safeguarding Vulnerable Patients: By ensuring that all frontline staff are aware of how to raise a safeguarding concern and that effective systems are in place to Page 62 of 140

63 safeguard patients, in accordance with the processes outlined by the Surrey Safeguarding Adults Board and the Surrey Safeguarding Children s Board. Also by promoting systems that ensure that all vulnerable patients receive appropriate personalised care and that their privacy and dignity is maintained. Patient Experience: By promoting active and open channels of communication so that patients feel able to make comments on the care that they receive while utilising patient and carer stories to inform and improve services. The CCG will also actively seek out opportunities to work in partnership with patients and carers to plan and improve services and care. Workforce Development: Promote strong clinical leadership in order to develop a compassionate, competent and caring workforce, with appropriate levels of staff to provide patients with safe and effective care. Also by ensuring that frontline clinical staff has access to appropriate training to support their delivery of high quality care and have the freedom to speak up about their concerns. Demand Management 93. Our strategies for demand management will be integrated as part of our planned care commissioning in line with mandatory high impact elective interventions. 94. Referral management and optimisation of existing clinical pathways will be reframed across primary and secondary care to ensure that patients are receiving care in the most appropriate place. Medicines Management 95. Priorities for medicines optimisation are outlined in Part 4: Enablers. 96. In addition, there is a local priority: Commissioning Intention Joint Formulary Description Implementation of the G&W CCG and RSCH Joint Formulary Page 63 of 140

64 3.2 NORTH WEST SURREY CCG Overview 97. In commissioning and sourcing provision of clinical services, the CCG will act to: Secure services that meet the needs of people who use the services; Improve the quality and patient experience, safety and effectiveness of services; Improve value in the provision of services. Financial Context and QIPP 98. The health economy continues to face significant challenge to financial sustainability and this work is central to its viability and system unification. On-going development of Quality, Innovation, Prevention and Productivity (QIPP) plans disaggregated from the STP overarching initiatives and based on evidence such as RightCare, is undertaken with our providers and partners to deliver our financial control totals. 99. Joint Delivery Programme: A core programme is jointly managed between the CCG and Ashford and St Peter s Hospitals NHS Foundation Trust (ASPH) through the Joint Programme Delivery Group to deliver overall value for the system. Initiatives are built from using RightCare, Better Care Better Health and national best practice as the evidence base and mechanism for delivery of system savings This approach ensures all new savings plans identify both QIPP and cost improvement plans (CIP) simultaneously, using a single agreed version of the activity information and move at a significantly faster pace to realisation. A range of new projects are being and will continue to be developed using this unified approach Project mandates have been agreed and schemes have been implemented across a range of areas, including but not limited to: Gastroenterology & Endoscopy (Irritable Bowel Syndrome, Upper GI) Outpatient Follow-Up Management (fractures, routine surgery, cancer surveillance) Circulation (Arrhythmia, Chest Pain, Hypertension, Varicose Veins) Community Models (Gynaecology, Ophthalmology, Diabetes) Integrated Dermatology Services Page 64 of 140

65 Locality Transformation, including the expansion of Locality Hub Services and the development of extended GP services Urgent Care Reconfiguration Assessment Units and Ambulatory Care Non-Elective Admissions Prevention 102. Additional initiatives will be identified and developed using the Value Based RightCare process. A range of delivery tools will be used as appropriate including, service redesign with existing providers, new procurement and, if required, market management. Urgent and Emergency Care 103. Commissioning Intention Urgent Care and GP Extended Access (Strategic Operational Group) ( SOG) Integrated Discharge Pathway (Strategic Operational Group) ( SOG) Description The CCG will work with system partners to review and improve the configuration of urgent care services across the catchment. This will include the design and accreditation of Urgent Treatment Centre(s) (UTCs), the review of urgent care access points and the development of ambulatory pathways and the provision of extended GP services in each Locality area. This links to the GP Extended Services Commissioning Intention in the Primary Care section and interfaces with the procurement of the Integrated Urgent Care Service. The CCG will work with system partners to develop a single integrated service to support people following an acute episode of care. This will include the greater integration of health, social care and CHC resources post-hospital care, the development of comprehensive intermediate care services, delivered holistically with physical health, Page 65 of 140

66 Ambulatory Care mental health and social care expertise. This programme of work will also include a review of the community hospital model to define the function, role and level of provision for these services. A review of acute emergency and community ambulatory care provision, ensuring a full range of pathways is available in accordance with national guidance. The proportion of patients utilising each pathway as opposed to inpatient services will be set out based on available evidence. Available ambulatory care pathways will be reviewed jointly with relevant providers against best practice set out in national guidance and support the business as usual delivery of ambulatory emergency care. Planned Care 104. Commissioning Intention Description Cardiology Work is being undertaken between primary and secondary care clinicians as part of the STP to redesign clinical cardiovascular pathways such as heart failure, chest pain and Atrial Fibrillation (AF). Work has begun on redesigning the chest pain pathway which will reduce the over-reliance on invasive cardiovascular procedures by identifying interventions or treatments that add value to patient care and provide financial efficiencies. This work is establishing clear referral criteria and utilising best practice guidelines to reduce angiographic rates alongside an increase secondary prevention and anti-anginal therapy. Diagnostic Testing The CCG will review diagnostic pathways to ensure patient experience and clinical interaction is optimised. Page 66 of 140

67 Pathway Development Pelvic Pain and Genital Dermatology Virtual Clinics and Remote Access to Consultant Opinion The review will seek to develop pathways to create improvements and efficiencies and identify the action to be taken across commissioned services. The CCG will work with system partners on the fundamental redesign of key specialty areas, moving towards a single pathway, agreed and functional across primary, community and secondary care. This will include the integration of services and the exploration of new mechanisms to better share expertise and resources across the whole pathway. Prominent specialty areas will include, as a minimum, diabetes, cardiology, respiratory and catheter/continence care. Support the mobilisation of sexual health and HIV services commissioned by Public Health and NHS England. This will include arrangements for pelvic pain and genital dermatology services and their pathways. Ashford and St Peter s Hospitals recognises its duty in continuing to provide the best care for patients needing these services. Public Health, NHSE, and NWS CCG continue to work collaboratively to ensure these services continue to be provided in line with best practice, national clinical guidance, commissioning responsibilities and available resources across the health and care system. The CCG will continue to develop virtual clinic offerings in a range of specialty areas including fracture clinic, surgical and cancer disciplines. The commissioner will continue to encourage the uptake of new technology to allow patients and clinicians to access specialist advice as quickly and easily as possible. Page 67 of 140

68 Out of Hospital Care 105. Commissioning Intention Non Elective Pathway Expansion of Locality Hubs (Strategic Operational Group) ( SOG) New models of care in residential and nursing homes A single Intermediate Care Team Description The CCG plans to consult on our Urgent Care & Out of Hospital strategy to ensure that patients have access to an optimal range of services that address urgent care needs in the most efficient and effective way. The strategy will align with the CCG s plans to develop and enhance access to Primary Care and the wider objectives of ensuring that all services are sustainable and, fit for the future. The CCG will work with provider partners across the system on the review, development and expansion of integrated care models. This will include the development of Locality Hub services for those with complex needs ensuring equitable geographical coverage, delivery of services at scale as well as a reactive and outreach service offering. The CCG will develop and implement new models of care for our population in residential and nursing homes ensuring they have equitable access to health and care services. This will build on the learning of the national Vanguard programme and the new models for care in care homes supported by NHS England This will provide a full spectrum of support in the community when someone deteriorates or after admission to hospital. Brings together expertise from health, social care, District and Borough council services and the voluntary sector to aid recovery and maintain independence. Page 68 of 140

69 Primary Care 106. Entering the second year since taking on Delegated Commissioning for Primary Care Commissioning from NHS England, the CCG remains committed to build on its successes and learning in implementing the GP5YFV Commissioning Intention Deliver high quality sustainable primary care at scale Locally Commissioned Services (LCS) Commission additional capacity in primary care in line with NHS England access requirements Develop a planned care Description Explore opportunities for further development of locally commissioned services to support case finding e.g. for Atrial Fibrillation (AF) which can lead to strokes; and the Proactive Anticipatory Care Plans as strategies to reduce urgent and emergency care demand. Explore opportunities for further development of practice based locally commissioned services to support a shift in care to the closer to home setting; and explore opportunities to increase health promotion and ill health prevention e.g. through additional incentives to support diabetes education; undertake more diagnostic test such as ECGs and spirometry and explore opportunities to optimise the provision of inter-practice services e.g. minor surgery (joint injections and skin lesions), ear suctioning and micro suction, phlebotomy / INR monitoring; using non-medical workforce models for delivery where it is clinically appropriate to do so. Rolling out the provision of GP appointments in the evenings and at weekends (known as extended access) to 100% of the local population by September 2019, allowing booking of GP appointments and future integration with NHS 111. Exploring opportunities to accelerate the development of the local GP federation and establishing an organisational form with CQC registration so that it is not excluded from delivering provider functions. Work collaboratively with the responsible commissioner Page 69 of 140

70 system which delivers core performance standards for this care setting. Sepsis (septicaemia) awareness and education and STP colleagues in order to leverage the collective powers and resources of the commissioning architecture to support the delivery of sustainable and high quality core primary medical services; and subject to members vote and an authorisation decision, seek to take on delegated co-commissioning for primary care. We will use existing systems, processes and communication routes to ensure our healthcare professionals in primary care and out of hours services are aware of the risks, signs and symptoms of septicaemia (sepsis) and ensuring that this awareness is not lost in the future. Long Term Conditions 108. Commissioning Intention Cancer Description Development and implementation of the following services at ASPH: Risk stratified pathways for stable cancer patients post treatment: Breast, Prostate and Colorectal. (Breast OAFU implemented in 2016). Two Week Rule (TWR) pathway for Iron deficiency anaemia aimed at standardising referrals and optimising pathways. Appropriate referral of patients to the right specialty at right time first time: improving patient experience and reducing demand on TWR services. Vague Symptoms Clinic based on the Manchester and Ipswich models working with local community providers and charities such as CRUK, Macmillan to improve RTT, care closer to home and aid QIPP delivery by discharging patients from Trust setting with a route for re-referral. Recent clinical audit of Page 70 of 140

71 Diabetes Stroke emergency cancer presentations in A&E identified the need for such a clinic to support early detection of cancer in the community. A non-invasive Medical Thoracoscopy service aimed at repatriating patients from St George s Hospital that currently attend the hospital to undergo an invasive procedure (VATS). Resulting in efficiency savings and improved patient experience. To commission all the components of the recovery package e.g. treatment summaries and HNA. The CCG is investing in significant improvements into Primary Care Diabetes provision to improve the 3 NICE treatment targets. The CCG is expanding structured patient education services and investing in improvements to diabetes inpatient care, foot services and specialist community provision. NWS CCG, G&W CCG and Surrey Downs CCG are committed to improving the outcomes for patients who suffer a stroke in our populations. The benefits of concentrating expertise and services on fewer sites makes a compelling argument. The Surrey Stroke Review recommended 3 co-located HASU/ASU across Surrey and the proposal for West Surrey is HASU/ASU at both Frimley Park Hospital (FPH) and Ashford and St Peter s Hospital (ASPH). In responding to the consultation the commissioners recommend that : NWS population is best served by a co-located HASU/ASU at St Peters Hospital, Chertsey in line with the original proposal. Further that bedded rehabilitation continues to be provided from Ashford Hospital while the stroke pathway is mobilised with increased early supported discharge (ESD) provision, that over a period of 2 years that ASPH consolidate stroke rehabilitation beds to a single site. Page 71 of 140

72 Guildford and Waverley population will be best served by co-located HASU/ASU at ASPH, and HASU at FPH with a networked ASU in Royal Surrey County Hospital (RSCH). Further, that specialist bedded rehabilitation is provided from RSCH. NWS CCG and G&W CCG are committed to ensuring that the stroke pathway delivers the improved outcomes for patients and that the hospitals providing the stroke services are sustainable for the future. In order to ensure that the pathways set out in this document are delivered, as modeled, the CCGs will establish a Surrey wide stroke oversight group which will include the commissioners and providers across Surrey to ensure that Surrey wide services are sustainable going forward and any interdependencies are identified and managed. The stroke oversight group will have a specific focus on ensuring the West Surrey pathway is delivered in line with the proposals set out in this document and will have a responsibility to address issues where they arise, taking remedial actions should they be necessary. The Committees in Common is recommended the above as the outcome and CCGs response to the Surrey Stroke Review and feedback from the public consultation. Page 72 of 140

73 Mental Health 109. Commissioning Intention Acute Liaison Service Dementia Safe haven Description The CCG has commissioned a 24/7 liaison service for the past 2 years and, following a successful bid for transformation funding, we will be implementing core 24 standards for emergency care from April A programme board has been established with partners from Ashford and St Peter s Hospitals (ASPH), Royal Surrey County Hospital (RSCH) and Surrey and Borders Partnership NHS Foundation Trust (SABP) to oversee and monitor implementation and delivery of agreed outcomes and KPIs. The programme board will also evaluate benefits realisation for continued investment in 2019/20. The Dementia Strategy has been developed with partners to ensure services are optimised for improved patient outcomes and experience. This will enable a shift of provision; to an increased out of hospital model with a focus on primary care and third sector provision. It is expected that the programme includes: Review Dementia and wellbeing advisor posts in primary care Scope community based memory service including memory clinics Revised model of inpatient provision Services provided to meet and go beyond national diagnosis rates Primary Care Dementia champions Implementation of Namaste care programme in care homes. The CCG will continue to promote the safe haven service for our residents and local partners eg police, A&E. We will continue to monitor suite of performance indicators Page 73 of 140

74 Suicide prevention and evaluation of the return on investment with our commissioning partners in Surrey. We continue to explore the scope for geographical accessibility and service development. We will ensure the safe haven service is fully integrated within the crisis response services. Recent published figures show that NWS CCG rate of mortality from suicide is higher than the England average and the Surrey Heartlands average. Local work will take place with Surrey Public Health to develop a plan that looks to reduce this by a higher percentage than the national 10% target. Quality 110. Quality remains central to the work of the CCG and we will continue to strive to improve quality through effective commissioning, performance and quality assurance processes allowing us to translate our findings and lesson learnt to opportunities to support our system providers to deliver upon the CCG s Quality principles: Ensure excellent patient experience and best outcomes for all people in North West Surrey Eliminate avoidable harm and reduce variation in healthcare Consistently commission evidence based practice 111. We continue to face some service and quality challenges affecting the achievement of national quality indicators, targets and standards as described below. We work actively and continuously with our providers and system partners to address these issues and ensure that we incorporate requirements and expectations for delivery in the contractual agreements in place with service providers: Parity of Esteem NHS Constitutional Standards Skilled and integrated workforce; New models of care: Quality Impact Assessments on service reviews and changes Safe and harm free care Culture and behaviour Page 74 of 140

75 Quality across the whole health and social care system; including primary care cocommissioning and strengthening monitoring and assurance mechanisms through improved information, data and analysis. Demand Management 112. The Referral Support Service (RSS) is used to reduce referral variation across all specialities by ensuring best practice pathways and thresholds are followed, providing equity across the healthcare system and ensuring that patients are referred to the most appropriate service first time. This service eases the workload on GP Practices by supporting patients with the choice agenda and booking their first outpatient appointment or therapy appointment. Additional support is provided from targeted educational programmes and advice and guidance from the clinical triage GPs, cardiology GP with Special Interest (GPSI) and Consultants The CCG is seeking to strengthen and broaden the utilisation of RSS, planning for condition of payment for services based on all referrals reaching the healthcare providers via e-rs by 2018/19. This transition will commence with fax, post and referrals being phased out. Furthermore the CCG will actively support GP Practices with utilising e-rs for two week wait cancer referrals As part of the development of referral management, the commissioner has implemented technology for triage through the use of dermatoscopes and Consultant Connect which provides access to telephone advice The CCG is continuing its programme of work to reduce unwarranted clinical variation through targeted support to general practices and providers. This work includes the utilisation of RightCare peer benchmarking of clinical pathways to ensure practice and thresholds are embedded and improved. This includes service reviews, introduction of primary care locally commissioned services and procurement activity The commissioner is seeking to radically transform the way in which follow-up consultations are accessed in North West Surrey. In the majority of cases routine follow up appointments will not to be booked by provider clinicians but initiated by the patient in accordance with their condition and care needs, for example open access breast follow-ups The turnaround times for advice and guidance via e-rs are to be significantly strengthened to ensure that responses are provided within two working days for 80% of responses for services that cover 75% of GP referrals by Quarter 4, 2018/19. Page 75 of 140

76 Medicines Management 118. Priorities for medicines optimisation are outlined in Part 4: Enablers section. Page 76 of 140

77 3.3 SURREY DOWNS CCG Overview 119. As a Clinical Commissioning Group, our role is to commissioning high quality healthcare services that meet local needs, are effective in improving health outcomes and achieve good value for money Our commissioning intentions for summarise the work that is already underway across a range of areas and our plans for the future, focussing on opportunities that have been identified to improve care and efficiency through activity and performance data (including through the national RightCare programme) Central to this is a vision for greater integration, with the majority of care delivered through a locality-based model, where services are designed to meet local needs, supplemented by more specialised services provided at scale. This ambition will require closer working across every part of the system, including health and social care and is reliant on a number of enablers including: an integrated health and social care workforce that works together to deliver wrap-around care, based on individual needs, better sharing of information and a greater focus on patient outcomes As a commissioning group, we have already started this work, for example through our work on supporting our frail and elderly patients in community hubs. We are already working with partners through the Surrey Heartlands partnership to align our priorities and resources to maximise the benefits of closer working and identify areas where we can collaborate to move at pace Moving forwards, we are keen to explore opportunities that may exist through Accountable Care Systems and other vehicles such as devolution, which will help make our vision a reality. The involvement of our clinicians, key stakeholders and our local population will be crucial in shaping our plans and in developing a model of care that achieves our ambition and meets the needs of our local population. Financial Context and QIPP 124. Surrey Downs CCG remains a financially challenged organisation. Excluding a national 1% system contingency release of 3.6m in 2016/17, the CCG has a cumulative deficit of 37.5m to year end 2016/17 and a 2017/18 plan for an in year deficit of m (i.e. cumulatively, assuming plan is delivered, the CCG deficit will be 48m as it exits 2017/18). Page 77 of 140

78 125. In the context of the CCG s historic and structural deficit issues, the CCG (in conjunction with commissioner and provider partners across the STP) will need to examine different ways of working and commissioning within its financial envelope, which will include QIPP, but which will increasingly extend to managing within the financial envelope of the wider Surrey Heartlands system, and leveraging the benefits of delivering systems efficiencies across a wider footprint Locally the CCG s priorities will be determined in the first instance by RightCare benchmarking which highlights where the CCG has unwarranted variation compared to peers (e.g. MSK and COPD/Respiratory). At a wider system level, the CCG s focus will be on areas that can most effectively be done Surrey-wide (e.g thresholds and POLCE). The CCG will also work with the STP architecture to align itself to the key Surrey Heartlands clinical workstreams and seek to optimise how it commissions healthcare in these areas. Urgent and Emergency Care 127. Our plans in this area focus on greater integration and prevention to reduce avoidable non-elective admissions. Commissioning Intention Integration development of locality models (including community hubs) Description The CCG will continue to integrate and develop community services to support localities, including the commissioning of core services and specialist services, where appropriate. This will include expansion of the Community Hub model to achieve a more proactive approach and earlier identification of patients who are at risk of hospital admission. This will include consideration of the working age population and any interventions required to specifically target this population. Integration shared care plans The CCG will continue to move forwards with plans to implement shared care plans, where patient consent has been given. Sharing care plans can improve communication between patients and agencies, ensure the appropriate treatment is initiated quickly and ultimately improve outcomes. Our plans include Page 78 of 140

79 Ambulatory care Urgent care: Patient flow and discharge to assess models of care Urgent care - A&E increasing the sharing of records on systems such as the South East Coast Ambulance Service records portal (IBIS), and the implementation of Patient Knows Best software for some specialties. See Part 4, section 100 Digital technologies for more information on information technology as an enabler. We will be carrying out a review of acute emergency and community ambulatory care provision to ensure the appropriate clinical pathways are in place. Ambulatory care pathways will be reviewed jointly with relevant providers against best practice national guidance and any opportunities to improve pathways will be explored. The CCG will review discharge to assess models of care with a view to reducing length of stay, supporting High Impact Change models, the strategic direction of A&E Delivery Boards and the STP Out of Hospital Programme. The CCG will work with its partners to reduce non elective hospital admissions by supporting A&E front door initiatives, where clinicians such as GPs and community teams are placed in A&Es to triage and treat patients where clinically appropriate. This work will involve reviewing the existing arrangements and relevant patient pathways, particularly in relation to seasonal escalation planning and system resilience. End of life care Respiratory The CCG will implement its End of Life Care, working with local providers. We are working with providers to improve respiratory care, with a particular focus on flu and increasing uptake of the flu vaccine for at risk groups. Planned Care 128. In planned care, our focus is on extending the projects we already have in place and initiating new service redesign plans, where opportunities to improve care and efficiency have been identified. Page 79 of 140

80 Commissioning Intention Adult hearing services Cardiology (heart care) Urology Dermatology (skin care) Description The CCG is aligning its local services with the NHS England commissioning framework, ensuring a move towards a more outcome-based approach to commissioning adult hearing services. This will mean greater provision of community services (including direct access and self-referral) for people with simple, noncomplex hearing loss. We will continue to monitor implementation of local community cardiology services and continue to develop new local pathways for chest pain and heart failure. Across Surrey Heartlands, we are working with primary and secondary care clinicians locally to redesign clinical cardiovascular pathways including pathways for chest pain and heart failure. Work has already begun on redesigning the chest pain pathway to ensure appropriate clinical interventions are explored before more invasive cardiovascular procedures are undertaken. This will improve patient care and provide financial efficiencies. The CCG will review urology care, specifically diseases of the urinary tract, including conditions such as incontinence, infertility, cancer and reconstruction of the genito-urinary tract. Reviewing and improving systems and processes related to continence in the urology pathway will support the movement of specific urology conditions into the community, delivering improved patient outcomes, as well as ensuring efficiency savings. Activity data suggests that in many cases these conditions are seen, treated and followed up in secondary care inappropriately so this is an area we are exploring. Following successful implementation of phase one of our tele-dermoscopy service, which has increased access to specialist dermatology care in the community, we are currently looking to extend the scope of this service Page 80 of 140

81 Diagnostics Advice and guidance List of Procedures with Restrictions and Thresholds further. This will include exploring the introduction of a service for the management of rashes and chronic conditions, through a community-based clinic. The CCG will review the provision of direct access diagnostic services to identify any opportunities to improve the current pathway. The review will consider accessibility and any areas of duplication and if required we will initiate a pathway re-design based on the findings to streamline the pathway and address any other issues identified. Plans are underway to implement a system for primary care clinicians (principally GPs) to access prompt, remote advice from specialists working in acute trusts and local providers. This scheme will support GPs in making better referrals by minimising unnecessary referrals as well as delivering the potential to trigger more urgent referrals. It will also strengthen links between primary and secondary care clinicians. We will also be working with Dorking practices to develop the advice and guidance scheme across the Dorking locality. The CCG will continue with on-going work to review policies, procedures and thresholds on a rolling review to ensure first line treatments are being fully explored before more invasive procedures are being considered. Musculoskeletal care (MSK) To ensure equity across Surrey Heartlands, the CCG will review its weight management and smoking cessation related requirements with those of the other Surrey Heartlands CCGs. We will also be reviewing the CCG s Assisted Conception (IVF) policy. The CCG will continue locality engagement and work across the Surrey Heartland Partnership with the aim of reducing unwarranted variation and agreeing on a single pathway across the STP, work collaboratively to introduce self-management programmes, work to Page 81 of 140

82 Gynaecology Ophthalmology (eye care) standardise referral process across localities and the use of a wider Surrey Heartlands website for patients to use. The CCG is working collaboratively with Sutton and Merton CCGs and providers to review current gynaecology pathways. In line with the national guidelines, stakeholders are working jointly to ensure the transfer of general gynaecological from secondary care into the community, reducing inappropriate referrals and improving efficiencies within pathways. There are also plans to expand gynaecology services in the community, which will provide additional capacity and resource for activity moving from the acute services. This will lead to more care delivered in the community, reduced waiting times in secondary care, improved patient experience and a reduction in unnecessary outpatient appointments. Following an Any Qualified Provider (AQP) process with local community providers and High Street optometrists, during 2018/19 the CCG will implement the new PEARS and Stable Glaucoma Monitoring pathways. The CCG will promote the new services in the community and across Surrey Heartlands Partnership. Page 82 of 140

83 Out of Hospital Care 129. Our plans in this area focus on commissioning a wider range of services in community settings, closer to home. Commissioning Intention Non elective pathway Expansion of locality hubs Description We plan to engage on our local plans aligned with the STP out of hospital programme to ensure that patients have access to an optimal range of services that address urgent care needs in the most efficient and effective way. This will align with the CCG and STP plans to develop and enhance access to Primary Care and the wider objectives of ensuring that all services are sustainable and, fit for the future. The CCG will work with provider partners across the system on the review, development and expansion of integrated care models. This will include the development of Locality Hub services for those with complex needs ensuring equitable geographical access, delivery of services at scale, as well as a reactive and outreach service offering. Primary Care 130. Our primary care strategy centres on continuing to work with localities to implement the NHS s GP Five Year Forward view. Commissioning Intention Extended access Description In line with the GP Five Year Forward View, we will move forward with plans to improve access to GP services, with appointment available from 8.00am to 8.00pm during the week and extended access at the weekends. This will include pre-bookable routine appointments and urgent appointments and will be provided via hubs across the three localities. Page 83 of 140

84 Primary Care Quality Standards Primary care transformation Primary care IT Delegated commissioning arrangements Sepsis (septicaemia) awareness and education We will continue to develop the CCG s Primary Care Quality Standards, which provide a wider range of services in the community, ensuring that services are of high quality and outcomes focussed and reflect the CCG s commissioning intentions. We will continue to support the development of the three localities within the CCG to deliver primary care services at scale. We will continue to support practices in the utilisation of IT services to support practice workstream. The CCG will implement an e-consultation system across all practices. We will continue to engage member practices on the issue of delegated commissioning and if this is supported by practices, we will submit an application to NHS England. We will use existing systems, processes and communication routes to ensure our healthcare professionals in primary care and out of hours services are aware of the risks, signs and symptoms of septicaemia (sepsis) and ensuring that this awareness is not lost in the future. Long Term Conditions 131. Given our ageing population, our plans include more support for people with longterm conditions and greater integration between services to keep people well at home and prevent unnecessary hospital admissions. Commissioning Intention Cancer Description As part of local implementation of the NHS England Cancer Five Year Forward View the CCG will continue its work on three main areas: early detection and screening, risk stratified follow up pathways and living with and beyond cancer). We will continue our work on the roll out of risk stratified Page 84 of 140

85 Cancer Diabetes Stroke follow up pathways of stable cancer patients post treatment to primary care for further management of their symptoms. The Prostate pathway of transferring stable patients to primary care has already been launched in 2017 and will continue to be monitored in 2018/19. In addition, development and implementation of an Anaemia pathway working with local community providers is being scoped. Other pathways for the transfer of stable patients to primary care to be launched in 2018/19 include breast and colorectal. Thyroid, head and neck and haematology pathways are additional opportunities for the CCG to launch as a transfer of patients to primary care during 2018/19. The Surrey Heartlands Partnership focus will be on early detection and screening improvements and on patients living with, and beyond, cancer improving patient outcomes and quality of life. The third focus area produced by NHS England (Risk Stratified Follow Up Pathways) is being reviewed locally by CCGs, with a view to roll out across Surrey Heartlands to create uniformity of pathways and sharing of best practice. Surrey Downs will be working with the wider Surrey Heartlands STP on a transformation project to improve Diabetes care. The project is focussed on three areas: - Structured education - Increasing the number of patients who attend education - Diabetic Inpatient Specialist Nurses Following a review of stroke services, the CCG is working with local acute and community providers to address the current variation in stroke care that exists and design a pathway that enhances stroke care in line with the South East Coast Stroke Services Specification. Page 85 of 140

86 Mental Health 132. Surrey Downs CCG is part of the Surrey Heartlands Collaborative and the commissioning intensions are created and delivered via the collaborative partnership. Local commission intentions are provided by the CCG to ensure there are no gaps in efficiency and quality within the local health economy Commissioning Intention Description Psychiatric Liaison Service We intend to complete a review of the Psychiatric Liaison Service at Epsom Hospital to understand the level of service required and if local needs are being met. Dementia We will continue to commission Mental Health Practitioners (MHP) based in the Community Hubs to screen for new cases of dementia to increase diagnose rates in line with national targets, The CCG is also working with Surrey and Borders Partnership Foundation NHS Trust and Epsom Hospital to improve the referral pathway and the assessment process for dementia. We are also working to improve the number of annual care plan reviews completed in primary care, working with CCG clinical leads and the localities. Improving Access to Psychological Therapies (IAPT) To increase the number of people using IAPT services in line with NHS England requirements, the CCG is developing plans to integrate these services with other patient pathways including cancer and long-term conditions, where people may also experience mental health issues. Safe Haven We will review the Safe Haven service at Epsom to ensure the service is effective and meeting local needs. Page 86 of 140

87 Children and Maternity Care 134. Surrey Downs CCG is part of the Surrey Heartlands Collaborative and the 135. commissioning intentions are created and delivered via the collaborative partnership. Local commissioning intentions are provided by the CCG to ensure there are no gaps in efficiency and quality within the local health economy. Commissioning Intention Child and Adolescent Mental Health Services (CAMHS) Community Paediatric Clinics Children and Family Health Surrey (new service) Maternity services Description Surrey Downs CCG plans to commission the Behaviour Pathway for children with Neurodevelopmental Disorders (BEN) following the completion of a business case by Surrey and Borders Partnership NHS Foundation Trust. Paediatric clinics delivered via two GP localities in conjunction with Epsom Hospital Paediatricians will continue to be commissioned by the CCG. The CCG will oversee the transfer of the Kingston Paediatric Audiology service and the Epsom Hospital Looked After Children Health Assessments service to the new Children and Family Health Surrey service. The CCG will continue to work with partners to improve maternity care. This work will be led through Surrey Heartlands and will include implementation of the Better Births programme. Quality 136. The commissioning of high quality and safe services for our population is key to achieving good outcomes. Quality and safety is an integral part of all of the CCG s local Commissioning Intentions and of the wider Surrey Heartlands Partnership. Specific areas of focus during are: Monitoring quality and performance: We will continue to monitor providers performance against key quality standards and work with providers on any areas of improvement that are required. Page 87 of 140

88 Reduction in the incidence of Healthcare Acquired Infections: The CCG will work with local systems to achieve the ambition of reducing Healthcare Associated Infections with a particular focus in 2018/19 on Gram Negative Blood Stream Infections (BSIs). By taking a system wide approach, and focussing on the root causes of identified BSIs, the CCG will be able to facilitate a more targeted approach to improvements in care delivery. Safe Discharge and Transfer: In support of other workstreams there will be further focus on the flow of patients through healthcare services to ensure that patients are managed safely through systems and that their experience is always positive. This work will be supported by a number of other programmes in place such as the SHP Safe Discharge and Transfer work stream and the National CQUIN programme. Quality care homes: We will continue to work with care and residential homes to identify clients at most risk of hospital admission and work with providers to ensure they receive increased support in the community, where this is needed. Patient experience and engaging our local community: Continue to deliver our comprehensive Communications and Engagement Strategy to ensure the voice of local people and patients is sought and that feedback is used to inform our commissioning plans and priorities. Page 88 of 140

89 Demand Management 137. Through our Referral Support Service we will ensure patients are referred to the most appropriate service and that patient choice is promoted. Commissioning Intention Referral management Description The CCG will review its current referral management and peer review in primary care with all providers. There are a number of options being reviewed. These include developing patient decision aids, making referrals through the Referral Support Service mandatory for all GP practices and peer review schemes such as learning loop dashboards. We will also be working with localities to develop a simple and easy to read dashboard for all GP practices to provide further information about referrals and waiting times. The dashboard will include waiting times for outpatient services, A&E performance for acute providers, community waiting times, the average response time for advice and guidance by trust and referrals saved and slot allocation on e-rs. Medicines Management 138. Priorities for medicines optimisation are outlined in Part 4: Enablers. Page 89 of 140

90 3.4 SURREY COUNTY COUNCIL Overview 139. Surrey County Council aims to achieve the following in the areas below: Adults Social Care: Adult Social Care has a statutory responsibility under the Care Act The Act places general responsibilities on local authorities for promoting people's wellbeing, focusing on prevention and providing a universal information and advice service. The vison to meet these duties is to promote people s independence and wellbeing through personalised care and support and by working collaboratively with partners to deliver better outcomes at less cost. Delivering this vision will mean people in Surrey: Stay healthy and are supported to live in their local community with choice and control. Know about and can access information and services to help prevent, reduce and delay the need for care and support. Can prepare for an assessment of their care and support needs using selfassessment tools. Experience health and social care working together to meet their needs. Feel safe and have a good experience when receiving care and support. Public Health: To improve and protect the health of people living and working in Surrey through close work with partner organisations to understand and address the wider issues that influence people s health locally. This involves: Providing public health information and understanding to enable decisions that are based on people s need and what is effective. Commissioning services that support people to make positive changes to their health that are relevant throughout their life. Working with partners to protect Surrey residents from communicable diseases and environmental hazards. Children Schools and Families: To ensure that children in Surrey get the right help, care and protection at the right time so they can thrive. SCC will also tackle inequalities early so no child has a worse chance in life than other children. This Page 90 of 140

91 commitment supports the partnership vision for all children and young people in Surrey to be happy, healthy, safe and confident in their future. Financial Context 140. Surrey County Council is facing one of the most challenging financial times in its history. The council has to manage acute financial pressures including rapidly rising demand for services (particularly social care, both children and adults), the need to pay higher prices for the services the council commissions driven by market forces and the council s ongoing commitment to services vital for residents such as maintenance and improvement of the county s extensive highways network These financial pressures come at a time of significant government funding reductions. The huge reduction in local government funding over the last decade is well documented, but Surrey has been particularly disadvantaged by a number of government decisions. The current local government finance settlement means that not only will Surrey not receive any revenue support grant funding whatsoever by 2019/20, but Surrey will be required to pay a contribution to the government out of local taxation raised by this time In the face of these financial pressures and sweeping reductions in government funding, the council has chosen to increase council tax and raise the maximum possible Adult Social Care precepts rather than implement detrimental cuts to services that would otherwise be required. Beyond this, the council is taking forwards a range of measures to help alleviate pressures including: Pursuing conversations with government about funding levels for service areas where it is has been particularly disadvantaged, such as learning disabilities and public health. The council has welcomed the additional funding provided for Adult Social Care announced in the 2017 Spring Budget, but Surrey s allocation has been comparatively small and falls a long way short of bridging the funding gap that has arisen due to other government funding reductions. Applying to become a business rates retention pilot. If successful, this should enable the authority to retain more income to support local service delivery, although as the pilot is for one year only it cannot be assumed as an ongoing benefit in the council s medium term planning. Continuing to focus on driving efficiency and innovation across all of the services the council delivers, whilst recognising that any further efficiency gains are likely to be marginal after many years of savings. Page 91 of 140

92 143. However, these measures alone are unlikely to enable to council to set a sustainable budget in the medium to long term. The council recognises therefore the need for more wide-reaching transformational savings. The commissioning intentions set out in this document are made with the need for these transformational savings in mind, in recognition that the nature of services the council delivers and the way these services are commissioned will need to adapt and shift in the years ahead in order to maintain high quality for residents within ever more stretched financial resources. Commissioning Intentions 144. The following intentions relate to some of the collaborative areas already highlighted previously and provide further detail together with identifying additional intentions that are being led by Surrey County Council: Public Health, 2018/ Commissioning Intention Description Sexual Health Continue to embed the new model of provision and with development of relevant pathways across the county Substance misuse Establish the Adult Integrated Substance Misuse service Review and continue provision of substance misuse treatment for young people 0-19s Ensure sustained delivery of the children s community health service transformation plan Mental Health Continue to commission work on anti-stigma / time to change along with suicide prevention and mental health training. Healthy Weight Review provision of programmes for very young and families with the potential scope to integrate current services and extend service provision Public Health Agreement Review and develop the provision of Public Health Services in GP and Pharmacy Agreement Services in GP practices and Pharmacy including: including Sexual health, - NHS Health Checks, Stop smoking, Shared care (substance misuse), Homeless Page 92 of 140

93 care, Needle Exchange and supervised consumption Smoking cessation High impact Complex Drinkers programme Social Prescribing Review performance of stop smoking provider with a view to recommission in 2019/20 Working with partners, align and explore external funding opportunities to continue provision of the high impact complex drinkers programme and develop a common model of social prescribing Adult Social Care, 2018/ Commissioning Intention Accommodation with Care review for Residential, Nursing & Extra Care including the review of existing residential block contracts Ongoing or continued commitment to commission services Housing Related Support Implementation Implementation and Embedding of recently commissioned Home Based Care. Technology Enabled Care Description Actively working to deliver the best options of accommodation with care and support to Surrey residents. Developing integrated approach across health, care and the community, and re-shaping the market to ensure everyone has access to the right support regardless of tenure. Working with Partners and provider to continually review and improve existing services their delivery and developments to meet changing needs. This includes: Carers Advocacy Community Connections Following on from the review of Housing Related Support, the implementation of the changes agreed in delivery of support. Following the recent re-tender of Home Based Care services, working with partners and providers on the effective implementation of the new contract including changes and improvements. This will be critical the ongoing effective delivery of these services across Surrey. Working with Partners to continue to explore and Page 93 of 140

94 Service future commissioning opportunities with partners Commissioning Review and future approach for : Equipment and Adaptations services Learning Disability Services Review Continue to explore opportunities with partners for High Impact Change Models develop effective ways to use Technology in care. Review and recommissioning, where appropriate, a number of services delivered across Surrey these include: Dementia Navigators Home from Hospital Stroke Service Information and Advice Benefits Advice ICT/Re-ablement integration Wellbeing Prescription Advisors Working with partners to review options for the future delivery of a number of services that could have beneficial links. To review the current delivery of these services and seek opportunities for efficiency and explore future efficient delivery models. These include: Community Equipment Services Disability Facilities Grant Handy Person Services Home Improvement Agencies Review of activities in the delivery of effective and efficient services for people with learning disabilities: These include: Learning Disability Cost of Care Project Review of services including transport Working with Partners to seek improvement to the approach to manage transfers of care. This opportunities include: Discharge to Assess models Trusted Assessors Page 94 of 140

95 Children Schools and Families, For more detail and a further description of each of the following commissioning 148. intentions please see Child First, Commissioning Intentions for Children in Surrey on the Surrey County Council website. Commissioning Intention Description Prevent problems escalating by identifying issues early and ensuring children, young people and families needing extra help receive timely, preventative support Provide a positive experience of SEND services and support for children, young people and families Provide the right early support to promote good emotional wellbeing, physical and mental health Prevent and reduce the impact of abuse (including domestic abuse) and neglect Provide placements or accommodation for looked after children, care leavers and unaccompanied asylum seeking children that are appropriate, local and value for money Prevent and reduce the impact of child sexual exploitation (CSE) and children who go missing from home and care Increase educational achievement, progress, health outcomes and engagement of vulnerable children and young people throughout their life course Provide educational opportunities for children and young people with SEND in local schools or colleges that offer the best value Increase participation in education, training and employment post 16 for children and young people in our vulnerable groups Increase school readiness and reduce the health development and attainment gap for disadvantaged groups in early years Page 95 of 140

96 PART 4: ENABLERS Contracting Framework for New Models of Care (Integrating care: contracting for accountable models, NHS England, Version 2, August 2017) 149. The national bodies have designated eight emerging Accountable Care Systems (ACSs), along with two devolution areas (Surrey Heartlands and Greater Manchester), that will lead the way in implementing the priorities set out in Next Steps. An ACS is an evolved version of an STP, potentially covering a sub set of Surrey Heartlands Partnership geography, in which commissioners and providers, in partnership with Surrey County Council, will take explicit collective responsibility for resources and population health. In return, we will gain greater freedom and control over the operation of our local health system and how funding is deployed As described in the Multispecialty Community Provider (MCP) and Primary and Accountable Care System (ACS) Frameworks, we envisage three main contractual approaches through which accountable models can be established in practice: Virtual : The first approach would see practices, local community services providers and commissioners enter into an alliance agreement which would overlay (but not replace) existing commissioning contracts. This agreement could establish a shared vision, a commitment to managing resources together, as well as clear governance and gain/risk sharing arrangements, together with an agreement about how services will be delivered operationally. Partially integrated : The second approach would be for commissioners to re procure, under a single contract, all services that would be in scope of a fully integrated model except for core general practice. Fully integrated : The third approach would be for commissioners to re procure, under a single contract, all of the in scope services, including core general practice Surrey Heartlands will be working with partners in the forthcoming years to agree the best approach in implementing the new models of care ln line with the aspirations outlined in the Operating Plan, contracts have been be agreed with Acute, Mental Health and Ambulance providers for two years with a Page 96 of 140

97 planned refresh in 2018/19 where necessary. The following key principles remain where refreshes are undertaken for 2018/19: Start with a real baseline. Focus on system control total vs. individual organisational control totals. Place based approach to planning both for CCG commissioned services and specialised commissioning. Marginal rate payment mechanisms aligned across the footprint. Collective approach to risk share. Open book approach to planning. Single version of activity. Single version of efficiency QIPP/CIP becomes a single plan. Single control mechanism on investments and income generating business cases. Review Activity Planning Assumptions (APAs) to support system redesign. Local Incentives. No acquisitive strategies between providers in the footprint; actively pursue repatriation of spend going outside (CCG and NHS England) The CCGs aim to continue to develop new and innovative contracting and pricing mechanisms that will incentivise better outcomes for patients, a fair deal for providers and will represent value for money for commissioners The CCGs will seek to agree local payment arrangements where most appropriate to support transformative change and sustainability. This will include local variation to support patient initiated follow ups Where relevant, the CCGs will be modelling the impact of the introduction to HRG4+; which is anticipated to more accurately account for complexity, we will work with providers to ensure the transition does not adversely affect financial balance and activity is contracted within available resource To treat patients equitably, adherence to defined clinical thresholds and criteria for treatment will be a condition of payment for services. Healthcare providers should Page 97 of 140

98 ensure effective internal clinical governance controls and assurances are in place to avoid undertaking activity that cannot be reimbursed. Procurement 157. Procurements scheduled during 2018/19 are: CCG Procurement Description Guildford & Waverley; Integrated Urgent The new service will be commissioned North West Surrey; Care Service incorporating the NHSE service Surrey Downs; and specification and latest released East Surrey guidance. The new contract will go live on 1 April 2019 and will include a clinical assessment service along with the face to face treatment provision during the evening and weekends. Guildford & Waverley; North West Surrey; Wheelchair Services Intention is to commission a new Surreywide community wheelchair service from Surrey Downs; East April The CCGs intend to procure Surrey; and Surrey Surrey-wide Wheelchair and Seating Heath services incorporating the specialist provisions in line with the need to integrate NHSE Specialised Commissioning provisions to deliver appropriate and effective local placed based solutions. Procurement is expected to commence in early 2018 Guildford & Waverley Adult Community Delivery of adult community services from Services April Surrey Downs Adult Community Services Surrey Downs Adult Hearing Services Delivery of adult community services from October The CCG is aligning its local services with the NHS England commissioning framework, ensuring a move towards a more outcome based approach to commissioning adult hearing services. This will mean re-procurement of incumbent AQP Page 98 of 140

99 Surrey Downs Surrey Downs Community cardiology Community ophthalmology provision of community direct access and self-referral services for people with simple, non-complex hearing loss from May Delivery of community based ECGs; revised pathways including diagnostics for chest pain and heart failure in 2018/19. Ophthalmology PEARS service for Minor Eye Conditions and Stable Glaucoma Monitoring in community to be launched in November 2017 under AQP procurement framework as 3 year contract with 2 optional years extra. New service contracts to be awarded mid-october Surrey Downs Community X-ray Community X-Ray service for Dorking locality ends in The CCG intends to review current arrangements with an option to re-procure services in 2019/20 and consider any impact across the SHP. Surrey Downs Elective activity - Independent Sector Contracts - Commissioning for value Current independent sector AQP contracts end in The CCG will review elective activity services currently provided by our independent sector providers, including the consideration of new pathways and allowing for local variation. Surrey Downs Musculoskeletal care (MSK) and Clinical Assessment Treatment Service (Surrey Downs CCG) The CCG is currently working up a business case with options that are aligned to the Surrey Heartlands MSK pathways. The timing of procurement will need to align with the ending of the CCG s Clinical Assessment Treatment Service pilot in 2018/19. Surrey Downs Patient Transport The CCG contracts with Epsom Hospital Trust to provide the core contract for patient transport. In 2017 it is expected that a south west London wide procurement Page 99 of 140

100 (including Surrey Downs CCG) will result in a contract award to commence contract mobilisation 01/11/17, with a contract start date of 03/02/2018. CQUIN 158. CQUINs will cover the next two financial years, It is the CCGs aim that use of incentives will strengthen system wide service transformation for citizens, enabling mobilisation of strategic change and quality improvements to be realised It is anticipated that CQUINs will be designed to support system wide strategic transformation as described in the Sustainability and Transformation Plan. The CCG anticipates it is likely to consider development of local CQUINs supporting new models of urgent and emergency care, primary care access to secondary care advice and guidance, improved cancer pathways, workforce health and wellbeing programmes, and strategic clinical pathways which complement the national CQUIN14. Development of schemes will be jointly designed and there is scope for cross organisational delivery The CCGs will develop Quality Premiums in line with its CQUIN to enable cohesive system wide service transformation, supportive of the national direction. They will be clinically and managerially led and are seen as key enablers to facilitate the delivery of National Targets. The commissioners will commence development and co-design in response to the publication of national guidance. Digital Technology 161. Key enablers in the CCGs strategic plans are the digital programmes. The CCGs, working with Surrey County Council and Surrey Providers (including physical health, mental health and social care) have produced a Surrey Digital Roadmap (SDR) which will enable the ambitious vision of the Surrey Heartlands STP s transformation programme to be delivered supported by local operating plans. The SDR is being delivered through the three strategic objectives agreed by the STP Partnership: Page 100 of 140

101 162. The objective will be delivered through the programmes outlined below which are and will continue to be progressed throughout Digital transformation: Deliver an interoperability architecture The core of the digital transformation program is to deliver interoperability between the SHSTP partners and our neighbours. This capability will enable delivery of all clinical work streams in the SHSTP. We are at an early stage in our interoperability journey and are still to agree an architecture, our proposed draft architecture is shown below which extends the Code4Health platform. Digital transformation: Deliver Integrated Care Record The architecture will be agreed during 2017 alongside the SHSTP wide digital strategy. This work stream will enforce delivering national standards such as NHSNumber, AoMRC, SNOMED and dm+d, supporting nationally defined open APIs and using the architecture patterns in the HSCIC interoperability handbook. Building on the proposed interoperability architecture, we will implement the capability to share patient care records, subject to appropriate patient consent and requestor access Page 101 of 140