DARLINGTON CLINICAL COMMISSIONING GROUP

Transcription

1 DARLINGTON CLINICAL COMMISSIONING GROUP CLEAR AND CREDIBLE PLAN Working together to improve the health and well-being of Darlington May 2012 Darlington Clinical Commissioning Group Clear and Credible Plan

2 Contents Executive Summary 5 1 Introduction Who we are What we are trying to change and why How we are going to change services How we will measure that we are making a difference Vision The Case for Change Health Need Disease Prevalence (Quality Outcomes Framework) Health challenges Demographic changes Insight from our patients What we see as clinicians Programme Budget Data Financial considerations What our key partners are saying to us The Darlington Formative Health and Wellbeing Board What our main providers are saying ISOP and CCP Cross-CCG approaches in Year Quality Driving up quality in primary care Performance Delivery of Operating Framework Priorities Informatics Strategy 43 Darlington Clinical Commissioning Group Clear and Credible Plan

3 5. Defining our Strategic Aims External SWOT analysis Internal SWOT analysis - capacity and capability Our Goals Our Strategic Approach Getting a grip of the system Making best use of what we ve got Investing for improvement Prioritisation of attention, effort and investment Programmes and Initiatives Track record of delivery Alignment for PCT Cluster ISOP QIPP Programmes Demonstrating alignment of activities with our strategic objectives Working with neighbouring CCGs to share and spread good practice Exclusions from our plan 65 Strategic Aim 1: Improving the health status of people in Darlington 67 Strategic Aim 2: Addressing the needs of the changing age profile of the population of Darlington 79 Strategic Aim 3: Taking services closer to home for the people of Darlington Our Financial Strategy Understanding our commissioning allocation Risk Sharing Use of non-recurring funding Applying 2012/13 business rules Financial scenarios Delivery Deliver 2013 The Darlington CCG delivery framework 98 Darlington Clinical Commissioning Group Clear and Credible Plan

4 11. Governance Future arrangements establishing the governing body, CCG Board and Executive Financial Governance Equality and Diversity Risk management and ongoing monitoring 106 Appendices 109 Appendix 1: Overview of Health Needs 110 Appendix 2: Gap analysis 123 Appendix 3: Overview of Programme Budgeting 131 Appendix 4: Commissioning intentions 136 Appendix 5: Communication and Engagement plan 137 Appendix 6: Medium Term Financial Strategy 148 Appendix 7: Governance 170 Appendix 8: Full Risk Assessment 171 Darlington Clinical Commissioning Group Clear and Credible Plan

5 Executive Summary Executive Summary In developing our five year clear and credible plan Darlington CCG has worked together with our patients, the public, clinicians, providers, our Local Authority and our many other community partners in order to ensure all of our stakeholders have had a role to play in shaping our healthcare services of the future. In this plan, which is focused on improving the health, healthcare services and healthcare outcomes of our local population, we aim to capture what will be different in the new healthcare system and put forward a case for change based on sound clinical evidence, the thoughts of our patients and the public and our own experiences as clinicians delivering services. Our plans now and in the future need to be built up from and reflect the contributions of all within the local health and social care system, stimulating clinical engagement in order to improve quality, productivity and health outcomes whilst at the same time reducing unwanted variation and inequality in the services we offer, all delivered within the finances available to us. The development of our plan has been underpinned by the three principles of reform as set out in the white paper Equity and Excellence: Liberating the NHS (DH, July 2010): An increase in patient choice and control A focus on healthcare outcomes and quality standards An increase in the freedom of frontline professionals and the development of strong leadership roles Within this plan we have outlined in detail: Our Vision: Working together to improve the health and well-being of Darlington For the population of Darlington this means: health services which are safe and of the highest quality best possible health outcomes joined up services which benefit patients and the public and give best value for money Darlington Clinical Commissioning Group Clear and Credible Plan

6 Executive Summary Our strategic aims: To improve the health status of the people of Darlington To address the needs of the changing age profile of the population of Darlington To take services closer to home for the people of Darlington Manage our resources effectively and responsibly. Our strategic goals: Improving the health status of people from Darlington Over the 5 years of this plan we will look to: reduce <75 all-cause mortality by 16% reduce mortality from causes responsive to health care by 30% reduce <75 all CVD mortality by 20% reduce <75 Stroke mortality by 28% reduce <75 Cancer mortality by 17% These trajectories will close the gap between Darlington and the National average. Addressing the needs of the changing age profile of the population Over the 5 years of this plan we will look to: Drive improvement in the management of long term conditions through primary care by supporting all practices to attain a high level of achievement across a range of QOF indicators. These indicators relate to the conditions associated within an ageing population (for example diabetes, CHD and dementia). This improve in primary care will be supported by targeted commissioning interventions that will reduce admissions for acute exacerbation of COPD and unnecessary admission to acute care for patients with dementia. Darlington Clinical Commissioning Group Clear and Credible Plan

7 Executive Summary Taking services closer to home whilst ensuring current services are accessible, timely and of a high level of quality Over the 5 years of this plan we will look to: Commission more services from a community or primary care setting where safe and appropriate to do so. We will monitor this through the number of services commission through the Any Qualified Provider mechanism and the change in total proportion of spend in the acute sector over time. We will also measure access and quality targets to ensure current planned and unplanned services remain responsive to local needs. As well as improving access in commissioned services, we will support all practices to maintain high levels of access in primary care as measured through a range of QOF indicators. Making the best use of public funding Year on year over the 5 years of this plan we will: Achieve financial balance and control totals on the commissioning allocation Secure commissioning support within the running cost allowance Delivery of CCG QIPP plans including demand management We have also included a detailed outline of our three stage strategy development and implementation process: Stage 1: Getting a grip of the system. This first stage will see us get a better understanding of our use of secondary care services, prescribing practice and use of continuing healthcare in order to allow us to manage demand more effectively Stage 2: Making best use of what we ve got. Reviewing services for effectiveness, redesigning priority pathways and disinvesting in poorly performing services to improve quality, access and value for money Stage 3: Investing for improvement. Once we have assessed the current services and redesigned pathways where appropriately, we will invest our uncommitted recurring resource to improve the health outcomes and reduce health inequalities of our population for the long term future. Darlington Clinical Commissioning Group Clear and Credible Plan

8 Executive Summary Over the lifetime of this plan we also face a number of specific health challenges and opportunities: We need to focus on addressing the significant public health issues affecting population of Darlington, cancers, cardiovascular disease, chronic obstructive airways disease, stroke and dementia There has not been significant focus on providing care closer to people s homes through appropriate clinically led pathway review and development We have an ageing population with increasing demand on healthcare, particularly patients with long term conditions, which we cannot sustain given the funding scenarios over the next five years We need to improve the quality of care and reduce variation in primary care in order to improve health outcomes and experience for patients and to contribute to the Quality, Innovation, Productivity and Prevention (QIPP) agenda. We believe that by putting in place the appropriate constitutional and governance arrangements to ensure we have the capacity and capability to fulfil our statutory duties and by working collaboratively with all of our stakeholders in the development of a plan which not only has a clear and continuing prioritisation of QIPP and the initiatives set out in our ISOP, but which also reflects both the required national outcomes and the objectives set out in our local joint health and wellbeing strategies; that we are in a strong position to lead the on-going development and delivery of this plan and so make a real difference to the health outcomes of our local population. Darlington Clinical Commissioning Group Clear and Credible Plan

9 Introduction 1 Introduction 1.1 Who we are Darlington CCG was established in October 2011 as part of the recent changes to the NHS outlined in the white paper Equity and Excellence: Liberating the NHS (DH, July 2010) and the recent Health and Social Care Bill. This legislation has provided a unique opportunity for front line clinicians to lead the commissioning and design of local services to meet the needs of local people. Darlington CCG is made up of twelve GP member practices and represents a population of just over 100,000 people. The area covered by DCCG is predominately urban, centred on the town of Darlington, and is coterminous with Darlington Borough Council (DBC). Despite the compact nature of the area there are some marked differences in health between the various wards of the Borough and we do not underestimate the steep trajectory of development required to enable our organisation to become an intelligent commissioner with the capacity and capability to meet the health challenges of our population. As a new clinical commissioning organisation we recognise that we are at the very beginning of our journey and it is our intention to not only build upon our past experiences, gained both as a practice based commissioning (PBC) group and then subsequently as a pathfinder consortium and GP lead commissioning group, but to also continue to draw on the skills and expertise currently within NHS County Durham and Darlington to assist us and ensure we continue to develop the commissioning skills, knowledge and experience we will need in order to successfully deliver our plan. 1.2 What we are trying to change and why This plan aims to capture what will be different in the healthcare system going forwards and puts forward a case for change based on sound clinical evidence, the thoughts of our patients and the public, and our own experiences as clinicians delivering healthcare services every day. In addition we have also accessed data from public health, service performance and financial experts to build up a picture of the challenges and opportunities that we face as a commissioning organisation. Darlington Clinical Commissioning Group Clear and Credible Plan

10 Introduction Our Key Challenges: We know that Darlington has an increasing and an ageing population which will bring an increased demand on healthcare from cancers, cardiovascular disease, stroke, dementia and long term conditions such as diabetes and chronic obstructive airways disease (COPD). Cardiovascular disease and cancers already account for the majority of early deaths in Darlington. We need to do more to improve the overall quality of care and reduce clinical variation in health care in order to optimise health outcomes and overall patient experience for everyone. We know that although there are many more services now delivered in the community and closer to home for patients, this shift needs to be accelerated through transformational change underpinned by the redesign of pathways of care to give the best outcomes from the resources available. This plan clearly sets out our priorities and why our chosen priorities will lead to greatest health gain taking into account future changes. Our plans now and in the future need to be built up from and reflect the contributions of all within the local health and social care system, stimulating clinical engagement and improving quality within the finance available. 1.3 How we are going to change services To be an effective commissioning organisation, our strategic aims must not only be ambitious but, more importantly, underpinned by practical implementation plans developed with our stakeholders and owned by our member practices and partner organisations. We will work closely with our current hospital and community services in order to ensure clinicians from a range of professions and a variety of settings are able to collectively shape services locally to best reflect our patients needs. As part of our pathfinder programme we are taking forward clinical pathway work for Musculo-Skeletal Services (MSK) and engaging a range of clinicians with a common purpose to improve services for the defined patient group. This work extends beyond the Darlington locality and through learning and evaluation of the programme of work we are informing a future model for pathway development which can be applied to a range of care pathways. Darlington Clinical Commissioning Group Clear and Credible Plan

11 Introduction Equally importantly we will build a true partnership with Darlington Borough Council to support one another in tackling the common challenges that can only be solved by adopting a joined up approach across the health and social care pathway. This together with the coming together of organisations in the Darlington Partnership and its vision for Darlington expressed within One Darlington Perfectly Placed offers an early opportunity for our CCG to sit alongside our partners in order to develop a shared vision and approach that defines health and well-being in its widest sense, and so optimises health outcomes. We will also work in partnership with the two neighbouring clinical commissioning groups in North Durham and Durham Dales, Easington and Sedgefield, taking advantage of the benefits of whole health economy working, to ensure we deliver our aims and make best use of available resources and effectively manage our levels of risk. As a CCG, and up until our full authorisation, we are supported by NHS County Durham and Darlington as the umbrella statutory NHS commissioning organisation. It is therefore essential that our commissioning plan acknowledges and remains consistent with the PCT Integrated Strategic and Operational Plan (ISOP) 2011/ /15 whilst ensuring that our clear and credible plan captures the opportunities for strengthening clinical leadership and engagement in the commissioning of health services from this point onward. The Integrated Strategic and Operational Plan (ISOP) outlines how the PCT (NHS County Durham and Darlington) will ensure the delivery of national, regional and local priorities over the defined period, ensuring financial stability and improved levels of service performance whilst at the same time facilitating the transition towards clinical commissioning. We believe our clear and credible plan is consistent with the ISOP themes and will carry these forward, beyond the lifespan of the ISOP, to the point at which we will be required to demonstrate alignment to the priorities of the new wider system. This will include demonstrating strategic alignment with the priorities of the Darlington Health and Wellbeing Board, the refreshed Local Strategic Partnership at a local level and the overarching strategic aims of the NHS Commissioning Board. Our governance arrangements will be reviewed and refreshed as we move along the trajectory from being a composite part of NHS County Durham and Darlington to a fully authorised governing body in our own right operating within the NHS. Darlington Clinical Commissioning Group Clear and Credible Plan

12 Introduction Financial Overview Our clear and credible plan is based on assumptions around National financial allocations and any required levels of efficiency we are required to achieve. These assumptions have allowed us to plan how we will deliver our key priorities whilst ensuring we meet our statutory financial requirements. 1.4 How we will measure that we are making a difference Over the next five years we will track our progress against our plans and more importantly measure the impact they have on the health outcomes we are looking to improve. We will work closely with stakeholders such as Darlington Local Involvement Network (LINk) and emerging HealthWatch and other patient groups as well as the new Health and Wellbeing Board for Darlington to ensure all our stakeholders are informed of our progress to date, aware of our on-going areas for improvement and involved in celebrating with us in those areas where we demonstrate success. Alongside this plan, we have developed a communication and engagement strategy for Darlington where there is potential for a joined up approach with DBC that will enable our future work to reflect even more the needs of our local population. The next five years will be both challenging and exciting, but we are committed to making a difference to the people of Darlington and we look forward to updating you with our progress in the future. Dr Harry Byrne Dr Andrea Jones Dr Richard Harker Interim Chair Interim Vice Chair Clinical Quality Lead Darlington CCG Darlington CCG Darlington CCG Darlington Clinical Commissioning Group Clear and Credible Plan

13 Vision 2. Vision Darlington is a unique place in which to live and work, but not one without health challenges. Our role as a clinical commissioning group is to understand what our population both needs and wants, consider the evidence base and quality outcomes and then act to deliver these improvements within the defined financial framework. To give ourselves the best chance of success on behalf of our population, our vision alongside our partner organisations is: Working together to improve the health and well-being of Darlington For the population of Darlington this means: health services which are safe and of the highest quality best possible health outcomes joined up services which benefit patients and the public and give best value for money In order to achieve this vision, we have developed strategic aims that cover and define the challenges facing us. These are: To improve the health status of the people of Darlington To address the needs of the changing age profile of the population of Darlington To take services closer to home for the people of Darlington As a CCG we will be investing roughly 740m over the five year lifespan of this plan. At the same time our healthcare providers will have to become more efficient than ever to respond to the current economic climate. Because of this we recognise that as investors of public money, we have a fourth strategic aim to: Manage our resources effectively and responsibly. Whilst delivering these aims given the current economic climate, we must ensure that we are making the best use of public money within Darlington. Darlington Clinical Commissioning Group Clear and Credible Plan

14 Vision Improving the health status of the people of Darlington The Darlington Single Needs Assessment (SNA) indicates that nearly a quarter of the residents of Darlington live in the most deprived areas of England. Furthermore, just under a quarter or residents live in the least deprived areas which signifies a major disparity across the town of the varying levels of health and deprivation. Men from the least deprived areas of Darlington live 13.4 years longer than those from the most deprived areas; with the difference in life expectancy for women between these two areas is 10.3 years. By working with partners in social care and public health, we can jointly focus on the underlying risk factors and wider determinants of ill-health and health inequality so that the people of Darlington can expect to live longer, healthier lives in the future and the differences in life expectancy are narrowed. We will influence and shape this at a strategic level as core members of the Darlington formative Health and Wellbeing Board as well as those areas of joint priority delivered through the established Joint Strategic Commissioning Group and including re-ablement and section 75/256 agreements. Addressing the needs of the changing age profile of the population of Darlington The percentage of the population over 50 years of age in Darlington is increasing and the majority of older people now live more independently within their own homes. A large rise is predicted in the number of people diagnosed with dementia and current statistics show that 19.3% of the Darlington population live with a long-term limiting condition, which is above the England average. By working with partners and commissioning a range of new services, we will ensure that the people of Darlington with long term conditions will be able to live a healthier life that is less reliant on the NHS in the future. Darlington Clinical Commissioning Group Clear and Credible Plan

15 Vision Taking services closer to home for the people of Darlington In recent years several significant changes have taken place in the way the configuration of healthcare services that the people of Darlington use. In the main these large scale changes have centred on more specialised services however with the strengthening of clinically-led commissioning comes the opportunity to re-shape the services to better reflect the needs of the people of Darlington. Over the next five years we aim to focus much more on what can be provided locally in Darlington, where it is safe and appropriate to do so. Our CCG will develop a clinical strategy to inform this future direction and influence the shape of the provider landscape. Making the best use of public money within Darlington Given the financial challenge facing the NHS and the wider economy over the coming years, we are committed to making the best use of public money in Darlington and operating within our budget. Our CCG boundary is completely coterminous with Darlington Borough Council and as such is a recognised strength and opportunity. The consolidation of close working relationships with Darlington Borough Council alongside voluntary sector organisations will enable a clear advantage for partner organisations to optimise the impact of joined up commissioning decisions on patient outcomes and the overall health and well-being of local people. Over the five years of this plan, local people will see that we will have considered the information we have on health and service needs, shared this with them and listened carefully to their views as we deliver planned changes in services over time services whilst living within our means and demonstrating real value for money. We will work closely with our local authority partners to ensure we are making the most of economies of scale and value for money. Darlington Clinical Commissioning Group Clear and Credible Plan

16 Vision Values As a Darlington PBC group, local practices established a series of values that have been built into a compact between the CCG and its member practices and will inform our approach to clinical commissioning and responsibilities to the local community: Open, transparent and inclusive relationship between practices, practitioners and with patients the public and partners Commitment to improve the care and outcomes for people Fairness and equity in the use and deployment of resources Commitment to eliminate unwarranted variation Focused on transformation with a clear and credible clinical focus Foster strong clinical relationships as a driver for change These values will be reviewed and refreshed as Darlington CCG moves towards authorisation as a statutory body. The tangible benefits of a compact can readily be demonstrated, for example all practices have contributed practice data to the SNA and all practices have agreed move to SystmOne as the preferred clinical system early in the next financial year. The practices have collectively taken forward a scheme to look at referral management through peer review at practice and CCG level aimed at reducing variation in practice and improving the quality of referrals to secondary care. Darlington Clinical Commissioning Group Clear and Credible Plan

17 Vision Engagement In developing our vision, purpose and values, we have worked closely with GPs and staff from our member practices through our management and decision making mechanisms. Over the course of 2011 we have held a number of engagement workshops with patients and stakeholders, including provider organisations, local authority and other statutory and non-statutory organisations to explore opportunities through the new and emerging clinical commissioning system. To support on-going delivery of our Clear and Credible Plan, we have developed a Darlington Communications and Engagement Strategy (see appendix five) which is to be read alongside the Clear and Credible Plan and the Organisational Development Plan as a formal strategic document. This overarching strategy includes the following: Engagement Plan for Darlington; Engagement Plan for the Darlington Clinical Commissioning Group Clear and Credible Plan / Vision; Communications Plan for Darlington; Stakeholder Map; Patient and Public Involvement Toolkit The communications and engagement strategy sets out how Darlington intends to engage with people at all stages of decision-making about health and healthcare through patient, carer and public involvement, in the context of existing NHS policy, best practice and legislation. It states a commitment to achieving effective engagement and communications and outlines how Darlington will develop engagement and communications functions and implementation plans to support its vision and priorities. The document also outlines how the Equality Delivery System (EDS) will be implemented for Darlington. As the Clear and Credible Plan is an important vehicle for public accountability, we will develop a public facing version of the plan to provide a focus for discussions on local health needs and priorities. The overall aim of the engagement plan for Darlington is to ensure the CCG has a structured and systematic mechanism for patient, carer and public engagement. Our CCG aims to give meaningful voices to patients and the public to influence planning and commissioning decisions. We recognise the new NHS architecture will require a new approach to engaging with patients and public engagement, particularly given the emphasis on patient experience in the emerging quality and outcomes frameworks. Darlington Clinical Commissioning Group Clear and Credible Plan

18 Vision While the Department of Health, the NHS and its constituent bodies have consulted and engaged with patients and the public in the past, the reforms imply a new set of players leading those discussions, with key roles for Clinical Commissioning Groups and HealthWatch. Our CCG, the PCT communications and engagement team together with the Local Authority and Public Health colleagues have recently agreed to undertake a joint approach to patient and public involvement and engagement. This cross-organisation task and finish group is working on a Joint Public Patient Involvement and Engagement Implementation Plan to be delivered by October This joint working group recognises that we will need to develop innovative ways of engaging with patients and the public as Darlington s Single Needs Assessment and Darlington s Health and Wellbeing Strategy develop during Working collaboratively with our Local Authority and public health partners, we intend to take a three tiered approach to Public Patient Involvement and Engagement in Darlington: 1) Strategic commissioning level 2) Clinical specific level 3) Practice forum level Our CCG aims to capture the perspective of patients and the public by talking and listening carefully to people. In this way we hope to gain a full, robust and complete lay person perspective. Furthermore the CCG aims to secure lay representation at key levels of the organisation; clinical board and its sub committees, the governing body and importantly the pathway/service redesign work streams and task and finish groups. The CCG clinical board assumes collective responsibility for driving forward its vision and aims in collaboration with member practices and other key stakeholders. Our Darlington GP practices have a long established track record of good collaborative working across the practices as well as with other commissioners, particularly other localities. The three local CCGs are developing how to work together, including specified areas for confederated working and risk sharing. Involvement of stakeholders in the development of Darlington CCG clear and credible plan and vision has included on-going communications via a series of regular briefings to NHS and local authority staff, GP practices, the Health and Partnerships Scrutiny Committee, Darlington Local Involvement Network (LINk), formative Health and Wellbeing Board, local Foundation Trusts, other providers and MPs. Darlington Clinical Commissioning Group Clear and Credible Plan

19 Case for Change 3. The Case for Change The starting point for the development of the vision for this plan was to fully understand the health needs of the local population, the patients experience of the services they receive, insights from the GPs and their teams delivering care to their patients and the financial environment in which we operate. This was supplemented by the identification of opportunities to make improvements in service efficiency and performance. Our awareness of the public health challenges in Darlington through previous PBC arrangements and learning from our pathfinder projects further strengthens our case. Darlington Clinical Commissioning Group Clear and Credible Plan

20 Case for Change 3.1 Health Need Using the Single Needs Assessment, Practice Health Profile and other sources of epidemiological and demographic data, Darlington CCG has developed a picture of the health challenges facing our local populations. Darlington is significantly worse than the England average in the following areas: Lifestyle (smoking, healthy eating, binge drinking). Over 65 s not in good health Incapacity benefit for mental illness Hospital stays for alcohol related harm Substance misuse 3.2 Disease Prevalence (Quality Outcomes Framework) Quality Outcomes Framework (QOF) prevalence rates for Darlington can be used as proxy measures for disease prevalence for the Darlington locality. GP practice registered disease prevalence in Darlington is 20% higher than the England average for the following diseases: Chronic Obstructive Pulmonary Disease (COPD also the second most common cause of emergency admissions to hospital) Coronary Heart Disease (CHD) It is worth noting that QOF measures may reflect the proactive approach in Darlington to screening and disease detection by the member practices allowing for intervention and support at an earlier stage than would otherwise have happened (rather than a simple measure of high level of disease locally compared to the national picture). This is reflected in development of community CHD services by the Darlington practices including an integrated heart failure service comprising a GP with a special interest, specialist heart failure nurses and consultant cardiologist. Darlington Clinical Commissioning Group Clear and Credible Plan

21 Case for Change 3.3 Health challenges Darlington stands behind the national average in many of the key headline health measures: Men in Darlington are living 1.7 years less than the England average and women are living 1.5 years less than the England average Inequalities in life expectancy exist within Darlington with life expectancy for men living in the most deprived areas over 13.4 years lower than for men living in the least deprived areas. For women it is 10.3 years lower Between 2007 and ,129 people in Darlington died aged less than 75 years Cardiovascular disease (CVD) and cancer account for around 63% of early or premature deaths in Darlington. The underlying risk factors that drive this level of ill health are also stark: Binge drinking prevalence is estimated to be 31% in Darlington, 18% higher than the National estimate Smoking remains the biggest single contributor to the shorter life expectancy experienced locally Finally, diseases associated with getting old are also significant locally: Dementia prevalence is predicted to rise in Darlington to 8.1% by 2030 COPD prevalence is greater in Darlington (2.2%) than England (1.6%). A full outline of the health need of our CCG area and the gap analysis undertaken against our commissioning intentions can be found in Appendices One and Two. Darlington Clinical Commissioning Group Clear and Credible Plan

22 Case for Change 3.4 Demographic changes As shown in the figure below, the population of our CCG will age significantly over and beyond the life of the plan. An ageing population makes a higher demand on health services for example there will be an impact on the prevalence of long term conditions as well as the level of dependency found in Darlington. Darlington Demographic Shifts By 2030 it is forecasted that there will be a 51% increase in the over 65 years registered population. The number of people aged 85 years and over in Darlington is projected to increase by almost two thirds by A large rise is predicted in the number of people diagnosed with dementia (predicted to increase by 61% by 2026) and current statistics show that 19.3% of the Darlington population live with a long-term limiting condition, which again is above the England average. Darlington Clinical Commissioning Group Clear and Credible Plan

23 Case for Change 3.5 Insight from our patients We have well developed links with patients through our member practice forums and the face to face communication between clinicians and patients. We have developed a robust patient and engagement involvement strategy and operational plan for the whole of our community that will link these elements together into a comprehensive approach that puts patient needs at the centre of what we do. In September 2011 and in collaboration with Darlington Borough Council we undertook a joint consultation exercise with attended by patients, carers, third sector organisations as well as local stakeholders. The event gave local people the opportunity to have their say about the health services that are important to them; how they can get involved in how local health services are commissioned (planned and purchased); and how they wish to be engaged and communicated with in the future. The event had the following objectives: Commence sharing with the community of Darlington the national changes that are impacting on the clinical commissioning group and the local authority Highlight changes for Health and Social Care across Local Authority and Health Outline any key Public Health challenges Raise awareness of HealthWatch and consult on involvement of the community in future HealthWatch arrangements. Raise awareness that the Clinical Commissioning group and the local authority are working together on this agenda Highlight local health priorities as identified in Single Needs Assessment and engage the community in consultation around how we can address these priorities Commence discussions on how the community can influence the future and what public and patient involvement needs to look like in Darlington Those who attended identified the following health priorities in Darlington: Stopping smoking Reducing alcohol related deaths Improving dental health Tackling obesity Reducing teenage pregnancies Improving access and choice to services Prevention and education Concerns that there is insufficient funding to maintain existing health and social care services Darlington Clinical Commissioning Group Clear and Credible Plan

24 Case for Change Better promotion of health checks Lack of awareness around commissioning services, and the impact of future changes Improving communication with people using a range of methods The need to reduce health inequalities which affect the local population Building on this successful event and as described earlier we are working jointly with DBC and Public Health colleagues to develop a Joint Public Patient Involvement and Engagement Implementation Plan (to be completed by October 2012). 3.6 What we see as clinicians As a part of the transition to the new system of clinical commissioning we are proactively informed by our clinicians about service changes that need to happen in order to improve service safety, quality, access, outcomes or efficiency. The opportunity of face to face contact with patients and their carers gives clinicians important insights into where we can direct our efforts to improve what health care services are provided and how they should be provided. This plan aims to triangulate the evidence of need and views of patients and the public with the experience and insights of clinicians delivering services so that any changes made bring about real improvements in the health outcomes and experiences of our local population. We believe this will demonstrate the value add of clinical commissioning and underline its difference to those approached that have gone before. Public Health / Prevention We see a huge variation in terms of deprivation across Darlington, which is supported with the data presented within the SNA. The area that we feel would make the most impact would be the provision of more integrated obesity pathways of care and interventions to support our population to stay healthy and reduce the likelihood of developing other long term conditions in future years. There is a current gap in service provision for the Darlington population. As we know from our QOF prevalence rates we have a high percentage of our population diagnosed with coronary heart disease and diabetes-obesity has a direct impact on these conditions. Darlington Clinical Commissioning Group Clear and Credible Plan

25 Case for Change Long Term Conditions We will be recognised for delivering proactive healthcare service where we can jointly care plan with our patients to help manage their long term conditions (Darlington will face an increasing elderly population in future years who are likely to be living longer with potentially more than one long term condition) We will lead the development of more streamlined and co-ordinated approach to long term condition care planning along with the pathways that support our patients throughout their condition. We are leading the development of care closer to home for patients with long term conditions to address the current gap in local clinical knowledge and put in place actions to address the cost pressure associated with secondary care referrals. Delivering the Right Care, in the Right Place The North East in general has a high dependency on secondary care services. We want to ensure our patients are seen at the most appropriate care setting for their condition. We are initially focussing on specified musculoskeletal pathways to improve not only the patient experience but also to drive efficiencies that exist within the healthcare system by reducing the revolving door experience that exists for many of our patients. This area of work is led by our MSK clinical co-ordinators. We have captured the learning from the pathfinder projects to strengthen our commissioning approach over time By streamlining the MSK pathways, we aim to achieve more cost effective pathways which ensure patients receive the right care at the right time and to develop a framework for all future pathway developments. We are reviewing the access to community bed provision in Darlington sin order to offer patients a facility when they require local access to specialist health interventions but do not require secondary care level input. Darlington Clinical Commissioning Group Clear and Credible Plan

26 Case for Change Patients with Mental Health needs Mental Health is an area of increasing prevalence for Darlington and we will ensure our patients have a sustained access to appropriate mental health services. We will focus on areas where current services do not fully support patients or areas we feel that an improvement in service can be made. This work is led by our clinical leads for Mental Health. For Darlington, we believe that further work around the pathway and access to care and support for patients with personality disorders needs to be undertaken. We aim to complement our local counselling service to offer more specialist support services particularly around psychosexual counselling. Patients needing Emergency Care We are investigating the reasons behind the high levels of A&E attendances and emergency admissions. This key area of work is led by our clinical lead for unscheduled care We know that we have a high level of paediatric admissions within Darlington in particular related to respiratory conditions. Our Children s lead clinicians are working jointly with secondary care to improve the management of children with respiratory conditions and the poorly child pathway. We aim to reduce the minor injuries that attend A&E within primary care working hours. We would like to be able to ensure that our population s health care needs can be met by improved access to primary care where ever appropriate to do so in order to reduce the reliance of A&E attendances for appointments and reduce unnecessary activity through Darlington urgent care centre in hours. Resolving service quality issues with our providers Clinical letters from some of our providers are either late or inaccurate and often a clear care plan on discharge is not apparent. We are working with our providers to improve both the quality of the primary care referral letters that providers receive, but equally the quality of the information that is receive back to the referring clinician. This and other areas of clinical quality are led by our GP lead for clinical quality. Darlington Clinical Commissioning Group Clear and Credible Plan

27 Case for Change 3.7 Programme Budget Data Darlington CCG has access to the County Durham and Darlington Annual Value Population Review a locally produced guide to the nationally collected programme budget data that compares spend with outcomes within disease areas. This guide identifies areas of potential opportunity to re-design services to improve efficiency and maximise effectiveness of spend. An overview of the Darlington spend profile can be found in Appendix Three. In 2009/10 the level of expenditure on the Trauma and Injuries programme in Darlington was significantly greater relative to other PCTs (there were no programme areas where expenditure was significantly lower). With respect to outcome, there were no programme areas that had significantly worse or better outcomes than other PCTs during 2009/10. There are a number of areas in 2009/10 where there may be more moderate resource or outcome issues. Programme areas with potential overuse of resources (Higher Spend and Better Outcomes) Trauma and Injuries* Endocrine, Nutritional and Metabolic (Inc. Diabetes) Healthy Individuals *significant Programme areas with potential misuse of resources (Higher Spend and Worse Outcomes) Problems of the Respiratory system Neurological system Problems of circulation Dental Problems Programme areas with potential underuse of resources (Lower Spend and Worse Outcomes) Cancers and Tumours Conditions of Neonates The majority of the budget that supports the expenditure on the Healthy Individuals programme will move to the Local Authority as a part of the Public Health transition process. Investment in this area also fits in with the strategic direction of the CCG so in reality would not be considered at this stage an overuse of resources. Darlington Clinical Commissioning Group Clear and Credible Plan

28 Case for Change 3.8 Financial considerations In order to meet the demands placed on the health system by the increasing demographic need and increasing patient expectation the NHS was set the QIPP challenge. This challenge was to drive up the quality and productivity of the health system to realise the 20bn saving required to reinvest to meet these financial pressures. QIPP (Quality, Innovation, Productivity and Prevention) began in 2010 as a set of planning assumptions that set out to define the potential impact on commissioners and providers financial allocations/contracted levels of income. The County Durham and Darlington cluster have an agreed QIPP target of 224m for the four years from 2011/12 to 2014/15. These figures are set out in the table below. CDD Cluster Total 2011/12 ( 000s) 2012/13 ( 000s) 2013/14 ( 000s) 2014/15 ( 000s) Total ( 000s) Provider (technical) efficiencies 44,726 46,844 47, ,222 PCT/CCG (allocative) efficiencies 19,497 9,657 6, ,061 Total QIPP Target 64,223 56,501 53,970 49, ,283 Darlington Clinical Commissioning Group Clear and Credible Plan

29 Case for Change A simple apportionment of these cluster-wide totals using weighted capitation provides indicative QIPP totals for Darlington CCG as shown below: Darlington CCG 2011/12 ( 000s) 2012/13 ( 000s) 2013/14 ( 000s) 2014/15 ( 000s) Total ( 000s) Provider (technical) efficiencies PCT/CCG (allocative) efficiencies 6,709 (delivered) 7,027 7,174 7,324 28,233 2,925 (delivered) 1, ,409 Total QIPP Target 9,633 8,475 8,096 7,438 33,642 It must be noted that these figures are based upon a simple apportioned split of the cluster-wide total and will need to be revisited once firm allocation details are confirmed for public health, specialised commissioning, and CCG funding. The savings target for 2011/12 has been delivered ensuring Darlington CCG is entering 2012/13 with a balanced financial position and without legacy debt. We will work collaboratively with other CCGs in County Durham and Darlington with regard to delivering QIPP. Darlington Clinical Commissioning Group Clear and Credible Plan

30 Case for Change 3.9 What our key partners are saying to us The Local Authority have provided their perspective on key drivers and issues which they feel should be visible and addressed in our clear and credible plan. Drivers for change: Delivery of joint strategies through joint commissioning between health and DBC need to be actively explored. There is a desire and an opportunity for collaborative working on pathways of care and programmes which prevent poor health and dependence on social care and those that enable people to better manage long term conditions. Some examples include: 1) Improve health status through early intervention and prevention programmes in adults and children 2) Address the needs of the changing age profile- build capacity in the communities to self-manage; joint commissioning of services to deliver Older Peoples Strategy; Intermediate Care Plus; Older Peoples Mental Health; Long Term care including support for people at home; Continuing Health Care 3) Taking services closer to home- commissioning support for people in the community where appropriate. Efficient deployment of public resources - Making best use of public money. Align resources for best outcomes focusing on community premised on prevention, personalised and person-centred but prioritised care Opportunities for system wide working on community issues (anti-social behaviour, poverty, school attendances) that impact on well-being Financial position of more for less, reducing directly funded services for empowerment of individuals and communities, manage change in voluntary and community sectorsthrough Darlington Together. Quality of care and safeguarding for children and vulnerable people or for those in time of need- for example following planned admission. Issues to be addressed: Consider opportunities for closer working with the DBC Strategic Commissioning Teamdevelop commissioner led services (rather than provider led) Transfer of shared line management responsibility for the Head of Strategic Commissioning & Partnerships from PCT to Darlington CCG Balance need for Darlington CCG to manage and monitor high proportion of budget for acute and secondary care with community prevention and provision Smarter information sharing on which to base commissioning and monitoring Governance of joint groups and reporting arrangements Darlington Clinical Commissioning Group Clear and Credible Plan

31 Case for Change Continued support from the CCG for Darlington Joint Commissioning Strategies which have been developed with the PCT 3.10 The Darlington Formative Health and Wellbeing Board The health and social care reforms impose a duty on local authorities and clinical commissioning groups from April 2013 to jointly produce a Health and Wellbeing Strategy to meet the needs of the population as identified in the SNA. This strategy will be discharged by the Health and Wellbeing Board. The Darlington Health and Wellbeing Board is currently in a formative state and has representation from our CCG where the interim chair as well as senior officers are part of the core membership. It will be vital that our clear and credible plan aligns to the health and wellbeing strategy (when developed) however in the transition we believe that our current plan both acknowledges and aligns to key strategic plans including One Darlington Perfectly Placed, the developing Area Wide Strategy and the identified action priorities of the Darlington Partnership What our main providers are saying As the major provider of acute and community services in Darlington, County Durham and Darlington Foundation Trust (CDDFT) have provided their perspective on key drivers and describe Darlington CCG, working jointly with the Local Authority and local providers is perfectly placed to realise the potential to transform health and care services for the benefits of the residents of Darlington. Working jointly, utilising the SNA and the emerging Health and Wellbeing strategy will be key to implementing a local approach. This approach will provide our partners with a jointly agreed locally determined set of priorities. Decisions about health and care will be made on the basis of local clinical expertise, evidence from the SNA and input of local people. The development of relationships and the modelling of the collaborative approach that the new system is designed to deliver should be hard wired into the way of operating. CDDFT believes a key component of such an approach would be the development of a Darlington clinical services strategy that would address a whole system approach; including health improvement services, community services, hospital services and the social care interface. The overall approach should be captured in an integrated pathway of care with an emphasis on care closer to home. Other key aspects of this joint working would need to address the effective management of demand and capacity as well as the development of the local health economy infrastructure. Darlington Clinical Commissioning Group Clear and Credible Plan

32 Case for Change As the main provider for Mental Health and Learning Disabilities, Tees, Esk and Wear Valleys Foundation Trust (TEWV) are delighted with the way the Darlington CCG has become an integral part of the local health and social care system, keen to learn, establish relationships and build on the strong foundations that exist. A great example of this was the way the CCG helped and played an important role in the Darlington Dementia Collaborative. TEWV hope that the partnership way of working will continue so that together we can ensure that people with mental health problems and people who have a learning disability are able to successfully lead a good, self-determined lifestyle, receiving the appropriate help they might need from time to time. Key priorities include working together to: Develop and implement clinical pathways that are evidence based, in accordance with best practice the recent guidelines for dementia are a good example of this. Improve the physical health of people who have a mental health problem or a learning disability to substantially reduce the premature death rate. Improve the mental health of people who have long term health conditions. These are pre-requisites to enable people to have a good life. Ensure we have healthy children in Darlington, building resilience and capability - this will reduce people experiencing mental ill health in adulthood. Reduce stigma and discrimination that is too often associated with and experienced by people who have mental ill health or a learning disability Help keep people well and independent, receiving any help and support people need at home, thus reducing the need for admission to hospital. Darlington Clinical Commissioning Group Clear and Credible Plan

33 ISOP and CCP 4. ISOP and CCP 2012/13 is a pivotal year in the transition to the new commissioning structure with the PCT Cluster providing assurance and statutory responsibility for commissioning activities but having devolved responsibility for this to CCGs using a sub-committee arrangement. As part of the national assurance arrangements, the Cluster is required to produce an Integrated Strategic and Operational Plan which details how NHS commissioners within County Durham and Darlington will: 1) Continue to deliver the commissioning strategy and QIPP efficiencies 2) Maintain and improve performance including delivery of national priorities 3) Ensure safe transition to the new NHS. This plan outlines how the CCG will contribute to the delivery of objective 1 above whilst the ISOP outlines a series of cross-ccg approaches (signed up to by all CCGs in County Durham and Darlington) to deliver objective 2. These cross-cutting approaches for 2012/13 allow CCGs to continue to meet national requirements whilst giving us time to develop local approaches that fully meet the needs of the local populations for authorisation in October Cross-CCG approaches in Year 1 In Year 1 of this plan, the CCG will adopt cluster-wide approaches to the delivery and adoption of plans in the following areas: Ensuring Quality Maintaining and improving performance Delivery of Operating Framework priorities The IMT/Informatics Strategy As well as signing up to these common approaches in the ISOP in 2012/13, the CCG will develop locally specific approaches ready for the refresh of this plan in 2013/14. Darlington Clinical Commissioning Group Clear and Credible Plan

34 ISOP and CCP 4.2 Quality Darlington CCG recognises that quality of care is paramount to patients. During 2012/13 the CCG will work across the PCT cluster to deliver the quality agenda whilst developing a bespoke approach in Darlington in readiness for authorisation and beyond. Whilst the full County Durham and Darlington approach to quality can be found in the ISOP, key actions for the CCG in 2012/13 will be: Aligning the National Quality Outcomes Framework with the strategic aims in our Clear and Credible Plan Making use of the Legacy Document created by the PCT Cluster as part of transition Using Commissioning Support Unit (CSU) support to continue to deliver workforce assurance (using the national workforce assurance toolkit) and quality monitoring (e.g. Patient Reported Outcome Measures and Summary Hospital-level Mortality Indicator Monitoring) Identifying a quality lead from the clinical community within Darlington Taking on the leadership and delivery of the quality actions and risks within the transition plan Our approach to ensuring clinical quality The overall strategic aim is to improve the health and well-being of the population of Darlington. Clinical quality is viewed as an integral part of achieving this, ensuring that our patients experience safe and effective care and that their experience is positive across primary, secondary and tertiary care. Our primary goals are to: Immediately safeguard patients; Ensure continued provision of services to the population; Secure rapid improvements to the quality of care at failing organisations; and Drive up quality and foster a culture of safety across primary care As future commissioners, it is vitally important that we safeguard quality across primary, secondary and tertiary care. Second to the primary defence of first line staff, the commissioner s role as a contract manager is viewed as the next line of defence. In order to achieve this, we will ensure that the clinical quality, contracts and performance commissioning support teams, provide us with real time intelligence and the most up to date information in relation to clinical quality and agreed standards of care. Darlington Clinical Commissioning Group Clear and Credible Plan

35 ISOP and CCP In order that we hit the ground running, we will ensure that there is a robust system for handover from the PCT cluster that effectively captures and transfers organisational memory, and that the current systems and processes are adopted and adapted until our own clinical quality infrastructure matures. This journey begins with the appointment of an interim lead nurse, identification of a clinical quality lead, and joint working with the cluster board nurse and medical director. A key part of this process will be to understand and make best use of the cluster legacy documents and existing quality risks that are specific to Darlington and those that relate to the health system as a whole. Currently, there are separate compliance frameworks for different types of providers, we will look to utilise the forthcoming quality dashboard to achieve a much closer alignment and understanding of the health system as a whole. This type of approach will be more sensitive to quality issues, so that underperformance can be spotted and tackled through performance management routes and before it becomes a serious failure and requires a regulatory response. Our lead nurse and clinical quality lead and the named CCG clinical leads will all have a key role in understanding local and system-wide issues and ensure that correction action plans are put into place to maintain patient safety and provision of service. Whilst a quality experience is what we want to commission for our patients, we will ensure that the board understands its responsibilities, as set out by the National Quality Board, in responding to the early warning signs reported against our main providers and understanding their role in actively seeking assurance, through the quality infrastructure and processes, that remedial actions are being taken to keep patients safe. This will involve visiting providers to see that patients are being cared for in a safe and appropriate environment. The board will also look to see that leadership of our provider organisations are fully engaged in reviewing the quality of their health system and they are involved in setting improvement priorities and evaluating their impact as part of their Quality Accounts. Research and innovation will form part of what we do in the development and measurement of services both across primary and secondary care. We will make the most of existing research governance arrangements, but will also look to shape the areas of research undertaken across our academic and clinical networks to benefit us as commissioners. Darlington Clinical Commissioning Group Clear and Credible Plan

36 ISOP and CCP Positioning clinical quality in our everyday commissioning business Clinical quality is one of the key determinants when establishing the priorities for service developments. We will ensure that the intelligence gathered from clinical quality informs what services we choose to review and how any changes in service delivery will impact on quality and the broader healthcare system. The development of three clinical commissioning groups across County Durham and Darlington potentially fragments how quality is managed with our main providers. Whilst we can influence how patient experience is improved in our own locality, we need to have a proactive approach to work with our clinical commissioning colleagues across the whole population and with our neighbouring CCGs when necessary. In response to this and in partnership with our colleague across County Durham and Darlington, clinical quality will be governed on three levels: 1) Member practice, in order to drive up patient experience and service delivery, but also for member practices to consider quality information as a commissioner. 2) Clinical commissioning group, in order to have an overview of patient experience across member practice, but also to consider quality information as a commissioner and the impact of poor quality performance and experience on patients. This will inform future commissioning decisions and areas of escalation. 3) Pan clinical commissioning, to understand and respond to patient experience and safety issues across the health system. This will involve using the information gathered via the contract management processes and daily reporting events, as well as, dealing with national reporting. It will be the role of the clinical commissioner to balance the matrix of quality (shown below) and ensure that member practices understand their contribution and the assurance routes for delivery. Quality Matrix Improving patient safety & experience primary care practices Primary care development as commissioners Increasing provision in primary care Contractual management of quality through performance Pan CCG focus CCG focus Member practices focus Darlington Clinical Commissioning Group Clear and Credible Plan

37 ISOP and CCP In Darlington, we will have a documented approach to clinical quality, it will deliver both a framework for assuring the board that there are systems, processes and resources in place to ensure that clinical quality is managed across commissioned and contracted services and that we have a continuous improvement approach to drive up quality across providers and primary care. The approach will also demonstrate how the key elements of quality, as outlined in the NHS Outcomes Framework as well as in High Quality Care for All patient safety, patient experience and effectiveness of care, will be governed through our CCG structure and constitution. The NHS Outcomes Framework 2011/2012 set out the five national outcome goals. We know that the NHS Commissioning Board will use these domains, through the emerging national quality dashboard, to monitor progress and safety of commissioned services. We will use the domains of quality outcomes to align our strategic leadership (shown below) and to inform our local improvement programme. Strategic leadership of the clinical quality domains Domain 1 Preventing people from dying prematurely Domain 2 Domain 3 Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Effectiveness Clinical quality lead Domain 4 Ensuring that people have a positive experience of care Patient Experience lead nurse Domain 5 Treating & caring for people in a safe environment and protecting them from avoidable harm Patient Safety lead nurse Source: NHS Outcomes Framework 2011/2012, DH, 2010 It will be the responsibility of our CCG board to ensure that the delivery of the indicators above and areas for improvement, within each of the 5 domains, are achieved through the commissioning of quality healthcare and escalation of poor performance. The monitoring of such areas will be structured through our quality group, existing information flows, partnership involvement and contracting performance mechanisms, which we are already members of. Darlington Clinical Commissioning Group Clear and Credible Plan

38 ISOP and CCP In Darlington, clinical quality is already discussed at our commissioning group and our emerging governing body. Discussion at these forums will help our executive and member practices become fully appraised of the quality agenda, related areas of concerns and agreed areas for escalation with providers. The information shared through the commissioning support team will also be used to inform the decisions we make as commissioners. The local quality forum will continue to examine the intelligence, national and local quality standards and oversee the strategic delivery of an effective quality assurance process across our own clinical commissioning group. When necessary this forum will take action and make recommendations for areas of improvements, as part of the commissioning cycle to the commissioning group and emerging governing body. This will be a joint approach with the clinical quality lead, lead nurse, members of the commissioning support team and senior commissioning lead. Locally, the CCG quality lead and lead nurse will understand quality issues and the potential impact they have on patients so they can keep the Board and member practices appraised of such matters. The contractual management of quality will continue to be centrally governed through provider quality review groups and contract performance meetings. The future leadership of these groups will involve the lead clinical commissioner and the CCG lead nurse. The CCG lead nurse will have a global overview of the health system and provider performance. The CCG understands the importance of good collaborative working with other commissioners, particularly other local and regional CCGs and the emerging NHS Commissioning Board. In relation to the quality of commissioned services as a whole, we will strive to maintain an overview of the health system through the emerging clinical quality infrastructures, but also through a health system-wide forum which will bring together the lead nurse, CCG clinical quality leads and commissioning support staff to understand the effectiveness of services, trends of performance and make recommendations for improvement via the contract management and quality review forums. The first major piece of work we will prepare to deal with, under the supervision of the PCT Board nurse and medical director is the second report following the review of Mid Staffordshire Francis 2 due in May/June of this year. The outcomes for improvement will be monitored through the existing quality review groups. Darlington Clinical Commissioning Group Clear and Credible Plan

39 ISOP and CCP In order for us to be effective as commissioners we need to continue to actively use the current reporting system (Safeguard) and tools to foster a culture of reporting patient concerns, contracting issues and patient safety incidents or near-misses to benefit the commissioning cycle as a whole. From which, we will be able to undertake a combined approach to investigating the root causes of issues and communicate the lessons learned to commissioning staff (as well as providers). We see that the information gained through the clinical quality system as being key to the decisions we make on commissioning and decommissioning of services in the future: putting patient safety, patient experience and clinical effectiveness at the heart of local commissioning process. Darlington Clinical Commissioning Group Clear and Credible Plan

40 ISOP and CCP 4.3 Driving up quality in primary care One of our primary goals will be to drive up quality in primary care. Not only will this aim to foster a culture of patient safety, but also to improve the experience of patients through the reduction of variation in practice. Although the NHS Commissioning Board will be responsible for the commissioning of primary care services and the performance register, the CCG will continue to drive innovation in primary care and manage a programme of continuous improvement to improve the quality of provision in general practice. This work will be the primary responsibility of the clinical quality lead, but will engage and secure local leadership from across the GP practices. 4.4 Performance As part of the transition from PCT to clinical commissioning, Darlington CCG has undertaken a review of the headline performance metrics that describe how the system is working for our patients. This transition will be phased over the life of the clear and credible plan. In the early months of Year 1 of the plan, we will assume direct accountability for the performance across a range of key areas. These measures are: 18 Week RTT 95th Percentile Cancer 62 Day Waits C. Difficile A&E 4 Hour Waits Ambulance Category A response rates Mixed Sex Accommodation Stroke patients spending 90% of time on a specialist ward Choose and Book Darlington Clinical Commissioning Group Clear and Credible Plan

41 ISOP and CCP Performance in these areas going into the planning period is RAG rated as follows: RTT admitted 95 th percentile 62 Day Cancer C-diff A&E 4 Hour Mixed Sex Accom Ambulance Cat A Stroke Choose & Book Utilisation Darlington CCG C. Difficile C. Difficile has been a very challenging target in 2011/12. On behalf of the CCG the CSU has put in place escalation processes and key priorities for action including Strengthening antibiotic prescribing stewardship in primary care Targeted work in care homes with an increased incidence (actions such as education and training to reduce the risk of transmission of C. Difficile between residents) For 2012/13 the Operating Framework has set a tighter non-negotiable target for C.Difficile which underlines the essential collaborative working required across the CCGs in Durham and Darlington to share best practice and review any areas for improvement locally. Choose and Book When properly implemented, Choose and Book (C&B) can provide significant benefits not only for patients, but also for referrers, providers and for the wider NHS, by delivering choice, certainty, security and reliability. Although the usage of C&B in Darlington is good, there is some degree of variation between Practices in the manner in which the system is applied. Darlington CCG will continue to encourage GPs to utilise C&B when referring patients and will work with the CSU to successfully implement any recommendations from the County Durham and Darlington C&B Steering Group. Hyperacute Stroke Towards the end of 2011 there was a major change for Darlington residents with respect to hyperacute stroke service provision. Following a full consultation exercise by NHS County Durham and Darlington the provision of the immediate acute care phase of a patient with a stroke was transferred to the University Hospital of North Durham. As the future commissioners Darlington CCG are eager to understand and monitor any immediate and longer term quality impacts that the reconfiguration has demonstrated specifically for the population of Darlington. We will build this into our performance reporting framework Darlington Clinical Commissioning Group Clear and Credible Plan

42 ISOP and CCP alongside any other local service redesign initiatives set out in our plan and which we implement over time. These requirements over and above that already provided within the standard reporting framework will be agreed with the CSU and specified as part of our service agreement. We believe that involvement of local clinicians in the performance monitoring and reporting system will ultimately influence sustained improvements in performance. As previously mentioned as a first step Darlington CCG has identified a lead GP for clinical quality who will lead clinical quality review meetings with providers to drive up improvements in performance as part of the contract performance monitoring process. 4.5 Delivery of Operating Framework Priorities The NHS Operating Framework for 2012/13 outlines the key challenges facing the healthcare commissioners. Emphasis is given on the requirement nationally to deliver the QIPP agenda to make up to 20 billion of efficiency savings by 2014/15 in order to continue meet growing demand and continue improving quality. Particular areas of national policy focus for 2012/13: Dementia and care for older people; Carers; Heath Visiting and Family Nurse Practitioners; Military and Veterans Health. Darlington CCG will work collaboratively with other CCGs and partners to deliver the above. Darlington CCG has taken on the role as the lead CCG for Military and Veterans Health for County Durham and Darlington and will ensure delivery of the agreed action plan. The Operating Framework also emphasises an outcomes based approach and lays out the five high level domains that will form the NHS Outcomes Framework which include: Preventing people from dying prematurely; Enhancing quality of life for people with long term conditions; Helping people to recover from episodes of ill health or following injury; Ensuring that people have a positive experience of care; Treating and caring for people in a safe environment and protecting them from avoidable harm. Darlington Clinical Commissioning Group Clear and Credible Plan

43 ISOP and CCP In the forthcoming year we have identified opportunities to address these areas for example the Health Visitor and Family Nurse Practitioners expansion programme is being delivered across three CCGs in one efficient work stream. The outcome domains within the framework line up to a significant extent to our CCGs overarching strategic aims: Improving health of our population would prevent people dying prematurely; Tackling the challenges of the ageing population provides greater emphasis on those with long term conditions improving their quality of life; Making services more responsive and accessible to our communities' needs will have the effect of increasing their experiences of the care that they receive. This alignment is presented as Plan on a Page (see page 66) 4.6 Informatics Strategy Darlington CCG recognises that informatics and information technology are key enablers in delivering improvement in both service quality and outcomes for patients as well as improving efficiency in for providers and commissioners. Darlington GP practices have a good track record of working collaboratively for informatics solutions such as the comprehensive deployment of SystmOne clinical system for all Darlington practices as well as national programmes such as Summary Care Record, NHS mail, Electronic prescribing and Choose and Book. In the commissioning environment Darlington CCG will build on these experiences to ensure that informatics solutions: Support the implementation of our strategic initiatives Provide the information necessary to manage demand on health care services Deliver the national priorities outlined in the current and previous Operating Frameworks for England Supporting implementation of our strategy For initiatives undergoing implementation in 2012/13, our CCG has fully considered the IMT implications to ensure successful delivery. Examples of this include: The development of an e-learning self-management tools for diabetes The development of the Points tool for COPD patients as a quality indicator of condition management Darlington Clinical Commissioning Group Clear and Credible Plan

44 ISOP and CCP Supporting demand management High quality information is vital to enable clinicians to make informed decisions when undertaking commissioning to manage demand on the local health service. Our CCG will: Continue with the interpretation training for CCG members using RAIDR. This training will support clinical decision making to address unnecessary variation in patient pathways, outcomes or quality of care. Trial the use of the LACE module within RAIDR as a predictive modelling tool to identify patients with a higher risk of admission/re-admission to secondary care using a national recognised algorithm. We plan to implement the LACE tool in 2012/13 and evaluate its effectiveness. Utilise Map of Medicine (MoM) where it is appropriate to do so to support the introduction of new best practice and evidence based pathways. The learning from the MSK carpel tunnel pathway will be used to further develop MoM across a range of pathway redesign initiatives. In June 2012 Darlington practices will achieve complete deployment of SystmOne as the preferred clinical system. This will enable information sharing across the CCG and facilitate numerous initiatives where comparative data and information is required for quality impact measurement, audit and evaluation. Darlington CCG has developed and implemented a bespoke GP intranet which is used to share information, facilitate discussion and information/data transfer between member practices. The commissioning section of the Darlington GP intranet is to be further developed to enable storage and retrieval of essential commissioning information as well as the evidence repository for the CCG authorisation process and beyond. Darlington Clinical Commissioning Group Clear and Credible Plan

45 ISOP and CCP Delivering national IM&T priorities Darlington CCG will support the continued implementation of national programmes such as: Summary Care Records (SCRs). SCRs have many benefits for patients and healthcare staff by providing access to health information that has previously been unavailable and enabling better informed clinical decision making. Electronic Prescribing (EPS). This service will allow prescribers to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice, making the prescribing and dispensing process safer and more convenient for patients and staff. Choose and Book. The NHS Constitution sets out choice as a right and the Operating Framework for the NHS in England 2012/13 states that there should be a presumption of choice for most services from 2013/14. When properly implemented, Choose and Book (C&B) can provide significant benefits not only for patients, but also for referrers, providers and for the wider NHS, by delivering choice, certainty, security and reliability. Securing informatics and IMT support and further planning Darlington CCG recognises the need to have an appropriate level of informatics and technology support to enable our commissioning initiatives as well as support our wider statutory functions as a clinical commissioning group, in particular information governance responsibilities. Our CCG will develop a service level agreement (SLA) with the North East Commissioning Support Unit for the appropriate level of IMT/Applied Informatics support and implementation services for both the commissioning functions of the CCG and the business development needs of primary care as we look to re-shape the health economy. This will include a review of the potential of telemedicine to support better management of long term conditions and in moving care closer to patients homes. The initial SLA will be in place by the end of April For full details of these approaches, see the NHS County Durham and Darlington Cluster Integrated Strategic and Operational Plan Year 2 Refresh. Darlington Clinical Commissioning Group Clear and Credible Plan

46 Defining our Strategic Aims 5. Defining our Strategic Aims Based on the assessment of our populations health need, demographics, financial considerations, service performance and the insight of clinicians and patients we feel that the case for change is clear. To determine our course of action, we have reviewed this evidence with the national policy direction laid out in the Operating Framework for the NHS in England 2012/13. This review was then supplemented by two SWOT analyses, one of the external environments that our CCG will be commissioning in and the other internal capabilities of our CCG itself. 5.1 External SWOT analysis A SWOT analysis was carried out against each of the strategic objectives with a risk assessment made against each opportunity and threat. The full detail of these drivers and analysis is as follows. Darlington Clinical Commissioning Group Clear and Credible Plan

47 Defining our Strategic Aims Darlington Clinical Commissioning Group Clear and Credible Plan

48 Defining our Strategic Aims 5.2 Internal SWOT analysis - capacity and capability In order to assess our internal capabilities we have taken advantage of a range of organisational development events, diagnostic events and strategic planning events involving GPs from the Darlington locality as well as practice managers, other clinical staff and senior commissioning support staff from the PCT. The diagnostic events used a nationally recognised self-assessment tool to enable reflection on values, culture and wider organisational health. The tool describes six domains recognised as authorisation criteria. The average scores from the self-assessment were as follows: Domain Average Score Maturity level 1 Clinical Focus and Added Value 32% Getting started 2 Engagement with Patients / Communities 40% In development 3 Clear and Credible Plan 30% Getting started 4 Capacity and Capability 24% Getting started 5 Collaborative Arrangements 40% In development 6 Leadership Capacity and Capability 34% Getting started The assessment scores were reflective of those expected of a newly formed organisation. We then assessed our strengths, weaknesses, opportunities and threats at a strategic planning event in early November Clinicians and other staff from the Darlington Practices attended this event alongside the CCG commissioning support staff to have a collective view on 1) Our current internal capacity and capability to achieve authorisation and beyond 2) Immediate and future development needs to support delivery of the clear and credible plan Darlington Clinical Commissioning Group Clear and Credible Plan

49 Opportunities Threats Strengths Weaknesses Defining our Strategic Aims The key areas from the internal analysis are outlined below and have helped to form the case for change and strategic aims and initiatives of the plan. The analysis takes account of our current and future organisational capabilities to lead commissioning of health care in the new system. All GP practices engaged Commitment to a collective approach one Darlington practice Size and Geographic coherence Single LA-co-terminous Strong sense of identity Commissioning experience through pathfinder projects Pathfinder working with LA and voluntary sector Clinical leadership (need more) Emerging understanding of needs of the population Size and lack of finances Lack of succession planning Evolving organisation Large single provider FT Small pool of staff resource Data analysis obtaining relevant data to inform commissioning decisions Perceived changes to Dr/patient relationship Impact on practices to support active engagement Lack of broader clinical engagement from nursing and other professions Do things differently Joint commissioning Collaborative working Strong clinically informed commissioning quality, safety and effectiveness Patient focus on outcomes and experience One Darlington Practice approach Shape provider landscape Adoption and spread of good practice Risk sharing with other CCGs Ability to manage public/patient expectations More organisational change (political) Lack of succession planning Conflict of interest issues Cost savings/financial environment Time and capacity to lead and implement change Other organisations well established (FT/LA) whilst CCG is learning This analysis has helped us to identify the initial priorities of our organisational development plan which not only ensures successful set up of our new organisation but also underpins the successful delivery of this clear and credible plan. The Darlington CCG Organisational Development (OD) Plan 2011/12 describes the full plans and timeframes for delivery. Full implementation of the OD plan will assist delivery of our clear and credible plan not only in terms of the capacity and capability to lead clinical commissioning but also to ensure delivery against priorities. Within our OD plan we have identified five key themes forming the building blocks for organisational development, namely:- Leadership [clinical and non-clinical] Board development Team development Intelligent commissioner Partnerships and Engagement/relationship management Darlington Clinical Commissioning Group Clear and Credible Plan

50 Defining our Strategic Aims In summary We have used the experiences of the pathfinder to further inform our commissioning approaches and we now believe we have a much greater understanding of the key issues and challenges for the health needs of population of Darlington. Our strategic aims have been developed through engagement and feedback from our member practices as well as key stakeholders, patients and the public. The two SWOT analyses have helped define the wider context of the strategic aims, the operational activities that will deliver them and the identification of support and development needs necessary to succeed in achieving our goals. Darlington Clinical Commissioning Group Clear and Credible Plan

51 Our Goals 6. Our Goals For each of our strategic aims we have set ourselves realistic yet ambitious goals by which we can measure our success. To measure success in improving the health status of people from Darlington we will use the following indicators: <75 All cause mortality Mortality amenable to healthcare <75 Cardiovascular disease (CVD) mortality <75 Stroke mortality <75 Cancer mortality To measure success in addressing the needs of the changing age profile of the population we will use the following indicators: Dementia prevalence Emergency hospital admissions: diabetic ketoacidosis and coma Hospital procedures: lower limb amputations in diabetic patients Bowel Cancer screening coverage Emergency hospital admissions and timely surgery: fractured proximal femur Emergency hospital admissions for chronic obstructive pulmonary disease Emergency hospital admissions for coronary heart disease Emergency hospital admissions for Long Term Conditions Hospital procedures: primary/ revision hip and knee replacements Hospital procedures: Cataract removal Vaccination: Influenza uptake for those over 65 years Delayed Transfers of Care To measure success in taking services closer to home whilst ensuring current services are accessible, timely and of a high level of quality we will use the following indicators: Number of new services commissioned from a primary care or community setting Cancer waiting times Referral to treatment waiting times Accident & Emergency Clinical Quality Indicators Choose and Book Ambulance Response Times Darlington Clinical Commissioning Group Clear and Credible Plan

52 Our Goals To measure success making the best use of public funding we will use the following indicators: Financial balance and achievement control totals on the commissioning allocation Securing commissioning support within the running cost allowance Delivery of CCG QIPP plans including demand management The following tables identify some examples of the headline public health measures, performance metrics and primary care measures that we help demonstrate success. Full performance monitoring to support the implementation of this plan can be found in the Deliver 2013 Darlington Delivery Plan. Darlington Clinical Commissioning Group Clear and Credible Plan

53 Our Goals Darlington Clinical Commissioning Group Clear and Credible Plan

54 Our Goals Darlington Clinical Commissioning Group Clear and Credible Plan

55 Our Goals Darlington Clinical Commissioning Group Clear and Credible Plan

56 Our Strategic Approach 7. Our Strategic Approach Our strategy has three key stages, is delivered through a series of programmes and initiatives and supported by the strengthening of partnerships, development of primary care and aligned enabling strategies. The three stages are: 1) Getting a grip of the system: Management of demand and cost control 2) Making best use of what we ve got: Reviewing services for effectiveness, redesigning priority pathways and disinvesting in poorly performing services to improve quality, access and value for money 3) Investing for improvement: Investing uncommitted growth funding and released efficiencies for long term health gain 7.1 Getting a grip of the system Our SWOT analysis and financial risk assessment has highlighted the need for Darlington CCG to make sure that we are managing the areas of spend with greatest variability inyear. These areas (secondary care activity paid for under payment by results (PBR) tariff, prescribing and Continuing Healthcare) are all funded through non-block contracts and over-performance in any of these areas can threaten the CCGs ability to deliver financial balance or draw resource identified for other purposes to provide a contingency fund. Contract Transitions - Stocktake, Stabilise and Shift Moving from existing PCT contracts to new contract arrangements under the authority of CCGs will require a significant programme of work by the CSU to securely transfer contracts and obligations for contract management over to the CCG by 1 April Each contract will need to be evidenced by a physical copy of the NHS standard contract. Our CCG will work closely with the CSU to ensure the contract transitions project is successfully concluded to minimise risk and satisfy all legal requirements. Darlington Clinical Commissioning Group Clear and Credible Plan

57 Our Strategic Approach Contracting for a realistic level of activity Darlington CCG has worked with the CSU contracting team to agree a contract mandate which will determine the negotiation strategy for each of the main contract areas. In particular, due to the variable nature of the payment mechanism (tariff), our CCG will continue the approach taken in Year 1 to agree realistic and affordable levels of elective and non-elective activity from secondary care providers. Planned Care activity In 2011/12, Darlington CCG saw a reduction in GP referrals associated first outpatient attendances but this was offset by an increase in referrals and associated outpatients from other (non-gp) sources. This overall increase in first outpatients also saw an increased conversion rate from 2010/11 which led to a significant increase in elective activity (12.7% increase on G&A specialties using month 9 MAR data). The CCG intention for planned care activity is to therefore commission a stable level of GP referral-led demand increased slightly to reflect the impact of extension of the national bowel cancer screening programmes, changes to the HPV screening pathway and from the identification of unmet need (e.g. through the Health Checks programme). Growth in ophthalmology activity (which involves a long term treatment regime) has been identified in 11/12 and is expected to continue to grow in 12/13. There has also been increased day case activity linked to new NICE drug approvals for haematology and anti- TNF utilisation continues to grow. The Cluster also forecast an increase in referrals from other sources (which make up approximately 40% of all referrals) to reflect demographic changes and increase in screening services (e.g. retinal screening). Planned Care activity increases will be mitigated by our approach to demand management and QIPP transformation schemes outlined later in this plan. Darlington Clinical Commissioning Group Clear and Credible Plan

58 Our Strategic Approach Non-elective activity In 2011/12 Darlington CCG saw an unprecedented reduction in non-elective activity in the acute sector. Due to the high level of risk associated with non-elective activity (fewer contract levers and impact of patient behaviour etc.) we will plan for a similar planned level of activity as in 2011/12 but look to deliver the actual out-turn again in 2012/13. This will allow the CCG time to investigate the cause of the reduction in non-elective activity and to understand any re-classification of activity that may have happened during this time that will protect the CCG from over-committing itself in year 1 of the plan. The impact of business rules outlined in the Operating Framework regarding marginal tariffs and non-payment for a proportion of emergency readmissions has been factored in to these forecasts. Demand management In order to deliver the realistic levels of activity commissioned from the acute sector in 2012/13 we have identified a clear approach to demand management based on: Analysis of variance and adoption of best practice. Our CCG has now fully implemented the RAIDR business intelligence system that provides the information necessary to understand changes in referral patterns and spend across disease areas. We will direct the CSU via the SLA to supplement the information with analysis that identifies further opportunity to management demand potentially through the adoption of pathway changes implemented in neighbouring CCGs where it is appropriate to do so. Service re-design. Using activity analysis supported by softer intelligence from practices, pathway innovations will be introduced using non-recurring funding to pump prime and double run until robust evaluation and impact assessment can be carried out. Activity management through contract levers. We will direct the CSU via the SLA to introduce activity management arrangements with providers over-performing against contracted levels of activity that isn t caused by increased referrals from general practitioners. This activity management will bring providers back to contract levels or secure rebates to CCG budgets where adequate evidence cannot be given for any over-performance. Darlington Clinical Commissioning Group Clear and Credible Plan

59 Our Strategic Approach Where de-commissioning is necessary, our CCG will direct the CSU via the SLA to undertake a robust de-commissioning process that meets best practice identified by the National Audit Office and procurement legislation and involves wider stakeholders when appropriate. Prescribing Our prescribing processes will be as effective as possible to maximise patient safety and best utilise our prescribing budget. Darlington CCG in partnership with the CSU medicines management team has reviewed the National Prescribing Centre working document 2010 Ensuring the delivery of prescribing, medicines management and pharmacy functions in primary and community care and has agreed how the competencies and key functions will be delivered. Operational functions will be delivered at a locality level to ensure effective clinical engagement and the review of local prescribing data to eliminate unnecessary variation and share best practice. A number of strategic functions will be shared with neighbouring CCGs and will be delivered at a County Durham and Darlington level and North East Regional level, supported by the CSU, to ensure effective use of resources. The prescribing and medicine management agenda will be led by our local clinicians in the form of GP Prescribing Leads and practice prescribing leads within the CCG. The GP Prescribing Lead is supported by medicine management advisors employed by the CSU or by service level agreements to deliver the Prescribing Strategy and annual work plan. Local clinical engagement is arranged through the Locality Prescribing Sub-Group which is responsible for the delivery of the strategy and work plan, including QIPP targets, working within the agreed budgets. The Darlington CCG Prescribing Sub-Group will have clear governance and reporting arrangements currently under consideration as part of the overall governing body arrangements. Darlington CCG will develop a Prescribing Strategy and annual work plan including QIPP plan by June This will be based on available national and local guidance, including the King s Fund Report The quality of GP prescribing 2011 and local prescribing data analysis provided by the CSU, and will be shared and agreed with all local stakeholders. Darlington Clinical Commissioning Group Clear and Credible Plan

60 Our Strategic Approach Continuing Healthcare Continuing health care (CHC) spend continues to present a very significant challenge and cost pressure to our CCG, as it has for our PCT predecessors. Our primary goal is to ensure that we understand the process for allocating resources for packages of care and that we are assured that the process is consistent and delivers the right outcomes for patients. This area will continue to be a challenge and cost pressure in light of our aging population and increase in long tern conditions. We need to continue to work with our colleagues in the CSU to ensure that the budget takes into account these areas of growth. We will also work collaboratively across county Durham with our neighbouring CCG and the local authority to share our knowledge and insights and develop a plan. We have identified a lead clinician and have the support and expertise of the continuing healthcare team in the CSU to help us move forward. A working group across County Durham and Darlington will hold a number of meetings in the first 6 months of 2012/13 and develop proposals for the CCG to consider and agree. This work needs to include the work of DBC who also see CHC spend as a key pressure and risk. Given the variable and increasing costs with this area the CCG has entered into a risk sharing agreement for continuing healthcare via the Durham and Darlington Confederation to mitigate the potential impact. This approach combined with the clinical led working group will help us keep a grip of this area as well as plan for future years. Demand management in Year 2 and onwards Over the life of the Clear and Credible Plan, more tariff based contracts will appear as block contracts are replaced. Our CCG will direct the CSU through the SLA to assess the impact of this particularly for Ambulance and Mental Health Contracts to ensure adequate demand planning occurs for 2013/14. Darlington Clinical Commissioning Group Clear and Credible Plan

61 Our Strategic Approach 7.2 Making best use of what we ve got With fair and realistic levels of activity contracted before each year begins and demand management arrangements in place to mitigate against the pressure of an ageing and growing population, Darlington CCG will review a range of services each year to understand if they are delivering improved quality and health outcomes for patients whilst representing good value for money for commissioners. These reviews will run alongside the clinical strategy that will be developed in tandem with clinicians from a range of sectors to inform the re-design and in some cases decommissioning of existing services. 7.3 Investing for improvement Once demand is managed, variable costs controlled, services have been reviewed and existing pathways redesigned, our CCG will look to invest unallocated growth and released allocative efficiencies in long term health improvement on a recurring basis. This investment will be targeted on an evidence based approach and direct towards interventions and services that will give the greatest return on investment. When doing this, we will utilise a robust and transparent prioritisation process. 7.4 Prioritisation of attention, effort and investment We will utilise a robust, open and transparent process for the investment of funding (both from growth in allocation or release of allocative efficiency). The first level of prioritisation has already been undertaken as part of the planning round for 2012/13. This involved: The use of a robust prioritisation tool with weighted domains to rank initiatives Facilitated support from the CSU and public health partners Use of the Single Needs Assessment and other data such as practice health profiles Engagement from GPs and other clinicians within the CCG The output of the prioritisation exercise can be found in the financial appendix to this plan and reflected in the commissioning intentions for 2012/13. Darlington Clinical Commissioning Group Clear and Credible Plan

62 Programmes and Initiatives 8. Programmes and Initiatives The delivery of the strategic aims and goals through the strategic approach will be achieved through a broad range of CCG specific and cross-ccg commissioning intentions, service reviews, contract negotiations and partnership working organised into programmes. These programmes and initiatives build on the track record of delivery from the pathfinder projects and can be aligned to the PCT Cluster QIPP programmes outlined in the ISOP for 2012/ Track record of delivery The Darlington Pathfinder projects are already providing evidence of local clinical leadership and engagement underpinned by a better understanding of local population needs and system wide opportunities to improve patient outcomes and quality of service provided. This learning must be built upon to ensure that our CCG develops the knowledge, skills and mind-set to shape care and services that improve outcomes for Darlington. The key areas of the Darlington pathfinder which are to be carried forward as integral to the clear and credible plan are: Darlington MSK ICATS procurement MSK pathways- pan CCG lead Urgent Care integration COPD acute exacerbation pathway/ltc Strengthening strategic and operational partnerships with the local authority Darlington Clinical Commissioning Group Clear and Credible Plan

63 Programmes and Initiatives 8.2 Alignment for PCT Cluster ISOP QIPP Programmes The CCG will contribute to the delivery of QIPP through the improvement of clinical pathways as identified in the commissioning intention summaries in the strategic objective section of this plan. Progress on these initiatives will be reported as part of broad programmes of work to the cluster as described in the CDD Cluster ISOP. The Cluster QIPP programmes are: Transforming Planned Care: By re-designing elective pathways and managing variation as described in the demand management approach, the CCG will contribute to savings and cost avoidance for elective and planned care. Transforming Urgent Care: By reforming the way the urgent care system is delivered and through improved joint working with social care, the CCG will contribute to savings and cost avoidance for non-elective and unplanned care. Transforming care for patients with long term conditions and care for the elderly: By supporting patients to better their own long term conditions and providing more services in a community setting, the CCG will contribute to savings and cost avoidance for non-elective and unplanned care where patients are admitted to secondary care for exacerbation of their condition and elective and planned care where services are commissioned more cost effectively from primary care and community rather than acute settings. Transforming Mental Health and Learning Disabilities: The CCG will work collaboratively with other CCG in the cluster to introduce a range of liaison services between mental health, nursing homes and the acute sector. These evidence-based systematic reviews show that the use of liaison psychiatry services can help reduce length of stay, improve clinical outcomes and patient satisfaction in the adult population. In the elderly, return to independent living can be improved and subsequent health care utilisation, including emergency care activity and clinic visits, reduced. These services will also deliver the CCGs commitments to improve care for patients with dementia as outlined in the Operating Framework for the NHS in England 2012/13. Darlington Clinical Commissioning Group Clear and Credible Plan

64 Programmes and Initiatives 8.3 Demonstrating alignment of activities with our strategic objectives In order to deliver our strategic aims we have identified a range of commissioning intentions. Darlington practices developed intentions based on local health needs and service priorities utilising available information for Darlington (SNA, practice health profiles) and the clinical and patient insight they gain through work in general practice. The intentions were prioritised in a robust and transparent way using a tested prioritisation methodology with engagement and involvement from practices and clinicians to ensure maximum impact against priority areas. Many of these intentions built on the lessons learned and progress made in our pathfinder projects in 2011/12. Some of our intentions developed at practice level have been likewise identified by other CCGs and strengthened the case for County Durham and Darlington cluster wide intentions. The detail of each of the initiatives within these programmes of work will be found in detailed Case for Change (outline business case) documentation and supported by project plans for ensuring tracking and management of implementation. The schemes within these programmes will also benefit from analytical support that will help identify unmet need and the impact of the demographic changes so that the resulting service changes are reflective of future needs. In order to simplify the complex series of commissioning and operational activities the CCG will lead, direct and work in partnership on, we have produced a Plan on a Page as a communication tool. This plan can be found on page Working with neighbouring CCGs to share and spread good practice Darlington CCG fully understands and acknowledges the need for collaborative working across the cluster and pays equal attention to those cluster wide commissioning intentions as the sum of the parts for the benefit of the Darlington population. An example includes the recent community nursing review which is comprehensively looking at community nursing services across County Durham and Darlington led by the cluster on behalf of all the CCGs and involving lead clinicians from each of the CCGs. Another example is the acute exacerbation pathway for COPD- a County Durham and Darlington wide pilot which is informing commissioning intent for 2012/13. Where appropriate we will co-ordinate commissioning activities with neighbouring CCGs to ensure economies of scale, spread cost and maximise impact for specific programme areas. This may be done at service level (as in the review of community nursing) or across disease areas e.g. for patients with mental health needs and for those with learning Darlington Clinical Commissioning Group Clear and Credible Plan

65 Programmes and Initiatives disabilities. These programmes of work will be co-ordinated through the appropriate contract support lead with identified clinical leads within each CCG. Specialist commissioning such as Public Health, Children s commissioning and Mental Health are noted alongside our local initiatives. Darlington CCG recognises the key role these commissioning intentions have in filling any gaps identified in the health needs analysis which are not already covered by the Darlington initiatives. 8.5 Exclusions from our plan In the new healthcare system and clinical commissioning arrangements, a number of functions will not transfer from the PCT cluster to our CCG. Commissioning of Primary care (GMS/PMS, Optometry and Pharmacy), offender health and other specialised commissioning is likely to transfer to the National Commissioning Board and Public Health arrangements for Darlington will transfer to the Local Authority. Programmes and initiatives related to these areas do not therefore feature within this plan. Darlington Clinical Commissioning Group Clear and Credible Plan

66 Informatics Performance Improvement and Operating Framework Delivery Quality and Safety Programmes and Initiatives Darlington CCG Plan on a Page Vision Strategic Aim Outcomes Strategic Initiatives Working together to improve the health and well-being of Darlington 1. Improving the health status of people from Darlington 2. Addressing the needs the changing age profile of the population of Darlington 3. Taking services closer to home for the people of Darlington 4. Making the best use of public money within Darlington NHS Outcome framework (domain 1,3 and 5) 1. Preventing people dying prematurely 3. Helping people to recover form episode of ill health or following injury 5. Treating and caring for people in a safe environment and protecting them from avoidable harm NHS Outcome framework (domain 2 and 3) 2. Enhancing quality of life for people with long term conditions 3. Helping people to recover form episode of ill health or following injury NHS Outcome framework (domain 4) 4. Ensure that people have a positive experience of care Financial balance and delivery of QIPP Darlington Specific Public Health CROSS CCG PUBLIC HEALTH Long Term Conditions CROSS CCG LTC/JOINT COMMISSIONING/EOL Urgent Care Planned Care Clinical Care CROSS CCG - CHILDRENS CROSS CCG MENTAL HEALTH QIPP Programme 1. Review of local care pathway for the management of overweight and obese patients 1. Re-commission Tier 1 and 4 alcohol services 2. Expand community weight management services 3. Review and expand exercise on referral across County Durham 4. Commission maternal obesity brief intervention training 5. Commission physical activity interventions for pregnant and post-natal women 6. Pilot an enhanced 12-week smoking quitters service 7. Re-commission the Health Checks programme 8. Extend the national bowel cancer screening programme 1. Develop a patient-home centred acute exacerbation pathway for COPD 2. Review the children s asthma and wheezing pathway 3. Develop COPD clinics in a primary/community setting 4. Develop e-learning self-management tools for diabetes patients 5. Develop an integrated primary/community setting based diabetes clinic 6. Review intermediate care bed services in Darlington 7. Develop a clinical advisory and training service for nursing homes 8. Develop pulmonary rehabilitations services 1. Review of Community Nursing 2. Develop diabetes services in primary care (including insulin initiation) 3. Establish a gold standard framework for locality registers for those in last year of life 4. Partnership working with the Local Authority on joint priorities 1. Contribute towards the review the Darzi centre at Darlington 2. Co-locate Darlington urgent care and accident and emergency facilities 3. Review paediatric pathways from accident and emergency 1. Re-design and implementation of 4 MSK pathways 2. Review Darlington chiropody and podiatry services 3. Develop a cardiology clinic in a primary/community setting 4. Develop an ophthalmology clinic in a primary/community setting 5. Develop a primary/community setting erectile dysfunction clinic 6. Review pathway for paediatric physiotherapy and paediatric audiology 7. Develop an consultant advice service 1. Support provider-led developments to improve patient care 1. Implement the a call for action health visitor expansion programme and the expansion of the FNP 2. Review children and young people s OT, physiotherapy and SALT services 1. Align mental health staff to general practice 2. Improve equity of autism assessment and diagnosis 3. Deliver the dementia strategy 4. Expand improving access to psychological therapies 5. Re-commission out of area placements 1. Improved budget management through use of RAIDR tool 2. Improved use of medicines management service to control prescribing costs 3. Explore opportunities of integrated commissioning with Local Authority Cross-cutting Programmes Darlington Clinical Commissioning Group Clear and Credible Plan

67 Programmes and Initiatives Strategic Aim 1: Improving the health status of people in Darlington Overview The key actions that will improve the health status of people in Darlington: Partnership working with the Local Authority Establishing the Health and Wellbeing board and developing the Health and Wellbeing Strategy Working with the public health function through transition Improving access to, and use of, public health intelligence Influencing the behaviour of the public in regards to health and healthy lifestyles Delivering headline CCG initiatives in 2012/13 Partnership working with the Local Authority Our CCG understands the importance of, and has a track record of, good collaborative working with other commissioners and partners. Darlington CCG intends to deepen its already close working relationship with Darlington Borough Council in regards to their commissioning functions for local people and work has progressed to establish the Darlington Partnership in February Darlington CCG alongside the PCT as the current statutory NHS body are key partners in this arrangement. The ambitions and intentions of Darlington CCG demonstrate alignment and consistency with those strategic aims of One Darlington Perfectly Placed. As the two organisations come together as partners alongside other partners under the umbrella of the Darlington Partnership and the Health and Wellbeing Board it will allow for the organisations to use their own foundations and vision to influence and shape the vision and direction and the shared priorities in the form of a Health and Wellbeing Plan for Darlington. This will ensure we are best prepared to: support patients who need both health and social care engage in the commissioning of services that will move to be the responsibility of local authorities in 2013/14 (in particular Public Health and Children s Services) make best use of public resource and avoid cost-shifting between the health and social care sectors deliver our strategic aims Darlington Clinical Commissioning Group Clear and Credible Plan

68 Programmes and Initiatives Alongside the local authority and wider partners as part of the Darlington Local Strategic Partnership our CCG is taking forward three action priorities which are aligned to the Darlington Single Needs Assessment and reflected in the strategic aims of this plan. The three action priorities are: Alcohol Vocational Opportunities for Young People Ageing Working with the public health function through transition The CCG has worked through the Director of Public Health for Darlington and the aligned Public Health Consultant to ensure that local commissioning intentions and those from the NHS County Durham and Darlington Public Health function address the range of health challenges, particularly regarding the underlying causes of ill-health such as smoking and alcohol misuse. These commissioning intentions can be found in the strategic aims summary table. Using Public Health intelligence Darlington CCG will work with Public Health colleagues and the North East Public Health Observatory to develop specific tools to inform current and future commissioning. This would involve the use of current population data sets contained within existing strategic documents such as the Single Needs Assessment and the CCG population profile and the application of specific tools and techniques to manipulate the data to model future need and impact of current or potential commissioning intentions on specific population outcomes. Techniques such as comparative analysis and trend analysis would show specific deficits in outcomes and contribute to the analysis of the major contributory factors to early death and poor life expectancy. Modelling current and future trends of the key population health indicators would provide linear projections to future end points, and provide commissioners an insight into potential future outcomes and provide some insight into potential needs and service demands in Darlington in future years. The application of Scenario modelling, informed by the latest evidence base, will provide clinical commissioners with an assessment of the potential the impact of current interventions on the population outcomes as well as the impact of potential commissioning decisions. This would also enable the potential impact of other inputs such as economic or demographic factors to be factored into commissioning decisions and demonstrate some interdependencies that may exist. Darlington Clinical Commissioning Group Clear and Credible Plan

69 Programmes and Initiatives Behavioural change Public We will use what we know about our communities to engage with different people and groups in ways that best meet their needs, and to communicate messages which aim to improve health. We will utilise the intelligence gained through our engagement activities to ensure patients, carers and the public s experiences, views and opinions are integral to our planning and commissioning of services. We will also make us of links with demographic data held locally to support targeted engagement activity. By developing our relationships with partners and providers and our engagement with communities, we will be able to better record the information we receive which in turn will help us to increase the impact we have on shaping local health services and health outcomes. We will develop working relationships between the CCG and Commissioning Support functions to ensure that patient experience data requirements are clearly included in service specifications and provider contracts; and are linked to performance and quality improvement. We will also work in partnership with public health and health prevention professionals to actively contribute to the health prevention agenda through collaborative social marketing approaches. Darlington Clinical Commissioning Group Clear and Credible Plan

70 Programmes and Initiatives Headline Initiatives for 2012/13 Project Name CCG Delivered by 1. What is the proposal and summary rationale? 2. Current Status and Cost 3. Consideration of Options 4. Proposed Service Model and Implications Implement the a call for action health visitor expansion and family nurse partnership expansion programme Darlington CCG NE CSU on behalf of Darlington CCG This proposal is the delivery of a national priority within the NHS Operating Framework. The operating framework states, PCTs should ensure they develop effective health visiting services, with sufficient capacity to deliver the new service model to be set out in the Health Visitor Implementation Plan A Call to Action (p.33). A national increase in health visitors by 4,200 by April 2015, Locally equating to 39 additional health visitors across County Durham and Darlington. There are currently wte Health Visitors (HV) employed by the County Durham and Darlington Foundation Trust (as at 31st March 2012). This includes 22 Practice Teachers (PT) and increased Family Nurses (FNP). The current service is for 0-4 year olds, delivering a historical service model. Patients access the service through hospital midwives or their general practitioner. Employed by CCDFT community services arm but some specialist health visitors work on complex cases are in Acute. The current service costs 15,861,000 on block ( 2.296m Darlington; County Durham. The capacity of the current provision does not meet the DH guidance in A call to Action p4/7. The current level of Community Practice Trainers meets the learning needs of the trainee s throughput necessary to meet the health visitor directive. The aim of the new expanded service is to meet the requirements of the A call to Action plan to provide additional health visitors in County Durham and Darlington over the next three years and provide the necessary training infrastructure through additional community practice teachers. The new service model will deliver the full scope of the healthy child programme. There is an additional cost to deliver the HV expansion programme which has been agreed. The HV definition allows the inclusion (previously excluded in the baseline data cleanse) of HVs working in Safeguarding (13.5 wte) which will increase the nos. of HVs to 161.0wte in 2012 and the additional 22 wte posts the PCT agreed to invest from 1st April 2012 across County Durham & Darlington with CDDFT will bring the nos. of HVs up to 183.0wte which will exceed A Call to Action target in 2012/13 of 179.5wte. 5. Risks 50% of the current health visitor workforce is close to retirement age putting achieving the requirement at risk should these attrition rates increase suddenly. Darlington Clinical Commissioning Group Clear and Credible Plan

71 Programmes and Initiatives 6. QIPP Implications Quality: A more comprehensive service will be provided Innovation: An integrated service model of delivery Productivity: The health visitor will be delivering a better value for money service Prevention: Supporting the delivery of the public health outcomes framework (prevention agenda) 7. Key Milestones New Service specification April 2012 Delivery programme to train staff start April 2012 Phase out HV Imms and Vacs September 2012 Delivery programme to train staff end September 2012 New student nurses start October 2012 Project complete October 2012 Darlington Clinical Commissioning Group Clear and Credible Plan

72 Programmes and Initiatives Summary of activities that will deliver this strategic aim: Strategic Aim: To improve the health status of the people of Darlington Link to case for change: Premature Cancer, Stroke and CHD Mortality are greater than the England average. Prevalence of Heart Failure, CHD, Obesity, Hypertension, Diabetes and Cancer are greater than the England average. Population change Health need Patient insight Clinical insight Premature mortality rates for the biggest killers (heart disease, cancer and stroke) in Darlington are higher than England. Cardiovascular disease (CVD) and cancer account for 63% of early or premature deaths in Darlington. Life expectancy for men living in the most deprived areas of Darlington is over 13 years lower than for men living in the least deprived areas. Service issue/opportunity What we ll be doing to address this in the next five years: Year 1 (2012/13) Darlington CCG Specific Commissioning Workstreams Reviews Pathway Re-design Pilots New Services Align mental health staff to GP practices- (to be led by mental health commissioning team) Urgent care provision within primary care and nursing/care homes Community bed provision including intermediate care beds. Primary/ Community diabetes pathway Personality disorder pathway Asthma and wheezing pathway (under 16) Psychosexual counselling provision Erectile dysfunction pilot (link to CVD and diabetic prevalence) Community COPD clinic Community diabetic clinic Extend sexual health clinics (Intrahealth proposal) On-line diabetes education tool. Podiatric surgery in a community setting (from Sedgefield pilot) Diabetic foot care (Grey text intentions dependant on outcomes of review/pilot) CCG Initiatives Agreeing primary care pre and post COPD exacerbation pathways Agreeing primary care pre and post asthma exacerbation pathways for under 16 Continue with embedding best practice via POINTS tool for COPD management Darlington Clinical Commissioning Group Clear and Credible Plan

73 Programmes and Initiatives Cluster Working (2012/13) Working collaboratively with other CGGs across County Durham and Darlington Public Health: Expansion of Weight Management Services; Review and Expand Exercise on Referral Programme; Pilot a 12 smoking week quitter service; Re-Commission Healthchecks Programme; Full Cost Benefit Review of Public Health Services. The PCT Cluster Children s Commission Team: Expand the Health Visitor Programme; Commission Maternal Obesity Brief Intervention Training; Commission Physical Activity Interventions for Pregnant and Post Natal Women; Safe at Home Project; Review Maternity Services; Increase Access to Breastfeeding; Commission Childhood Obesity MEND Project. PCT Cluster Mental Health Team: Align Mental Health Staff to General Practice; Improve Access to IAPT; Improve Equity of Autism Assessment and Diagnosis. Contracting intentions: Expansion of the national bowel cancer screening programme National campaigns: Public Awareness campaigns for Bowel Cancer, Throat Cancer and Mouth Cancer (check!) Contribution from Partners (2012/13) Working with partners for a common cause Local Authority: Section 256; etc Providers: CDDFT; TEWV; 3 rd sector etc.. Darlington CCG will fully engage with partnership working to support the delivery of this strategic objective. Year 2 (2013/14) Proposed year 2 Darlington CCG Workstreams Reviews Pathway Re-design Pilots New Services Weight management / Integrated obesity pathways Paediatric pathway for non-elective emergencies Paediatric pathway to improve access to physiotherapy services and audiology services rapid advice service Community ophthalmology service Community cardiology clinic Pilot for primary care urgent care provision including nursing and care homes. Community bed provision including intermediate care beds Pulmonary rehabilitation (countywide provision) Community COPD clinic Community diabetic clinic Erectile dysfunction clinic On-line education tool for diabetes (Grey text intentions dependant on outcomes of review/pilot) Darlington Clinical Commissioning Group Clear and Credible Plan

74 Programmes and Initiatives Year 3-5 (2014/ /18) Proposed year 3-5 Darlington CCG Workstreams Reviews Pathway Re-design Pilots New Services To be determined To be determined To be determined Community ophthalmology clinic Community cardiology clinic Primary care support for urgent care provision at nursing and care homes rapid advice service. (Grey text intentions dependant on outcomes of review/pilot) What we ll measure to see if it s working: NHS Outcome framework (domain 1,3 and 5) 1. Preventing people dying prematurely 3. Helping people to recover form episode of ill health or following injury 5. Treating and caring for people in a safe environment and protecting them from avoidable harm A Call for Action Indicators - <75 All cause mortality - Mortality amenable to healthcare - <75 Cardiovascular disease (CVD) mortality - <75 Stroke mortality - <75 Cancer mortality Darlington Clinical Commissioning Group Clear and Credible Plan

75 Programmes and Initiatives Strategic Aim 2: Addressing the needs of the changing age profile of the population of Darlington Overview The key actions that will help address the needs of the changing age profile of the population of Darlington are: Strengthened joint commissioning including use of the Joint Fund and re-ablement funding Implementation of our headline initiatives for 2012/13 Implementation of Cross-CCG initiatives for 2012/13 Joint Commissioning in Darlington There are many opportunities for health and social care improvements to be led by jointly involving health and local authority commissioning. We will look to work closely with our local authority partners to fully understand the services that are currently jointly commissioned between health and social care. There is a well-established Joint Strategic Commissioning Group in place in Darlington which has focussed on a small number of joint priorities around adult services and strategies and action plans. The work plan of this group determines the work priorities of the joint funded strategic commissioning manager who has dual accountability to both the PCT (CCG) and DBC to deliver agreed outcomes. This arrangement will need to be refreshed as the commissioning environment changes to ensure the priorities, responsibilities and governance arrangements are aligned. A key feature of joint commissioning will be to understand the impact the schemes funded through the Fund for Joint Working on Health and Social Care that was given to PCTs to passport to local authorities using a Section 256 agreement. This fund was made on a two-year non-recurring basis for 2011/12 and 2012/13. This funding was directed to be used to develop new services and ensure the maintenance of current services that make an impact on issues identified in the Single Needs Assessment. The Operating Framework has confirmed that this funding shall be made available again in 2012/13, 2013/14 and 2014/15 but on a non-recurring basis so an assessment needs to be made against the schemes evaluated and their quality impacts and outcomes and also the potential impact of the withdrawal of funding for each of the services funded by this allocation in 2015/16. Plans will then need to be made to mitigate the risk of withdrawal of the service or to jointly identify alternative sources of funding unless new guidance is received. Darlington Clinical Commissioning Group Clear and Credible Plan

76 Programmes and Initiatives The focus for the use of the Joint Funding in 2012/13 will be: Review the provision of community beds in Darlington Support the Integration of Intermediate care beds Development of a re-ablement team Provide supported hospital discharge Another area of potential joint working is on the re-ablement agenda. National funding has been made available to support the better re-ablement of patients waiting for discharge for a hospital setting. We will build on the work already undertaken across Health and Social Care to make best use of this investment. The focus for re-ablement in 2012/13 will be: Year of care tariffs in primary care, where primary care agencies are given an annual budget to spend on individual patients who are known to make extensive use of health and social care services. This would build upon the findings of the bespoke patient and carer engagement exercise commissioned and delivered in 2011/12. Year of care tariffs in primary care are a proactive approach which harnesses primary care knowledge of the patients and expertise to provide a patient-centred, joined up approach across all health and social care provision, CCG commissioning intentions where these meet the three criteria for re-ablement funding (ensuring timely discharge from hospital, maximise independent living and reducing avoidable hospital readmissions) Project Name CCG Delivered by 1. What is the proposal and summary rationale? Acute Exacerbation Pathway for COPD Darlington CCG Darlington CCG A working group was assigned to look at how to reduce emergency admissions by 20%, reduce LOS and the number of re-admissions. Based on the Easington pathway, the multi-disciplinary group redesigned a care pathway that could be rolled out across all the localities. The rationale for this pilot is to understand whether a rapid response service will reduce the number of emergency admissions for people exacerbating with COPD and improve the care pathway with improved outcomes for patients. Darlington Clinical Commissioning Group Clear and Credible Plan

77 Programmes and Initiatives 2. Current Status and Cost This pathway has been established in Easington and from the data we collected 63 patients in Easington were admitted onto the pathway of which 57 (90.5%) had no admission or A&E attendance recorded after being discharged from the pathway. Average LOS in Easington in for COPD was 6.33 days. Based on this average LOS and an average cost of admission- these 57 patients who were treated via this pathway saved 360 bed days and approximately 132,354. This pathway has the potential to make significant savings from admissions and readmissions and will help to reduce the number of beds required in a secondary care setting. Based on these early indications, a pilot of 6 months is proposed from 1st October 31st March within existing nursing resources across all localities to establish a robust data set to evaluate thoroughly the impact both from a commissioner perspective and a provider one, as this pilot will then give clearer indication as to the longer term viability of funding this pathway. Initial short term set up costs for small pieces of equipment have been agreed to be funded from Darlington s transformation fund (11.5k) 3. Consideration of Options 4. Proposed Service Model and Implications After the pilot has completed, an options appraisal as to the best way forward for commissioning this service will be documented and assessed With efficiencies generated we can reduce admissions for patients exacerbating with COPD, then the proposal would be to go via a contract variation to add a service specification into the current provider contract Current Activity and costs at locality level: The table shows an indication as to the cost of COPD admissions across all locality areas COPD led to 2072 emergency admissions in , costing 4.7m Locality Admissions Total Bed Days Excess Cost Bed Days ( '000) Cost of EBDs ( '000) Durham Dales Darlington Derwentside DCLS Easington Sedgefield Co. Durham & Darlington Number and cost of emergency COPD admissions by locality 2010/11 5. Risks The risk of not proceeding with the proposal is non-delivery of Darlington Clinical Commissioning Group and non-delivery of contributing to ISOP QIPP target, however the risk. Darlington Clinical Commissioning Group Clear and Credible Plan

78 Programmes and Initiatives 6. QIPP Implications Quality: Contribute to care closer to home agenda Innovation: A more responsive service to meet patients needs in times of crisis. Productivity: A reduction in COPD related non-elective emergency admissions Prevention: Enhanced patient experience, shift from secondary care reliance to a service that is more closer to home for patients 7. Key Milestones A pilot began in December 2011 with the expectation to go live in October/November 2012 (dependant on project evaluation) Project Name CCG Dementia Services Darlington CCG Delivered by 1. What is the proposal? 2. Consideration of Options NE CSU on behalf of Darlington CCG The operating framework 2012/13 makes explicit the requirement to focus on dementia care with specific reference to improving diagnosis rates, reducing unnecessary hospital admissions, improving dignity in care for patients, giving staff appropriate training, reducing inappropriate prescribing of antipsychotic medication and improving overall quality of life for older people with dementia. Additionally the national strategy for mental health No Health Without Mental health makes clear the requirement to address the interface between physical and mental health. The proposal has two separate but aligned models of working with associated costs and KPI s, a care home liaison proposal which has already been approved and an acute care liaison project. 1. Care Home Liaison Service Proposal: The philosophy of the service will be to develop and deliver consistent person-centred mental health care to older people in Care Homes across County Durham and Darlington. 2. Acute Care Liaison Service Proposal: The service will be a single seamless service across Adult Mental Health and MHSOP, there will be a number of sub specialities; A+E, DSH, Chronic Somatisation (MUPS), Ward base liaison, Dementia, Delirium and Depression. A comprehensive model will include work related to alcohol associated problems; however the exact nature of this cross working needs to be developed. LD the service model will ensure Greenlight principles are followed. The Liaison role will include links with LD services. 3. Proposed Service Model and Implications 1. Care Home Liaison Service Proposal: The model would offer short term assessment and interventions for acute inpatients. Depending on the clinical presentation follow up and further therapeutic interventions will be offered depending on the level of need. When required the service will facilitate effective Darlington Clinical Commissioning Group Clear and Credible Plan

79 Programmes and Initiatives transfer to specialist mental health services, either in secondary care, crisis services, IAPT, care home liaison, older person CMHTs. The service will also enable timely discharge by providing intense mental heal support to older people in their own homes in the immediate post-discharge period. 2. Acute Care Liaison Service Proposal: Agree and establish core data and baselines required for project outcomes/engagement with acute trust and key stakeholders re project/recruit project Management/Project Manager to develop implementation plan QIS principles to underpin each stage of implementation/complete workforce development plan In excess of 4m funding has been identified to fund the programme across County Durham and Darlington, of which a significant proportion is a re-direction of technical QIPP efficiencies 4. Risks 1.The project will require partnership approach between TEWV and CDDFT 2. Accommodation required in YHND and on acute wards with networked access to TEWV IT systems/need to review CQUIN targets to ensure KPIs reflect as appropriate/engagement with acute trusts and key stakeholders/others to be identified 5. QIPP Implications 1.Care Home Liaison Service Proposal: Quality: Reduction in the levels of prescribing of anti-psychotic medication in dementia through working collaboratively with primary care colleagues (Operating Framework 2012 P12 Section 2.8) Innovation: Increase the number and range of meaningful activities provided within care homes and make provision for a programme of education and skills development to the Care Homes workforce. Help care home staff to develop the skills needed to manage Behavioural and Psychological symptoms of dementia Productivity: Increased rates of detection of dementia and other mental health problems Prevention: Reduction in Falls and in turn a subsequent reduction in emergency admissions, reduce the number of admissions into Acute and Mental Health Trust beds through working collaboratively with primary care colleagues and reduce the number of people from Care Homes who are admitted to hospital at the end of life 2. Acute Care Liaison Service Proposal: Quality: Reduce length of acute in-patient stay (reduction in Occupied Bed Days) (Outcomes Framework 2.3), reduce re-admissions to acute hospital (Outcome Framework 3b) Innovation: Increase detection of delirium will contribute to a reduced length Darlington Clinical Commissioning Group Clear and Credible Plan

80 Programmes and Initiatives of stay; reduced admissions for DSH; Reduced attendances to acute trust by top 50 frequent attenders Productivity: One hour response time in A+E do we need another KPI about effectiveness as well EG reducing admissions to acute hospital from A + E for those with a mental health disorder Prevention: Increased detection and treatment of depression, reduced admissions to Care Homes from hospitals, increased diagnosis of dementia in hospitals (Operating Framework 2012 CQUIN Target p39 and to Operating Framework 2012 p12 section 2.8) 6. Milestones June 2012: Establishing core team and merging of OPMH/ acute by AMH and MHSOP; Recruitment to key posts; Accommodation and infrastructure; Training and development for all recruited staff. September 2012: Begin delivery of service model and key interventions within UHND/ Shotley. Bridge and Chester le Street; Complete recruitment with required staff for work within UHND. Training and development for all staff; Commence data capture, monitoring and analysis; Implement information sharing with commissioners as agreed. December 2012: Monitoring and evaluation of outcomes identified to date; Review via formal mechanism with Commissioners. March 2013: Scope expansion to DMH / Bishop Auckland; Discuss with Commissioners further roll out proposals ;Continue monitoring and review of current service model. 2013/14: Q1 Implement model into DMH and Bishop Auckland. Complete scoping exercise for other community hospitals Richardson/ Sedgefield/ Weardale/ Peterlee Hospital. Q3 Discuss and confirm recurrent funding arrangements with Commissioners. Q4 Confirm next steps for service model dependant on outcome of funding discussions with commissioners. Darlington Clinical Commissioning Group Clear and Credible Plan

81 Programmes and Initiatives Summary of activities that will deliver this strategic aim Strategic Aim: Address the needs of the changing age profile of the population of Darlington Link to case for change: The population of Darlington is ageing, and with the associated long term conditions of an a more elderly population places a significant growing pressure on the local health economy Population change Health need Patient insight Clinical insight Service issue/opportunity Around 37% of the population is aged 50+. This is projected to rise around 41% by What we ll be doing to address this in the next five years: Year 1 (2012/13) Darlington CCG Specific Commissioning Workstreams Reviews Pathway Re-design Pilots New Services Align mental health staff to GP practices- (to be led by cluster mental health commissioning team) Urgent care provision within primary care and nursing/care homes Community bed provision including intermediate care beds. Community nurses, Matrons and specialist nurses. Chiropody/podiatry provision Community diabetic clinic Personality disorder pathway Osteoporosis pathway- primary and secondary care prevention. On-line educational tool for newly diagnosed diabetics. Community COPD Clinic Community diabetes clinic Acute exacerbation pathway (COPD) Psychosexual counselling provision Urgent care co-location with A&E (Grey text intentions dependant on outcomes of review/pilot) CCG Initiatives Embed Gold Standards Framework (GSF) in nursing homes Establish education and training packages to be delivered within care and nursing homes. Darlington Clinical Commissioning Group Clear and Credible Plan

82 Programmes and Initiatives Cluster Working (2012/13) Working collaboratively with other CGGs across County Durham and Darlington PCT Cluster Long Term Conditions Team : Commission Home Oxygen Assessment Service; Review End of Life Services; Review Intermediate Care Services; Whole System Development of Services to Deliver LTC Support, Including a Review of Community Nursing; Establish a Gold Standard Framework for Locality Registers for Patients who are in their Last Year of Life due to their Illness and Diagnosis PCT Cluster Mental Health Team: Deliver the National Dementia Strategy. Contribution from Partners (2012/13) Working with partners for a common cause Local Authority: Section 256; etc Providers: CDDFT; TEWV; 3 rd sector etc.. Darlington CCG will fully engage with partnership working to support the delivery of this strategic objective. Year 2 (2013/14) Proposed year 2 Darlington CCG Workstreams Reviews Pathway Re-design Pilots New Services Weight management / Integrated obesity pathways Not defined rapid advice service Community ophthalmology clinic Community cardiology clinic Pilot urgent care primary provision/ pro-active primary care management in nursing and care homes. Community bed provision including intermediate care beds Pulmonary rehabilitation Osteoporosis pathway for primary/ secondary care prevention. Chiropody/podiatry provision Community COPD clinic Community diabetic clinic Erectile dysfunction clinic On-line education tool for newly diagnosed diabetics. (Grey text intentions dependant on outcomes of review/pilot) Darlington Clinical Commissioning Group Clear and Credible Plan

83 Programmes and Initiatives Year 3-5 (2014/ /18) Proposed year 3-5 Darlington CCG Workstreams Reviews Pathway Re-design Pilots New Services To be determined To be determined To be determined Community ophthalmology clinic Community cardiology clinic Urgent care provision and primary care management for nursing and care homes rapid advice service (Grey text intentions dependant on outcomes of review/pilot) What we ll measure to see if it s working: NHS Outcome framework (domain 2 and 3) 2. Enhancing quality of life for people with long term conditions 3. Helping people to recover form episode of ill health or following injury Changing Age Profile Indicators - Dementia prevalence - Emergency hospital admissions: diabetic ketoacidosis and coma - Hospital procedures: lower limb amputations in diabetic patients - Bowel Cancer screening coverage - Emergency hospital admissions and timely surgery: fractured proximal femur - Emergency hospital admissions for chronic obstructive pulmonary disease - Emergency hospital admissions for coronary heart disease - Emergency hospital admissions for Long Term Conditions - Hospital procedures: primary/ revision hip and knee replacements - Hospital procedures: Cataract removal - Vaccination: Influenza uptake for those over 65 years - Delayed Transfers of Care Care Closer to Home Indicators - Number of new services commissioned from a primary care or community setting - Cancer waiting times - Referral to treatment waiting times - Accident & Emergency Clinical Quality Indicators - Choose and Book - Ambulance Response Times Darlington Clinical Commissioning Group Clear and Credible Plan

84 Programmes and Initiatives Strategic Aim 3: Taking services closer to home for the people of Darlington Overview The key actions that will enable us to bring services closer to patients homes are: Developing primary care Extending patient choice Developing a clinical strategy across Darlington Implementing our headline initiatives Working with neighbouring CCGs on cross-cluster initiatives A Matrix of Clinical Leaders We are encouraging and enabling clinicians through their specific interests and skill sets to undertake commissioning improvements through a range of pathfinder schemes from idea generated through to delivery. In Darlington we have developed a matrix of clinical leaders, clinical capacity and capability for leading service improvements and shaping commissioning decisions. All the clinical leads have an agreed set of priorities and milestones for delivery which are directly linked to our strategic aims and initiatives in this plan. In order to support clinicians in commissioning and the behavioural change and ownership of the delivery of initiatives needed in 2012/13 we plan to: Ensure all of our initiatives are clinically led and supported by appropriate project management, service improvement methods, and technical skills. Ensure the use of data and information is clinically led and directed and that the right tools are available for clinicians. Put governance arrangements in place so that clinicians inform and lead decision making across our organisational structures. We plan, through our CCG clinical leadership infrastructure to develop effective relationships with clinicians in provider services. Within these relationships we will seek to improve the quality and cost effectiveness of services and make the most of our collective clinical experience and insights by: Reviewing and developing appropriate pathways for patients that provide quality outcomes and efficient utilisation of our resources particularly around avoiding unnecessary admissions to secondary care Providing appropriate commissioning and management support to clinical leaders and practices to be able to undertake planned programmes of work Darlington Clinical Commissioning Group Clear and Credible Plan

85 Programmes and Initiatives A Clinical Strategy for Darlington Darlington CCG is committed to working with all stakeholders in order to ensure priorities are aligned and there is a whole system approach to planning and prioritising health care in Darlington. The CCG will play a pivotal role in shaping the provider landscape using the clinical strategy for Darlington as a vehicle for transformational change. The clinical strategy will be developed by clinicians from a range of sectors, informed by patients, the public and all partners including the voluntary sector. Over time the strategy will drive commissioning intentions as well as guide individual decision making and is key for the long term sustainability of the local health and social care system. Primary Care and Community Development Darlington primary care practices are working towards improving the services offered to the population of Darlington, by adopting a one big practice type approach. In essence this is to develop our approach to sharing best practice and developing more streamlined pathways. As part of our established way of working, Practices work collaboratively to improve pathways of care and reduce the unexplained variation that exists within primary care. We believe that we can do more locally by improving and enhancing the skill mix offered within a primary and community care setting to support our population s needs and prevent unnecessary secondary care activity. We will work with all our partners including patients and the public, community staff, social care staff, nursing and care homes, voluntary sector organisations, to ensure the relevant people have input into the work we undertake to improve the health and well-being of our population and we work together in a much more co-ordinated approach to reduce the duplication of people s efforts. Patient Choice In order to commission more care from a community setting, our CCG will use choice, contestability and competition as levers for change and drive up quality whilst at the same time working to further support integration of services where patients will benefit from more joined up working. Darlington Clinical Commissioning Group Clear and Credible Plan

86 Programmes and Initiatives Darlington CCG current usage of secondary care services is as follows: Provider Outpatients % Elective % Non Elective % County Durham and Darlington NHS Foundation Trust South Tees Hospitals NHS Foundation Trust Independent Sector Total Newcastle upon Tyne Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust City Hospitals Sunderland NHS Foundation Trust Gateshead Health NHS Foundation Trust Others NHS - PCT Other NHS Providers In order to further develop patient choice Darlington CCG will: Look to utilise the Any Qualified Provider (AQP) mechanism to support the delivery of our strategic aim to bring care closer to patients homes. Using AQP to open up services allows patients to choose from a wider range of providers (all of whom meet NHS quality standards). Continue to support the introduction of Choose and Book Use quality outcome and performance measures to help inform patients of the range of potential treatment options open to them. Whilst looking to working with our main acute provider (County Durham and Darlington Foundation Trust) to get the most from Darlington Memorial Hospital, we will also look to identify opportunities to commission secondary care services from other providers in Teesside (e.g. North Tees and Hartlepool NHS Trust and South Tees NHS Foundation Trust to reflect population and access) and look to increase the utilisation of the Independent Sector where appropriate to do so. This will help secure more responsive and accessible services and drive up quality standards for our patients. Darlington Clinical Commissioning Group Clear and Credible Plan

87 Programmes and Initiatives Headline initiatives for 2012/13 relating to Strategic Aim 3 Project Name CCG Delivered by 1. What is the proposal and summary rationale? Implementation of the Urgent Care Strategy - Completion Darlington CCG NE CSU on behalf of Darlington CCG In 2008 County Durham PCT and Darlington PCT published Our Strategy for Urgent Care Services which sets out the direction of travel to develop and deliver a model of urgent care services that is effective and ensures that patients are treated in the right place and at the right time by services that best meet their needs. The strategy builds upon national, regional and local policies as well as the outcome of a series of stakeholder events. The proposal is to ensure that during 12/13 that the full 24/7 Urgent Care Strategy is implemented. To date 24/7 Single point of access and urgent care transports have been developed and operationalized. Elements of the 24/7 Clinical Service are in place however integration / co-location of Accident and Emergency and Urgent Care at Darlington Memorial has not yet happened. 2. Current Status and Cost 3. Consideration of Options The current service is part of a block contract which is activity based with a marginal rate and costs Darlington approximately 2.9m per annum. 1. Co-location The FT have worked with the PCT cluster Estates team to cost up the capital requirements for integration at DMH with this information being fed into a full business case (as part of a CDDFT-wide Urgent Care business case). The essence of the clinical model for the co-located sites is: a shared reception facility; an integrated workforce; senior Emergency Care Practitioner see, assess and treat at the front end of the pathway; separate streams for majors and minors 2. Move to tariff Because A&E and UCC activity will become inextricably intertwined in the new integrated clinical model, it will be difficult to implement fully at the two Integrated Centres and fund Urgent Care on block and A&E on tariff therefore we need to explore the best funding model for delivery of an Unscheduled care service. 3. Options A number of options have been researched including a status quo option (which is not agreeable) through to a 24/7 GP-led urgent care service with a centralised home visiting and telephone consultation service which will be integrated fully with A&E when on an acute hospital site. Darlington Clinical Commissioning Group Clear and Credible Plan

88 Programmes and Initiatives 4. Proposed Service Model and Implications The service option is to operate a 24/7 service at Darlington Memorial Hospital (DMH) via a co-located / integrated Urgent Care Centre (currently at Doctor Piper House) and Emergency Department (ED) 5. Risks Increase demand in the in-hours period initially by providing 24/7 Urgent Care access and less efficient use of primary care. Further financial risks may arise depending on the funding model agreed. 6. QIPP Implications 7. Key Milestones Quality: 24/7 access for patients, improved pathway, carer closer to home Innovation: Improved pathway for patients Productivity: Reduced inappropriate attendances at ED, reduction in ED attendances Prevention: n/a Discussion paper to Confed in April 2012 Service model decision June 2012 Service go live Autumn 2012 Darlington Clinical Commissioning Group Clear and Credible Plan

89 Programmes and Initiatives Summary of activities that will deliver this strategic aim: Strategic Aim: To take services closer to home for the people of Darlington Link to case for change: The CCG has a varied demographic profile including small urban populations, small towns and large under populated rural areas. This variety presents significant challenges as regards access to health and other services. Population change Health need Patient insight Clinical insight Service issue/opportunity We send too many of our patients to secondary care facilities when potentially they could be treated in a more cost effective local setting which is more convenient for the patient What we ll be doing to address this in the next five years: Year 1 (2012/13) Darlington CCG Specific Commissioning Workstreams Reviews Pathway Re-design Pilots New Services Community, district and specialist nursing review Align mental health staff to GP practices. Anterior knee, pain, mechanical knee pain and OA Knee Shoulder pain Lower back pain Foot pain Osteoporosis pathway. Community diabetic clinic Personality disorder pathway Community bed provision including intermediate care beds. Psychosexual counselling Erectile dysfunction pilot On-line education tool for diabetes Community COPD clinic Community Diabetic clinic. Carpal Tunnel pathway Co-location of Urgent care and A&E with Darlington CCG initiative of ensuring more low level urgent care needs are met by increased primary care provision. Urgent care co-location with A&E CCG Initiatives Agreeing primary care pre and post COPD exacerbation pathways Agreeing primary care pre and post asthma exacerbation pathways for under 16 Continue with embedding best practice via POINTS tool for COPD management. Darlington Clinical Commissioning Group Clear and Credible Plan

90 Programmes and Initiatives Cluster Working (2012/13) Working collaboratively with other CGGs across County Durham and Darlington PCT Cluster Long Term Conditions Team: Whole System Development of Services to Deliver LTC Support, Including a Review of Community Nursing PCT Cluster Mental Health : Align Mental Health Staff to General Practice; Improve Access to IAPT PCT Cluster Urgent Care: Deliver Urgent Care Strategy Including and Satellite by Appointment Service in Rural Areas Contribution from Partners (2012/13) Working with partners for a common cause Local Authority: Section 256; etc Providers: CDDFT; TEWV; 3 rd sector etc.. Darlington CCG will fully engage with partnership working to support the delivery of this strategic objective. Year 2 (2013/14) Proposed year 2 Darlington CCG Workstreams Reviews Pathway Re-design Pilots New Services Weight management / Integrated obesity pathways Paediatric pathway (non-elective) Paediatric pathway to improve access to physiotherapy and audiology services. rapid advice service Community ophthalmology clinic Community Cardiology Clinic Urgent care provision and primary care management for nursing and care homes Community bed provision including intermediate care beds Community Pulmonary rehabilitation Community COPD clinic Community diabetic clinic Erectile dysfunction clinic On-line educational tool for newly diagnosed diabetics. (Grey text intentions dependant on outcomes of review/pilot) Year 3-5 (2014/ /18) Proposed year 3-5 Darlington CCG Workstreams Reviews Pathway Re-design Pilots New Services To be determined To be determined To be determined rapid advice service Community ophthalmology clinic Community Cardiology Clinic Urgent care provision and primary care management for nursing and care homes (Grey text intentions dependant on outcomes of review/pilot) Darlington Clinical Commissioning Group Clear and Credible Plan

91 Programmes and Initiatives NHS Outcome framework (domain 4) 4. Ensure that people have a positive experience of care Urgent Care Indicators What we ll measure to see if it s working: - Financial balance and achievement control totals on the commissioning allocation - Securing commissioning support within the running cost allowance - Delivery of CCG QIPP plans including demand management Darlington Clinical Commissioning Group Clear and Credible Plan

92 Our Financial Strategy 9. Our Financial Strategy In order to deliver our CCG strategic aims there needs to be a clear alignment between our financial and operational planning. In this section we will outline our approach to investment of our commissioning allocation, how we have identified our priority areas and how we will use the financial and contracting tools and mechanism to deliver the improvements we have outlined earlier. This financial strategy will describe how we will manage the funding pressures (QIPP) to both commissioners and providers over the lifespan of our plan. 9.1 Understanding our commissioning allocation The latest timelines for the national publication of CCG allocations to support this work are as follows: 1) High level indicative estimates of baseline spending were published on 7th February 2012 to support initial planning by emerging Clinical Commissioning Groups. 2) CCG Allocations for 2013/14 are expected to be published by the end of December The information published on the 7th February 2012 is based upon the expenditure returns submitted in September 2011 for each CCG (excl. red rated CCGs) adjusted for 2012/13 prices. It includes details of the consultation and review process (including a dedicated address for feedback). There have been no further publications of allocation figures for CCG s, therefore assumptions using existing published fair shares models from the Department of Health have been used to estimate anticipated CCG funding. These estimates build upon the baseline budgets adopted by the CCG in March 2012, and will be subject to a further refresh once fully coded and costed activity information is available in respect of the financial year 2011/12, in June The allocations for 2013/14 onwards are expected to be published by the end of the calendar year and are expected to be based upon a revised funding formula (ACRA). It is expected that any difference between the baseline allocation and the target allocation will be subject to a pace of change policy. Once published, these figures will enable a further refresh of financial plans for 2013/14 and onwards. Darlington Clinical Commissioning Group Clear and Credible Plan

93 Our Financial Strategy The table below shows an extract from the financial planning model for Darlington CCG showing income and expenditure forecasts for 2011/12 to 2016/17 under the most likely base case scenario. Darlington Clinical Commissioning Group (CCG) Financial Summary Recurring Outturn Forecast period FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17 '000 '000 '000 '000 '000 '000 COMMISSIONING BUDGETS: Acute Services 76,557 76,391 77,537 78,700 79,880 81,078 Mental Health / Learning Disability Services 14,788 15,150 15,377 15,608 15,842 16,079 Community / Primary Care Services 13,622 15,571 15,882 16,200 16,524 16,854 Continuing Healthcare / Funded Nursing Care 8,649 8,943 9,122 9,304 9,490 9,680 Childrens Services Prescribing 17,118 17,157 17,671 18,201 18,747 19,310 TOTAL COMMISSIONING BUDGETS 131, , , , , ,682 CORPORATE BUDGETS & RESERVES: Management & Organisation ,844 2,844 2,844 2,844 TOTAL CORPORATE BUDGETS & RESERVES ,844 2,844 2,844 2,844 TOTAL CCG BUDGETS 131, , , , , ,526 The financial model has been built using several key assumptions as listed below: Starting point is forecast financial outturn for 2011/12 as at 31 January 2012 Estimated investments for 2012/13 have been included Estimated reductions for public health transfers to the Local Authority and Public Health England have been included. Estimated reductions for specialised services transfers to the NHS Commissioning Board have been included. It should be noted that these assumptions will be revisited during the planned updates of the financial model during the financial year 2012/13 as shown in the timeline below: Baseline Budget adopted by CCG (March 2012) Estimated investments included for CCP (April 2012) Refresh using 11/12 full year activity (June 2012) Refresh using confirmed CCG Allocations (December 2012) Darlington Clinical Commissioning Group Clear and Credible Plan

94 Our Financial Strategy Due to the consistency of boundaries and population between the predecessor commissioning body Darlington PCT and Darlington CCG, there are no immediate implications of moving towards the existing fair shares model from the Department of Health, and practice level budgets in previous financial years have been calculated using this existing approach. 9.2 Risk Sharing Currently the CCG risk management arrangements are based entirely on that of the PCT. A CCG risk register will be completed by end of April The CCGs have yet to determine and agree risk sharing of risk pooling arrangements via the Confederation but will be completed in line with the requirements of the 100% delegation of budgets to the CCGs. The CCG is developing a risk-sharing approach for the following areas: A risk-share arrangement across localities within the CCG for all areas of commissioned spend to manage the CCG position. A formal risk-share arrangement across CCGS for high cost patients. An informal risk-share arrangement across all CCGs within the County Durham and Darlington Cluster for all areas of commissioned spend. 9.3 Use of non-recurring funding In discussion with the PCT Cluster in 12/13 pre-authorisation, we will look to direct a significant element of the CCG allocation held non-recurringly (2% of the CCG allocation) to stimulate innovation. This funding will be used to: Pump-prime and double run transformation pilots in line with our QIPP strategy Support practice level innovation to improve patient pathways Support providers to introduce pathway changes that support better whole system working Support providers where they look to reduce capacity following commissioning interventions This non-recurring funding will be deployed in a staged way that ensures that risk of overperformance on variable contract lines can be covered in-year without the risk of generating significant back-loaded slippage at year end. Darlington Clinical Commissioning Group Clear and Credible Plan

95 Our Financial Strategy 9.4 Applying 2012/13 business rules In line with CCGs across the North East, we will take a consistent approach to applying the rules related to the net 1.8% tariff reduction outlined within the Operating Framework (for the acute secondary care contracts we will apply a 1.5% tariff reduction as 0.3% is already applied within tariff pricing). Across all sectors we intend to use the 1.8% tariff saving as a lever for change by reinvesting the released efficiency back into contracts on a non-recurrent basis and steering providers towards the delivery of services that meet the commissioning intentions of the CCG. This will help mitigate against the risk of destabilising providers from the compound impact of technical efficiencies incurred through payment rules and allocative efficiencies from the potential loss of activity. By agreeing the outlined contracted levels of activity and application of business rules we will ensure a level of stability within providers whilst allowing CCGs to re-design clinical pathways and deliver QIPP with a lower level of risk. Darlington Clinical Commissioning Group Clear and Credible Plan

96 Our Financial Strategy 9.5 Financial scenarios Darlington CCG has ensured that this plan can be implemented using a range of financial scenarios through robust prioritisation of investment, realistic contracting of variable activity (acute tariff, prescribing and continuing healthcare) and delivery of efficiency through QIPP schemes. The main features of the three scenarios can be described as follows: Base Case (Likely) Scenario In this scenario the CCG will contract for a realistic level of activity over the life of the plan based on past activity performance and forecast future demand. Unallocated resource would be invested in the series of prioritised initiatives that will improve health outcomes, reduce health inequalities identified and bring care closer to peoples homes. Upside Scenario In this scenario the CCG will again contract for a realistic level of activity over the life of the plan. The additional unallocated funding will be used to go further, faster on the delivery of the strategic priorities and to incentivise providers to further improve quality and experience for our patients who use their services. Downside Scenario In this scenario the CCG would shift the focus of activities to the management of demand and mitigation of cost increases. The CCG would contract for lower than expected levels of activity and use all the available levers to manage demand. This would include more time spent on the reduction of variation in referral patterns, introducing elective pathway changes (funded from the 2% non-recurring element of the allocation) and helping patients, particularly the elderly and those with long term conditions avoid admission to secondary care. The full details of these scenarios and the wider financial strategy of the CCG can be found in appendix 6. Darlington Clinical Commissioning Group Clear and Credible Plan

97 Delivery 10. Delivery Our Organisational Development Plan and SWOT analysis identified a wide range of support needed to be secured in order to successfully deliver the aims and goals in this plan. Using our running cost allowance to secure effective support The 2012/13 NHS Annual Operating Framework indicates a CCG running cost allowance based on the size of the population for which we have commissioning responsibility. This allowance of 25 per head of population from 2013/14 means that we have 2.686m to invest in the management structure that will oversee the statutory responsibilities and operational delivery of our CCG and also to purchase the technical commissioning support necessary to do this efficiently and effectively. Running Costs based on 25 per head ( 000) CCG Total 2,686 We confirmed a management and operational structure for our CCG at the end of January 2012 (using a phased approach) and will develop a memorandum of understanding (MoU) with County Durham and Darlington/North East Commissioning Support Unit by end April A formal business agreement will follow on in line with the checkpoints required for the CSU and the milestones for our authorisation process. Darlington CCG subscribes to the collaborative commissioning arrangements with other CCGs in County Durham and Darlington. Development and formalising of the County Durham and Darlington Clinical Commissioning Confederation is progressing with the heads of terms agreed by all three CCGs in April The Confederation is a voluntary association with the purpose of securing the coordination of collaborative commissioning arrangements and risk sharing in the following areas: Commissioning and co-ordination of contracting arrangements Continuing Health Care Management of risk, specifically high cost/low volume and individual funding decisions Darlington Clinical Commissioning Group Clear and Credible Plan

98 Delivery 10.1 Deliver 2013 The Darlington CCG delivery framework Deliver Darlington 2013 is the first Delivery Plan published by the Darlington CCG. Deliver 2013 is a delivery plan for the Darlington Health System. Staff in the CCG and the CSU will continue to deliver on the commitments set out in the plan as the CCG s health commissioning functions and responsibilities continue to develop during this transitional year. This plan articulates how Darlington CCG will deliver planning requirements; financial and operational requirements; quality and safety requirements and transitional requirements. The plan provides details of the milestones associated with the delivery of these requirements; in particular the delivery plan articulates within the financial and operational requirement section how Darlington CCG will deliver key priority areas linked to our four Strategic Aims. The key strategic aims reflect the priorities set out in the NHS Operating framework 2012, NHS County Durham and Darlington ISOP 2012/13, Darlington CCG Clear and Credible Plan 2012/13-17/18, the Darlington Single Needs Assessment and the government white paper Equity and Excellence: liberating the NHS (2010). Programme management expertise and support will be secured via an SLA with the CSU. Using ASPYRE programme management software delivered through routine reports to the CCG Board, Executive and/or other subcommittees and fora, progress against the delivery plan will monitored to ensure risks are identified and mitigated in real-time. Darlington Clinical Commissioning Group Clear and Credible Plan

99 Governance 11. Governance Darlington CCG has a responsibility for securing high quality services for our local population, working with partners to commission services which give optimum outcomes for patients and the population and driving up the quality of primary medical care. The successful delivery of our clear and credible plan is founded on having the right governance and constitutional arrangements as well as capacity and capability for delivery. Over the course of 2012/13 these arrangements will be developed in stages in readiness to assume responsibilities devolved by the PCT cluster and key milestones along our critical path to authorisation. We plan to have appropriate arrangements fully in place that address the requirements of the Health and Social Care Bill and guidance in the form of Towards establishment creating responsive and accountable clinical commissioning groups (DH February 2012). The success of Darlington CCG is predicated on balancing a number of factors and principles: Autonomy at our local CCG level while exploiting economies of scale for tackling common issues at a cross CCG/Confederation level Developing a lean organisational structure, while ensuring sufficient resources and capabilities are in place to deliver the ambitions of the commissioning plan whist establishing a new organisation and achieving successful authorisation. Capturing and developing skills with the organisation whilst utilising external expertise and commissioning support. During this transition period in 2012/13, prior to Darlington CCG being fully authorised, the CCG Board is established as a sub-committee of the PCT Cluster Board. The CCG sub-committee has a membership comprising: three GP clinical lead representatives from Darlington practices, an interim chief operating officer (ICOO) who is an executive director of the PCT, a PCT non-executive director (NED) - as interim chair a lead nurse, a senior finance lead, the director of public health for Darlington, lay representatives local authority representative. Darlington Clinical Commissioning Group Clear and Credible Plan

100 Governance The terms of reference for the CCG sub-committee are agreed and articulate the responsibilities that have initially been delegated from the PCT cluster to Darlington CCG. The senior executive team includes the interim chief operating officer (responsible to the PCT cluster chief executive), interim senior finance officer, interim chair (GP), interim Vice Chair (GP), interim clinical quality lead (GP), the lead nurse and Deputy ICOO. The main purpose of the group currently is to oversee the operational management of the CCG in its commissioning role and ensure, in the short term, that the CCG successfully assumes commissioning responsibilities from the PCT and achieves full authorisation. The capacity and capability to deliver the clear and credible plan is provided through two routes. A number of staff from the PCT cluster are aligned to provide capacity and capability to support delivery of our plan and undertake functions which will be increasingly undertaken by the SCGG. These staff will continue to employed by the PCT during this phase of transition but will have their objectives aligned to those of the CCG to support the achievement of authorisation. Pragmatically, in the initial phase staff with roles aligned to the CCG will either sit with the CCG or within the developing commissioning support unit (CSU) within the PCT. Staff within the CSU will continue to provide commissioning support and back office functions which will be coordinated through a designated relationship manager. Work is progressing to understand the critical posts required in the CCG home team to lead, govern and deliver the business of the CCG versus what capacity and capability will sit in the CSU supporting delivery of the commissioning functions. The backdrop and challenge for this work is the finite running costs allocation for our CCG as well as the costs of the CSU Future arrangements establishing the governing body, CCG Board and Executive Governance arrangements for Darlington CCG are still to be finalised and are being developed in alignment with the timescales for authorisation. The clinical board has recently been reviewed together with the practice leads and GP chair roles in order to establish core members (Chair, Vice-chair, member representatives, Practice nurse lead, and practice manager lead) who have a clear mandate to operate as member representatives of the governing body for the CCG. The first meeting of the new governing body was early April Darlington Clinical Commissioning Group Clear and Credible Plan

101 Governance From 1 April 2012 our emerging accountability, decision making arrangements and the way we engage the twelve constituent member practices is shown in the figure below. Darlington CCG Leadership, Engagement and Decision making Each CCG is required to have a governing body. The legislation will identify a statutory core membership although there must be some local flexibility to identify additional members. The core membership must include: GP or other health care professionals Chair of the governing body Lay member with a lead role in overseeing key elements of governance Lay member with a lead role in championing patient and public involvement Clinical member (a doctor who is a secondary care specialist) Clinical member (a registered nurse) Accountable officer Chief finance officer Darlington Clinical Commissioning Group Clear and Credible Plan

102 Governance The Darlington CCG interim governing body comprises the 12 member practices, each with a member representative who attends the governing body meetings. The governing body aims to establish a CCG board which will comprise Chair, Vice chair, Accountable Officer, Chief Finance Officer, Lead nurse, Secondary Care clinician and two lay members. Figure on page 103 illustrates the emerging leadership and decision making arrangements to be agreed with member practices. Governing body member role descriptions will need to reflect the legislative framework. The guidance sets out core role outlines supported by specific attributes and competencies for all members of the governing body, who will be expected to work together as a team to ensure that CCG exercises its functions effectively, efficiently and economically in accordance with its constitution as agreed by its member practices. Our CCG is actively seeking Lay representation for the sub-committee and governing body in the first instance. We have successfully secured an interim lay representative for patient and public engagement who joined the CCG subcommittee in April Appointments of CCG board members including chair, accountable officer, chief finance officer, nurse and lay representatives will follow in line with the National timeframes (April-June 2012). The final governing body constitution and appointments are to be complete by July Subject to national milestones and processes There are number of immediate developments towards the future governance arrangements that will be taken forward with constituent member practices between April 2012 and October These are: Participation and action planning from the board to board development session on 24 April The learning and action planning will not only prepare the sub-committee members and senior leadership team for their delegated responsibilities but also set the trajectory milestones for the authorisation application. Completion of the scheme of delegation and financial controls at CCG to support responsibilities delegated by the PCT cluster, subject to a satisfactory performance review. Completion of financial and governance training for sub-committee members, governing body members and senior leadership team. Arrangements for finalising the CCG constitution and relevant terms of reference Development of a compact between member practices of the governing body. Identification of the chair of audit committee and chair of the remuneration committee Establishing arrangements for the audit committee and remuneration committee including appointment of chairs for these committees. Establishing the essential CCG subcommittee arrangements in order to move forward delivery, demonstrate financial and overall organisation wide governance and grip. Darlington Clinical Commissioning Group Clear and Credible Plan

103 Governance We are currently working with external providers in a consultancy capacity to support us in delivery of a development programme for the governing body but Emerging structure for leadership and decision making We have adopted the PCT cluster Conflicts of Interest Policy as the CCG Conflicts of Interest Policy and are currently in the process of establishing Conflicts of Interest Registers at CCG level. Darlington Clinical Commissioning Group Clear and Credible Plan

104 Governance 11.2 Financial Governance In line with the CCG strategic aim to manage our finances wisely, we have developed robust governance framework to oversee this management and prioritisation of our investment. The CCG has a robust financial reporting system, building upon the existing system in place for County Durham PCT. This system ensures that relevant, accurate, timely financial information is available for decision makers at CCG, Locality and Practice levels. This financial reporting is underpinned by a suite of governance documents including Standing Orders, Standing Financial Instructions, Financial Limits, and a comprehensive Scheme of Delegation. These governance documents were formally adopted by the CCG in March 2012.in preparation for the expansion of their delegated budget responsibility and increased accountability. The Interim Chief Officer (ICO) will identify individual staff members as authorised signatories for expenditure, and budget management responsibilities linked to the approved scheme of delegation and financial limits. Financial accountability within CCG Ultimate financial accountability for the CCG will be subject to transition during the lifespan of this plan. Until 31 March 2012, the ultimate accountability will rest with the PCT Cluster Chief Executive, although some areas of budgets are currently delegated to the CCG with responsibility delegated to the ICOO. In respect of the financial year 2012/13, the CCG will assume responsibility for the full range of relevant budgets. During this period, the PCT Cluster Chief Executive will continue to delegate responsibility for these budgets to the ICO. From 1st April 2013, the CCG Accountable Officer will assume full financial accountability for CCG budgets. Across this entire period, the Accountable Officer will liaise with both the PCT Cluster Director of Finance, and Senior Finance Officer for the CCG to provide assurance that all necessary measures are in place to deliver the control totals agreed at the outset of each year. Darlington CCG recognises the need for demonstrable grip and financial governance through close monitoring of financial performance. A proposed subcommittee of the emerging CCG board will oversee performance and finance. This arrangement will be confirmed by the end of April 2012 and in discussion with membership of the governing body. The Performance and finance subcommittee will ensure robust financial management of delegated funds, and recommend actions to the board to ensure delivery of financial control totals. Darlington Clinical Commissioning Group Clear and Credible Plan

105 Governance 11.3 Equality and Diversity In order to ensure that no groups or individuals are disadvantaged by our commissioning activities, we have carried out a full Equality and Diversity Screening assessment of our plan. Further screening assessments will be carried out at service level when re-designing or commissioning pathways of care. Darlington Clinical Commissioning Group Clear and Credible Plan

106 Risk Management and Ongoing Monitoring 12. Risk management and ongoing monitoring Our CCG risk management arrangements and processes are based on the PCT cluster s existing arrangements. A Darlington CCG risk register is in development with support from the CSU risk management team (to be populated by end April 2012) to be initially routinely reported through the CCG subcommittee, CCG executive and when established the risk and assurance subcommittee of the CCG Board. The ICO will be responsible for the risk management strategy, policy and processes. Darlington CCG has carried out a full assessment of this plan using a standard scoring methodology to understand the key risks to the delivery of the plan, the capacity and capability of our CCG to implement the plan and the financial resilience of the CCG and wider health economy. The top four risks areas are: 1) Strategic delivery - Failure to secure the pathway design, project management, procurement and transformational skills. Relatively small running cost allowance due to small population size of Darlington CCG creates a risk in being able to carry and contract in enough commissioning support and clinical time to deliver the plan. This will be mitigated through close working with our local authority partner and where appropriate to do so cross-ccg working via the Confederation. 2) Financial resilience Increases in continuing health care costs above an affordable level. Due to the relatively small size, the CCG is more susceptible to variations in financial performance. This will be mitigated by the risk sharing model outlined below and specifically managing high risk budget lines such as CHC. 3) Financial resilience Impact of an aging population contributing to increased costs. Managing demand on the secondary care system (both planned and unplanned). This will be mitigated by our demand management approach, use of RAIDR, targeted commissioning intentions and our clinical strategy. 4) Organisational readiness establishing unrealistic timescales that don t recognise the depth of organisational development needed to assume full responsibilities from the PCT cluster whilst delivering the business and establishing a new organisation. Full details of the methodology, risks and mitigations can be found in appendix 8. Darlington Clinical Commissioning Group Clear and Credible Plan

107 Risk Management and Ongoing Monitoring On-going monitoring This Clear and Credible Plan was agreed through the formal CCG governance process and a wide range of touch points shown on page 93. This approach over the course of the development of the plan ensured effective engagement with clinicians as well as key stakeholders. Performance monitoring of the implementation of the plan, impact of the strategic initiatives on their stated KPIs and associated health and quality outcomes will be monitored at both the Darlington CCG governing body level and at the Darlington CCG sub-committee. Darlington Clinical Commissioning Group Clear and Credible Plan

108 Risk Management and Ongoing Monitoring Darlington Clinical Commissioning Group Clear and Credible Plan

109 Appendices Appendices Appendix 1: Overview of Health Needs Appendix 2: Gap analysis Appendix 3: Overview of Programme Budgeting Appendix 4: Commissioning intentions Appendix 5: Communication and Engagement plan Appendix 6: Medium Term Financial Strategy Appendix 7: Governance Appendix 8: Full Risk Assessment Darlington Clinical Commissioning Group Clear and Credible Plan

110 Appendix 1 Appendix 1 Overview of Health Needs Key cross cutting health related messages from the Darlington Single Needs Assessment:- Population Growth Darlington's population is ageing as a result of people living longer Darlington's aged 50+ population is projected to rise to 40.9% of the total population by The aged 75+ population is projected to increase to 10% of the total population Darlington has some of the most deprived areas in England, and is ranked 79th most deprived local authority out of 324 in England There are almost 4,200 older people are living in poverty in Darlington (ONS Mid 2008 LSOA population estimates). Life expectancy People are living longer however inequalities in life expectancy exist between Darlington and England. For example, life expectancy for; Men living in Darlington are living 1.7 years less than the England average (Darlington Health Profile 2011). Women living in Darlington are living 1.5 years less than the England average (Darlington Health Profile 2011). Check wording Inequalities in life expectancy exist within Darlington. For example: o Life expectancy for men living in the most deprived areas is over 13.4 years lower than for men living in the least deprived areas. For women it is 10.3 years lower (Association of Public Health Observatories 2010,) Darlington Clinical Commissioning Group Clear and Credible Plan

111 Appendix 1 Disease and mortality Early death rates from cancer and cardio vascular disease have fallen however they are higher in Darlington than the England average. Cancer incidence in Darlington: Is higher for women than men Is closely correlated with deprivation. The distribution of cancer incidence rates ( ) in Darlington is not equal, it is higher in the more deprived MSOAs Cancer mortality in Darlington is: Significantly higher for men than women Between 2007 and ,129 people in Darlington died aged less than 75 years Premature mortality rates (under 75years) for the biggest killers (heart disease, cancer, stroke) in Darlington are higher than the England average. o Cardiovascular disease (CVD) and cancer account for around 63% of early or premature deaths in Darlington. o Smoking remains the biggest single contributor to the shorter life expectancy experienced locally GP practice registered disease prevalence in Darlington is 20% higher than the England average for the following diseases Chronic Obstructive Pulmonary Disease (COPD also the second most common cause of emergency admissions to hospital) Coronary Heart Disease (CHD) Darlington Clinical Commissioning Group Clear and Credible Plan

112 Appendix 1 Childhood Obesity Childhood obesity shows a significant variation in prevalence between reception and Year 6. Year 6 prevalence is almost double that of reception Childhood obesity prevalence in reception does not vary within Darlington; however there is variation in obesity prevalence in Year 6 children. Poverty is key determinant of what families eat. Overweight young people have a 50% chance of being overweight adults Breast feeding is a major contributor to good health in both mother and child Teenage Conceptions Teenage conception rates in Darlington are higher than the England average but have been falling over time there is a strong relationship between teenage conceptions and deprivation within Darlington Prevention of under 18 years conceptions is central to improved outcomes for young women and men Alcohol Darlington has significantly higher rates of hospital admissions for alcohol related harm for both men and women compared to the England average Binge drinking prevalence is estimated to be 31% in Darlington, higher than 18% estimated adults who binge drink nationally The Social Norms Survey (a large scale drug and alcohol survey carried out in Darlington Schools) is the basis for development of positive messages to reinforce healthy choices with young people. Substance Misuse Drug misuse is a complex public health issue which also has links with crime and disorder. The DAAT (Darlington Drug and Alcohol Action Team) commissions prevention activity and treatment services Most young people in Darlington do not misuse drugs or alcohol PDU (Problem Drug User) data suggests the majority of opiates users in Darlington are known to treatment Service data indicate people under 25 years are more likely to report cannabis, alcohol or cocaine use, while over 25 years were more likely to report opiates or amphetamine use Men are more likely to use drugs and access treatment than women. Darlington Clinical Commissioning Group Clear and Credible Plan

113 Appendix 1 Adult Obesity The Darlington Health Profile (201) reported that there is higher prevalence of obese adults in Darlington (26%) than England average (24%) NHS Health Checks programme has to date screened 5,561 patients between the age of 40 and 74, this population had an obesity rate of 30% The Darlington Sport and Physical Activity strategy is broadly based in approach and engages private and public sector partners. Dementia The effect of an ageing population will include an increase in the numbers of people living with dementia, their health and social care needs and the needs of their carers Dementia prevalence is predicted to rise in Darlington to 8.1% by 2030 i.e., the proportion of people aged 65 years and over Dementia is the main cause of mental health admissions among older people. Learning Disabilities The number of people with severe and profound learning disabilities is predicted to increase by 1% each year due to increasing life expectancy and the growing number of children with such disabilities In children attending school in Darlington had Special Educational Needs statement (2010 figure was 390). There were also 1,526 children receiving School Action support and 1,125 receiving School Action Plus support In 2009/10 there were 180 (71.9%) adults with learning disabilities known to Social Services who were in settled accommodation at the time of their last assessment there were also 15 (5.9%) adults with learning disabilities known to Social Services who were in employment Darlington Clinical Commissioning Group Clear and Credible Plan

114 % of LSOAs Appendix 1 Inequalities exist both between Darlington, the NE region and England but also within Darlington with Darlington having some of the most deprived areas in England, and is ranked 79th most deprived local authority out of 324 in England. Around 39% of Darlington's lower super output areas (LSOAs) are in the most deprived 30% nationally with almost 16% of Darlington's LSOAs are in the most deprived 10% in England % of LSOAs by national deprivation deciles, Darlington. Source: ID2010, DCLG Deprivation Decile (ID2010) Deprived Affluent Inequalities in life expectancy exist within Darlington. For example life expectancy for men living in the most deprived areas is over 13.4 years lower than for men living in the least deprived areas. For women it is 10.3 years lower (Association of Public Health Observatories 2010). Slope Index of Inequality for Life Expectancy by Deprivation Deciles to Darlington. Source: APHO, The size of the gap in LE between rich and poor has fallen for males, but the difference is not statistically significant The size of the gap in LE between rich and poor has increased for females, but the difference is not statistically significant The size of the gap in LE between rich and poor is greater for males than females, but the difference is not statistically significant. Darlington Clinical Commissioning Group Clear and Credible Plan

115 Appendix 1 What does the Data tell us? Darlington experiences significantly greater levels of premature deaths than England for many causes (SMRs figure). Between 2007 and ,129 people in Darlington died aged less than 75 years SMRs which are statistically significantly higher in Darlington than England are: 1. Persons. COPD Acute myocardial infarction (AMI) Lung cancer All circulatory diseases All causes 2. Males. COPD AMI All circulatory diseases All causes 3. Females. COPD All causes Darlington Clinical Commissioning Group Clear and Credible Plan

116 Appendix 1 COPD COPD prevalence is greater in Darlington (2.2%) than England average (1.6%). There are over 2,200 people registered with COPD in Darlington (QOF, 2009/10). This prevalence varies by practice by between 1% and 3%. It is estimated there are over 600 people in Darlington with undiagnosed COPD. Invisible Lives Chronic Obstructive Pulmonary Disease (COPD) finding the missing millions (British Lung Foundation, 2007) estimated there are 2.8 million people in the UK with undiagnosed COPD, which if left untreated could severely restrict their lives and eventually kill them. The COPD Prevalence Modeller (based on the Health Survey for England 2001 and a representative sample of the population of England who had lung function tests and data collected on relevant risk factors) estimates 600 patients with COPD in Darlington that have not been recognised by their GP ( missing ). The model gives an estimate of the number of patients a practice could expect to have based on the population characteristics. Premature COPD mortality rates for the period were significantly higher in Darlington than England for both males and females. There was no significant difference between Darlington and the North East. During this period 78 people aged less than 75 died from COPD. Directly age standardised premature mortality rates per 100,000 for COPD, Darlington, North East and England, pooled. Source: NCHOD. Darlington Clinical Commissioning Group Clear and Credible Plan

117 Appendix 1 Mental Health Prevalence modelling in health conditions likely to affect the care needs of those aged 18-64( ), Darlington. Source: PANSI, Darlington Clinical Commissioning Group Clear and Credible Plan

118 Appendix 1 Projecting Adult Needs & Service Information System (PANSI) % change over time ( ) Darlington Clinical Commissioning Group Clear and Credible Plan

119 Appendix 1 The population projections show an increasing number of elderly people as illustrated in the graph below. The number of people aged 65 and over in Darlington is projected to increase from 17,400 in 2008 to 23,800 in 2023 and 29,100 in The number of people aged 85 and over is projected to increase from 2,400 in 2008 to 3,800 in 2023 and 6,000 in This will have an impact on the prevalence of long term conditions overtime as well as the levels of dependency found in Darlington. The graph below shows the projected percentage change over time for significant health conditions for those over 65 years. Local QOF data (2009/10) indicates a prevalence of 0.6% for dementia for Darlington against a regional and national average of 0.5%. Dementia prevalence is predicted to increase in Darlington between 2010 and The proportion of people aged 65 and over with dementia in Darlington is predicted to increase from 7.1% in 2010 to 8.1% by 2030, a rise of nearly 1,000 cases. Nationally, dementia is the main cause of mental health admissions among older people, accounting for 41% of all mental health admissions (21% unspecified dementia, 14% vascular dementia and 5% Alzheimer s Disease) (APHO, 2008). The national hospital admissions rate for dementia amongst year olds is approximately 200 per 100,000 rising to around 600 per 100,000 at 85 and over. The overall admissions rate for over 65 s for dementia nationally (ibid). It is estimated that after the age of 60 the prevalence of dementia doubles every five years so that about 22% at 85 and 30% of those aged over 95 are affected. Darlington Clinical Commissioning Group Clear and Credible Plan

120 Appendix 1 Darlington Clinical Commissioning Group Clear and Credible Plan

121 Appendix 1 Childhood Obesity Childhood obesity is a key public health issue, posing a major health challenge and risk to future health and wellbeing and life expectancy in Darlington. Obesity prevalence varies significantly between reception and year 6 in Darlington, the North East and England Obesity prevalence in Darlington is not significantly from England or the North East for reception or year 6. Rates in both reception and year 6 have seen little variation over time in Darlington, the North East and England Obesity prevalence 2006/ /10, Reception and Year 6, England, North East and Darlington. Source: NCMP 2009, National Obesity Observatory (NOO). Overweight young people have a 50% chance of being overweight adults, and children of overweight parents have twice the risk of being overweight compared to those with healthy weight parents. Obese 10 to 14-year olds with at least one obese parent have a 79% chance of becoming obese adults (Whitaker et al (1997) cited in Kopelman et al (2004, p4). Currently there is inequitable access to evidence based material, support to tackle obesity and specific targeted interventions for children and young people across Darlington. Darlington Clinical Commissioning Group Clear and Credible Plan

122 Appendix 1 Obesity prevalence and deprivation, Reception and Year 6, Darlington MSOAs. Source: NCMP , National Obesity Observatory Poverty is the key determinant of what families eat. It is suggested that lower income families spend a much higher proportion of income on food than higher income families. The link between sustained breast feeding and deferred weaning (to at least six months) and reduced risk of childhood obesity is increasingly well established. There is now good evidence of the link between breast feeding and improved emotional attachment between infant and mother. Darlington Clinical Commissioning Group Clear and Credible Plan

123 Appendix 2 Appendix 2 Gap Analysis Through the health care planning process to meet the necessary timelines to both inform contract negotiations and inform healthcare providers of potential service changes Darlington CCG developed a set of commissioning intentions. Since this process a more locally focussed population profile has become available. This document is embedded below: Population Health Profile - Darlington.pd The purpose of the gap analysis is to ensure that the derived commissioning intentions delivers against any local issues identified in the health profile. Demographic Changes The ONS residential populations over the past 3 years have been significantly less than the population that is registered at general practices within Darlington CCG. The table below illustrated the extent of this difference Darlington Clinical Commissioning Group Clear and Credible Plan

124 Count of Age Groups (000s) Appendix 2 In order to plan for services, and address the need for the ageing population it is necessary to forecast the change in registered practice population. This was done by applying an error multiplier derived from average difference from previous 4 years applied to the ONS growth forecasts. Full methodology can be provided under request but due to the file size it has not been embedded. Demographic Shifts in GP Registered Population Darlington Demographic Shifts Q2 2011/ Age Groups From the diagram above it can be clearly seen that over the next twenty years Darlington have registered practice population that are ageing. Ageing population make a higher demand on health services. The table below indicates some key issues that the analysis has revealed: By 2030 it is forecasted that there will by a 51% increase in the over 65 registered population in the Darlington CCG, with the other age groups remaining relatively stable (within -/+ 5%). Age Group 2011/12 Q Darlington Total Directly age standardised premature mortality rates per 100,000 for COPD, Darlington, North East and England, pooled. Source: NCHOD. Darlington Clinical Commissioning Group Clear and Credible Plan

125 Appendix 2 QOF Prevalence The tables below provides Darlington CCG level QOF prevalence health data benchmarked against the North East (SHA) average and England average as included in the Darlington health profile. Red represents an indicator which is worse than the England average and the North East average; amber represents where the indicator is than the England average or the North East average; green represents where the indicator is better than the England average and the North East average. Disease Area Chronic Obstructive Pulmonary Disease Register England North East Darlington 2009/ / / / / / % 2.50% 2.30% Heart Failure Prevalence 0.70% 0.80% 0.80% Coronary Heart Disease Prevalence Stroke / Transient Ischaemic Attacks (TIA) Prevalence 3.40% 4.60% 4.20% 1.70% 2.20% 2.00% Obesity Prevalence (16+) 10.50% 13.10% 13.70% Hypertension Prevalence 13.50% 15.30% 14.20% Diabetes Mellitus (Diabetes) Prevalence (ages 17+) 5.50% 5.90% 6.30% Mental Health Prevalence 0.80% 0.80% 0.90% Asthma Prevalence 5.90% 6.20% 5.80% Smoking Prevalence n/a n/a n/a Cancer Prevalence 1.60% 1.70% 1.50% Epilepsy (18+) 0.80% 0.90% 1.00% Hypothyroidism 3.00% 3.70% 3.10% Palliative Care 0.20% 0.20% 0.40% Dementia 0.50% 0.60% 0.70% Depression (18+) 11.20% 15.10% 13.20% Chronic Kidney Disease 4.30% 5.00% 4.40% Atrial Fibrillation 1.40% 1.60% 1.60% Learning Disabilities (18+) 0.40% 0.60% 0.50% Definitions of RAG Ratings Applies to County Durham and Darlington Applies to DDES, North Durham, Easington, Sedgefield, Dales, Derwentside and DCLS If worse than England and North East = Red If worse than England but not the NE = Amber If worse than England, NE and CD = Red If worse than England and NE but not CD = Amber Darlington Clinical Commissioning Group Clear and Credible Plan

126 Appendix 2 APHO derived Locality health indicators Figure 21 and 22 in the locality Health Profile s provide information at Middle Super Output Level on some key health indicators. Unfortunately, this information is not readily available at the locality level, and due to a complex methodology it is not easy to definitively derive. However, due to the similar (size and type) populations of a middle super output area (within the localities) it would be reasonable to estimate a proxy measure using an average of the locality MSOAs. Table 1.2 APHO MSOA derived health indicators Disease Area (09/10) England 2009/ /11 North East 2009/ /11 Darlington 2009/ /11 Obese Children Obese Adults Adults who smoke Binge drinking Healthy eating (Good) All Cause premature mortality Premature cancer mortality Premature CVD mortality Premature CHD mortality All age stroke mortality All age respiratory mortality Definitions of RAG Ratings Applies to Darlington If worse than England and North East = Red If worse than England but not the NE = Amber Darlington Clinical Commissioning Group Clear and Credible Plan

127 Appendix 2 Summary of Health Needs From the statistics presented, Darlington CCG has the following health outcome which are both worse than the England and Northeast average: Heart Failure Prevalence Obesity Prevalence Diabetes Mellitus Prevalence Mental Health Prevalence Palliative Care Epilepsy Prevalence Dementia Prevalence Atrial Fibrillation All Age Stroke Mortality Ageing Population Gap Analysis Is the need addressed by the interim Commissioning Intentions Health Issue CVD Issues: Heart Failure and Atrial Fibrillation Commissioning Intentions / Workstreams That will contribute towards: Prevention, managing demand (need), better treatment, managing any long term effects Darlington specific: Community Cardiology Clinic Intermediate Care Beds Specialist Nursing Home Care Support Service Clusterwide: Re-commission Health Checks Programme; Review Intermediate Care services; Whole Systems Development of services that deliver Long Term Conditions Support, including Community Nursing; Gold Standard Framework for Locality end of life Registers. Darlington Clinical Commissioning Group Clear and Credible Plan

128 Appendix 2 Health Issue Diabetes Mellitus Prevalence Commissioning Intentions / Workstreams That will contribute towards: Prevention, managing demand (need), better treatment, managing any long term effects Darlington specific: Community Nursing On-line training tool for diabetes Diabetic Community Clinic Intermediate Care Beds Clusterwide: Review Intermediate Care services; Whole Systems Development of services that deliver Long Term Conditions Support, including Community Nursing All Age Stroke Mortality: Darlington specific: None Clusterwide: Re-commission Health Checks Programme; Review Intermediate Care services; Whole Systems Development of services that deliver Long Term Conditions Support, including Community Nursing; Gold Standard Framework for Locality end of life Registers; Develop a community stroke rehabilitation team across County Durham and Darlington The re-design of the Hyper Acute service will contribute. The anti-coagulation service currently in procurement will also contribute. Obesity: Adult Obesity Prevalence Darlington specific: Integrated Obesity Pathways Cluster CIs: Expand access to community weight management services Maternal Obesity Review of Exercise on Referral; Physical activity interventions for pregnant and post natal women. Darlington Clinical Commissioning Group Clear and Credible Plan

129 Appendix 2 Health Issue Palliative Care: Percentage of registered patients on palliative care register Commissioning Intentions / Workstreams That will contribute towards: Prevention, managing demand (need), better treatment, managing any long term effects Darlington specific: Community Nursing; Intermediate Care Beds; Specialist Nursing Home Care Support Service Clusterwide: Review Intermediate Care services; Whole Systems Development of services that deliver Long Term Conditions Support, including Community Nursing; Establish a Gold Standard Framework for Locality Registers for Patients who are in their last year of life due to their illness and diagnosis The end of life rapid response pilot would contribute toward the end of life part of the palliative care pathway Mental Health: Mental Health prevalence Darlington specific: Practice attached Community Psychiatric Nurse; Personality Disorder Pathway Clusterwide: Align mental health staff to general practice; Expansion of Improving Access to Psychological Therapies; Improve equity of autism assessment an diagnosis; Deliver the dementia strategy; Re-commission out of area placements. Dementia: Dementia prevalence Epilepsy: Epilepsy prevalence Darlington specific: none Clusterwide: Whole Systems Development of services that deliver Long Term Conditions Support, including Community Nursing Darlington specific: None Clusterwide: DDES CCG are developing an outreach Epilepsy service (which could cover the whole of the cluster) Darlington Clinical Commissioning Group Clear and Credible Plan

130 Appendix 2 Health Issue Ageing Practice Population: Commissioning Intentions / Workstreams That will contribute towards: Prevention, managing demand (need), better treatment, managing any long term effects Darlington specific: Community Nursing Specialist Nursing Home Care Support Service Clusterwide: Review Intermediate Care services; Whole Systems Development of services that deliver Long Term Conditions Support, including Community Nursing Darlington Clinical Commissioning Group Clear and Credible Plan

131 Appendix 3 Appendix 3 Overview of Programme Budgeting Using the NHS County Durham and Darlington Annual Population Value Review (the local interpretation of programme budgeting data developed in-line with national best practice guidelines) the CCG has been able to understand (within the limitations of the data), the relationship between past investment and health outcomes. As Darlington CCG shares a boundary with the predecessor commissioning PCT, a direct interpretation of the programme budget data is possible. The figure below depicts the high level relationship between spend (low to high) and outcome (poor to good): No outcome indicators readily available Outcome indicators available Programme Area Abbreviations Infectious Diseases Inf Hearing Hear Disorders of Blood Blood Cancers & Tumours Canc Circulation Circ Maternity Mat Respiratory System Resp Mental Health MH Neonates Neo Endocrine, Nutritional & Metabolic End Dental Dent Neurological Neuro Genito Urinary System GU GI System Gastro Healthy Individuals Hlth Learning Disabilities LD Musculoskeletal Musc Social Care Needs Soc Adverse effects & poisoning Pois Trauma & Injuries Trauma Darlington Clinical Commissioning Group Clear and Credible Plan

132 Appendix 3 The figure below Darlington 2009/10 shows the programme budget spend and outcome summary. In 2009/10 Darlington PCT had: 3 programme areas within the high spend better outcome quadrant 5 programme areas within the lower spend better outcome quadrant 2 programme areas within the lower spend worse outcome quadrant 4 programme areas within the higher spend worse outcome quadrant 8 programme areas did not have a recommended outcome measure. Darlington PCT has 1 outlying programme area (greater the 2 standard deviations from the national average) within the quadrant analysis, which was the Trauma and Injuries programme area. The Trauma and Injuries programme area had a level of spend significantly greater than the national average % 60.00% 40.00% 20.00% 0.00% 30% Primary Care Expenditure Split - all programmes 70% Secondary Care 34% Primary Care 66% Secondary Care 37% Primary Care 63% Secondary Care 2007/ / /2010 Darlington Clinical Commissioning Group Clear and Credible Plan

133 Number of Programme Areas Appendix 3 In 2009/10 expenditure across all but 5 programme areas for Darlington PCT is greater in secondary care than primary care. Over the past three years the difference in proportion has decreased. Expenditure Benchmarking Lowest Quintile Second Quintile Third Quintile Forth Quintile Expenditure Level Highest Quintile High Spend Areas - Endocrine, Nutritional and Metabolic Programme - Problems of Learning Disability - Neurological Disorders - Problems of Circulation - Problems of the Respiratory System - Dental Problems - Problems due to Trauma and Injury - Adverse Effects and Poisoning Expenditure benchmarking analysis across the 23 programme areas informs that for Darlington PCT: 4 programme areas are within the lowest quintile; 5 programme areas are within the second quintile; 5 programme areas are within the third quintile; 1 programme areas are within the forth quintile; 8 programme areas and within the highest quintile, of which 6 were within the top 20 highest expenditure level and 1 in the top 10 highest expenditure across all 152 PCTs. Darlington PCT spends the 9th highest amount per head of population on the Trauma and Injuries programme area out of 152 PCTs. Darlington Clinical Commissioning Group Clear and Credible Plan

134 Appendix 3 Outcome Benchmarking Outcomes worse than benchmarking averages Outcomes between worst and best of benchmarking averages Outcomes better than benchmarking averages Number of Programme Areas Outcome Hotspot 3 worse outcomes in: - Problems of the Respiratory System 2 worse outcomes in: - Cancers and Tumours - Endocrine, Nutritional and Metabolic Problems - Problems of Circulation - Problems due to Trauma and Injuries - Problems of the Genito Urinary System Across 55 outcome areas during 2009/10 Darlington PCT has: 21 outcomes better than SHA, Industrial Hinterland and England Average; 17 outcomes between worst and best of benchmarking averages; 17 outcomes worse than SHA, Industrial Hinterland and England Average. Three of the worse outcome areas are within the Problems of the respiratory system programme area. Darlington Clinical Commissioning Group Clear and Credible Plan

135 Appendix 3 A more detailed programme level summary is given in table below: Darlington Clinical Commissioning Group Clear and Credible Plan

136 Appendix 4 Appendix 4 Commissioning Intentions Q4 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 Contractual negotiation Diabetes Foot care Carpal Tunnel pathway Review Countywide schemes or led externally Community nurses, matrons and specialist nurses Primary care counselling and psychology to include psychiatric nursing attached to GP practice. Community bed provision including intermediate care beds. Darzi centre review Urgent care provision for nursing and care homes. Weight management/ integrated obesity pathways Pathway redesign Anterior / Mechanical Knee pain OA knee Osteoporosis Lower back pain Asthma and wheezing pathway Community diabetic clinic pathway Personality disorder pathway Paediatric pathway (non-elective) in secondary care Paediatric pathway to improve access to physiotherapy and audiology. Shoulder pain Foot pain Transformation fund pilot Acute exacerbation pathway for COPD (countywide pilot) Intermediate care bed provision. Psychosexual counselling provision Psychosexual counselling provision Erectile dysfunction pilot On-line education tool for diabetes Community COPD Clinic Community diabetic clinic rapid advice service Community ophthalmology clinic Community Cardiology clinic Pilot primary care support for urgent care provision to nursing homes- (from review) Commission new/extend current (grey text dependent on outcome of review/pilot) Urgent care co-location with A&E Chiropody/podiatry. Acute exacerbation pathway for COPD (countywide pilot) Community bed provision including intermediate care beds. Pulmonary rehabilitation Community COPD clinic Community diabetic clinic Erectile dysfunction pilot On-line education tool for diabetes Community ophthalmology clinic Community Cardiology clinic Pilot primary care support to nursing homes- (from review) rapid advice service Darlington Clinical Commissioning Group Clear and Credible Plan

137 Appendix 5 Appendix 5 Communications Strategy Darlington Clinical Commissioning Group (CCG) Localised Operational Engagement Plan 2011/12 Introduction: The document below has been produced in line with NHS County Durham and Darlington s GP Led Commissioning Engagement Plan 2011/12. It is essential that patient and public engagement expectations are both understood and fulfilled. The draft plan will assist in the consideration and development of ongoing involvement mechanisms for the CCG and will support the key drivers for engaging with key stakeholders and the local population of Darlington. The plan will enable the CCG Board to have an awareness of the need for engagement activity, including a high-level overview of legislation and policy must-do s and an understanding of engagement considerations and challenges at different stages of the commissioning process. What do we mean by patient public and carer engagement? Patient, public and carer engagement is primarily about listening to feedback from local people with a view to informing service improvements. Engagement activity may range from informing patients to proactively seeking views through to the co-production of services with full participation from patients. Engagement can be proactive and reactive, formal and informal, quantitative and qualitative. Patient involvement also encompasses the personalisation agenda and an increasing priority to ensure individuals are active partners in their own care. Darlington Clinical Commissioning Group Clear and Credible Plan