Expression of Interest for the Co-commissioning of Primary Care Services STATEMENT FROM OUR CHAIRMAN AND CHIEF ACCOUNTABLE OFFICER

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1 Brierley Hill Health and Social Care Centre Venture Way Brierley Hill West Midlands DY5 1RU Tel: Fax: June 2014 Dudley Clinical Commissioning Group Expression of Interest for the Co-commissioning of Primary Care Services STATEMENT FROM OUR CHAIRMAN AND CHIEF ACCOUNTABLE OFFICER We welcome the offer from NHS England to work in partnership with willing CCGs to develop effective local models of primary care co-commissioning. We believe NHS Dudley CCG is ideally placed to take full advantage of the opportunities such a partnership would offer for our patients including better quality of care, improved outcomes, reduced inequalities, more integrated services and greater patient and public involvement. Even before this bold policy statement from NHS England, our CCG s clinical leaders had expressed a strong desire to work towards co-commissioning, and both ourselves and NHS England Team have included this within our strategic plans. We have already developed, with our Area Team, structures for joint performance management of primary care. These structures complement the CCG s wellestablished mechanisms which we use to engage with our member practices and work with them to improve primary care provision. Our two and five year plans have at their heart the development of excellent primary care services as the essential foundation for future improvements to local health and social care in particular the provision of more and better care closer to home and more effective integration of health and social care services. Our vision is of a more cohesive system of population-based health and wellbeing services, which wraps Expression of Interest for Co Commissioning of Primary Care Commissioning Page 1

2 community health services, mental health services and social care around general practice. As well as a clear mandate from our clinical leaders to work towards this model, we also have support from our patient groups who understand, but are frustrated by, the current structural divides. Other key stakeholders are also supportive including our local Health and Wellbeing Board who have formally backed our publicly stated aim of working towards co-commissioning of primary care. We are enthused by the opportunities that a locally-focussed, clinically-led cocommissioning could bring and we believe that a Dudley is an ideal proving ground for this innovative approach. David Hegarty CCG Chair Paul Maubach CCG Chief Accountable Officer Expression of Interest for Co Commissioning of Primary Care Commissioning Page 2

3 Executive Summary Dudley CCG is exceptionally well placed to co-commission primary care medical services with NHS England in that, with the existing arrangements that we already have in place with our local Area Team, we are already operating at the first level of cooperation. In line with both our own strategic plan, and our local NHS England Area Team s strategic plan, we should move to co-commission services as soon as possible this year. Ultimately we are expressing an interest in, subject to certain conditions, a phased process to fully devolved commissioning of primary care services from April To support this arrangement, we will build on our existing robust governance structure and establish a specific, additional, primary care commissioning committee with independent, non-executive oversight. As a consequence of our proactive approach to quality improvement in primary care we already have the lowest number of outlying practices of any CCG within the Area Team. Full commissioning of primary care will enable us to further reduce variations in performance between practices and raise standards overall with a consequential benefit on reducing inequalities in health and wellbeing. Full commissioning will also enable us to establish whole system outcomes for population health improvement, with primary care at the heart of a comprehensive model for integrated, population-based health and wellbeing services. This will therefore enable us to accelerate the pace of change to deliver better outcomes for our population. Why Dudley CCG? Dudley CCG is well placed to co-commission primary care medical services with NHS England for the following reasons: - We are the only CCG in the Birmingham and Black Country Area Team to have a well-established Primary Care Development Strategy approved by our Health and Wellbeing Board. - We have already realised significant benefits and improvements to patient care as a result of our Primary Care Development Strategy Expression of Interest for Co Commissioning of Primary Care Commissioning Page 3

4 - We have an established and effective joint working arrangement with the Area Team that has resulted in Dudley having the lowest number of outlying practices of any CCG within the Area Team - We have already demonstrated effective governance arrangements with a specific committee for primary care development which includes representation from the Area Team; and a joint reference group with the Area Team for reviewing primary care performance - We have a well established and effective membership engagement team that works directly with our practices on quality improvement - Our practices have managed their commissioning performance and shown demonstrable improvements in managing variation through a system of peer review, education, engagement and support - We negotiated with our Area Team a suspension to the retiring elements of the Quality and Outcomes Framework for the last quarter of to ensure that all our practices moved to one clinical system - All of our practices are now operating the same clinical system, and we are actively developing our plans on how we can use that system across the CCG to both: a) support service integration and maximise the efficiencies and effectiveness within General Practice; and b) to improve the efficiency and effectiveness of our commissioning processes - We have facilitated improvements in access to primary care all practices have participated in audits with the Primary Care Foundation - A short animation has been produced by animators DoodleAd that reflects the improvements that we have made working with the Area Team and patient groups to improve access. The animation can be viewed on our web site at the link below - We have a well-established and award winning GP education programme, and are in the process of developing our wider education programme with practice nurses and non-clinical staff - Dudley practices already have well developed model of integrated working for primary, community, mental health, social care and public health activities to support older people Expression of Interest for Co Commissioning of Primary Care Commissioning Page 4

5 - Our primary care development strategy is aligned to the Area Team primary care strategic plan: our plans around service integration and our intention for effectively re designing outcomes measures are referenced in the Area Team s primary care strategy - We have support for co-commissioning from: o our Patient Opportunity Panel (a panel comprising representation from 41 practice patient participation groups); o the Dudley Local Medical Committee; o Dudley Health and Wellbeing Board. - In 2013 we commissioned 5 community teams supporting primary care and General Practice to operate over 7 days per week as part of our integrated service delivery model - In 2014 our integrated service delivery model is being expanded to include a broader range of services including mental health and social care with primary care services at the centre thus establishing population-based health and wellbeing services - As evidence of how we are improving outcomes for our population in our practices exceeded their Quality Premium targets for both Atrial Fibrillation and Hypertension which in effect means that c50 strokes were prevented - All of our practices have completed practice development plans: The CCG now has a profile of all staff group retirements in the next 5 years, and practice aspirations for training and development that we are supporting through our engagement activities - We have already developed our model for our Health Infrastructure Strategy (which includes primary care estate developed at scale). We are first CCG to do this; are quoted as national exemplar and our understanding is that CHP want to partner with us to develop this nationally Why do we want to do co-commissioning in Dudley? Our intention and the basis of our expression of interest described below is predicated on three areas that are essential to the delivery of our strategic plans 1. To effectively review and pilot new ways of commissioning outside of the core requirements of GMS setting one set of outcome measures that will apply to Expression of Interest for Co Commissioning of Primary Care Commissioning Page 5

6 all those services commissioned and working as part of an integrated population=based health and wellbeing service with primary care at the heart of the model. Commissioning for shared outcomes across the whole system of integrated care enables us to ensure that all the organisations working in Dudley are working to the same outcome objectives for our population. This therefore ensures full system alignment and consequently will enable us to achieve those outcomes more quickly and more consistently than would otherwise be possible. 2. To have the ability to lead and manage the process for review and revising all GP contracted activity outside of GMS (so including QOF, enhanced services and PMS resource allocations), and retain any surplus within Dudley to reinvest within Dudley to improve the quality of primary care services and support the delivery of our service integration model. A clear commitment to allow us to coordinate the full envelope of resources and retain them within Dudley will enable us to fully implement our Primary Care Strategy. This includes ensuring the future sustainability of local services within an integrated model; improving our primary care infrastructure and delivering primary care at scale. With fully devolved commissioning we would expect to undertake this review process with the aim of implementing improvements within 2 years. 3. To finalise and implement our Healthcare Infrastructure strategy which would enable us to complete plans for developing primary care at scale across the CCG We would intend to accelerate the pace of review of primary care contracts in order to enable the investment plan required to support the infrastructure strategy. However we would be looking for freedom and flexibilities on pooling budgets and on the management of surpluses across years in order to enable resources to be used longer-term and more strategically to enable this agenda. A. Who s involved? This expression of interest is made on behalf of Dudley Clinical Commissioning Group. We are not seeking to co commission with other CCGs. Our CCG and local authority is co-terminus, with our member practices serving the vast majority of the same population, with one main principle provider of acute and community services. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 6

7 B. Intended benefits and benefits realisation Our expectation is that delegating responsibility for Primary Care through a cocommissioning arrangement will enable both the CCG and NHS England to deliver improved outcomes for our population at a faster pace, and in a more integrated way, than would otherwise be realisable. We believe that our ability to commission integrated services which improve quality and cover the full care pathway would be greatly enhanced if we had responsibility for directly commissioning primary care services. We feel that the co-commissioning of primary care (GP) services supports the delivery of the following strategic aims: Improving the quality and accessibility of primary care services Reducing health inequalities Ensuring equitable access to high quality services for local people Supporting the provision of more local services, closer to patients homes Supporting collaborative approaches to the provision of local services Ensuring the provision of more integrated services for patients and carers at a locality level Supporting the development of primary care and the individuals who work in it Enabling the delivery better primary care infrastructure and primary care at scale Enabling the development of shared outcome measures across the whole system of care Co-commissioning will enable practices to more clearly contribute to the outcome measures that are set out in our operational and strategic plans. For example: Securing additional years of life for people with treatable conditions:- 3.5% reduction in potential years of life lost (PYLL) per annum from 2087/100,000 in 2012/13 to /100,000 in 2014/15 and 1685/100,000 in 2018/19 Improving quality of life for 15m plus people nationally with one or more long term conditions:- 70/100 people in 2012/13 reporting improved health status increasing to 71.6/100 in 2015/16 and 74/100 people in 2018/19; Establishing shared outcome measures for our most significant long-term conditions so that primary, community and specialist care providers all work to the same objectives for same populations of patients. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 7

8 Reducing time spent avoidably in hospital through more integrated community care:- Avoidable emergency admissions to be reduced from 8142 (2596 per 100,000) in 2012/13 to 8013 (2530/100,000) in 2015/16 and 2018/19 Increasing number of people with positive experience of care in general practice and in community:- Reducing the average number of negative responses per 100 patients from 6.1 in 2012/13 to 5.66 in 2015/16 and 5 in 2018/19. Achieving greater service integration The central component of our strategic plan is the development of integrated primary, community and social care services, which ultimately removes the traditional silos and boundaries between organisations in order to deliver populationbased health and wellbeing services. Our approach is based upon initially integrating primary, community, mental health, social care and public health activities to support older people. This will be extended to other services and all population groups over the period of our strategy. Our model supports integration with voluntary and community sector services at a locality neighbourhood level. Integration will take place at three levels practice level; locality level within our 5 CCG localities; and at Borough wide level. Integrated teams will integrate services from practice to Borough wide level and connect local services more effectively with their local communities. At present, we commission all those services (either directly or jointly with Dudley MBC) that make up our locality based integrated service model, with the exception of GP services. Our ability to effectively commission the central component of our integrated model will enable us to pilot new ways of commissioning for primary and community services developing the same outcome measures for all health and social care providers serving the same population. Raising standards of quality: a new method of contracting Co-commissioning provides the opportunity to bring together the contracting of primary care with our contracting of community care. This will enable an integrated model of delivery, supporting the national Better Care Fund initiative; will remove traditional boundaries between services by bringing together all population-based care into one set of integrated services based upon the general practice registered patients; and will establish shared outcome measures for improved population health and wellbeing. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 8

9 Our shared intention with NHS England will be to achieve a stepped change in how primary care systematically manages long-term conditions to deliver healthy life expectancy. This will enable us to significantly refocus large proportions of care and support into the community, based around general practice; and will enable us to establish more comprehensive and fully integrated outcome objectives to understand the needs of those living with long-term conditions and reflect them in our priorities. Raising standards of quality: outcome measures Our shared intention with NHS England is to develop and pilot a set of outcome measures that we develop, in agreement with our membership, that supports one set of outcome measures for all those services operating as part of our model for integrated care. The outcome measures will contribute to those quality standards set out within our strategic and operational plans. Enhancing patient and public involvement in developing services The development of our registered population is crucial to the success of co commissioning. Our strategic plans set out how we want to create a patient population that takes responsibility for its own health and wellbeing. To do this we intend to privilege our registered population via our member practices and develop our interaction and engagement through our Patient Participation Groups (PPGs). We currently have 41 practices out of 47 who have a Patient Participation Group and our intention is that by the end of 2014 all practices will have a group established. We want our patients to take more ownership for their own healthcare, and to be actively involved in how we improve the health outcomes of our population. We will do this by developing our PPGs to have a more influential voice within the CCG, through practice, locality and Board level. We have commissioned a project via the Voluntary Sector that will work with these volunteer groups to help them to grow and develop to be more effective and efficient in their operation, particularly around power and influence. We are working on this agenda in partnership with our member practices; therefore the outcome of this work will be shared responsibility for healthcare and wellbeing. We want our PPGs working in partnership with our member practices to determine outcome measures at a practice level. To co-produce the quality outcomes that they expect of the practice in respect of patient experience to jointly agree those measures with the practice and work in partnership with the practice to ensure that those improvements are made. For example, in all practices in Dudley could only access an incentive commissioned by the CCG that demonstrated that the practice had actively worked with its PPG to demonstrate improvements made to access primary care. Such improvements had to be mutually determined and agreed with the PPG. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 9

10 Tackling Health Inequalities Dudley is characterised by significant health outcome differences between the most and least deprived parts of the Borough and bears the legacy of post industrialisation. Our JSNA sets out a number of key messages which have informed our plans and outcome ambition. Both our operational and strategic plans provide a full and comprehensive commentary on the work that is being undertaken to ensure that we reduce the health inequalities that exist in Dudley. The ability to co-commission provides us with opportunity to develop and pilot the commissioning of a set of quality outcome measures that are specific to the challenges that we have in Dudley, and that will apply to all of those services commissioned and providing our integrated care model. For example: We have specific health inequalities for the male population both in terms of mortality rates in the year age band and alcohol specific problems for the year age band. This is contributing to a widening of life expectancy gap between the most and least deprived parts of our population. We need to ensure our locality based service delivery model provides an appropriate, differential intervention at neighbourhood level to respond to local health inequalities. Interventions in relation to cancer, heart disease, stroke, liver disease and stroke are required. We must ensure that our practices perform well in delivering smoking cessation services. The systematic management of patients with long term conditions in primary care and community health services will be a major contributor to our success, including the management of diabetes. We have a growing frail elderly population, we need to improve the care pathway to prevent unnecessary admissions and create the conditions to enable people to be re-abled and retain their independence in their communities. We require a continued focus on mental health and the relationship between mental health, physical health and the management of long term conditions. We need to ensure that our approach to prescribing and the input of our practice based pharmacists continues to improve our performance in relation to the use of drugs to reduce cholesterol, reduce blood pressure and manage atrial fibrillation. We need to ensure that our work on the systematic management of long term conditions, redesigning urgent and planned care pathways and integrating services in our localities is sensitive to the needs of our child population. As part of our approach to the Equality Delivery Scheme, we need to facilitate work with those groups protected by legislation where the difference in health outcome and need is greatest, as well as analyse the barriers to improved patient access and experience for these groups. This will be reflected in our Equality Objectives. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 10

11 We use an asset based approach to our work with partners in addressing the wider determinants of health. Reducing variation In order to reduce variation in practice and eradicate inefficiencies we already benchmark variation by practice, and support each practice through engagement activities, education, training and support. This has been very successful in ensuring that Dudley has the lowest number of outlier practices of any within the Birmingham and Black Country Area Team. We are seeking to further develop the information that we use to benchmark by individual clinician and clinical team. We will use centralised risk stratification and population utilisation analytics to identify vulnerable patients and at risk groups who aren t receiving the care they need and would benefit from targeted support. We are seeking to further develop the benchmarking information that we provide to our practices and locality groups, into one framework that will measure the outcomes of our practices as part of our integrated locality model. Improving system effectiveness A key strategic objective is to improve system effectiveness. This means making it our business to focus on achieving efficiency and best practice in front-line care. We want to enable and support practices to improve their back-office efficiency and reduce overheads in order to focus on front-line care. The development of commissioning-led information systems is a key component of this approach. We have already invested in IT designed for this purpose: to develop systems to benefit clinical effectiveness efficiency and safety. We will also be investing in mobile technology for all primary and community services. We have recently moved to a position where all of our practices now operate the same clinical IT system. This provides incredible opportunities in maximising both the clinical an non clinical efficiency in the work of the practices, for example, in the use of risk stratification and the identification of patients, sharing of clinical protocols, coding and reporting for the purposes of claiming payments from NHS England and other commissioning organisations. With either co-commissioning or devolved commissioning of primary medical services we will be able to reduce the transaction costs of commissioning as we can use standardised reporting processes from the singly IT system to automatically supplying all necessary information for the purposes of reporting information and making payments. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 11

12 C. Scope The core responsibilities that under-pin our arrangements for the co-commissioning of primary care are set out below. We are expressing an interest to adopt a phased approach: establishing cocommissioning arrangements as soon as possible in ; with a move to devolved commissioning from April 2015, subject to certain conditions We see the initial scope of responsibilities of NHS England and the CCG in 2014/15 and from April 2015 as follows NHS England Core Responsibilities as part of Joint Commissioning Arrangements In 2014/15: o To hold the contract for the provision of core GP primary care medical services o To manage the contract for the provision of GP primary medical services, and continue to discharge their functions as part of cocommissioning with the CCG Long-term: o To set the overall total long-term financial envelope for the commissioning of primary medical services for Dudley practices; o To agree with Dudley CCG the overall long-term outcome objectives for quality improvement in primary care in Dudley; o To manage revalidations and individual performers reviews. CCG Core Responsibilities as part of Joint Commissioning Arrangements In 2014/15 o To advise NHS England in the management of the contract for the provision of core GP primary care medical services Long-term: o To hold the contract for the provision of core GP primary care medical services o To manage the contract for the provision of GP primary medical services o To review and re-commission all non-core GMS contracts (e.g.: QOF, PMS and enhanced services) as a key component of our overall integration model o To have the flexibility to manage the overall financial envelope to achieve the quality targets defined by NHS England Expression of Interest for Co Commissioning of Primary Care Commissioning Page 12

13 o To set the quality outcome standards (subject to NHS England approval) for integrated primary and community contracts, whilst still maintaining clear sources and application of funds, in order to achieve maximum outcome benefits across the whole health and social care system in Dudley The table below sets out those areas referenced in the letter dated 9 th May 2014 inviting expressions of interest. Area Within Scope Working with patients and the public and with the Health and Wellbeing Board to assess needs and decide strategic priorities Designing and negotiating local contracts (e.g. PMS, APMS, and any enhanced services commissioned by NHS England) Approving discretionary payments Managing financial resources and ensuring that expenditure does not exceed the resources available Monitoring contractual performance Applying contractual sanctions Deciding in what circumstances to bring in new providers and managing associated procurements and making decisions on practice mergers Managing the performers list, revalidation and appraisal Dudley CCG conditions and requirements from NHS England Our expression of interest is conditional upon certain requirements and support from NHS England. Prior to moving to co-commissioning, we would expect a clear commitment from NHS England that there would be a agreed long-term financial plan covering Dudley practices. We would also expect a clear commitment that any surplus delivered as a result of the co-commissioning with Dudley CCG is retained within Dudley to reinvest to improve the quality of primary care services and support the delivery of our service integration model and healthcare infrastructure. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 13

14 Prior to full devolved commissioning we would, in addition, expect the following: Full transparency by NHS England on current contracts, funding levels, forecast projections and cost improvement plans for primary care; Agreement that there is to be no cross-subsidy of resources or CIPs between other NHS England commissioned services and the primary care services in Dudley; Agreement on a 5-year financial plan for Dudley primary care; which is consistent with the NHS England 5-year plan for primary care; Agreement that Dudley CCG can operate with some additional freedoms and flexibilities on how the primary care resources are managed including: o The flexibility to manage across years any in-year surpluses that may be generated - in order to enable better long-term investment planning; o The flexibility to pool primary care resources with other commissioning budgets within our overall integration model Agreement that Dudley has the same level of access as other areas, to national NHS England funding that may be available for premises, IT capital, etc Note: We anticipate that our development of a single primary care information system will enable us to achieve substantial efficiencies in the transactional costs of primary care commissioning subject to agreement with NHS England on how contractor payments are managed and what reporting requirements are necessary. We would therefore also expect the need for any NHS England management costs in support of devolved commissioning to be discussed within this context. D. Nature of Co Commissioning We appreciate that there is a spectrum to the way in which co-commissioning could be undertaken. We already have involvement in influencing commissioning decisions made by the Area Team through our interface group that has been established and operating over the past 12 months. This is a jointly established group which reports to the CCG Primary Care Development Committee and the CCG Quality and Safety Committee. This Group also links into the NHS England local Area Team and reports via the Area Team representative to the Primary Care Commissioning Committee. The overall purpose of the group is to provide a forum for the CCG and NHS England Area Team to work jointly to review and monitor quality in primary care. The group has been very effective in improving quality and managing variation, for example, Dudley has the lowest number of outlying practices within the Area Team as measured using the NHS England primary care web assurance tool. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 14

15 We are therefore expressing an interest to establish a phased approach: implementing co-commissioning arrangements with NHS England as soon as possible in 2014/15; and devolved commissioning arrangements from April Under these arrangements we would expect to work on the following agendas: 1. Review and pilot new ways of commissioning outside of the core requirements of GMS setting one set of outcome measures that will be apply to all those services commissioned and working as part of an integrated community and primary care service. 2. Lead and manage the process for review and revising all GP contracted activity outside of GMS (so including QOF, enhanced services and PMS resource allocations), and retain any surplus within Dudley to re-invest within Dudley to improve the quality of primary care services and support the delivery of our service integration model. 3. Implement our Health Infrastructure Strategy to enable primary care in Dudley to be delivered at scale PMS Reviews 20 of 47 of the practices within Dudley are operating a PMS contract. We are aware that the Area Team are required to review these contracts, particularly with a view to demonstrating that all practices are moving towards a position of equitable funding. We are keen to lead this review as part of the co-commissioning of primary care services. We are keen to establish the relationship between quality outcomes and funding levels and ensure that the resources currently allocated to Dudley practices within the PMS contracts, are retained within Dudley as part of the resource allocation for primary care. E. Timescales We already have well established plan and system of work in place to cocommission primary care medical services. The timeline below provides an overview and high level set of markers for implementation, some of which have already been achieved. Co-Commissioning High Level Actions and Timetable Primary Care Development Strategy in place Primary Care Implementation Group established CCG and NHS England Interface Group established By Jun-13 Jul-13 Sep-13 Expression of Interest for Co Commissioning of Primary Care Commissioning Page 15

16 Dudley Health and Wellbeing Board support for the Primary Care Development Strategy Agreement to establishment of a single IT system across Dudley Primary Care Co Commissioning Dudley Health and Wellbeing Board support for co-commissioning Patient Panel and LMC support for co-commissioning NHS England approval for co-commissioning and phase one of establishing co-commissioning in-year CCG develop governance structures for in-year and future commissioning arrangements Agree first phase of new primary care outcomes framework Begin implementation of new outcomes framework Devolved Commissioning NHS England provide full information on contracts, financial plans, etc for primary care CCG submit revised constitution to NHS England for approval CCG and NHS England agree 5-year financial plan and conditional criteria for devolved commissioning Identify additional staffing implications to undertake devolved commissioning Agree structure and content of PMS review Develop and agree principles for new quality framework for integrated primary and community service Agree outcome measures for new quality framework Agree mechanism to review and evaluate effectiveness of new quality framework Begin devolved commissioning with new integrated outcomes framework Begin PMS / Primary Care contract review programme Sep-13 Jan-14 Jan-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Sep-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Apr-15 We will obviously develop and agree this timetable for implementation with NHS England. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 16

17 F. Governance We recognise that the governance surrounding co-commissioning is likely to be the single biggest issue, particularly from a public perspective. Our constitution already describes the way in which we manage our statutory duty with regard to managing conflicts of interest. This is line with the guidance on managing conflicts of interest published by NHS England. We fully recognise the need for an amended governance structure to adopt cocommissioning and we will adopt the following principles: We will differentiate between primary care development and primary care commissioning. Issues relating to co-commissioning will therefore not be discussed at our Primary Care Development Committee. We will establish a new committee reporting to the governing body, including representation from NHSE. The primary care commissioning committee will have significant independent, non-executive oversight. We will consider appointing an additional lay member with a specific remit for this purpose. We will identify a new clinical lead for primary care commissioning. This will be in conjunction with the Local Medical Committee We will identify new internal commissioning resource, reporting to the Accountable Officer We will identify new internal finance resource, reporting to the Chief Financial Officer We will develop a new performance framework for primary care commissioning, reporting to the new committee with oversight from Finance and Performance Committee and the Governing Body We will establish a new financial framework for primary care commissioning, applying segregation within the financial ledger We will commission our internal and external auditors to provide a view on the robustness of our systems and processes to manage primary care commissioning We will amend our conflict of interest policy as appropriate The interface group that is already established with the NHSE will be developed to support our plans for co-commissioning We will amend our scheme of delegation, and constitution, to reflect the above G. Engaging member practices and local stakeholders Patient Participation Groups (PPGs) Expression of Interest for Co Commissioning of Primary Care Commissioning Page 17

18 We have many examples of how our PPGs have worked with our member practices to help make improvements to primary care services, and provide a patient perspective on how the practice works and give an opinion on the wider NHS. We currently have 41 PPGs established, with a further 6 in development this from a total of 47 member practices. Our PPGs were involved in the co-production of our primary care development strategy, and have an elected patient representative who sits on our primary care strategy implementation group. Our PPGs have told us that they do not understand why the CCG has a statutory duty to improve the quality of primary care services, but do not hold the budget or the contract for primary care medical services. On the 4 th June 2014 a further event was held with our Patient Opportunity Panel (POPs) where we discussed out desire to put forward our expression of interest for the co commissioning of primary care medical services. The POPs were fully supportive of our proposals. We provided a brief for all out PPGs that is attached in Appendix 4. Member Practices All of our member practices were involved in the development of our Primary Care Development Strategy, and have expressed their support for our proposals for the co-commissioning of primary medical services. At out last members event in May we set out our intention to pursue an expression of interest to co-commission, and we followed this by discussing our proposals with each member practices through our locality meetings in with member practices in June. The practices response has been positive, but has been qualified by their desire that NHS England continues to have responsibility to apply contractual sanctions, and that manage the performers list. A copy of this expression of interest will also be shared with all member practices. Health and Wellbeing Board The Health and Wellbeing Board have approved our Primary Care Strategy and are supportive of our intention to pursue the co commissioning of primary medical care services, as described in the content of document. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 18

19 Local Medical Committee Despite there being some resistance nationally to co commissioning, the Dudley Local Medical Committee have offered their support to our expression of interest and proposals to develop co commissioning. This is qualified in that the LMC do not want to see a direct involvement for the CCG in applying contractual sanctions and managing the performers list elements that we have excluded from the scope of our expression of interest. H. Monitoring and Evaluation The CCG and Area Team already have a well-established process to monitor and evaluate the performance of General Practice within Dudley. This process that involves the Area Team, CCG, LMC and Local Authority Pharmaceutical Team meeting on a bi-monthly basis to assess and review quality performance, understand any performance challenges and then enact a package of education, training and support for practices with a view to minimise poor performance and the subsequent prosecution of the contracts. We will develop a system and process by which to monitor and evaluate the effectiveness of co-commissioning. We have already commenced work on establishing a new tool that will monitor and evaluate the quality of primary care comparative to the contract value per head of population. This will bring together quality information from the NHS England assurance tool, our local commissioning dashboard, prescribing performance, public health information, patient experience information, and contract values per head of population. We have already begun the work to determine one set of quality outcome standards for integrated primary and community contracts in order to achieve maximum outcome benefits across the health and social care system in Dudley. I. Enabling Functions: Improvement Support for Practices The ability of practices to respond will absolutely rely on the ability of the CCG to provide support through our education, training, mentorship, engagement activities. We have an Organisational Development plan that describes the support we will provide to ensure that our ambitions for co commissioning can be realised. The CCG has well established Primary Care Support team, led by a Head of Membership Development and a GP Engagement Lead. The team has day to day liaison with the primary care commissioning team of the Area Team; reviews data and other relevant intelligence; and provides reports to appropriate committees and the joint interface group with the Area Team. Expression of Interest for Co Commissioning of Primary Care Commissioning Page 19

20 Enabling Functions Currently in Place Community Engagement Team Membership Development Team Award winning GP Education Programme Practice Nurse Development Programme Non Clinical Development Programme System Leadership Support Change Management Programme across Health and Social Care Single primary care IT system to enable efficient delivery Conclusion We believe that this presents a tremendous opportunity to implement our strategic plans to their full potential. In particular, the establishment of shared outcomes across all of the services within our population-based health and wellbeing model of care will enable us to fully realise the potential for improved outcomes for the Dudley population Supplementary and Supporting Information Appendix 1: Dudley Clinical Commissioning Group Long-term Strategic Plan Appendix 2: Dudley Clinical Commissioning Group Primary Care Strategy Appendix 3: NHS England, Birmingham, Solihull and the Black Country Area Team Primary Care Strategy Appendix 4: Co Commissioning Brief for Patient Opportunity Panel and Patient Participation Groups in Dudley Appendix 5: Functions aligned to co-commissioning within Birmingham, Solihull and the Black Country Area Team Appendix 6: Dudley Local Medical Committee letter of support Appendix 7: Dudley Health and Wellbeing Board minutes January 2014 (resolution 4, page 19) Expression of Interest for Co Commissioning of Primary Care Commissioning Page 20

21 Dudley Clinical Commissioning Group Long Term Strategic Plan From: Dependency, Hierarchy and Modernism To: Autonomy, Networks and Mutualism CCG Strategic Commissioning Plan 1 P a g e

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23 Contents Page Item 2 Background 3 Re-Imagining Healthcare 5 Arriving at and Agreeing our Vision 8 Achieving Sustainable Care In A Reductionist Economy 9 Our Underlying Principles 12 Our Key Outcome Objectives 16 A Re-Imagined Health and Care System 25 System Initiatives Impact on Providers and Partners 31 Managing Relationships and the Market 32 Next Steps Implementing the Vision 1 P age

24 Dudley Clinical Commissioning Group Long Term Strategic Plan From: Dependency, hierarchy and modernism To: Autonomy, Networks and Mutualism 1. Background This plan sets out where we expect the Dudley health and care system to be in five years time, the objectives we wish to fulfil and the characteristics it will display. It reflects our vision to promote health and wellbeing and to ensure high quality services for the people of Dudley. It is designed to support our overarching objective to improve the healthy life expectancy of the population. To achieve this we must:- promote good health and wellbeing; reduce inequalities in health; and commission services and interventions that help us all achieve those goals; privilege services which operate on a population basis and which are designed to support health and wellbeing particularly primary prevention services; recognise the key role of the individual person, in contributing to their personal health and wellbeing and the collective engagement of the local population in contributing to their collective health and wellbeing; so promoting recognition of autonomy for the individual alongside mutual roles and responsibilities. Overall our key aims are to improve: healthy life expectancy; health outcomes; quality and safety; and system effectiveness. We must allow variations in the delivery of services to reflect different needs and inequalities in health in our local communities. However, we must remove variations in the delivery of services to reflect different needs and inequalities in health in our local communities and we must remove variations in performance and clinical practice which adversely affect the delivery of health outcomes. In so doing, our system will be built in a way which reflects the 5 domains of: - preventing premature deaths; best quality of life for people with long term conditions; quick and successful recovery following ill health; great care experience; keeping patients safe and protected from harm. 2 P age

25 2. Re-Imagining Healthcare We have re-imagined healthcare in terms of:- a mutualist culture the structure of the system population health and wellbeing services health and wellbeing centres for the 21 st Century Innovation and learning and in a way which reflects the 6 key system characteristics necessary for a sustainable health and care system set out in Everyone Counts: Planning for Patients 2014/15 to 2018/19. 3 P age

26 Five-year Strategy Plan on a Page To promote good health and wellbeing; and ensure high quality health services for the people of Dudley From: Dependency, Hierarchy and Modernism To: Autonomy, Networks and Mutualism Objective: Effective and Efficient Care Clinicians have more time to spend with those who need it most Pathways of care (both urgent and planned) are as efficient as possible 20% efficiency gain for planned care 15% reduction in urgent care Avoidable emergency admissions reduced to 2332 per 100,000 by 2018/19 Objective: Healthy Life Expectancy Premature mortality is reduced Inequalities in Health between all population groups are reduced Health and wellbeing services are at the heart of healthcare delivery 3.5% reduction in potential years of life lost per annum to 1685/100,000 by 2018/19 Objective: Mutual approach to achieving best possible outcomes Patients can quantify the real value of the services that they receive Individuals achieve greater autonomy from healthcare All service providers network better around the needs of patients EQ 5D Score 74% of people reporting health has improved by 2018/19 Objective: High Quality Care for all Services are safe and unwarranted variations are minimal Patients are treated with care and dignity and not over-treated Our system is transparent and learns and improves with the public Eliminating avoidable hospital deaths MRSA zero tolerance Grade 4 pressure ulcers zero tolerance Reimagining: A MUTUALIST CULTURE. Creating opportunities for active citizenship in vibrant communities and a participative mechanism of engagement for all registered members. Changing the way we evaluate healthcare so that the patient can articulate the value of the services they are receiving. Promoting mutual responsibility between patient and professional to manage risk and personalise healthcare planning. Reimagining: A NEW STRUCTURE OF DELIVERY Changing the definitions of services from primary, community, mental health, social care and acute to: planned care, urgent care, reablement care and proactive care. Removing the boundaries between different professions to privilege population-based healthcare in the community with a networked primary care and registered population at the centre. Reimagining: POPULATION HEALTH AND WELLBEING. Enabling a step change in how our GPs coordinate the systematic management of long term conditions to achieve healthy life expectancy. Differentiating between: population health and wellbeing services - where continuity is key; from urgent care - where responsive access is the priority. Reimagining: HEALTH & WELLBEING CENTRES FOR THE 21 st CENTURY. Supporting the development of new centres of care across the borough to provide modern facilities in our communities. Investing in front-line staff so they have the best possible training, support and satisfaction from a job well done and by extension providing best possible care to our population. Reimagining: INNOVATION AND LEARNING. Using research to test and evaluate the key components of this strategy. Making it our business to focus on achieving efficiency and best practice in front-line care. Working better with technology: both within the health and social care eco-system as well as with individual patients. Supported by: Our 2-year Organisational Development Plan and our 2-Year Operating Plan Enabler: A mutualist based relationship with member practices and responsible local citizens developing PPGs and an autonomous registered membership. Enabler: Development of person-centred information: PSIAMS personalised patient-driven reporting on the value of care ; Risk stratification to target resources based upon individual patient risk profiling. Enabler: Commissioning for value: removing unwarranted variation in care and evaluating individual clinical performance to inform patient choice Enabler: Commissioning-led populationbased information systems and integrated IT that enable health and wellbeing services; mobilise front-line staff; support market shaping and market entry; and reduced cost to providers Enabler: Our Primary Care Strategy and Estates Strategy with Co-Commissioning of Primary Care with NHS England. Enabler: Joint governance, performance and commissioning frameworks with all partners. Better Care Fund with Dudley MBC. Memorandum of Understanding with the Office of Public Health. Enabler: Network leadership, training, evaluation and research programmes 4 P age

27 3. Arriving At and Agreeing Our Vision Our re-imagined system has been designed and based upon our analysis of the challenges our system faces. These are described further below. This is a Dudley system arrived at by working with our partners. Our 2 year operational plan, our Better Care Fund Plan, the associated metrics and outcome targets were approved by the Dudley Health and Wellbeing Board, in the context of Dudley s Joint Strategic Needs Assessment (JSNA) and Joint Health and Wellbeing Strategy (JHWS), on 26 th March This strategic plan was subsequently approved by the Health and Wellbeing Board on 17 th June From a system perspective there are two key issues which partners face across the NHS and local government delivering an effective urgent care system and integrating services in such a way as to deliver the objectives of the Better Care Fund. Our system wide governance arrangements reflect this. Our Urgent Care Working Group and our Integrated Services Working Group both report to The Health and Social Care Leadership Group which consists of chief executive/director representatives from the NHS, local government and the voluntary sector. This in turn reports to the Health and Wellbeing Board on key aspects of system wide performance which includes delivery of:- Joint Health and Wellbeing Strategy priorities; this plan; Better Care Fund outcomes. HEALTH AND WELLBEING BOARD HEALTH AND SOCIAL CARE LEADERSHIP GROUP INTEGRATED SERVICES WORKING GROUP URGENT CARE WORKING GROUP Our Strategy reflects our system values and principles:- aiming for the provision of innovative, integrated, localised and personalised services that give excellent value for money; 5 P age

28 focusing services on prevention and early detection and recognising the need for people to take responsibility for their own health and wellbeing; recognising the potential for individuals and communities to maintain and sustain health and wellbeing and the contribution they can make to shaping services; tackling health inequalities through the concept of proportionate universalism ; working in partnership to improve health and wellbeing; continued improvement in the quality and safety of our services; safeguarding children, young people and adults. The analysis set out below provides the basis for our re-imagined system. Much of the detail is contained within our operational and organisational development plans. a) Challenges There are a number of significant challenges in terms of the system, the financial environment, performance and health status. These are described in our operational plan (pp. 8 13). i) The system The key system challenges are:- growing demand from an ageing population; sustainability of our main provider Dudley Group NHS FT and our local authority; inflexibility of local organisations and unresponsive service provision; cultural changes required to secure the engagement of clinicians and deliver our integrated service model. ii) Financial The key financial challenges are:- delivering a redesigned urgent care system and an integrated service delivery model capable of reducing demand on hospital services; delivering the efficiencies required to achieve a balanced Better Care Fund Plan. iii) Provider Performance Specific performance challenges remain in relation to:- ED 4 hour wait; referral to treatment times for elective care; waiting times for some community services. 6 P age

29 Our operational plan sets out the specific initiatives we will put in place to address these challenges. iv) Health Status and Health Inequalities We have examined the JSNA, Commissioning for Prevention, CSU QIPP Opportunities Pack, the Commissioning for Value Pack and the CCG Outcome Indicators Framework. These show that:- we have specific health inequalities for the male population both in terms of mortality rates in the year age band and alcohol specific problems for the year age band; this is contributing to a widening of the life expectancy gap between the most and least deprived parts of our population; we need to ensure our locality based service delivery model (see below) provides an appropriate, differential intervention at neighbourhood level to respond to local health inequalities; interventions in relation to cancer, heart disease, stroke, liver disease and stroke are required. We must ensure that our practices perform well in delivering smoking cessation services; the systematic management of patients with long term conditions in primary care and community health services will be a major contributor to our success, including the management of diabetes; we need to make every contact count in primary care and other settings; we have a growing frail elderly population, we need to improve the care pathway to prevent unnecessary admissions and create the conditions to enable people to be re-abled and retain their independence in their communities; we require a continued focus on mental health, in the context of achieving parity of esteem, as well as the relationship between mental health, physical health and the management of long term conditions; we need to ensure that our approach to prescribing and the input of our practice based pharmacists continues to improve our performance in relation to the use of drugs to reduce cholesterol, reduce blood pressure and manage atrial fibrillation; we need to ensure that our work on the systematic management of long term conditions, redesigning urgent and planned care pathways and integrating services in our localities is sensitive to the needs of our child population; as part of our approach to the Equality Delivery Scheme, we need to facilitate work with those groups protected by legislation where the difference in health outcome and need is greatest, as well as analyse the barriers to improved patient access and experience for these groups. This will be reflected in our Equality Objectives; 7 P age

30 we need to use an asset based approach to our work with partners in addressing the wider determinants of health. b) Community and Clinician Engagement Our re-imagined system has been formed by engaging with:- our healthcare forum our network of patient participation groups the Health and Wellbeing Board and our JHWS our GP membership stakeholders through the Call to Action process This engagement has informed, in particular, our plans for:- a simplified emergency and urgent care system improved access to primary care integrated community health and social care services more support to enable patients to manage health problems, including long term conditions 4. Achieving Sustainable Care in a Reductionist Economy Our NHS is at a tipping point. The NHS cannot continue to deliver healthcare using the same organising principles as it has done in the past. Rising demands from the growing elderly population, patients with increased co-morbidities, an increased range of therapies, rising costs of all treatment modalities, and limited economic resources create big challenges we must address. However, these challenges are not insurmountable. The greater challenge is whether we can re-imagine how we work and adapt to delivering healthcare in a networked society. Our NHS organisations have been established within a modernist paradigm, working with imposed reductionist efficiency, performance targets and operating in organisational and professional silos which are insufficient to respond to these big challenges. This undermines the ability to deliver better outcomes for our population and contributes to risk averse practices, creating dependency and overmedicalisation of care. Our structures, business models, service provision and organisational cultures need to be radically re-assessed in light of the social, technological, environmental and economic challenges we face. In current thinking, hospitals are conceptualized and invested in as the central delivery point of healthcare; healthcare is delivered as a supply-led process: patients fit into the system - it is not demand-led, i.e. designed around individual patient contexts and needs. Healthcare economics attempt to measure and cost episodes of care, thereby turning patients into diagnostic categories and numbers. This is false 8 P age

31 accounting as it doesn t account for externalities, i.e. the unseen costs of the holistic social and health care required by a patient who increasingly presents with complex healthcare needs. In addition, there is a dependency and conformist mindset which risks diminishing human compassion, creativity and innovation. Instead we conceptualize Community Hubs (10 15 locations across 5 localities) of healthcare as the central delivery point of healthcare and well-being; GPs as generalists are highly regarded within the healthcare system, and hold commissioning power; registered members of GP practices (their patients) are members of the mutualist healthcare community and as members contribute fully to healthcare decisions within their locality. Autonomy is a principle that ensures registered members have maximum control over their lives; and healthcare economics are holistic and systemic, accounting for real costs of care, including external costs and taking longer-term perspectives. Finally our workforce is encouraged to be collaborative, transparent and develop an adaptive culture, that is more human in its response, and always thinks about patients in their context. So our strategy endeavours to reassess these factors, proposing a new vision for health and wellbeing services. This strategy starts with the patient perspective, in the context of a networked community. It will recognise the importance of clinical leadership and the pivotal role of general practice. Reimagining the organisation and culture of services to enable sustained health and wellbeing for everyone is our challenge. 5. Our Underlying Principles We operate to six key principles: a) Patient and Public Involvement The meaningful involvement of patients and public is of paramount importance. Throughout the NHS the patient is usually the coordinator of their care. It is key that contact with healthcare professionals adds clinical value. We believe this contact must be re-aligned, from a hierarchical dialogue expert to receptive patient, to an horizontal dialogue expert to expert. Patients/families are most knowledgeable about their symptoms, bodies and psychological and social state. This self- expertise remains an under-tapped resource that if accessed will transform healthcare and well-being. Supporting autonomous living is of paramount importance. However when people do use healthcare we want them to have clearer information about the quality of services in order to inform their choices; and we want them to be better able to share whether services are working for them. b) Clinically Led The public register with their GP and through the coordination that their GP provides, that they are able to best access the healthcare they need. So our future health system will be organised around this key relationship between patient and their GP; 9 P age

32 providing a personalised service. Similarly, all population-based healthcare will be commissioned on a registered-population basis and will be organised in accordance with our GP and CCG structures (so around practices, localities and borough-wide) in order to enable a clear clinically-led approach to healthcare delivery. c) Primary care at our heart The vast majority of care is either delivered by General Practice or is accessed through it. The success of primary care is therefore central to the future success of our health services locally. We have already developed a primary care strategy, in conjunction with the Health and Wellbeing Board and NHS England. There are significant recruitment and retention challenges for our primary care services so development of primary care infrastructure and workforce will be central components to our on-going work we want Dudley to have a national reputation as the best place to work for GPs along with their extended primary care and community staff. We will further enhance our shared commissioning of primary care with NHS England in order to ensure that this can be achieved. d) Working with Partners in our Communities Our locality-based approach to the Better Care Fund initiative recognises the need to network our GPs, patients and associated primary care/community services, social care and the voluntary sector in order to respond to the variable needs of different communities across our population. Health inequalities can only be addressed through a jointly targeted community-based approach. We will build our partnership relationships through the organisation of all of our services for all of our populations based on clinical need. e) Focus on Quality and Continuous Improvement We will take a predominantly developmental approach to quality improvement that encourages transparency by all our service providers to reduce variations in care and outcomes; and to aim for best practice performance. We will expect every service to be able to demonstrate the value and quality that it provides to patients. We will utilise a continuous evaluation process that will ultimately ensure that we do not commission any service that cannot demonstrate value; and will actively promote those that can demonstrate best outcomes for patients. f) Live Within Available Resources Dudley CCG will meet its financial responsibilities to address the reasonable needs of our population within available resources. This necessitates a drive for continuous efficiency and improvement given the economic constraints we face. Our emphasis will always be to maximise the effectiveness and availability of front-line services. 10 P age

33 It is against these principles that we test out each commissioning initiative. Our analysis of two key initiatives urgent care and services integration is set out below:- Principle Urgent Care Model Service Integration Patient and Public Involvement Clinically Led Primary Care at Our Heart Working with Partners in Our Communities Focus on Quality and Continuous Improvement Informed by patient and public engagement via Healthcare Forum and other mechanisms The prime point of contact for registered patients, in the first instance, should be their general practice. Through our cocommissioning arrangements we will work with our membership to increase access to primary care for registered patients and ensure that unregistered patients are given the opportunity to register. A better service model, enabling GPs and other clinicians to use their skills to manage urgent care better within a supportive system will enhance the workforce and attract staff to Dudley. Being able to access care appropriately is a key mechanism for responding to health need. Variability of access leads to health inequality. Our urgent care model is designed to facilitate access, whilst ensuring that other community based responses to urgent care situations are available. We will develop clear clinical protocols that provide a consistent response to those patients accessing the system Informed by patient and public engagement via Healthcare Forum and other mechanisms A common population base is the pre-requisite for this model. Services will be organised at practice, locality and borough levels led by clinicians. Enhancing clinical leadership and giving clear responsibility to deliver effective services for their registered patients will be a key factor in building an enhanced workforce and attracting staff to Dudley. Our service model will provide a targeted response to health need and health inequality. A voluntary sector link worker in each locality will ensure that services are connected to voluntary and community sector services and opportunities to enhance capacity identified for action. We will have clear indicators in place for all our integrated teams at each population level, linked to the Better Care Fund metrics. These will 11 P age

34 Live Within Available Resources Our urgent care service will ensure appropriate access to urgent care, avoid unnecessary use of ED and deliver an economic benefit. be used to drive up performance and reduce unnecessary variation. Our integrated services model is designed to remove unnecessary admissions to secondary care and nursing/residential care, as well as facilitating early discharge and reducing the dependency of individuals. This will deliver a clear economic benefit to the system. 6. Our Key Outcome Objectives Our key outcome objectives are derived from the findings in our Joint Strategic Needs Assessment and designed to meet the needs of our population. These objectives include parameters that we can currently measure; however we will also be designing new measures which in the future will more accurately reflect the new structure and design of services that we are trying to create. Our operational plan (pp14 18) and Appendix 1 to this plan sets out our outcome ambitions, their relationship to the JSNA and our initiatives to respond to them. a) Effective and Efficient Care Our health and social care system must be as efficient, effective and adaptive as possible in order to meet the rising needs of our population within our more challenging economic constraints. Therefore our emphasis will be to maximise the benefit and potential of front-line interactions by our clinicians with our patients; and to avoid unnecessary interventions wherever possible. 12 P age

35 Existing measures in place include:- reducing time spent avoidably in hospital - 2,322 avoidable admissions per 100,000 by 2018/ Emergency admissions composite indicator Emergency admissions composite indicator 2250 Baseline 2014/ / / / /19 increasing proportion of older people living at home: People still at home 91 days after discharge 230 as at 2018/19 We will identify the most efficient pathway for each intervention and de-commission pathways that do not meet this standard Future measures will evaluate:- ensuring clinicians have more time to spend with those who need it most pathways of care (both urgent and planned care services) are as efficient as possible with minimal variations in performance between clinicians b) Healthy Life Expectancy Our overarching objective is to improve the healthy life expectancy of the population we serve. Existing measures that we use to evaluate this include:- securing a 3.5% reduction per annum in avoidable years of life lost for people with treatable conditions to 1685/100,000 in 2018/19 13 P age

36 improving quality of life for people with Long-term conditions - 74% of people report their health status has improved in 2018/19 to bring the CCG up to the performance of comparator CCGs Future measures will include:- delivering improvement to reduce the inequalities in health between different groups thus ensuring parity of esteem for all vulnerable groups; ensuring Health and wellbeing services are at the heart of healthcare delivery. c) Mutual Approach to Achieving Best Possible Outcomes Improvements needs to be measured and understood both from a clinical outcome perspective but also from the value that is derived and perceived by the patients receiving care. Also outcome objectives need to be shared in advance between the individual and the service. 14 P age

37 Existing measures in place include a variety of patient related outcome measures for certain treatments and somewhat limited patient experience measures:- increasing people's positive experience of hospital care: average number of negative responses per 100 patients reduced to 145 by 2018/19 to bring the CCG up to the performance of comparator CCGs increasing number of people with positive experience of care in general practice and the community: Average number of negative responses reduced to 5/100 patients by 2018/19 to bring the CCG up to the performance of comparator CCGs However in the future we will develop measures which place the emphasis on patient-led outcome objectives to:- enable patients to quantify the real value of the services that they receive; ensure our PSIAMs system of personalised patient driven reporting is in place for all commissioned services. demonstrate how individuals achieve greater autonomy from healthcare; demonstrate how all service providers network better around the needs of patients. 15 P age

38 d) High Quality Care For All The public expect the NHS to deliver safe and effective services. We already have a wide range of quality improvement measures and CQUIN arrangements which cover mortality indices, reducing rates of infection, safeguarding children and adults from harm, and evaluating and learning from serious incidents. As we progress with the delivery of this strategy we will develop measures to ensure that:- services are safe and unwarranted variations are minimal patients are treated with care and dignity and not over-treated our system is transparent and learns and improves with the public 7. A Re-Imagined Health and Care System a) Re-Imagining Healthcare a Mutualist Culture (Citizen participation and empowerment) The NHS constitution sets out rights for the individual in respect of healthcare which Dudley CCG supports and we will ensure these are delivered for our population. However, rights alone are insufficient. They promote a consumerist attitude to healthcare and also a top-down culture whereby those in power give rights to the recipients of care. This is unsustainable and undesirable in an economically constrained system. It fails to recognise the importance of mutual engagement which balances rights alongside responsibilities. Individuals are then expected to use resources responsibly and to recognise that they are part of a community, and the community is part of them. Individuals must take responsibility, as much as is possible, for managing their own health and wellbeing. Our philosophy is to support individuals to do this and so reduce their demands on healthcare. We will therefore invest in activities that encourage adoption to this way of thinking and which provide proactive intervention and advice to the population. We will also foster health as a community responsibility by supporting integration with the voluntary sector; facilitating active community engagement between NHS services, public health and voluntary/community sector services. In addition, we will change the basis of future engagement from the representative mechanism of the willing, to a participative mechanism for all. This will involve the development of information tools that enable every person receiving healthcare to articulate the benefits (or otherwise) of the care that they receive and the personal impact that it has had for them (One such mechanism currently being piloted through 16 P age

39 our Building Healthy Partnerships programme is the PSIAMS tool see Operational Plan pp. 25 and 26). We will then be able to use actual patient feedback to evaluate the effectiveness of services as determined by the patients themselves. Ensuring that every person is an engaged and registered member of our CCG is also an important way in which we will address inequalities in health and parity of esteem for all vulnerable groups including the homeless, ethnic groups, disabled people, new migrants and arrivals to the borough - and is central to our approach to equality, diversity and inclusion. Priority of action will be given to ensuring reliable data in primary care to identify groups with worse outcomes; and we will design new services to ensure improved access (so for example our new urgent care centre will include mechanisms for registering anyone who attends, who is not already registered with a GP). Our CCG is a membership organisation and is ultimately funded to support those people who register with our GPs. We have started our membership engagement through the development of our patient participation groups linked to each of our practices; and we will continue to strengthen this as a key means of engagement. However in five years we will have developed an active membership programme for all those people registered with our GPs. This will incorporate a patient portal providing health and wellbeing advice enabling access to their records; and clear mechanisms for support and access to healthcare through their GP. Opportunities for giving feedback and participating in shaping and informing the development of their local healthcare services will be integral. We currently have a way of working where increasingly components of our healthcare service work on a protocol driven model of care. This is positive in creating minimum and consistent standards but it also leads to reduced individual clinical judgement and a risk averse approach which ultimately results in too many people being referred on to more intensive services and contributes to rising patient dependency. Instead we will actively promote a new way of working which encourages mutual responsibility between patient and professional; and supports increased personalised care which enables individuals to have a greater say in managing risk and the outcomes that they want to achieve. This approach will reduce dependency and over-medicalisation of patients. This mutualist approach will create a more engaged relationship with our registered population where they have a clear share in how services are shaped and developed; as well as a more personalised service which encourages more autonomous self-management. Most importantly our members will know, value and understand the benefits of being a member of our CCG. b) Re-Imagining Healthcare the Structure of the System 17 P age

40 (Access to highest quality urgent and emergency care) (A step change in productivity of elective care) The traditional organisational structures of healthcare are inadequate to meet the conflicting challenge of rising demand versus reducing resources. The existing separation of services into primary care, community services, mental health services and acute services is artificial, contributes to silo working and doesn t reflect the needs of the modern population. We have already started to rethink the organisation of care into four different groupings: - planned care: value-added treatment interventions with defined outcomes; - urgent care: short-term interventions to help and treat you in a crisis; - reablement care: services designed to help reduce your dependency; - proactive care: population-based care to help you manage your health needs. Commissioning healthcare on this basis enables us to set common performance improvement requirements for each of these groups of services and brings consistency for mental health patients as well as other vulnerable groups. Parity of esteem for all groups is a theme throughout our organisation and our providers. In planned care we will be commissioning based on measureable value-based outcomes of the services provided. We will have systems in place to monitor and report on variations in individual clinical performance with the aim of improving both the whole pathway efficiency of services (left-shifting the distribution curve), as well as the outcomes of treatment. Ultimately, we will set prices for planned care on the basis of best practice performance (on effectiveness of outcomes and total pathway efficiency) and will expect providers to adhere to those performance standards. We will expect our service providers to have dedicated facilities and capacity for planned care, without risk of significant interruption from urgent care, so that both clinicians and patients can provide and experience a high quality, efficient and effective service. With urgent care we will have established our new urgent care centre at Russell s Hall Hospital and we will implement new pathways of care for both our 18 P age

41 frail elderly population and also for mental health care, so that A&E is not part of the pathway, but instead enables patients to go direct to the most appropriate service. We will commission emergency medical care as an extension and integral part of population-based health and wellbeing services. This will then create a paradigmshift in the organisation of care for our frail elderly population: instead of urgent treatment being managed within the confines of the hospital; services will instead be managed between the home and the hospital. This will both enable more patients to stay at home as well as enable clinicians to better co-ordinate capacity between community and hospital care. Similarly A&E will therefore be available solely to provide genuine accident and emergency care particularly trauma and emergency surgery. Our reablement services will form part of our extended partnership with social services and the voluntary sector. We will be commissioning services specifically to reduce dependency and enable individuals to return or stay at home wherever possible. This directly correlates to the national Better Care Fund objectives of reducing the future need for residential and nursing care. Also, we will engage with the public about expectations on healthcare to ensure that patients, carers and families support the need for people to move quickly to as low a dependency setting as possible, recognising that hospitals should only be used for short-term treatment interventions that make a difference. Our integration model works on five local communities and is designed to deliver our approach to proactive care. This organises services based around the needs of the person and integrates community services, mental health services and social services around our general practices so that all services are working with the same groups of patients. This enables both personalised care, as well as firmly basing the team that supports them within the local community of healthcare. This emphasises a network approach to health and social care delivery. Our partnership with Dudley MBC and with the local VCSE through our Building Healthy Partnerships programme is essential to securing a sustainable and integrated service. We will commission services that are available 7 days per week. The developments we are already implementing in relation to our integrated service delivery model will be available on this basis. Over the next five years we will develop our integration model into comprehensive, population based, health and well-being services. This will include the management of all long-term conditions and emergency medical care for the frail elderly. c) Re-Imagining Healthcare Population Health and Wellbeing Services (A modern model of integrated care) 19 P age

42 Within the next five years will re-commission pro-active population-based healthcare services via a different model. We need a step change in how primary care systematically manages long term conditions to deliver healthy life expectancy: so we will bring together all populationbased care into one set of integrated services based upon the populations registered with general practice. GPs are at the heart of this model, as the key co-ordinators of care; and this recognises the dual roles of providing: on-going health and wellbeing care support which can be planned over time; as well as the need for more urgent access in times of illness or crisis. We will therefore commission these two types of activity separately:- - for health and wellbeing care patients prefer continuity of clinician/professional; - for urgent care, speed and ease of access is important. In addition we will differentiate between different levels of intensity of service. For example:- - proactive care is about supporting people to remain healthy and is linked to the Dudley Office of Public Health and Dudley MBC programmes for prevention; - long-term care support to those living with long-term conditions would include a mix of longer, pre-bookable appointments with GPs and/or specialists; - enhanced and end of life care (including community care in the home, or nursing / residential care) will be improved through the use of risk stratification, partnership with social care and the voluntary sector; - we will engage in a broader discussion with the public about how best to support people at home near the end of their lives. Should so many treatments that overmedicalise care be carried out? We will be having discussions with our population, our patients and their families to ensure they have the support they need to manage their circumstances, whatever they may be, with dignity and compassion. level of intensity of support high low Population Health and Wellbeing Services Health and Wellbeing Care Urgent Care Starts with universal Advice on how to services for children. Proactive Care Self-management manage minor Includes wellbeing advice ailments (NHS 111) and support Long-term Care Helping individuals to manage living with their long-term condition(s) Pharmaceutical support Medication and advice from your pharmacist 20 P age

43 Enhanced Care End of Life Care Significant support for those living with the most complex needs and co morbidities Care and support when you need it most. GP-led Access Community Rapid Response to the home Urgent appointments at your local, or nearby, practice For the frail elderly and those with complex conditions Note: there is an assumption in this table that end of life demands high support- whereas our aim is to return the care to the community- diminishing professional support Health and Wellbeing Care will be personalised to the individual. For many individuals they are the main co-ordinator of their care for 99% of the time so the level of intervention and NHS support will be minimal; will be designed to enhance the individual s self-management; and can be provided on a planned basis particularly proactive care and long-term care. Enhanced Care will include some enhanced support that would be provided on an on-going 7-day basis depending on the needs of the individual (eg: community nursing support into the home; or 7-day nursing or residential care). Similarly End of Life Care will include access to significant support on a 7-day basis if and when it is necessary. Urgent Care within this model will be provided on a 7-day basis. In these circumstances, expediency of access to an appropriately qualified individual, based on an assessment of your need, is more important than continuity of care. Therefore GP services in particular can only be provided once primary care is organised at scale across localities. However the lack of continuity of individual clinician can be mitigated through continuity of information by our establishment of a single GP IT system which allows access to complete medical records. These plans can be achieved through commissioning the services at scale; and by improved integrated commissioning with NHS England (as the organisation that procures GP services) - so we will pilot this approach with NHS England for cocommissioning this model of service. This will bring together their contracting of primary care with our contracting of community care. This will enable an integrated model of delivery, supporting the national Better Care Fund initiative; will remove traditional boundaries between services by bringing together all population-based care into one set of integrated services based upon the general practice registered patients; and will establish shared outcome measures for improved population health and wellbeing. Our shared intention with NHS England will be to achieve a stepped change in how primary care systematically manages long-term conditions to deliver healthy life expectancy. This will enable us to significantly refocus large proportions of care and support into the community, based around general practice; and will enable us to establish more comprehensive and fully integrated outcome objectives to understand the needs of those living with long-term conditions and reflect them in our priorities. 21 P age

44 d) Re-Imagining Healthcare Health and Wellbeing Centres for the 21st Century (Wider primary care, provided at scale) In Dudley we are fortunate to have modern hospital facilities that can provide excellent care for our population when they need it. However, the quality of primary and community care facilities is much more variable and much of it does not meet the needs of our population. High quality facilities are key to allow us to make the quantum leap in terms of care for our communities. In addition we have a workforce that is often under pressure and there are increasingly shortages (nationally) of staff in key groups. For example, a significant proportion of our GPs are expected to retire in the next 5 years so we need to recruit new GPs in to work in Dudley. During the next five years we will put in place an innovative development programme for the healthcare estate in Dudley. We will encourage existing practices to come together to both make full use of the existing high quality facilities as well as develop new larger centres. These new centres will provide the focal point for our approach to delivering health and wellbeing services and so will have the capacity to provided specialist clinics (eg: for long-term conditions) as well as extended general practice. This will bring longer-term population-based healthcare out into the community as part of our locally integrated services. We will be actively encouraging independent developers to work with us to access the capital required for this development programme; and we will be working with NHS England to put in place the necessary agreements on pooling CCG and NHS England resources in order to develop the financial arrangements to provide the revenue support needed. We want Dudley to be the place where people want to come and work because they will get the best possible training, support and satisfaction from a job well done; by extension, our population will get the best possible care. So investing in our workforce is mission critical. We will therefore expand our current education and training programme to put in place comprehensive training and support for all the staff groups that are part of these new health and wellbeing services. We have inherited a system from our predecessor organisations which has allowed significant variation (over 100% variation) in the levels of investment in primary care between practices; and in the organisation of community services across the borough. We will implement a new quality performance framework that correlates financial investment with outcome performance in order to incentivise high performance - but paid for at the right price. In addition, we intend to free-up our front-line staff across primary and community services, to both maximise their opportunities for work with patients and achieve 22 P age

45 better outcomes. To achieve this we will invest in systems design and integrated services at scale, to both centralise support functions and improve technological support to maximise front-line capacity and efficiency. e) Re-Imagining Healthcare Innovation and Learning We are a learning organisation and as such we highly value, and are investing in, research and organisational development. We have established links with the HSMC at Birmingham University to develop our evaluation and review of services; and we have developed a substantial organisational development programme for both the CCG and our healthcare system. We will also use research to explore and evaluate some of the key concepts and ideas in our strategic plan to ensure that we accelerate our progress - so developing the best possible services for our population. Funding will be made available to support innovation at both practice and locality level. This resource, a total of 200,000 on a non-recurrent basis, will be allocated to our five localities and they will determine how it is used. In conjunction with the HSMC, we will develop a consistent mechanism for the evaluation of our development programme and use this to inform future commissioning decisions. This will be complemented by a new research assistant post to enhance our research and development capacity and capability. We will seek to embed the principles of invention, adoption and diffusion. Innovation, in terms of:- the development of our community rapid response service; measuring individual consultant performance; having one IT system for all 49 GP practices; using the PSIAMS system to understand commissioning impact; providing practices with the opportunity to innovate with our innovation fund. lies at the heart of our plan In our first year we will make significant steps to improved working with technology as all our GPs will be using the same clinical IT system. This will not only enable integrated working between practices but will also enable access to other services (such as A&E) and so significantly improve the quality and safety of care to all of our population. Subsequently, we will commission for a comprehensive information system, which incorporates GP IT, to provide the infrastructure and system support for all services that are part of our integration model. We will then require all providers that 23 P age

46 contribute to the integrated model, to use this information system thus establishing a comprehensive population-based information database which underpins our population-based health and wellbeing services. We will only commission from service providers who commit to using this system and database and this system will very clearly incorporate rules on data sharing so that only the right people have the right access at the right time. This approach to commissioning-led information will also significantly improve provider efficiency and effectiveness; reduce barriers to market entry; and improve contractual efficiency with our CCG. So for example: all the required performance reporting, invoicing and validation processes will be co-ordinated centrally and derived from the directly inputted patient/clinician activity. Payments will be automatically made by the CCG to providers in accordance with the agreed contract so all associated back-office functions for both primary and community providers will no longer be necessary. Smaller organisations, including new social enterprises and VCSE organisations will more easily be able to participate in our health and social care economy because they will not need to invest in these costs, which can often be prohibitively expensive for smaller organisations. A key strategic objective is to improve system effectiveness. This means making it our business to focus on achieving efficiency and best practice in front-line care: Firstly, enabling providers to improve back-office efficiency and reduce overheads in order to focus on front-line care. The development of commissioning-led information systems is a key component of this approach. Secondly, ensuring that we maximise the efficiency and opportunity of our front-line staff. We will invest in IT designed for a specific purpose: to develop systems to benefit clinical effectiveness efficiency and safety. We will also invest in mobile technology for all primary and community services Thirdly, reducing variations in practice in order to eradicate inefficiencies. We will benchmark variation by individual clinician and clinical team. We will use centralised risk stratification and population utilisation analytics to identify vulnerable patients and at risk groups who aren t receiving the care they need and would benefit from targeted support. Fourthly, supporting patients in maximising their autonomy. We will empower our population by investing in publicity and advice; recognise that the individual s identification with community is manifest through a multitude of different networks; we will invest in voluntary sector support and learn from their connections and identity with communities; and we will embrace new technologies which enable remote or self-monitoring of health conditions. Our population-based design to future healthcare delivery will make it easier for other GPs to join our CCG in the future. We will develop an induction process to 24 P age

47 support new practices to join our CCG which will include GP IT integration: a practice development and mentorship programme: our approach to mutualist healthcare and registered membership; and the integration of community and social care services around the practice. We also believe that we have a responsibility with the wider NHS to share our good practice and also learn from others. So we will work with other CCGs to establish an Organisational Development and Learning network to exchange ideas and learning. We will also develop a franchise approach to our population health and wellbeing model of delivery, linked to registered membership. This will enable other CCGs, with endorsement from NHS England to utilise and apply our new model of care with their groups of practices. This will therefore enable a rapid roll-out of our model to other areas of the NHS, should they want our help and support. 8. System Initiatives Our operational plan (pp.24 45) sets out the key initiatives we will implement during in relation to the 6 key system characteristics of:- citizen participation and empowerment wider primary care, provided at scale a modern model of integrated care access to highest quality urgent and emergency care a step change in the productivity of elective care specialised services concentrated in centres of excellence The next step is to build on these initiatives to create our re-imagined system that is consistent with these 6 characteristics. This requires the implementation of some key system enablers:- a) Co - Commissioning Primary Care We will review existing contractual arrangements with our member practices, establishing a clear set of financial rules. As a result of this we will work with practices to reconfigure the primary care landscape, create more efficient provider models and release revenue streams for reinvestment in our system of primary care at scale. b) Developing the Estate We will review our existing infrastructure and agree a development plan that will support our vision of modern health and wellbeing centres. We will support the revenue consequences of the development programme through reinvesting resources released from our reconfiguration of primary care. 25 P age

48 c) Exploiting Information Technology The implementation of a single IT system for primary care and the development of a commissioner led information system to be used consistently by our commissioned providers will provide the basis for delivering service efficiencies by:- removing unnecessary transaction costs systematising the way in which care is delivered, removing unnecessary variation delivering better quality emergency and urgent care through the use of a single IT platform improving productivity d) Encouraging Market Entry We will create more responsive community health services geared towards our view of population health and wellbeing. These services will be consistent with our model of integrated delivery at borough, locality and practice level. We will extend our existing delivery model through the further transfer of services from secondary care into the community such that the prime point of access to consultant level services takes place outside the hospital setting. These actions will support:- wider primary care provided at scale through revitalised general practice, delivered from first class premises using modern technology, integrated with other services around the patient and delivering consistent services. a modern model of integrated care with the patient and primary care at its heart as part of a mutual culture. Where services operate at practice, locality and borough level, using the hospital as the delivery point of last resort and enhance the health and wellbeing of the population served. access to the highest quality urgent and emergency care through integrated community services and a modern urgent care centre. 9. Impact on Providers and Partners Our plan impacts on providers in two ways:- in terms of the assumptions we have made about commissioned levels of activity and the associated impact on income; our view of the shape of future health and care delivery. a) Future commissioned activity 26 P age

49 Our operational plan (pp.36 42) and the graphs below show that by 2018/19 activity levels, having accounted for demographic growth, will have reduced as follows:- emergency admissions 1574 admissions ED 24,145 attendances elective inpatients 800 cases day cases 3,665 cases out - patient first appointments 1,686 attendances 27 P age

50 28 P age

51 29 P age

52 These changes will have a prime impact on our main provider of acute and community health services Dudley Group NHS FT. To be sustainable this requires the implementation of a significant cost reduction programme to bring income and expenditure into balance by 2015/16 in the first instance and through to 2018/19. b) Future shape of health and care delivery Our re-imagined health and care system is based upon:- a renewed role for general practice at its heart; the integration of community health, mental health and social care services led by general practice; the market entry of new providers of community health, including mental health services; the movement of more services from hospital settings into the community supported by a refreshed 21 st Century infrastructure; professionals organising themselves differently in teams around the patient with a distributed system of leadership. This will have an impact upon:- Dudley Group NHS FT as our provider of hospital and community health services; Dudley and Walsall Mental Health Partnership NHS Trust as our provider of acute and community mental health services; Dudley MBC as the provider of adult social care services. The scenarios they face are:- i) Do nothing activity levels in relation to emergency admissions to hospital and residential/nursing care will increase. Discharges from care will be delayed. Dependency levels will increase. Better Care Fund financial planning assumptions will not be delivered. Additional costs will be incurred by the CCG, Dudley Group NHS FT and Dudley MBC placing further strain on the system, requiring health and social care services to be de-commissioned. ii) Base Case all partners and providers implement the integrated care model. Unnecessary admissions to hospital and residential/nursing care will be prevented. Discharges will take place in a timely manner to the most appropriate setting, reducing levels of dependency. Appropriate community infrastructure will be available to support people living in supportive settings. Better Care Fund financial planning assumptions will be met. The health and care system will be in equilibrium. iii) Best case all partners and providers recognise the need to secure significant organisational change and create a more responsive and appropriate service model. A community health, mental health and social care 30 P age

53 provider/s is/are established integrating services around the patient and led by general practice; utilising a modern estate and IT infrastructure, delivering population based health and wellbeing. There is a clear bias towards delivering more services out of acute settings and in the community. In patient services are of a specialist nature only. Better Care Fund financial planning assumptions are met. Change is continuous. Service efficiencies are driven out to maintain performance. The best case is reflected in our activity assumptions that have been agreed with providers and reflected in our contracts. The table below illustrates the potential impact of these changes on existing providers: - Provider 14/15 Contract value 15% NEL Reduction Potential Loss of Income due to Strategic Plan 20% Electives Services potentially CQUIN Efficiency reprocured as part of Impact new community model Total Value at Risk Dudley Group of Hospitals 184,648,535 6,221,850 6,635,764 44,226,619 1,427,106 58,511,340 Dudley & Walsall Mental Health 26,193, ,209, ,244 17,640,021 Black Country Partnerships 11,209, ,574, ,363 4,688,889 West Midlands Ambulance 8,405, , ,100 15, , ,825,851 6,635,764 66,010,922 1,986,813 80,855,350 The financial impact on the 15% non-elective and 20% elective efficiency targets are built into our contracts with the key providers as well as being agreed with the Health and Wellbeing Board. Further discussions will take place regarding our community services model. 10. Managing Relationships and the Market The CCG and the system have a multi-faceted approach to relationship and market management. This is delivered through:- a) our formal contractual relationships - holding our providers to account for performance and using contractual levers such as the application of penalties, to deliver service change; b) testing the market - using appropriate procurement mechanisms such as AQP, where value and outcomes are not being delivered; c) monthly strategic partnership meetings with our main providers designed to oversee major strategic change; d) joint appointments to manage interface issues; e) clinical engagement between CCG clinical leaders and clinicians in our providers; f) system wide groups ( see above) dealing with key strategic issues service integration and urgent care; 31 P age

54 g) an organisational development programme across the CCG, Dudley Group NHS FT, Dudley and Walsall Mental Health Partnership NHS Trust and Dudley MBC to deliver the system s distributed leadership model. The significant steps required to deliver this are already being implemented: - activity levels agreed in contracts; acute capacity reduction plan agreed; procurement process for new urgent care centre commenced; community rapid response service commissioned and implementation commenced; supporting organisational development programme commenced across health and social care. The governance process described at page 5 will continue to provide oversight of this. 11. Next Steps Implementing This Vision As the local leaders of the healthcare system, our OD programme for the system is one of the most important aspects of what we do. So our organisational development plan realises our strategic vision by setting out the development programme and operational objectives for all of the components of this strategy over the first two years. This takes account of the external environment, constraints and challenges within which we are working and maps out our programme for development against the six components of our OD model:- - Purpose - Structure - Rewards - Mechanisms - Relationships - Leadership 32 P age

55 Then the first operational stages of this five-year strategy are set out in our two-year operating plan. The following diagram provides an illustration of how the main operational plan initiatives provide the start point to subsequently enable our reimagined health and social care system as set out in this strategy. This is then fully realised with the addition of the key enablers that are explained in both the operational plan and this strategy. These plans together therefore lay the foundations for all of the key components for achieving this longer-term vision. 33 P age

56 JSNA Outcome Ambition Initiative Gap in life expectancy for the least and most deprived areas of Dudley has widened mostly due to chd, copd and lung cancer in men. Securing additional years of life Nearly one fifth of year olds are living with a long term limiting illness. The rate of delayed discharges attributable to social care is higher than the national rate. 3.5% reduction in potential years of life lost per annum from 2087/100,000 in 2012/13 to 1685/100,000 in 2018/19. Improving the quality of life for people with long term conditions. Average EQ-5D score for people with one or more long term condition to increase by 1.6% from 70/100 people in 2012/13 to 74/100 in 2018/19. Reducing time spent in hospital through more integrated care Avoidable emergency admissions to reduce from 2448/100,000 in 2013/14 to 2322/100,000 in 2018/19. Appendix 1 Systematic management of long term conditions Prescribing for heart disease Prescribing for cholesterol Smoking cessation Diabetes LES and diabetes control Responsive IAPT services Diagnosing and responding to dementia Diagnosing hypertension Vascular checks Improved recording in disease registers for heart failure, hypertension and kidney disease Community based respiratory service COPD LES review Revised diabetes LES Community diabetes team Rapid Response Team Redesigned virtual ward Care home CPN 7 day services Community respiratory, diabetes and anticoagulation services Enhanced telehealth and telecare Community pain, dermatology and ophthalmology services 20% of single person households are in the 60+ age range. Increasing the proportion of people living independently at home. Integrated locality services Rapid Response Team Social prescribing 34 P age

57 Musculoskeletal services present an opportunity to improve the patient pathway, secure value for money and deliver better outcomes. Systematic management of long term conditions is required in primary care. Emergency admissions for gastroenteritis and lower respiratory disease are increasing for the age group. People still at home 91 days after discharge to increase by 4% from 86% at March 2013 to 90% at March Increasing people s positive experience of hospital care. Reducing the average number of negative responses from per 100 patients in 2012/13 to 145 per 100 patients in 2015/16. Increasing the proportion of people with a positive experience of GP care and in the community. Reducing the average number of negative response from 6.1 per 100 patients in 2012/13 to 5 in 2015/16. Eliminating avoidable deaths in hospital. scheme Community development workers Clear clinical standards Efficient planned care pathways Patient safety CQUIN Organisational learning CQUIN Medication error reporting Better access 7 day services Active patient participation groups Reducing variation Transfer of services to primary care Managing long term conditions Single IT system for 49 practices MRSA zero tolerance Grade four pressure ulcer zero tolerance Reducing infection rates including Cdiff Reducing medication errors 35 P age

58 Primary Care Development Strategy 2013

59 Primary Care Development Strategy 2013

60 Foreword Primary care is facing unprecedented challenges. Our Values: caring We will be a organisation patient-centred We will be a organisation. We will work together as teams within the organisation and with partners safety Quality and will be the foundation of everything we do. leads We will be an organisation which by example. We have the biggest change in the NHS since its inception, severe national economic constraints, an ageing population and increase in demand. Over the last decade, general practice has become more robust in its governance and clinical practice and is in a much better place to face the rigours of modern health care. There are, however, further demands on primary care which are currently underway or which we will face in the coming years. Care Quality Commission registration, revalidation, GP workforce issues and changes to the general practitioner contract will mean that we will have to contend with a more difficult working environment in the future. In developing this strategy we have taken into consideration the objectives set by NHS England to improve quality and reduce variation in general practice. We have listened to what patients want, which is improved access to services and continuity of care with their family doctor. The CCG membership has been clear that the main issue that they have to deal with is of increasing workload. The problems have arisen because of a lack of service capacity due to increasing demand and underinvestment in primary care over the last few years. The strategy looks at increasing capacity in general practice and investment in primary and community care along with the development of integrated extended primary care teams using innovative solutions which the Health and Social Care Act offers us. Primary care is at the heart of the delivery of the new NHS agenda and it is only by recognising that it has this pivotal role and by supporting practices to deliver good quality general practice that we can meet these challenges. We will be a learning organisation. We will be an inclusive organisation. We will have a focus on prevention and health promotion. We will be an innovative organisation. We will promote excellent financial management. Dr. Jas Rathore Clinical Executive Finance and Performance 2 3

61 Contents Page Primary Care Development Strategy Summary on a Page Summary on a page 5 1. Introduction 6 2. Vision and Aims 7 3. Arrangements for Commissioning Primary Care from April Scope of the Strategy 7 5. Primary Care in Dudley 8 6. Challenges Facing Primary Care in Dudley Being Accountable to our Patients and Communities Priorities for Developing Primary Care in Dudley 12 - Managing Workload and Improving Access 12 - Developing Integrated Locality Based Services 14 - Managing the Shift from Secondary to Primary Care Service Provision 15 - Urgent Care - Primary Care s Role 16 - Building Resilient Primary Care and Supporting Practices to Thrive 17 - Reducing Unwarranted Variation and Rewarding Excellence Clinical Priorities Health and Wellbeing - Delivering Public Health Priorities and Reducing Health 20 Inequalities 11. Measuring and Monitoring Quality in Primary Care Premises Principles to Inform Decision-making and Investment Decisions for Primary Care 24 Development 14. Implementing the Strategy and Monitoring Progress 24 Attachments Attachment 1 Dudley CCG Strategic Commissioning Plan on a Page 25 Attachment 2 Practice List Sizes Map & Key 26 Attachment 3 NHS England National Priorities for Quality Improvement 5 Domains 28 Attachment 4 Quality in Primary Care - Monitoring Process 29 Our Vision and AIms: To ensure high quality, accessible primary care for the people of Dudley To support local practices to maintain an improve the quality of primary care provision for patients To support the CCG s strategic aims by contimuing to reduce health inequalities, improving health outcomes, improving services and improving health & safety Priorities for Developing Primary Care Improving Access & Managing Workload Primary Care s role in delivering the Urgent Care Strategy Our Objectives: Local Clinical Priorities for Primary Care: Local Quality Premium Areas Dementia Atrial Fibrillation Hypertension Developing Locality-based Services Building Resilient Primary Care & Supporting Practices to Thrive Managing the shift from Secondary to Primary Care Reducing Unwanted Variation & Rewarding Excellence Quality and Productivity Indicators in QOF OPD Pathways: Cardiology, Pain Management, Ophthalmology Reduction in Avoidable A&E Attendances Emergency Pathways: Atrial Fibrillation, Acute Asthma, Frail Elderly UTIs To contribute to the CCG s wider strategic priorities for improving health & health services Related CCG Strategies and Policies Premisis Planning Framework CCG Communications and Engagement Strategy CCG Research and Development Strategy CCG Innovation Strategy Quality Monitoring Process CCG Financial Plan CCG OD Strategy - CCG IT Strategy Glossary 30 References 31 Author Mrs Gillian Goodlad Contributors Dr Jas Rathore Dr Tim Horsburgh Dr Kevin Dawes Dr Richard Gee Mr Daniel King Mr Paul Maubach Mrs Carol Jones Ms Helen Ashford Related CCG Documents CCG Primary Care Premises Planning Framework CCG IT Strategy CCG Research and Development Strategy CCG Innovation Strategy 4 5

62 1. Introduction 2. Vision and Aims 4. Scope of the Strategy Dudley Clinical Commissioning Group (CCG) has identified a need for a primary care development strategy which supports local practices to further improve the quality of primary care and helps the CCG to meet its overall strategic aims. Primary care services are the bedrock of local healthcare. Over 90% of all patient contact with the health service happens in primary care. In addition, general practitioners are the key gatekeepers to hospital and other specialist healthcare services. Achieving the aims and priorities of the CCG s wider strategic commissioning plans will in large part be dependent upon local practices being able to deliver improvements and participate fully in the prevention agenda. Ensuring stable, high quality, accessible primary care services is therefore essential to meeting the healthcare needs of our population. As a clinically-led membership organisation, Dudley CCG is uniquely placed to deliver change and improvement in primary care. This strategy aims to build on this opportunity, whilst acknowledging the freedoms and restrictions of the new NHS arrangements for the direct commissioning of primary care. The priorities which have been identified locally also mirror many of the key elements of the top ten priorities for commissioners published by the Kings Fund in 2012 and updated this year. A key feature of the priorities set out by the King s Fund is the extent to which they involve a change in primary care itself and the way in which primary care works with the rest of the system. If CCGs are to maximise the opportunities afforded by the direct engagement of GPs in commissioning, then it will be necessary to invest in developing it members, growing as a strong commissioning organisation and building good working relationships across the health system. These aspects are addressed in the CCG s Organisational Development Plan. This strategy also builds upon some of the aims and ambitions set out in Dudley PCT s primary care strategy Reaching Excellence. The vision for primary care in Dudley is: To ensure high quality, accessible primary care services for the people of Dudley. The aims of the strategy are: To support local practices to maintain and improve the quality of primary care provision for patients To support the CCG commissioning strategy by contributing to reduce health inequalities, improving health outcomes, improving services and improving health and safety. 3. Arrangements for Commissioning Primary Care from April 2013 As part of the new NHS organisational arrangements from April 2013, there have been significant changes in the way in which primary care services are commissioned. In summary: This strategy focuses on general medical services and does not directly cover pharmacy, dentistry and eye care services. This reflects the fact that the CCG s membership is comprised of general practitioners and the CCG s responsibility to ensure the continuous improvement of primary medical services. The priorities set out in this strategy are based on: What member practices have told us about their key concerns and how these should be addressed What patients and our local communities have told us about their current primary care services The CCG s agreed strategic aims and priorities (and those of Dudley s Health and Wellbeing Strategy) The national must do s and performance management requirements. NHS England commissions national primary care services. They hold primary care contracts and are responsible for planning, securing and monitoring services commissioned by them in respect of primary care. CCGs are responsible and accountable for commissioning local enhanced services. In addition, CCGs have a statutory duty to assist and support NHS England in securing continuous improvement in the quality of primary medical services. These new arrangements have implications for the remit, development and implementation of this strategy, as they determine what the CCG has direct control over and what is outside its direct control in relation to the commissioning of primary care. It is clear that CCGs will now be required to play an active role in supporting NHS England to exercise its responsibilities. This means that close working between the CCG and The NHS England local Area Team (AT) will be essential. Neither organisation will be able to bring about the required changes alone or by focussing solely on those services over which they have direct budgetary control. This reinforces the need for Dudley to have a clear local strategy for primary care, with agreed aims, processes and policies. This will offer clarity and assurance to the AT that Dudley CCG is equipped to meet any national performance requirements for primary care and is likely to give the CCG more freedom to address its local priorities in the way it thinks best for its local communities. 6 7

63 5. Primary Care in Dudley Many of the features of the local population and the current primary care delivery models remain unchanged from those described in the PCT strategy Reaching Excellence. General issues affecting primary care in Dudley, and as reflected in the local Health and Wellbeing Strategy, include: Rising demand for healthcare services A slower than average rate for improving local people s health Persistent long-term inequalities, (despite targeted action having been taken in the past) Worsening trends in lifestyle risks, particularly from obesity and alcohol Significant levels of undetected and untreated disease. Facts and Figures Dudley CCG has a population of approximately 314,500. There are 49 General Practices plus a Walk in Centre in Dudley. These practices occupy 47 main practice premises and 9 branch surgery sites, making a total of 58 facilities. The CCG has organised its practices into 5 geographical localities. (see map below) There are 199 General Practitioners, (174 WTEs). Almost 27% of Dudley GPs are aged 55 or over (compared to a national average of 22%). More worryingly, over 10% (21) GPs are aged 65 or over compared to a national average of only 4%. In some practices half or more of the GP workforce is over 60. (This is important because over a quarter of GPs may retire during the next ten years.) Practices vary in size. Total list sizes range from just over 1,000 patients to 25,000 patients. Nearly one fifth of practices in Dudley are single handed which is almost double the national average. Over 40% of practices in Dudley have 2 partners or less, compared to a national average of 28.5%. (see Attachment 1) Practice list sizes per WTE GP vary, with the average being 1,808 per WTE GP (national average 1,765). Further work is required to understand the impact of the availability of other community and primary care services alongside GPs has on the WTE requirement. Surgeries by Locality Kingswinford, Amblecote and Brierley Hill 23 High Oak Surgery 24 Kingswinford Health Centre 25 Moss Grove Surgery 26 Summerhill Surgery 27 Rangeways Road Surgery 28 Wordsley Green Health Centre 28A Market Street Surgery (Wordsley Green Branch) 29 AW Surgeries 29A Withymoor Surgery (AW Branch) 30 Waterfront Surgery 31 Brierley Hill Health Health and Social Care Centre 32 Quincy Rise Surgery 33 Three Villages A A /31 34A 38 34B A / A B A 44 43A B 48 48A Sedgley, Coseley and Gornal 1 Northway Surgery 2 Bath Street Surgery 3 Bilston Street Surgery 4 Coseley Medical Centre 5 Woodsetton Medical Centre 6 The Ridgeway Surgery 7 The Greens Health Centre 8 Lower Gornal Health Centre 8A Masefield Road Surgery (Lower Gornal Branch) 9 Castle Meadows Surgery Dudley and Netherton Dudley and Netherton 10 St James Medical Practice (Dr White) 11 St James Medical Practice (Dr Porter) 12 Eve Hill Medical Practice 13 Tinchbourne Street Surgery 14 Cross Street Health Centre 15 Steppingstones Medical Practice 16 St Thomas's Medical Practice 17 Central Clinic 18 Bean Road Surgery 19 Keelinge House Surgery 20 Netherton Surgery 20A Hazel Road Surgery (Netherton Surgery Branch) 21 Netherton Health Centre 22 Quarry Road Surgery Halesowen and Quarry Bank 39A Chapel House Lane (Wychbury Branch) 40 Thorns Road Surgery 41 Quarry Bank Medical Centre 42 Clement Road Medical Centre 43 Feldon Lane Surgery 43A Hawne Lane Surgery (Feldon Lane Branch) 44 Crestfield Surgery Ltd 45 Alexandra Medical Centre 46 Lapal Medical Practice 47 Meadowbrook Surgery 48 Halesowen Health Centre 48A Tenlands Avenue Surgery (Halesowen HC Branch) 48B Coombs Road Surgery (Halesowen HC Branch) 49 St Margaret s Wells Surgery Out of Area 39B Cradley Road Surgery (Wychbury Branch) Current accessibility for existing primary care facilities in terms of geography appears good and most of the population are within 30 minutes walking distance of a GP surgery. The majority of residents have good access to public transport, with most residents living within minutes of their nearest GP practice. Stourbridge, Wollescote and Lye 34 Worcester Street Surgery 34A Meriden Avenue Surgery (Worcester St Branch) 34B Greenfield Avenue Surgery (Worcester St Branch) 35 Pedmore Medical Practice 36 Chapel Street Surgery 37 The Limes Surgery 38 Norton Medical Practice 39 Wychbury Medical Group Data correct as of April

64 6. Challenges Facing Primary Care in Dudley There are a range of significant challenges facing primary care generally and GP practices in particular. These include: Rising workload and pressure on access. Rising demand from patients within the context of limited and stretched capacity in primary care has been placing increasing pressure on practices. This is a major barrier to practices being able to maintain or improve quality standards and impedes their ability to support new care pathways. Proposed changes to the national contract and other national initiatives will have a significant impact on general practice in a range of ways. The detail of the impact of the various changes on individual practices is difficult to calculate, but we know that most practices will need to make significant adaptations to their organisational arrangements to implement these changes successfully, meet required performance standards and maintain income. Changes include: - Changes to the Quality and Outcomes Framework indicators with increased thresholds - Introduction of new Directed Enhanced Services - Equitable funding proposals from 2014 onwards will impact differentially on practices. In addition to the concerns regarding the impact of these changes on workload and income, there are also concerns that this will be a negative impact on patient access, and recruitment and retention to general practice in the medium term. A changing workforce and labour market point to the need for detailed and proactive succession planning and recruitment and training plans. For example, up to one quarter of Dudley GPs may retire within the next 10 years. In addition, other issues such as CQC registration, revalidation and the national contract changes outlined above will have a direct effect on the primary care workforce. Pressure on practice income due to cost inflation, static pay settlements and increasing activity. The proposed national contract changes and the introduction of capitation based budgets will affect practices differentially and the full implications of this for future primary care provision in Dudley need to be gauged. Historic funding differences between practices and between GMS/PMS overall is a specific challenge within Dudley and there is a need to understand the impact of the proposed contract changes and develop strategies to manage the change smoothly, fairly and safely. Increased transfer of work from secondary to primary care. Pressure on premises which are too cramped and/ or not of a sufficiently high standard for modern day primary care service provision. Too much unwarranted variation in GP practice performance and the quality of service offered to patients. Reduced organisational and management capacity at Area Team level due to the recent NHS reorganisation. In addition to the expected teething problems, this seems also to be resulting in significant delays to decision-making processes for crucial issues e.g. practice merger requests. The priorities and actions set out in this strategy must enable the CCG and its members to meet these challenges. This will require willingness from members to: - work together - adopt best practice - think and act innovatively. 7. Being Accountable to our Patients and Communities The CCG already has a great deal of information regarding local patients views of primary care services and their priorities for improvement. The CCG has established a range of processes for involving local patients and community groups in the work of the CCG which are overseen by the CCG s Communications and Engagement Committee. Many of the issues most regularly raised by patients mirror those of local practices. Especially those focussed on access issues which directly relate to practices concerns regarding the increasing pressures on their available capacity. The key messages and issues have been consistent over the last few years and are set out below. Patient Concerns Telephone access and access to appointments especially same day access. NB this is by far the greatest concern raised by local people. Ensuring continuity of care between primary and secondary care and vice versa. Communication needs of those with sensory impairment. More time during consultations for explanation and checking patients have understood. Taking proper account of carers needs and their views regarding the needs of those they care for. Improved links with social services and sign-posting. Being treated as an equal and with dignity and respect. Understanding patients needs and helping them to get the right help at the right time. Informed choice more advice. (GPs, patients and specialists do not always share a common understanding of why a referral is being made, for example, whether it is primarily for diagnosis, investigation, treatment or reassurance.). More telephone consultations. Lack of understanding re role of nurses and nurse practitioners feeling of being offered a lesser service if not seeing a doctor. The way in which the priorities identified in this strategy are addressed will take account of these views and address the concerns of local people

65 8. Priorities for Primary Care Development This section forms the most important part of the strategy as it sets out the key priority areas for developing primary care locally and the ways in which the CCG will seek to address these. Managing Workload and Improving Access Why this is a priority During work on this strategy, the consistent message we received from member practices was that the workload in primary care has become unmanageable within the existing capacity and is in danger of compromising the quality of the service offered. This is mirrored by the views we have consistently received from patients - that difficulty in getting appointments continues to be their number one concern. There is a need therefore to develop plans which create capacity in primary care, help to reduce pressure on practices and improve access for patients. Whilst the average national list size per GP has dropped since over the last 20 years, the average consultation rate has risen. (The consultation rate is the average number of consultations per patient on the practice list, per year.) The current average consultation rate across Dudley is 5.26, which is marginally below the expected rate of (The expected rate is the rate adjusted for local demographic characteristics.) National trends have seen a fairly stable trend upwards since 1994 when the rate was 3.5 and rising by about 1 per decade. Most of this is driven by increasing numbers of treatments and procedures available in the community, less hospital based follow up and an aging population living longer with more disease. None of these factors have eased during the last 5 years since the latest national consultation rate figures were published and the local Dudley rates, (calculated in March of this year, would appear to demonstrate that this trend has continued. The impact of this rising trend is huge for individual practices. For example, for a practice with a list size of 10,000 patients, an increase of 1 in the consultation rate represents an additional 10,000 consultations per year, (nearly 200 per week) which need to be accommodated. This rise in demand has not been matched by an increase in resource within primary care. Solutions The CCG has funded the Primary Care Foundation to conduct a baseline audit of the current workload in terms of appointments, telephone traffic, opening times etc. This is helping individual practices to quantify the pressures on their current capacity, identifying where and when these are greatest. This will inform individual practice development plans. There is some evidence to show that some relatively simple modifications can improve patient satisfaction and help to make the workload more manageable. The PCF has therefore been working with practices to identify modifications to current working practices to help them better manage demand. The headline findings from this work when taken collectively have also helped the CCG to identify the key issues and help to produce plans to mitigate these pressures. The key messages are: - The need to improve continuity of care for patients there is good evidence that this reduces emergency admissions, leads to reduced consultation rates and, as this is also the top of the majority of patients wish lists, improved patient satisfaction - The need to ensuring effective telephone response - The need to re-balance practice systems, particularly appointments systems, to ensure that, as far as possible, they do not work against continuity of care. (As the expected consultation rates are adjusted to account for local demography, a higher consultation rate is not normally an indication of a greater health need or a more deprived population. Rather, it is often an indication that patients are being seen more often than is necessary for the overall health needs of the practice population. This can be caused by a number of factors, but foremost amongst these is practice systems which work against continuity of care) - There is evidence of a link between high patient satisfaction scores and high QOF scores and vice versa. In addition, there is evidence that ease of access for patients can affect their use and interaction with those services and therefore any connected services e.g. A&E. - Need to review current practice with regard to the clinical assessment of home visit requests to ensure that requests are assessed quickly and any resulting urgent home visits are completed earlier in the day. The CCG is putting in place plans to build on the GPs with a special interest (GPWsI s) development programme to improve capacity in primary care, help with the retention of GPs, aid service development and help succession planning. Ensuring that the CCG thinks carefully about the way in which it procures additional services from primary care (including any new Local Enhanced Services (LES ). This includes: - Planning new procurements carefully and avoiding hurried introduction of new schemes - Ensuring procurements cover a time period which is long enough for practices to make sensible choices regarding any additional staffing to cover the procured service requirements and ensure that this represents a genuine increase in capacity within primary care where this is required - Newly procured services should be monitored to ensure they are delivering the agreed improvements for patients and commissioners. This includes agreeing in advance the outcome measures and the action which should be taken if these outcomes are not being achieved either by individual practices or across the board. - Ensuring that the improvements afforded by the introduction of newly procured services in primary care will be available to all patients across the CCG area irrespective of which practice they are registered with. Further development to encourage increased selfmanagement by patients. Around 70% 80% of people with long-term conditions can be supported to manage their own condition (Department of Health 2005).There are a number of well-established selfmanagement programmes that aim to empower patients to improve their health. Evidence has highlighted the importance of ensuring the intervention is tailored to the condition (de Silva 2011). For example, structured patient education can be beneficial for people with diabetes, while people with depression may benefit more from cognitive and behavioural interventions. Recent work conducted by the Richmond Group of Charities and The King s Fund (2012) called for patients to be offered the opportunity to co-create a personalised selfmanagement plan which could include the following: - patient and carer education programmes - medicines management advice and support including advice about diet and exercise - use of tele-care and tele-health to aid selfmonitoring - psychological interventions (e.g., coaching, including telephone based coaching) - pain management - patient access to their own records

66 Developing Integrated Locality Based Services Why this is a priority Both practices and patients have identified the need for much better coordination and integration between services. Highly integrated primary care systems that emphasise continuity and co-ordination of care are associated with better patient experience (Starfield 1998; Bodenheimer 2008). Few practices now have the close links they would wish with colleagues in the wider primary healthcare and community services team particularly District Nursing. The coordination and integration of care seems to be quite variable for patients with on-going health needs. Nursing services across GP practices and the community are not always well coordinated and carers and voluntary sector services are not seen as being an essential part of the primary care system. This leads to more fragmented care for patients and their carers and more pressure on GPs and other professionals struggling to provide this care in isolation. In addition, there are some services which should be provided as close to patients homes as possible, but which smaller practices do not have the capacity to provide. Solutions the CCG will support the development of the role of localities, to enable them to gain more control over the development of services within their area. This will promote integration between local health services and also with social services and other community and voluntary groups. The CCG will develop plans to commission community services in a way which requires providers to ensure they are locality based and are directly linked to individual practices (or groups of practices) to enable a more integrated approach to planning and delivery of services within the locality. CCG members will agree a minimum range and quality of services which will be available, (over and above core GMS), at practice and locality level. Building up a core of services based around multi-disciplinary teams and extended teams including primary care based mental health services, psychology services, pharmaceutical advisers, counsellors etc. Developing locality based education, research and training. Further work to learn from best practice elsewhere, where moves towards community-based multiprofessional extended primary healthcare teams based around general practices that include generalists working alongside specialists and care coordinators have delivered significant improvements in patient experience, outcomes and satisfaction. The CCG and localities will support closer working between practices in order to ensure that the full range of services are available to all patients within their locality irrespective of which practice they are registered with. In addition, closer working should help practices to build resilience and manage costs. This will need to be done in a way which does not undermine continuity of care for patients. Managing the Shift from Secondary to Primary Care Service Provision Why this is a Priority Recent years have seen a steady increase in the transfer of work and services to primary care which were previously carried out in secondary care settings. This includes care pathway changes such as; - reduced number of hospital follow-up appointments - earlier discharge from hospital - more post-operative care done in primary care - more primary care led management of long term conditions. These changes, together with an ageing population and increased prevalence of chronic diseases, call for a strong shift away from the current emphasis on acute and episodic care, towards prevention, self-care, more consistent standards of primary care, and care that is well co-ordinated and integrated. To date, however, movements towards more care being provided in primary care and community settings have not generally been matched by a shift in resources. The scale of the change management task to achieve this fundamental shift has generally been underestimated and moves to change the balance in the way in which care is provided have often been under planned and left to drift. There has been an assumption that doing more in primary care and community settings will result in savings. This does not happen however unless the increased investment in community services has been accompanied by a clear and planned strategic disinvestment from hospitals. The CCG needs to be able to make a robust case for such disinvestment where it is clinically justified, and will need strong communication and political skills in order to overcome resistance to such change whether from local communities or from local practices. Solutions The CCG will commission improved access to diagnostics and secondary care advice e.g. extending direct access to imaging and electrophysiological diagnostics. Commissioning more accessible specialist advice without the requirement for an outpatient appointment. The CCG will make further use of Local Enhanced Services (or other procurement vehicles) which ensure that primary care is appropriately resourced to develop and participate in new care pathways which address local priorities and provide better services for patients. The CCG will develop a comprehensive and innovative IT Strategy which supports better coordination and integration across services and allows commissioners to track spend at each stage of the patient journey. Ensuring that the primary care aspects of the CCG s strategy for Long Term Conditions are appropriately implemented via specifically commissioned services and care pathway development and implementation for conditions such as diabetes, rheumatic diseases, knee replacements, hip replacements, gallstones etc. The CCG will consider the further development of locality attachments for hospital consultants based on the paediatrics model currently being implemented. This will promote closer working and learning and education. The CCG will ensure that local Quality Premium targets are introduced in a way which enables Primary Care to be supported to deliver them. The CCG will seek to ensure that primary care premises are developed to support service delivery in primary care settings where this is clinically appropriate. Localities will build links with local community and voluntary sector groups to further support the delivery of coordinated care for patients

67 Urgent Care Primary Care s Role Why this is a priority Both nationally and locally, urgent care services continue to be a high priority. Urgent care services consume a large part of the available healthcare resource. These are costly services which should only be used when necessary. Dudley has a higher than average admission rate for conditions which would not normally require hospital admission. National benchmarked data suggests that there are higher than expected numbers of patients going to hospital A&E with conditions that can readily be treated in primary care. In addition, once patients reach the hospital they are often admitted with conditions for which admission is largely preventable. This is especially true of ambulatory caresensitive conditions (ACS) such as congestive heart failure, diabetes, asthma angina and hypertension. According to the Kings Fund, ACS conditions account for 15.9% of all emergency admissions and national evidence demonstrates that there is a significant variation in how effectively ACS conditions are managed in primary care which impacts upon admission rates. This issue is therefore directly linked to primary care. It is interesting to note that at the CCG s Urgent Care event with the local Healthcare Forum most of the issues raised by patients related to the difficulties in accessing primary care which they felt contributed to pressure on A&E services. See patient comment boxes. Standardised set up for all GP practices with criteria Need improved access to primary care outside of routine work hours Spend money on GP surgeries instead so they provide out of hours CCGs to be stricter with GP practices set standards of what GPs have to do More availability of appointments in primary care including extended hours PATIENT COMMENTS Greater co-operation between practices to cover longer hours e.g. rota More receptionists to receive calls to avoid the engaged tone Need to see GPs as required difficulty to speak to GP or get an appointments and the problems start when you need emergency access Better telephone access to GP surgery Building Resilient Primary Care and Supporting Practices to Thrive Why this is a priority As has been outlined in the earlier section, general practice is facing a series of major challenges over the coming months and years. Whilst all practices will be affected, it is likely that some practices may be more adversely affected than others, or that some practices are less well placed than others to weather the changes and challenges. If Dudley CCG is to be successful and ensure high quality healthcare services for local people, it is essential that it has stable and strong primary care primary providers. By anticipating the likely local impact of planned changes at a national level and by mapping local trends in terms of retirements, recruitment and retention etc., CCG members will be much better placed to develop agreed strategies for successfully coping with these changes. Solutions Close working with the NHS England local area team to ensure that the CCG has some influence over the direct commissioning of primary care, for example following the retirement of a single-handed practitioner, and can shape local services in line with agreed local strategies. Develop a practice nurses group to provide professional support, lead innovative solutions to service provision in primary care and support high quality service provision consistently across the CCG area To increase the number of training practices in Dudley Solutions To ensure that the CCG s Urgent Care Strategy takes full account of primary care s current and potential contribution to managing urgent care across Dudley. to develop and evaluate a pilot scheme which sees a step change in the quantum and nature of primary care commissioned with the express aim of reducing avoidable A&E attendances and admissions, and improving coordination and integration across services in and out of hours. To take a pro-active and appropriate approach to consider the role of primary care in relation to innovative responses to the national move towards 7 day primary care and community services and the availability of key health and social care services at evenings and weekends. To work with local practices to design solutions which fit local circumstances and meet the needs of patients and practices. To ensure that the urgent care strategy includes specific actions such as the use of risk stratification tools, clinical decision support software within GP practices, and a range of relatively simple primary care based interventions to improve the early identification and successful management of ACS patients Other primary care based aspects of urgent care will also be reviewed within the context of the urgent care strategy including: - disease management and support for selfmanagement for those with long-term conditions (see also workload section above) - telephone health coaching - increased continuity of care within GP practices (see also workload section above) - ensuring effective out of hours arrangements - providing effective signposting to help patients choose the right service - the ability to flex primary care and community services in response to short-term changes in demand - processes within practices for the timely review and management of requests for home visits (see also PCF work above) The use of real time information and IT to support early decision-making in primary care To compile clear plans based on the detailed modelling of anticipated local changes e.g. retirements, premises changes, income changes. Supporting each member practice to develop a practice Organisational Development plan, (which also meets AT requirements), and to ensure that wider CCG strategies and plans reflect these individual plans Support practices (and practice managers) to explore cooperative approaches within a locality model, (where this is desirable and supported by local practices) e.g. sharing back room functions e.g. payroll, centralising call and recall, choose and book. NB such cooperative models could be of any size or shape (of 2 practices or more) to suit local practice requirements and would not need to encompass a whole locality To develop a CCG based primary care support team with senior clinical and managerial leadership To explore the establishment of a shared locum bank for local practices in order to improve quality and effectiveness of locums To support and further develop the practice managers group to lead innovative solutions to issues facing primary care and to support high quality practice management consistently across the CCG area To continue initiatives which support and enable member practices to participate in the work of the CCG and be kept informed. For example, the practice engagement LES which supports practice attendance at meetings, improving practices ability to engage with the CCG support team and produce practice development plans To support workforce training and development, (e.g. CCG wide procurement where this benefits members), developing the mentorship schemes, statutory training/revalidation/support, remediation etc The CCG will ensure appropriate links with education and training networks including Local Education and Training Boards (LETB s) To develop the Primary Care Quality Monitoring Group to ensure on-going close liaison between the CCG, the AT, LMC and Responsible Officer. (See diagram Attachment 4) To ensure that the CCG Organisational Development Strategy has an emphasis on supporting the development of CCG members. This should set out how CCG members will work together to support each other to build a strong, high quality CCG, and how CCG membership benefits members and ultimately their patients

68 Processes for supporting the CCG member practices are summarised in the diagram below: Reducing Unwarranted Variation and Rewarding Excellence CCG Accountability Primary and Community Integration GP Lead: 5 GP Chairs Locality Commissioning 5 Locality Groups Developing PPGs Closer Working Between Practices Peer Review Implementation of Quality Premium Understanding Patient Experience National Quality Dashboard Practice Performance Commissioning Scorecard By Practice NHSE Contract and Performance Quality Productivity Indicators Individual Practice Visits GP Lead: Richard Gee Why this is a priority At a national level, we know that there is substantial variation between practices in the range, quality and experience of services such as the systematic implementation of approaches towards secondary prevention. For example, disease registers where only a minority of patients receive all recommended interventions. Current information and benchmarking data for Dudley demonstrates that locally there is some significant variation in the quality and outcome of services offered by individual practitioners, practices and localities. Some of these differences can be readily explained and may even be desirable given the different needs of individual localities and patient preferences. Other differences, however, are not readily explained and demonstrate differences in access and quality between practices which are not acceptable for patients and which need to be addressed to ensure improved equitable health outcomes in Dudley. Dudley CCG as a membership organisation is committed to driving up quality, rewarding excellence and driving out poor quality primary care services. GP Lead: David Parry Annual Quality & Productivity Peer Review GP Mentorship Programme Practice Nurse Mentorship Programme GP Engagement and Membership Development GP Lead: Jas Rathore Practice Manager Alliance Productive Practice Improving Patient Access Solutions The CCG will complete further work to share detailed benchmarking information regarding primary care service delivery with practices and agree actions arising from this. CCG members will agree a process for monitoring and managing primary care performance against the national assurance framework (and any locally agreed indicators), and will work closely with NHS England local Area Team to ensure that local knowledge is applied to raw data. The CCG will build on the PMS Review work undertaken by the PCT to agree further quality measures with practices and support sustainable moves towards equitable resource distribution. In doing this the CCG will work with the NHS England local Area Team to take account of national initiatives in this respect. CCG members will agree a scheme which incentivises good performance against agreed indicators and rewards excellence as judged against national benchmarks. Developing GPSIs GP Appraisal Workforce Development Monthly GP Education Events Practice Manager Mentorship Programme Supporting Premises Development Business Support Business Information (MiCS) IT Infrastructure and Systems Premises Investments Programme The CCG fully acknowledges the central role practice managers have in the delivery of high quality primary care services and will work with practices to ensure all practices have access to consistently high quality practice management and organisational skills. There is good evidence to demonstrate that the achievement of clinical priorities (particularly those related to prevention and management of long term conditions), are directly influenced by how well practices can organise their activities to ensure that they consistently reach all targeted patients. In addition, those areas which are of most concern to patients i.e. access to appointments etc. are those which are most directly affected by the way in which the practice is managed. The CCG will ensure that methods of procuring services from primary care will ensure equality of access for all patients

69 9. Clinical Priorities for Primary Care 11. Measuring and Monitoring Quality in Primary Care The priorities identified in this primary care development strategy are designed to support primary care to deliver high quality services generally and any specifically identified clinical priorities. Primary care has a crucial role in delivering all of the national priorities across each of the 5 domains as set out in attachment 3. In addition to the national priorities, there are specific local clinical priority areas for primary care linked to the quality premium and the quality and productivity indicators for QOF. Local Quality Premium Areas Dementia Atrial Fibrillation Hypertension Quality & Productivity Indicators in QOF OPD Pathways: Cardiology, Pain Management, Ophthalmology Reduction in Avoidable A&E Attendances Emergency Pathways: Atrial Fibrillation, Acute Asthma, Frail Elderly UTIs To contribute to the CCG s wider strategic priorities for improving health & health services 10. Health and Wellbeing - Delivering Public Health Priorities and Reducing Health Inequalities By supporting the development of high quality primary care, this strategy is also designed to ensure that local primary care providers are best placed to play their part in the delivery of Dudley s Joint Health and Wellbeing Strategy Wellbeing for life our plan for a healthier Dudley borough The aim of this plan is to improve the health and wellbeing of local people and reduce health inequalities. Dudley is changing and although in national comparisons it scores average for deprivation, the health of people in Dudley lags behind the rest of the country. Some people are living longer and fewer are dying from the big killers cancer, respiratory disease and heart disease - but not all. There are stark differences across the Borough, with certain wards experiencing disproportionately high levels of ill health and deprivation. Improvements over the last decade have been partly due to improved living conditions and treatments but are also due to people reducing risks to their own health by stopping smoking and reducing cholesterol levels. Rising obesity levels and alcohol consumption are increasing risks into the future. Primary care in Dudley has a crucial role to play in responding to these changes. More systematic primary prevention in general practice has the potential to improve health outcomes and save costs (Health England 2009). For example, five minutes of advice in a general practice setting to middle-aged smokers to quit smoking can increase quit rates and save 30 per person for a cost of 11 per person. Evidence suggests that the inverse care law applies and those in greatest need are least likely to receive beneficial services. Identifying those at risk and intervening appropriately is one of the most effective ways in which GPs can reduce the widening gaps in life expectancy and health outcomes (Marmot Review 2010). More systematic and proactive management of long term conditions and preventative healthcare initiatives will improve health outcomes, reduce inappropriate use of hospitals, and have a significant impact on health inequalities. In order to ensure this systematic approach it is crucial that practices are organised and managed to excellent standards (see sections above), and the CCG is committed to supporting all practise to ensure that they have access to this. More specifically, primary care has a key role in delivering a range of public health initiatives including: Immunisation programmes Child health Cytology/breast screening NHS Healthchecks Early detection programmes Diabetes, hypertension The CCG will continue to ensure that practices are supported and monitored to ensure that these initiatives are successfully delivered. National Assurance Framework Phrases such as improving the quality of primary care are used frequently, but in order for this to be meaningful for practitioners and patients there is a need to define what is meant by good or high quality and identify how this would be measured or demonstrated. Inevitably different practitioners have different perspectives on this and service users often have yet another view. There are now, however, some performance indicators which have been nationally determined. NHS England has provided a suite of measures which are intended to be transparent and consistent. This indicator set applies to all practices and Area Teams nationally and allows for comparisons to be made across CCGs, nationally or in customised clusters for practices or CCGs with similar characteristics. This tool is called the Primary Medical Assurance Framework: web interface and has recently been launched. The web interface provides pre-analysed data to facilitate relationships between area teams and practices. Unique practice profiles are also available. It will be important for member practices to understand how to use the tool to compare their practice with peers. Events to introduce practices to the tool are being held nationally and the CCG will be arranging workshops locally. Local workshops will be focussed not just on how practice can use the tool but also on understanding how the tool will be used by NHS England and CCGs. Local Processes for Monitoring Quality CCG members will need to agree which other sets of data and benchmarking information should be used locally in addition to the national assurance tool. This will be based on processes currently in use, but these will need to be updated and streamlined in order to reduce duplication and focus on areas of most interest locally e.g. local priority areas. The organisational arrangements for how this data is reviewed and acted upon will also need to be agreed. An outline process built around a joint primary care quality monitoring group has been drafted. Attachment 4 summarises this and shows how this will link directly to the CCG s wider Committee structure and therefore governance arrangements. The CCG is currently in the process of discussing this with the Area Team in order to ensure that the CCG and Area Team processes are dovetailed as far as possible

70 12. Premises Premises Suitability If the CCG is to respond local health needs and develop service models which provide opportunities for more integrated care, closer to patient s homes, primary care premises development will be essential. The CCG is fast moving towards a position where the lack of suitable premises will lead to sub-optimal arrangements for service delivery and the loss of opportunities for closer working between practices to deliver a wider range of services. This is of even more concern when one considers that the areas with the most pressing need for re-developed premises are those with the highest deprivation scores and where there are the greatest health inequalities. As a result of the recent NHS reorganisation, the process for approving and funding new primary care premises developments is currently unclear, although we do know that this will be under the control of NHS England and its local Area Teams. Whatever the process, however, it is almost certain that this will involve prioritisation between different CCG areas and that decisions to fund new developments will only be made where it can be demonstrated that they address pressing needs and are congruent with local strategic plans. It is essential, therefore, that the CCG has a clear idea of its preferred direction of travel and its premises development priorities in order to be able to act promptly once the process is known and influence funding decisions in ways which support its strategic service development plans. CCG members will agree prioritisation criteria for new premises developments which take account of both known and opportunistic aspects of premises development. These then need to be applied to the current information and priorities agreed. CCG members will agree the minimum criteria which will be applied to new premises developments in order to ensure that these meet the strategic service needs. The CCG will consider pulling together broad outline costs for a replacement/development programme to address the most urgent needs in order to provide a basis for planning and discussion with the local Area Team. Colour Key Not Suitable Limited Suitability Suitable Incomplete Data New Premises Under Construction A A /30 28A A A 10/10A B 38A 43 42A 47B As part of this process, the CCG has undertaken an initial review of local primary care premises to begin informing this process. This is summarised in the map below. This review, together with existing data and the previous PCT Commissioner Investment & Asset Management Strategy (CIAMS), helps the CCG to begin to focus on potential priority areas for premises development. In order to move forward with this crucial area the CCG will need to ensure that the following actions are incorporated into the implementation plans for this strategy: 1 Northway Surgery 2 Bath Street Surgery 3 Bilston Street Surgery 4 Coseley Medical Centre 5 Woodsetton Medical Centre 6 The Ridgeway Surgery 7 The Greens Health Centre 8 Lower Gornal Health Centre 8A Masefield Road Surgery (Lower Gornal Branch) 9 Castle Meadows Surgery 37 33B A 48 The CCG will ensure that it keeps abreast of local Area Team plans for managing the premises development process and participate fully in this. The CCG will ensure that the local Area Team is fully aware of the urgency of the need for premises developments to ensure that patients are receiving care in facilities which are fit for purpose and to enable the delivery of service developments in areas of greatest health need. (i.e. putting all new developments on hold indefinitely is not an option.) The CCG will agree a view regarding its preferred procurement route and whether it wishes to have a choice -at the very least some clarity regarding the application of the LIFT exclusivity agreement to the CCG is required. (Some schemes, especially small individual schemes, are unlikely to be considered viable via a LIFT route and the CCG needs to have the flexibility to devise innovative solutions to these.) 10 St James Medical Practice (Dr White) 10A St James Medical Practice (Dr Porter) 11 Eve Hill Medical Practice 12 Tinchbourne Street Surgery 13 Cross Street Health Centre 14 Steppingstones Medical Practice 15 St Thomas's Medical Practice 16 Central Clinic 17 Bean Road Surgery 18 Keelinge House Surgery 19 Netherton Surgery 19A Hazel Road Surgery (Netherton Surgery Branch) 20 Netherton Health Centre 21 Quarry Road Surgery 22 High Oak Surgery 23 Kingswinford Health Centre 24 Moss Grove Surgery 25 Summerhill Surgery 26 Rangeways Road Surgery 27 Wordsley Green Health Centre 27A Market Street Surgery (Wordsley Green Branch) 28 AW Surgeries 28A Withymoor Surgery (AW Branch) 29 Waterfront Surgery 30 Brierley Hill Health Health and Social Care Centre 31 Quincy Rise Surgery 32 Three Villages 33 Worcester Street Surgery 33A Meriden Avenue Surgery (Worcester St Branch) 33B Greenfield Avenue Surgery (Worcester St Branch) 34 Pedmore Medical Practice 35 Chapel Street Surgery 36 The Limes Surgery 37 Norton Medical Practice 38 Wychbury Medical Group 38A Chapel House Lane (Wychbury Branch) 39 Thorns Road Surgery 40 Quarry Bank Medical Centre 41 Clement Road Medical Centre 42 Feldon Lane Surgery 42A Hawne Lane Surgery (Feldon Lane Branch) 43 Crestfield Surgery Ltd 44 Alexandra Medical Centre 45 Lapal Medical Practice 46 Meadowbrook Surgery 47 Halesowen Health Centre 47A Tenlands Avenue Surgery (Halesowen HC Branch) 47B Coombs Road Surgery (Halesowen HC Branch) 48 St Margaret s Wells Surgery 38B Cradley Road Surgery (Wychbury Branch) Data correct as of April

71 13. Principles to Inform Decisionmaking Processes for Primary Care Development and Investment Reaching agreement regarding future models of service delivery and making investment decisions is not a straightforward process. For any issue, it is likely that there will be a range of varying, strongly held views across the patch and it is important, therefore that members have an agreed set of underlying principles which guide future strategic and investment decisions and ensure that these are made fairly and in an open and transparent way. Underlying Principles for Decision-making Decisions should improve services and outcomes for patients Investment decisions must be made in line with locally agreed policies for managing conflicts of interest and procurement (which are compliant with national and statutory requirements) Priorities for investment should be in line with CCG strategic aims e.g. reducing health inequalities, and support the achievement of local priorities for quality and service improvement Decisions must be transparent and made via agreed processes as set out in the CCG s Constitution Decisions should, wherever possible, seek to reduce unwarranted variation Investment decision-making should allow for the encouragement of innovation and rewarding excellence That all member practices will be consulted and have the opportunity to give appropriate consideration on future models of service delivery 14. Implementing the Strategy and Monitoring Progress Once the final strategy is agreed and signed off by CCG members there will need to be a clear process for implementing and monitoring progress for each of the priority areas and action plans. This process will be overseen by the Primary Care Development Committee which will approve the implementation plan and will receive regular reports on progress against this plan. The implementation of the Strategy will be led and coordinated by the Head of Membership Development. Reports on progress will also be made to individual locality groups and to the CCG membership engagement events. In addition, regular reports on progress will be made to key patient groups including the CCG Patient Opportunities Panel (POPs) and the local Healthcare Forum. Patient groups will be central to the process for developing and monitoring the detailed implementation plans. Research has shown that direct involvement of patients can be a great driver for change and for ensuring actions are delivered. As a minimum, each action/priority will have an outcome measure or measures, together with milestone measures. These outcome measures will be agreed with CCG membership. Strategic Commissioning Plan on a Page Summary Our Vision: To promote good health and ensure high quality health services for the people of Dudley What We Do: Our Objectives: Reducing Health Inequalities Reducing premature mortality Reducing emergency hospital admissions due to alcohol Reducing childhood obesity Reducing CVD mortality Improve AF review and treatment rates Our Commissioning Priorities: Children s Services Reducing childhood obesity Safeguarding children Improving Access to Cardiology Reducing cardiovascular disease mortality Our Key Documents and Government Processes: Membership & Public Engagement Finance and Performance Framework Financial Plan CCG Constitution and Committees Set the vision and objectives for healthcare in Dudley Hold the local health economy to account for delivery Facilitate improvements and transformational changes Engage with our public and patients Support quality improvement with our members Ensure good governance and work with key partners Improving Urgent Care Reducing avoidable emergency inpatient admissions Ophthalmology Pathway Improving access to ophthalmology services Primary Care Strategy Supporting quality improvement in primary care sevices Reducing unwarranted variation in performance Delivering Best Possible Outcomes Improve patient experience of healthcare (use of friend and family test) Increased early detection of dementia Reducing the levels of undetected hypertension and diabetes Improve access and choice of services Primary Care Mental Health Improving the levels of diagnosis of dementia Improving Stroke Care Reducing mortality rate from stroke Improving AF review and treatment rates Health & Wellbeing Board Strategy Strategic Commissioning Plan Communications and Engagment Strategy Equality and Diversity Strategy Supporting Organisational Development Plan Improving Quality and Safety Reduce incidence of pressure ulcers Reduce unwarranted variations Reduce incidence of Clostridium Difficile Zero tolerance of MRSA bacteraemia Safeguarding children and adults Improving Care for Older People Reducing incidence of pressure ulcers Safeguarding adults Community Nursing Services Improving care to people with limiting long term illmess, health problem or disability National Planning Guidance QIPP Plan Quality and Safety Strategy and Framework Improving Diabetes Services Reducing the levels of undetected hypertension and diabetes Alcohol Service Reducing emergency admissions linked to alcohol Prioritisation of Resources Improving productivity to achieve financial sustainability Redesigning services to provide more efficient care to patients Research, Innovation and Change Models 24 25

72 Surgery Patient List Sizes Surgery Patient List Sizes Surgery Patient List Sizes Key 1 Northway Surgery 5, Waterfront Surgery 6,418 Key 0-2,999 Patients 3,000-5,999 6,000-8,999 9,000-11, Bath Street Surgery 3 Bilston Street Surgery 4 Coseley Medical Centre 5 Woodsetton Medical Centre 6 The Ridgeway Surgery 2,727 2,999 7,026 6,328 8, Brierley Hill Health Health and Social Care Centre 31 Quincy Rise Surgery 32 Three Villages 2,151 3,218 9,346 12,000-14,999 15,000-19,999 20,000+ 8A The Greens Health Centre 8 Lower Gornal Health Centre 8A Masefield Road Surgery (Lower Gornal Branch) 9 Castle Meadows Surgery 7,754 8,970 * 4, Worcester Street Surgery 33A Meriden Avenue Surgery (Worcester St Branch) 33B Greenfield Avenue Surgery 24,995 * /10A 11 19A St James Medical Practice (Dr White) 2,307 10A St James Medical Practice (Dr Porter) 5, Eve Hill Medical Practice 7, Tinchbourne Street Surgery 1, Cross Street Health Centre 4,363 (Worcester St Branch) 34 Pedmore Medical Practice 35 Chapel Street Surgery 36 The Limes Surgery 37 Norton Medical Practice 38 Wychbury Medical Group * 3,704 1,877 7,962 5,810 21,395 27A 14 Steppingstones Medical Practice 6, St Thomas's Medical Practice 16 Central Clinic 1,205 4,155 38A Chapel House Lane (Wychbury Branch) * /30 28A B 47B Bean Road Surgery 18 Keelinge House Surgery 19 Netherton Surgery 19A Hazel Road Surgery (Netherton Surgery Branch) 20 Netherton Health Centre 2,091 6,351 2,582 * 7, Thorns Road Surgery 40 Quarry Bank Medical Centre 41 Clement Road Medical Centre 42 Feldon Lane Surgery 42A Hawne Lane Surgery (Feldon Lane Branch) 3,680 3,777 3,386 8,390 * 33A 33B A 43 42A Quarry Road Surgery 2, Crestfield Surgery Ltd 44 Alexandra Medical Centre 45 Lapal Medical Practice 1,555 2,884 6, A High Oak Surgery 23 Kingswinford Health Centre 24 Moss Grove Surgery 25 Summerhill Surgery 2,800 7,861 14,685 5, Meadowbrook Surgery 47 Halesowen Health Centre 47A Tenlands Avenue Surgery (Halesowen HC Branch) 7,455 4,871 * 26 Rangeways Road Surgery 5,049 47B Coombs Road Surgery 27 Wordsley Green Health Centre 9,849 (Halesowen HC Branch) 2,295 27A Market Street Surgery (Wordsley 48 St Margaret s Wells Surgery 9,108 Green Branch) * 28 AW Surgeries 18,763 28A Withymoor Surgery (AW Branch) * 38B Cradley Road Surgery (Wychbury Branch) * * Branch data is included with the Main Practice data with the exception of 47B Coombs Road Surgery (Halesowen HC Branch) Data correct as of April 2013

73 NHS Outcomes Framework 2011/12 at a Glance One framework defining how the NHS will be accountable for outcomes Five domains articulating the responsibilities of the NHS Ten overarching indicators covering the broad aims of each domain Thirty-one improvement areas looking in more detail at key areas within each domain Fifty-one indicators in total measuring overarching and improvement area outcomes * Shared responsibility with Public Health England **EQ 5D TM is a trademark of the EuroQol Group. Further details can be found at: ***Indicator also included in the Adult Social Care Outcomes Framework Indicators in italics are placeholders, pending development or identification of a suitable indicator 2 Enhancing quality of life for people with long term conditions Overarching indicator 2 Health-related quality of life for people with long-term conditions (EQ-5D)** Improvement areas Ensuring people feel supported to manage their condition 2.1 Proportion of people feeling supported to manage their condition*** Improving functional ability in people with long-term conditions 2.2 Employment of people with long-term conditions Reducing time spent in hospital by people with long-term conditions 2.3.i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) 2.3.ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Enhancing quality of life for carers 2.4 Health-related quality of life for carers (EQ-5D)** 1 Preventing people from dying prematurely Overarching indicators 1a Mortality from causes considered amenable to healthcare (The NHS Commissioning Board would be expected to focus on improving mortality in all the components of amenable mortality as well as the overall rate) 1b Life expectancy at 75 Improvement areas Reducing premature mortality from the major causes of death 1.1 Under 75 mortality rate from cardiovascular disease* 1.2 Under 75 mortality rate from respiratory disease* 1.3 Under 75 mortality rate from liver disease* 1.4 Cancer survival i One- and ii five-year survival from colorectal cancer iii One- and iv five-year survival from breast cancer v One- and vi five-year survival from lung cancer Reducing premature death in people with serious mental illness 1.5 Under 75 mortality rate in people with serious mental illness* Reducing deaths in babies and young children 1.6.i Infant mortality* 1.6.ii Perinatal mortality (including stillbirths) 3 Helping peopleto recover from episodes of ill health or following injury Overarching indicators 3a Emergency admissions for acute conditions that should not usually require hospital admission 3b Emergency readmissions within 28 days of discharge from hospital*** Improvement areas Improving outcomes from planned procedures 3.1 Patient-reported outcomes measures (PROMs) for elective procedures Preventing lower respiratory tract infections (LRTIs) in children from becoming serious 3.2 Emergency admissions for children with LRTIs Improving recovery from injuries and trauma 3.3 An indicator needs to be developed. Improving recovery from stroke 3.4 An indicator needs to be developed. Monitoring Quality in Primary Care - Proposed Process NHS England (local) Area Team Contracts directly with practices for GMS/PMS services Primary Care Quality Monitoring Group 4 CCG Responsible for ensuring the continuous improvement in the quality of primary care via; monitoring, supporting and developing member practices CCG Primary Care Development Committee 1 CCG Quality & Safety Committee 2 Primary Care Support Team 5 CCG Finance & Performance Committee 3 Enhancing quality of life for people with mental illness 2.5 Employment of people with mental illness 4 Ensuring that people have a positive experience of care Overarching indicators 4a Patient experience of primary care 4b Patient experience of hospital care Improvement areas Improving people s experience of outpatient care 4.1 Patient experience of outpatient services Improving hospitals responsiveness to personal needs 4.2 Responsiveness to inpatients personal needs Improving people s experience of accident and emergency services 4.3 Patient experience of A&E services Improving access to primary care services 4.4 Access to i GP services and ii dental services Improving women and their families experience of maternity services 4.5 Women s experience of maternity services Improving the experience of care for people at the end of their lives 4.6 An indicator needs to be developed based on the survey of bereaved carers Improving experience of healthcare for people with mental illness 4.7 Patient experience of community mental health services Improving recovery from fragility fractures 3.5 The proportion of patients recovering to their previous levels of mobility/ walking ability at i 30 days and ii 120 days*** Helping older people to recover their independence after illness or injury 3.6 The proportion of older people (65 and over) who werestill at home 91 days after discharge from hospital into rehabilitation services*** 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Overarching indicators 5a Patient safety incident reporting 5b Severity of harm 5c Number of similar incidents Improvement areas Reducing the incidence of avoidable harm 5.1 Incidence of hospital-related venous thromboembolism (VTE) 5.2 Incidence of healthcare-associated infection (HCAI) i MRSA ii C difficile 5.3 Incidence of newly acquired category 3 and 4 pressure ulcers 5.4 Incidence of medication errors causing serious harm Improving the safety of maternity services 5.5 Admission of full-term babies to neonatal care Delivering safe care to children in acute settings 5.6 Incidence of harm to children due to failure to monitor GMS/PMS Contractual Activity and Performance Primary Care based service provision Primary Care led commissioning/ service consumption Note 1: CCG Primary Care Development Committee is responsible for overseeing all CCG activity in relation to the development of primary care. This includes mentoring, training, education, research initiatives. Note 2: CCG Quality and Safety Committee is responsible for monitoring CCG wide quality indicators and ensuring action is taken to improve quality where this is falling below agreed standards. Note 3: CCG Finance and Performance Committee monitors performance in relation to commissioned services Note 4: Primary Care Quality Monitoring Group has joint membership from Area Team, CCG and LMC. Reviews and monitors primary care quality using data and soft intelligence. Agrees appropriate actions and keeps progress under review. Actions could range from mentoring, training and support, to the instigation of a more formal process in relation to contract compliance which would be led by the AT. Note 5: CCG Primary Care Support team is led by Head of membership Development and GP Engagement Lead. It supports each element of the process. Reviews data and other relevant intelligence and provides reports to appropriate committees. Has day to day liaison with AT. Improving children and young people s experience of healthcare 4.8 An indicator needs to be developed

74 Glossary: Abbreviations References Bodenheimer T (2008). Co-ordinating care a perilous journey through the healthcare system. New England Journal of medicine, vol 358, pp Abbreviation A&E ACS AT CCG CEO CHD Meaning Accident and Emergency Ambulatory Care sensitive Conditions NHS England local Area team Clinical Commissioning Group Chief Executive Officer Coronary Heart Disease LMC LTC MDT NGMS NHS NICE NRT Local Medical Committee Long Term Conditions Multi Disciplinary Team New General Medical Services National Health Service National Institute for Clinical Excellence Nicotine Replacement Products Department of Health (2005). Supporting people with Long-term Conditions: An NHS and social care model to support local innovation and integration. London: Department of health Dudley Primary Care Trust. Primary Care Strategy Reaching Excellence. Health England (2009). Intervention Report: Report no 5. NHS Information Centre. Trends in Consultation Rates in General Practice 1995/1996 to 2007/2008: Analysis of the QSearch Database. September 2008 Joint Health and Wellbeing Strategy - Wellbeing for life our plan for a healthier Dudley borough CIAMS CQC CQUIN CVD DES DNA DoH EMI EPP FOI GMS Commissioner Investment and Asset Management Strategy Care Quality Commission Commissioning for Quality and Innovation Cardio Vascular Disease Directed Enhanced Service Did not attend Department of Health Older People with Mental Illness (Elderly Mentally Ill) Expert Patients Programme Freedom of Information General Medical Services OD OPD OOH PCDC PCF PCT PMS POPS PSA QIPP QMAS Organisational Development Out Patient Department Out of Hours Primary Care Development Committee Primary Care Foundation Primary Care Trust Primary Medical Services Patient Opportunity Panel Public Service Agreement Quality, Innovation, Productivity and Prevention Quality Management and Analysis System The King s Fund (2013) Transforming our Healthcare System Ten Priorities for Commissioners. (Revised version 1 April 2013) Marmot Review (2010). Fair Society, healthy Lives: Strategic review of health inequalities in England, post London. NHS Dudley. Commissioner Investment and Asset Management Strategy (CIAMS) Starfield B (1998). Primary Care: Balancing health needs, services and technology. Oxford: Oxford University Press. GP General Practitioner QP Quality Premium GPAQ General Practice Assessment of Quality QOF Quality and Outcome Framework GPwSI GPs with Special Interest SLA Service Level Agreement HR HV IAPT Human Resources Health Visitor Improved Access to Psychological Therapies SSDP THR TKR Strategic Services Development Plan Total Hip Replacement Total Knee Replacement IT Information Technology UTI Urinary Tract Infection LETB LES Local Education and Training Board Local Enhanced Service WIC WTE Walk in Centre Whole Time Equivalent LIFT Local Improvement Finance Trust 30 31

75 Dudley Clnical Commissioning Group Brierley Hill Health and Social Care Centre Venture Way Brierley Hill West Midlands DY5 1RU Telephone: Website: Facebook:

76 Birmingham Solihull and the Black Country Area Team A summary of the Five Year Primary Care Strategy: High quality care for all now and for future generations 1

77 NHS England The Birmingham, Solihull and the Black Country Area Team s Five Year Primary Care Strategy High quality care for all now and for future generations 2

78 1. Introduction NHS England is the body which leads the NHS in England and its vision is to ensure High quality care for all: for now and for future generations. Its main aim is to improve the health outcomes for people in England, and it sets the overall direction and priorities for the NHS as a whole. NHS England s Area Teams are also responsible for directly commissioning NHS primary care services provided at GP surgeries, dental practices, opticians and pharmacies. Delivering better care and improved outcomes for our patients and our population at all times is the Birmingham, Solihull and the Black Country Area Team s main mission set out in the Five Year Primary Care Strategy. This report provides a brief overview of the main challenges facing the area and how the quality of patient care can be improved. It also provides a brief context of the geographical areas and some examples of where there is variation in health provision or outcomes. It is important to note that this variation can also involve non-clinical aspects, like the experience of patients, and differences in workforce. We ve produced this report as an introduction to the Five Year Primary Care Strategy as part of our engagement with key stakeholders. A list of questions about the Strategy is available in Appendix 1. We d really like to get your responses to these, and any other feedback you d like to provide. This summary covers primary care (including general practice, dentists, eye health and pharmacy). More detailed information about our challenges in primary care can be found in the full Five Year Primary Care Strategy document. You can get a copy of this, and find more information, by ing 2. Local context The Birmingham, Solihull and the Black Country Area Team (BSBC) is part of NHS England s Midlands and East region. Our area covers the second largest conurbation in 3

79 England, with a geographical area of 763 square km, and a high population density. Our area comprises six metropolitan districts; Birmingham, Solihull, Sandwell, Walsall, Wolverhampton and Dudley. GP services in our area are supported by seven Clinical Commissioning Groups (CCGs); Birmingham Cross City, Birmingham South Central, Sandwell and West Birmingham, Solihull, Walsall, Wolverhampton and Dudley. BSBC has a population of 2,420,700 1, which includes a large BME (black and minority ethnic) population. The demographics of the population differ across the region. In Birmingham for example, 67% of the population is of a white European ethnicity compared to 92% in Dudley. Birmingham has a average age of 36 years, whilst Solihull has an average age of 42 years. In our area, six out of seven CCGs have higher than average levels of deprivation. Life expectancies also differ greatly across our region. Only Solihull and Dudley have life expectancy figures similar to or better than the national average. The remaining four local authority areas have life expectancy figures below the regional and national average. The Midlands and East region has 2,419 GP surgeries in total. Of these, 490 are within BSBC. 3. Health Inequalities Within BSBC, two of the most significant issues in health inequality are obesity and smoking, which contribute to increased health risks for our population. There are also other significant health issues in our communities, which are explained in more detail within the full Primary Care Strategy Census 4

80 4. Variation in Primary Care The Area Team uses a national framework to look at any variations in primary care, and also spread good practice while helping and supporting GP surgeries to develop and improve. At a practice level, BSBC has the second highest number of GP outliers across England (57) in the National Medical Services Assurance and Quality Improvement Framework 2. A GP practice being an outlier means that it is performing significantly better or worse than the standards expected of it. The Area Team looks at both positive and negative outliers to identify issues with GP practices. For instance, a practice with a high prevalence of diabetes might be classed as an outlier, but is likely to mean that the practice is good at diagnosing the disease at an earlier stage. Practices can also be outliers for having lower rates of prescribing antibiotics. The Area Team would also recognise this as an achievement as it would show that antibiotics were being used appropriately for patients with infections rather than those with viruses like colds or flu. The Area Team uses the national framework to look at this variation across a number of indicators. We have identified a number of areas where the Area Team is significantly different to the rest of England and we need to make improvements in the quality of primary care. More information on these key areas of clinical variation can be found in the full Strategy. Patient Experience: The Area Team s Primary Care Strategy is particularly looking to address the variation in patient experience 3. The National GP Survey 4, published in July 2013, indicated that patients registered with GPs in the Birmingham, Solihull and the Black Country appear to be the least National Medical Services Assurance and Quality Improvement Framework 4 GP National Patient Survey

81 satisfied across the Midlands and East region, with responses significantly below the national average. Other areas of quality improvement that we need to make are: To increase the number of patients taking up the offer of health checks so that health problems are identified sooner and, where possible, help to be prevented. To improve care for people with diabetes, as recommended by the National Institute for Health and Care Excellence (NICE). To increase the uptake of flu vaccination in people in at-risk groups and those over Our approach The Area Team has worked with key stakeholders to produce its Five Year Primary Care Strategy, including our seven CCGs, Public Health England, and the Health and Wellbeing Boards and Health Overview and Scrutiny Committees based in local authorities. The Area Team used the five domains in the national NHS Outcomes Framework 5 when producing the Strategy (see Figure 1 below). Figure 1: NHS Outcomes Framework 2014/15 5 NHS Outcomes Framework 2014/15 6

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