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4 Table of Contents FOREWORD... 7 EXECUTIVE SUMMARY... 8 PLAN ON A PAGE... 9 SECTION ONE INTRODUCTION, BACKGROUND AND STRATEGIC CONTEXT Background and Context About Us Joint Strategic Needs Assessment (JSNA) Unit of Planning Health and Well Being Board Ipswich and East Suffolk CCG Values and Priorities The Ipswich and East Suffolk Local Health and Social Care System Health and Social Care Strategy and Five Year Plan Better Care Fund Ipswich and East Suffolk CCG Commissioning Plans Governance Management Arrangements Supporting Business Processes SECTION TWO OUTCOMES Fundamental 1 Delivering across the five domains and seven outcome measures Fundamental 2 Improving Health Fundamental 3 Reducing Health Inequalities Fundamental 4 Parity of esteem Page 4

5 SECTION THREE PATIENT SERVICES Fundamental 5 New approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care Fundamental 6 Wider Primary Care, provided at scale Fundamental 7 A modern model of integrated care Fundamental 8 Access to the highest quality urgent and emergency care Fundamental 9 A step-change in the productivity of elective care Fundamental 10 Specialised services concentrated in centres of excellence SECTION FOUR ACCESS Fundamental 11 Convenient access for everyone Fundamental 12 Meeting the NHS Constitution standards SECTION FIVE QUALITY Fundamental 13 Response to Francis, Berwick and Winterbourne View Fundamental 14 Patient safety Fundamental 16 Compassion in practice Fundamental 17 Staff satisfaction Fundamental 18 Seven day services Fundamental 19 Safeguarding SECTION SIX INNOVATION Fundamental 20 Research and innovation SECTION SEVEN DELIVERING VALUE Fundamental 21 Delivering value for money for taxpayers and patients and procurement SECTION EIGHT ENABLING AND SUPPORTING PROGRAMMES Organisational Development Communications and Engagement Information Management & Technology (IM&T) Page 5

6 Performance Delivery Procurement and Market Reviews APPENDICES GLOSSARY Page 6

7 Foreword This Plan presents the NHS Ipswich and East Suffolk Clinical Commissioning Group (I&ESCCG) Operational Plan for the period It sets out our vision for the future of health and health care in Ipswich and East Suffolk. Our local vision identifies eight key strategic priorities. These build on and represent a commitment to the NHS Constitution and the NHS Planning Guidance (Everyone Counts) and reflect our continuing commitment to local service improvement to meet local priorities and needs. To implement our Operational Plan we have developed detailed commissioning, delivery and operational plans for each of the financial years contained within it. This will include a series of timetabled programme and project plans. This Plan therefore draws together a number of key and significant work programmes. Its aim is to provide a comprehensive statement of direction and intent for Ipswich and East Suffolk CCG and highlight the priorities for service improvement which in turn will require a detailed programme of investment to support service transformation. We have developed a strategic vision for a healthier population. This two year plan reflects the enhanced clinical contribution of not only the GPs involved in the CCG but the wider clinical community the CCG has managed to engage with locally to give added expertise to its intentions and ambitions. Clinically led commissioning in I&ES CCG is determined to keep the patient at the centre of its services and looks to continually improve the experience and quality of those services through its networks with clinicians, patients, social care, the voluntary sector and the providers of health and social care. Page 7

8 Executive Summary We [Ipswich and East Suffolk Clinical Commissioning Group] have produced this two year Operational Plan in response to Everyone Counts: Planning for Patients 2014/15 to 2018/19 (NHS England, 2013). We describe in detail our plans for the two year period from April 2014 to March It builds on our strategic plans and describes key operational metrics related to outcomes, NHS Constitution, activity, and the Better Care Fund; that are needed to support the assurance of, and measure performance against, our five year strategic plan ( ). We have written it so you can clearly see the links to our strategic plans (e.g. Clinical Strategy, Integrated Plan, draft 5 year Strategic Plan, and Suffolk s Health and Wellbeing Strategy); and fundamental elements of NHS England s guidance, which are: outcomes, patient services, access, quality, innovation, and delivering value. It is divided into the following sections: Introduction, Background and Strategic Context Outcomes Patient Services Access Quality Innovation Delivering Value Enabling and Supporting Programmes. Sections two to seven cover the requirements of the national guidance fundamentals. These sections explicitly set out our approach to delivering against these fundamentals, as below: Outcomes Section Two Patient Services Section Three Access Section Four Quality Section Five Innovation Section Six Delivering Value Section Seven. 8 P a g e

9 Plan on a Page 9 P a g e

10 Section One Introduction, Background and Strategic Context 1.1 Background and Context The requirement to produce detailed Two Year Operational Plans was introduced by NHS England in their planning guidance: Everyone Counts: Planning for patients 2014/15 to 2018/19. They state it must demonstrate that the Five Year Strategic Plan is the driving force behind transformation change; which must be explicit in how it deals with local ambitions for outcomes within the available funding. The guidance says that plans should be: bold and ambitious; developed in partnership with providers and Local Authorities; and locally lead. Our Operational Plan provides a local response to the NHS England strategic vision for the provision of consistently high quality care for all, now and for future generations. NHS England Strategic Vision The 2014/15 CCG Outcomes Indicators Set has a range of indicators spread across five domains of better outcomes to be delivered: Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with LTCs, including mental health illnesses 10 P a g e

11 Domain 3 Helping people to recover from episodes of ill-health or following injury Domain 4 Ensuring that people have a positive experience Domain 5 Treating and caring for people in a safe environment. Introduction, Background and Strategic Context These outcomes have been translated into seven specific, measurable ambitions or critical indicators of success for CCGs: securing additional years of life for people with treatable mental and physical health conditions improving health-related quality of life for people with Long Term Conditions, including Mental Health reducing the amount of time people spend in hospital by having better more integrated care in community increasing proportion of older people living at home independently following discharge from hospital increasing the number of people with physical and Mental Health conditions who have a positive experience of hospital care increasing the number of people with a positive experience of care outside of hospital, in General Practice and in the community making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. NHS England has identified three more key measures where there is an expectation of significant focus and rapid improvement: 1. improving health 2. reducing health inequalities 3. moving towards parity of esteem, ensuring an equal focus of improving mental health and physical health. In five years time as a result of strategic change locally the system will have taken steps for high quality, sustainable health and care based on six characteristics: new approach to ensuring citizens fully included in all aspects of service design and change, and patients empowered in their own care wider primary care provided at scale modern model of integrated care access to highest quality urgent and emergency care 11 P a g e

12 Introduction, Background and Strategic Context step change in productivity of elective care specialised services concentrated in centres of excellence. In addition to the six characteristics above, there are four essential elements that will apply to all of the characteristics, and the CCG is expected to articulate clearly in its plans how these will be implemented to drive up outcomes for patients and local communities. The essential elements are: Quality focusing on patient safety, patient experience, compassion in practice, staff satisfaction, seven day services (local contracts for 2014/15 will include an action plan to deliver the 10 clinical standards of the Keogh report), and safeguarding. Access focusing on disadvantaged and minority groups, extending access in primary care. Innovation delivering change through innovation, adopting and promoting best practice, continual research and evaluation. Value for money focusing on effectiveness, efficiency and improved procurement. 12 P a g e

13 Introduction, Background and Strategic Context 1.2 About Us We provide healthcare services for around 385,000 people in Ipswich and East Suffolk. In 2014/15 we will spend around 400m on commissioning healthcare services for those people. We are a strong united body, with four localities, each with its own group of practices, who meet together regularly. At these monthly meetings representatives of the member practices discuss health issues affecting their local populations and they form the basis of a twoway dialogue between the Clinical Executive and the member practices. The large geographical area we cover together with a marked variation in factors such as rurality, urbanisation, deprivation and the like, results in each locality having its own distinct set of circumstances with its own unique challenges. The solutions we come up with need to be influenced by these local differences and the localities provide the ideal platform for grassroots clinicians and administrators to rigorously debate issues that affect patients and practices. The challenge that these fora provide is healthy for the Governing Body and Clinical Executive and numerous great ideas have emerged from the localities that are already shaping current and future actions. There are 41 practices that make up the 4 localities, which are: Suffolk Brett Stour Commissioning Ideals Alliance Deben Health Group Ipswich The area is predominantly rural and includes the Borough of Ipswich, District of Suffolk Coastal, parts of the Districts of Mid Suffolk and Babergh, and a small part of St Edmundsbury. There is one major town; Ipswich with a population of 133,400 and three towns with populations of more than 10,000 people, Felixstowe, Stowmarket, and Woodbridge. GP Clinical Leadership is derived from the Governing Body, Clinical Executive and Workstream GP commitment. Appendix 8 illustrates the breadth of leadership within the specific workstreams and GP Portfolio (@ March 2014). 13 P a g e

14 Introduction, Background and Strategic Context Figure 1: Geographical area of NHS Ipswich and East Suffolk CCG Figure 2: Population profile of NHS Ipswich and East Suffolk CCG Figure 1 shows our geographical area (to the right of Stowmarket (and the unit of planning includes West Suffolk CCG geography to the left of Stowmarket. Figure 2 shows our population pyramid. 16.9% of our registered population are under age 15 (England average 17.1%) and 9.3% are aged 75 or over (England average 7.5%). 50.4% are female (England average 50.2%). 14 P a g e

15 Introduction, Background and Strategic Context The age distribution of the East Suffolk population includes a lower proportion of children, young people and adults (up to age 44 years) and a higher proportion of middle-aged and elderly people compared with Suffolk overall and with England. The age distribution of the Ipswich population is similar to that of England but has a higher proportion of children, young people and adults (up to age 44 years) and a lower proportion of middle aged and elderly people compared with Suffolk overall. The population of East Suffolk is projected to increase by 16-32% between 2008 and The projected population growth will be accompanied by substantial (49%) growth, in people aged over 65 years, estimated at 60,800 between 2001 and The population of Ipswich is also growing and is projected to increase by 33% between 2008 and However, the projected population growth will not be accompanied by substantial change in the population age distribution. Chart 1: Population of people aged 65 years and over People in East Suffolk are relatively healthy compared to those in other parts of the country although there are still some significant issues to be addressed including tackling health inequalities in some areas. In addition, the growth in the elderly population brings with it extra demands for age-related services and support. Life expectancy at birth for Suffolk in for both males and females was higher than in England as a whole by 2 and 1.5 years respectively. However, there are significant health inequalities with a 5.5 year gap for men and a 4.3 year gap for women in life expectancy between those living in the most deprived areas, many of which are in Ipswich, and the least deprived areas. The main causes of death in the Ipswich and East Suffolk area are similar to England with over three quarters of all deaths caused by cancer, circulatory disease (including coronary heart disease and stroke) and respiratory diseases. Coronary heart disease (CHD) is the most prevalent cause of health inequalities in Suffolk, and cancer is the leading cause of premature mortality. A summary demographic profile of the CCG, as produced by NHS England, is available on 15 P a g e

16 Introduction, Background and Strategic Context 1.3 Joint Strategic Needs Assessment (JSNA) The Joint Strategic Needs Assessment (JSNA) provides an assessment of current and future health and social care needs. It has been produced by Suffolk s Health and Wellbeing Board; of which we are a member. The aim of the JSNA is to improve the health and wellbeing of the local community and reduce inequalities for all ages. It is not an end in itself, but a continuous process of strategic assessment and planning. We use it to help us determine what actions to take to meet health and social care needs, and to address the wider determinants that impact on health and wellbeing. An overview of Suffolk s population is set out in Table 1. The JSNA is a suite of documents including: The State of Suffolk Report 2011 Annual Public Health Reports (latest published September 2012) Suffolk Health and Wellbeing Strategy (currently in draft form) The Pharmaceutical Needs Assessment (PNA) The Suffolk Observatory I&ESCCGPublic Health Profiles1 For further information on the JSNA please visit Table 1: Overview of Suffolk s Population Area Life Expectancy Details In Suffolk life expectancy is good. In life expectancy at birth was 83.7 years for females and 79.9 years for males. Among local authority districts in Suffolk County in , Ipswich had the lowest life expectancy for both males and females, of 78.2 years for males and 82.8 years for females. The difference between the highest and lowest life expectancy for males across the districts of Suffolk was 2.5 years, and for females was 1.6 years. 16 P a g e

17 Introduction, Background and Strategic Context Area Population Change Details The population of Suffolk in 2011 was 730,100 an increase of 9.2% on ten years earlier. In 2011 there were 8,403 live births in Suffolk, of which 51% were births of males and 49% births of females. In 2011 there were 6,880 deaths in the county, of which 49% were deaths of males and 51% were deaths of females. Deprivation In % of Suffolk s population lived in the most deprived areas in England. This is about 52,200 people. It is estimated that around 20,100 children in Suffolk live in poverty. Premature Death Premature mortality is officially defined as mortality among persons aged under 75 years. In 2011 there were 1,901 premature deaths among residents of Suffolk including 869 from cancer and 416 from heart disease and strokes. Of all premature deaths, 59% were deaths of males and 41% were deaths of females. Premature death can be significantly reduced if people are supported in making healthier lifestyle choices. Lifestyle: Smoking In Suffolk about one in five adults smoke and each year about 1,100 deaths are caused by smoking. Smoking currently kills about three people each day in Suffolk. In 2010/ % of pregnant mothers in Suffolk smoked during their pregnancy. This was about 1,200 women. 17 P a g e

18 Introduction, Background and Strategic Context Area Lifestyle: Obesity Details A quarter of adults in Suffolk are estimated to be obese. In 2010/11 about 32,400 people were diagnosed with diabetes in Suffolk. In Suffolk, 8.6% of reception year children (ages 4 to 5 years) and 16.0% of Year 6 children (ages 10 to 11 years) were obese in 2011/12. In 2009/10 Suffolk had a lower proportion of 5-16 year olds participating in physical activity than the average for England. Alcohol Misuse Almost a quarter of people aged 16+ in Suffolk were estimated to be drinking at increasing or higher risk levels in 2008/09. An estimated 94,395 adults binge drink in Suffolk. There were 16,515 hospital stays for alcohol related harm in Suffolk in 2011/12. Suffolk has a higher than (regional) average rate of young people attending hospital for alcohol related harm. Drug Misuse It is estimated that there were 2,275 users of opiates and/or crack cocaine in Suffolk in 2010/11. There were just over 1,400 adults in drug treatment in Suffolk in 2010/11 whose main problem substance was either opiates or crack cocaine. Suffolk has a higher than (regional) average rate of adult hospital stays due to drugs. There were 45 drug related deaths in Suffolk between 2008 and Mental Health Mental illness sufferers are 1.5 times more likely to die prematurely. At any one time about 1 in 6 people will suffer from some form of mental health problem. Suffolk had a higher than (national) average proportion of its adult population suffering with dementia or depression in 2011/ P a g e

19 Introduction, Background and Strategic Context The information within the JSNA has informed the development of our Clinical Priorities and the Suffolk wide Health and Wellbeing Strategy. The links between the various components of the JSNA and Clinical Priorities document are outlined in Table Unit of Planning We are part of a unit of planning with West Suffolk CCG and Suffolk County Council; and together we will develop our Health and Care Strategic Planning. The Unit of Planning was agreed and determined in accordance with the requirements of NHS England in November. It is an essential part of our Five Year Strategy provisions, which focus on three key strategic programmes: A national drive looking for integrated health and care which saves money and improves outcomes and experiences for customers; A wish to work better together locally across the local health and social care system to ensure that we make best use of resources and minimises impacts of savings on customer care; To take full advantage of the potential of partnership working to prevent need and an increase in people s dependence. SUFFOLK HEALTH AND WELLBEING BOARD 1.5 Health and Wellbeing Board The Suffolk Health and Wellbeing Board was established in accordance with the Health and Social Care Act The Board has a duty to encourage integrated working between health, care, police and other public services in order to improve wellbeing outcomes for Suffolk. It is responsible for delivery of the JSNA and the county's Joint Health and Wellbeing Strategy. It has 22 members in total, comprising Elected Members [Councillors] and officers from the County Council, local clinical commissioning groups, NHS England, HealthWatch, the police, the voluntary sector and district and borough councils. Further details are available at: The Suffolk Health and Wellbeing Strategy aims to provide a focus for everyone whose work contributes to health and wellbeing, and to use existing countywide and local groups to deliver the outcomes wherever possible. The overarching aims and priorities of this strategy are included in Table P a g e

20 Introduction, Background and Strategic Context Table 2: Suffolk Health and Wellbeing Strategy s aims and priorities Priority one: Every child in Suffolk has the best start in life Why? Giving every child the best start in life is crucial to reducing health inequalities across the whole life course and establishing a good foundation for future development. Early intervention not only improves the life chances for our children, but is essential in reducing costs to the system. There is a strong link between poverty and poor health, educational and social outcomes. We know that in Suffolk children achieve less than the national average in educational attainment, and those in more deprived areas have worse outcomes than those in affluent areas. Priority two: Suffolk residents have access to a healthy environment and take responsibility for their own health and wellbeing Why? We know that a healthy lifestyle will improve the health and wellbeing of the population and that the environment we live in can facilitate this. If green spaces are available and people feel safe they are more likely to take exercise, which will improve their health and wellbeing. Tobacco is still the greatest behavioural risk factor and accounts for up to half of the life expectancy gap between deprived communities and the rest of the population. Increasing levels of obesity and excessive alcohol consumption affect quality of life and are increasing rates of long term conditions and hospital admissions. Alcohol and drug abuse also detrimentally affect communities; increasing high risk behaviour which can lead to more sexually transmitted infections and unplanned pregnancies, and also increasing levels of antisocial behaviour and crime. Priority three: Older people in Suffolk have a good quality of life Why? As the population of older people in Suffolk increases we want to create a county in which older people can enjoy a good quality of life. Ensuring the environment enables them to be active, engaged and independent in safe, supportive communities that value their experience and contribution, remains a challenge. We know that people who enter old age healthily have a longer healthy life expectancy. It is widely recognised that the current provision of health and social care services is unlikely to be sustainable in the face of anticipated future need and most of the disease burden is attributable to long term conditions. Priority four: People in Suffolk have the opportunity to improve their mental health and wellbeing Why? Good mental health is crucial to our overall health and wellbeing. Yet almost half of all adults will experience at least one episode of depression during their lifetime, self-harming in young people is not uncommon and 60% of older adults in acute hospitals have a co-morbid mental health condition 20 P a g e

21 Introduction, Background and Strategic Context These four priorities help to underpin the CCG s clinical priorities and QIPP programme and illustrate that the CCG s planning is based upon the JSNA. Priorities one and two are captured in the CCGs priority to improve health and wellbeing through partnership working and the Healthy Ambitions QIPP programme. Priority three is captured in the CCG s priority to improve the health and care of older people. Priority four is captured in our priority to improve access to mental health services. 1.6 Ipswich and East Suffolk CCG Values and Priorities Patients and the public are at the heart of all we do and our values set out below reflect this ideal: Patients first Action orientated drive and deliver quality improvements Teamwork clinical leadership, patients, public, providers and staff Integration for improved results Equality of opportunity Never overdrawn a balanced budget Timeliness decisions results Safe, sustainable systems. Our eight clinical priorities are: 1. To promote self-care. 2. To ensure high quality local services, where possible 3. To improve the health of those in need 4. To improve health and educational attainment for children and young people 5. To improve access to mental health services 6. To improve outcomes for patients with diabetes to above national averages 7. To improve care for frail elderly individuals 8. To allow patients to die with dignity and compassion and choose their place of death 21 P a g e

22 Table 3: Linkage between Health and Wellbeing Strategy and Clinical Strategy Introduction, Background and Strategic Context Health and Wellbeing Strategy Vision People in Suffolk live healthier, happier lives. We also want to narrow the differences in healthy life expectancy between those living in our most deprived communities and those who are more affluent through greater improvements in more disadvantaged communities. Priorities: Every child in Suffolk has the best start in life. Suffolk residents have access to a health environment and take responsibility for their own health and wellbeing. Older people in Suffolk have a good quality of life. People in Suffolk have opportunities to improve their mental health and wellbeing. Clinical Strategy Vision Long and healthy lives for everyone in Ipswich and East Suffolk. By long and healthy lives we mean people s physical and mental health and wellbeing. By everyone we mean children, young people and adults. We are committed to reducing the inequalities which individuals currently experience. Priorities: To improve health and educational attainment for children and young people. To improve outcomes for patients with diabetes to above national averages. To improve care for frail elderly individuals. To improve access to mental health services. To allow patients to die with dignity and compassion and choose their place of death. To improve the health of those most in need 22 P a g e

23 Introduction, Background and Strategic Context 1.7 The Ipswich and East Suffolk Local Health and Social Care System Our local health and social care system comprises: 41 GP member practices together with other primary care providers. Ipswich hospital, the main provider of our urgent, emergency, maternity and planned secondary care services. NHS Norfolk and Suffolk Foundation Trust, the main provider of mental health services. Suffolk Community Health Services, operated by Serco. Suffolk County Council with which we have a Section 75 agreement for universal children s services including health visitors and school nurses and which is the main provider of social care services. East of England Ambulance Service. local borough and district councils for wellbeing services. diverse range of independent and other NHS providers. We have established strategic planning relationships with clinical leaders from across our health system, including with: our GP member practices through our programme of CCG link GP meetings, locality groups, education and training events and practice manager networks; CCG Website is a dedicated resource for the public and wider membership. It is a well utilised resource with clinicians using the various resources. Regular feedback and updates on content are raised at the education and training events. The System Leaders Partnership exists to provide system leadership for delivery of elements of the joint Health and Wellbeing Strategy and other areas of agreed joint working as appropriate. Its membership comprises Chief Officers and Executive Directors drawn from Health Watch Suffolk, Local Government, NHS bodies, and the Police. The Partnership s key functions are to: identify and agree on areas of beneficial joint working priorities identified through the H&WB Board oversee the delivery of joint strategic aims where cross organisational co-operation is required scrutinise progress of the joint delivery health and care work streams and remove blockages to progress deliver system leadership in the optimum use of resources to deliver the best overall outcomes for Suffolk residents. 23 P a g e

24 Introduction, Background and Strategic Context Figure 3: Systems Leadership Partnership Board 24 P a g e

25 Introduction, Background and Strategic Context 1.8 Health and Social Care Strategy and Five Year Plan Improving outcomes for the population of Ipswich and East Suffolk is what drive us. We are leading our local health and social care economy to use the challenges we face, financial and otherwise, as a platform to make real and transformational change, which will make significant improvement to the quality of care provided to our patients and the outcomes we achieve. This means that we need to be able to communicate to you [the people we serve] and our partners a clear offer in terms of outcomes (i.e. additional years of life, improvement quality of life) rather than outputs (i.e. number of acute beds, number of operations), for the money we invest. We, together with NHS England s East Anglia Area Team, have been asked to set our level of ambition against seven (below) overarching outcomes. Securing additional years of life for the people of Ipswich and East Suffolk with treatable mental and physical health conditions. Improving the health related quality of life for the people of Ipswich and East Suffolk with one or more long-term conditions, including mental health conditions. Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital. Increasing the proportion of older people living independently at home following discharge from hospital. Increasing the number of people having a positive experience of hospital care. Increasing the number of people with mental and physical health conditions having a positive experience of care outside of hospital, in general practice and in the community. Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. We have already committed to creating and delivering an integrated health and care system that supports our population to remain living independently with a good quality of life for as long as possible. All partners are committed to delivering high quality person centred services, and agree that the only way to do this effectively is to work together to remove barriers, costs and ensure that we spend as much as possible of our budgets on direct provision care. The current national, regional and local position provides a massive opportunity and responsibility for transformational change in the system, breaking down historic organisational barriers and radically re-thinking how care can be provided in Suffolk. To do this the Suffolk system, including all our local health services, care services, district and borough councils, Suffolk County Council, West Clinical Commissioning Group, Ipswich and East Clinical Commissioning Group, our local GPs and our voluntary sector and communities need to develop a common united vision. 25 P a g e

26 Introduction, Background and Strategic Context To deliver this we will provide determined leadership to create a different system, one that works for our customers and patients, but is financially sustainable into the longer term. Crucial to this is an ambition to see the entirety of our system as a whole not as fragmented services and organisations with different priorities and drivers. We believe that if we can create a shared vision, with shared principles and priorities we can achieve so much more than we are able to on our own. We are committed to remove organisational barriers and to having relentless focus on improving the health and care outcomes for people in Suffolk. We will identify and work to remove any incentives for cost shunting or unnecessary duplication of provision, and be able as a system to invest in the right things for our customers and patients. The Health and Care Review that we have started in 2014 will cover three main areas: Supporting the health and independence of individuals Urgent Care Efficient Elective Care. Further details included in Table 4, 5 and P a g e

27 Introduction, Background and Strategic Context Table 4: Supporting the Health and Independence of Individuals Detail of programme This programme will initially focus on care for the frail, elderly, people with a learning disability and those living with single or multiple chronic long term conditions (including mental health conditions) to ensure care and support is focused around the individual. The intention is to support individuals to be as healthy and independent as possible. The programme will be asked to design an integrated health and care system for supporting the health and independence of individuals with particular focus on the frail, elderly, people with learning disability or those living with single or multiple chronic long term conditions (including mental health conditions). It is expected that both these areas of work will inform use of the Better Care Fund and re-commissioning of community services. What Good Would Look Like: Multi discipline approach of professionals designed around the individual not organisations, so that people receiving support will not see the organisational differences. Effective use of technology. Personal ownership of issues and solutions (supported by personal budgets) where appropriate. Appropriate support for carers. Strengthened community and population solutions that improve health and wellbeing, e.g. housing and transport solutions. Self-management, wherever possible, with appropriate support, information and education. Access to specialist clinical support in a community setting as appropriate. Comprehensive and standardised care planning agreed with the individual and family and available to all appropriate professionals. An affordable system. 27 P a g e

28 Introduction, Background and Strategic Context Table 5: Urgent Care Detail of programme This programme will be asked to design a truly integrated Urgent Care System covering health and care needs for East and West Suffolk. It is expected that this work will inform use of the Better Care Fund and re-commissioning of community services, out of hours services, 111 services and other urgent care services. What Good Would Look Like: Clear, limited entry routes for public and professionals. Effective timely phone, web and physical triage to direct people to the most appropriate urgent health and care support. Deliver as much health and care support as close to home as possible, including advice for self-care and management. Most appropriate use of the expertise of all individuals in the system with a move to or from hospital based care where possible, appropriate and cost effective. Effective use of technology. An affordable system. The level of urgent health and care support is the same over 24 hours, 7 days a week. Appropriate diagnostic tests can be accessed without defaulting to the urgent care system. 28 P a g e

29 Introduction, Background and Strategic Context Table 6: Efficient Elective Care Detail of programme We recognise the huge potential of this programme to redesign the health and care system across Suffolk. This programme will be asked to develop proposals for a networked approach to care between Ipswich Hospital NHS Trust and WSH (plus other organisations as appropriate). This work will include consideration of care provision away from the hospital sites. What Good Would Look Like: Resilient clinical teams able to attract and retain high quality staff. Appropriate emergency cover managed across the two sites. Effective use of technology. Affordable. Resilient clinical teams able to attract and retain high quality staff. Appropriate inpatient and outpatient access across the two sites plus other community sites. Effective use of technology. Affordable. Tiered approach with appropriate levels of professional input, depending on expertise required. Specific specialties will be prioritised and worked up on a case by case basis. 29 P a g e

30 Introduction, Background and Strategic Context 1.9 Better Care Fund The Better Care Fund (previously referred to as the Integration Transformation Fund) was announced in June 2013 as part of the Spending Round. It provides an opportunity to transform local services to improve the lives of some of the most vulnerable people in our society; giving them control, placing them at the centre of their own care and support, and in doing so, providing them with better integrated care and support and quality of life. The Fund will support the aim of providing people with the right care, in the right place, at the right time, including through a significant expansion of care in community settings. The Fund encompasses a substantial level of funding (circa 50m for Suffolk in 2015/16) to help manage system pressures and improve long term sustainability. It should be noted that this funding is not new money but is already embedded in partners current allocations. To realise the efficiency and healthy living gains reallocation decisions by all organisations will be required. The Spending Round established six national conditions for access to the Fund: protection for social services as part of agreed local plans, 7-day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends better data sharing between health and social care, based on the NHS number ensure a joint approach to assessment and care planning and ensure that, where funding is used for integrated packages of care, there will be an accountable professional agreement on the consequential impact of changes in the acute sector. Locally the Health and Wellbeing Board is leading on the development of the Better Care Plan and associated templates that need to be submitted to NHS England and the Local Government Association (LGA). These are building on the work already underway to improve sustainability, raise quality and reduce emergency readmissions. The full plan is available in Appendix 5. Our progress will be monitored by NHS England and the Local Government Association (LGA) against the following metrics: admissions to residential and care homes effectiveness of reablement delayed transfers of care avoidable emergency admissions patient/service user experience 30 P a g e

31 Introduction, Background and Strategic Context 1.10 Commissioning Plans Commissioning Intentions indicate to our current and potential new providers how, as a commissioning body, we intend to shape the system that provides health services for the population of Ipswich and East Suffolk. They also outline how we will respond to the publication of changes to the national priorities for the NHS by NHS England. The next two years will be financially challenging for us and it is likely that substantial efficiencies will need to be made, particularly in 2015/ /15 will therefore be a year where radical pathway redesigns are considered and difficult decisions are made about services which could result in decommissioning in some areas. These will build on the work of the Health and Well Being Board, the System Leadership Partnership Board and Governing Body. We have organised our workload and commissioning intentions into programme groups known as clinical work streams (See Figure 4), covering planned care/cancer and end of life care, integrated care, mental health/learning disabilities, children s young people and maternity and medicines management. In carrying out our commissioning functions, the we will: work with our local groups to effectively identify local health needs and commission services from the providers best placed to meet the needs of our patients and population look to support clinical innovation and best practice across areas commission services from providers who offer a safe and effective service commission services from providers who can offer best value for money commission services from providers who offer timely access to appropriate services work in partnership with providers to identify further areas for quality improvements that promote health outcomes while reducing costs for both the commissioner and the provider support providers to work collaboratively with each other and with the commissioners (across Health and Social Care) to improve the patient experience and assist in seamless Health and Social Care provision, contributing to QIPP (Quality, Innovation, Productivity and Prevention) objectives work towards ensuring there are agreed service specifications, contracts and outcome measures for all commissioned services work with all providers to ensure delivery against service specifications, activity levels, quality standards, performance targets/standards and budget take account of the local demographics so that our resources are appropriately targeted. 31 P a g e

32 Introduction, Background and Strategic Context 1.11 Governance We place the greatest emphasis on ensuring good governance across the organisation and have comprehensive arrangements in place. All staff must comply with the Group s policy on business conduct, including the requirements set out in the policy for managing conflicts of interest. The Governing Body meets monthly and has prime responsibility for the scrutiny and approval of strategic and operational plans. The Governing Body is supported by a number of formal sub-committees with delegated decision making responsibilities; Audit, Remuneration & Human Resources, and Clinical Scrutiny and Commissioning Governance, all of whom have a role in the oversight of the strategic planning process. There is also a weekly Clinical Executive meeting and monthly GP locality meetings, where decisions can also be delegated as appropriate. A monthly progress report is presented to the CCG Executive, detailing current issues (together with any risks and mitigations) and an assessment of whether individual projects are on track to deliver within agreed timescales. Monthly reports of overall progress and Exception Reports are presented to the CCG Governing Bodies alongside financial and acute activity information. This provides assurances around delivery and also provides an opportunity for risks and key issues to be highlighted at an early stage and remedial actions to be discussed and agreed. 32 P a g e

33 Introduction, Background and Strategic Context Ipswich and East Suffolk CCG Clinical Network Map Governing Body Chair : Dr Mark Shenton Figure 4 Health and Wellbeing Board Chair: Cllr Joanna Spicer Suffolk Commissioners Group Chair: Anna McCreadie Suffolk Leadership Board Chair: Julian Herbert Clinical Executive Chair: Dr Imran Qureshi System Wide Integrated Care Network Clinical Lead: Dr Mark Shenton Integrated Care Clinical Work stream Clinical Lead: Dr Paul Kaiser Planned Care (Clinical Lead: Dr Paul Bethell) / End of Life (Clinical Lead - Dr Pete Holloway) and Cancer (Clinical Lead - Dr Peter Holloway) Mental Health (Clinical Lead: Dr John Hague) / Learning Disabilities / Children, Young People (Clinical Lead: Dr Mike McCullagh) and Maternity (Clinical Lead: Dr Rosie Frankenberg) Clinical Work stream Medicines Management Clinical Work stream Clinical Lead: Dr Karen Blades Clinical Work stream Elective Care Network: I&ESCCG & IHT Project Boards: Musculoskeletal (Dr David Egan/Dr Paul Kaiser), Cardiology (Dr Paul Bethell/Dr Billy McKee), Dermatology (Dr John Flather/Dr Imran Qureshi), Outpatient Transformation (Dr Imran Qureshi/Dr Chris Scrase) Joint Commissioning Groups with Suffolk County Council, West Suffolk CCG and Great Yarmouth and Waveney CCG (Multiple Leads) Clinical Networks: Trauma and Orthopaedics (Dr Paul Kaiser/Mr Richard Baxandall), Cardiology (Dr Paul Bethell/Dr Paul Venables), Gastroenterology (Dr Paul Bethell/Dr Simon Williams), General Surgery (Dr Paul Bethell/Mr Abdel Omer), ENT (Dr Imran Qureshi/Mr Mahmoud Salam), Spinal (Dr Imran Qureshi/Mr David Cumming), Optometry (Dr David Egan/Mr Clive Edelsten) 33 P a g e

34 The Clinical Executive is our engine of innovation, driving forward the development of new clinical pathways and delivering robust review and performance challenge. It ensures that our plans are executed in full with the resultant continuous improvement in the quality and outcomes for patients and carers and a reduction in health inequalities across Ipswich and East Suffolk. The Clinical Executive is accountable to the Governing Body. The remit of the Clinical Executive Committee is to: develop the direction of commissioning/decommissioning strategy and intentions for the organisation champion research and lead innovation in care pathway re-design monitor clinical governance and quality including safety standards and recommend action to the Governing Body sustain and develop local GP engagement structures ( i.e. Locality and Development Groups and support to improve the quality of primary care) deliver broad clinical engagement including discussions with provider organisations, about long term strategy and plans including QIPP monitor and challenge provider performance, as required monitor financial performance and propose action to the Governing Body to ensure a balanced budget monitor all Key Performance Indicators and QIPP targets, identify risks and recommend remedial action to Governing Body review agendas for the Clinical Priorities Group 1.12 Management Arrangements Structure We have a shared management infrastructure arrangement with NHS West Suffolk CCG to deliver the priorities and work programmes set out by the two separate CCG bodies. This can be seen in Figure P a g e

35 Outcomes Figure 5: shared management infrastructure NHS Ipswich and East Suffolk CCG Chair NHS West Suffolk CCG Chair NHS Ipswich and East Suffolk CCG Governing Body Shared Accountable Officer NHS West Suffolk CCG Governing Body Chief Finance Officer Chief Nursing Officer Chief Contracts Officer Chief Corporate Services Officer Chief Operating Officer NHS Ipswich & East Suffolk CCG Chief Redesign Officer NHS Ipswich & East Suffolk CCG Chief Operating Officer & Chief Redesign Officer NHS West Suffolk CCG The structure is designed with consideration for: the specific functions required by each CCG; the need for a dedicated office to support each set of members and their Governing Bodies and the pace and scale of redesign work required in each area the expertise required for specific functions of safeguarding, quality and safety, financial management and contracting the economies of scale to be achieved through shared functions detailed financial projections for various configuration options were presented to GPCCs in October 2011 preserving the best of what works in Suffolk. 35 P a g e

36 Outcomes The resultant structure therefore comprises: single Accountable Officer dedicated Chief Operating Officer for each CCG dedicated Chief Re-design Officer for each CCG shared Chief Finance Officer, Chief Nursing Officer, Chief Contracts Officer and Corporate Services Officer. Chief Officers designed the structures of their offices in the context of the functions required and financial envelopes. The capacity and cost effectiveness of plans were scrutinised by the whole management team and both Suffolk CCG Governing Bodies, prior to staff consultation, after which further adjustments were made. Staff have been recruited to posts through a structured recruitment process in line with national and local best practice. Management arrangement principles I&ESCCG and NHS West Suffolk CCG are clinically-led organisations. Our vision, objectives and priorities have been developed by our GP-led Governing Body with input from GP member practices plus a range of stakeholders and supporting information. The mission of the management infrastructure is to deliver the outcomes set out by the two clinically-led CCG organisations in an efficient and effective manner. The core principles for the management team are: There are two separate clinically-led CCG organisations with different objectives and priorities. Success is about delivering for both organisations. Work is carried out on a locality specific basis unless it is more effective to work jointly across both CCGs. Best practice and learning is shared across the management team for the benefit of both CCGs. Support for delivery of the CCG outcomes is sourced from the best value for money route available, whether this is in-house delivery or outsourcing. 36 P a g e

37 Outcomes Arrangements for shared management of the management infrastructure A formal signed agreement has been put in place between the two CCGs setting out arrangements for the management of the shared management infrastructure. This is provided in a management arrangements document. Performance management of the shared arrangement is the responsibility of the Accountable Officer. An I&ESCCG and NHS West Suffolk CCG Group has been established to review operation of the management arrangements and make decisions on significant changes Supporting Business Processes The Chief Redesign Officer is accountable to the Chief Officer and Governing Body for the development and delivery of the Quality, Innovation, Productivity, and Prevention (QIPP) programme, working closely with other Chief Officers and the CCG GP Clinical Leaders. The QIPP Plans are developed through the CCG Clinical Work Streams who are accountable to the Clinical Executive for development and delivery of their portfolio plans. Each Clinical Work Stream is supported by the Chief Officer s Team and their supporting staff. There is a schedule of formal meetings, which are minuted and progress is reported to the Clinical Executive through a monthly Redesign report, which is supplemented by the comprehensive integrated performance report including all aspects of QIPP. The following bulletted list summarises the accountability for each Clinical Work Stream. Accountable GP is accountable for ensuring delivery of all aspects of the Clinical Programme, and will be held to account by the Clinical Executive and the Governing Body in public Board meetings. Accountable GP will be held to account through local population e.g. through Health Overview and Scruitny Committee, local engagement forums and press. Chief Contracts Officer is accountable for delivery of performance metrics within the Programme. Chief Nursing Officer is accountable for delivering clincial quality within the Programme. Chief Redesign Officer is accountable for delivering service redesign within the Programme Chief Operating Officer for Medicines Management. Chief Redesign Officer is accountable for delivering budgets within the Programme Chief Operating Officer for Medicines Management. 37 P a g e

38 Outcomes We have established a Redesign Programme Management Office (PMO) to support Clinical Leads with our Quality, Innovation, Productivity and Prevention (QIPP) Programme and the associated Work Streams. The PMO works closely with the Finance and Contracts Team to track progress of the individual QIPP projects through a quantitative assessment of delivery against a suite of agreed Key Performance Indicators (KPIs) that cover both activity levels and financial spend); and a qualitative assessment of delivery against key milestones. The Chief Redesign Officer formally reviews all QIPP projects on a monthly basis, with support from other Chief Officer Teams. The outcome of these reviews is reported to the Clinical Executive. 38 P a g e

39 Section Two Outcomes The NHS Outcomes Framework was developed in December 2010, following public consultation, and is updated on an annual basis to ensure that the most appropriate measures are included to respond to the government s Mandate to NHS England. Work is on-going to improve the framework as a whole by refining existing indicators and developing new indicators in areas currently not covered. The indicators of the NHS Outcomes Framework are grouped around five domains, which set out the high-level national outcomes that the NHS should be aiming to improve. For each domain, there are a small number of overarching indicators followed by a number of improvement areas. They focus on improving health and reducing health inequalities; and support the Public Health Outcomes Framework, and the Adult Social Care Outcomes Framework. 39 P a g e

40 Outcomes The 2014/15 CCG Outcomes Indicators Set has a range of measures spread across five categories of better outcomes to be delivered: Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with LTCs, including mental health illnesses Domain 3 Helping people to recover from episodes of ill-health or following injury Domain 4 Ensuring that people have a positive experience Domain 5 Treating and caring for people in a safe environment. There are four essential elements that will apply to all of the characteristics, and the CCG is expected to articulate clearly in its plans how these will be implemented to drive up outcomes for patients and local communities. The essential elements are: Quality, focusing on patient safety, patient experience, compassion in practice, staff satisfaction, seven day services (local contracts for 2014/15 will include an action plan to deliver the 10 clinical standards of the Keogh report), and safeguarding; Access; focusing on disadvantaged and minority groups, extending access in primary care; Innovation; delivering change through innovation, adopting and promoting best practice, continual research and evaluation; Value for money; focusing on effectiveness, efficiency and improved procurement. These outcomes have been translated into seven specific, measurable ambitions or critical indicators of success for CCGs: Securing additional years of life for people with treatable mental and physical health conditions Improving health-related quality of life for people with Long Term Conditions, including Mental Health Reducing the amount of time people spend in hospital by having better more integrated care in community Increasing proportion of older people living at home independently following discharge from hospital Increasing the number of people with physical and Mental Health conditions who have a positive experience of hospital care Increasing the number of people with a positive experience of care outside of hospital, in General Practice and in the community Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. In five years time as a result of strategic change locally the system will have taken steps for high quality, sustainable health and care based on six characteristics: New approach to ensuring citizens fully included in all aspects of service design and change, and patients empowered in their own care; Wider primary care provided at scale; Modern model of integrated care; Access to highest quality urgent and emergency care; Step change in productivity of elective care; and Specialised services concentrated in centres of excellence. 40 P a g e

41 Outcomes The CCG Outcomes Indicator Set provides clear, comparative information for CCGs, Health and Wellbeing Boards, local authorities, patients and the public about the quality of health services commissioned by CCGs and the associated health outcomes. The indicators are useful for CCGs and Health and Wellbeing Boards in identifying local priorities for quality improvement and to demonstrate progress that local health systems are making on outcomes. CCG Outcomes Indicator Set measures are developed from NHS Outcomes Framework indicators that can be measured at clinical commissioning group level together with additional indicators developed by National Institute for Health and Care Excellence and the Health and Social Care Information Centre. All of the CCG outcomes indicators have been chosen on the basis that they contribute to the overarching aims of the five domains in the NHS Outcomes Framework. The Indicator Set does not in itself set thresholds or levels of ambition for CCGs, it is intended as a tool for CCGs to drive local improvement and set priorities. The CCG outcomes tool and explorer which provide interactive access to key data for CCGs have been updated and the latest versions can be found at: Originally published in December 2012 as part of the of information packs for CCGs and Local Authorities that set out key data to inform the local position on outcomes across NHS, Social Care and Public Health. The CCG packs provide a more detailed analysis of NHS outcomes and other relevant indicators. These are still available to view as individual pdf documents at Table 7 is the CCG Outcome Indicator position as of 2012, published in the Outcomes benchmarking support packs: CCG Level. 41 P a g e

42 Outcomes Table 7: I&ESCCG Outcome Indicator position as of P a g e

43 Outcomes 43 P a g e

44 Outcomes Fundamental 1 Delivering across the five domains and seven outcome measures Our current position on outcomes as set out in the NHS Outcomes Framework Our actions needed to improve outcomes Domain 1 Preventing people from dying prematurely Overarching indicator Potential years of life lost from causes considered amenable to healthcare: adults, children and young people. Improvement areas: reducing premature mortality from the major causes of death reducing premature death in people with severe mental illness reducing deaths in babies and young children reducing premature deaths in people with learning disabilities 44 P a g e

45 Outcomes Table 8: Our position against domain 1 improvement areas using latest (2012) data Source: NHS England s CCG Outcomes Tool. Available at: accessed on 3 February What we will do: We have developed three new pathways for cardiovascular disease: atrial fibrillation, palpitations and syncope. We have three more pathways in progress for 2014/15: chest pain, murmurs and heart failure. The new integrated cardiology service will ensure patients are seen faster in the right setting as an outpatient, rather than experiencing delays and thus seeking emergency care. We are establishing a new respiratory clinical network to address service redesign in this specialty and improve the long term conditions interface between care settings to ensure improve patient management. We are establishing a MDT approach to alcohol services with public health, mental health services, emergency care and we our gastroenterology clinical network is working on a new end to end alcohol pathway for liver disease patients. 45 P a g e

46 Outcomes Domain 2 Enhancing quality of life for people with long-term conditions Overarching indicator Health-related quality of life for people with long-term conditions. Improvement areas: ensuring people feel supported to manage their condition improving functional ability in people with long-term conditions reducing time spent in hospital by people with long-term conditions enhancing quality of life for carers enhancing quality of life for people with mental illness enhancing quality of life for people with dementia. Table 9: Our position against domain 2 improvement areas using latest (2012) data Source: NHS England s CCG Outcomes Tool. Available at: accessed on 3 February P a g e

47 Outcomes What we will do: We have established an Integrated Diabetes Service. The service provides outreach via diabetes consultants and specialist nurses to five GP practices. A plan is in place for each practice to be serviced at least once in 2014/15. The diabetes centre at Ipswich Hospital has been commission to outreach work in populations of high risk, such as care homes, learning disability services and ethnic minorities for patients that do need to go to Ipswich Hospital (those with foot problems which may require debridement, the CCG has brought in enhanced targets for general practitioners and the diabetes centre accepting the referrals which vary between same day and two weeks depending on the condition. A Systm One module has been place in the diabetes centre which will allow patients to be reviewed and discussed between primary and secondary care without the need for the patient to make a journey to the hospital. Our local asthma pathway for children will be extended to adults. We are reviewing our pulmonary rehabilitation services and have received a business case with our local provider to further develop this service. Domain 3 Helping people to recover from episodes of ill health or following injury Overarching indicators: emergency admissions for acute conditions that should not normally require hospital admission emergency readmissions within 30 days of discharge from hospital. Improvement areas: improving outcomes from planned treatments preventing lower respiratory tract infections in children from becoming serious improving recovery from injuries and trauma improving recovery from stroke improving recovery from fragility fractures 47 P a g e

48 Outcomes helping older people to recover their independence after illness or injury improving recovery from mental illness. Table 10: Our position against domain 3 improvement areas using latest (2012) data Source: NHS England s CCG Outcomes Tool. Available at: accessed on 3 February What we will do: We are introducing a new stroke service, and are currently undergoing a tender to ensure improved early supported discharge. We are procuring a new musculoskeletal (MSK) physiotherapy service to embed our osteoarthritis hip and knee pathways, so that all patient benefit from our physiotherapy support programme prior to surgery for improved outcomes. This pathway approach was recently included in a DH best practice case study publication. We are reviewing our pathway for children with lower respiratory track infections to ensure that these are managed electively instead of an emergency admission pathway. 48 P a g e

49 Outcomes Domain 4 Ensuring that people have a positive experience of care Overarching indicators: patient experience of GP and out of hours services patient experience of hospital care Friends and Family Test for acute inpatient care and A&E. Improvement areas: improving people s experience of outpatient care improving hospitals responsiveness to personal needs improving people s experience of accident and emergency services improving women and their families experience of maternity services improving the experience of care for people at the end of their lives improving experience of healthcare for people with mental illness improving children and young people s experience of healthcare improving people s experience of integrated care. Table 11: Our position against domain 4 improvement areas using latest (2012) data Source: NHS England s CCG Outcomes Tool. Available at: accessed on 3 February P a g e

50 What we will do: Outcomes Patient experience is measured through the Friends and Family Test, as well as rigorous scrutiny of complaints data and PALS records. A strong indicator of this is the new service specification for early supported discharge being shared with the public for comment, resulting in a far stronger specification because of input from the public. For procurement we hold specific events to help shape services, working with the Redesign Team and the public and their representatives to refine and challenge our thinking. Examples include dermatology, cardiology, children and emotional well-being services, stroke and diabetes. On 1 February we began using Patient Opinion to help collect and collate patient feedback. Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Overarching indicator Patient safety incidents reported. Improvement areas: reducing the incidence of avoidable harm improving the safety of maternity services delivering safe care to children in acute settings. 50 P a g e

51 Outcomes Table 12: Our position against domain 5 improvement areas using latest (2012) data Source: NHS England s CCG Outcomes Tool. Available at: accessed on 3 February What we will do: We currently have no patients with MRSA or C Difficile. Our reporting over the last year shows that we are consistently achieving our national targets. We will monitor the implementation of patient safety alerts issued through NHS England in monitoring of its local contracts and quality measures with providers. We will collaborate in the use and requests for information from providers in support of quality, safety and regulation by Care Quality Commission (CQC) e.g. through quality surveillance groups and shared intelligence. It will utilise datasets and metric available through the Health and Social Care Information Centre (HSCIC) to monitor and benchmark the quality of local services. 51 P a g e

52 Outcomes Outcome Ambition 1 Securing additional years of life for the people of Ipswich and East Suffolk with treatable mental and physical health conditions Our position in England is 26 th out of 211 CCGs; and 1 st within East Anglian Area, as illustrated by Charts 2 and 3. The trend has been positive since 2009 with a reduction from 1,909 to 1,671 years of life lost, as illustrated by Chart 4. During this period our position has improved compared to other CCGs by moving from 66 th in England and 4 th within the East Anglia Area. Chart 2: I&ESCCGposition across England Chart 3: I&ESCCGposition across East Anglia Area Team Chart 4: I&ESCCGtrend over P a g e

53 Outcomes Reducing premature mortality is an aim that is shared between the NHS and Public Health Outcomes Frameworks. The contribution that can be delivered by the NHS is best measured by potential years of life lost from causes considered amenable to healthcare. CCGs will have the most significant impact in reducing premature mortality by determining which contributing factors are of greatest impact to their local population, particularly taking into account the causes of premature mortality for those living in areas of deprivation. Our plans for period 2014/15 to 2015/16 are to continue to reduce the years of life lost, as described in Table 13 and illustrated in Chart 5. Table 13: Our plan to secure additional years of life for the people of Ipswich and East Suffolk with treatable mental and physical health conditions over period 2014/15 to 2015/16 Notes Baseline 2014/ Measure to be used Potential years of life lost from conditions considered amenable to healthcare a rate generated by number of amenable deaths divided by the population of the area. 1,671 (2012 Data) Source: NHS England s Levels of Ambition Tool Reduction to 1619 for 2014/15 Reduction to 1601 for 2015/16 Quality Premium Measure Improvement to be locally set and no less that 3.2%. CCGs should focus on improving in areas of deprivation in developing their plans for reducing mortality. 3.2% equate to 54 years of life 1619 for 2014/15 Support measures None n/a n/a 53 P a g e

54 Outcomes Chart 5: Our plan to secure additional years of life for the people of Ipswich and East Suffolk with treatable mental and physical health conditions over period 2014/15 to 2015/16 54 P a g e

55 Outcomes Outcome Ambition 2 Improving the health related quality of life for the people of Ipswich and East Suffolk with one or more long-term conditions, including mental health conditions Our position in England is 45 th out of 211 CCGs; and 3 rd within East Anglia Area, as illustrated by Charts 6 and 7. The trend has been positive since 2011/12 with an increase from 74.4 to 75.6 years of age, as illustrated by Chart 8. During this period our position has improved compared to other CCGs by moving from 72 nd in England and 5 th within the East Anglia Area. Chart 6: I&ESCCGposition across England Chart 7: I&ESCCGposition across East Anglia Area Team Chart 8: I&ESCCGtrend over 2011/12 to 2012/13 55 P a g e

56 Outcomes Our plans for period 2014/15 to 2015/16 are to improve the health related quality of life for the people of Ipswich and East Suffolk with one or more long-term conditions, including mental health conditions, as described in Table 14 and illustrated in Charts 8, 9 and 10. Table 14: Our plan to improve the health related quality of life for the people of Ipswich and East Suffolk with one or more long-term conditions, including mental health conditions over period 2014/15 to 2015/16 Notes Baseline 2014/ Measure to be used Health related quality of life for people with long-term conditions (measured using the EQ5D tool in the GP Patient Survey) 75.6 (2012/13) Source: NHS England s Levels of Ambition Tool Increase to 76 in 2014/15 Increase to 77 in 2015/16 Quality Premium Measure IAPT roll-out: 15% in 2014/15 i. Achieve 15% for CCGs below that level 12.2% (13/14) 15% in 2015/16 ii. Additional locally set improvement for those 15% or near 15% N\A Support measures Increase in dementia diagnosis rate to 67 per cent by March 2015 Achieve the IAPT recovery rate of 50% In 2012/13 there were 2,737 patients on the CCG s Dementia Register 50% Dementia diagnosis rate: a) Increase to 54.73% in 2014/15 b) Increase to 67% in 2015/16 IPAT recovery rate: a) 50% in 2014/15 b) 50% in 2015/16 56 P a g e

57 Outcomes Chart 8: Average EQ-5D score for people reporting having one or more long-term condition Chart 9: IAPT roll-out: To achieve 15% for CCGs Chart 10: Increase in dementia diagnosis rate to 67 per cent by March P a g e

58 Outcomes Outcome Ambition 3 Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital Our position in England is 66 th out of 211 CCGs; and 3 rd within East Anglia Area, as illustrated by Charts 11, 12 and 13. The trend has been varying since 2009/10 moving between 1,672 (2009/10), 1,753 (2010/11), 1,627 (2011/12), and 1,749 (2012/13) as illustrated by Chart 10. During this period our position compared to other CCGs has varied by moving between 57 th (2009/10), 58 th (2010/11), 48 th (2011/12) in England; and 3 rd in (2009/10) and (2010/11) and 2 nd (2011/12) within the East Anglia Area. Chart 11: I&ESCCGposition across England Chart 12: I&ESCCGposition across East Anglia Area Team Chart 13: I&ESCCGtrend over 2009/10 to 2012/13 58 P a g e

59 Outcomes Our plans for period 2014/15 to 2015/16 are to continue to reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital, as described in Table 15 and illustrated in Chart 14. Table 15: Our plan to continue to reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital, over period 2014/15 to 2015/16 Baseline 2014/ Measure to be used A rate comprised of: unplanned hospitalisation for chronic ambulatory care sensitive conditions unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s emergency admissions for acute conditions that should not usually require hospital admission emergency admissions for children with lower respiratory tract infections Source: Levels of Ambition Atlas Reduction to 1732 in 2014/15 Reduction to 1646 in 2015/16 Quality Premium Measure As per (above) outcome measure As above In 2014/15 a phased reduction is planned: Q Q Q Q P a g e

60 Outcomes Chart 14: Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital 60 P a g e

61 Outcomes Outcome Ambition 4 Increasing the proportion of older people living independently at home following discharge from hospital. Our plans for period 2014/15 to 2015/16 are to increase the proportion of older people living independently at home following discharge from hospital. Whilst CCGs and Area Teams are not expected to set a quantitative level of ambition for this outcome; we have been working with Health and Wellbeing Board partners to set out how we will improve outcomes on this ambition our their five year strategic plans. Outcome Ambition 5 Increasing the number of people having a positive experience of hospital care Our position in England is 56 th out of 211 CCGs; and 8 rd within East Anglian Area, as illustrated by Charts 14 and 15. There is no trend analysis available because only 2012 data available at present. Chart 14: I&ESCCGposition across England Chart 15: I&ESCCGposition across East Anglia Area Team 61 P a g e

62 Outcomes Our plans for period 2014/15 to 2015/16 are to increase the number of people having a positive experience of hospital care, as described in Table 16 and illustrated in Chart 16. Table 16: Our plan to Increase the number of people having a positive experience of hospital care, over period 2014/15 to 2015/16 Baseline 2014/ Measure to be used Patient experience of inpatient care (2012 data) Reduction to in 2014/15; and to in 2015/16 Quality Premium Measure Friends and Family Test: specific actions to improve low scores % improvement on GP out of ours experience Chart 16: The number of negative ( poor ) responses to survey questions per 100 patients 62 P a g e

63 Outcomes Outcome Ambition 6 Increasing the number of people with mental and physical health conditions having a positive experience of care outside of hospital, in general practice and in the community Our position in England is 90 th out of 211 CCGs; and 3 rd within East Anglian Area, as illustrated by Charts 17 and 18. There is no trend analysis available because only 2012 data available at present. Chart 17: CCG position across England Chart 18: CCG position across East Anglia Area Team Our plans for period 2014/15 to 2015/16 are to increase the number of people with mental and physical health conditions having a positive experience of care outside of hospital, in general practice and in the community, as described in Table 17 and illustrated in Chart 19. Table 17: Our plan to increase the number of people with mental and physical health conditions having a positive experience of care outside of hospital, in general practice and in the community, over period 2014/15 to 2015/16 Baseline 2014/ Measure to be used Composite indicator comprised of (i) GP services, (ii) GP Out of Hours Reduction to 5.08 in 2014/15; and 4.47 in 2015/16 63 P a g e

64 Outcomes Chart 19: The proportion of people reporting poor experience of General Practice and Out-of-Ours Services 64 P a g e

65 Outcomes Outcome Ambition 7 Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. Our plans for period 2014/15 to 2015/16 are to make significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care, as described in Table 18. Table 18: Our plan to make significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care, over period 2014/15 to 2015/16 Notes Baseline 2014/ Measure to be used Hospital deaths attributable to problems in care. This indicator is in development. Quality Premium Measure Improving the reporting of medication errors Indicator is in development Ipswich Hospital NHS Trust 6.2% (medium acute average 10.3%) Norfolk and Suffolk NHS Foundation Trust 6.1% (NRLS average 8.3%) East of England Ambulance Service NHS Trust 8.5% (NRLS average 2.5%) N.B. Suffolk Community Services (Serco) NRLS data is due for release in April 2014 Indicator is in development The CCG proposed level of increase is 2% based on review of the current National Reporting and Learning System (NRLS) data Support measures MRSA zero tolerance; and Clostridium difficile reduction 100 (2013/14) 99 (2014/15) 65 P a g e

66 Outcomes Section Summary: Reviewing Cardiology, Respiratory, Alcohol pathways as the areas identified as major causes of premature mortality. Long Term Conditions, continue to develop the Integrated Diabetes Service, extend the local Asthma Pathway for children to adults, review our Pulmonary Rehabilitation Service. Recovery from ill health and injury we are introducing a new stroke service with early supported discharge. Musculoskeletal (MSK) Physiotherapy Service and are reviewing the Children s Lower Respiratory Track Pathway Patient Safety is closely monitored for MRSA and C Difficile. On 1 February 2014 we began using Patient Opinion to help collect and collate patient feedback. 66 P a g e

67 Outcomes Fundamental 2 Improving Health Working with H&WB partners, for planned outcomes from taking the five steps recommended in the commissioning for prevention report Working with Health and Wellbeing partners our planned outcomes from taking the 5 steps recommended in the commissioning for prevention report will be included in our Self-Care plan Improving health and supporting self-care We are committed to improving health, to supporting and developing self-care and to addressing inequalities. The joint Health and Wellbeing strategy has a strong focus on improving health through joined up partnership working. We are developing proposals for health and independence with Suffolk County Council (Suffolk County Council). Prevention can potentially reduce ill health and health care demand, leading to financial benefits. NHS England s Commissioning for Prevention Report identifies five key steps for CCGs to undertake. These are outlined below: Analyse key problems identify the main causes of ill health in collaboration with public health. These are nationally heart disease, back pain, stroke, lung cancer and COPD. The CCG has identified the reduction in heart disease related mortality and morbidity as a key target. Prioritise and set goals identify common priorities and goals and share these with partners. We are committed to the Health and Wellbeing Strategy which has key outcomes and plans. Identify high impact programmes programmes should be evidence based and include primary prevention, early detection and secondary prevention. Public Health has provided a digest of evidence for the Better Care Fund which includes prevention. Plan resources resources should be reallocated where appropriate, and be drawn from the whole range of partners including education and employers. Outputs should be measured in terms of reductions in activity. Measure and experiment assess success with process and outcome measures, and evaluation where needed. 67 P a g e

68 Outcomes The Five Key Steps in addressing the Commissioning for Prevention five key steps we have started to outline our draft Self-care Plan, the emerging themes and content are described below. The steps and progress against each are considered below. NHS England describes CCGs as being at one of three stages At the start, emerging or mature. Step 1 Analysis of key problems Include CCG profiles to show East Suffolk values. In Suffolk life expectancy is good. In life expectancy at birth was 83.6 years for females and 79.9 years for males. The population of Suffolk in 2012 was 732,300. In 2012 there were 8,316 live births in Suffolk, of which 51% were births of males and 49% births of females. In 2012, there were 7,055 deaths in the county, of which 47% were deaths of males and 53% were deaths of females. In 2010, 7.4% of Suffolk s population lived in the most deprived areas in England. This is about 52,200 people. It is estimated that around 20,100 children in Suffolk live in poverty. Premature mortality is officially defined as mortality among persons aged under 75 years. In 2012 there were 1,949 premature deaths among residents of Suffolk, including 931 from cancer and 437 from heart disease and stroke. Of all premature deaths, 58% were of males and 42% were of females. Premature mortality can be significantly reduced if people are supported in making healthier lifestyle choices. In Suffolk about one in five adults smoke and each year about 1,100 deaths are caused by smoking. Smoking currently kills about three people each day in Suffolk. Suffolk has a higher than (national) average rate of pregnant females smoking at the time of delivery. A quarter of adults in Suffolk are estimated to be obese. In 2011/12, about 34,000 people were diagnosed with diabetes in Suffolk. In Suffolk, 7.8% of Reception Year children (ages 4 to 5 years) and 16.9% of Year 6 children (ages 10 to 11 years) were obese in 2012/13 Suffolk has a higher proportion of adults participating in the recommended level of physical activity than the national average 68 P a g e

69 Outcomes Almost a quarter of people aged 16 years of age or over in Suffolk were estimated to be drinking at increasing or higher risk levels in 2008/09. An estimated 94,395 adults binge drink in Suffolk. This is defined as eight or more units on one day in last seven for men, and six or more for women. 852 Suffolk resident adults in treatment for alcohol misuse in 2012/13. There were 16,515 hospital stays for alcohol related harm in Suffolk in 2011/12. Suffolk has a higher than (regional) average rate of young people attending hospital for alcohol related harm. It is estimated that there were 2,275 users of opiates and/or crack cocaine in Suffolk in 2010/11. There were almost 1,300 adults in drug treatment in Suffolk in 2012/13 whose main problem substance was either opiates or crack cocaine. Suffolk has a higher than (regional) average rate of adult hospital stays due to drugs. There were 45 drug related deaths in Suffolk during Mental illness sufferers are 1.5 times more likely to die prematurely. At any one time about 1 in 6 people will suffer from some form of mental health problem. Suffolk had a higher than (national) average proportion of its adult population suffering with dementia or depression in 2011/12. Step 2 Prioritise and set goals A number of priorities have been identified through analysis and also consultation. The CCG has identified the reduction of heart disease as a key target for the two year plan. The Health and Wellbeing Board has developed a multi-agency strategy with four key outcomes: every child in Suffolk has the best start in life Suffolk residents have access to a healthy environment and take responsibility for their health and well being older people in Suffolk have a good quality of life people in Suffolk have the opportunity to improve their mental health and well being. The CCG Stakeholder Event on Self Care identified key priorities: healthier living peer and group support 69 P a g e

70 Outcomes provision of information health professionals supporting self-care empowering individuals to self-care. Step 3 Identify high impact programmes There are many evidence based programmes underway in Ipswich and East Suffolk CCG both in self-care and health improvement: these are within the CCG work streams project charters jointly with Suffolk Public Health through the Health and Wellbeing Strategy commissioned by NHS England for Suffolk. Examples are given below. Self-care programmes within CCG work streams: DESMOND Diabetes education programme information booklet for parents on minor illness in children proposals for Heart failure Telemedicine Directed Enhanced Service (DES) breast feeding preventing admissions in over 75s. Screening and immunisation programmes commissioned by NHS England: breast and cervical screening mammography colorectal screening aortic aneurysm 70 P a g e

71 Outcomes child health pneumococcal and shingles flu programme. Health improvement programmes commissioned or delivered jointly with Public Health Smoking cessation tiered service Live well programmes including obesity focused on deprived areas, people with LD, chronic disease and mental health problems Making Every Contact Count Falls prevention programme NHS Health Checks delivered within GP and through provider services. Health and Wellbeing Strategy Mental health promotion strategy being developed to include evidence based interventions Health and independence self-care stream is developing self-care proposals. Step 4 Plan resources Our investment in self-care and prevention can be identified in a number of areas as outlined below. Other investments/resources are more challenging to quantify. Step 5 Measure and experiment All of the existing programmes have agreed performance indicators. Evaluations have been undertaken in services, for example, NHS health checks and smoking cessation. National evidence and guidance has been followed. Out Communications Team have planned and delivered key message on self-care and prevention through local newspapers and radio. These include pieces on keeping well in the winter, accident prevention, heat waves, flu vaccination, hay fever. The communication strategy must form a central part of any self-care and prevention programming. 71 P a g e

72 Outcomes IT can be used to creatively support the delivery of health promotion messages and facilitation of self-care. This could include use of public facing websites and also supporting practice based systems in providing leaflets and point of care information for patients and professionals. We are committed to ensuring the issues of self-care and prevention are addressed within every key work stream area. Within the mental health work stream, further work is needed on lifestyle issues associated with dementia prevention and on a joint suicide prevention programme. The integrated care work stream has discussed the re-introduction of the Expert Patients Programme (EPP). Planned care has considered Telemedicine options and recommended heart failure as an option for the DES. The Health and Independence work has a self-care subgroup developing proposals. Further work is required during to: Establish a virtual workstream with GP lead, Lay Governing Body member, key managers, Public Health representative Identify current self-care and health improvement programmes within each work stream and joint with partners Ensure ongoing work is evidence based and effective see Better Care Fund briefing provided by Public Health Analyse health needs to identify any additional priorities/gaps Estimate resources currently being expended and quantify expected benefits (if possible) Ensure ongoing public and stakeholder involvement. Finally we should undertake a self assessment against the levels outlined by NHS England and aspire to move from At the start/emerging to Mature within 2 years. 72 P a g e

73 Outcomes Section Summary: Prioritise and set goals identify common priorities and goals and share these with partners The CCG has identified the reduction of heart disease as a key target for the two year plan Health and Wellbeing Board has four key outcomes: every child in Suffolk has the best start in life Suffolk residents have access to a healthy environment and take responsibility for their health and well being older people in Suffolk have a good quality of life people in Suffolk have the opportunity to improve their mental health and well being. Focus areas :Self-care programmes, Screening and immunisation programmes, Health improvement programmes, Mental health promotion strategy, Health and independence self-care stream is developing self-care proposals 73 P a g e

74 Outcomes Fundamental 3 Reducing Health Inequalities Identification of the groups of people in our area that have a worse outcome and experience of care and our plans to close the gap Implementation of the five most cost effective high impact interventions recommended by the National Audit Office (NAO) report on health inequalities Implementing Equality Delivery System (EDS2) We are identifying the groups of people in our area that have worse outcomes and experience of care and our plans to close the gap by working proactively with H&WB partners to deliver the HWS, including those areas of the strategy focusing on health improvement and prevention. We will actively contribute to the work to: a) Decrease the harm caused by alcohol to individuals and communities by: Ensuring that acute trusts assess alcohol intake and provide brief interventions to their patients where appropriate. We will expect at least one member of staff per ward to be trained in assessment and brief intervention. Working jointly with NHS England to ensure that those GPs signed up to the alcohol DES offer appropriate brief intervention and referral where the alcohol tool assesses the need. Working with Suffolk County Council to ensure comprehensive treatment services are available to the population where those funded by the NHS are part of an integrated service. b) Decrease the prevalence of smoking by: Ensuring acute trusts identify smoking status and refer smokers to stop smoking services. Working jointly with NHS England to encourage GPs to actively take up the Suffolk County Council contract for level 2 stop smoking services. c) Increase the prevalence of Breast Feeding by funding: A CQUIN which supports the delivery of UNICEF stage 2 Breast Feeding Initiative. 74 P a g e

75 Outcomes Ipswich and East Infant feeding co-ordinator (April 2015 role will move into Health visiting contract to be held by Public Health) Breast Feeding Home visiting support (for one year as will also go into Health visiting contract) d) Reduce Health inequalities through working with NHS England and Suffolk County Council to address the major factors contributing to increased risk of vascular disease by: Increasing the prescribing of drugs to control blood pressure by December 2014 we will have produced a baseline to ensure equity or prescribing in our deprived populations with an action plan to improve prescribing and reduce any inequality. Increasing the prescribing of drugs to reduce cholesterol by December 2014 we will have produced a baseline to ensure equity or prescribing in our deprived populations with an action plan to improve prescribing and reduce any inequality. Encouraging practices with low levels of level 2 smoking services to increase their activity. Encouraging practices to actively offer NHS health checks. Increasing understanding of health inequalities by improving data recording of protected characteristics in the Equality Act 2010 particular relating to BME and LGBT communities where evidence suggests major health inequalities exist. Latest evidence about LGBT and health inequalities can be seen at. We are committed to improving our approach to equality and diversity linked to health inequalities; and identified two key objectives: To embed a systematic process for collecting data and engaging organisations representing protected groups in order to establish need and develop responsive services which address inequalities. Senior leaders and other line managers provide leadership, support and motivation for their staff to uphold the CCGs value of equality of opportunity to improve the health of those most in need. We will continue to work closely with Public Health Suffolk, as set out in our Memorandum of Understanding with Suffolk County Council, to ensure that our change programmes are underpinned by robust health needs assessment, evidence of the effectiveness of interventions and service configurations together with local/national benchmarking analysis. We will also continue to work closely with Health and Wellbeing Board partners to ensure that change programmes are effectively monitored and evaluated in order to demonstrate delivery of the required outcomes in the context of the Health and Wellbeing Strategy. We are working with partners on implementation of the five most cost effective high impact interventions recommended by the NAO report on health inequalities. One of our clinical priorities is to improve the health of those most in need. Health inequality can 75 P a g e

76 Outcomes be defined as differences in health status or in the distribution of health determinants between different population groups. For example, differences in mortality rates between people from different socioeconomic groups. Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned. Our local Public Health Profiles show that life expectancy at birth for Suffolk in for both males and females was higher than in England as a whole by 2 and 1.5 years respectively. However, the report showed significant health inequalities between those living in the most and the least deprived areas of Suffolk, with a 5.5 year gap for men and a 4.3 year gap for women in life expectancy. This is a key area of focus for us with many programmes of work underway. We are committed to: 10% reduction by 2015 in the difference in mortality due to circulatory disease (including coronary heart disease and stroke) in people under 75 years between people living in the 20% most deprived areas of the CCG compared with the other 80% (based on figures for ). Support to reduce smoking in pregnant women, where currently the proportion smoking at the time of delivery across the whole of NHS Suffolk is 13.4%. 100% of children being registered on both primary care and health visitor list within two years. Improving breastfeeding rates (currently measured at six weeks) in the worst areas up to the level currently enjoyed by the best areas within two years. Collaborating with the local community and services to ensure that 100% of clients known to the marginalised and vulnerable adults service are registered with primary care within one month of first contact. 20% reduction in use of A&E by homeless adults service within one year, using baseline figures for 2012 once they are available at CCG level. We are implementing the Equality Delivery System (EDS2) and have published our equality objectives, priorities and action plan. In September 2013 we used the EDS to refresh our equality objectives in collaboration with members of staff, and communities representing diverse groups. We are implementing our action plan with its four equality objectives and will next review progress in September Since the introduction of the EDS2 we have been working with local NHS partners to determine if future joint working will be beneficial. 76 P a g e

77 Outcomes We will review the prescribing of drugs that control blood pressure and reduce cholesterol by: looking at benchmarking data showing how we compare to other CCGs on our usage of drugs within these classes mapping our prescribing data against a range of admissions data to see if there is any obvious trend providing educational resources to clinicians reminding them of prescribing best practice develop our joint formulary with Ipswich Hospital NHS Trust which will reflect best practice double the capacity of smoking cessation services this is the responsibility of Public Health. Section Summary: Increase the prevalence of Breast Feeding by funding to supports the delivery of UNICEF stage 2 Breast Feeding Initiative. Decrease the prevalence of smoking working with acute trusts to identify patient smoking status and refer smokers to stop smoking services. To reduce the risk of vascular disease by increasing the prescribing of drugs to control blood pressure and the prescribing of drugs to reduce cholesterol. We are implementing the Equality Delivery System (EDS2) to refresh our equality objectives in collaboration with members of staff, and communities representing diverse groups. 77 P a g e

78 Outcomes Fundamental 4 Parity of esteem Identification of the groups of people in our area that have a worse outcome and experience of care and our plans to close the gap Implementation of the 5 most cost effective high impact interventions recommended by the NAO report on health inequalities Implementing EDS2 We are allocating resources to mental health to achieve parity of esteem; as illustrated by our overarching aims for mental health: Mental health provision will be open and accessible to all people who need it regardless of their age and the diagnosis and severity of their mental health condition and include those marginalised from society. No mental health service user should need to be returned to their GP for onward referral for another mental health service. To Commission mental health and learning disability services which are integrated with the wider health and social system and which support the recognition that people s mental health should be seen as part of their overall physical and mental wellbeing. To achieve these we will: Embed and further develop its psychiatric liaison service in Ipswich Hospital, to expand the service for young people aged and to address long term conditions. There will be a full evaluation in quarter two of 2014/15 which will inform the commissioning model going forward into 2015/16 and beyond. During 2014/15 develop a comprehensive post diagnostic service model for people with dementia and their carers for procurement in 2015/16. This work is being undertaken jointly with West Suffolk CCG and Suffolk County Council. Remodelling our Learning Disability services to meet the new service specification we have developed in partnership with West Suffolk CCG. This is for a new community wide and modernised learning disability service to be commissioned in partnership between the CCGs and Suffolk County Council. 78 P a g e

79 Outcomes Working jointly with Health and Social Care commissioners to set out formally the scope and extent of joint commissioning arrangements and the governance underpinning them. This will include modelling of new community based rehabilitation pathways and remodelling of our mental health pooled fund. The 2014 mental health needs assessment will include a specific focus on perinatal mental health. Ahead of its publication: we are working with Norfolk and Suffolk NHS Foundation Trust to ensure that the services offered by the Suffolk Wellbeing Service are accessible and available to pregnant women and new mothers. We will support Norfolk and Suffolk NHS Foundation Trust to develop more effective relationships with the Ipswich Hospital Midwifery Service so that there is a better understanding of what the Wellbeing service offers and to put in place clear referral pathways. Establishing these pathways will help contribute to the 15 per cent treatment rate for IAPT during 2014/15. We shall be supporting work between Public Health, Ipswich Hospital NHS Trust and Norfolk and Suffolk NHS Foundation Trust to develop guidance that supports midwives to understand mental health history and use this to allocate women to the correct maternity tariff. In 2014/15 Norfolk and Suffolk NHS Foundation Trust will enter its second year of service redesign to implement its new operating model and achieve 20% savings by We will continue to closely work with Norfolk and Suffolk NHS Foundation Trust to address any performance and contractual issues as they arise and to support them in their service redesign. Areas of particular focus will include: inpatient Services; Crisis Care; Personality Disorder; Substance Misuse; and Rehabilitation Pathways. In response to identified service gaps we are investing recurrent funding from 2013/14 in specific areas namely: Adult and Youth Autism Diagnostic and Assessment Services we have previously had no service for these areas. Investment of 408,000 pa. Enhanced provision of Memory Assessment Services which includes a remodelled service including delivery of diagnosis via 10 GP practices working collaboratively with our acute provider, to ensure service resilience to meet the rising demographic. Investment 400,500 pa. Improved Emotional Resilience for Children and Young People. To improve identification and support for young people with mental health problems we have a new strategy and action plan to modernise Children s Emotional Wellbeing Services has been produced in partnership with Suffolk County Council. This has identified the significant service gap in provision for children and young people requiring tier two mental health services. A business case has been completed in 2013/14 for a resilience hub service model for young people with emerging conduct disorders and other mental health needs. In 2013/14 we will be: increasing the number of primary mental health workers for children and young people West Suffolk CCG contribution 133k pa. 79 P a g e

80 Outcomes Further developing our children s IAPT service model. Implementing the priorities in the Children s Emotional Wellbeing Action Plan. The new community model of mental health sees the delivery of a Youth Pathway as part of a wider Norfolk and Suffolk NHS Foundation Trust integrated delivery team. This service offers support to young people up to the age of 25. Transition to adult services is not aged based but happens when the young person s needs can be best met by workers based in the adult pathway. As the Adult and Youth Pathways are part of a locality based Integrated Delivery Team with staff based in one location with shared MDTs there is a structured approach to transition that provides the young person with a supportive transition to adult services. We have been working with West Suffolk CCG, Norfolk and Suffolk NHS Foundation Trust and other stakeholders to develop the Resilience Hub concept. This is a local approach that will strengthen the delivery of primary care mental health services. The approach focuses on supporting other professionals, particularly in schools, and creates a new role that will specialise in providing therapeutic interventions. The Hub recognises the role and contribution many services make to children s emotional wellbeing and promotes partnership, for example in the development and delivery of parenting programmes. We are awaiting final sign off of the increased investment required to make this possible. For our plans to reduce the 20 year gap in life expectancy for people with severe mental illness, we will work in partnership with health and social care commissioners and statutory providers as key members of the Suffolk Joint Commissioning Group for Mental Health and Learning Disabilities, and the Children s Joint Commissioning Group, both of which report to the Suffolk Health and Wellbeing Board and support the delivery of the Health and Wellbeing Board s Action Plan. We will ensure we are key partners in the planning and development in Suffolk across all agencies of working arrangements which will directly benefit the health and wellbeing of people with mental illness and in particular so can respond to the following action plan priorities: Every child in Suffolk has the best staff in life. To ensure people in Suffolk have the opportunity to improve their mental health and wellbeing. This includes ensuring that mental health is everyone s business, not just health, social care and the voluntary sector but employers, education and the criminal justice system. Suffolk residents have access to a healthy environment and take responsibility for their own health and wellbeing. This includes access to suitable housing. The Suffolk Joint Commissioning Group for Mental Health and Learning Disabilities has agreed to develop a health and social care five year strategy for mental health services in Suffolk during This document will describe the aspirations for aligned pathways and is 80 P a g e

81 Outcomes expected to be clear about the actions required to address gaps in life expectancy. The approach and actions included in the strategy will be shaped by workshops that are taking place during March These workshops are being coproduced with service users with a service user led steering group designing the format and content. The workshops are a start of a process that leads to the production of a coproduced strategy. Being well in the Wild is an asset based approach to create stronger links between those working in health and wellbeing and those in the natural environment. A process of asset based work took place in January 2014 and a workshop of 33 people representing 21 different organisations have formed an action plan for 2014 that will support increased access to the natural environment for those with severe mental illness. The Most Active County action plan promotes mental activity as well as physical activity. The Inaugural Event on the link between physical activity, health and wellbeing took place on 15th January 2014 with national speakers from National Institute for Health and Care Excellence, University of Essex and Sport England. We will continue to support the Health and Wellbeing Board to promote Let s get active in Suffolk as a way of reducing physical inactivity and promoting social connectedness through Objective two and four of the Health and Wellbeing Board Plan. To ensure more appropriate responses to crisis we are supporting a pilot project between Norfolk and Suffolk NHS Foundation Trust and the Suffolk Constabulary that will see two mental health care coordinators working alongside police colleagues both providing training and support and offering a joint response to emergency calls that have a mental health element. The service will go live during April Colleagues from Public Health will be supporting the evaluation of the pilot. Our mental health planning responds to the recommendations of the Suffolk Joint Strategic Needs Assessment including: Mental Health (currently under production) Children s Mental Health Needs Assessment (2013) Maternity Needs Assessment (2013) Dementia Needs Assessment (2013) Needs Assessment of Children with Communication Difficulties (2013) 81 P a g e

82 Outcomes Section Summary: To develop our Psychiatric Liaison Service in Ipswich Hospital, to expand the service for young people aged and to address long term conditions. Develop a comprehensive post diagnostic service model for people with dementia and their carers. Remodelling our Learning Disability Services. The 2014 mental health needs assessment will include a specific focus on perinatal mental health. Increasing the number of primary mental health workers for children and young people. Further developing our children s IAPT service model. Implementing the priorities in the Children s Emotional Wellbeing Action Plan. Commence the development of a five year strategy for mental health services in Suffolk during P a g e

83 Section Three Patient Services Fundamental 5 New approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care How we will commission services so that patients and citizens have the opportunity to take control How we will put real time patient and citizen voice at the heart of decision making How we will include authentic citizen participation in the design of our plans How we will promote transparency in local health services Sharing Patient Information The Integrated Diabetes Service will employ EDSM and Electronic referrals enabling a full and appropriate exchange of clinical patient information integrating with the GP health record that use SystmOne. A manual process to exchange data between the diabetic clinic and surgeries that do not use SystmOne is being developed. Patient sharing has progressed significantly within Suffolk. The EDSM (Enhanced Data Sharing Model) project has and continues to involve all health services that utilise TPP SystmOne clinical system within the region. Much development has been made in enabling the sharing of patient information with GP s and community services that now have new processes in place and protocols for sharing, this has also included training and a Suffolk wide patient information leaflet. It is anticipated that shortly all SystmOne surgeries will be trained within Suffolk, therefore giving the ability to share detailed patient records with other services. There has been agreement with Child and Adult services for information protocols to be set with the introduction of EDSM The enablement and use of EDSM progresses further projects such as the Integrated Diabetes Service and Electronic Palliative Care Co-Ordination Service. Patient Opinion On 1 February, the CCG began using Patient Opinion to help collect and collate patient feedback. Plans are underway to promote the use of Patient Opinion to the public to make sure people are aware of it as a route to set out their complaints and complements and suggestions for improvements. Patient experience is measured through the Friends and Family test, as well as rigorous scrutiny of complaints data and PALS records. 83 P a g e

84 Patient Services NHS Choices provides the digital front door, and there are links in place on our website. Work is underway to build comprehensive information, which has seen improvements in the hip and knee operation pathway. Our events have gathered vital input into how to improve our work to empower patients. Empowering patients We engage with the public and stakeholders to promote our work and encourage debate on priorities. A strong indicator of this is the new service specification for Early Supported Discharge being shared with the public for comment, resulting in a far stronger specification because of comments from the public. We will continue to hold specific events to help shape services, working with the redesign team and the public and their representatives to refine and challenge our thinking. Examples include dermatology, cardiology, children and emotional well-being services, stroke and diabetes. The final evaluation panels for each of these work streams will also include a patient representative. These experts will ensure that the patient voice heavily influences the final decision as to which organisation/organisations receive the contract to deliver these local services. At each Governing Body meeting a patient attends at the start of the meeting to tell a patient story which is relevant to one of the meeting s main papers. This enables the service change or message to be given context. 84 P a g e

85 Project charters Patient Services In order to help embed the approach of engaging with patients as partners in the redesign process, all redesign programmes have project charters which have to be signed off by the relevant Clinical Work Streams, an important aspect of this relates to describing how patients will be involved in the re-design and decision making process. We will use Patient Opinion, an on-line and independent way to share feedback, to further encourage debate Supportive arrangements: Complaints, compliments and PALs data will be monitored. At each of the Governing Body meetings and as part of relevant redesign work streams a patient is invited to give their first-hand experience of a specific service. A website went live in autumn 2012 and is resourced to be up-to-date and informative. All information, including that shared with GP member practices, is available on line. All documents that relate to the commissioning and planning process are made available through our website. Service Specifications We will continue to involve patients in developing service specifications and in the procurement process. CQUIN During the planning for next year 2014/15 the CQUIN development involved a group of patients who were part of the process to prioritise the CQUINs to go forward into the commissioning process. Health and Social Care Review Strategic Plans, infrastructure arrangements are well developed to jointly engage with local people around 3 important themes; local hospitals, urgent care and living independent lives. This engagement task is being undertaken with colleagues from Suffolk County Council. Contracts Any contract for new providers includes requirements for provider patient groups to be set-up to enable robust feedback on the quality of health services and patient care as well as involvement and engagement in decisions about service development, patient care and mechanisms for involving individuals in decisions about their health. 85 P a g e

86 Patient Participation Groups Patient Services We are making links and establishing relationships with GP patient groups to involve them in the process of decision making about our priorities and to encourage their contribution to our work both at a strategic level, and where appropriate, at an operational level. This will help us ensure that we are looking at primary and community services in a joined up way from the perspective of those that use the service. The GP training events are a good mechanism for feeding back on issues that arise from primary practice including issues of transition between primary and secondary care. The Health and Wellbeing Board We are working actively with the health and wellbeing board, and hence the full range of partners represented on this board, in order to ensure that we tackle issues of health, including inequalities, in a joined-up manner. We are also part of the Suffolk Joint Commissioners group which provides an opportunity to engage in joint commissioning in order to meet public and patient needs in a joined up way. We have jointly appointed a champion for Young People's Health with the health and well-being board. The aim of this appointment is to give young people a stronger voice to influence their healthcare. Voluntary & Community Sector (VCS) We recognise how important it is to engage with the voluntary and community sector. Building on a detailed process to co-produce with the voluntary sector we have developed and recently agreed a VCS strategy. This will help frame and structure an on-going programme of work with the VCS over the next 2 years. A project plan has been agreed with representatives of the local VCS. This programme is to be launched with an event jointly led by us and the VCS. The event will explore how to work together more effectively and in particular working together in relation to the Better Care Fund. The strategy identifies a three-fold relationship with the sector; VCS as campaigning organisations, VCS as conduits for advice and guidance when seeking to reach certain elements of the population when seeking to re-design services and finally as providers of services. In respect of this third aspect of the VCS and us are looking to support the sector through engagement days, what if meetings and the opportunity to shadow our staff. Points of View Points of View is our free mailing list; members of the public register an interest in receiving updates from us and opportunities to get involved at meetings and events. As a result, members receive a monthly newsletter from us, as well as being the first to hear the latest news from health partners and the latest consultations, surveys, meetings and events. 86 P a g e

87 Patient Involvement: CYP and Mental Health and Learning Disabilities Patient Services We are working with Suffolk County Council to develop a joint autism plan for young people aged The plan is being coproduced with parents and carers through a steering group. The steering group is influenced by a local voice of the child and young people group that is made up of parents and carers of young people with autism. The steering group also links to the Suffolk Parent and Carers Network. We are working with Norfolk and Suffolk NHS Foundation Trust to remodel specialist learning disability services. The draft service specification being used as the basis for this redesign was coproduced with service users and family carers through a process of 3 design workshops, 2 focus groups and a paper based exercise. A new community memory assessment service will be launched during The new service model has been developed to respond to stakeholder concerns about delays in access, location of provision, role of the local GP and timeliness of referral. The new service will be consultant led and delivered in 10 primary care locations across our area. Assessment will be carried out by specialist dementia nurses with diagnosis clinics being held in primary care practices. The real innovation is seeing diagnosis and follow-up being provided by an Norfolk and Suffolk NHS Foundation Trust consultant / associate specialist working alongside a local GP with special interest. This means that diagnosis and follow up will be delivered by consultant or by a local GP working with the onsite support of the secondary specialist. Implementing EDS 2 We are committed to using EDS2. We have used the EDS to refresh our equality objectives in September 2013 with the help of members of staff and communities representing diverse groups. The CCG s equality objectives are online, here: We are currently implementing the action plan for our four equality objectives and will review progress in August/September Holding meetings in Public The Community Engagement Partnership is a group made up of representatives from the community, specifically mental health, disability and the BME community. It is chaired by the lay member for patient and the public involvement. This group is about to be refreshed so that it will become a sub-committee of the Governing Body; it will have a stronger role in identifying health issues and views about services across a wide range of communities that are represented in our area through the members' established networks; the group will also have a role in sharing our proposals at an early stage. 87 P a g e

88 Patient Services Both the Governing Body and the Community Engagement Partnership are held in public to promote transparency and greater public involvement. Papers and minutes from both of these meetings are now available on our new website a week prior to the meetings Social Media This is an area we are continuously looking to improve on and develop. With the implementation of our Facebook page on the horizon including the increased use of Patient Opinion on our Website to help support live feedback on patient s experience of their local healthcare. Stakeholder Events Self-care discussion Event 21 May At the first stakeholder event held in September 2012 that helped launch the CCG, the participants voiced a significant interest in the issue of ill-health prevention and self-care, the subject of self-care was the main topic to our second stakeholder event. The half-day session was devised to prompt discussion within participant groups. The questions and structure of the event were developed by the CCG Community Engagement Partnership. Dementia Consultation Workshop 26 February This public consultation event was set up to help redesign the service for Dementia patients, and to improve the diagnosis rate. The aim of the redesigning of the Dementia service was to: 1) To increase dementia diagnosis from 42% to 75% by 2015/ P a g e

89 Patient Services 2) To develop more comprehensive, cohesive and integrated services across the dementia care pathway, providing services near to where people live. 3) To ensure an effective response to the needs of people affected by dementia. The feedback received from delegates at this Workshop was used by Ipswich and East Suffolk CCG and Suffolk Adult and Community Services to inform their commissioning intentions to redesign dementia services. Town Talks, Village Voices 29 October Town Talks, Village Voices was the third stakeholder engagement event held by the NHS Ipswich and East Suffolk Clinical Commissioning Group (CCG), following on from the Self Care event in March Town Talks Village Voices saw CCG General Practitioners and lead officers set out stalls in ten locations across Ipswich and East Suffolk, such as swimming pools, shops and churches. Members of the public were asked what would you like the NHS to do differently if you were taken ill? and whether they had any experience of 111 and a number of other health care related issues. Transforming Outpatients together On 17 th March meeting held to discuss redesign of outpatient services at Ipswich Hospital. Its purpose was to focus on the positive to redesign so that services deliver a good experience for patient and staff all of the time. 89 P a g e

90 Patient Services Partnership Working The CCG continues to build on the already excellent relationships fostered across Ipswich and East Suffolk. The CCG actively engages with the Ipswich and East Suffolk Community on a number of levels, below highlights a few meetings the CCG has a specific agenda item for, updating both patients and public on a regular basis: Healthwatch and the BME and Diversity Group Healthwatch we enjoy a good relationship with Healthwatch Suffolk who provides invaluable feedback in respect of local services and on particular themes, e.g. stroke services A member of our engagement team attends meetings of the BME Healthwatch group and this is providing valuable insight into specific inequities in health outcomes and service providing for different ethnic groups. We are planning to use this information to inform our plans. The key objective of the group is to ensure the voice of BME communities is being heard in the work of the health services Suffolk. It is recognised that BME communities include people with different characteristics and background such as race, age, sexual orientation, disability, religion and belief, ex-users of drug and alcohol, and ex-offenders etc. The group takes a holistic and inclusive approach to work with all sections of the BME communities. Age UK POPS events The Partnership with Older People in Suffolk (POPS) organises group forums around the county to discuss and make recommendations on key issues that affect older people in order to inform service delivery in health and social care. Ipswich Hospital User Group The Ipswich Hospital User Group (IHUG) meets every six weeks and involves a representative from every user group. The purpose of this group is to contribute to the continuous improvement of services delivered by the Trust by ensuring that the views of service users are sought, co-ordinated and feedback to the hospital. Every other meeting we have an item on the IHUG agenda to give an update as to the developments across each of the work streams. 90 P a g e

91 Voluntary and Community Sector Engagement Strategy Patient Services We have worked with local voluntary sector organisations to agree how they will support us in three distinct ways; direct delivery of some services, providing lay input into the re-design process and (where appropriate) to campaign on key messages that relate to the people of Suffolk. The strategy identifies some of the potential issues and scopes out an approach that we could usefully adopt to work more effectively with the VCS. Implementing EDS 2 we have committed to using EDS2. We have used the EDS to refresh our equality objectives in September 2013 with the help of members of staff and communities representing diverse groups. Our equality objectives are online, here: tydeliveryobjectives.aspx We are currently implementing the action plan for its four equality objectives and will review progress in August/September Since the introduction of the EDS2, alongside the West Suffolk CCG we have been working with local NHS partners to determine if future joint working will be beneficial. 91 P a g e

92 Patient Services Section Summary: At each Governing Body meeting a patient attends at the start of the meeting to tell a patient story which is relevant to one of the meeting s main papers. This enables the service change or message to be given context. Implementing EDS 2. Events examples: Transforming Outpatients together, Town Talks, Village Voices 29 October 2013, Dementia Consultation Workshop 26 February 2013, Self-care discussion Event 21 May We will develop a Voluntary Care Strategy. We are working with Suffolk county council to develop a joint autism plan for young people aged Healthwatch - the CCG enjoys a good relationship with Healthwatch Suffolk who provide invaluable feedback in respect of local services and on particular themes. Age UK POPS events, the Partnership with Older People in Suffolk (POPS) organises group forums around the county to discuss and make recommendations. 92 P a g e

93 Patient Services Fundamental 6 Wider Primary Care, provided at scale Our understanding of the potential contribution of primary care to delivery of your ambition Working with partners and the public to develop an integrated approach to primary and community services, with joint commissioning as appropriate How we will enable primary care to operate at greater scale to improve access and continuity of care and to enable our urgent and emergency care network to function effectively In response to the Call to Action we are working across a broad range of activities to ensure that primary care and the CCG have joint strategies to deliver our two and five year plans. These focus on: supporting vulnerable people and avoiding admissions improved access and integration of services education, training and sustainability in workforce local Service Developments communication. What we will do: Ensuring tailored care for vulnerable and older people The delivery of the Government s focus on those patients aged 75 and over and those with complex needs. The new GP contract secures specific arrangements for all patients aged 75 and over to have an accountable GP. We will support practices in transforming care of patients to reduce avoidable admissions through providing funding for practice plans. 160 GP practice staff have met to consider approaches to support the accountable GP and in developing and delivering care plans for patients aged over 75. We are committed to investing the required 5 in addition to the continuation of local contacts for enhanced clinical services to care homes and supplementary Multi-disciplinary Team meetings engaging social and community care partners. 93 P a g e

94 Patient Services Practices are considering approaches which combine individual practice, locality and CCG-wide contributions and include specific services for housebound patients, practice peer review with geriatricians as well as falls prevention and management. Our Ambition Over the next two years we will: Mobilise primary care resources through a local primary care strategy, within the context of national and area team strategies for primary care is one of the five enablers of our Five Year Clinical Strategy (approved by Governing Body ). The primary care strategy will inform major change to local services. Include how we will facilitate local practices to work cooperatively to enable aspects of primary care provision to be provided at scale. Development of a primary care strategy with local partners and the Area Team that addresses issues of practice viability as a result of contract changes. The other aspect of the strategy that is relevant is how the CCG and Area Team helps to shape primary care to enable GP services to be provided at scale and hence enhance capacity whilst retaining the local face of general practice and supporting continuity of care. Access, Integration and Quality We look actively at quality of outcomes and experiences at national and local levels. Performance against national and most area benchmarks is high. Our GPs currently deliver high quality care GP patient survey identified that 89.71% of patients had a good overall experience of their GP surgery (England average 86.74%). Only 9.56% of patients with a long standing health condition felt that they do not have enough support from local services and organisations to help manage their conditions (England 11.77%). Where variation exists we work through localities and with the support of our practice implementation and prescribing teams to help identify the reasons for variation and support improvements. Integration: Collaboration within Primary Care and with System Partners: All Ipswich and East Suffolk practices are members of the Suffolk Federation 180 GPs and other practice staff engage in education and training programmes each month focused on developing clinical knowledge and developing commissioning plans in localities. All practices have access to our dedicated on-line training resources. These programmes are essential to ensuring the quality and safety of our services and we are committed to their continuation and expansion. GPs are engaged with secondary care clinicians through our Integrated Care Network, Clinical Networks, Clinical Quality Improvement Task Force and the Clinical Leaders Programme 94 P a g e

95 Patient Services We will work with the Area Team and local partners to explore how further joint work with local pharmacists, opticians and dentists can be developed to facilitate a local system this is both resilient and tailored to meet the needs of local people. This will support the extension of overall capacity and make better use of existing professional capacity. Investment in primary care services, integrated into our wider health system We have committed 250,000 in additional services to care home patients in 2013/14. At our January Governing Body meeting it was greed to continue funding into 2014/15 for 92 homes. We have invested in additional 275,000 in multi-disciplinary teams to complement the national DES and ensure 10 MDTs each year for sustained multi-disciplinary identification, discussion and management of complex patients It is planned over the next 5 years to invest additional resources in local primary care providers on a significant scale to facilitate the implementation of our 5 year Clinical Strategy and to enable the development of a right sized secondary care. Training and Education Programme The Commissioning Implementation Team are working closely with GP training lead Dr Juno Jesuthasan and the Redesign Team to plan a training and education programme for all practice staff for 2014/15. The GP training will be of the same format with a clinical presentation from a secondary care consultant, followed by either a locality meeting or Development Workshop where new pathways or services will be launched. The programme will be scheduled throughout the year in line with the Redesign Team s project plans. The training programme will also incorporate practice nurses and HCAs, as well as non-clinical staff Sustainability Supporting Organisational Development; Recruitment; Retention We will help enable primary care to operate at greater scale to improve access and continuity of care with secondary and other community health and social care providers by: Working with our Area Team, Local Medical Committee, Suffolk Federation and individual members to support the sustainability of vibrant, high quality primary care services. Member practices will be invited to engage in our Organisational Development Plan diagnostics in the last quarter of Following analysis with practices we will agree together the support which they require to adapt to the requirements of the new contract and participate fully in the new health economy. We will also work with these partners as well as our wider NHS and public sector partners to improve the recruitment and retention of our primary care workforce. We will continue to invest in training and education for our GPs, nurse teams, practice managers and other practice support staff in order to ensure a sustainable workforce and quality of primary care which sustains and exceeds our 95 P a g e

96 Patient Services current high standards. We seek to create a health system with a working environment which attracts and retains current and new talent in new ways. We will continue to engage NHS Property Services in our service re-design programmes to ensure that the re-modelling of services includes full consideration of the opportunities of the current primary and wider NHS estate in our area are realised and developed and that financial risks are mitigated effectively. We anticipate this will be a key enabler to our developing primary care strategy. We are keen to work with the Area Team to ensure that sufficient estate is available to match the ambitions for primary care in Suffolk. We will implement our comprehensive IT strategy, developed with clinical leadership in 2013, focused on seamless patient care and aligned to national requirements and priorities. We will deliver work programmes to ensure improvements in: information at the point of care; mobility and agility of data so that tests, results and care can all be delivered in the locations that best suit patient s needs; access to clinical knowledge and intelligence to design and deliver the highest quality of care. The CCG sees increased investment in primary and community services as an essential lever to re-shape the local health economy. It is a crucial element to facilitate the move to provide services which are more accessible and supports the re-focussing of the secondary care sector to concentrate on patients who are more acutely ill. Local aspects of this approach include: continuation and expansion of services to care homes falls housebound multi-disciplinary teams. Enabling primary care to operate at greater scale to improve access and continuity of care will enable our urgent and emergency care network to function effectively. Primary Care has strong representation at both the Integrated Care Workstream and the Integrated Care Network through clinical executive GP representatives and the latter with representation from Out of Hours provider, Suffolk Community Healthcare provider and Suffolk GP Federation. Integrated Care has developed a programme of related projects building on work previously undertaken to mature the integrated care agenda in order to ensure better integration across the system in order to operate at a greater scale to improve access and continuity of 96 P a g e

97 Patient Services care for the Ipswich and East Suffolk population. There are a number of projects that involve primary care at the forefront of redesign and delivery to ensure patients are clinically managed effectively and in the most appropriate environment., includes: Residential care and nursing homes proactive approach to all patients residing in care homes through regular ward rounds with improved clinical outcomes and reduction in need for calls to urgent care services. Winter planning proactive support to COPD patients who are more at risk over the winter period. Winter planning joint working with Ipswich Hospital both in and out of hours for patients who could be seen safely within a primary care environment, triage and redirection for appropriate treatment. Utilisation of Quality Outcomes Framework, Quality and Productivity Indicators has encouraged and supported the utilisation of new initiatives such as a number of admission prevention schemes; new integrated diabetes service and dementia services. Through regular training and education events all projects that have an impact or rely on primary care are taken to the wider CCG members for their ideas, views and comments at an early stage. This enables GPs to help shape and form the final products and keep them as simple and easy as possible for busy clinicians to use going forward and ensure that they are patient outcome focussed. We will continue to utilise these forums to provide feedback and evaluation on projects implemented to date and encourage engagement to develop more projects with primary care to ensure that these function effectively during the next two years. Facilitating integration through commissioning and local service transformation We see increased investment in primary and community services as a crucial lever to re-shape the local health economy. It is a central tenet of our strategy to provide services which are more accessible and support the re-focussing of the secondary care sector to concentrate on patients who are more acutely ill. This will include continuation and expansion of existing services as well as the respecification of services. Specific examples include: Continuation and expansion of services to care homes to include very sheltered housing. Proactive management of housebound patients. Multi-disciplinary teams. Falls (see below). We recognise the Falls Project as a large programme of work over the next two years. A five year Suffolk falls and fragility fracture prevention strategy will underpin the redesign work required. This is based upon the four objectives from the Department of Health s 97 P a g e

98 Patient Services Systematic approach to Falls and Fracture prevention. An Integrated Falls and Fragility Fractures consisting of health, social and voluntary sector partners have identified areas where there are gaps in the falls pathway and scoped ideas and solutions to meet the gaps. Areas within the project for development include: A clear falls pathway which enables health, social and voluntary organisations to identify and support patients earlier to prevent falls. Develop an electronic falls assessment where data could be shared easily between primary and secondary care to prevent duplication. Utilisation and promotion of assistive technology to support our most vulnerable falls patients upon discharge. Map the provision of OTAGO (strengthened balance training) based exercise and increase provision to meet the growing needs. Develop a falls directory for clinicians to enable signposting. Public health campaigns around prevention of falls and bone health to support self-care. Wider falls awareness training and improving content and ensuring availability of training within health, social and voluntary care sector. Dementia services In line with the national dementia strategy we are committed to increasing the dementia diagnosis rate and will be investing in the development of a Community Memory Assessment Service in 2014/15. This service will focus on providing memory assessment in primary care settings and will see capacity increase from around 500 assessments a year to over 1,500. This will support us to achieve a significant increase in the local dementia diagnosis rate. We are working with both Suffolk County Council and West Suffolk CCG to review the current post diagnosis pathway and develop a more integrated approach to commissioning and delivering dementia services. This includes ensuring there is a clear pathway between the new psychiatric liaison service, the dementia intensive support service and community dementia provision. Dermatology services We are procuring an integrated community dermatology service with hospital in reach in order to develop a model of care for people with skin conditions to ensure that patients are seen by the right person, in the right place at the right time and can move readily between the levels of care as necessary. The proposed service will ensure patients are seen in a timely manner by the most appropriate service, thereby allowing acute hospitals to see the most complex patients. 98 P a g e

99 Patient Services Re-shaping our Out of Hours services is a priority for the next two years. We will achieve this through engagement with local professionals and local people in respect of what services they would like to see as part of the OOHs system. This work will shape the service model which will be provided following a tendering exercise as part of an overall transformation of our urgent care system. Children s Admissions What we will do: We have changed the asthma discharge pathways within Ipswich Hospital, to provide patients, parents and carers with detailed advice and support around asthma management and medication changes. This has had a significantly positive impact in reducing admissions in this area by 14% Year To Date (YTD) as at November 2013 compared with November We had a QIPP target to reduce lower tract infections and asthma emergency admissions in 2013/14. In November 2013, our number of lower tract infection emergency admissions was 106 YTD compared with 146 at November Our asthma emergency admissions decreased from 621 YTD in November 2012 to 535 YTD in November We will continue to closely monitor and reduce these admissions. We have been working closely with Ipswich Hospital around achievement of best practice tariff for the care of paediatric diabetes patients. Ipswich hospital has significantly improved their care pathways for these vulnerable children and has successfully achieved the best practice criteria. Communication Involving people, improving health is the ethos behind everything we do. Earlier in the document we talked about the engagement work we are carrying out with this in mind. To make it effective, we must communicate well too. That means making sure we have the mechanisms in place to talk to, as well as, listen to the people we serve. The Communications Team works to build our reputation raise our profile and arm people with knowledge about our services. Our Media Team has strategies in place which are strengthened by excellent partnerships with other NHS providers, as well as Healthwatch Suffolk and the Health and Wellbeing Board. The GPs have been trained to give them the confidence to work with the media; we regularly promote the CCG, and have recently seen successes from our paid for seasonal campaign. We are building on our social media presence and aim to push this even further to make sure we are part of the conversations. We have agreed between partners to use #SuffolkNHS and #SuffolkHealth to share our news. 99 P a g e

100 Patient Services Section Summary: Collaboration within Primary Care and with System Partners: All Ipswich and East Suffolk practices are members of the Suffolk Federation. GPs are engaged with secondary care clinicians through our Integrated Care Network, Clinical Networks, Clinical Quality Improvement Task Force and the Clinical Leaders Programme. Well established Training and Education. GP training continues with a format of clinical presentations from a secondary care consultant, followed by either a locality meeting or Development Workshop. It is planned over the next 5 years to invest additional resources in local primary care providers on a significant scale. The communications team works to build our reputation, raise our profile and arm people with knowledge about the services we have. Social media presence we have agreed between partners to use #SuffolkNHS and #SuffolkHealth to share our news. 100 P a g e

101 Patient Services Fundamental 7 A modern model of integrated care What we will do to ensure people with multiple long-term conditions and clinical risk factors are offered a fully integrated experience of support and care To ensure people with multiple long-term conditions and clinical risk factors are offered a fully integrated experience of support and care we are developing a new urgent care model which will improve patient experience by implementation of a more integrated service system-wide. To ensure people with multiple long-term conditions and clinical risk factors are offered a fully integrated experience and support and care, we have worked in partnership with West Suffolk CCG and Suffolk County Council to establish a Health and Independence Programme Board, on which all partners in the local health economy are represented, including community healthcare, adult social care, children s services, district councils, acute and community hospitals, hospices, police and crime commissioner, voluntary sector and Healthwatch Suffolk. From the Programme, six key principles have arisen: People have access to high quality, trusted information which is available in a variety of different places and formats. Integrated Neighbourhood Teams or Networks provide a responsive and effective model of community support. The teams are multiagency and include GPs, community health, social care, district council services and input from the voluntary and community sectors. Front line staff is empowered to make decisions across the system. However the service users remain central within the decision making process. There are community hub buildings which hold the integrated teams and are a key location for information, and other services such as GP surgeries and pharmacies. People s care is co-ordinated by a lead professional (Care Lead), with one outcome focused, holistic and personalised plan which is shared across the system and with the person themselves (Shared Care Plan). The lead professional has sufficient time to plan with their customer/patient (Case Management). People have the tools to self-manage their long term condition, including having control over personal budgets (health and social care). 101 P a g e

102 Patient Services The system recognises the value and importance that family carers bring how does the system meet the needs of family carers better. These principles are being used by to design Integrated Neighbourhood Teams (Figure 6.) or Networks of Care; we will use the strategic opportunity afforded by the expiry of the community health contract in 2015 to hard wire Integrated Neighbourhood Teams or Networks into local health and social care services. In addition, we are commissioning a number of contributing services or enablers prior to or during 2014/5, and working with operational teams to align current practices. These include: Alignment of general practice boundaries with social care team and community healthcare team boundaries, to form Integrated Neighbourhood Teams where all staff is co-located where possible. Recruitment of lead consultant geriatricians for each sub CCG locality, who are working with local Integrated Neighbourhood Teams in supporting MDTs. Risk stratification software. A policy where all patients under the care of community health services have a named case manager appropriate to the patient s need, and a shared management plan. Community-based clinics from consultants, including Comprehensive Geriatrics Assessments (CGA) and movement disorder clinics. A shared electronic care record for palliative care. Alignment of GP boundaries with community healthcare and adult social care has already been agreed (see below). This has not had any contractual implications with providers. 102 P a g e

103 Patient Services Figure 6: Integrated Neighbourhood Teams 103 P a g e

104 Patient Services It is anticipated that the increased prevention and coordination activities of the Integrated Neighbourhood Teams/Networks will reduce the need for urgent care; the local health economy is however examining, through the Urgent Care Programme Board ways of integrating health and social responses into a specification for a single system, incorporating: Three digit number. Out of hours Primary Care. Urgent community healthcare, including support for frail elderly individuals. Urgent mental healthcare. Urgent social care [or the coordination of the urgent social care]. Signposting to non-nhs services, including self-care options such as pharmacies, and voluntary sector. Accident and Emergency patients who are identified as not having an emergency need. Ambulance patients who are identified as not having an emergency need. Assessment of urgent patients in a hospital setting. We will be engaging with providers in March and April 2014 to co-produce a service specification for a single system, and will commence wider public engagement in May Following procurement and mobilisation, the integrated urgent care service is due to start in the third quarter of 2015/16. The Better Care Fund is one of the key enablers that will allow the transformation of both long-term conditions and urgent care. In February Public Health Suffolk published its rapid review of evidence related to interventions that have an impact on Better Care Fund outcomes; a copy is available in the Appendix 5. A key outcome for us is to enhance the quality of life for people with long-term conditions. Work in this area is on-going to improve the functionality of people with conditions such as Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Mental Illness, Dementia and Ambulatory Care Sensitive Conditions (ACSC). Implementation of the risk stratification tool will ensure early identification and more proactive management of people with these conditions by the Integrated Neighbourhood Teams/Networks. Safeguarding The safeguarding project stage 1 has enabled the sharing of safeguarding information between all parties that use SystmOne who are involved in the care of Children. This is also encompassing non SystmOne users in Stage 2 due to be completed by the end of March P a g e

105 Patient Services Stroke Services During 2012/3 we convened with West Suffolk CCG a new Stroke Network to identify areas in which local stroke services differed from the standards set out in the NHS Midlands and East Service specification. The two priorities for improvement were hyperacute stroke services and early supported discharge services. The CCGs at Governing Body level approved plans for hyper acute stroke services to be delivered by a network of stroke consultants from Ipswich and West Suffolk Hospitals and on-site specialist nursing, physiotherapy, occupational therapy and speech and language staff. This arrangement went live on 6 th January 2014 and will run to March 2015 in the first instance. The operational aspects of the service are overseen by a four-weekly Acute Clinical Workstream; an agreed extensive evaluation framework, with a view to whether this is the appropriate long-term model, has been agreed by a Project Board containing both Suffolk CCGs, both acute Trusts, Healthwatch, the Stroke Association, NHS England (East of England Cardiovascular Strategic Clinical Network Manager), Suffolk Community Health and Suffolk County Council. The first quarter of the data will be presented to the Suffolk Stroke Review Project Board in May 2014 and a full year s worth of data will be presented in Feb The CCGs are currently out to procurement on Early Supported Discharge services; the expected date for ratification of the tender award is July We have worked closely with the Stroke Association and Healthwatch and Public Health Suffolk to develop an evidencebased patient-focused set of key performance indicators for the service, which should go live in November Care Homes In 2014/15 we plan to continue to embed and evaluate the residential care and nursing homes contract (care home contract) and work towards improving knowledge and the support for care homes. Part of providing more proactive care to our patients in residential care and nursing homes has been via the introduction of a new care home contract. This contract aligns a GP practice to a specific care home so that patients can receive more proactive care to prevent emergency admissions. This is in the shape of regular ward rounds, medication reviews, advance end of life care planning, dementia and falls screening and improved long term condition monitoring. The GP practice links in with community healthcare teams, Ipswich Hospital for consultant led advice and guidance services and admission prevention services where appropriate. The next stage for planned for 2014/15 in development would be to offer the service to patients in very sheltered housing as this is a cohort of patients who may be housebound. 105 P a g e

106 Patient Services Falls Unlike other major disease areas, the national trends for the incidence and costs associated with falls and fragility is growing, with published reports from the Department of Health predicting a doubling in the associated costs by the year We will map the current falls pathways and establish and a working group will formulate recommendations to make a more integrated falls service for work to commence in 2014/15. The recommendations span the whole pathway from improving care for patients sustaining a fractured neck of femur to signposting patients to exercise classes to ensure maintaining mobility and balance. The new falls pathway will be publicised and understood so all health and social care professionals and the voluntary sector are aware how patients enter it and patients will need to understand self-care more to prevent falls. The falls assessment information for patients will be made accessible to all health professionals involved in a patients care and to prevent duplication of effort. Personal Health Budgets Personal Health Budgets are being progressed jointly with Suffolk County Council. A project manager will be employed to ensure robust systems and processes are put in place as well as the monitoring of clinical outcomes with each package. Suffolk is on track to have this implemented by October A recent review conducted by Department of Health highlighted that we were on track with other CCGs that did not participate in the pilot roll out of Personal Health Budgets. Education, Health and Care (EHC) Plans We recognise the importance of working with our colleagues in Suffolk County Council to ensure the implementation of the Special Education Needs and Disability (SEND) reforms in September 2014 and to create a framework that will enable the payment of Personal Health Budgets. An executive lead for implementation of the reforms has been agreed. We will be an active member of the monthly steering group overseeing the implementation process. We shall support colleagues in Suffolk County Council to work directly with our providers to map the current local health offer. We will be responsible for signing this off. We will work with Suffolk County Council to develop a core speech and language theraphy offer for children and young people. The process of developing this will be used as an exemplar of the process to be used in other areas as the requirement to jointly commission is taken further. 106 P a g e

107 Patient Services Section Summary: Establishing Integrated Neighbourhood Teams. CCGs at Governing Body level approved plans for hyper acute stroke services to be delivered by a network of stroke consultants from Ipswich and West Suffolk Hospitals. Through the Urgent Care Programme Board ways of integrating health and social responses into a specification for a single system. Continue to embed and evaluate the residential care and nursing homes contract. Personal Health Budgets are being progressed jointly with the Suffolk County Council. To ensure the implementation of the Special Education Needs and Disability (SEND) reforms in September P a g e

108 Patient Services Fundamental 8 Access to the highest quality urgent and emergency care How our strategic plan is in line with the vision set out in the Urgent and Emergency Care Review Phase One Report Documents/UECR.Ph1Report.FV.pdf. How we will determine the footprint for our urgent and emergency care network during 2014/15, working with key partners and informed by a detailed understanding of our area: o patient flows o the number and location of emergency and urgent care facilities o the services they provide o the most pressing needs for your population. How we will be ready in 2015/16 to begin the process of designation for all facilities within our network. It has been recognised that there is a need to change how we deliver services to meet patient s needs and expectations. In a society where other services are available 7days a week it is congruous that we build on the growing enthusiasm for such service delivery and build on the current good practice to provide equitable access, care and treatment regardless of the day of the week. For the system to be as efficient and effective as possible we need to manage demand and flow across the health and care system including primary, community and acute care. We therefore need to maximise utilisation of appropriate levels of resources by ensuring the best advice and support is available to the patient at the time of need. We will need to ensure that health and social care services are integrated at the point of delivery; ensure provision of proactive care for the frail elderly and those with long term conditions, giving these patients greater control of their care and promoting independence (selfcare) and support the four emerging principles for urgent and emergency care in England to deliver a system that: Provides consistently high quality and safe care, across all seven days of the week. Is simple and guides good choices by patients and clinicians. 108 P a g e

109 Patient Services Provides the right care in the right place, by those with the right skills the first time. Is efficient in the delivery of care and services. Furthermore another rationale for this programme is that the number of GP consultations has risen over recent years and, despite rapid expansion and use of alternative urgent care services, attendances at A&E departments have not reduced. This indicates either unmet demand across the whole system or supply induced demand: increased uptake as a result of increased provision of services. The fragmentation and diverse nomenclature of urgent care services across England causes confusion amongst patients and healthcare professionals in terms of services offered. This can lead to patients presenting at services that may not best suit their needs - review High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review End of Phase 1 Report. In order to develop their plans providers will initially be required to write a comprehensive strategy and action plan for the Integrated Care Network designed to deliver the requirements of NHS Services, 7 Days a Week to include; workforce plans, resource plans, communications and interagency working. These plans will need to consider improved 7 day access/working; the overall length of stay and integrated care discharge planning within the acute & community setting. Our current model is illustrated in Figure P a g e

110 Patient Services Figure 7: Current Model of Urgent and Emergency Care ENTRY POINTS ADMISSION PREVENTION INITIATIVES INPATIENT CARE Care Co-ordination Centre (Community Health Services) Integrated Neighbourhood Teams using risk stratification and case management Short Term Spot Purchased Beds e.g. Aldringham (Winter only) Primary Care and 111 Interface Geriatrician and Falls Prevention Step up and Step Down Beds (Winter only) PATIENT Emergency Admissions Unit, Admission Prevention Service, COPD Admission Avoidance Service, Dementia Intensive Support Team Acute Inpatient Bed 999 Roving Emergency Care Practitioner A&E Walk in Patients to IHT Primary Care Streaming Late PM (Winter Only) Noting the quality constraints in Section 5, the local Health and Care Review - Urgent Care Programme has sought to develop a whole system model in relation to the future Urgent Care. During Phase 1 of the Programme, the Urgent Care Clinical Steering Group has developed a high-level diagram for the East and West Suffolk Urgent Care System, which is given in Figure 8. Our Governing Body agreed strategic commissioning intentions, which included two key developments, compared to the present: Virtual Health and Social Care Coordination; and Bespoke urgent care assessment at front of both acute trusts. 110 P a g e

111 Patient Services The form that will undertake these functions is anticipated to be a Health and Social Care Coordination Centre and Urgent Care Hub respectively. Figure 8 starts with the patient or customer in the blue box at the top; from right to left, there are a number of routes via which patients could access urgent care in the new system: At present, some long-term patients with a very high risk of severe and sudden complications have direct appropriate access to specialist services, for instance neutropaenic patients on chemotherapy at risk of overwhelming sepsis or some patients with very severe mental health conditions. It is anticipated that appropriate forms of direct access should remain in place for known complex patients and local commissioners will work with providers to ensure these instances are fully captured. Many patients care themselves without contacting the health system. Within core general practice hours ( ) people contacting their general practice would continue to speak to a member of staff at their local practice. Local commissioners recognise that general practice meets a very significant proportion of the urgent care need in Suffolk and is likely to do so in the future. Where General Practice assesses the patient as having needs that they cannot meet without further advice, assessment or treatment, they will have access to a Health and Social Care Call Coordination Centre via a dedicated line for professionals. This Centre is described in further detail in the next section. People in Suffolk will continue to have access to 999 for genuine emergencies, and the Ambulance Trust will continue to dispatch to genuine emergencies, and these patients could subsequently be taken to the acute trust (to either the Urgent Care Centre or A&E as appropriate). There would however be a facility for the 999 service to hand over less acute patients to the Health and Social Care Coordination Centre. People in Suffolk can currently telephone to access urgent care, in the form of advice or referral, via the 111 service, which is separate from phoning an in hours general practice. The 111 service is subject to the development of a national specification and at present it is not clear how much local adaptation will be permitted. Nevertheless local commissioners endorse the principle that telephone access should be available both in hours and out of hours, but that all numbers other than 999, direct access or local general practice should all lead to the Health and Social Care Coordination Centre. This includes out of hours primary care and calls currently routed to mental health and community services call centres. 111 P a g e

112 Patient Services Figure 8: Proposed East and West Suffolk Urgent Care System 112 P a g e

113 In terms of attending services at the acute hospital without a prior appointment: Patient Services Commissioners intend that patients or customers who attend the acute hospital unannounced, would by default be seen by the Urgent Care Hub, but with the support of acute trust facilities and A&E only if required. It is rare that a patient arriving by means other than an ambulance requires resuscitation. It is not proposed that the A&Es at Ipswich and West Suffolk Hospitals be moved; the commissioners wish to work with the providers to explore having both an A&E and Urgent Care Centre at both hospitals, with the Urgent Care Centre filtering out less serious cases from A&E and working closely with the Health and Social Care Coordination Centre and Community Services. This is in line with national think that A&E and Urgent Care Centres should ideally be co-located. Health and Social Care Coordination Centre Commissioners intend that there be a single source of care co-ordination for urgent health and social care, which: Need not necessarily be on a single site, nor necessarily co-located with areas where patients physically go for assessment, but acts as single coherent organisation. Would handle patients who call 111 or equivalent successor, out of hours general practice calls, and if feasible the current call receiving and coordination facilities in existence separately for mental health, social care and community health. Would take a lead in compiling a Directory of Services, including both commissioned and non-commissioned services, which could include non-health (e.g. voluntary sector and housing). Would coordinate a seamless transfer of patients into the correct service within the Directory, whether they be based in the community (see section 6.3) or at the acute trust (see section 6.4). This might for example include providing non-clinical activity to support a referring clinician and a clinician within the Directory of Services, for example booking transport if appropriate. It is anticipated that the Health and Social Care Coordination Centre would have lines for access by professionals and lines for access by the public. NHS and Suffolk County Council commissioners will continue to work closely with operational and clinical experts in the Urgent Care Programme to produce a high quality section pertaining to this part of the specification. 113 P a g e

114 Patient Services Community-based Urgent Care The care co-ordination centre can refer patients or help referring clinicians to access community-based services as represented by the triangle on the right-hand side of Figure 8. Some patients with more severe health and social care needs require the services to travel to them, as represented by the bottom triangle. In other cases patients would travel to closer services in locations other than West Suffolk and Ipswich Hospital, as represented by the trapezium. Commissioners intend to commission services for patients to be visited in his or her own home. At present, services that are currently provided in patients homes, including community health services, Crisis Resolution and Home Treatment Team, Out of Hours General Practitioner, Paramedics, Social Care, Dementia Intensive Support. Commissioners regard the current reasons for visiting patients in their own home to be reasonable balance between the needs of the housebound and the needs of the general population; however the shape of these services may differ in the future. The Urgent Care Programme will work closely with the Health and Independence Programme to define a comprehensive list of health needs requiring domiciliary visits. Commissioners intend that the following services relevant to urgent care would be provided in a fixed community setting: Community spokes for the Urgent Care Hub, where patients could be assessed face-to-face, as directed by the Health and Social Care Co-ordination Centre. At present, current out-of-hours bases for primary care contain relatively few facilities and clinical staff; commissioners would like to explore whether diagnostics such as ultrasound and D-dimers, or facilities for treating minor injuries as directed by the Health and Social Care Coordination Centre. Community inpatient beds, accessed through the Health and Social Care Co-ordination Centre, for step up, step down or step across purposes. Opportunities for ambulatory care or urgent outpatient appointments (for example Comprehensive Geriatric Assessment). The Urgent Care Programme is working closely with the other two strategic work streams (Health and Independence and Efficient Elective Care) to ensure alignment in the proposals. It will also be mindful of the strategic work currently being undertaken by East of England Ambulance Service NHS Trust. 114 P a g e

115 Patient Services Services based at the Acute Trust Campuses Commissioners intend to commission urgent care services at the sites of both Suffolk acute trusts, however a broader response, with greater links to the community services, would now be offered in the form of an Urgent Care Hub at each of West Suffolk and Ipswich Hospitals, represented by the trapezium in left hand triangle. The Urgent Care Hub would: Act as a site which would see all unannounced arrivals to the acute trusts site (other than 999), and manage most of these, passing only the severest cases to A&E. Act as a site where the Health and Social Care Coordination Centre could direct patients on foot or ambulance for face-to-face assessment. The Urgent Care Hub is likely to provide the following services: primary care treatment of injuries other than major trauma diagnostics commissioned urgent specialty input especially medical, surgical, mental (both adults and children) and paediatric specialities, such that patients did not need to go to A&E proper just to receive an opinion. Ideally, some lead clinicians from each speciality would work at the interface between the acute and community settings. transfer people to community services, facilitated if required by Health and Social Care Coordination Centre social care liaison services. Under these commissioning intentions, A&E facilities, which would continue at both Ipswich Hospital and West Suffolk Hospitals, could focus on being an Emergency Centre genuinely for emergencies: patients requiring resuscitation, ITU, HDU or at risk of organ failure or damage patients who require operating theatre patients with major trauma. It is anticipated that patients should not be in A&E solely for specialist opinion, radiological or biological investigation and that instead these should also be provided through the urgent care hub. The commissioners will work with the local acute trusts to determine whether 115 P a g e

116 Patient Services patients who require a short period of close observation might be admitted as inpatients or dealt with by the urgent care hub or a more local spoke. Together with West Suffolk CCG we have commissioned Out of Hours Primary Care, Community Health Services, and NHS 111 with contracts which expire in Both CCGs are seeking to ensure that beyond this date, the Urgent Care system in Suffolk is able to provide a high quality service which meets a number of strategic challenges, which include the following: Population growth, in particular for persons over 65. By 2031, there will be a 55% increase in the number of persons over the age of 65 in Suffolk, and a 72% increase in the number of persons over 75. Higher numbers of patients with long-term conditions, many of which can be associated with urgent complications; recent research has indicated that over 40% of patients have at least one long-term condition, and approximately 20% have two or more. Feedback from local stakeholders, particularly in relation to accessing urgent care, receiving a coordinated and integrated response, and ensuring the accident and emergency departments are truly for emergencies.. Major financial constraints, especially in the next two to three years. NHS England is conducting an Urgent and Emergency Care Review, led by Sir Bruce Keogh. The Phase 1 report shares many of the principles developed by the local commissioners, and has contributed to local urgent care design in Suffolk. These include the following principles: For those people with urgent but non-life threatening needs, we must provide highly responsive, effective and personalised services outside of hospital. These services should deliver care in or as close to people s homes as possible, minimising disruption and inconvenience for patients and families. For those people with more serious or life-threatening emergency needs we should ensure they are treated in the centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery. In total there were five stakeholder events across Suffolk: Town Talk Village Voices, where CCG General Practitioners and lead officers set out stalls in ten locations across Ipswich and East Suffolk, such as local swimming pools, shops and churches. Members of the public were asked what would you like the NHS to do differently if you were taken ill? and whether they had any experience of 111. The Ipswich and East Suffolk Integrated Care Network (commissioners, providers and partners) The Ipswich and East Suffolk General Practice membership at large at the Suffolk Showground. 116 P a g e

117 Patient Services The larger West Suffolk CCG Stakeholder Engagement event, which was held at Ickworth Hall. This featured members of the general public, grassroots general practice, Healthwatch and representatives from providers. The System Leadership Partnership Board (commissioners, providers, partners and the wider public sector such as District Council and Police and Crime Commissioner). A large amount of material was generated from the stakeholder events, which in totality included comments from approximately 40 break out groups across both West Suffolk and Ipswich and East Suffolk. The Urgent Care Clinical Steering Group considered the transcripts and reports of these events and identified the three most commonly recurring themes: Access. In many of the scenarios, groups commented that a greater degree of clinical input would help avoid unnecessary emergency department attendance. Some also commented that there were potentially too many access points. The need to integrate the system s response. Working through the clinical scenarios emphasised the need for the urgent care systems to be fully integrated with mental health, and that for some scenarios, it was not clear who was responding. Some stakeholders explicitly advocated reorganisation of services into a single provider or umbrella organisation. Patients who might need to be assessed quickly but not necessarily by A&E. Stakeholders identified particular circumstances (such as a feverish child, head injury and severe bladder infection) where patients might need to be seen urgently, but not necessarily by in A&E. Clinical Effectiveness Keogh (2013) sets out the case and evidence for change around 7 day working. He confirms that considerable evidence has emerged over the last 10 years linking the reduced level of service provision at the weekend and poor outcomes for patients admitted to hospital as an emergency. Reduced service provision throughout hospitals, including fewer consultants working at weekends, is associated with this higher weekend mortality rate. This suggests that a change in workforce arrangements is required to ensure that the right number of experienced and highly qualified staff is always available, alongside a change in service arrangements across the whole system to ensure the availability of support services. The evidence base for improving urgent and emergency care in England indicates that there is variation in access to primary care services across England leading to many patients accessing urgent and emergency care services for conditions that could be treated in primary care - Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal. Hospitals should therefore meet patient and public expectations by providing a consistent service 7 days a week. Various components of this strategy are supported by a broad range of public and professional bodies e.g. General Medical Council, Academy of Medical Royal Colleges, Royal College of Physicians, Royal College of Surgeons, National Institute for Health and Care Excellence, National 117 P a g e

118 Patient Services Confidential Enquiry into Patient Outcomes and Death. This programme forms part of CQUINs for 2014/15 with Ipswich Hospital NHS Trust, Suffolk Community Health and Norfolk and Suffolk NHS Foundation Trust. Impact on Overall Health Self-care for minor ailments and self-management of long-term conditions are effective at improving quality of life and reducing dependency on urgent and emergency care services (Keogh 2013). This programme is part of a major shift in the way in which people are to be treated within the NHS. It will impact specifically on mortality rates, length of stay, readmission rates and patient experience. The 10 key standards are: patient experience time to first consultant review multidisciplinary Team review shift handovers diagnostics intervention/key services mental health on-going review transfer to community, primary and social care quality Improvement It is anticipated that implementation of the above should reduce weekend mortality rates by 16%. In addition 7 day working will improve discharge planning and reduce length of stay. Readmission rates will be reduced by increased collaboration daily. People will receive an equitable service. 118 P a g e

119 Patient Services Workforce Planning Commissioners to ask the Providers to share their workforce plans with them on development of short term deliverable plans, such as Winter Planning to ensure that additional services are commissioned and provided for a specific period of time. The Commissioners to link in with the LETB for support to address significant gaps in service provision in the future across primary, community and secondary care services as part of general future proof workforce planning. To establish alternative options to skills work force, such as Nurse Consultants, GPwSI, etc. and to predict shortfalls (for example Integrated Geriatricians) and consider alternatives as part of the redesigning and embedding clinical pathways across complex health and care systems. 119 P a g e

120 Patient Services To work collaboratively with providers and develop joint training programmes across clinical networks, organisations and disciplines (for example OTAGO training) to address with gaps in service provision as part of planning and commissioning for the future. Ambulance Service As the lead CCG for commissioning the East of England Ambulance Service NHS Trust we recognise the need for the service to undertake a significant transformation programme in order to improve clinical quality safety and outcomes for patients. As a key priority designing and implementing a new model of urgent and emergency care is fundamental to managing demand, reducing avoidable admissions and ensuring the patient receives the right care, at the right time and in the right place. The role of the 999 service is integral to the successful model of urgent care, and will be a key driver in reducing demand., The Keogh review specifically refers to 999 services and the need to have the appropriate workforce it states by extending paramedic training and skills, and supporting them with GPs and specialists, we will develop our 999 ambulances into mobile urgent treatment services capable of dealing with more people at scene, and avoiding unnecessary journeys to hospital. However in order to deliver this East of England Ambulance Service NHS Trust have to undertake a significant transformation programme, the service is not meeting current performance targets, most noticeably delays in response and adequate suitably qualified workforce correlate in an inability to currently deliver a safe and effective 999 services or the benefits outlined in the Keogh review. In addition there is a need to ensure that both the 999 ambulance fleet and equipment are fit for purpose, both from a clinical quality and safety aspect, but also that equipment meets the needs of the system wide transformation agenda aligning with our vision for an integrated urgent model of care. As a CCG we therefore recognise the need to work with East of England Ambulance Service NHS Trust and other commissioners in recognising the transformation required at a large scale across the organisation, this includes recognising investment is required from our transformation fund. This will be reliant on East of England Ambulance Service NHS Trust producing a credible plan and trajectory to recover performance but most importantly providing a safe and sustainable 999 service going forward. Our main priority remains reducing current delays, including significantly reducing tail times for response and transportable provision in order to get the right and most appropriate level of care and treatment for the patient. Following a system wide risk summit in January East of England Ambulance Service NHS Trust and commissioners had a number of actions, these included reviewing the governance arrangements of the consortia including keeping one consortia, this has now been completed. There were a number of specific issues in relation to East of England Ambulance Service NHS Trust most notably addressing the key safety issues, as commissioners we have therefore agreed over and above the nationally mandated targets local tail targets, East of England Ambulance Service NHS Trust also have to deliver produce a full recovery plan with clear trajectories and milestones by the 31 st March. In addition we are proposing a number of local quality requirements that are still under contract negotiation. 120 P a g e

121 Patient Services Section Summary: Improve 7 day access/working; the overall length of stay and integrated care discharge planning within the acute & community setting. Self-care for minor ailments and self-management of long-term conditions. Provide the right care in the right place, by those with the right skills the first time. As the lead CCG for commissioning the East of England Ambulance service we recognise the need for the service to undertake a significant transformation programme in order to improve clinical quality safety and outcomes for patients. Develop a new model of Urgent Care in response to the Keogh Report. 121 P a g e

122 Patient Services Fundamental 9 A step-change in the productivity of elective care A step-change in the productivity of elective care How we will consider a new model of elective care for our local providers to achieve a 20% productivity improvement within 5 years, so that existing activity levels can be delivered with better outcomes and 20% less resource We have a strategic programme for Elective Care which supports the development of its 5 year strategy. The Efficient Elective Care Programme Board which commenced on the 20 th February 2014 has three main aims to: develop a more networked approach to care and provide more integrated services to patients ensure the long term sustainability of high quality services within Suffolk enable Suffolk to respond to the 20% elective productivity challenge made by NHS England. This programme is working on a systematic review of current service provision and use of elective care across Suffolk. It will be opportunistic where change is required. The programme is clinically led, supported by organisational buy in. A series of subgroups are being established to support the work programme and they will cover, a systematic review of current service use and provision of elective care across Suffolk that will: Agree the quality of care and the clinical outcomes we would like to see delivered across all elective care settings Assess the variation in referral patterns and service delivery, including resource utilisation, and establish the opportunities to reduce that variation. Identify appropriate opportunities for increased prevention; self-care and community based elective activity. Agree service areas with the greatest opportunities for service improvement and improved commissioning and provision efficiencies. Establish closer clinical engagement, leading to joint clinical networks, e.g. across both hospital sites and / or with primary and community care as appropriate. Ensure system resilience and sustainability, e.g. in particular specialties and in areas of workforce scarcity. 122 P a g e

123 Patient Services Establish the opportunities for different procurement approaches to improve outcomes, service integration and value for money, e.g. joint CCG procurements, total packages of care, prime contractor, local tariffs and year of care tariffs. Develop proposals for the delivery of the identified opportunities. For the first two years of this programme there are a range of projects devised to support the productivity target. Our Local Elective Care Network aims to: Lead the review and transformation of elective care services in Ipswich and East Suffolk, individual members are accountable to their respective organisation s groups (Ipswich and East Suffolk CCG Planned Care Work Stream and the Ipswich Hospital NHS Trust Elective Care Programme Board). Agree and implement a local plan for the transformation of elective care and to make recommendations to the Efficient Elected Care Programme Board. Provide operational and implementation support to the service change being developed and progressed by Clinical Networks. Ensure the learning from the diagnostic review is incorporated into the programme of work. Oversee the progress of the 2014/15 CQUIN scheme and ensure the outputs of the clinical networks link into the transformation of elective care. Engage patients / public involvement in the redesign of elective care. Produce an evaluation of elective care transformation. 123 P a g e

124 Patient Services Figure 9: Local Elective Care Network This Planned Care programme of work will be taken forwards within a locally tiered structure for delivery and accountability. To deliver 20% reduction over 5 years 124 P a g e

125 Patient Services Figure 10: Efficient Elective Care Programme Board ( associated task and finish groups) ( associated task and finish groups) (associated task and finish groups) Joint Hospital CCG The Elective Care Network is central to the coordinated local delivery. The overall aim of the project is to deliver a transformation of the whole patient pathway in line with the principles previously agreed by the group. This would deliver improved patient experience, quality, achieve cost savings and improve efficiency across outpatient and elective care which will contribute to the overall planned care QIPP target and ensure that the patient s journey is smooth, simple and safe. The Terms of Reference are sited in Appendix P a g e

126 Patient Services As part of this co-ordinated approach the Ipswich Hospital Trust and CCG have organised a series of joint events, firstly a Patient Workshop in March 2014 so they can inform on the required changes for outpatient services from a patient perspective. This will be followed at the end of March 2014 with a joint clinically-led session on outpatient transformation split into three key focus areas, see Figure 11. Figure 11: Outpatient Transformation For us, the Planned Care Workstream will lead a broad range of projects and procurements, as per Figure 12. Figure 12: Planned Care Workstream 126 P a g e

127 Patient Services A key component to successful delivery of our productivity and savings will be through the Clinical Network. See Appendix 11 for generic terms of reference. Each Network is responsible for contributing to the 2010 National Productivity Target with 4% indicated for each network in 2014/15. There are eleven Clinical Networks and the table in Appendix 14 shows the service redesign and pathways that each Network will pursue across the next two years. The Clinical Networks are supported by our CQUIN to ensure that funds are available for clinical engagement and initiatives/equipment to deliver the required change. The Clinical Network are established as a vehicle to oversee the implementation of integrated pathways across primary, community and secondary care services addressing patient need and influencing outcomes as per Figure 9. The focus of the networks is broader than just the clinical aspects and covers the following areas: Continuously improving the clinical quality of care for patients. Ensuring the best use of NHS resources. Clinically led review of existing and any proposed new pathways with redesign where appropriate of end to end pathways to eliminate waste. Reviewing and sharing best practice new technology, National Institute for Health and Care Excellence, change in practice. Managing the overall system performance in the context of ensuring health economy sustainability. The Clinical Networks will work on four levels: strategy and planning operational and delivery support and review performance monitoring and evaluation engagement and Support. 127 P a g e

128 Patient Services Section Summary: Strategic Programme: Efficient Elective Care to delivery 20% productivity through integrated models of care for long term sustainability. Local Elective Care Network: joint programmes for service transformation on Outpatients, Diagnostic Review and Elective Care Transformation CCG Planned Care Workstream: Major procurements, Referral Management, X11 Clinical Networks for service transformation, Cancer pathways, End of Life Education, Individualised 128 P a g e

129 Patient Services Fundamental 10 Specialised services concentrated in centres of excellence How our strategic plans address whether our providers are seeing and treating a sufficiently high enough volume of patients to meet specified clinical standards, in line with the need to concentrate specialised services in centres of excellence, linked to Academic Health Science Networks How our plans are ensuring that specialised services in our area are connecting actively to and maximising the opportunities of working with research and teaching Through the Suffolk System Leaders Partnership Board, we are jointly leading with West Suffolk CCG a clinically-led Chief Executive level Programme Board known as Efficient Hospitals where opportunities for networking, collaboration and economies of scale will be developed over the early months of 2014/15. The focus of the programme in the latter months of 2014/15 will be the implementation of the arising proposals, following engagement and formal consultation (where the latter is appropriate). Whilst there is no teaching hospital with which the CCG is host commissioner, Ipswich Hospital has recently been accredited as a national spinal centre. In January 2014, the Ipswich Hospital had a peer review visit as part of the process for PCI accreditation. Activity into the new centre will be in a phased manner to achieve the annual compliance level of 400 PCIs. From the range of national specialised Services, Ipswich Hospital is currently compliant across a number of services, including Specialised Endocrinology, Renal Dialysis (Hospital & Home), Rheumatology, Cancer Chemotherapy, Cancer: Teenager and Young Adults, Specialised Ear Surgery, Complex Spinal, Paediatric Oncology, Gynaecological Cancer. All these services will be reviewed for compliance with national specifications. Section Summary: Work alongside the Area Team to deliver the Specialised Commissioning Strategy. Local providers have submitted their responses to the national derogation process to determine future compliance against the new national service specifications for specialised services. 129 P a g e

130 Section Four Access Fundamental 11 Convenient access for everyone How we will deliver good access to the full range of services, including general practice and community services, especially mental health services in a way which is timely, convenient and specifically tailored to minority groups For General Practice Access Overall patients experience of accessing GP services in Ipswich and East Suffolk exceeds the England average for all indicators. 89.2% of patients were able to get an appointment to see or speak to someone as compared with the 86.4% England average. 81.1% of patients had a good overall experience of making an appointment as compared with the 76.3% England average. 63.7% of patients were able to see their preferred GP on most occasions. This is above the England average although an area for continuous improvement. Working with the Area Team and practices, we are committed to continuously improving this experience through a range of mechanisms including extending, where appropriate, the range of services to be provided in local surgeries to reduce the necessity for patients to travel to secondary care settings. We will build on investments this year in diagnostic capacity in primary care including 24hour electrocardiogram (ECG) and dementia screening. We plan to extend local contracts with GP practices to ensure equity of access to minor injuries, wound care and phlebotomy services, amongst others. We are also committed to improving significantly access to GP services for patients who are unable to travel to their practice through, for example, continuation of our proactive nursing and residential home contract and services for housebound patients. Over the next 12-months we will develop proposals for a new care system in our area which will include current out of hours, 111 and community service provision. Improvements in access and patient experience of these services and continuity of care for all patients will be key considerations in this process. As we review current services and design new services we will engage actively with representatives of minority groups through the mechanisms which we have established this year including our Community Engagement Partnership with membership from protected 130 P a g e

131 Access groups, our strong relationship with Healthwatch, Community Action Suffolk and individual organisations as well as user groups, patient and public participation groups. We will continue to ensure engagement in setting strategy, service specification development, procurement, monitoring and evaluation in order to ensure continuous improvement in access and experience. For Community Services we have an Integrated Care approach developed a programme of related projects building on work previously undertaken to mature the integrated care agenda in order to ensure that at times of urgent need, when clinically correct, all patients are supported in the community and where possible maintained at home. The objective being to improve their health and wellbeing by helping to keep people as independent and active as is possible. There is emphasis on equality by ensuring accessibility for all. This programme is underpinned by the four emerging principles for urgent and emergency care in England to deliver a system that: provides consistently high quality and safe care for all, seven days of the week is simple and guides good choices by all patients and clinicians provides the right care in the right place, by those with the right skills the first time for all is efficient in the delivery of care and services. The Integrated Care Programme supports the Joint Health and Wellbeing Strategy for Suffolk. The various projects for 2014/15 and 2015/16 includes admission prevention, alcohol and substance misuse, care homes, falls fragility and fractures, integrated neighbourhood teams, winter planning and 7 day working. All of these are indivisibly linked and will ensure good access to a full range of services from primary care, Ipswich Hospital NHS Trust, Suffolk Community Health and Norfolk and Suffolk NHS Foundation Trust in a way which is timely, convenient and specifically tailored to ensure accessibility for everyone. We have established an Urgent Care Working Group (Integrated Care Network) consisting of commissioners, providers from statutory organisations, primary care, voluntary care sector and representation from patients via Healthwatch Suffolk will oversee the delivery and performance of the various projects. This will provide the assurance process to ensure that high quality, accessible and responsive services are provided equitably to the Ipswich and East Suffolk population. Mental Health Access In 2013/14 the CCG has been working with the Ipswich and Suffolk Council for Racial Equality (ISCRE) group, to deliver dementia information workshops to the Hindu, Bangladeshi and Afro Caribbean communities. This has delivered valuable information about dementia and raised dementia awareness through workshops targeted at each community. However, the really gainful aspect of the project has been the capturing of feedback about attitudes to current services and requirements for future provision that will be 131 P a g e

132 Access summarised in a report and DVD to be produced in the next two months. This intelligence will be used to develop the integrated dementia service model for Suffolk, which is being worked up for delivery over the next two years. What we will do: We will strengthen the Primary Mental Health Worker functionality for vulnerable children across Suffolk. This will focus on delivering support and earlier intervention treatments to vulnerable children and their families with emotional wellbeing needs. We will provide timely, convenient access to key support services to help this group of children. From the Suffolk Needs Assessment data, we are aware that minority groups have a significant prevalence in this area and this will be used to apportion the extra support across the county. We will modernise our learning disability service across Suffolk, looking to further our community service provision. We are aware of key areas across the county which have a higher percentage of learning disability service users from marginalised communities and we will ensure that we work with them to address their specific needs. Our Redesign Team support the leadership of Gulshan Kayembe who is the patient and public involvement lay member of the Governing Body. Gulshan has identified one of the biggest future challenges locally is tackling mental health issues for minority groups and is actively supporting the teams to ensure associated needs are addressed in redesigning services. Section Summary: General Practice Access Overall patients experience of accessing GP services in Ipswich and East Suffolk exceeds the England average for all indicators. Investments this year in diagnostic capacity in primary care including 24hour ECG and dementia screening Various projects for 2014/15 and 2015/16 includes admission prevention, alcohol and substance misuse, care homes, falls fragility and fractures, integrated neighbourhood teams, winter planning and 7 day working. Working with the Ipswich and Suffolk Council for Racial Equality (ISCRE) group, to deliver dementia information workshops to the Hindu, Bangladeshi and Afro Caribbean communities. We will strengthen the Primary Mental Health Worker functionality for vulnerable children across Suffolk. Gulshan Kayembe who is the patient and public involvement lay member of the Governing Body has identified one of the biggest future challenges locally is tackling mental health issues for minority groups. 132 P a g e

133 Access Fundamental 12 Meeting the NHS Constitution standards Our plans include commissioning sufficient services to deliver the NHS Constitution rights and pledges for patients on access to treatment as set out in Annex B and how they will be maintained during busy periods The delivery of the NHS Constitution is written into the NHS Standard Contract which is used consistently with all our providers. Contract meetings regularly monitor the compliance with constitutional rights at specialty level and where breaches occur appropriate measures are taken to ensure performance is recovered quickly. When a specialty level breach is known a Contract Query Notice will be issued and a Remedial Action Plan meeting held within 10 operational days. Mandated contract sanctions will be applied. The Remedial Action Plan will outline both the recovery trajectory and the key actions required to recover performance. Where internal solutions are not available or not sufficiently quick to recover, Providers are expected to outsource for known capacity gaps. Where longer term capacity gaps become apparent the CCG will consider sourcing alternative suppliers. The NHS Constitution sets out a range of rights and pledges to which patients are entitled, and to which we are committed to delivering. These include: 18 Weeks The Commissioner will attend Patient Treatment List meetings as and when appropriate this may be because: there is a performance issue on going and the Commissioner needs assurance that plans are being delivered; there is a deterioration in waiting list numbers or shape which flags the risk of future concern for 18 weeks; the Commissioner decides to undertake a spot check to assure itself the Provider is managing waits appropriately. In 2013/14 our main Provider has had problems in the following areas: orthopaedics this was driven by growth in spinal activity we anticipate this has now been resolved 133 P a g e

134 Access general surgery intermittent problems have occurred in this specialty a remedial action plan is being finalised (the second in 2013/14). This aims to recover by April 2014 further assurance is needed before the Commissioner will be satisfied that sustainable recovery has been achieved oral surgery this is due to increased demand from primary care. The CCG has raised this with NHS England. Diagnostic test waiting times in 2013/14 main provider had difficulties with maintaining the 6 week target due to problems with ultrasound capacity. A Contract Query Notice was issued and performance has now recovered to 6 weeks. We will actively manage performance in 2014/15 and 2015/16. A&E waits performance against the 4 hour standard has been generally good apart from a period between August and November. A Contract Query Notice was applied and significant work undertaken to ensure recovery including extensive work over the winter period. Performance has been above 95% since December 2013 and is at 95.55% year to date. We will continue to actively manage performance in 2014/15 and 2015/16. Cancer waits (2 week wait) our main provider was above the standard of 93% all year. Performance is monitored monthly and remedial action will be taken if performance was to drop. Cancer waits (31 days) our main provider was above the standard of 96% all year. Performance is monitored monthly and remedial action will be taken if performance was to drop. Cancer waits (62 days) performance fell below the 85% target in June 2013 and is expected to fall below in January and February The Trust has shared a remedial action plan and this will be closely monitored to ensure recovery by March Category A ambulance calls category A calls resulting in an emergency response arriving within 8 minutes 75% (standard to be met for both Red 1 and Red 2 calls separately). Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95%. As part of the planning process, we will commission a sufficient level of activity to ensure the rights and pledges are met. In addition, the NHS Standard Contract details the requirement for providers to comply with the NHS Constitution. We will monitor delivery of this through monthly contractual Service Level Agreement meetings, and apply contractual consequence for providers failing to meet the mandated Operational Thresholds. These include sanctions that can be applied if planned operations are cancelled, feedback and complaints. 134 P a g e

135 Access If further escalation is required, under the terms of the contract, the provider is required to agree a Remedial Action Plan, and actions will be set out to ensure remedy accommodating demand and peaks in activity. The delivery of the NHS Constitution is written into the NHS Standard Contract which is used consistently with all our providers. Contract meetings regularly monitor the compliance with constitutional rights and where breaches occur appropriate measures are taken to ensure performance is recovered quickly. Providers are expected to outsource for known capacity gaps in the short term, where longer term capacity gaps become apparent we will consider sourcing alternative suppliers. The NHS is founded on a common set of principles and values that bind together the communities and people it serves patients and public and the staff who work for it. The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. All NHS bodies and private and third sector providers supplying NHS services are required by law to take account of this Constitution in their decisions and actions. We have embraced the seven principles that underpin the NHS Constitution: The NHS provides a comprehensive service, available to all; Access to NHS services is based on clinical need, not an individual s ability to pay; The NHS aspires to the highest standards of excellence and professionalism; NHS services must reflect the needs and preferences of patients, their families and their carers; The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population; The NHS is committed to providing best value for taxpayers money and the most effective, fair and sustainable use of finite resources; The NHS is accountable to the public, communities and patients that it serves. We have aligned our priorities (as set out on Section 3) to these principles. 135 P a g e

136 Access Section Summary: We are committed to delivering all NHS Constitution Rights. We have been focussing on those that the system finds currently challenging, 18 Weeks, Diagnostic Waiting Times, Cancer Waits and Ambulance Waiting Times Category A 136 P a g e

137 Section Five Quality Quality Statement Commissioning high quality compassionate care is at the heart of everything Ipswich and East and West Suffolk Clinical Commissioning Groups strives to achieve for the people of Suffolk Suffolk CCGs quality ambition is to: Place the established understanding of quality at the heart of everything it does to achieve commissioning high quality services through its mission statement. Develop a shared understanding and prioritisation of delivering high quality and safe care to Suffolk. That shared understanding will be all our staff, each NHS provider and our local partners including but not restricted to Local authority, voluntary sector, health watch and the care home sector. Improving quality and healthcare outcomes for patients remains the primary purpose. The cultures, values and behaviours is the first line of defence in safeguarding quality. Greater emphasis on the involvement of clinicians being at the heart of commissioning. Commissioners statutory duty and responsibility for: meeting the needs of the local population through commissioning high quality services Obtaining assurance and securing continuous improvement in the quality of commissioned services and the outcomes that are achieved. This Quality Strategy is an integral part of our overall Integrated Governance and Risk Management Strategy, outlining the structures and process that are in place to support the quality assurance and improvement framework. Quality Focus In its report Quality in the new health system maintaining and improving quality form April 2013 the National Quality Board set out its expectation that quality is the organising principle of the NHS and that a relentless focus on quality means a relentless focus on how we can positively transform the lives of the people who use and rely on our services. 137 P a g e

138 Quality Ipswich and East and West Suffolk CCGs are responsible for meeting the needs of their populations though the commissioning of high quality services and to work as part of the whole health and social care system to safeguard high quality and patient safety through integrated planning or these services. The Health and Social Care Act 2012 puts a duty on CCGs to exercise their functions with a view to securing continuous quality improvement in the quality of services and the outcomes that are achieved from this provision. In setting the bar high for quality the CCGs will work with their providers to ensure that not only do they deliver the essential standards of quality and safety regulated by the CQC, but they also strive for excellence and innovation in practice to drive up those standards for patients and their families. It is imperative that the CCGs also ensure that early warning systems both locally and in conjunction with the Area Team s Quality Surveillance Group are utilised to detect the signs of a failing service or provider organisation or where patient safety is being compromised. Early intervention with stakeholders and partners to prevent the major failings highlighted by the Francis report must be a priority for the CCGs and their systems, processes and governance. The Government s response to the Francis Report Hard Truths: essential actions outlines its commitment to a duty of candour to patients and families where care failings occur and the CCGs will promote and monitor this approach in their commissioned services. Patient Safety has also been highlighted as of primary importance by Professor Don Berwick in his report Improving the safety of Patients in England stating the NHS should Place the quality of patient care, especially patient safety, above all other aims. The CCGs will engage with the new patient safety collaborative being set up by NHS England and with the new systems for reporting and learning from patient safety incidents to prevent reoccurrence and to drive improvements in practice and service delivery. In particular the culture of reporting and learning is key to this; and the CCGs will be seeking to engage with provides to achieve this aim in relation to key outcomes. Quality Premium The Quality Premium rewards CCGs for improvements in the quality of health services they commission and for associated improvements in health outcomes and reducing inequalities. The Quality Premium paid in 2015/16 to reflect the quality of the health services commissioned by them in 2014/15 will be based on six measures that cover a combination of national and local priorities. These are: Reducing potential years of lives lost through causes considered amenable to healthcare and addressing locally agreed priorities for reducing premature mortality (15 per cent of quality premium). Improving access to psychological therapies (15 per cent of quality premium). 138 P a g e

139 Reducing avoidable emergency admissions (25 per cent of quality premium). Addressing issues identified in the 2013/14 Friends and Family Test (FFT), supporting roll out of FFT in 2014/15 and showing improvement in a locally selected patient experience indicator (15 per cent of quality premium). Improving the reporting of medication-related safety incidents based on a locally selected measure (15 per cent of quality premium). Quality Further local measure that should be based on local priorities such as those identified in joint health and wellbeing strategies (15 per cent of quality premium). Our plans represent a significant challenge and programme of change in light of the current financial climate. Part of our future funding will include a Quality Premium if we secure quality improvements against certain measures from the CCG Outcomes Indicator Set. We will be targeting the following areas to secure these additional resources: Enhancing quality of life for people with dementia, to improve Estimating the diagnosis rate of people with dementia. In 2014/15 we have identified the need to improve the diagnosis rate of people with dementia, with an increase in the dementia register. The number of patients on the dementia register in 2012/13 was 2,737, which is significantly below the suggested prevalence of 5,500. To improve the diagnosis rates we are investing in our Memory Service, so that they have capacity to see 1,600 patients per annum, which is a substantial increase on the 500 patients they assessed in 2012/13. The expanded service is scheduled to go live in quarter two of 2014/14; with the assumption of a 50% referral to diagnosis rate. It is being additionally supported with a CQUIN to support case management in primary care. However, we will be unable to meet the national mandated target of 67% by March 2015 as we will not have sufficient capacity in the new service despite increased investment. We also recognise that there is a change in culture needed in primary care to increase the referral rate from all practices and we anticipate this taking more than 12 months. We believe that we will be able to deliver 67% by March For the Friends and Family Test (FFT) to show improvement in a locally selected patient experience indicator the clinical executive has chosen to improve the experience of care for people of GP out of hours services (NHS OF 4a ii) Commissioning for Quality and Innovation (CQUIN) We are using Commissioning for Quality and Innovation (CQUIN) to incentivise shifts in quality and innovation with our main NHS Providers. It is ttypically worth 2.5% of the contract value; and must: improve quality and outcomes while maintaining financial management be an incentive to providers to deliver quality and innovation above the baseline requirements set out in the standard NHS contract 139 P a g e

140 Quality be achievable, clear and unambiguous be generated through clinical engagement. The tables below detail our schemes for 2014/15. When developing new schemes we will continue to generate them using the inclusive and co-production methodology developed with West Suffolk CCG and partners in 2012/13. Table 19: Ipswich Hospital NHS Trust CQUIN 2014/15 Name of Scheme Brief overview of key elements % of total CQUIN Friends and Family Test Nationally mandated scheme 5% Safety thermometer Nationally mandated scheme falls and pressure ulcers 7.75% Dementia Nationally mandated scheme 7.25% Psychiatric Liaison Elective transformation Deteriorating Patient Continuation of 2013/14 scheme with final evaluation of whether this will be a scheme that the CCG and acute providers wish to invest in in 2015/16 Continuation and extension of 2013/14 scheme, particularly ALL, clinical networks, surgical benchmarking, gallstone pathway Ipswich Hospital NHS Trust scheme utilising technology to monitor patients through mobile applications Shared Care Drugs To agree and document protocols for the use of shared care drugs 2.5% 7.5% 32% 6.25% 7 day working Continuation and extension of 2013/14 scheme moving towards Keogh s clinical standards and surgical/geriatric liaison End of life Training and education programme for Ipswich Hospital NHS Trust staff 2.75% 29% 140 P a g e

141 Quality Table 20: West Suffolk NHS Foundation Trust CQUIN 2014/15 Name of Scheme Brief overview of key elements % of total CQUIN Friends and Family Test Nationally mandated scheme 5% Safety thermometer Nationally mandated scheme falls and pressure ulcers 10% Dementia Nationally mandated scheme 5% Psychiatric Liaison Integrated Working Continuation of 2013/14 scheme with final evaluation of whether this will be a scheme that the CCG and acute providers wish to invest in in 2015/16 Joint scheme across all WSFT providers aiming to integrate workforce planning, share records more effectively and give common information to patients 7 Day Working Continuation and extension of 2013/14 scheme 30% 9% 17% Ambulatory Pathways Care Detailed co-production of a series of pathways relating to ambulatory care 12% Clinical forums Providing dedicated time for clinicians to discuss and design planned care pathways in a similar way to those developed in orthopaedics Shared Care Drugs To agree and document protocols for the use of shared care drugs 2% 10% 141 P a g e

142 Quality Table 21: Norfolk and Suffolk NHS Foundation Trust CQUIN 2014/15 Name of Scheme Brief overview of key elements % of total CQUIN Friends and Family Test Nationally mandated scheme 5% Safety thermometer Nationally mandated scheme falls 5% Physical illness Nationally mandated scheme 5% Psychiatric Liaison Continuation of 2013/14 scheme with final evaluation of whether this will be a scheme that the CCG and acute providers wish to invest in in 2015/ % Mental Health Input into Police responses In the east of Suffolk - Norfolk and Suffolk NHS Foundation Trust to provide mental health professionals to work with the police to respond to situations where people with mental health illness need support 7% Implementing Recovery through Organisational Change (ImROC) Piloting of the recovery college methodology with children 8.5% Integrated working Macmillan Counselling Joint scheme across all West Suffolk CCG providers aiming to integrate workforce planning, share records more effectively and give common information to patients Funding to contribute to the Macmillan pilot project seeking to evaluate the impact of counselling for patients with cancer 6% 1.2% 142 P a g e

143 Quality Table 22: Suffolk Community Healthcare CQUIN 2014/15 (Draft) Name of Scheme Brief overview of key elements % of total CQUIN Friends and Family Test Nationally mandated scheme 5% Safety thermometer Nationally mandated scheme falls and pressure ulcers 5% Dementia in the community To up skill community nurses in the care of patients on their caseload who have dementia as a co-morbidity 15% 7 Day Working Where not already contracted for and beneficial to the health system, extended services to the weekends 40% Patient Voices Integrated working In depth service user interviewing to elicit learning about patient experience and potential for improvement Joint scheme across all WSFT providers aiming to integrate workforce planning, share records more effectively and give common information to patients 15% 20% Section Summary: Using Commissioning for Quality and Innovation (CQUIN) to incentivise shifts in quality and innovation with our main NHS Providers 143 P a g e

144 Quality Fundamental 13 Response to Francis, Berwick and Winterbourne View How our plans will reflect the key findings of the Francis, Berwick and Winterbourne View Reports Our plans reflect the key findings of the Francis, Berwick and Winterbourne View Reports. Francis Report The main aims of the Francis Report recommendations are to: Foster a common culture shared by all in the service of putting the patient first. Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated. Provide professionally endorsed and evidence-based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service. Make all those who provide care for patients individuals and organisations properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service. Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do. Develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system. Following the publication of the Francis Report and subsequent related reports by Profesor Don Berwick on patient safety and Sir Bruce Keogh into 14 hospitals with higher than expected mortality rates, the Ipswich & East and West Suffolk CCGs have responded to the findings and recommendations in the following ways. We are establishing and ensuring that systems are embedded, to ensure that patterns of concern are recognised and compliance with essential standards of quality and safety are maintained. Through joint working with the Suffolk County Council and Local Area Team (NHS England) the CCGs is seeking to ensure openness, transparency and candour throughout the system about matters of concern. These are discussed regularly by the CCG s Governing Bodies and with other stakeholders, e.g. at the Local Area Quality Surveillance Group. 144 P a g e

145 Quality Contract specifications and incentives, for example CQUIN, are being used to enable improvements in local services and to encourage and enhance the local providers of services to pursue high quality effective services. The CCGs will continue to monitor quality information generated by providers collected through inspections carried out at Quality Improvement Visits and from investigations of incidents and from complaints. Providers are held to account for necessary improvements and action plans and to report on themes and trends in their Boards and Annual Reports and Quality accounts. The CCGs will continue to consult with patient forums and local representative groups. They have developed an inclusive approach to decision-making processes through Board and public meetings and other stakeholder events. Both CCGs maintain high visibility through interactions with their local communities and provider services to promote a recognisable identity which becomes a familiar point of reference for stakeholders. Berwick Report The Berwick report, published in August 2013 identified a number of key areas for improving hospital standards in England. Highlighting the need for state wide improvements the report called for patients first culture placing greater emphasis on compassion in care and transparency. The report echoes concerns underlined in both The Mid Staffordshire NHS Foundation Trust Public Inquiry and the Keogh Report, which brought into question the quality of hospital standards. In a coordinated effort to improve services every hospital in the country is to be inspected by CQC by 2015 other key points of the report include: new Ofsted-style ratings for hospitals and care homes a new Independent Chief Inspector of Hospitals and Chief Inspector of Social Care a new statutory duty of candour will ensure honesty and transparency are the norm in every organisation overseen by the CQC nurses working for up to a year as a healthcare assistant as a prerequisite for receiving funding for their degree nurses skills being revalidated healthcare support workers and adult social care workers having a code of conduct and minimum training standards. the Government has also published a revised NHS Constitution following recent public consultation. It incorporates many of the changes that were consulted on and, where possible, further changes resulting from additional suggestions heard through consultation. 145 P a g e

146 Quality the Department of Health will become the first department where every civil servant will gain real and extensive experience of the frontline. We continue to work on our response to the Berwick Report and have started to address the recommendations. All leaders concerned with NHS healthcare political, regulatory, governance, executive, clinical and advocacy should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support. The CCGs as part of the NHS will continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning. The CCGs will maintain and develop a patient safety strategy; which will be in partnership with providers across Suffolk. This will ensure learning from incidents and serious incidents is reviewed, identifying trends and themes triangulating this with other quality indicators to identify early warning signs in the system. This will involve transparency and a duty of candour to deliver continuous improvement in patient safety. Increased reporting will be paramount to this as this will be a clear indicator that each commissioned provider has a no blame culture and is using patient safety metrics as a learning tool to improve patient outcomes. The CCGs will develop models, systems, and processes for assessing and improving safety and the quality of care. Patient safety measures will be evidenced as a priority in provider contracts and for future service design. The CCGs should engage positively with Health Education East of England to ensure sufficient staff is available to the local health system in future years.. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported. We will be monitoring of capacity of organisations to deliver safe services through well trained and adequate staffing resource occurs through quality and contractual monitoring systems. The CCGs will need to ensure that the providers of services have in place adequate training and support to their staff to ensure that good quality care and patient safety approaches are adopted and are part of the service specification of its commissioned services. Further to this to support the training and education of staff through partnership working and planning through HEE and locally in relation to CPS e.g. contract with HEIs (UCS). Patients and their carers should be heard and have a powerful presence and are involved at all levels within healthcare organisations and having an impact from board of trust to the ward and frontline services. The CCGs through Quality reporting and monitoring are assured that each commissioned provider has clinical governance structure in pace to rigorously challenge patient safety and clinical quality when it is falling below acceptable standards The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS. 146 P a g e

147 Quality Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public. Our performance packs relating to provider and CCG performance are available for public meetings and each CCG s website. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care. The CCGs should and seek continuous improvement through the complaints process; the system should be easy to access, should welcome and respond positively to complaints. All complaints should be investigated thoroughly being transparent to the patient and their family using a coordinated approach with other agencies if care has overlapped. The CCGs will seek to use the patient voice to improve the quality and safety of care. We promote a duty of candour implemented by providers alongside public involvement in service redesign and scrutiny The CCGs will monitor the implementation of patient safety alerts issued through NHS England in monitoring of its local contracts and quality measures with providers. The CCGs will ensure they collaborate in the use and requests for information from providers in support of quality, safety and regulation by CQC e.g. through quality surveillance groups and shared intelligence. It will utilise datasets and metric available through the NHSIC to monitor and benchmark the quality of local services. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment. Winterbourne View In response to Winterbourne View we will: In response to Winterbourne, the cohort of Suffolk winterbourne clients has been reviewed as per winterbourne concordat. All clients have had a joint review by their CCG, Norfolk and Suffolk NHS Foundation Trust and Suffolk County Council and all have discharge dates and supported to access supported living arrangements in Suffolk where appropriate. A joint winterbourne sub group will feed into a joint commissioning forum to ensure the needs of the learning disability clients within Suffolk have the right services in place to ensure they are supported to live as independently as possible. 147 P a g e

148 Quality The winterbourne concordat will also provide a backdrop for improving services for other vulnerable groups including children and young people. Section Summary: Our plans will reflect the key findings of the Francis, Berwick and Winterbourne View Reports 148 P a g e

149 Quality Fundamental 14 Patient safety How we will address the need to understand and measure the harm that can occur in healthcare services, to support the development of capacity and capability in patient safety improvement How we will increase the reporting of harm to patients, particularly in primary care and focused on learning and improvement The Suffolk strategy focuses on the three domains of quality defined in High Quality Care for All (2008): 1. Safety: do no harm keep patients as safe as possible; 2. Effectiveness: success clinically effective and cost effective treatments; and 3. Patient experience: quality of caring understanding patient satisfaction through their experiences. Suffolk s strategy also reflects the five domains of the NHS Outcomes Framework (2011): Preventing people from dying prematurely; Enhancing quality of life for people with long-term conditions; Helping people recover from periods of ill health or following injury; Ensuring people have a positive experience of care; and Treating and caring for people in a safe environment; and protecting them from avoidable harm. We will: Commission services that are safe, clinically effective and support a positive care experience. Design an evidence-based dashboard for our Governing Body that provides both assurance and early warning of quality concerns in commissioned services. Review the quality assurance mechanisms that are in place across the range of commissioned services and ensure appropriate quality monitoring and governance arrangements are in place. Develop a systems wide professional and public communications campaign for harm free care. 149 P a g e

150 Fully implement the Clostridium difficile reduction plan. Commission 100% use of high impact intervention. Quality Work with health care regulators, Suffolk County Council, Healthwatch Suffolk and other commissioners to share information and support continuous quality improvement. Develop and implement a commissioning Infection Prevention and Control Strategy. The scrutiny of information and metrics reported to us includes the safety thermometer, never event and serious incident data and the other quality metrics will enable the consideration of emerging themes and trends in patient safety and harm to patients. We will cooperate with and participate in the emerging patient safety collaborative being set up by NHS England whose aim is to provide a network of patient safety learning and improvement to continually improve care at the front line and to reduce the likelihood of harm to patients. The increase in reporting of harm and in particular the reporting of medicines related incidents will be promoted through contractual and quality improvement discussions with providers and stakeholders. Monitoring levels of reporting through the NRLS system and through Serious incident reporting routes will support the NHS Outcomes framework aim of higher reporting and the emergence of diminishing levels of harm are achieved by providers of services through the application of best practice and innovative approaches to service delivery, e.g. pressure ulcer prevalence. We will optimise the use of root cause analysis of all incidents including those in the infection control review process for MRSA and C Difficile to identify lessons learned and action required to prevent recurrence. We will actively participate in quality surveillance group to identify early warnings of service and quality failings in order to address the risks to patient that they potentially raise. Section Summary: Fully implement the Clostridium difficile reduction plan Develop and implement a commissioning Infection Prevention and Control Strategy To work with provider to increase the reporting of harm and in particular the reporting of medicines related incidents Work with health care regulators, Suffolk County Council, Healthwatch Suffolk and other commissioners to share information and support continuous quality improvement. 150 P a g e

151 Quality Fundamental 15 Patient Experience How we will set measureable ambitions to reduce poor experience of inpatient care and poor experience in general practice How we will assess the quality of care experienced by vulnerable groups of patients and how and where experiences will be improved for those patients How we will demonstrate improvements from FFT complaints and other feedback We will encourage feedback and value the role of patients and healthcare professionals in shaping, monitoring and improving services The CCG will continue to report, monitor and provide feedback regarding concerns raised by the public and other agencies. Use patient stories at all levels of the organisation to illustrate patient experience and to determine commissioning intentions. Provide a framework and training to support involvement of CCG members, lay personnel, GP practices and patients in quality assurance processes e.g. mystery shoppers and involvement in quality improvement visits Utilise Patient Advisory Groups, Patient Reference groups and other community groups to support patient experience feedback Quality dashboard reporting will assure each provider is performing against agreed metrics. Patient experience metrics will be triangulated with other quality indicators such as patient safety reporting and will have a high profile through quality sub group meetings for each contracted provider. Safeguarding remains a priority for us; ensuring compliance against legislation and national and locally agreed policies. A Safeguarding dashboard will assure commissioners that reporting thresholds are robust, investigations are transparent and ensure learning is continuous to ensure the vulnerable achieve the best possible care and robust information sharing processes are in place providing a seamless transition between services. Patient experience metrics are reviewed contractually for all commissioned providers identifying trends and themes of the complaint and whether there are month on month improvements. Evidence is provided through ward to board that complaints and patient voices remain an integral part of business. FFT is applicable to all providers, inpatient areas, A&E, paediatrics, obstetrics and gynaecology and outpatient clinics. 151 P a g e

152 Quality An increase in the number of patients asked is being incentivised through the national CQUIN for 14/15. This will include FFT staff surveys, as well as annual staff surveys and recruitment that are focused on each organisations values and behaviours. Our quality improvement visit programme also focuses on feedback from patient and staff ensuring whistleblowing policies are known and understood and staff trusts the organisation has a no blame culture. Our CQUIN for FFT is driving zero detractors and this will be concentrated within inpatient areas of all providers. This will provide an opportunity for providers to review patient safety clinical quality and patient experience metrics to improve the overall patient satisfaction in their experience of care. Patient experience of vulnerable patients will be improved through learning from serious incidents and serious case review findings. Joint working with Suffolk County Council to ensure admission prevention strategies and early supported discharge is in place. Liaison nurses for Psychiatry, learning disabilities and dementia forms part of the strategy of both CCGs. Development of specific feedback mechanism related to each vulnerable group will be integral to capture issues important to them as well as capturing carer feedback. Through adult safeguarding forums and information sharing mechanisms with Healthwatch Suffolk, CQC, Suffolk County Council and both CCGs will continue and strengthen by joining quality monitoring of providers, particularly in the care home sector and supported living. We will continue to review all patient experience feedback from both the provider and CCGs which are reported monthly through performance reporting to both Clinical Executive and Governing Bodies. We will monitor staff feedback more consistently through the FFT test will provide an opportunity to monitor improvements month on month, work with providers to identify areas of concern and triangulate with patient safety and patient experience metrics. Also because this is a national initiative the ability to measure against other providers will be an added bonus, however each provider will need to provide information from staff to ensure improvements are being made. 152 P a g e

153 Quality You Said We did Equality Delivery System new equality objectives You said on the basis of the evidence presented and discussion both the CEP and CEG representatives were invited to give an overall grade of either red (undeveloped); amber (developing); green (achieving) or purple (excelling). Their overall conclusion led us to the development of our new equality objectives that can be seen on our website at: ydeliveryobjectives.aspx We did Moving into the the new evidence process will be undertaken in conjunction with Ipswich Hospital, West Suffolk Hospital, Norfolk and Suffolk NHS Foundation Trust, Serco and East Anglia Ambulance, so that the recipients of the evidence can see the entire pathway of evidence and how each of the providers work affects the other. Both the CEP and the CEG believed that in order to see the whole evidence picture ensuring a more rounded grading process if the CCGs EDS evidencing process was performed in partnership with our health care partners. 153 P a g e

154 Quality CEP feedback Self Care event Self Care leaflets You said Following the successful engagement event in 2013 on self-care, communication was the recurring subject that the participants taking part in the event wanted for the CCG to improve upon: Leaflets need to be tailored to suit different needs Make it easy for people to look after themselves with simple information, that s easy to access. We did Since the event the medicines management team at the CCG has developed self-care leaflets ranging from head lice to athletes foot, these leaflets have been circulated across the areas GP surgeries and are soon to be disseminated across the Suffolk libraries and schools. Community need for Dementia friendly environment You said The new service model has been developed to respond to stakeholder concerns about delays in access, location of provision, role of the local GP and timeliness of referral. We did A new community memory assessment service will be launched during The new service will be consultant led and delivered in 10 primary care locations across our area. Assessment will be carried out by specialist dementia nurses with diagnosis clinics being held in GP practices. The real innovation is diagnosis and follow-up being provided by an Norfolk and Suffolk NHS Foundation Trust consultant / associate specialist working alongside a local GP with special interest. This means that diagnosis and follow up will be delivered by consultant or by a local GP working with the onsite support of the secondary specialist. Translation of CCG materials with a more diverse range of languages You said Through regular engagement undertaken by the CCG with our partners, patients and the public it became abundantly clear that there was a need for many of the CCGs leaflets and promotional material especially around keeping you and your family well to be translated in a range of languages to meet the need of the local community. This is something that both the BME and Diversity Group and the Ipswich and Suffolk Council for race equality have previously identified as a need. We did The CCG has now translated leaflets in the top ten most requested translations (through language line) ranging from Romanian and Bengali to Kurdish and Lithuanian. 154 P a g e

155 Quality Website public consultation You said website users told us that the website was difficult to navigate, complicated and it was hard to find specific documents. We are now in the process of updating the content and shape of our website. It is not only important to ensure the content is relevant and fresh, but also well crafted, so feedback from our users was paramount to help aide this. They also told us that the website didn t comply with the accessibility guidelines. We did The CCG sent out a survey via survey Monkey to our GP practices, Community Engagement group, stakeholders and I&ESCCGforum. We also advertised the survey via a pop up on our website. A Task and Finish group was established to encourage feedback and opinions which included members of the public and GP practices. A total of 136 surveys were completed and fed back, giving us an excellent foundation to work from. Joined up care Joint formulary (Primary care & Ipswich Hospital NHS Trust) You said Currently both primary and secondary care use different formularies. GPs raised their concerns about this inconsistency as patient care is adversely affected if doses are missed or medication is frequently changed. We did The joint formulary is a new initiative between the CCG and the Ipswich Hospital NHS Trust which aims to reduce prescribing inconsistency and smooth the transfer of patients between primary and secondary care. Development of the joint formulary is underway, and doctors, nurses and pharmacists from both care sectors are involved. 155 P a g e

156 Quality VCS Engagement Strategy You said Through a number of our engagement events, including our most recent Town Talks, Village Voices there was a shared desire to Bring voluntary sector closer, make sure GPs are aware of voluntary schemes. We did This consistent feedback has led the CCG to develop a Voluntary and Community Sector engagement strategy that has been jointly agreed by the Suffolk Congress (a collaborative network which is open to all voluntary and community sector groups in Suffolk) which is very much led by the need to bring GPs, commissioners and the VCS together in order to learn more about the work each sector undertakes in Suffolk. More information to families and children You said Patients and the public of Suffolk felt that it was young families and schools that were often missing with the engagement undertaken by the CCG. We did As part of our winter engagement plan each student at every primary and nursery schools across East Suffolk received a letter from the CCG promoting and raising awareness of the 111 service and how to keep well over the winter period. Care in the community Child and adolescent mental health services You said Parents of young people with mental health felt there was a need for better community services to support parents, a need for community interventions and a programme that helps to promote self-management of specific mental health conditions. We did The CCG has been working with West Suffolk CCG, Norfolk and Suffolk NHS Foundation Trust and other stakeholders to develop the Resilience Hub concept. This is a local approach that will strengthen the delivery of primary care mental health services. The approach focuses on supporting other professionals, particularly in schools, and creates a new role that will specialise in providing therapeutic interventions. The Hub recognises the role and contribution many services make to children s emotional wellbeing and promotes partnership, for example in the development and delivery of parenting programmes. 156 P a g e

157 Quality Section Summary: Friends and Family Test (FFT) is applicable to all providers, inpatient areas, A&E, paediatrics, obstetrics and gynaecology and outpatient clinics. Quality dashboard reporting will assure each provider is performing against agreed metrics, including Patient experience metrics. Patient experience of vulnerable patients will be improved through learning from serious incidents. Safeguarding remains a priority for each CCG; ensuring compliance against legislation and national and locally agreed policies. 157 P a g e

158 Quality Fundamental 16 Compassion in practice How our plans will ensure that local provider plans are delivering against the six action areas of the Compassion in Practice implementation plans How the 6Cs are being rolled out across all staff Over the last few years there has been an increasing perception that the caring dimensions have been focused on targets, financial constraints, reduction in length of stay, increased acuity and technical competence (DH 2005; Burdett Trust for Nursing 2006; London Network 2007; Help the Aged 2008; Healthcare Commission 2009; Patients Association 2009) Alongside this has been a perception within the nursing profession that nurses have lost their way (Maben & Griffiths 2008). Addressing compassion in practice is fundamental to the approach we are taking to commissioning from all its providers across all settings and in developing integrated working with local stakeholders in social care and the voluntary sector. The Parliamentary and Health Service Ombudsman in 2011 in the report Care and Compassion highlighted gaps in the promise of care and compassion and the personal experiences of in particular older people accessing NHS care. We continue to develop its community and patient involvement strategies to ensure that the vision and culture underpinning the 6c s are reflected across the health and care sector for the Suffolk population in its planning and design of services. This has led to Compassion in Practice, the new three year vision and strategy for nursing, midwifery and care staff. The vision is based around six values care, compassion, courage communication, competence and commitment. The vision aims to embed these values, known as the Six C s, in all nursing, midwifery and care-giving settings throughout the NHS and social care to improve care for patients. Suffolk s strategy aligns to the national vision for nursing as described in Compassion in Practice and provides the opportunity for discussion at local level to plan how the vision will be realised. It outlines ways that individuals, teams, managers and organisations can demonstrate and embrace the six values (care, compassion, competence, communication, courage and commitment) and the actions that go alongside them. Specific areas are identified to work on to help these behaviours become embedded in practice. Nursing is a major component of nearly every healthcare service that we commission from our providers including hospitals, community services, mental health care, nursing homes or care provided in the home. We recognise that nurses, midwives and care staff will lead or support many of the changes needed for us to realise our ambitions. 158 P a g e

159 Quality We will ensure that all of our providers focus on the Six C s putting the person being cared for at the heart of the care they are given. Where our population is in need of NHS services we will seek to guarantee that they are respected and involved in care decisions, treat with dignity by a workforce who are competent, committed and have the courage to act as the patient advocate at all times. Each provider are developing value based recruitment, staff surveys as part of the Friends and Family test ensuring a workforce has high morale to deliver safe and effective care. A recent internal audit reviewing systems and processes has highlighted areas to strengthen within the governance arrangements for the CHC team. Local policies and procedure in conjunction with other NHS providers, local authority and other relevant partners are in progress. Robust data capturing will provide us with clear evidence how we are conforming to the national Framework for NHS Continuing Healthcare particularly around assessment within 28 days of referral and identifying the rationale behind each case that has fallen out of that KPI. Monthly reporting to the Clinical Executive highlights how we deliver the process, the capability and capacity of the team, the training provided to other key stakeholders and Continuing Healthcare (CHC) staff. A recent review of the IT system and development of a report will identify clinical and financial risk to both the clinical exec and governing body on a monthly basis. We will work with providers of education to ensure that compassion in practice is a key component in education and training for all staff and that raising awareness in the workplace and settings were service users access care are prominent. Section Summary: We will ensure that all of our providers focus on the Six C s putting the person being cared for at the heart of the care they are given (care, compassion, competence, communication, courage and commitment) To strengthen the governance arrangements for the CHC team The CCG will work with providers of education to ensure that compassion in practice is a key component in education and training for all 159 P a g e

160 Quality Fundamental 17 Staff satisfaction An in-depth understanding of the factors affecting staff satisfaction in the local health economy and how staff satisfaction locally benchmarks against others How our plans will ensure measureable improvements in staff experience in order to improve patient experience Staff satisfaction as a metric is not only necessary for healthcare providers to encourage staff engagement (the process by which staff comes to have a positive attitude towards the organisation and its values) but to accelerate it; evidence from a wide range of sources, highlights that: Patient satisfaction is consistently higher in trusts with better rates of staff health and wellbeing. There is a link between higher staff satisfaction and lower rates of mortality and hospital-acquired infection. Stress and burnout are more frequent in the NHS than in other sectors. Approximately 30% of sickness absence in the NHS is due to stress. Steps we can take to increase staff engagement include: Articulating values in plain English and showing how they translate into behaviours, this forms part of compassion in practice, with value based recruitment. Giving frontline staff the voice to implement changes to services and solutions to problems when they arise. Train staff to be able to deliver care in an emotional setting, allowing training for reflective practice. Developing leaders ensuring they have the right management skills. This will include clinical staff. Staff voices are heard through annual surveys but the development of Friends and Family Test ensure the staff voice is heard continuously. This will provide a staff voice identifying trends and themes and the ability to triangulate this information with other quality and safety metrics provide live measurement of both staff and patients. The Quality Improvement visit programme represents an opportunity for commissioners to fulfil their duty to patients and the public for the quality of commissioned services by: 160 P a g e

161 Connecting with patients, carers and staff at the point of care. Further developing relationships and understanding between clinical commissioners and providers. Developing a better understanding and experience of the care environment that has been commissioned. Quality Enabling commissioners to triangulate evidence of adherence to care standards, achievement of Suffolk-wide Harm Free Care, CQUINS, Patient Experience and staff satisfaction. We have comprehensive appraisal process that supports our objectives. The personal development needs are collated by HR and used to develop the CCG training plan. Our staff undertakes surveys relating to EDS2, Behaviours and Values and through a number of staff engagements groups; Staff Partnership Forum, Great Big Ideas, OD Group and Staff Away day Group has an in-depth understanding of the factors affecting staff satisfaction in the local health economy. In-terms of staff satisfaction locally, we were being benchmarked against the Investors in People Standards. In 2013 we were recognised as one of the top ten NHS organisations at the HSJ Annual Awards for Staff Engagement. Following the Staff Away Days we survey our staff on their thoughts and views of the Away Day. Two of the speakers, at the 2013 away day were patient representatives Ipswich Hospital User Group and West Suffolk PPI. We have delivered a range of workshops, all day, half day and Lunch and Learn (1 hour) on a range of areas that includes; The Francis Report; Stress Awareness; Communication Skills; Integrated Service Planning to mention a few. At the Governing Body meetings, this includes employees. Patients tell their stories of their experiences of NHS Services, which influence the design of services. Appraisal objectives and development needs are reviewed regularly to ensure that staff members are online to meet their objectives and development needs. The Knowledge and Skills Framework (KSF) outlines provide clear and coherent standards that relate to the CCG objectivess this work is supported by the findings of Borrell and West, which says that there is a clear correlation between patient outcomes and employee engagement and satisfaction. The plans ensure that there will be measureable improvements in staff experience in order to improve patient experience. How will this happen? The values and behaviours have four dimensions: Integrity, Respect, Enabling Excellence, and Patient Centred. All employees have embedded in their PDR the aforementioned behaviours, by focusing employees objectives and personal development plans, particularly around Enabling Excellence, Patient Centred using user feedback from GP Practices, User Groups, 161 P a g e

162 Quality Locality meetings, 360 feedback for Chief Officers, Public Engagement Events (You said, We did), Service Redesign (Evaluation) Staff survey as tools for benchmarking and to obtaining patient feedback. The CCG will be able to evaluate whether the staff forums, the embedding of EDS into Chief Officer PDRs, the training needs interventions, storytelling and user feedback of the Continuing Healthcare Service have; improved the patient experience. Section Summary: Steps we can take to increase staff engagement include: Articulating values in plain English and showing how they translate into behaviours, this forms part of compassion in practice, with value based recruitment. Giving frontline staff the voice to implement changes to services and solutions to problems when they arise. Train staff to be able to deliver care in an emotional setting, allowing training for reflective practice. Developing leaders ensuring they have the right management skills. This will include clinical staff. 162 P a g e

163 Quality Fundamental 18 Seven day services That the action plans submitted by our providers (a requirement within the Service Development and Improvement Plan section of the NHS Standard Contract) give you confidence that they will be able to comply with all ten of the Seven Day Service Clinical Standards by 2016/17. If not, how our strategic and operational plans are going to ensure these standards are being met for patients. How our strategic plans are addressing the need to provide consistently high quality urgent and emergency care services outside of hospital across the seven day week. What we will do: We are investing 1m through CQUIN in the acute sector to assess baselines and make significant progress towards each of the 10 Standards in 2014/15. It is highly likely this will be repeated in 2015/16 to enable compliance by 2016/17. Norfolk and Suffolk NHS Foundation Trust and Suffolk Community Health will be required to develop a plan for delivery of the standards that directly relate to them. They also have CQUIN schemes relating to 7 day working and psychiatric liaison. Ipswich Hospital NHS Trust are incentivised to do this through the CQUIN which is likely to be a 2 years scheme, if they don t meet the milestones in the CQUIN they don t get paid. The CQUIN is the change driver, the trust is clear that 7 day working is required through the Keogh report. Certain services are 24/7 already e.g. stroke. At a Clinical Executive meeting it was agreed there is likely to be a transformation pot which will be used on joint WSH/Ipswich Hospital NHS Trust services so likely more services will be 24/7 across the 2 trusts. Psychiatric Liaison and 7 day working We will commission further work to embed and further develop the psychiatric liaison service in Ipswich Hospital. This new service was established in 13/14 to provide a prompt single point of triage and assessment for patients presenting in A&E (and inpatients), to provide specialist assessment and treatment for patients with suspected or confirmed mental health, alcohol / substance 163 P a g e

164 Quality misuse and psychological needs. The team are an integral part of the improved pathways of care between acute settings and appropriate mental health and other related community services. They are available to facilitate prompt discharge, with community support where required, once acute physical needs have been addressed. They work in partnership with other agencies to manage the care of people who re-attend frequently at hospital, managing their needs appropriately to reduce further re-admissions. The service is covered 7 days a week from 7am to 9pm and works closely with the Norfolk and Suffolk Foundation Trust s Access and Assessment Team which is covered 24/7. The key performance indicator targets for 2014/15 are: What we will do To meet the standards for Seven Days a Week working where a mental health need is identified following an acute admission, the patient must be assessed by psychiatric liaison within the appropriate timescales 24 hours a day, seven days a week: Within 1 hour for emergency care needs* Within 14 hours for urgent care needs** * An acute disturbance of mental state and/or behaviour which poses a significant, imminent risk to the patient or others. ** A disturbance of mental state and/or behaviour which poses a risk to the patient or others, but does not require immediate mental health involvement. During 2014/15, the service will also provide detailed local data about the scope and potential impact of psychiatric liaison treatment for long term conditions to include COPD, medically unexplained symptoms and diabetes. There will also be a strengthened focus on children from ages This service is funded via CQUIN money and the intention throughout 2014/15 will be to provide strong evidence and outcomes to evaluate its impact and clinical effectiveness in order to support future mainstreaming of the service from 2015/16 onwards. Activity levels For acute contracts we will: Continue to support the national Payment by Results (PbR) structure but move to local tariff options were appropriate and permitted. Review block services with a view to transfer to cost and volume/ develop robust service specifications where appropriate. Review day case procedures expected to be done as OP procedures and specify commissioning levels. 164 P a g e

165 Require compliance with national guidance over recording of day cases versus outpatient procedures. Require compliance with 2014/15 payment by results guidance and national data definitions. Quality Develop pathways for outpatient services to achieve maximum efficiency and quality of care, e.g. one-stop clinics, multidisciplinary clinic, parallel clinics and triage to most appropriate clinics. Review maternity pathways to ensure compliance with PbR rules and no duplication of payments. Identify potential services eligible for Best Practice tariffs and agree plans/timetable for introduction (must have adequate supporting information). Review of tariffs for urgent and emergency care which may require local tariffs to be developed and agreed (including, but not limited to, short stay emergency paediatric admissions). We will work with providers to explore opportunities for incentives for managing internally generated demand. Clinical Effectiveness Professor Sir Bruce Keogh (2013) set out the case and evidence for change around 7 day working. Considerable evidence has emerged over the last 10 years linking the reduced level of service provision at the weekend and poor outcomes for patients admitted to hospital as an emergency. This reduced service provision throughout hospitals, including fewer consultants working at weekends, is associated with the higher weekend mortality rate. This suggests that a change in workforce arrangements is required to ensure that the right numbers of experienced and highly qualified staff are always available, alongside a change in service arrangements system-wide to ensure the availability of support services. CQUINs have been developed locally for 2014/15 with Ipswich Hospital NHS Trust, Suffolk Community Health and Norfolk and Suffolk NHS Foundation Trust relating specifically to the development and implementation of 7 day working. Impact on overall health 7 day working is part of a major shift in the way in which people are to be treated within the NHS. It will impact specifically on mortality rates, length of stay, admission and readmission rates and patient experience. The 10 key standards are: Patient experience patients and families and/or carers must be actively involved in shared decision making. Time to first consultant review all emergency admissions must be seen and have a thorough clinical assessment by a consultant within a specific timescale. 165 P a g e

166 Quality Multidisciplinary Team review all emergency admissions must be assessed by an MDT within a specific timescale, overseen by a competent decision maker. Shift handovers handovers should be conducted at a designated time and place and should be facilitated by a competent decision maker. Diagnostics inpatients must have scheduled access to 7 day diagnostics services within specific timescales e.g. x-ray, ultrasound, computerised topography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology. Intervention/key services timely 24 hour access, seven days a week to consultant directed interventions. Mental health where a mental health need is identified following acute admission, patient assessment by psychiatric liaison is undertaken within specific timescales. On-going review all patients on high dependency areas must be seen and reviewed by a consultant twice daily, when stepped down to general ward review by consultant once daily. Transfer to community, primary and social care support services within the acute hospital, primary care, community and mental health must be available 7 days a week. Quality Improvement all those involved in care delivery must participate in the review of patient outcomes to drive forward quality improvement. It is anticipated that implementation of the above standards should reduce weekend mortality rates by 16%. In addition 7 day working will improve discharge planning and reduce length of stay. Admission prevention and readmission rates will also be reduced by increased collaboration with primary, community and mental health. What we will do Impact on health inequalities This programme is mandated by the Government. We have developed CQUINs with Ipswich Hospital NHS Trust, Suffolk Community Health and Norfolk and Suffolk NHS Foundation Trust around 7 day working, it is anticipated that 7 day working will be part of baseline core services for providers by 2016/17. Inequalities will be addressed by ensuring that people receive a consistent and equitable service 7 days a week in contrast to the current 5 day a week culture. The co-joined focus on acute, primary, community and mental health will ensure that services are delivered in a timely and convenient way, which is specifically tailored to all minority groups. 166 P a g e

167 Current Benchmarking Quality Access to urgent GP appointments across England is variable and, in urban areas where demand is high and transient populations exist, many may use an A&E department as their first point of urgent and emergency care. Between 10 and 30 per cent of patients attending A&E departments are thought to present with conditions that could have been resolved in primary care (Carson D et al 2010). Implementation and cost effectiveness The costs for 7 day working will be met through CQUIN payment and will provide superior health outcomes for people within our area. The Keogh Report indicates that the current model of care will result in a funding gap of 30 billion between 2013/14 and 2020/21 (approximately 22% of projected costs in 2020/21). In this context, NHS providers and their commissioners face difficult choices when deciding where to invest their resources to ensure best outcomes for patients and value for taxpayers (NHS England 2013). However 7 day working is deemed achievable with minimal investment if services reviewed and reconfigured. This project is part of a series of related projects building on work previously undertaken to develop and integrate admission prevention schemes in order to ensure that at times of urgent need, when clinically correct, patients are supported in the community and where possible maintained at home. The objective being to improve their health and well-being by helping to keep people as independent and active as is possible. The series of projects aim to achieve a 15% reduction in A&E attendances and non-elective admissions over 2 years (excluding <19 years, maternity, obstetric and reproductive health, and oncology) equating to 7.2m across the CCG) (6% 2014/15 and 9% 2015/16). The Integrated Care Programme supports the Joint Health and Wellbeing Strategy for Suffolk. The various projects for 2014/15 includes admission prevention, alcohol and substance misuse, care homes, falls fragility and fractures, integrated neighbourhood teams and winter planning. In addition there will be particular emphasis on the establishment of 7 day working across the system. The integrated care programme aims to support practitioners to optimise the clinical management of patients resulting in the reduction of A&E attendances, reduction of unnecessary admissions; reduction in length of stay, reduction in readmissions, improvement in patient flow and better patient experience. The programme will be delivered as part of a system-wide approach to reducing urgent care demand in partnership with stakeholders through the Integrated Care Network. 167 P a g e

168 Quality Section Summary: We are investing 1m through CQUIN in the acute sector to assess baselines and make significant progress towards each of the 10 Standards in 2014/15. Norfolk and Suffolk NHS Foundation Trust and SCH will be required to develop a plan for delivery of the standards that directly relate to them. They also have CQUIN schemes relating to 7 day working and psychiatric liaison. 168 P a g e

169 Quality Fundamental 19 Safeguarding How our plans will meet the requirements of the accountability and assurance framework for protecting vulnerable people. The support for quality improvement in application of the Mental Capacity Act. How we will measure the requirements set out in your plans in order to meet the standards in the prevent agenda. The Suffolk wide system has reviewed its adult safeguarding strategy as well as developing a system wide action plan of implementation. This will include information sharing mechanisms and aligning clinical incident and serious incident reporting to Suffolk County Council. Identifying reporting thresholds in line with the DH, No Secrets guidance which is facilitated by the health sub group chaired by the CCGs. Adult safeguarding training will be standardised against the Bournemouth competency framework. MCA/DOLS competency framework will be developed and rolled out as a Suffolk wide system within health. Reporting mechanisms in the form of KPIs will be clearly set out in each contract with providers and reporting on all aspects will take place monthly. QIV review safeguarding systems and processes as well as asking staff and patients for feedback. Safeguarding referrals and lack of reporting will be monitored through quality sub group meetings that fit within the contractual process. Workshops and training to raise awareness of the Prevent strategy within the healthcare will take place with a DVD-based training package called HealthWRAP Workshop to Raise Awareness of Prevent. A workshop, aimed at any NHS staff; front line staff, managers and clinicians, is designed to help make them aware about their contribution in preventing vulnerable people being exploited for terrorist purposes. The workshop will improve the understanding of the processes used by terrorists to radicalise individuals and ensures staff are aware of who to contact within their organisation to discuss any concerns. Numbers of staff who access this training will be monitored through the contractual process. 'Preventis part of the Government s counter-terrorism strategy CONTEST, which is led by the Home Office. The health sector has a non-enforcement approach to Prevent and focuses on support for vulnerable individuals and healthcare organisations. The 169 P a g e

170 Quality Department of Health and the health sector are key partners in working to prevent vulnerable individuals from being drawn into terrorist-related activities. Following the pilot phase, most healthcare organisations at local level concluded that since Prevent is about recognising when vulnerable individuals are being exploited for terrorist-related activities, it follows that it is most appropriately managed within existing safeguarding structures, working closely with emergency planning. Situating Prevent within safeguarding enables the programme to continue regardless of future changes to the NHS organisational structure. It is also in line with wider attempts to mainstream Prevent in other government sectors. We have two measurements would be undertaken by provider organisations The providers toolkit/ audit and % staff received 'prevent awareness 'training as part of safeguarding training. the support for quality improvement in application of the Mental Capacity Act how you will measure the requirements set out in your plans in order to meet the standards in the prevent agenda Vulnerable Children form part of the Safeguarding children project and the Safeguarding project supports the Safeguarding Vulnerable People in the Reformed NHS; Accountability and Assurance Framework However Vulnerable Adults have not yet been addressed Adult safeguarding is similar to safeguarding children and young people as Suffolk County Council leads as the statutory agency. The adult safeguarding board hosted by the local authority has membership of all key stakeholders which includes membership of both commissioners and providers. The lead for safeguarding represents both Suffolk CCGs at the partnership board and chairs a health sub group to provide assurance of safeguarding processes across all commissioned services is in place whilst driving the health agenda influencing the partnership in key strategy areas for future development. The health sub group also ensures key actions from the partnership are driven forward. Information sharing practices are being evidenced through joint working and reporting of safeguarding issues through clinical quality reports for all providers to ensure key learning points and system wide learning is implemented. Increased surveillance of all commissioned providers through quality improvement visit programme provides assurance that adult safeguarding processes, reporting, training and education is in place and recommendations for improvements are monitored through quality sub meetings that fit into the monthly contractual review process. Information from these visits is shared openly with the Suffolk County Council and the CQC to promote a system wide response to areas of concern or to disseminate good practice. 170 P a g e

171 Quality Serious incident reporting from NHS providers is shared with adult safeguarding of the local authority to ensure how root cause analysis and lessons learned and implementation of are robust and provides the partnership board that health investigations identify change in practice to improve the overall patient experience. Suffolk has two lead GPs that provide clinical leadership for Adult safeguarding, they assist with the strengthening of safeguarding processes within Primary health care, raise awareness of the safeguarding agenda, identify education opportunities, provide advice and support to GPs and monitor outcomes and action from investigations. All commissioned providers are undergoing a self-assessment to review adult safeguarding policies and procedures and education and training. This will be reported to the health subgroup developing actions plans with each provider which will feed into the adult safeguarding board work plan. A self- assessment on all clinical staffs understanding of the mental capacity act and DOLs will coincide with this self-assessment and education and training will be developed Suffolk wide to address the training needs identified. All providers are currently suing the SCIE guidance around MCA and DOLS and all providers have an induction programme for all new starters as well as having yearly updates. The self-assessment will be completed by June 30 th and reported to the August meeting of the Safeguarding Adults Board. Section Summary: Suffolk has two lead GPs that provide clinical leadership for adult safeguarding. All commissioned providers are undergoing a self-assessment to review adult safeguarding policies and procedures and education and training; which will be completed by 30 th June and reported to the Safeguarding Adults Board in August. 171 P a g e

172 Section Six Innovation Fundamental 20 Research and innovation How our plans fulfil your statutory responsibilities to support research How we will use Academic Health Science Networks to promote research How we will adopt innovative approaches using the delivery agenda set out in Innovation Health and Wealth: accelerating adoption and diffusion in the NHS We are highly innovative in our approach to service delivery. This encompasses both radical approach to care delivery and a substantial increase in the use of technology to deliver more local and more flexible services. We have a lead GP for Research Dr Karen Blades and a lead for research within the Redesign Team who are actively making links with the appropriate Regional Groups. Below are a few examples of this: The Advice Letter Listing scheme allows general practices to obtain management plans from hospital consultants without the need for patients to travel unnecessarily for outpatient appointments. This very much follows the Digital by Default initiative laid out in Innovation Health and Wealth and was a HSJ Award for Improving Care with Technology. For diabetes, we have commissioned a shared electronic record between primary and secondary care which will enable hospital consultants to view primary care patients diabetes records, including blood glucose, cholesterol, blood pressure and drug history with their consent. In many cases it is anticipated that this will allow highly expert advice to patients in primary without the need for patients to travel to Ipswich Hospital. In addition, the Information Technology has the capability to produce dashboards which will help secondary care clinicians target greater community support in the form of outreach diabetes specialist nurses; this was shortlisted for the national Finnamore 'Health and Health Services: The Next 20 Years' competition. The Norfolk and Suffolk Clinical Community Node of the Eastern Academic Health Science Network has committed that it will increase CCG engagement and scrutiny as the programme develop(s), we recognise the need for patient and public involvement in overall strategic planning, and will work closely with the new CRN. We have already identified a lead GP and Officer to engage with the Community as they develop and recognise that the portfolio of dementia, mental health and diabetes bears a high relevance to our local commissioning plans. In these service developments, we have extensively used the support of Public Health Suffolk to develop indicators in relation to service evaluation, which will help us to generate evidence that could contribute to their objectives 172 P a g e

173 Innovation and generate research papers in relation to NHS service improvement. This would support future bids for the use of the Regional Innovation Fund. In 2013 the Suffolk CCGs were shortlisted in the Staff Engagement category of the HSJ Awards. The award is about recognising organisations that have turned the theory of engaging with staff into reality and can show how staff engagement is delivering innovation, higher quality services and contributing to the QIPP agenda. It recognises organisations that are able to demonstrate that staff engagement is at the heart of their culture where they are at the heart of decision making processes, feel valued, and understand the values of the organization. We are proud of our achievements particularly on work around engagement and partnership working with trade unions. The award recognised the environment that has been created where staff are at the heart of decision making processes, feel valued, and understand the values of the organisation Our Community Glaucoma Service has enabled an optometrist, two clinical assistants, an administrator and consultant reviewers to deliver the service in the community via a purpose built van. It has enabled savings Activity base 5,000. Annual savings against tariff are circa 35k + reduction from appointments at national tariff to one appointment at local tariff, a fall from 664,125 to 206,325. The Community Glaucoma Service nb. For further information please visit our website French President views surgery at Ipswich Hospital from Strasbourg thanks to new high-tech video link. Surgeons at Ipswich Hospital had their handiwork overseen by an international dignitary today even though he was hundreds of miles away in France. It was all part of a demonstration of a new piece of technology which should improve the training and mentoring of surgeons. Put simply, a robot with a flat-screen monitor and a camera can be placed in an operating theatre to beam pictures all over the world. This allows the staff at Ipswich Hospital to run joint mentoring sessions with the European Institute of Telesurgery in Strasbourg (EITS) who they have a partnership with. 173 P a g e

174 Innovation Outcomes Clinics see up to 20 patients a day. Normal patients are discharged; low-risk (50%) and stable (25%) are managed on six-month or annual intervals. A small percentage remains in the acute hospital. Consultant reviews take place within seven days. Patient feedback is positive. Waiting times are four weeks. Care is closer to home. Strategic Clinical Networks Cancer We hold a bi-monthly Cancer Locality Group, Chaired by the Lead GP for Cancer and End of Life and attended by representatives from the local hospital, local hospice, voluntary sector, patient groups and the Strategic Clinical Network (Cancer). The Chair of the locality group attends the Anglia Local Cancer Forum part of the East of England Strategic Clinical Network. Through the locality group and the Local Cancer Forum we work closely with providers and the SCN to ensure local cancer services become / remain compliant with national guidance and work to address national priorities. Mental Health We have been working with West Suffolk CCG and Suffolk County Council to develop a joint model for delivering dementia services. To support this we have been working closely with the dementia sub group of the local Mental Health SCN. We explained the work we are doing locally and how the challenges we face will be replicated in systems across the region. We therefore agreed to share the systems work to date to explore what tools could be developed to support us that would be helpful to colleagues across the region. This included meeting with public health England, health economists and others to explore the gaps in our outline business case and how national and regional best practice evidence could be used to support our system and others to develop robust business cases. Stoke and Diabetes We have had a strong reciprocal relationship with the Cardiovascular Strategic Clinical Network, covering also stroke and diabetes. The East of England Cardiovascular Stroke Network Manager is on the Suffolk Stroke Review Project Board, which is serviced by Ipswich and East Suffolk CCG officers. This input has been vital in terms of developing the detail of the service model for hyperacute stroke services, advising on likely issues and risks, and the approval of an evaluation framework. The Network has also helped the CCG in its development of the Early Supported Discharge service specification which is currently out to procurement, for instance advising on likely activity levels and whether other such services in the region have been able to see patients who are fed by nasogastric tube. 174 P a g e

175 Innovation In turn, we have been very supportive of the proposals for a new Heart Centre at Ipswich Hospital, where the provider worked very closely with the Network, and has consistently attended the Anglia Stroke Network meetings, being only the commissioners represented at the last session. Although the Strategic Clinical Network had yet to convene for diabetes in this region, our CCG officers have a very good relationship with Dr Nick Morrish the chair, and have exchanged ideas with Bedfordshire in relation to Integrated Diabetes Services which bear close similarity to that of Ipswich and East. The Project Director for Stroke, Diabetes and Urgent Care at CCG level has a fortnightly teleconference with the East of England Cardiovascular Stroke Network Manager. Commissioning for Better Value The Commissioning for Value programme is collaboration between NHS Right Care, NHS England and Public Health England. Its aim is to identify priority programmes that offer CCGs the best opportunities to improve healthcare for their populations improving the value that patients receive from their healthcare and improving the value that populations receive from investment in their local health system. In November 2013 they published bespoke insights packs for each CCG. These packs are for use by the local health community and its partners, GP commissioners and leaders and CCG Senior Management Teams and Health and Wellbeing Boards. They will support local discussion about prioritisation and utilisation of resources across a range of service areas (e.g. cancer, neurological, and circulation). The charts below illustrate how improvements could save lives and resources across elective and non-elective admissions, and prescribing. The highlights from our pack include: The programme areas that offer the greatest opportunity in terms of both quality and spending are: Circulation Problems (CVD), Endocrine, Nutritional and Metabolic Problems, Genitourinary, Mental Health Problems and Respiratory System Problems. The programme areas that appear to offer the greatest opportunity for quality-related improvements are: Circulation Problems (CVD), Endocrine, Nutritional and Metabolic Problems, Genitourinary, Mental Health Problems and Respiratory System Problems. The programme areas that appear to offer the greatest opportunity for financial savings are: Cancer & Tumours, Mental Health Problems, Gastrointestinal, Circulation Problems (CVD) and Endocrine, Nutritional and Metabolic Problems. 175 P a g e

176 Innovation Figure 10: What are the potential lives saved per year? Figure 11: What are the potential savings on elective admissions Figure 12: What are the potential savings on non-elective admissions Figure 13: What are the potential savings on prescribing. 176 P a g e