Commissioning Guidance: Thames Valley & Milton Keynes Strategic Clinical Networks. August 2015

Transcription

1 Commissioning Guidance: Thames Valley & Milton Keynes Strategic Clinical Networks August 2015

2 Contents Principles & Purpose Long Term Conditions End of Life Care Maternity Children Cardiovascular Cancer Notes for use i): For those with interest in specific networks please navigate using buttons to the left ii): Best viewed in In slideshow mode to allow compatibility iii) This document embeds internal and external links for further information/evidence Neurological Conditions Mental Health

3 Principles & purpose

4 Principles & purpose The intention of this document is to enable discussion and to inform commissioning decisions for the next year s planning round and beyond; at the AO/Clinical Chairs as well as Commissioning manager levels but most importantly to help inform, influence and offer support to CCG programme boards, clinical commissioners and Health & Wellbeing Boards. This will also support NHS England in its commissioning role. The guidance aims to synthesize national and local priorities, benchmark outcomes and/or service provision across the region and relate it to national standards, NHS England average and best practice guidance. Impartial clinical input has then honed the what and how of the commissioning advice. Some elements relate to commissioner asks, dates for upcoming events and offers of support from TVSCN clinical and managerial leads Back to Contents

5 Long Term Conditions

6 Long Term Conditions Management Why the priority? The NHS Five Year Forward View, sets out how the health service needs to change, arguing for a new relationship with patients and communities. It makes a specific commitment to do more to support people with long term conditions to manage their own health Effective self-management requires clinicians to work in partnership with patients. Lifestyle changes are recognised as a significant contributor to positive self-management It is known that up to 50% of people do not take medications as prescribed. The combination of engaged, empowered patients, HCPs committed to partnership working, supported by a proactive organised system delivers better patient outcomes Wagner, Chronic Care Model

7 Long Term Conditions Management Confidence in managing own health CCG name % Very confident Results for England as a whole 43% NHS SLOUGH CCG 35% NHS WINDSOR, ASCOT AND MAIDENHEAD CCG 40% NHS MILTON KEYNES CCG 42% NHS SOUTH READING CCG 43% NHS CHILTERN CCG 43% NHS BRACKNELL AND ASCOT CCG 44% NHS AYLESBURY VALE CCG 45% NHS OXFORDSHIRE CCG 45% NHS WOKINGHAM CCG 47% NHS NORTH & WEST READING CCG 48% NHS NEWBURY AND DISTRICT CCG 49% Helped put written care plan together CCG name % Yes % No Results for England as a whole 72% 28% NHS CHILTERN CCG 61% 39% NHS OXFORDSHIRE CCG 64% 36% NHS NEWBURY AND DISTRICT CCG 64% 36% NHS AYLESBURY VALE CCG 67% 33% NHS SLOUGH CCG 70% 30% NHS WINDSOR, ASCOT AND MAIDENHEAD CCG 71% 29% NHS NORTH & WEST READING CCG 71% 29% NHS BRACKNELL AND ASCOT CCG 74% 26% NHS WOKINGHAM CCG 77% 23% NHS MILTON KEYNES CCG 82% 18% NHS SOUTH READING CCG 86% 14% Data Source: GP Patient Survey (The latest data are from the July 2015 publication, collected during July-September 2014 and January-March 2015) Over 90% of patients would like to be more involved in their care. 85% of GPs report that they do this but only 50% of patients agree, with less than half involved in discussing or setting their own goals

8 Compelling evidence for care planning People involved in care planning have better outcomes in terms of physical health, less depression, and improved confidence and skills for self-management (Cochrane Review). BEST PRACTICE EXAMPLE Achievements at Tower Hamlets through Care Planning links the improvement in uptake of diabetes care processes with clinical outcomes 92% of registered population (Type 2 diabetes) taking part in care planning Patient perceived involvement in care rose from 52-82% 72% received all 9 processes in National Diabetes Audit: Best in England (Average 49%) Impact on blood pressure

9 LTC - Care Planning & Patient Education All CCGs have engaged with the SCN LTC programme and have included person centred care/care planning features in their LTC models of care Training across Thames Valley has already delivered: 8 x 2hour care planning taster sessions delivered to 194 HCP 8 x 1+1/2 day care planning training courses to 186 HCPs from 77 GP practices and integrated teams from MK and Oxon. 5 HCP have undertaken a 3 day train the trainer programme, increasing the TV pool of trainers to 8 Upcoming events: The SCN in conjunction with HETV are offering care planning training for primary care and integrated care teams: September: 15 th and 22 nd October: 5 th and 6 th November: 4 th, 12 th and 18 th December:10 th and 16 th Train the trainer: Spring 2016 Contact: abimbola.odubayo@nhs.net to book a place julia.coles1@nhs.net for advice All CCGs wanted to be included in the diabetes patient education review. A cross government party report recommends comprehensive patient education for those with diabetes CCGs have made use of the offer of the expert hub with experts contributing to programme boards/steering groups in the majority of CCGs

10 Long Term Conditions Commissioner recommendations: Promote the uptake of care planning training, identifying from this pool clinical champions to become local trainers Once identified, champions to take TVSCN-supported Train the Trainer programme Base LTC plans on the House of Care framework, ensuring effort is focussed on all aspects, with metrics and outcomes that reflect all components. Progress through commissioning plans the adoption of care planning in a systematic way using the rolling programme on offer through the SCN. Develop commissioning plans for the long term sustainability of care planning Determine number, mix of local trainers, and/or facilitators to work at team/practice level. Provide a rolling programme of training, on-going support, audit and evaluation Develop a plan for the spread of care planning across all LTCs Use the recommendations of the diabetes patient education report to develop commissioning plans for the provision of comprehensive education for patients - go to for the full report (due end August 2015) Set up processes to capture patient needs identified in care planning consultations, and reflect these interventions in commissioning plans as defined as social prescribing. Back to Top Take a networked approach to developing an education strategy for HCPs to support on-going education in care planning and recognising the complexity of patients with co-morbidities.

11 End of Life Care Back to Contents

12 End of Life Care End of Life Care is everybody s business Every year approximately half a million people die in England. This is expected to rise by 17% by 2030, with a significant increase in the proportion who are aged over 85 years. High quality generalist end of life care provided by non specialist health and care staff as core work, is required by all. A proportion of people have complex needs and require specialist palliative care. For at least three quarters of deaths it is not sudden but is expected, providing opportunity to plan. In the last 12 months of life people have on average 3 or more unplanned admissions to hospital. Nearly 30% of current acute hospital in-patients will die during the next 12 months. Patients receiving hospice at home services are likely to die in the place of their preference (88% achieved their preferred place of death). Adoption of an integrated electronic palliative care record will support achievement of preferred place of death (82% of those who recorded their preference achieved this).

13 End of Life Care in the Thames Valley End of Life Care is everybody s business The presence of end of life care in CCG strategies is not consistent across TV. In a review of TV HWB strategies less than half included any reference to end of life care. End of life care and complaints is a recurring theme in the Ombudsman's Casework. ( Dying without Dignity ) Key themes feature again and again in the 12 case studies; poor symptom control poor recognition of dying poor communication inadequate OOH services poor care planning delays in diagnosis and referral With right care and treatment, peoples suffering can be avoided or lessened, as can the anguish their relatives and carers experience subsequently. (Ombudsman Report)

14 End of Life Care - Costs End of Life Care is everybody s business Hospital costs escalate in the last days and weeks of life. With the right care and treatment there is significant opportunity to improve the experience of patients and their families. Source: Public Health England: What We Know Now Many of the people admitted to hospital from areas containing care homes are close to the end of life. Areas with a care home have almost double the percentage of emergency admissions. Source: Georghiou et al, Nuffield Trust, 2012 Source: The Health Foundation, Nuffield Trust report - A commissioning focus on end of life caredriving up standards, improving the quality of care, and reducing unwarranted variation will have a positive impact on patient/carer experience and costs Source: Georghiou and Bardsley, Nuffield Trust, 2014

15 End of Life Care End of Life Care is everybody s business A 16% variation in deaths in hospitals exists across Thames Valley Source: National End of Life Care Intelligence Unit

16 End of Life Care End of Life Care is everybody s business National Survey of Bereaved People (VOICES) by CCG Combined data from the 2011 and 2012 VOICES surveys VOICES - England, 2014 was published on 9 th July

17 End of Life Care End of Life Care is everybody s business Commissioner recommendation Develop a robust End of life strategy using the House of Care framework, underpinned by One Chance to Get it Right The ideal EoLC Strategy includes the following strategic components; clear lines of accountability with reporting requirements from the EoLC locality group to the CCG board an EoLC Locality group that meets regularly, with committed key stakeholders who are decision makers, and who are representative of all aspects of EoLC and specialist palliative care engagement with local Health and Wellbeing Board to ensure a clear commitment to EoLC in their strategy. there is formal alignment with other CCG work-streams particularly LTC and urgent care programmes engagement with TVSCN Commissioner Forum to support expert EoLC commissioning across the network to share best practice and help overcome barriers and challenges

18 End of Life Care End of Life Care is everybody s business Commissioner recommendation (cont.) Commission/ require providers to engage in a rolling programme of education and training of the workforce e-elca Support primary care in early identification of those who may be dyinwww.dyingmatters.org/gp Promote/incentivise comprehensive use of an integrated electronic record sharing eg EPaCCS Work with acute providers in the adoption of the service specification for specialist palliative due September/October 2015 Develop new outcome metrics that capture patient and carer experience of care in all settings, to replace the emphasis on place of death.eg time spent in/out of hospital, number of emergency admissions, investigations/interventions of last weeks of life. Drawing on - Practice based surveys/ CCG Clinical concerns or Datix feedback, National EOL Care Profiles and use of ELCQua Engage with Dying Matters week and promote across CCG EoLC outcomes are included on the CCG board dashboard, are regularly reviewed by the exec team and there is clear accountability at board level.

19 The Ideal CCG End of Life Strategy A locally developed and owned vision for end of life care operationalised through the strategic plan. Delivered and overseen by a locality stakeholder group - with comprehensive representation across health and social care. A clear vision for end of life and specialist palliative care services for the local population that has the person at its centre. Core components Education and training - to ensure staff can deliver high quality EoLC. Commissioning and assurance of an integrated service across all providers - including third sector, community and acute providers Best use of existing, and creation of new levers to embed good practice e.g. quality premium target, CQUINS, CES, primary care standards Development of services to provide 24/7 access to support those at end of life, ensuring that patient choice and wishes are respected. End of Life Care is everybody s business

20 End of Life Care Events & Resources Upcoming events: the SCN in conjunction with HETV is offering the following workshops- exploring the theme of End of Life Care is everybody s business. Events: 22 September - Difficult decision making in EoLC (full, waiting list) 8 Oct The Frail Elderly 1 Dec Dementia 9 Feb Supporting education and training for EoLC Useful links and resources- *NEW* Ambitions for Palliative and End of Life Care- a framework for local action *NEW* Actions for End of Life Care Actions for End of Life Report Marie Curie Dementia Report Living & Dying with Dementia Help the Hospices review of H&WBB strategies The National Council for Palliative Care End of Life Care is everybody s business Contact: Julia Coles, Senior Clinical Network Manager julia.coles1@nhs.net Back to Top

21 Knowledge hub NICE guidance CQC s thematic review One Chance to Get it Right Priorities for Care National audit Care coordination - EPaCCS Concise and clear information Carers included VOICES-SF PfC secure and detained settings Inequalities addressed Communities of practice Transforming EoLC in acute hospitals Priorities for Care of Dying Person Guidance on personalised care planning Data and intelligence know-how Other professional know-how Specialist palliative care service specification Incorporating EoLC into service specs for specific groups Individual-level palliative care clinical dataset Input to Seven Day Services programme NHS Standard Contract Commissioning Toolkit National development currencies Metrics to support commissioning insights, indicators

22 Maternity Stillbirth Reduction Maternity Capacity Perinatal Mental Health AHSN Maternity Projects Back to Contents

23 Maternity Still Birth Reduction NHS England has made it a priority to reduce stillbirth rates: as a Mandate objective from the government to NHS England and features in the NHS England Business Plan 2014/ /17 Neonatal mortality and stillbirths is a key indicator in the NHS Outcomes Framework The Five Year Forward View identifies as a priority, a new care model to drive improvements in wider maternity services Also being developed through Saving Babies Lives is the Care Bundle for Still Birth reduction, these contain: Element 1: Reducing smoking in pregnancy by carrying out a Carbon Monoxide (CO) test at booking to identify smokers (or those exposed to tobacco smoke) and referring to stop smoking service/specialist as appropriate Element 2: Identification and surveillance of pregnancies with foetal growth restriction Element 3: Raising awareness amongst pregnant women of the importance of detecting and reporting reduced foetal movement (RFM), and ensuring providers have protocols in place, based on best available evidence, to manage care for women who report RFM Element 4: Effective foetal monitoring during labour

24 Maternity Still Birth Reduction Thames Valley SCN Still Birth Audits in 2014 show high rates of still births within patch. Group Findings No of cases % 1 2 There is clear explanation independent of care e.g. congenital/genetic abnormality There is an explanation and it might have been influenced by improvement in care There is no obvious explanation Total 71 Audit data suggests improvements in service and quality can be gained through focus on recommendations for group 2 Key findings from the Thames Valley Expert Panel (Collected by midwives and 6 acute Trusts. Reviewed by an expert group included Consultant Midwife and Obstetricians from OUH, BHT, FPH and AHSN): Commissioners to support primary care education in ensuring aspirin, high dose folic acid, GTT, VTE given to those mothers with pre-existing conditions as per NICE guidance Increase post mortems to understand cause of death Standardise fundal height measurement (undertaken across providers through maternity group hosted by TVSCN Increase communication between trusts through transfers of information

25 Maternity Still Birth Reduction Commissioner recommendations: Standardise symphysis fundal height measurement TVSCN are leading with Head of Midwifery Group across providers to develop improvements and undertake education with midwives across providers Maternity primary care education in each CCG CCGs to state requirement in commissioning plans of Obstetricians within providers to deliver pre-pregnancy assessments to improve the still birth rate and reduce maternal deaths for women with a pre existing medical condition as required in Saving Lives, Improving Mothers Care (Confidential Enquiry into Maternal Morbidity and Mortality (MBRRACE-UK Dec 2014) CCGs to undertake GP education on the timely prescribing of aspirin and correct doses of folic acid. Explore the use of a risk assessment form. Link with Maternity Network Oxford AHSN who will focus and lead on improving the management of small for gestational age babies and reduced foetal movements Align to NHS England saving babies lives care bundle all maternity providers completed baseline and we are monitoring progress quarterly As per the MBRRACE-UK report organisations whose stabilised & adjusted stillbirth, neonatal or extended perinatal mortality rate fall within the amber band should consider carrying out a local review. TVSCN Network can provide support for sharing and learning from these reviews

26 Maternity Still Birth Reduction Mortality rate (stabilised & adjusted mortality rates), Year 2013 Stillbirth CCG Total births per 1000 total births Stabilised & adjusted Crude (95% CI) England 665, (4.1 to 4.42) Aylesbury Vale 2, (3.64 to 4.95) Bracknell & Ascot 1,476 * 4.13 (3.47 to 4.83) Chiltern 3, (3.61 to 4.87) Milton Keynes 3, (3.64 to 4.93) Newbury & District 1,239 * 4.19 (3.54 to 4.91) Nort & West Reading 1, (3.54 to 4.85) Oxfordshire 7, (3.76 to 5.00) Slough 2, (3.46 to 4.85) South Reading 1, (3.52 to 4.80) Windsor, Ascot & Maidenhea 1, (3.46 to 4.75) Wokingham 1,698 * 4.22 (3.65 to 4.95) Mortality rate per 1,000 births Neonatal Extended perinatal per 1000 live births per 1000 total birhs Stabilised & adjusted Stabilised & adjusted Crude Crude (95% CI) (95% CI) (1.73 to 1.94) (5.9 to 6.28) (1.52 to 3.61) (5.24 to 8.03) * (1.12 to 2.55) (4.56 to 6.92) (1.36 to 2.97) (5.04 to 7.28) (1.48 to 3.12) (5.32 to 7.78) * (1.08 to 2.67) (4.71 to 7.40) (1.44 to 3.20) (4.99 to 7.63) (1.26 to 2.38) (5.21 to 7.33) (1.32 to 2.84) (4.90 TO 7.14) (1.30 to 2.84) (4.71 to 7.17) (1.48 to 3.43) (4.99 to 7.51) * (1.13 to 2.40) (4.87 to 7.25) MBRRACE-UK recommendation: Source: MBRRACE-UK Organisations whose stabilised & adjusted stillbirth, neonatal or extended perinatal mortality rate fall within the amber band should consider carrying out a local review. Back to Maternity *** Mortality rates have been referenced against the UK average as a benchmark. When benchmarked against Sweden, virtually the whole country is red.

27 Maternity Capacity Reviews (Phases 1 & 2) The Thames Valley Senate has been asked to consider if the capacity and capability of maternity services within the Thames Valley (including Milton Keynes) is sufficient to respond to demand over the next 10 years and we have agreed that the Senate and the SCN will work together to respond to this question Next steps for TVSCN Maternity Network Draft phase 2 Maternity Capacity report is out for comment and will be discussed at the senate council meeting on September 22nd We are seeking your views as to what extent the reports capture the current experience of maternity services. Are they comprehensive or has something key been missed? Comments and feedback, including the identification of any areas which you believe are important to the question would be appreciated. rebecca.furlong@nhs.net We will be aligning the final reports to the National Maternity review

28 Maternity Capacity Phase 1 report Change in live birth numbers and estimated increase in birth numbers from 2011 to 2020, by CCGs Between 2002 and 2012, births in TV increased by 5,650, or almost 22% Trend data suggested that the lower estimate should be used in planning future provision. All hospitals in TV were operating outside of the Royal College of Midwives recommendations on ratios of midwives to births, and were also out with the differentiated levels recommended by Birthrate Plus, taking into account recommended community and home birth ratios

29 Maternity Capacity Draft Phase 2 report currently being reviewed Proportion of consultant-led, midwife-led and home births taking place at Thames Valley providers, 2013/14 In there were 4775 midwife-led births; 88% took place in alongside midwife-led units 12% took place in stand-alone midwife led units This is broadly in line with national proportions Percentages of mothers with risk factors across TV Trusts Percentage of pregnancies in age categories vs national average % current smokers hypertension Trust diabetes BHT % 2.20% HWPH % 5.10% OUH 10.3 RBH % 3.50% Source: Phase 2 report Providers trust TV England Mothers under 19 1% 0.4% Mothers over 35 25% 19.4% Back to Maternity

30 Perinatal Mental Health The estimated perinatal mental health for Thames Valley (2013) is nearly 15,000 numbers per year. About 40% of conceptions (includes Adjustment disorders and distress) Variation in provision exists across Thames Valley. Since the TVSCN perinatal scoping paper (January 2015), some CCGs are reviewing provision and investment or have committed to investment. Service specification plans are also in development. Numbers of Chronic Conceptions serious in 2013 Postpartum mental psychosis illness Estimated Perinatal mental health numbers Mildmoderate Severe depressive depressive illness and illness anxiety states Post traumatic stress disorder Adjustment disorders and distress Total Rate per Bracknell Forest UA 1, Milton Keynes UA 4, ,042 1,917 Reading UA 3, ,377 Slough UA 3, ,355 West Berkshire UA 2, Windsor and Maidenhead UA 2, Wokingham UA 2, Buckinghamshire 7, ,630 2,999 Oxfordshire 9, , ,105 3,874 Thames Valley 36, ,081 4,503 1,081 8,106 14,915 TVSCN Offer Department of Health has committed 15 million for Perinatal Mental Health recurrent over 5 years To gain a full insight into this issue please connect with the Network to access; The recently appointed TVSCN Perinatal Mental Health project lead (Bryony Gibson - 2 days/week). Her role includes support to locality perinatal networks and CCGs to enable commissioning of perinatal mental health services bryony.gibson@berkshire.nhs.uk Up to date information from the national perinatal mental health leads able to advise on DH funding to CCGs. Link to the established TV Perinatal Mental Health SCN Regional Network which links with Oxford AHSN and HETV to focus on data, pathways and equitable provision of services. Back to Maternity Back to Mental Health

31 AHSN - Premature Babies Extremely premature babies have been found to have an increased rate of survival if they are born in a Level 3 unit (Marlow et al, 2014). In comparison with some other areas, our rates of delivery outside of a Level 3 unit were significant. (eg Wessex 20% v TV 50%) The Oxford AHSN Maternity Network audited all cases of babies born outside of a Level 3 unit in the area (April 2012-March 2014) to determine factors that may have prevented the in utero transfer (IUT) of women before delivery. In response to the findings the Maternity Network improved the referral pathway for IUTs, and developed a set of network-wide clinical guidelines for suspected extreme preterm labour. Current deliveries in a Level 3 unit have improved from 50% to 75% in the last 6 months since the project has begun implementation. The report is available at Extreme preterm = <27/40 singleton,,28/40 multiple or <800g = Born in a Level 3 unit = Born outside of a Level 3 unit Cont

32 AHSN - Reducing unwarranted variation and reducing harm Oxford AHSN Maternity Network have developed an agreed set of network wide guidelines which are currently in the process of being implemented in every Trust. They have been designed as simple algorithms which can be incorporated into existing guidelines. They have been developed in response to identified variation in the region and in response to stakeholder needs. The Maternity Network will continue a rolling programme of network wide guideline development. The first bundle includes; Management of Preterm IUGR Management of Preterm SROM Management of Preterm labour Rhesus Administration of Magnesium Sulphate Example: An incident occurred in one Trust where a woman was given a significant overdose of Magnesium Sulphate as emergency treatment for an eclamptic fit. On analysis, it was clear that the junior doctor who administered it followed the guidelines of the Trust he had just rotated from, and was more familiar with. Each Trust was using an slightly different method of drawing up this drug. As our area regularly and routinely rotates its junior medical staff it was essential the risk was negated. The Oxford AHSN Maternity Network have gained agreement from all Trusts to follow the same administration protocol, which will also be taught to the junior medics by the Thames Valley School of Obs and Gyn. For more information

33 AHSN - Other projects Connecting Ultrasound Scanning systems between hospitals to aid diagnosis, communication and reduce unnecessary appointments (due to complete Autumn 2015) Developing a network wide patient outcome database for use for local service audit and research Piloting and introducing innovations as appropriate for example, Intelligent Ultrasound system in Oxford and Milton Keynes Working with the SCN on the Stillbirth care bundle with a particular focus on SGA Six monthly Shared learning events learning from others experience across the network eg unusual/interesting clinical cases, learning from incidents Connecting fetal medicine staff to improve referral pathways and care Clinical Lead Mr Lawrence Impey (Consultant Obstetrician, OUH), lawrence.impey@ouh.nhs.uk Network Manager/ Lead Midwife Katherine Edwards, katherine.edwards@maternity.oxfordahsn.org Back to Maternity

34 Mental Health Network Children Mental Health Funding Back to Contents CAMHS Eating Disorders Transition from Children to Adult Services Reducing avoidable emergency admissions for children

35 Mental Health Funding CAMHS & Eating Disorders Allocation of Mental Health Funding to CCGs Area Names Total weighted populations with SMR <75 adjustment and uplifted by ONS population growth to 2015 Shares of weighted populations Initial allocation of funding for eating disorders and planning in 2015/16 ( ) Additional funding available for 2015/16 when Transformation Plan is assured ( ) Minimum recurrent uplift for 2016/17 and beyond if plans are assured includes 30m for Eating Disorders ( ) England 30,000,000 75,093, ,093,000 NHS Aylesbury Vale 187, % 98, , ,539 NHS Bracknell and Ascot 128, % 67, , ,659 NHS Chiltern 295, % 154, , ,388 NHS Milton Keynes 248, % 130, , ,665 NHS Newbury and District 110, % 58, , ,300 NHS North & West Reading 105, % 55, , ,775 NHS Oxfordshire 614, % 322, ,222 1,128,312 NHS Slough 147, % 77, , ,801 NHS South Reading 115, % 60, , ,574 NHS Windsor, Ascot and Maidenhead Back to Children 144, % 75, , ,974 NHS Wokingham 144, % 75, , ,498 Source: Local Transformation Plans for Children and Young People s Mental Health and Wellbeing, Guidance and support for local areas - Annex 4

36 CAMHS CAMHS spend per head of population <18, 2012/13 Spend ( ) on CAMHS: spend per head of population <18 (mapped from PCT) Primary care CCGs Overall prescribing Secondary care Community care Other/Unknown NHS Aylesbury Vale CCG NHS Bracknell And Ascot CCG NHS Chiltern CCG NHS Milton Keynes CCG NHS Newbury And District CCG NHS North & West Reading CCG NHS Oxfordshire CCG NHS Slough CCG NHS South Reading CCG NHS Windsor, Ascot & Maidenhead CCG NHS Wokingham CCG Source: Fingertips.phe.org.uk - Children's and Young People's Mental Health and Wellbeing

37 CAMHS Increase waiting time and demand ensures CAMHS remains a National and local priority to improve services. Future in Mind report written by the CYP MH task force gives a clear direction and key principles. All CCGs have been allocated funding for both general CAMHs and eating disorders, to be released on development of CCG transformation plans involving key partners (Health and wellbeing boards, local partners, specialist commissioners) When NHS England assurance process is complete, further funding to be released c. November 2015 TVSCN Offer TVSCN s CAMHS clinical lead Dr Stephen Madgwick is available to support CCGs and the system to develop the transformational plans by providing clinical advice, steer and national links. To link CCG commissioners with specialised commissioners to progress transformation plans There is a joint SCN/ AHSN best practice group on eating disorders to implement eating disorders best practice standards Best practice events CAMHs bringing whole system (Community, Education, Social care, Voluntary sector) together to learn and share Back to Children Back to Mental Health

38 Eating Disorders July Access and waiting time standard for Children and Young people (CYP) CYP referred for an assessment or treatment of an eating disorder will access NICE concordat treatment within 1 week for urgent cases and 4 weeks for routine cases This guidance for commissioners is to establish and maintain a community based eating disorder service and how it will be implemented. This must be included in the Transformation plans for the Autumn to access the funds of 30 million per year for 5 years to implement the proposed transformation of eating disorder services for CYP in England. The aim is for commissioners to align with the recommendations from Future in Mind Report The Community eating disorder service has key recommendations which include; Cover a minimum population of 500,000 Receive a minimum 50 new eating disorder referrals a year Enable Direct access including self referral and via primary care (GP/schools/voluntary sector) While services are being established (some may exist or may need to be extended) the 7 day service can be a goal Work with NHS England Operations to ensure transformational plans are ambitious and based on clinical practice Back to Children Back to Mental Health

39 Transition from children to adult services From patient satisfaction surveys undertaken by TVSCN employed Network Transition nurse in RBFT between Jan2015-June2016 (Survey of 78 patients) had the following results: Feedback from service users and parents/guardians Adult ward / OP environments Unfamiliar adult wards Old people can be scary, Adult services may not be as caring How self-advocacy will be encouraged in an unfamiliar, busy environment Different consultants at every appointment in adult service Transfer clinics Not enough joint clinics with adults and paediatric consultants Transferred to adults without support and proper planning Information giving Signposting to available services post 18 to be available allowing informed choice No clear pathway and who they will be referred to post transition Other There is uncertainty about the future Worried about changes to funding of services such as OT not enough regular appointments in the adult service

40 Transition from children to adult services Last year s commissioning guidance highlighted that Transition of young people from paediatric to adult services is a priority. TVSCN work to date Alongside our Network s activities on creating a Transition Stakeholder group, we have funded 2 x Network Transition Nurses, one at RBFT and a second based at OUH to offer a wider educational role across acute and community Trusts to offer providers resources to improve Transition. Key to this is; Pilot of 2 x cohorts (RBFT) to implement Ready, Steady, Go the evidenced best practice pathway for Transition Working with all Trusts (acute and community) to develop Transition pathways, DNA pathways, IT systems which reflect required changes and improve service user experience based on RBFT model Commissioner recommendation Ensure Trusts are adhering and compliant with You re welcome - Quality criteria for young people friendly health services Ensure Trusts have nominated Transition Leads both Operationally and at Board level Require Provider organisations to access education and learning opportunities through the Transition nurses Commissioning representation to participate within TVSCN Transition and CAMHS Networks Back to Children

41 Reducing avoidable emergency admission for children Source: Variation in Paediatric Care in the Thames Valley, AHSN Data: HES 2013/14 from TVSCN

42 Reducing avoidable emergency admission for children (1) Emergency admissions children with lower respiratory tract infections (LRTIs), 2013/14 (2) Unplanned hospitalization for asthma, diabetes and epilepsy in under 19s, 2013/14 Source: Fingertips - Children and Young People's Health Benchmarking Tool

43 Reducing avoidable emergency admission for children Phase /16: The SCN are utilising their project resource to embed the training and provide further support to practices through the following methods; Follow up evaluation post educational sessions to understand impact of education sessions on managing respiratory illness in childhood with specific focus on asthma management Promote the link of Personal Asthma Action Plans (PAAP) to GP practice systems Audit uptake of the Personal Asthma Action Plans (PAAP) in disease management Formal launch of the Puffell asthma self-management deck to GP practices to include Puffell posters and leaflets (Slough CCG) Further Opportunities The plan to extend the GP facilitation and educational model which focused on asthma/respiratory illness in children for 14/15 (as above) to have a wider paediatric care focus for 15/16 in primary care to deliver multi-professional training and education. This can be achieved through working with Oxford AHSN to widen focus, on their soon to be published Variation report, into emergency admissions in children presenting with either Gastroenteritis or Fever/Sepsis all ages (2 of the highest avoidable emergency admissions for children). Back to Children

44 Cardiovascular Heart Failure Back to Contents Atrial Fibrillation Familial Hypercholesterolemia Diabetes Renal Disease Stroke Services

45 Cardiac Heart Failure 14% increase in emergency admissions where HF is primary diagnosis with an 18% increase in annual emergency admission costs related to HF 6.24million* Estimated 2017/18 annual emergency admission costs related to HF across Thames Valley It is estimated that over a four period from , there were approximately 1,300 thirty-day readmissions within Thames Valley with heart failure as the primary diagnosis million* spend on emergency admissions between across Thames Valley. Source: Optum Consulting

46 Cardiac Heart Failure Commissioner recommendation; In line with improvements seen in Stroke Services through analysis of SSNAP data, we recommend National Heart Failure Audit data collation continues to be a priority for CCGs in their information ask of Trusts Continue engagement and drive adoption of Heart Failure Day Case Unit (as below) with support from TVSCN (Source: NHFA 2012/13 next published data Oct 15) BEST PRACTICE EXAMPLE Adoption of Heart Failure ambulatory day care model Whitley Day Unit at RBFT set up as pilot site in February patients treated between 23rd February and end of June % were discharged after treatment and 30% admitted to the ward; of those 30% admitted 37.5% were admitted for non-heart failure reasons 233 bed days saved in 4 months (equating to 700 days annually) Back to Cardiovascular

47 Cardiac Atrial Fibrillation Significant number of strokes continue to be AF related Under-diagnosed Significant number of high risk patients not anti-coagulated Proportion of patients not therapeutic > 5.1 million per year could be saved with appropriate anticoagulation across Thames Valley Commissioner recommendation: Request CCG clinical and commissioning leads engage with the newly formed Cardiac Coalition Group (led by Dr Raj Thakkar) to work towards the West Hampshire model based on NICE guidance requiring; Back to Cardiovascular Identifying at risk patients and medication transfer GP education Patient education Event: Cardiac Masterclass September 17 th Holiday Inn, High Wycombe

48 Cardiac - Familial hypercholesterolemia The case for change for providing cascade testing for FH is still a present issue further bolstered by recent NCD and Public Health England endorsement and NICE (2008) guidance Evidence now suggesting affordability in treatment has greatly improved due to generic statin prescribing and managing FH care through alternative models in general practice Accessing testing and tracing of family members can be undertaken through established service routes Commissioner recommendation: CCGs utilise Medway Audit Tool to enable identification of patients through ECR Since there are relatively small numbers of patients in each CCG region, TVSCN can link up CCGs from across region to engage service providers in offering a comprehensive service (e.g. Harefield ) Back to Cardiovascular

49 Diabetes CCG performance across the Diabetes care processes QOF data 8 care processes Source: Public Health Profile Fingertips - Diabetes

50 Diabetes Patient with diabetes meeting treatment targets HbA1c 58mmol/mol, cholesterol <5mmol/L and their relevant blood pressure target Source: NDA 2012/13 N.B. the relationship between the uptake of 8 care processes and HbA1c levels is not directly linear comprehensive care planning is critical for success. Source: Public Health Profile Diabetes, fingertips

51 Outcomes Versus Expenditure (DOVE) Tool - Diabetes quadrant chart 2013/14 Data: Total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 59mmol/mol or less in the TVSCN area

52 Diabetes Aims of the Network; Support improvement at locality level Improved uptake of the 8 care processes Move diabetic foot care from average to excellent (TVSCN to provide commissioning advice) Commissioner recommendations: Ensure appropriate leadership and governance in place to deliver House of Care approach: Comprehensive implemented pathways in line with House of Care Systematic adoption of care planning Maintain robust diabetic registers & reduce exception reporting in primary care Commission comprehensive diabetes patient education programme as described in Long Term Conditions slides Engage with TVSCN working group on diabetic footcare to ensure best practice and an end to end approach Continued partnership working with AHSN on islet cell transplantation, GDM, Monster Manor, Hypo management Events Diabetic foot group - September 9th Back to Cardiovascular Diabetes Reference Group - November 18 th (with Prof. Jonathan Valabhji, Diabetes NCD)

53 Renal Disease Cardiovascular disease profile, Kidney Disease published March 2015 A national initiative is underway to improve the diagnosis and management of AKI Analysis of hospital activity data has not been included in this profile as it under estimates the true level of AKI and may be misleading. Information from the national AKI initiative will be included in future profiles. Aim to implement the Think Kidneys National Programme Benefits reduced admissions, readmissions and better patient care Commissioner recommendations Ensure secondary and primary care are sighted on required action plans (next slide) Connect with AHSN patient safety collaborative

54 Acute Kidney Injury Back to Cardiovascular AKI National Programme Key Milestones AKI Programme DETECTION WORKSTREAM EDUCATION WORKSTREAM INTERVENTION WORKSTREAM RISK WORKSTREAM MEASUREMENT WORKSTREAM IMPLEMENTATION WORKSTREAM September April 2016 Sep-Mar 2014/15 Apr-15 May-Sep 2015 Oct-15 Nov-Mar 2015/16 Apr-16 Develop Secondary Care education packages including pilot testing Develop Secondary Care education packages including development of tools and pilot testing Develop Secondary Care Risk Assessment tools and pilot tools Implement Secondary Care AKI Warning Test Launch Secondary Care education packages Launch Secondary Care package Launch Secondary Care Risk Assessment Tools CCG Level report on inititation of Secondary Care AKI Warning Test Develop Primary Care education packages including pilot tsting Develop Primary Care education packages including development of tools and pilot testing Develop Primary Care Risk Assessment tools and pilot tools Design Quarterly Reports at CCG level for Primary Care HQIP Proposal Test Primary Care in shadow form Test Education packages for Primary Care Test Primary Care packages and tools Test Primary Care Risk Assessment tools Commence Quarterly Reports at CCG Level based on shadow form results from Primary Care Data Development of Primary Care Commissioning levers and tools Development of Secondary Care Commissioning levers and tools Refine Primary Care education packages Refine Primary Care packages and tools Refine Primary Care Risk Assessment tools Launch AKI Warning test to Primary Care Launch Primary Care education packages Evaluation of Primary Care packages Launch Public/Patient Campaign Launch Primary Care packages Launch Primary Care Risk Assessment tools Registry in place Costed Business Case National Audit Formal quarterly reports at CCG level re uptake in primary care

55 Stroke Services Newbury North and Windsor, National Aylesbury Bracknell Milton South Chiltern and West Oxfordshir Slough Ascot and Wokingham and Ascot Keynes Reading Vale CCG CCG District Reading e CCG CCG Maidenhead CCG CCG CCG CCG CCG CCG CCG Mortality within 30 days of hospital admission for stroke /14 Standardised Mortality Ratio (SMR) Overall SSNAP level: Average SSNAP level for providers within your CCG Apr-Jun 2014 D C D E C B D D B D B Jul-Sep 2014 C B C E B B C D B D B Oct-Dec 2014 C B C E B B C D B D B Jan-Mar 2015 C B C E C C C D C D C % treated by a stroke skilled ESD team Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr Mar % with a 6 month follow-up assessment Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr Mar Source: SSNAP Note: A SSNAP scoring system has been derived to provide a summary of performance based upon results for 44 key indicators which are grouped into 10 domains covering key aspects of stroke care. For Domains 1 10, the scores have been calculated and given a performance level (A-E). A is the best level and E is the worst.

56 Stroke Services Summary scoring by providers: Team-centred Total KI level Period (Quarter) Wycombe General Hospital Wexham Park Hospital Jul-Sep 2013 C E Milton Keynes General Hospital Insufficient records Horton General Hospital John Radcliffe Hospital Royal Berkshire Hospital Frimley Park Hospital Luton and Dunstable Hospital D D B B E Oct-Dec 2013 C E E D C B C E Jan-Mar 2014 D D D E C A C E Apr-Jun 2014 C D D D D A B E Jul-Sep 2014 B D D D C A B E Oct-Dec 2014 B D E D C A B E Jan-Mar 2015 A D E E B B B E Source: SSNAP Note: A SSNAP scoring system has been derived to provide a summary of performance based upon results for 44 key indicators which are grouped into 10 domains covering key aspects of stroke care. For Domains 1 10, the scores have been calculated and given a performance level (A-E). A is the best level and E is the worst.

57 Stroke Services Thames Valley & Milton Keynes Vision for Stroke Services: ALL stroke patients to be treated in a HASU for the first 72 hours of care Clinical case in line with; Department of Health National Stroke Strategy (2007); Royal College of Physicians - National clinical guidelines for Stroke (2012) British Association of Stroke Physicians Stroke Service Stanards (2014); and NICE guidance (2008, reviewed 2014) Centralised stroke care provides evidence based improved patient outcomes as evidenced in London and now Manchester There is a strong relationship between patient volumes and improved outcomes c 900 patients pa seen as model throughput Commissioner recommendations Ensure all stroke patients are directed to a HASU for first 72 hours of care; Ensure comprehensive access to ESD services (current range across TV treated by an ESD team 20.3% %); Ensure stroke rehabilitation services are provided 7 days a week; Provide comprehensive access to 6 month reviews (current variation in TV ranges from 1% - 73%) Back to Cardiovascular

58 Cancer Cancer Pathway Cancer Early Diagnosis Cancer Pathway - prostate Cancer Survivorship Back to Contents

59 Cancer Pathway Back to Cancer

60 Cancer Early Diagnosis National outcomes framework indicators CCG Indicator Compare to last year: 1.4 Under 75 mortality rates from cancer (ALL), Year 2013, DSR per 100, One year survival (%) of all cancers (ages 15-99), Year 2012 Increase Similar Decrease 1.11 One year survival (%) of breast, lung & colorectal cancer (ages 15-99), Year Early detection: percentage of cancers detected at stage 1 & 2, Year 2013 DSR LCI - UCI Percentage Percentage Percentage LCI - UCI Percentage LCI - UCI England ( ) ( ) 41.6 ( ) Aylesbury Vale CCG ( ) ( ) 23.7 ( ) Chiltern CCG 96.5 ( ) ( ) 18.1 ( ) Milton Keynes CCG ( ) ( ) 27.2 ( ) Oxfordshire CCG ( ) ( ) 44.4 ( ) Swindon CCG ( ) ( ) 45.2 ( ) Newbury & District CCG ( ) ( ) 37.6 ( ) North & West Reading CCG ( ) ( ) 39.4 ( ) South Reading CCG 110 ( ) ( ) 39.7 ( ) Wokingham CCG 99.9 ( ) ( ) 46.7 ( ) Bracknell & Ascot CCG ( ) ( ) 20.5 ( ) Slough CCG ( ) ( ) 17.7 ( ) Windsor, Ascot and Maidenhead CCG ( ) ( ) 20.1 ( ) Similar to England Better than England Lower than England Source: HSCIC, CCG Outcomes Indicator set ( Early detection: percentage of cancers detected at stage 1 & 2, Year 2012

61 Cancer Early Diagnosis National outcomes framework indicators England average for early detection increased by approx. 5% Thames Valley position variable; 8 CCGs have increased their early detection rate 2 CCGs stayed the same 2 CCGs worsened n.b. Most CCGs are below the England average Source: HSCIC, CCG Outcomes Indicator set ( Early diagnosis improves survival therefore is a key indicator

62 Cancer Early Diagnosis National outcomes framework indicators Commissioner recommendation; Require Trusts to complete staging at diagnosis of at least 70% This information will allow appropriate quality improvement initiatives to be targeted at primary or secondary care systems Source: HSCIC, CCG Outcomes Indicator set (

63 Cancer Early Diagnosis Five Year Forward View states: One in three of us will be diagnosed with cancer in our lifetime. Fortunately half of those with cancer will now live for at least ten years, whereas forty years ago the average survival was only one year. But cancer survival is below the European average, especially for people aged over 75, and especially when measured at one year after diagnosis compared with five years. This suggests that late diagnosis and variation in subsequent access to some treatments are key reasons for the gap. Faster Diagnosis: We need to take early action to reduce the proportion of patients currently diagnosed through A&E currently about 25% of all diagnoses. These patients are far less likely to survive a year than those who present at their GP practice. Currently, the average GP will see fewer than eight new patients with cancer each year, and may see a rare cancer once in their career. They will therefore need support to spot suspicious combinations of symptoms. The new care models set out in this document will help ensure that there are sufficient numbers of GPs working in larger practices with greater access to diagnostic and specialist advice. We will also work to expand access to screening, for example, by extending breast cancer screening to additional age groups, and spreading the use of screening for colorectal cancer. As well as supporting clinicians to spot cancers earlier, we need to support people to visit their GP at the first sign of something suspicious. If we are able to deliver the vision set out in this Forward View at sufficient pace and scale, we believe that over the next five years, the NHS can deliver a 10% increase in those patients diagnosed early, equivalent to about 8,000 more patients living longer than five years after diagnosis.

64 Cancer Early Diagnosis Commissioning advice; CCG Outcome Framework includes a number of indicators that rely on earlier diagnosis of cancers. Earlier diagnosis will be achieved by: Supporting GPs to access diagnostic tests; make available advice from hospital specialists and encourage GPs to refer appropriately to secondary care Encouraging the public to act on the signs and symptoms of cancer earlier Developing and agreeing inter Trust referral processes Requesting your Provider Trust stages at least 70% of all cancers Advice & guidance for GPs access the Cancer SCN Primary Care Resource Toolkit Commissioner recommendations: ŸRequest and monitor your Provider Trust books the 1 st Outpatient appointment for 2ww referral within 5 working days Commission sufficient capacity to manage national Be Clear on Cancer campaigns see details of current and upcoming campaigns at: Commission services in accordance with the pathways agreed by the Thames Valley Cancer Network

65 NICE Guidance on Diagnostic Access Impact assessment This will increase costs through O/P appointments and diagnostic requirements Very detailed analysis for each CCG and Trust has been done to demonstrate the extent to which each cancer pathway is affected by the guidance. A workbook describing this has been provided to cancer leads at each CCG In summary, the impact is described in the table below; CCG lower estimate k upper estimate k Bracknell and Ascot Chiltern Newbury and District N and W Reading Oxon Slough S Reading Aylesbury Vale WAM Wokingham Swindon MK Trusts lower estimate k upper estimate k BHT HWPH OUH RBH Great Western MK Commissioner recommendation; In line with these increases, additional capacity may need to be commissioned

66 Cancer Early Diagnosis Event: Cancer Strategic Clinical Network Collaborative Commissioning workshop on Thursday 15 th October to support collaborative commissioning of cancer services taking into account the newly published Achieving World-Class Cancer Outcomes: a Strategy for England , NHS Five Year Forward View, and the publication of the revised NICE Cancer Urgent Referral Guidance. Case studies of successfully commissioned and implemented innovations addressing: Early Diagnosis Living with and Beyond Cancer Demand and Capacity Planning for Diagnostics You will be able to access all case study templates after the workshop for your own use. Contact: Lucy Grundonner to book a place - Lucy.grundonner@nhs.net Back to Cancer

67 Cancer Pathways prostate Cancer pathways are being refreshed by the SCN through it s engagement with TV tumour site specific clinical groups The prostate pathway shown on the right is one currently under review because of changes in technology and diagnostics Commissioner recommendation: CCGs commission cancer pathways in line with TVSCN agreed pathways CCGs engage with the SCN in the sharing and dissemination of the information Back to Cancer

68 Cancer Survivorship Number living with and beyond cancer up to 20 years after diagnosis West Berks Federation Berkshire East Cancer Prevalence (based on current 20- CCG year prevalence and indicative future Year 2010 Current Year 2030 Estimate Aylesbury Vale CCG 6,000 11,600 Chiltern CCG 10,600 20,500 Milton Keynes CCG 6,200 12,000 Oxfordshire CCG 20,600 40,000 Swindon CCG 5,700 11,000 Newbury & District CCG 3,200 6,200 North & West Reading CCG 3,200 6,200 South Reading CCG 2,200 4,300 Wokingham CCG 4,900 9,600 Bracknell & Ascot CCG 3,500 6,900 Slough CCG 2,700 5,200 Windsor, Ascot & Maidenhead CCG 4,400 8,600 Thames Valley SCN (TOTAL) 73, ,100 Source: NCIN, Cancer Commissioning Toolkit

69 Cancer Survivorship Five Year Forward View states: combined with this consolidation of the most specialised care, we will make supporting care available much closer to people s homes; for example, a greater role for smaller hospitals and expanded primary care will allow more chemotherapy to be provided in community. We will also work in partnership with patient organisations to promote the provision of the Cancer Recovery Package, to ensure care is coordinated between primary and acute care, so that patients are assessed and care planned appropriately. Support and aftercare and end of life care which improves patient experience and patient reported outcomes will all increasingly be provided in community settings. Commissioner recommendation Ensure all patients receive a formal treatment summary and have access to a holistic needs assessment. Encourage the development of health & wellbeing events; these can act as the bridge between initial treatment and living with or beyond cancer and will facilitate selfmanagement and enable less routine follow up Risk stratified pathways of care (prostate, colorectal and breast)

70 Cancer Survivorship Commissioner recommendations Undertake a phased implementation plan for all cancer services commissioned to deliver the recovery package as described in the National Cancer Survivorship Initiative (NCSI) and includes: At least 70% of all new patients will have a completed recovery package consisting of:- A Holistic Needs Assessment and care plan Opportunity to attend a health and well-being event A treatment summary All services for prostate cancer will be commissioned in line with NICE guidance through a timed pathway with follow up in line with the NCSI: MRI is performed pre-trus Bx for a given cohort as recommended in the Network pathway. 40% of new patients are followed up after treatment through a stratified pathway of supported self-management

71 Cancer Survivorship Commissioner recommendations (cont.) All services for colorectal cancer (CRC) should be commissioned in line with NICE guidance through a timed pathway with follow up in line with the NCSI: All surgeons are completing the required minimum numbers of 20 cases with curative intent per annum. Each MDT treats a minimum of 60 cases with curative intent per annum. Enhanced recovery programme embedded All suitable patients to be offered laparoscopic surgery and resection rates to match the England average. Age of referral for low, but not no risk of cancer lowered to 45 Define baseline and trajectory for % of new patients followed up through supported selfmanagement Barium enema is not to be used as a first diagnostic test for suspected colorectal cancer People who need emergency treatment should be treated by a colorectal cancer team Back to Cancer

72 Neurological Conditions Integrated Healthcare Strategy Forum Back to Contents

73 Neurological Conditions Long term conditions - rather than illnesses susceptible to a one-off cure - now take 70% of the NHS budget. Neurological disorders such as chronic headaches, movement disorders and epilepsy are hugely prevalent, impart major long-term disability and are very costly to the health sector. 30,000,000 25,000,000 20,000,000 Costs of admissions in Thames Valley across 2009/ /13 Elective costs: Non-elective costs: 42 million 75 million Total: 116 million over four years or 29m/yr 15,000,000 10,000,000 5,000,000 0 Epilepsy Headache and Migraine MS MND Movement disorders Muscle disorders ABI Elective Non Elective Data source: Neurological Commissioning Support Report

74 Neurological Conditions Integrated Healthcare Having commenced the work through the Mental Health, Dementia and Neurological Conditions Network we are pleased to see the design and take-up of headache pathways across the patch The Neurology Strategy Forum will continue to support this work, and also continue the call for Integrated Neurological healthcare to reduce Outpatient referrals whilst seeking to develop alternative models of community care. Commissioner recommendation: Utilise experience and outcomes from Headache Pilots and pathways across the patch e.g. Primary Care Headache GPwSI pilot (Oxford) evaluation; 70% increase in n. patients feeling able to manage their headache post-consultation Reduced costs per clinic (vs Acute outpatient consults) Reduced MRI requests (halving imaging requests and follow-up rates)

75 Neurological Conditions Integrated Healthcare TVSCN will support an Oxford pilot to develop a Rapid Response service for people with long term neurological conditions at high risk of developing respiratory and urinary tract infections. Delays in community physiotherapy or inappropriate treatment can be detrimental to patients health and recovery, and incur costly emergency or non-elective hospital admissions with potential long lengths of stay Evidence; In those with complex neurological conditions, Oxfordshire has a high rate of non-elective hospital admissions for Chest Infection and Urinary Tract Infections CI and UTI account for largest number of emergency admissions for that cohort Community physiotherapy waiting times are at 16 weeks, and with lack of expertise in specific respiratory management, the response to acute demands in the community is limited Draft proposal (in development); 6 month - 1 year pilot in Oxfordshire to develop an urgent response neuro-chest physiotherapy service for the community Physiotherapists would visit defined cohorts in their homes and deliver early intervention to prevent hospital admissions Staffed by physio team 8am-8pm, 7 days per week Back to Neurology

76 Neurology Strategy Forum The Neurology Strategy Forum exists to provide a framework and direction to improving TV neurology services, collectively consider real pathway solutions, recognise service excellence and high quality care, share best practice and innovative solutions, and leverage adoption and dissemination Areas of focus include: patient centred care, developing and delivering integrated pathways, reducing admissions, embedding informatics into patient care systems!!! Stop Press!!! TVSCN have been awarded the national lead to work collaboratively with other SCNs on developing Community Neurology Care Models. This will enable a greater focus for the patch on Planned Care relating to Epilepsy, Funny Turns & Post- Diagnostic services. Commissioner recommendation Back to Neurology Encourage commissioner and clinical lead attendance, interface and work collaboratively through the Strategy Forum on pathway developments e.g. Parkinson s pathway design (WAM CCG) and input into post-diagnostic services exercise Consider developing GP Neurology Leads within CCG structures Share learning on patient-centred care utilising technology (e.g. True Colours ) Event: 7 th October 12.30, Green Park Conference Centre, Reading, RG2 6DP

77 National Context Early Intervention in Psychosis (EIP) Back to Children *** Mental Health in Children & Young People CAMHS Mental Health Spend System Integration Eating Disorders Perinatal Mental Health System Integration Street Triage System Integration Liaison Psychiatry A&E Mental Health attendances Mental Health Back to Contents Suicide & Self-Harm Self-Management & Primary Care IAPT Dementia

78 Dr Geraldine Strathdee, National Clinical Director 5 Year Forward View - Mental Health across the Lifespan Being Born well Best early years Living and working well Growing older well Dying well At each life stage Building Positive mental health in individuals and communities through raising political & public awareness and reduced stigma Prevention of mental ill health in communities through addressing the fundamental causes in each community Improving access standards to timely, effective care for the 16 mental health care pathways maximizing the potential of the digital revolution Transformation of services to deliver Integrated treatment & care, better outcomes, quality & Value & personalized Right Care Building a sustainable future of Leaders, intelligence & and improvement programmes

79 How this Maps to the SCN MHDN Network Programme Being Born well Best early years Living and working well Growing older well Dying well At each life stage - Perinatal Mental Health Network - ELSA pilot project - CAMHS - Transition - Eating Disorders - Care Planning - Suicide Prevention and Intervention Network - IAPT - Crisis Care Concordat - Street Triage - Early Intervention in Psychosis - Strategic Dementia Forum - Dementia Diagnosis - Dementia Friendly GP Practices - Dementia Diagnosis Variation Event - Cancer and MH support: baseline - Advanced Care Plans -End of Life Care Network - End of Life master classes - System support for one chance to get it right

80 Five Year Forward View Priorities for Mental Health Mental illness is the single largest cause of disability in the UK and each year about one in four people suffer from a mental health problem. FYFV Inclusive of children, young people and adult mental health Parity of esteem by 2020 Improving Access to Psychological Therapies (IAPT) Crisis Care Concordat Liaison psychiatry Maternity (perinatal mental health) Children and adolescent mental health services (CAMHS) Eating disorders Alcohol Dementia Plus Prevention New access and waiting standards Choice and constitutional rights CQC Website and the mental wellbeing of the NHS workforce

81 The Forward View Into Action: Planning for 2015/16 Access and waiting time standards to be fully implemented from April 16 50% of people experiencing a first episode of psychosis to receive treatment within 2 weeks. 40m additional funding available to support this nationally 75% of IAPT patients to be in treatment within 6 weeks and 95% within 18 weeks. 10m additional funding to support this nationally 30m targeted investment in 2015/16 to support liaison psychiatry. Need to agree SDIPS to ensure appropriate levels of liaison psychiatry in acute settings 15m/ year committed for perinatal MH over 5 years NHSE to coordinate programme to spend 30m already announced in Autumn statement to establish community based specialist teams for CYP with eating disorders NHS England waiting time standards guidance published 12 February

82 The Imperative to Increase Mental Health Spend THE FORWARD VIEW INTO ACTION - PLANNING FOR 2015/16 : We expect each CCG s spending on mental health services in 2015/16 to increase in real terms, and grow by at least as much as each CCG s allocation increase CCG s planned % increase of MH spend should therefore equal or exceed the % increase of total allocation The Forward View Into Action also suggests how that additional spend might be targeted across mental health services Data source: Thames Valley Area Team and Milton Keynes CCG - Finance

83 Excess Under 75 Mortality Rate (Mental Health) FYFV sets a clear ambition to achieve parity of esteem by 2020 people with severe and prolonged mental illness die on average 15 to 20 years earlier than other people one of the greatest health inequalities in England. Data source: NMHDNIN - Severe Mental illness Profiles

84 SCN Priority Recommendations To achieve the aspirations of the FYFV, the SCN recommends a number of areas which CCGs and providers are able to influence. First and foremost: To maintain the stability of core services To build on the excellent improvements to Mental Health provisions in recent years To further build: System Integration: health system and public service sector Self Management: promotion and enabling Improving mental health services in Primary Care Children and adolescent mental health services Joint strategies between Local authority/ccg Perinatal mental health services Back to Mental Health

85 Early Intervention in Psychosis Source: Early Intervention in Psychosis Preparedness Programme (South of England) Oxford AHSN

86 Early Intervention in Psychosis South Region Early Intervention in Psychosis Website Next Steps CCG/Trust level preparedness assessments and action plans Proposal detailing funding allocation Targeted training and capacity building Back to Mental Health Source: Early Intervention in Psychosis Preparedness Programme (South of England) Oxford AHSN

87 Mental Health Spend MH spend by CCG ( ) Populations (ONS mid 2013) Spend FOT Spend per head Area Names All Ages Age 0-17 Age /15 000's (all ages) NHS Aylesbury Vale 199,461 45, ,056 17, NHS Bracknell and Ascot 134,359 31, ,485 12, NHS Chiltern 319,442 73, ,305 23, NHS Milton Keynes 261,357 65, ,095 24, NHS Newbury and District 105,712 24,358 81,354 12, NHS North & West Reading 99,907 23,195 76,712 12, NHS Oxfordshire 652, , ,117 63, NHS Slough 143,024 39, ,010 14, NHS South Reading 109,020 23,251 85,769 14, NHS Windsor, Ascot and Maidenhead 139,865 30, ,699 13, NHS Wokingham 157,866 36, ,369 15, Thames Valley SCN 2,322, ,365 1,792, , Social Care Spend 2013/14 Adults aged under 65 with mental health needs Data source: Thames Valley Area Team and Milton Keynes CCG - Finance Data source: The financial data is Revenue Outturn (RG) Specific and Special Revenue Grants: data The population data is Interim 2011-based Subnational Population Projections UA / County Population projections Year 2013: Age Bracknell Forest UA 72,820 2,225 Reading UA 101,839 4,609 Slough UA 90,915 2,944 West Berkshire UA 92,673 2,155 Windsor and Maidenhead UA 86,531 2,882 Wokingham UA 96,576 3,236 Milton Keynes UA 158,937 3,339 Buckinghamshire 298,502 6,629 Oxfordshire 401,695 8,424 England 32,576,427 1,066,107 Net Total Cost Costs per head ( thousand)

88 Mental Health Spend 2013/14 Back to Mental Health Data source: NHS England, CCG Programme Budgeting Benchmarking Tool Some CCGs have been flagged as having an issue with the quality of the data included, these issues may have an impact on the ability to benchmark

89 System Integration Developing real and effective service integration, particularly with social care Implementing whole-system changes which encourage wider partnership working across both organisations and sectors: Refining and embedding the evidence for street triage Creating new evidence for models of care such as liaison psychiatry by varying scale and impact to best effect Introducing mental health clinicians in A&E to improve immediate care and target a longer-term reduction in repeat attenders Supporting new projects enabled by the 2014 Mental Health Resilience Monies. Fully evaluating their impact, exploring scalability options, reaping the benefits, demonstrating patient outcomes, and embedding system change/reforms Integrated professionals and harnessing multi-disciplinary expertise i.e. greater integration with pharmacists and medicines optimisation Using collaborative implementation and subsequent effect of whole system approaches such as the Crisis Care Concordat Early intervention services to be exemplars for the holistic management of patient health and social care needs and recovery Real and seamless integration of technologies between systems of care Back to Mental Health

90 System Integration Street Triage Oxfordshire - Pilot data S136 Detentions have been falling due to the Street Triage team s ability to make informed decisions and find alternative pathways Pilot start Evaluation at the end of the scheme found that: 74% referred were known to MH services with ~50% having an active care plan. 93% were not involved in a criminal incident, with > 50% threatening self-harm. Source: Thames Valley Police 39.5% fewer people in Oxfordshire were detained using s.136 powers considerably greater than the reduction of 9% seen in Buckinghamshire (which is a control group) 62% of incidents resulted in averting a s.136 detention as opposed to 18% when giving phone advice to officers Back to Mental Health Repeat detentions fell by 60% during the period Prior to the pilot 35% of detentions resulted in no further Mental Health service referrals, this has fallen to below 25% during the evaluation period (this is a measure of inappropriate detentions) By averting s.136 detentions, pressure has been relieved on the AMHP service and the demand for s.12 doctors. A saving of up to 66,000 has been realised. 460 hours of s.136 suite occupation were avoided Commissioner recommendation: Consider commissioning a street triage service based on the learning from the Oxfordshire scheme to maximise the cost/benefit ratio.

91 System Integration - Liaison Psychiatry No Health Without Mental Health states 25% of those admitted to hospital with a physical condition also have a mental health condition 80% of all hospital bed days are occupied by people with co-morbid physical and mental health problems (Royal College of Psychiatrists, 2013) For the patient, liaison psychiatry positively supports and improves care for dementia, cancer, alcohol and drug misuse, depression, self harm, and psychosis Liaison psychiatry can also reduce length of stay, increase diversion at A&E, increase rates of discharge at MAU and from wards, reduce rates of re-admissions, promote independence and improve rates of discharge to own homes Liaison psychiatry pathway should include home settings: care and self management; Current attempts at integration use old liaison psychiatry model have meant; Services to general hospital provided by mental health trust Limited integration with general hospital and primary care KPIs set by provider and commissioner not medical trust Commissioner recommendation: New commissioning guidance for achieving integration is being developed by the Oxford AHSN to be published in Spring 2016 focussing on a detailed scoping of regional service structures, operations, KPIs, systematic reviews of evidence bases and a regional pilot of a PREM / PROM questionnaire Future: Target for A&E wait times is anticipated

92 System Integration Psychological Medicine Preferred model of integrated care for mental-physical co-morbidity; (Professor Michael Sharpe Oxford AHSN, Comorbidity Network Strategic Lead) Full integration of mental and physical care within the clinical team Psychological medicine (psychiatry and psychology) commissioned through Acute Trusts as recommended by the Academy of Medical Royal Colleges (2008) Embedded within and part of the medical specialties e.g. Medicine, cancer, palliative care, maternity, neurosciences Provides direct patient care as part of medical team; Training in mental health care for general hospital clinicians Develop local policies for more integrated systems Whole-person care is organised around the patient, not the providers Service objectives aligned with those of medical specialty Outcome-focused services Improved accountability to service using organization Framework for service evaluation and continuous improvement

93 Liaison Psychiatry Models of Delivery and their Effectiveness and Return on Investment The sporadic and unplanned growth of liaison psychiatry services means that in many places rudimentary liaison psychiatry services exist. Whilst they employ some service elements that other models have indicated would produce quality and cost effectiveness, it is suggested that they are at a level for which there is no evidence of likely return on investment. Core working or extended hours only. Provided there is no 24 hour demand, these services should be expected to return on investment but at a lower level. Core24 twenty-four hours, seven days a week. There is evidence that this service model, applied where there is 24 hour demand for services, will return on investment at or near the level of RAID. Enhanced24 with extensions to fill local gaps in service and some outpatient services. Clear published evidence of return on investment, this is the Rapid Assessment, Intervention and Discharge model for patients presenting with delirium and/or symptoms of dementia (RAID). RAID has an estimated benefit:cost ratio of 4:1 Comprehensive enhanced with inpatient and outpatient services to specialties at major centres. Will return on investment at or near the level of RAID. Key elements are based major centres providing regional and supraregional services. North West London RAID, Birmingham Leeds Back to Mental Health Source: Developing Models for Liaison Psychiatry Services Guidance; Dr Peter Aitken, Dr Sarah Robens, Tobit Emmens; South West SCN

94 A&E Mental Health Attendances Data source: NMHDNIN Community Mental Health Profiles A&E Attendance to acute trusts Back to Mental Health Data source: NMHDNIN - Severe Mental illness Profiles based on Monthly Mental Health Minimum Data Set (MHMDS) Reports, submitted by Mental Health providers

95 Suicide and Self Harm Prevention and Reduction Effective suicide prevention strategies are multi-agency, including: police, ambulance, local authority, third sector, criminal justice system, education/schools, media Crisis response systems and the Crisis Care Concordat are important approaches Most of the TV areas are below the England average on suicide. Commissioner recommendations Work closely with local authorities and embed suicide prevention strategies. Local authorities are aligned to the Suicide Prevention and Intervention Network (SPIN) Introduce and improve services for those bereaved by suicide Support improved data capture and understanding Improve risk assessment tools and training of frontline staff Promote and commission mental health first aid training Back to Mental Health Data source: NMHDNIN Community Mental Health Profiles

96 SCN Priorities: Promote Self Management Supporting people to manage their emotional distress and avoid crisis interventions Comprehensive care plans/ Personal contingency planning Self-management tools Supporting patients with their physical health: lifestyle choices, medications, health checks Supporting patients effectively in home settings and continuation of care Recovery being patient-led and appropriate for the individual Support severe mental illness patients to optimise recovery services Supporting patient preferred technologies Introducing technologies which enable patients to self manage Data source: QOF, NHSCIC

97 SCN Priorities: Primary Care Better mental health education in Primary Care, such as: Providing ten-minute CBT Mental health first aid Focus on prevention Physical health checks for all Models of Primary Care maximising the range of skills and staff, not just Doctors Dementia Friendly practices Focus on post dementia diagnosis care Back to Mental Health

98 Improving Access to Psychological Services TV is performing well against national target - 50% recovery rate for IAPT by Data source: NHS England IAPT Information Pack At least 75% of adults should have had their first treatment session within six weeks of referral, with a minimum of 95% treated within 18 weeks. A 10m additional investment is being made available to support these standards. Back to Mental Health Data source: NMHDNIN - IAPT