Herts Valleys Clinical Commissioning Group. Operational Plan 2016/17. 1 P a g e

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1 Herts Valleys Clinical Commissioning Group Operational Plan 2016/17 1 P a g e

2 This document is the one year Operati0onal Plan for Herts Valleys CCG. It outlines the actions we will take during 2016/17 to; deliver financial balance against the CCGs allocation improve access and quality in the services we commission as defined by the NHS Constitution implement the national vision set out in the five year forward view alongside the local vision set out in Your Care Your Future in the first year of a 5 year system or place based sustainability and transformation plan. Author Annette Keen Assistant Director of Planning and Transformation Executive lead Alan Warren Chief Finance Officer Revision and review history 01 First draft submitted to NHS England Annette Keen/Lynn Dalton 08/02/2016 Revisions as per formal feedback from NHS England Revisions as per formal feedback from HVCCG Executive 02 Second Draft submitted to NHS England Annette Keen / Lynn Dalton 02/03/2016 Revisions in line with feedback following circulation to key stakeholders in provider organisations Revisions as per formal feedback from HVCCG Quality and Performance Committee (24/02/2016) Revisions as per formal feedback from NHS England (22/03/2016) 03.1 Final draft for review by HVCCG Board Annette Keen / Lynn Dalton 11/04/2016 Revisions as per formal feedback from HVCCG Board (14/04/2016) 03.2 Final document for submission Annette Keen 18/04/ P a g e

3 Table of Contents National Requirements in the 2016/17 Planning Guidance... 5 Service delivery requirements... 5 Financial allocations for 2016/ CCG allocations... 6 Allocations for commissioners of primary medical care and specialised services... 7 Allocations for the sustainability and transformation /17 Operational Plan Summary... 8 HVCCG 2016/17 Operational Plans Commissioning plan for 2016/ Finance plan for 2016/ /17 Investment in Mental Health /17 Investment in the Better Care Fund /17 Quality Innovation Productivity and Prevention (QIPP) plan /16 Performance and 2016/17 plans - Constitutional standards and other key priorities Referral to treatment performance and plans Cancer performance and plans Urgent care performance and plans Quality and Safety performance and plan IAPT performance and plan Dementia Diagnosis performance and plan Transforming Care for those with Learning Disabilities Child and Adolescent Mental Health week waits for first episode of Psychosis Improving quality CQC Inspections in Hospitals CQC Inspections n Primary Care Improving care homes Improving Maternity Services Avoidable Hospital Deaths: Standardised Hospital Mortality Index Improving Stroke Services Patient Choice Sustainability and quality in General Practice Quality of Primary Care Services P a g e

4 Integrated working Working with Public Health Delivering our sustainability & transformation plan Links to other sustainability and transformation footprints Governance Conclusion P a g e

5 National Requirements in the 2016/17 Planning Guidance Service delivery requirements In December 2015 NHS England 1 published the 2016/17 Operational Planning Guidance which sets out the requirements for the NHS to deliver three interdependent and connected tasks or triple aim. first, to implement the Five Year Forward View; second, to restore and maintain financial balance; and third, to deliver core access and quality standards for patients The Spending Review has provided the NHS in England with a credible basis on which to accomplish three interdependent and essential tasks as it included an 8.4 billion real terms increase by 2020/21 which is front-loaded within allocations and a Sustainability and Transformation Fund. With these resources HVCCG is required to set out clear plans for using its allocation to close the health and wellbeing gap, the care and quality gap, and the finance and efficiency gap to deliver; improved health and wellbeing, transformed quality of care delivery, and sustainable finances This needs to be set within HVCCG s strategic objectives: Beneath the triple aim there are 9 must dos which every NHS system and each individual NHS organisation must demonstrate that they have plans to deliver. These 9 requirements set out in the planning guidance are to: 1. Develop a high quality and agreed sustainability and transformation plan and subsequently achieve what you determine are your most locally critical milestones for accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View. 2. Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through implementing the Right Care programme in every locality. 3. Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. 1 NHS England s statutory name is the NHS Commissioning Board (Health and Social Care Act 2012) 5 P a g e

6 4. Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through making progress in implementing the urgent and emergency care review and associated ambulance standard pilots. 5. Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. 6. Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission. 7. Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. 8. Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. 9. Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts. Financial allocations for 2016/17 CCG allocations HVCCG receives an annual allocation from NHS England which it uses to: commission services to meet the health and wellbeing needs for our population of over 630,000 known as programme costs; and fund the overheads associated with conducting our commissioning functions; known as running costs. The formulae which determine the CCGs allocation from NHS England have been amended for 2016/17 to reflect populations 2 as of October The weightings which apply to the allocation also include newly revised inequalities categories and a new sparcity allocation affecting just a very small number of CCGs. NHS England report the minimum growth for 2 Populations are weighted for age and gender 6 P a g e

7 CCGs to cover inflation, population and policy changes is 3.04% and average growth in CCG allocations is 3.4%. In 2016/17 CCGs are required to: adhere to the business rules set out in the planning guidance ensure that running costs do not exceed / head of population; and have robust QIPP plans in place to deliver savings to address the financial gap between the allocation and expenditure commitments. Details of how HVCCG will demonstrate compliance with the above requirements are set out below under financial plans for 2016/17 and 2016/17 Quality Innovation Productivity and Prevention (QIPP) plan. Allocations for commissioners of primary medical care and specialised services There has been 4.2% growth in allocations for the commissioning of services delivered by primary care medical (GPs). Allocations for commissioning specialised services from NHS Trusts who provide highly complex specialised care for rare illnesses and disorders have grown by 7% in response to rising drug cost pressures. Allocations for the sustainability and transformation In 2016/ billion has been set aside to deliver the triple aim with 1.8bn to support sustainability and 0.3bn to support transformation. The release of sustainability funding in 2016/17 will be made on a quarterly basis but is conditional on achieving recovery milestones on: Deficit reduction Progress on transformation; and Delivery of improvement trajectories on the following key access standards: A&E four hour waiting times Referral to Treatment times (incomplete pathways) 62 day cancer waiting times 6 week diagnostic waiting times Category red 1 red 2 and A19 ambulance response times In addition to the creation of the sustainability and transformation fund changes are also being made to the Primary Care Infrastructure Fund to enable system transformation to support implementation of the Five Year Forward View. Originally introduced in 2015/16, to support improvements in primary care including premises and technology, the renamed Primary Care Transformation Fund criteria will be broadened in 2016/17 to support improvements in primary care estate and infrastructure. 7 P a g e

8 From April 2017 onwards, the earliest additional transformation funding will be secured by systems with the most compelling and credible five year sustainability and transformation plans based on: scale of ambition and track record of progress made by all partners in addressing gaps in: health and wellbeing care and quality finance and efficiency reach and quality of the local process; including community and voluntary sector engagement strength, maturity and unity of the local system leadership and partnerships including clear governance arrangements level of confidence in planned actions and their timely implementation defined governance arrangements and demonstrable capabilities; and the extent to which systems can already identify tangible, early progress. 2016/17 Operational Plan Summary The HVCCG operational plan and the five year sustainability and transformation plan, being developed with East and North Hertfordshire and West Essex CCGs by June 2016, must collectively set out how we will deliver the triple aim, 9 must dos and our local strategic objectives for the west Hertfordshire system. Critically our 2016/17 operational plan is required to set out in-year commissioning, performance and financial priorities and the key actions being taken during year one of our five year sustainability and transformation plan to support delivery the Five Year Forward View and aggregate system financial balance. Our strategic outline case (SOC) for transformation in west Hertfordshire, Your Care, Your Future, sets out a whole system strategy for how to improve outcomes, quality and financial sustainability across the system. It has been co-designed with our local populations and with local clinicians in line with the Five Year Forward View 6 principles for engaging and involving patients, carers and local communities as set out below. 8 P a g e

9 Our strategic priorities identified in Your Care, Your Future are to focus on delivery of the future models of care, which will enable redevelopment of the West Hertfordshire Hospitals NHS Trust estate and implementation of a clinical strategy that focuses on service models to deliver joined up care in closer to homes settings in order to address the 177m gap in resources by 2019/20. In line with the direction of travel set out in the Your Care, Your Future strategic outline case (shown above) and the circulation, musculoskeletal and mental health opportunities identified in the RightCare commissioning for value packs we are developing the year on 9 P a g e

10 year roadmap for implementation (shown below) for sign off by the Programme Executive Group whilst we progress our year one priorities: For mental health and learning disabilities year one priorities are to focus on addressing identified gaps e.g. crisis care, recovery and prevention and improving the links between physical and mental health to begin implementing the future model of care for people with learning disabilities, child & adolescent mental health and adult mental health. For planned and unplanned care our year one priorities will focus on improvements in end of life care pathway, frailty, diabetes, stroke, development of pre-specialist community services and improvements in community beds and ambulance conveyances. 10 P a g e

11 1. The emerging roadmap (DRAFT) 2016/ / / to 2021 Phase Establish joined-up care closer to home Consolidate hubs The patient sees Hertfordshire is commissioning Palliative Care Coordination Centre Implement redesigned pathways for diabetes and respiratory to create seamless services Establishing a hyper acute stroke unit Extend / commission redesigned outpatient services for a range of care pathways: Gynaecology / MSK and Pain / Ophthalmology / ENT / Dermatology Commission a new model of care for the over 65s to join up services across primary / community / acute care Enhanced provision of postural stability classes to prevent falls Flexible model of community bed services Enhanced multidisciplinary team support to care homes Direct access to community diagnostics for echocardiogram and 24hr ECG Intelligent ambulance conveyancing / delivering Outcome based commissioning for gynaecology, diabetes and stroke via MCP framework An integrated Diabetes services MCP framework An accountable lead provider end to end pathway for stroke through MCP framework Open market procurement for outpatient redesign including Dermatology, ENT, MSK and Pain and Ophthalmology Prevention strategies defined for prediabetes, obesity, Atrial Fibrillation through case finding, early intervention and self care Joint Commissioning of community bed base services with HCC to realise economies of scale and flexibility across the system to support flow. Recovery college offer defined Commissioning strategy agreed to incentivise dementia outcomes Develop SOCs for WHHT and Hemel local hospital, and OBC for Harpenden Achieve delegated commissioning by Mar17 New 111 out of hours service New Primary Care led urgent / ambulatory care model developed Implement anew model for community beds and commission rehabilitation beds from residential care homes supported by wrap around non medical support services access to step up beds from the community Develop of a new model for improving access to primary care through enhancing roles in the primary care workforce Recovery Colleges in place for mental health Stroke: Lead provider model in place Mobilisation of all 2016/17 Redesigned services across Herts Valleys Develop an integrated community cardiology service building on diagnostics and further integration with other LTC services. Joint commissioning with HCC with our incumbent providers (primary, care (GP federations) community (physical and mental and acute) to develop integrated commissioning options for patients over 65s. Development of local QOF and integrating local commissioned primary care services through delegated commissioning Integrated services delivered via community hubs Primary Care is the de facto route in to hospital A&E seeing a significant reduction in community care cases Rehabilitation length of stays have reduced to 21 days Dementia Care provided in primary care Progressing towards commissioning Capitated budget / Accountable Care Organisation model for specific agreed pathways. Long-term conditions and Frail/Elderly services (including Dementia) to be commissioned through integrated commissioning channels; Commissioning with public health for tier 3 and 4 obesity services Consistent 7 day service experience Integrated services in all hubs enabling significantly reduced inpatient activity Multiple pre-specialist community services Patient-centred, safer maternity services with better continuity of care and multiprofessional working Personal care plans and budgets Voluntary Care services in Care Homes A single well promoted gateway to get help and support based on a child and young persons needs not their diagnosis Voluntary sector provision accounts for a significantly higher proportion of services Integrated teams operating on Kingfisher Court Co-location of physical and mental health services Learning Disability friendly communities established Recovery Colleges established Implement national maternity review Implement CAMHS transformation and multi-partnership working / info sharing 11 P a g e

12 Our plan will address: Improved health and wellbeing: We are commissioning services to meet the health and wellbeing needs of our population; meeting needs which arise through population or demographic growth and changes in the incidence and prevalence of ill-health due to lifestyle and other non-demographic changes. Transforming quality: We are commissioning services to ensure Constitutional standards and other key performance and quality priorities are met. Sustaining finances: We have set and will deliver a balanced budget for HVCCG and are providing leadership and support for the sustainability and transformation plan encompassing sustainability and transformation fund objectives and implementation of the Five Year Forward View. WE WILL PRIORITISE: The development and delivery of acute activity plans which reflect demographic and non-demographic growth including adjustments for non-recurrent changes and the impact of QIPP. The development of pre-specialist community services delivered locally across all localities. The development and delivery of case finding and case management for long term conditions and identifying people who will benefit from early interventions through risk stratification & other innovative approaches. Continue to develop services commissioned to rehabilitate older people after a hospital stay including specialist support at home. Transforming Care for people with learning disabilities The development and delivery of multi-disciplinary support centred around the person for those in care homes and with WE WILL SUSTAIN / IMPLEMENT: We will develop our procurement approach based on a lead provider partnership model as outline in Your Care, Your Future whilst simultaneously ensuring the approach will achieve productivity gains and improvements in outcomes which are comparable to upper quartile performance against relevant benchmarks. We will use our integrated commissioning approach and the Better Care Fund to identify collective benefits from Health and social care contracts to support our strategic priorities for reducing NEL admissions, A&E attendances and delayed transfers of care and implementation of the future models of care 12 P a g e

13 complex needs Developing improved End of Life Care Working with our providers on delivery of: 4 hour A&E waits 2 week cancer waits when breast cancer symptoms are present 6 week waits when referred for diagnostic tests 62 day cancers waits from referral by a GP to treatment Dementia Diagnosis rate of 67% Working with lead Commissioners and providers on delivery of: 18 week waits from referral to first treatment +52 week waits on incomplete pathways Eight minute response times for category A calls Delayed transfers of care Working with our providers on delivery of: quality improvement plans to allow subsequent lifting of special measures by the Care Quality Commission and NHS Improvement improvement trajectories and transformation plans to support providers access sustainability and transformation funds Delivery by our providers for: 62 day cancer waits from referral by an NHS screening programme or decision to upgrade the priority to treatment 31 day cancer waits from diagnosis to first treatment and surgical, radiotherapy and chemotherapy treatments 2 weeks cancer waits when referred urgently by the GP with suspected cancer Access to psychological therapies and recovery rate of >50% New mental health access standards for psychological therapies and first episode of psychosis Transforming care for people with learning disabilities In partnership with NHS England working with our 69 GP practices on development and delivery of: Plans to ensure sustainable primary care services through Co-Commissioning High quality and accessible primary care services 13 P a g e

14 Delivery of business rules, balanced plan and budget outturn for Herts Valleys CCG Delivery of the HVCCG 21.62m QIPP plan Provide system leadership and support to the Hertfordshire and West Essex sustainability and transformation plan Working in partnership with providers to assure delivery of milestones and quarterly objectives for transformation and improvement trajectories on access standards: A&E four hour waiting times Referral to Treatment times (incomplete pathways) 62 day cancer waiting times 6 week diagnostic waiting times Working with our providers to mobilise delivery the West Hertfordshire Transformation 10 year sustainability strategy Your Care, Your Future and mobilising a system wide approach to: Developing and delivering our west Hertfordshire future models of care Tackling unwarranted variations in access, outcomes and demand to improve the value of place based allocations Achieving a step change in community based provision and seven day services HVCCG 2016/17 Operational Plans Commissioning plan for 2016/17 HVCCG has 118 contracted providers with contracts valued at close to 600M. 31 contracts with acute providers are worth over 400m and the top 10 acute providers account for 90% of this expenditure (see financial plans for 20916/17 ). Our commissioning plans for the acute sector must ensure that the local population will access booked operations, diagnostic tests, outpatient appointments and urgent care in line with standards set out in the NHS Constitution and therefore we must consider population and service changes when determining the volume of activity we wish to commission by point of delivery (POD). In formulating our commissioning plan for 2016/17 we have utilised the national Indicative Hospital Activity Model (IHAM) methodology which contained pre-populated activity for 2014/15 and 2015/16. Growth in activity between 2014/15 to 2015/16 and 2015/16 to 2016/17 has been 14 P a g e

15 analysed using both local and national activity data. When the pre-populated activity undertaken in 2014/15 is compared against the national forecast outturn (FOT) of activity for 2015/16 3 the calculated growth by POD is consistently lower than when calculated using the local activity data (see below). However the figures have not been adjusted for non-recurrent changes or additional activity undertaken during 2014/5 or 2015/16 and therefore the percentage growth should be considered as gross. Calculated gross growth in activity 14/15 to 15/16 by POD In line with the IHAM methodology the national baseline for 2015/16 has been adjusted for the impact of non-recurrent activity changes and trends in demographic and non-demographic growth to identify the gross activity plan for 2016/17; these activity changes are shown below and translate into the following gross percentage growth: Consultant led first outpatient attendances 15.1% Consultant led follow up outpatient attendances 10.4% Total elective admissions ordinary and day case 10.5% Total non-elective admissions 1.8% Total A&E attendances 2.6% Calculated growth 14/15 to 15/16 NHS E 14/15 CCG 14/15 using NHS E numbers using HVCCG numbers Consultant Led First Outpatient Attendances (Total Activity) 177, , % 22.5% Consultant Led Follow-Up Outpatient Attendances (Total Activity) 381, , % 4.9% Total Elective Admissions (Spells) (Total Activity) [Ordinary Electives + Daycases ] 69,908 74, % 4.1% Total Non-Elective Admissions (Spells) (Total Activity) 69,060 71, % 0.7% Total A&E Attendances 185, , % 2.9% Gross activity was then adjusted for the impact of QIPP schemes in 2016/17 to produce our net activity plan as summarised in the table below. 3 FOT is determined by extrapolating activity data for months P a g e

16 Calculated net growth in activity 15/16 to 16/17 by POD CCG 15/16 Forecast outturn Non-recurrent activity changes To capture the effect of for example, changing definitions, boundaries, reporting standards. Underlying trend and demographic growth To capture any additional activity as a result of changes in population and underlying changes in trend Transformational change Apply the impact of transformation / allocative efficiency. To include for example: NCM s, UEC, RightCare, Prevention, Self care and procedures of limited clinical value. Policy changes To capture the impact of new policies, for example hospital 7 day services; primary care access, Cancer, M ental Health. 16/17 Annual Plan Calculated growth Consultant Led First Outpatient Attendances (Total Activity) 202, , % 0.6% Consultant Led Follow-Up Outpatient Attendances (Total Activity) 396, , % 1.4% Total Elective Admissions (Spells) (Total Activity) [Ordinary Electives + Daycases ] 71, , % 0.7% Total Non-Elective Admissions (Spells) (Total Activity) 68, , % -7.5% Total A&E Attendances 188, , % -0.1% on NHS E FOT on HVCCG FOT Consultant Led First Outpatient Attendances (Specific Acute) 189, , % 0.6% Consultant Led Follow-Up Outpatient Attendances (Specific Acute) 373, , % 0.9% Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases ] 71, , % 0.7% Total Non-Elective Admissions (Spells) (Specific Acute) 54, , % -3.9% Total A&E Attendances excluding planned follow ups 186, , % -0.1% 16 P a g e

17 Finance plan for 2016/17 NHS England made details available in January 2016 of the CCG s allocations for the period 2016/17 to 2020/21, the first three years described as firm allocations and the final two years as indicative allocations. The updating of capitation formula components, principally populations, and application of a new pace of change policy has seen the CCG s distance from target narrow from -4.9% (the newly calculated closing 2015/16 distance from target) to -2.6% (the equivalent for 2016/17). This translates to an increase in allocation of 45.5m or 6.6% and a programme allocation for 2016/17 of 733,574. Figures for each of the five years, together with the CCG s element of primary medical allocations (currently commissioned jointly with NHS England, who holds the budget) and specialised services allocations (commissioned by NHS England) are set out in the table below. The requirement for five-year Sustainability and Transformation Plans bringing together commissioners and providers across agreed geographical footprints will consider how all place-based health funding streams can be deployed to close the health and wellbeing gap, the care and quality gap and the finance and efficiency gap. Organisations 2016/17 Operational Plans will form the first year of delivery of the multi-year sustainability and transformation plan. The table shows the place based allocation for the west Hertfordshire branch of the Hertfordshire and West Essex sustainability and transformation footprint. 2016/ / / / / CCG Allocation 733, , , , ,210 Primary Medical Allocation 70,730 74,759 77,736 80,631 85,149 Specialised Services Allocation 145, , , , ,900 Total Place-based Allocation 949, ,809 1,012,773 1,047,180 1,098,259 In addition to the programme allocation, the CCG has been notified that its running costs allocation for 2016/17 is 13,203m. The national running costs amount is unchanged between 2015/16 and 2016/17 but its distribution between CCGs is based on updated population data which benefits Herts Valleys. Since the provision of CCG-level allocations, NHS England has confirmed that the headline growth figures do include some allocations that CCGs might have expected as in-year additions. These include the funding for GP IT and specific additional allocations for Child and Adolescent Mental Health Services (CAMHS). The financial plan reflects other commitments carried forward from 2015/16 to address and eliminate the underlying recurrent deficit in the CCG s finances. The financial plan reflects local activity growth rates and takes account of nationally notified business rules and other 17 P a g e

18 locally agreed requirements and assumptions. The table below identifies the most important of these: National Business Rules 1. Cumulative 1% surplus 2. 1% Reserve to be spent non-recurrently, uncommitted on 1/4/ % Contingency reserve 4. Mental Health budget increased in line with overall allocation growth: +6.6% Locally Determined Requirements 1. 5m reserve to begin implementation of Your Care, your Future 2. Re-establish MRET and Readmissions Credit reserves, and commitments funded from them 3. Re-establish Winter Resilience reserve, uncommitted apart from Winter 2015 schemes that continue beyond 31 March CCG contributions to BCF maintained and inflated at same rate as allocation increase: +6.6% Planning Assumptions Efficiency Provider inflation Demographic growth Acute -2.00% 3.63% 1.20% 1.36% Mental -2.00% 3.10% 1.20% 0.66% Health/LD Community -2.00% 3.10% 1.20% 1.00% Continuing 5.00% 1.20% 2.80% Care Prescribing 1.76% 1.20% 2.74% Other Primary -2.00% 3.10% 1.20% 0.66% Care Other -2.00% 3.10% 1.20% 0.66% Programmes Non-demographic growth The result of the application of the planning requirements and other assumptions, including net inflationary uplifts for different types of providers, demographic and non-demographic growth and other known commitments for 2016/17 is set out in the table below. This includes a Quality, Innovation, Productivity and Prevention (QIPP) target for 2016/17 of 21.62m, or 2.9% of the programme allocation, all of which is identified to specific schemes. 18 P a g e

19 Financial Position Revenue Resource Limit /16 b 2016/17 Recurrent 701, ,786 Non-Recurrent 16,994 7,008 Total 718, ,794 Income and Expenditure Acute 409, ,241 Mental Health 74,890 81,238 Community 60,235 66,635 Continuing Care 26,757 27,692 Primary Care 88,412 91,171 Other Programme 38,728 47,807 Primary Care Co-Commissioning - - Total Programme Costs 698, ,784 Running Costs 12,824 12,703 Contingency - 3,769 Total Costs 711, , / /17 Surplus/(Deficit) In-Year Movement Surplus/(Deficit) Cumulative 7,008 7,538 Surplus/(Deficit) % 1.0% 1.0% Surplus (RAG) AMBER GREEN 19 P a g e

20 Parallel work-streams are in place to negotiate individual provider contract values for 2016/17 within the available financial and activity envelopes and initial contract offers have been made to all local NHS providers. The local health and care system in west Hertfordshire is in financial deficit and the CCG s long-term strategy Your Care, Your Future describes actions over the next 10 years that will reduce the scale of the financial gap. The first year of implementing this strategy is 2016/17 and the CCG is planning to implement a number of transactional and transformational service redesign schemes that will contribute to shifting outpatient activity from hospital to community and primary care settings. 2016/17 Investment in Mental Health The 0.66% up-lift for non-demographic growth in mental is being used to support priorities set out in Your Care, Your Future and the planning guidance. The investment covers a range of service improvements across crisis intervention and support in urgent care to reduce A&E attendances and non-elective admissions along with the developments in routine care in line with the Five Year Forward View and Your Care, Your Future such as seven day services and west Hertfordshire future models of care; such as a recovery college. Investment profile for non-demographic growth in mental health funding 1,800 1,600 1,400 1,200 1, /17 Investment in the Better Care Fund The Better Care Fund is a single pooled budget to enable the integration of health and social care services. The HVCCG mandated contribution to the Hertfordshire Better Care Fund (BCF) hosted by Herts County Council is 34.8m. The financial plan shows the actual 20 P a g e

21 contribution is 98m and the cash element to support adult social care in 2016/17 is 15.5m. The additional contribution is made up of CCG contractual commitments to Hertfordshire Community NHS Trust, providers of continuing health care and local hospices. These health and social care contracts have been included in the Better Care Fund as the Hertfordshire wide system has identified the potential for benefits from an integration commissioning approach. During 2015/16 we will be working with the Kings Fund to identify the level of ambition for further integration. In HVCCG governance for the Better Care Fund is provided by the Integrated Commissioning Programme Board also known as the Living Well Programme. The objective of the Commissioning Programme Board is: Delivery of the best in class primary and community services for older people in Hertfordshire through the alignment of health and social care services Workstreams are being refreshed to ensure alignment with the west Hertfordshire transformation strategy Your Care, Your future and for 2016/17 this will include: Developing and implementing a whole system multi-speciality team (MST) approach to wrap community services around complex patients using an multidisciplinary team approach Implementing risk stratification for community teams Developing a systematic approach to self-management Defining and agreeing outcomes for integrated care including an integrated community hub to coordinate access to services Developing a focus on wellbeing/prevention in the wider population The Better Care Fund includes bespoke projects, rather than business as usual activity, which are anticipated to have a direct on non-elective admissions and A&E attendances. These projects include: Provision of integrated health and community teams clustered around patients in primary care Re-commissioning of specialist support at home to enhance enablement services Provision of integrated community nursing care beds as an alternative to an acute hospital admission A new acute based Community Navigator to follow up frequent attenders in A&E Early supported discharge service for stroke patients to include prevention of readmissions Provision of a complex care premium for nursing homes; and 21 P a g e

22 Provision of a multispecialty case worker. The HVCCG Board have identified an opportunity to review the methodology for assessing and monitoring the impact of these projects to improve assurance during 2016/17. The Better Care Fund has also established a system wide working group to develop the plan to roll out seven days services in health and social care. In hospitals this plan will focus on the 10 clinical standards with the four clinical standards listed below being prioritised for 2016/17 so that we can make progress in ensuring that patients admitted to hospital in an emergency receive the same quality of assessment, diagnosis and treatment seven days a week. Standard 2: Time to consultant review Standard 5: Access to diagnostics Standard 6: Access to consultant-directed interventions Standard 8:On-going review 2016/17 Quality Innovation Productivity and Prevention (QIPP) plan In 2015/16 HVCCG had a QIPP gap of 20.1m which was split between programme costs 19.4m (3% of the programme allocation) and running costs 0.69m (5% of running costs). At month 11 our year to date QIPP delivery was 87%. The forecast outturn is 85% compared with 61% achieved in 2014/15. Assurance processes to enable the scoping, testing, profiling, sign-off and assurance of delivery impact will continue into 2016/17 and include: Monthly analysis of KPIs 4 with reporting against these and defined milestones to quantify impact against plan for each workstream. Monthly assurance of reports using face to face meetings with delivery leads On-going review of the QIPP workstreams and checkpoint reviews undertaken by the clinical programme groups and the clinically led Commissioning Executive Committee Monthly assurance at the clinically led Financial Effectiveness Group and by the Quality and Performance Committee Use of refreshed corporate risk management processes through the Risk Management Forum using a corporate risks / issues log and escalation process for programme and operational risks. The HVCCG 2016/17 QIPP gap is 21.62m as shown in our plan on a page. 4 KPIs have clear technical definitions which ensures activity is not double counted across workstreams. 22 P a g e

23 Accident & Emergency Attendances 0.41M - Children's A&E - Redcutions in A&E attendances by patients from care homes - Conversion rates of non elective admissions to A&E attendances Emergency non elective Admissions 7.45M - Reductions in non elective admissions by patients from care homes - Reductions in non elective admissions for high vloume paediatric urgent care pathways - Care pathway related reductions in non elective admissions : Falls in >65s, End of Life Care, Long Term Health Conditions, older people and complex patients - Excess bed days - Redesigned community hub (living Well and IPA) Respiratory Service 0.99m Outpatients GP referrals and community based services (ENT, Cardiology, Dermatology, Gynaecology) - Conversion of Ward attenders from first to follow up (AEC ward attenders and general ward attenders) - Follow ups appointments - Continuing Health Care - Medicines management - Diagnostics - IAPT and AQP counselling Planned Care 10.05m - Procedures with limited clinical effectiveness (POLCV) and managing surgical thresholds (MST) - Complex patients - Excess bed days - Contract validations and efficiencies Total 21.62m A summary of our QIPP workstreams showing their activity changes by POD and their financial benefits profile is shown in the table below. Activity reductions for each workstream are phased to reflect timeframes for planned interventions to impact. The activity reductions have been apportioned to individual providers in line with their proportionate share of the baseline activity and this is included in the contract schedules. The activity reductions apportioned to individual providers were used to create savings profiles based on average costs for each specific provider (including impact of market forces factor (MFF) and the marginal rate emergency tariff (MRET). 23 P a g e

24 24 P a g e

25 Breakdown of Acute Trust provider QIPP schemes showing phasing by place of delivery (POD) and month ALL TRUSTS - activty reductions by POD and month Non-elective spells - all specialties E.C.23 BLANK2 Non-elective spells - G&A E.C.4 Daycase Elective Spells - G&A E.C.2 Elective Spells - all specialties E.C.21 Ordinary Elective Spells - G&A E.C.1 All First Outpatient Attendances - all specialties E.C.24 All First Outpatient Attendances - G&A E.C.5 First Outpatient Attendances following GP Referrals - all specialties E.C.25 First outpatient attendance following a GP referral - G&A E.C.12 All subsequent outpatient attendances - all specialities E.C.6 A&E attedances all types E.C.8 April May June , July ,133 1, August September October November , December January ,539 1, February ,582 1, March ,582 1, ALL TRUSTS Total 3,030 3, ,215 12,064 2,244 2,244 8,823 3,943 Aggregate acute trust savings profile by POD and month ALL TRUSTS - savings profile 000s by POD and month Gross SLA 15,089 BLANK2 less 50% / 30% Marginal rate credit- (-) Non-elective admissions - all specialties E.C.23 Daycase Elective Spells - G&A E.C.2 Ordinary Elective Spells - G&A E.C.1 All first outpatient attendances - all specialties E.C.24 All subsequent outpatient attendances - all specialities E.C.6 A&E attedances all types E.C.8 Excluded Drugs and Devices April 714 (169) May 757 (177) June 721 (176) July 723 (184) August 641 (163) September 729 (176) October 760 (184) November 703 (172) December 823 (198) January 726 (179) February 722 (177) March 722 (177) ALL TRUSTS Total 8,741-2,133 7, , , , ,784 Other 25 P a g e

26 Schemes have been developed using an extensive range of inputs and data including: Feedback from service reviews, engagement events and analysis for Your Care, Your Future Discussion with our Patient and Public Involvement group From partnership forums including our integrated clinical programme groups, the West Herts Health & Social Care Liaison Meeting Contract forums Benchmarking; and RightCare Commissioning for Value packs All schemes have a zero rated 5 as opposed to rolled over level of ambition set against refreshed 2015/16 baselines, with the exception of opportunity savings from some elements of costs effective prescribing switches (where because of quality and safety multiple switches between brands for our patients is not advocated). This approach allows HVCCG to assure the sustainability of workstream interventions achieved in 2015/16 and promote a culture of continuous learning and improvement by focusing on additional interventions or alternative delivery methods to continuously improve our QIPP delivery. All workstreams have a workstream summary which act as the project initiation document and includes: the workstream purpose and objective(s) named delivery, clinical and Executive leads critical assumptions / required changes in clinical behaviour by stakeholders key findings from the equality impact assessments bespoke delivery milestones with clear timescales with a breakdown by project within each workstream where relevant bespoke activity and savings profiles based on baselines which are cut by provider and place of delivery and reflected in the contract schedules where relevant. We will continue to use our bespoke workbooks to manage delivery and monitor the performance of QIPP workstreams. This methodology has been approved by our Quality and Performance and Commissioning Executive Committees and held up as an example of good practice because it provides open and transparent reporting to track the impact of each scheme. 5 The zero rated approach estimates the opportunity from an established point of zero with zero being the actual activity which took place in the baseline period. It utilizes much more detail and makes everyone much more accountable for delivering the opportunity. 26 P a g e

27 2015/16 Performance and 2016/17 plans - Constitutional standards and other key priorities The Commissioner level performance for HVCCG against Constitutional standards in 2015/16 is summarised in the tables below taken from the national source supplied on the Unify planning templates. In-year delivery of these standards has been managed through the Contract Quality Review Meetings (CQRM) and System Resilience Group including weekly system-wide calls with key stakeholders. Assurance has been provided internally through monthly and quarterly integrated quality and performance reports which are submitted to the Quality and Performance Committee and Board respectively and externally through quarterly CCG assurance reviews with NHS England. Where necessary, recovery plans have been taken forward through system-wide working using forums such as the System Resilience Group and Cancer network. These processes and the programme approach to improve performance across urgent care and manage episodic system pressure will continue to operate during 2016/17. Referral to treatment performance and plans 92% of patients wait less than 18 weeks to complete their treatment pathway (planned care) National Standard 92% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Incomplete Pathways < 18 weeks 29,278 30,871 30,860 30,159 29,965 29,218 30,089 28,911 28,261 27,019 27,842 28, Total Incomplete Pathways 32,688 34,590 35,094 34,872 34,885 33,872 35,475 33,946 33,172 31,051 30,639 31,067 % 89.6% 89.2% 87.9% 86.5% 85.9% 86.3% 84.8% 85.2% 85.2% 87.0% 90.9% 91.8% Incomplete Pathways < 18 weeks 30,022 34,547 34,517 32,659 31,312 30,988 30, Total Incomplete Pathways 32,637 37,444 37,523 35,371 33,908 33,464 33,371 % 92.0% 92.3% 92.0% 92.3% 92.3% 92.6% 92.8% 2016/17 Plan Incomplete Pathways < 18 weeks Total Incomplete Pathways % 91.7% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% % Provider performance priorities: Royal Free London NHS Foundation Trust is not achieving 18 week waits on incomplete pathways or 52 week waits following reinstated RTT reporting after a long period without data which has impacting on the HVCCG performance. 27 P a g e

28 During 2015/16 performance on waits was recovered by working with West Hertfordshire Hospital NHS Trust. Detailed work showed a shortfall between capacity for new outpatient slots compared with referrals received or demand ; particularly in Trauma and orthopaedics, ENT, Urology, General Surgery and Gynaecology. During 2016/17 we are focusing on increasing the capacity of existing community services, developing new community services and working with acute clinicians to reduce activity for follow up appointments by applying RightCare principles. HVCCG is working with lead commissioners in London regarding the RTT backlog at Royal Free London NHS FT which is due to be cleared by September Trajectories for delivery of these standards are shown above As a consequence of the capacity and demand issues highlighted at specialty level the Strategic Outline Case for Your Care, Your Future reflects musculoskeletal, pain, ENT and Gynaecology as priority areas for west Hertfordshire future models of care; therefore these are early priorities within our sustainability and transformation plan. 99% of patients access diagnostic investigations within 6 weeks of routine referral National Standard 1% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number waiting > 6 weeks Total Number waiting 7,760 7,924 8,006 7,948 7,487 7,897 8,537 8,859 8,431 8,400 8,950 9,502 % 4.1% 2.3% 2.0% 1.9% 2.2% 2.1% 1.1% 1.3% 1.9% 2.9% 2.1% 2.2% Number waiting > 6 weeks Total Number waiting 9,294 9,029 9,569 9,581 8,768 9,247 9,580 % 2.0% 2.1% 2.0% 1.9% 2.2% 1.6% 1.4% 2016/17 Plan Number waiting > 6 weeks Total Number waiting % 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% Provider performance priorities: Royal Free London NHS Foundation Trust is not currently achieving diagnostic waits In 2015/16 the CCG has worked with providers to enable 99% of patients to access diagnostic tests within 6 weeks from referral. HVCCG is working with lead commissioners in London regarding this standard which is due to be achieved by April The trajectory for delivery of this standard is shown above. 28 P a g e

29 Cancer performance and plans 93% of patients are seen within 2 weeks of urgent referral for Cancer National Standard 93% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number seen < 2 weeks ,213 1,152 1,180 1,313 1,153 1,260 1, Total number seen 1,022 1,002 1, ,094 1,293 1,213 1,225 1,360 1,192 1,288 1,514 % 93.6% 87.2% 82.1% 93.9% 83.6% 93.8% 95.0% 96.3% 96.5% 96.7% 97.8% 97.8% Number seen < 2 weeks 1,285 1,236 1,455 1,483 1,336 1,337 1, Total number seen 1,350 1,280 1,543 1,569 1,401 1,397 1,469 % 95.2% 96.6% 94.3% 94.5% 95.4% 95.7% 97.5% Number seen < 2 weeks /17 Plan Total number seen % 95.7% 95.6% 95.6% 95.6% 95.7% 95.6% 95.6% 95.7% 95.6% 95.7% 95.6% 95.6% 93% of patients are seen within 2 weeks of urgent referral for breast Cancer (previously not suspected) National Standard 93% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number seen < 2 weeks Total number seen % 85.7% 89.0% 90.2% 36.0% 47.9% 87.8% 96.4% 94.9% 91.6% 94.0% 95.9% 98.1% Number seen < 2 weeks Total number seen % 94.9% 89.1% 90.1% 85.9% 92.3% 96.4% 97.6% 2016/17 Plan Number seen < 2 weeks Total number seen % 93.1% 93.0% 93.8% 93.1% 93.2% 93.0% 93.2% 93.2% 93.4% 93.3% 93.3% 93.1% 29 P a g e

30 96% of patients wait less than 31 days - all treatments National Standard 96% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 31 days Total number treated % 95.4% 95.2% 96.5% 97.1% 93.9% 94.8% 95.5% 97.6% 95.7% 94.5% 96.9% 98.0% Number treated < 31 days Total number treated % 97.8% 99.5% 97.8% 97.9% 98.6% 97.4% 98.1% 2016/17 Plan Number treated < 31 days Total number treated % 98.0% 97.7% 97.8% 98.5% 97.9% 98.2% 98.3% 98.2% 98.0% 98.1% 98.0% 97.7% 94% of patients wait less than 31 days - surgical treatment National Standard 94% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 31 days Total number treated % 96.2% 100.0% 88.1% 96.7% 97.4% 100.0% 100.0% 100.0% 94.4% 93.9% 100.0% 90.0% Number treated < 31 days Total number treated % 100.0% 100.0% 95.1% 86.8% 97.1% 100.0% 100.0% 2016/17 Plan Number treated < 31 days Total number treated % 94.4% 94.4% 94.4% 97.0% 97.0% 97.0% 97.4% 97.4% 97.4% 97.1% 95.6% 95.2% 30 P a g e

31 98% of patients wait less than 31 days - drug treatment National Standard 98% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 31 days Total number treated % 98.7% 100.0% 98.6% 98.0% 100.0% 98.9% 98.9% 100.0% 100.0% 100.0% 100.0% 100.0% Number treated < 31 days Total number treated % 98.4% 100.0% 100.0% 98.5% 98.4% 98.7% 98.9% 2016/17 Plan Number treated < 31 days Total number treated % 98.6% 98.6% 98.6% 98.9% 98.9% 98.9% 98.7% 98.7% 98.7% 99.0% 98.4% 98.8% 94% of patients wait less than 31 days - radiotherapy treatment National Standard 94% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 31 days Total number treated % 96.7% 96.5% 97.5% 95.2% 96.9% 92.6% 95.7% 98.7% 100.0% 95.5% 98.9% 96.1% Number treated < 31 days Total number treated % 100.0% 98.8% 98.8% 93.9% 97.5% 95.2% 94.0% 2016/17 Plan Number treated < 31 days Total number treated % 96.5% 96.5% 96.5% 96.9% 96.9% 96.9% 95.8% 95.8% 95.8% 97.4% 96.3% 97.0% 31 P a g e

32 85% of patients wait less than 62 days from referral to treatment - all treatments National Standard 85% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 62 days Total number treated % 91.4% 80.8% 80.0% 65.7% 74.7% 73.3% 71.6% 79.2% 75.3% 75.3% 80.5% 78.6% Number treated < 62 days Total number treated % 93.9% 77.9% 81.3% 84.6% 87.5% 84.3% 80.0% 2016/17 Plan Number treated < 62 days Total number treated % 86.1% 85.8% 85.6% 85.7% 85.1% 85.3% 85.6% 85.1% 85.0% 85.0% 85.6% 85.3% 90% of patients wait less than 62 days from referral to treatment following referral by a screening programme to treatment National Standard 90% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 62 days Total number treated % 92.0% 88.9% 92.3% 94.7% 83.3% 100.0% 100.0% 100.0% 100.0% 100.0% 55.6% 88.9% Number treated < 62 days Total number treated % 87.5% 100.0% 92.3% 100.0% 100.0% 100.0% 90.5% 2016/17 Plan Number treated < 62 days Total number treated % 95.7% 94.1% 91.7% 94.4% 100.0% 100.0% 100.0% 94.1% 100.0% 100.0% 100.0% 100.0% 32 P a g e

33 Patients wait less than 62 days from referral to treatment following consultant decision to upgrade to treatment National Standard None Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number treated < 62 days Total number treated % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 66.7% 90.9% 75.0% 90.0% 84.6% 87.5% Number treated < 62 days Total number treated % 87.5% 90.0% 71.4% 100.0% 75.0% 54.5% 100.0% 2016/17 Plan Number treated < 62 days Total number treated % 85.7% 88.9% 88.9% 80.0% 90.0% 80.0% 87.5% 85.7% 81.3% 84.6% 82.4% 90.0% Provider performance priorities: West Hertfordshire Hospitals NHS Trust and Royal Free London NHS Foundation Trust are not achieving 2 week waits for breast symptoms. Royal Free London NHS Foundation Trust not achieving 62 day waits from urgent referral to treatment In 2015/16 performance on 2 week cancer waits for patients referred urgently by a GP has exceed the Constitutional standard but performance for breast symptoms has been inconsistent. An audit of 200 cases has shown patient choice is a key root cause therefore a partnership approach has been agreed for 2016/17 which will include improvements in patient information regarding urgent referrals and earliest appointments so they can be rebooked if patients do not attend. Trajectories for delivery of these standards are shown above. HVCCG clinical leadership for cancer is being strengthened by partnership support from Macmillan. These clinical leads will work with providers and the strategic clinical network to improve performance against cancer waiting times. Key actions for 2016/17 include continuing to provide assurance and lessons learnt to improve cancer pathways; particularly for the 62-day standard following urgent GP referral with additional focus on one year survival rates for lung, urology and colorectal cancers as early priorities for the West Hertfordshire element of the sustainability and transformation plan. 33 P a g e

34 Urgent care performance and plans 4 hour A&E waits performance and plan - West Hertfordshire Hospitals NHS Trust National Standard 95% Only monthly actuals have been provided below. Quarterly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number waiting > 4 hours Total Attendances % < 4 hours Number waiting > 4 hours ,413 1,547 Total Attendances 11,860 11,745 10,905 11,523 11, /17 Plan % < 4 hours 91.9% 94.1% 93.6% 87.7% 86.6% Number waiting > 4 hours Total Attendances % < 4 hours 85.0% 87.0% 89.0% 91.0% 93.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Provider performance priorities: A number of acute hospitals providing urgent care for the population of Herts Valleys are not achieving 4 hour A&E waits. As lead commissioner for West Hertfordshire Hospitals NHS Trust our priority in 2016/17 is to recover the performance for urgent care system along with A&E waits within West Hertfordshire Hospitals NHS Trust. During 2015/16 the System Resilience Group developed a comprehensive urgent care dashboard with activity data covering all main CCG contracted providers. This has enabled the CCG to benchmark performance against neighbouring CCGs and provider organisations on a weekly basis. In parallel the west Hertfordshire system is increasingly working collaboratively using bi-weekly CEO-led meetings to develop plans and implement strategies to recover performance; including implementation of recommendations from the specialist Emergency Care Improvement Programme team following a site based review. This delivered improved performance between April and August 2015 but this could not be sustained in the following months. 34 P a g e

35 A system-wide recovery improvement plan with key actions to improve system flow and improvement trajectories has been submitted to NHS Improvement. This states September 2016 as the agreed timeframe to recover A&E performance to 95%. Existing workforce resources have been directed by the Trust and CCG to support delivery of key actions within recovery plan and the System Resilience Group will target its funding at delivering the outcomes of the recovery plan. A programme management approach will be used to provide assurance that recovery of the 4 hour A&E standard is being delivered and processes to manage episodic peaks in urgent care activity are being improved. As members of the System Resilience Group NHS England and NHS Improvement will be directly involved in the on-going monitoring and development of the recovery plan. The trajectory for delivery of this standard is shown above. Key actions for 2016/17 to underpin delivery of this trajectory are to address: internal practices at Watford General Hospital A&E by focusing on trends in breach analysis by speciality and actions during times of stress which can facilitate or disrupt patient flow discharge processes for routine and complex patients; including application of standard operating processes with community partners to ensure effective use of community resources clinical decision making with community partners to ensure guidelines and procedures are used as an integral part of the patients journey through the system clinical processes which impact on patient flow and establish consistent approaches which are used by multidisciplinary teams in the day to day management of patients within the hospital ambulance turnaround times; and delivery of in-year transformation / QIPP workstreams which reduce A&E attendances and non-elective admission; the development of co-ordinated and consistent plans across the health, social care and the voluntary and community sector which support the prevention of A&E attendance and unplanned admissions as part of the sustainability and transformation plan. 35 P a g e

36 In addition to these immediate priority actions the recovery improvement plan demonstrates a broader vision to address partnership issues which impact on the ability to achieve the Constitutional standards for urgent care and enable more healthcare to be delivered closer to home. Key priorities to progress during 2016/17 have been identified as: GP service to streamline the care of patients treated in the A&E minors facility at Watford General Hospital; releasing secondary care capacity for those treated in the A&E majors facility to improve the timeliness and quality of clinical decision making to prevent unnecessary admissions and prevent overcrowding. Improve discharge pathways across the system Flexible staffing approaches between the emergency department and other areas receiving unplanned attendances and admissions to maximise clinical resource in the emergency department to improve the timeliness of clinical decisions making flow Twilight team to target potential breaches after 5pm and assist in making arrangements for morning discharges Consultant lead in Acute Admissions Unit to develop standard operating procedures with the emergency department System traffic management system to improve ambulance flow Consultant led ward rounds, 7 days a week (x 2 per day) to focus on immediate and potential discharges Business case development to evaluate the benefits of community based ward. There is an adverse impact on the quality and safety of patients when there are extended waits in A&E. Whilst there have been no in-year 12 hour trolley breaches at West Hertfordshire Hospitals NHS Trust quality and safety assurance visits are a key priority for the CCG. These review the impact of the queue nurse, healthcare support worker, Hospital Ambulance Liaison Officer (HALO) paramedic, patient safety nurse and extended role of the housekeepers in providing effective support for transferring patients from ambulances, improving patient experience, supporting the flow of patients through the department, meeting patients hydration and nutrition needs, identify patient issues and safety concerns. The Nursing and Quality team also review breaches of mixed sex accommodation in the Trust to evaluate any impact due to poor patient flow. Analysis shows breaches at the Trust since April 2015 have occurred in ICU and relate to the challenges of allocation of ward beds for patients who no longer require intensive care. The system resilience group have agreed plans at the Trust to reconfigure intensive care to minimise future breaches. 36 P a g e

37 Start Implement by Target to be met by 26/02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /06/ /06/ /06/ /06/ /07/ /07/ /07/ /07/ /07/ /08/ /08/ /08/ /08/ /09/ /09/ /02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /06/ /06/ /06/ /06/ /07/ /07/ /07/ /07/ /07/ /08/ /08/ /08/ /08/ /09/ /09/2016 Herts Valleys CCG 2016/17 Operational Plan During 2016/17 we will ensure these measures continue to be used to improve safety and quality. We will monitor this through on-going quality and safety visits and continue to incentivise the Test your Care dashboard which includes elements relating to the impact of staffing on patient safety and potential harms through a local CQUIN. Delayed transfers of care (DToC) Discharge to IMC delay reductions Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 System Recovery Improvement Plan IDT to Specialist home care / improved discharge flow Week Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 ID Org. Project Baseline Target Measure Target avg RP 9 HCC/ IDT Week DTOC reduction Current Avg wkly beds Target avg/wk. 2.5% 0 /wk. to Avg wkly Feb-16 Feb-16 Sep-16 as% of bed /wk. DTOC Actual usage Effecting timely discharge of patients who occupy inpatient beds is a key enabler for achieving the 4 hour A&E standard. The complexity of interdependencies and pressures of demand within our health and social care system means the 2.5% stretch target for delayed transfers of care (% of bed day delays per occupied bed) has been challenging. Focusing on delayed discharges once a patient is clinically fit to leave the hospital environment is a key priority in 2016/17. Key interventions included in the recovery actions plan to reduce delayed transfers of care are: Implementation of the Specialist Care at Home contract April P a g e

38 Recruitment of Social Workers within social care to provide additional weekend working and align with the Hospitals Twilight team development. Integration of a qualified Hertfordshire Community Trust in-reach worker within the Integrated Discharge Team to facilitate timely discharge to Community Beds Increased numbers of patient discharges being completed before midday in the acute and community hospitals Improved discharge planning within 48hrs of admission for patients who have experienced a stroke or have neurological conditions patients and patients who access intermediate care settings. Improved understanding and consistent application of the choice and personal healthcare budget policies across organisations for patients accessing residential, care home facilities or home care packages. The trajectory for delivery of this standard is shown above. Ambulance response times HVCCG is not the lead commissioner for the ambulance contract with East of England Ambulance Service NHS Trust (EEAST) and is not expected to submit trajectories for ambulance response time. However compliance with the ambulance response times is monitored by the System Resilience Group which is also focusing on staffing levels or shift fill and numbers of vehicles available using the urgent care dashboard. Ambulance turnaround times impact on achievement of the Red 1 eight minute response standard because it affects when crews can be released to respond to new call outs. Turnaround times are currently monitored at 30 and 60 minutes in terms of time from handover to clear ; with clear meaning when the crew can be released to respond to new call outs. At West Hertfordshire Hospitals NHS Trust the 15 minute ambulance handover element of this standard is performing adequately but the crew clear element is not. Actions to achieve the trajectory shown below are included in the recovery action plan (action 8). This will see dedicated A&E staff taking on the management of incoming patients to release the Hospital Ambulance Liaison Officer (HALO) from becoming involved in patient management duties because this detracts from their ability to facilitate the reporting of crew clear times. 38 P a g e

39 Quality and Safety performance and plan Healthcare Acquired Infections (HCAIs) National Standard None Monthly Diff Tolerance >> 10 APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Total Plan Provider performance priorities: In-year, three of our acute providers are already at their YTD Clostridium Difficile thresholds. The CCG will continue to prioritise improving performance in 2016/ P a g e

40 The incidence of healthcare associated infections (HCAIs) is monitored closely by the CCG s Nursing and Quality team in accordance with the policy for serious untoward incidents. It is reported to the Quality and Performance Committee and provider performance is managed through the monthly contract quality review meetings. The CCG MRSA threshold is 0 and therefore the single case which has occurred in 2015/16 means we have breached this standard. The rate of Clostridium Difficile cases for HVCCG has been consistently below the average for East of England and the national rate. An 8% reduction in cases from the position last year has been achieved with the greatest reduction in cases in non-acute settings, where cases reduced by 15%. In the same period MRSA bacteraemia has reduced by 60%. HCAIs will continue to be a priority for our quality monitoring and improvement approach in 2016/17. The trajectory for delivery of this standard is shown above. IAPT performance and plan IAPT rollout - Access to Psychological Therapies National Standard 3.75% Quarterly Diff Tolerance >> 5% The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders (local estimate based on Adult Psychiatric Morbidity Survey 2000) Plan % per quarter (e.g. 3.75%) The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders (local estimate based on Adult Psychiatric Morbidity Survey 2000). % per quarter (e.g. 3.75%) The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders % per quarter (e.g. 3.75%) Quarter 1 1,360 1,740 2,000 2,915 72,042 72, % 2.42% 2,325 2, , % % Quarter 2 Quarter 3 Quarter 4 72, % , % % 3.75% 72, % % 40 P a g e

41 IAPT recovery National Standard 50% Quarterly Diff Tolerance >> 20% Plan 2 treatments completed with recovery & caseness at the start of treatment 2 treatments completed with recovery & caseness at the end of treatment % 2 treatments completed with recovery & caseness at the start of treatment 2 treatments completed with recovery & caseness at the end of treatment % 2 treatments completed with recovery & caseness at the start of treatment 2 treatments completed with recovery & caseness at the end of treatment % Quarter 1 Quarter 2 Quarter 3 Quarter , % 52.57% 51.05% 51.47% ,305 1, % 51.3% % 50.0% 50.0% 50.0% IAPT waits (performance not available on unify for 2015/16) National Standard 75% Quarterly Diff Tolerance >> 10% Plan The number of ended referrals that finish a course of treatment in the reporting period who received their first treatment appointment within 6 weeks of referral The number of ended referrals that finish a course of treatment in the reporting period. % National Standard 95% Quarterly Diff Tolerance >> 10% Plan The number of ended referrals that finish a course of treatment in the reporting period who received their first treatment appointment within 18 weeks of referral The number of ended referrals who finish a course of treatment in the reporting period. % Provider performance priorities: To maintain 15% access and 50% recovery rates Quarter 1 Quarter 2 Quarter 3 Quarter % 75.0% 75.0% 75.0% Quarter 1 Quarter 2 Quarter 3 Quarter ,621 1,621 1,621 1, % 95.1% 95.1% 95.1% 41 P a g e

42 We are delivering the national standards for the number of people accessing psychological therapies and the proportion of people assessed as having recovered as a result of their treatment. During 2016/17 we will prioritise the self-help element of our west Hertfordshire future model for care by promoting increased numbers of self-referrals into the service through greater use of social media coverage and strengthened links to long term conditions clinics. This will support us move towards the national ambition of 25% of the population who could benefit from receiving IAPT services each year by 2020/21. We are already achieving the new standards for waits which require 75% of people to start treatment within 6 weeks rising to 95% within 18 weeks and Hertfordshire was a national pilot area for children and young people s IAPT and so we are well on track for this 2018 deadline. In 2016/17 we will sustain delivery of these standards and the trajectories for delivery of these standards are shown above. Dementia Diagnosis performance and plan National Standard 66.7% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number of People diagnosed (65+) Plan Estimated dementia prevalence (65+ Only (CFAS II)) 6,778 6,778 6,778 6,778 6,778 6,778 6,778 6,778 6,778 6,778 6,778 6,778 % 63.06% 63.78% 64.50% 65.23% 65.95% 66.70% 66.70% 66.70% 66.70% 66.70% 66.70% 66.70% As at the end of January 2016 GP Practices had recorded a rate of dementia diagnosis as 60.9% of the expected number of people over 65 with dementia. This is below the national standard of 67% despite having increased funding to the dementia diagnosis service over the last year to increase their capacity to diagnose more people. Alongside this, local GPs received direct enhanced services funding from NHS England to support improvements in Dementia diagnosis; this will be available as part of core funding in 2016/17 to enable them to continue to support improvements. In keeping with implementation of the Five year Forward View HVCCG GP practices are taking on additional responsibilities for dementia prescribing supported by local enhanced services funding where this is safe and appropriate to do so. This will release capacity in the dementia diagnosis service and enable them to focus on supporting more complex cases. The approach provides an opportunity to almost doubling diagnostic capacity in the short term from April 2016 subject to uptake of the local enhanced service by GP practices. This will enable the service to reduce the waiting list and therefore the trajectory for delivery of this standard, shown above, is not compliant until September 42 P a g e

43 2016. We will monitor performance on this standard through monthly meetings with dementia leads within Hertfordshire Partnership NHS Foundation Trust and Contract Review Meetings. Improving the dementia pathway and post-diagnostic support has been identified as key priority within Your Care, Your Future and we have agreed a new three year contract with Hertfordshire Partnership NHS Foundation Trust within which an early priority will be to streamline the dementia diagnosis pathways to improve patient experience. Additional key actions for 2016/17 to improve dementia diagnosis and care include: improving post diagnostic support by Hertfordshire County Council tendering for voluntary sector support for people with dementia and their carers delivering an updated dementia handbook to provide information for people with dementia and their loved ones. providing training for non-clinical staff and GP s on dementia developing dementia friendly communities and Dementia Action Alliances; and evaluating the impact of a clinical community dementia specialist nursing and a non-clinical support service to identify the most appropriate and effective model of support to commission as part of the west Hertfordshire future model of care for dementia. 43 P a g e

44 Transforming Care for those with Learning Disabilities In 2016/17 we are required to increase the number of people with learning disabilities /autism being cared for in the community rather than in inpatient facilities. HVCCG is a Learning Disability Transforming Care fast track area and we will continue with our programme of work to increase care in the community setting using our specialist learning disability and treatment services to support people and help them avoid admissions by: providing time limited intensive support in the persons home working with care providers to equip them with knowledge and skills to better support people with learning disabilities who have mental health problems or behaviours which pose challenges to remaining in the community and avoiding hospital admissions working jointly with the Community Learning Disability Team at Hertfordshire County Council giving positive behaviour support attending referral meetings to improve person centred team working and ensure appropriate allocation of resources providing rapid response to urgent referrals with the intensive nursing support function providing same day responses to referrals where there is a risk of placement breakdown developing local risk registers with Local Authority and CCG s to assist in flagging where placement/family breakdown might occur so that a crisis can be prevented providing pre-admission support through the care and treatment reviews (CTR)/ Blue Light Tool which brings all parties (person /family /social care provider) together to enable experts to seek alternative solutions to hospital admission; and incentivising the development of protocols for in hours and out of hours CTR process as the local learning disabilities CQUIN for 2016/17. We are not the lead commissioner for this Constitutional standard and the Hertfordshire wide trajectory has been submitted by E&NHCCG. Specialist Residential Services (SRS) The CCG is adopting the national lead s approach to ensure the safety and wellbeing needs of residents in specialist residential services by working with the range of different organisations involved in commissioning these services for adults with multiple complex needs linked to challenging behaviour, autistic spectrum and sensory processing disorders. Our priority in 2016/17 is to ensure safe and high quality care for these vulnerable people; with Hertfordshire residents having person centred plans in place. Addressing inequalities for people with learning disabilities Following a refresh of acute hospital registers in 2015/16 to improve systems to flag people with a learning disability we will continue to ensure actions for reasonable adjustments to 44 P a g e

45 meet additional needs when these patients visit local hospitals and healthcare facilities are addressed as an integral part of the west Hertfordshire future model of care. We will continue to promote the Hertfordshire Purple Star Strategy, Hertfordshire working with Seeability and local opticians to commission a pilot service providing enhanced eye tests for people with learning disabilities and / or autism who may need longer or multiple appointments to enable an eye test to take place given that people with learning disabilities have a higher prevalence of sight related issues than other people. In 2015/16 98% of GP practices signed up to the learning disability directed enhanced service commissioned by NHS England. Through our joint co-commissioning arrangements we aim to ask the Central Midlands primary care team to achieve 100% sign up by GPs to enable all patients aged 14 years and over to be offered access to an annual health check that includes the production of a personal health action plan. Alternatively we will ask Central Midlands to make commissioning arrangements to ensure that patients have access to this service even when their GP practice does not sign up for the learning disability Directed Enhanced Service. HVCCG have redesigned and launched new annual health check templates for use across all GP IT systems and we will use this as part of the approach to address health inequalities and improve outcomes. In line with national call to action a multi-agency medicines review project group has been established to work with GP practices to analyse prescribing of anti-depressants and antipsychotics for young people and adults with a learning disability and / or autism. The analysis will be used to identify the as is picture across the county and inform next steps. Child and Adolescent Mental Health Our local Child and Adolescent Mental Health Service (CAMHS) transformation plan builds on the whole system CAMHS review completed during 2015 with extensive engagement and involvement of patients, carers, local communities and health and social care providers. It is a priority for children s services in 2016/17 and key actions include: revising the model of CAMHS services locally to reflect the THRIVE model, rather than the existing tiered approach of access to more specialised services implementing significantly extending work with schools and other universal services to provide agreed early intervention using a whole systems prevention approach providing additional investment into counselling services for children and young people improving support for children and young people with autism Other initiatives which will be implemented in 2016/17 include: Using the Early Intervention and Practice Development Team to provide effective preventative support services for people with behaviour that is complex and challenges local providers. The service will provide interventions directly to people with complex needs as well as supporting the system and networks around them to ensure that they are able to remain in the community 45 P a g e

46 Using the Offending Behaviour Intervention Team to provide evidence based intervention and support for people with learning disabilities who have had contact with the Criminal Justice System and who present an active and high risk to others. 2 week waits for first episode of Psychosis During 2015/16 additional investment in mental health services was used to establish an Early Intervention in Psychosis service. Additional investment in 2016/17 will support the delivery of the new national standard that 50% of people are seen within 14 days and then receive a NICE compliant package of care. Improving quality CQC Inspections in Hospitals At the most recent CQC inspection our mental health provider was rated overall as Good and our community provider was rated overall as Requires improvement. Hertfordshire Community NHS Trust have been progressing their quality improvement plans which are monitored by the Nursing and Quality team. As the lead commissioner for West Hertfordshire Hospitals NHS Trust, which was rated inadequate by the CQC (September 2015) and placed in special measures by the NHS Trust Development Authority, we have been working closely with the trust. The CCG has provided advice and guidance to the programme of work undertaken by a dedicated team of doctors and nurses through the Assistant Director of Nursing. They have spent up to a day a week focused on this priority, with the aim of bringing the organisation out of special measures during the summer of Specific support to assure quality and safety is set out the relevant sections covering 4 hours A&E waits, healthcare acquired infections and maternity sections. Monthly quality assurance visits are focused on the areas identified as requires improvement. Workforce vacancy rates are improving and a series of quality related metrics relating to venous thromboembolism (VTE) hospital standardised mortality rates (HSMR) 6, stoke service metrics and backlog of serious incident reports have all improved. The CCG has also assured the Trust has plans in place to prevent breaches on mixed sex accommodation. In 2015/16 the CCG implemented a more strategic approach to identifying concerns by establishing a Quality Alert System (QAS) which provides an on-line platform for GPs to report quality issues relating to providers who have delivered care to Herts Valleys residents. This has allowed member practices to proactively engage with the commissioning and monitoring of commissioned services. Results for quarters 1-3 for 2015/16 (shown below) highlight small numbers in proportion to the number of hospital spells but common themes have emerged particularly relating to poor information in discharge letters, delayed discharge and missing discharge letters. 6 The trust has moved from being in the worst 10% of hospitals to be in the company of a small group of some of the best hospitals in this country. 46 P a g e

47 Our most frequently used provider has generated the highest number of alerts. All concerns are discussed as part of the regular quality monitoring discussions with our main providers; with medical / clinical issues being reviewed by a clinician at HVCCG and copied to the Medical Director at West Hertfordshire Hospitals NHS Trust where they are taken forward as appropriate. In 2016/17 Quality Alert response rates will be included in the contracts with our main providers. This will improve assurance regarding actions which are taken following receipt of quality alerts and enable information to be triangulated with other sources of intelligence and the CCG is using this proactivity to prevent the risk of providers being placed in special measures. CQC Inspections n Primary Care Twenty one GP practices in HVCCG area have had a CQC inspection visit reports and three have been visited with reports pending. There are currently no GP practices assessed as requiring improvement. The CCG will continue to actively support the development of practices to ensure the quality of services and prevent the risk of GP providers being placed in special measures by commissioning a GP and Practice Manager with experience of CQC 47 P a g e

48 inspections to provide support through facilitation visits and preparatory packs developed jointly by the CCG and Local Medical Committee (LMC). 100% of GP practices have attended the training offered and 90% have had facilitation support visits from the team. Feedback is being used by the Primary Care Working Group with to inform the quality assurance framework being developed jointly by the CCG and NHSE. During 2016/17 we will continue to work with the Central Midlands team at NHSE, on this issue under Joint co-commissioning arrangements which have been extended to April Improving care homes HVCCG has a proactive programme of care home visits. It has strengthened the care home improvement team and is providing targeted intensive support where appropriate and working proactively with the Care Homes provider association and County Council inspection team to prevent care homes falling in special measures or embargos. Improving Maternity Services Recommendations set out in the National Maternity Review have been included within the 2016/17 contract to ensure that all relevant providers report progress against the key areas for action. This includes reporting compliance in the use of the Saving Babies Lives care bundle to reduce the number of stillbirths and progress in relation to the organisations status in joining the Sign up to Safety campaign. The monthly contract quality review meetings include key areas of focus throughout the year where providers present areas of good practice and also areas for improvement. This includes maternity services and the progress being made against CQC improvement notice. The friends and families test (FFT) in maternity is monitored closely by the CCG s Nursing and Quality team and is covered under our review of the FFT. In 2015/16 the patient voice is heard through the Maternity Service Liaison Committee (MSLC) which provides a mechanism for concerns and feedback directly to the Trust and along with the friends and families test feedback supports on-going dialogue between the trust and patients to support improvement in maternity services. As maternity services is a key area of the CQC improvement plan at West Hertfordshire Hospitals NHS Trust we will continue to use the Maternity Service Liaison Committee as a way to take forward actions to improve the service during 2016/17; for example focusing on babies born with tongue tie to address the impact this has on new parents, including trying to establish feeding regimes. The CCG provides strong GP clinical engagement with maternity services and the GP lead reviews of all maternity related serious incidents. Clinical leadership within midwifery has now been addressed at the Trust along with increased midwife establishment. A range of metrics are shared via the quality schedule of the contract. For the 2016/17 contract this has been enhanced and a full maternity dashboard will be shared monthly. 48 P a g e

49 New metrics for perinatal mental health access and outcomes have also being included within the West Hertfordshire Hospitals NHS Trust contract for 2016/17 as part of priorities for improving prevention aligned with the west Hertfordshire future model of care set out in Your Care, Your Future. These metrics include the number of pregnant women who have had mental health status assessments completed and of those women who have had mental health issues identified, the number that have care plans in place. Maternity remains a key priority area for monitoring improvement during 16/17. Avoidable Hospital Deaths: Standardised Hospital Mortality Index All acute contracts held with the CCG set out the requirement for Trusts to report their hospital standardised mortality rates 7 (HSMR)/ summary hospital mortality indicator (SHMI) and crude mortality rates on a quarterly basis as shown in the table below. Indicator Trust Target Summary Hospital Level Mortality Indicator Jan 12 - Dec 12 Apr 12 - Mar 13 Jul 12 - Jun 13 Oct 12 - Sep 13 Jan 13- Dec 13 Apr 13 - Mar 14 Jul 13 - Jun 14 Oct 13 - Sep 14 Jan 14- Dec14 The CCG reports the mortality rates for each HVCCG acute trust on a quarterly basis to Board and sub-committees to the Board (Quality & Performance Committee). Apr 14- Mar 14 WHHT BCF & RFHFT* 100 LDHUFT Bucks ENHT *BCF merged with RFHFT from June 2014 The CCG applies thresholds to identify when Trusts are expected to provide evidence of action taken for improvements to be made. Increases of 4 or more points within each condition category will continue to be used as the threshold for 2016/17 and mortality rates and progress against the actions will continue to be monitored via the contract quality review meetings (CQRM) and at the West Hertfordshire Hospitals NHS Trust mortality review group. Improving Stroke Services Stroke has been a key focus during 2015/16 with the development of a system wide recovery action plan for key stroke indicators. There have been challenges during 2015/16 on a number of national stroke indicators however quarterly Sentinel Stroke National Audit Programme (SSNAP) data indicates a positive improvement for West Hertfordshire Hospital NHS Trust compared to other neighbouring trust. Under the leadership of the CCG stroke clinical lead all partners are working together to report performance on key indicators on a monthly and this will continue in 2016/17. 7 The Standardised Hospital-level Mortality rate is a sophisticated measure which compares the number of patients that die in a hospital with the number that would be expected to do so. 49 P a g e

50 Stroke is one of our key priorities identified in as outlined in the Strategic Outline Case for Your Care, Your Future and we will implement a Hype Acute Stroke Unit in 2016/17. The agreed stroke pathway across the Midlands and East Region includes a number of components as shown below. During 2016/17 the CCG will focus on improvements in the stages of the pathway shown in the figure below through the following types of service provision: Acute Stroke Unit Early Supported Discharge Specialist rehabilitation Home care provision TIA clinics Patient Choice Patients have a legal right to be offered the opportunity to make choices about the following types of planned care: Where to go for a first outpatient appointment for a physical or mental health condition To ask to change hospitals if they wait longer than the maximum waiting times for routine care (18 weeks) or when cancer is suspected (2 weeks) To choose a consultant or consultant led team, including named healthcare professional for mental health services To choose to receive treatment normally available on the NHS in other countries within the European Economic Area (EEA) subject to certain conditions. 50 P a g e

51 NHS Choices is the service which allows patients to book, change or cancel appointments online. All HVCCG, GP practices have clinical IT systems that are enabled to offer to use the NHS e-referral Service (ERS). To improve choice we have set out the requirement for providers to be compliance with the patient choice agenda by 2017 in the Service Development Improvement Plans (SDIPs) within the contract. In-year our acute provider will be disabling the facility for referrals to be made by fax and this is expected to increase the use of the NHS e-referral Service. As we develop our sustainability and transformation plan we will consider the use of personal health budgets, where relevant, as part of the new local pathways for end of life care and maternity. In 2015/16 offers of a personal health budget to patients in Continuing Healthcare have been standardised. We will build on the work undertaken in Continuing Healthcare and offer personal health budgets to people who use wheelchairs and those with Learning Disabilities working with Hertfordshire County Council to ensure that the integrated budgets provide holistic support to meet individual patient s health and social care needs and this has been signed off for inclusion in the local offer. Further scoping work will also be undertaken to look at extending access to users of Mental Health and wheelchair services and for patients with specific long term conditions and those needing end of life care. The 10 year transformation strategy for west Hertfordshire Your Care, Your Future has identified end of life care as an early priority. A Hertfordshire wide focus group has been developing strategies to improve patient and carer experience during end of life care and ensure that patients can achieve their preferences for end of life care and where they will pass away at the end of life. In 2016/17 the CCG will deploy an Electronic Palliative Care Co-ordination System (EPaCCS) which will be accessible by all relevant care professionals. The EPaCCS will hold details of all those patients deemed to be on the end of life care pathway and support navigation and co-ordination of support for these patients and their carers. It will also hold advanced care plans which detail individuals end of life care wishes and therefore it will provide the mechanism by which we can assure that patient choice at the end of life is being delivered. In addition to this the CCG is planning a targeted approach to education and training for health and social care professionals to promote an ethos of end of life care being everyone s business. Sustainability and quality in General Practice Herts Valleys Clinical Commissioning Group (HVCCG) has 69 member GP Practices delivering primary care medical services to a population of over 630,000 patients across the four localities of Dacorum, Watford & Three Rivers, St Albans & Harpenden and Hertsmere. In line with our constitution representatives on the CCG Board and its subcommittees are drawn from member practices. We have extensive engagement with member practices 51 P a g e

52 through clinical leadership roles, locality based and CCG wide clinical and management forums. Our Joint Co-Commissioning Committee (JCCC) has enabled us to establish strong clinical leadership for developing improvements in quality and service development. Going forward we will use this committee and our GPs in leadership roles to support implementation of the Five year Forward View including implementation of our west Hertfordshire future model of care, redesigned care pathways and service models to achieve the step change in community and primary care based services which can be accessed on a 7 day basis. Our priority for 2016/17 is to use the Joint Co-Commissioning Committee as the mechanism to drive the development, delivery and assurance of GP services in primary care in line with agreements to undertake joint co-commissioning with Central Midlands Regional team from NHS England which has been extended to April In the summer of 2016 the CCG will consult with the membership on moving to full delegated commissioning. Therefore this group will be a key enabler in delivering the vision set out in Your Care, Your Future as we progress our sustainability and transformation plans to establish hubs where primary, community and hospital health services and social care and wellbeing services focused on the needs of the local population can be co-ordinated and delivered using integrated systems and or co-located premises. Quality of Primary Care Services Our ambition is to achieve consistent high quality core and extended primary care services delivered by an appropriately skilled workforce whilst simultaneously enabling the capability of primary care services to manage unwanted variation in spend and patient outcomes. In 2016/17 we will continue to use the Kings Fund model for developing federated GP practices as part of our market development approach to enable them to share resources, bid for new services and where contractors feel it may be of benefit, consider a contractual merger to support the longer term sustainability of high quality primary care services. In January 2016 a new pilot programme of support was announced for vulnerable practices which will be led by the NHSE Central Midlands team. HVCCG is supporting this pilot programme and taking a tripartite approach with Central Midlands team and the Beds and Herts Local Medical Committee (LMC) in supporting practices to access this funding. We will use the existing assurance and development visits undertaken in practices by the CQC (see above), NHS England and the CCG, to support the sustainability of primary care practices. Practice visits National guidance for Improving Quality in General Practice required local area teams from NHS England to implement a programme of quality visits for their directly commissioned GP contractors. Practices requiring visits were identified using the Primary Care Web tool which collated data on a number of high level practice based indicators to identify outliers. During 2014/15 GP practices identified as outliers in 5 or more indicators 52 P a g e

53 were required to have a quality visit. Only two practices within HVCCG received visits which focused on fact finding and providing support to achieve engagement to improve quality metrics. During 2015/16 HVCCG implemented annual practice visits in line with the Member Practice Commissioning Agreement. The purpose the visit is to: Engage with the whole practice as a member commissioner and provider Two-way communication/feedback from CCG and from practice Understand the practice data and an open discussion on areas of improvement as highlighted from the practice action plan from the Local Incentive Scheme. Feedback from practices has been positive and visits will continue in 2016/17 supported by a HVCCG performance pack which enhances clinical engagement in strategic priorities and supports delivery of QIPP/ transformation plans. For 2016/17 the visits programme performance packs will begin to be used to support delivery of the RightCare agenda. The CCG is currently developing an approach to quality assurance for implementation in 2016/17 which is outlined in the figure below. The anticipated outcomes of this approach are that it: supports NHS England and the CCGs in their statutory responsibility to improve the quality of and access to primary care influences behaviour through clinically led peer review reduces unwarranted variation improves health outcomes improves patient experience and safety 53 P a g e

54 facilitates mature and constructive relationship with practices and to gain a better understanding of practice, NHS England and CCG issues develops and supports of an agreed practice action plan which should promote CQC compliance; and facilitates sharing of best practice. Quality and Outcome Framework The engagement work undertaken to support the development of our transformation strategy Your Care, Your Future identified a number of key priorities for improving the prevention, identification and management of clinical conditions. In the first year of our sustainability and transformation we have incentivised practices to address a number of these early priorities through a local enhanced service (LES). This promotes case finding and appropriate case management / treatment of patients with atrial fibrillation (AF) (for stroke prevention) diabetes, asthma and chronic obstructive pulmonary disease (COPD). These will impact on the prevalence and achievement domains of the QOF 8 and we will use the annual QOF data and analysis of practice returns and impact of our long term conditions QIPP / transformation workstream to evaluate the effectiveness of this enhanced service. A key risk associated with the strategy set out in the Five Year Forward View is that GP practices will not have the workforce or premises capacity to meet the additional demands arising from enhancing primary care services and this may have an adverse effect on primary care services. HVCCG is supporting the progression of practice centric and CCG wide bids to the primary care infrastructure fund to address local priorities relating to premises capacity and is undertaking partnership working to address workforce needs. As we implement our sustainability and transformation plan we will need to ensure the quality of primary care services is not adversely affected. We will use key quality indicators such as the GP patient care survey, friends and family test and QOF exemptions, primary care workforce survey and CQC visits to provide early warnings about the sustainability of primary care services. Analysis which provides a baseline for this approach is contained within appendices 1, 2 and 3. Primary Care Workforce NHS England has developed in collaboration with Health Education England (HEE), the British Medical Association (BMA) and the General Practitioners Committee (GPC) a new 10 point strategy known as Building the Workforce the New Deal for General Practice to ensure that we have skilled, trained and motivated workforce in general practice. 8 The Quality and Outcome Framework (QOF) was introduced as part of the 2004 General Medical Services (GMS) contract as a voluntary as a mechanism for ensuring that patients with specific long term conditions received consistent evidence based care wherever they live in England. 100% of practices in HVCCG have signed up to QOF. They report on progress against standards for the management of long term conditions annually (April to March). The process is enabled by clinical IT systems which include electronic QOF registers and results are published by the Health and Social Care Information Centre (HSCIC); practices are financially rewarded for their annual QOF achievement. 54 P a g e

55 It sets out a specific commitment to tackle workforce issues: improving recruitment in general practice retaining doctors within general practice supporting those that wish to return to general practice; and supporting vulnerable practices. In conjunction with the 10 point plan the Secretary of State for Health in June 2015 announced NHSE would work to develop a 10m programme of support for GP practices identified as in difficulty. We have worked with Health Education England and Hertfordshire University to create the GP and Practice nurse development programme which is currently being implemented over the next 5-7 years. In 2016/17 we will fund 7 GPs to undertake career development with placements to enhance clinical or commissioning skills and 8 places for newly qualified nurse to develop as practice nurses. Already there are 1,834 patients per GP in west Hertfordshire compared to an England average of 1,590. These shortages along with those across the professional or qualified health care workforce and the home care and voluntary sector workforce in Hertfordshire are being addressed as part of our sustainability and transformation plan. Improving Access in Primary Care We currently have a number of measures to support a step-change in access to primary medical services these include: Commissioning of one of the national Prime Ministers Challenge Fund (PMCF) pilots for increasing Out of Hours (OOH) 9 services within the Watford Locality. From September 2015 HVCCG took over responsibility for funding the pilot. The pilot is set to continue in 2016/17 with funding from NHS England. The CCG has supported provider development of the Doctor First model which has been piloted in our Hertsmere locality and has also invested in additional primary care capacity for children in A&E and in all practices to support winter pressures. The actual activity and impact of these schemes is being evaluated but early analysis using data submitted to date shows that primary care has delivered an additional 38,000 appointments over this period. Integrated working Working with Public Health HVCCG have an established working relationship with the local Public Health Team based at Hertfordshire County Council. The CCG is directly supported by a public health consultant on a day-to-day basis with the aim to improve population health outcomes, including reducing health inequalities through supporting the commissioning cycle, from assessing 9 OOH services operate from 6.30pm to 8am Monday to Friday, all weekends and bank holidays. 55 P a g e

56 needs for health services through to planning capacity and managing demand. This active role in commissioning service provision includes resource allocation and procurement and has been, and will continue to be, underpinned by the opportunities highlighted in the NHS RightCare resources and Your Care, Your Future priorities. The review and re-commissioning of clinical pathways will be based on data, evidence and practical support around spend, outcomes and quality. Exploring areas for integrated working and joint commissioning across the local health and social care system will be a key focus for this year. Although the CCG will not be part of the initial roll out of NHS RightCare during 2016/17, we have actively engaged with the programme and will be working closely to adopt and embed the principles and methodology within the organisation and wider health system to deliver our improvement objectives. This work will include intensive support to develop our local transformation leaders, clinical leads and CCG staff. In addition to this the NHS RightCare programme will work with the CCG tailoring the RightCare approach by focusing and supporting five projects which will include End of Life, Diabetes and Older people. The national programme will also support us with engaging with neighbouring CCGs to share learning and best practice. Herts Valleys CCG is directly supported by the knowledge and intelligence team within public health to help identify the most impactful opportunities for change, working through the JSNA and ensuring it is fit for purpose and developing locality profiles as well as bespoke data summaries underpinned and aligned to the Health and Wellbeing Strategy. The locality profiles have been used to identify inequalities and develop priorities for the 2016/17 MPCA. A key priority over the next twelve months will be to support the organisation scope, establish and embed self-management programmes with the aim to empower patients to improve their own health. In conjunction with this, Public Health will be working to take action to reduce the incidence of disease and health problems within the west Hertfordshire population by developing and implementing a prevention strategy. Both self-management and prevention outcomes have been included in the Primary Care Implementation Plan ( ) and will be incorporated in condition-specific pathways as part of a patient s journey. Hertfordshire will be a pilot site for the National Diabetes Prevention Programme (DPP) rolling out summer 2016 to identify and prevent high risk individuals for developing this chronic condition- the management and coordination of the programme for will be led by the Public Health team. Point of care testing for latent TB and HIV in high prevalence areas of west Hertfordshire will be rolled out in summer 2016 coordinated with Public Health. Public Health plays a key role and will continue to do so in demand management and prioritisation including prior approvals and individual funding requests. In addition Public Health is an active member of several programme boards and steering groups supporting quality assurance and performance, including clinical effectiveness, patient safety and patient experience. 56 P a g e

57 On-going joint working between GPs and the wider Public Health teams including screening, immunisations, healthcare acquired infections, GP practices as providers of preventive services, local authority commissioning of Public Health services, and joint strategic leadership through the Health and Wellbeing Board will continue to be supported and developed to improve the outcomes for the west Hertfordshire population. Delivering our sustainability & transformation plan We will work with East and North Hertfordshire and West Essex CCGs and providers and local authorities across this wider geography to develop the 5 year sustainability and transformation plan. Our approach is set out below will take a layered approach to meet local needs. The Your Care, Your Future programme board provides the forum for our partners in west Hertfordshire to agree our local plans and develop our local contributions and feed into the STP steering group through the Hertfordshire leaders forum and Herts STP project steering group. For west Hertfordshire, the local vision for care has been defined in Your Care, Your Future, which describes how we will make the Five Year Forward view a sustainable reality for our population. We will achieve this by building a model of personalised care, promoting selfand community-based support to alleviate the pressure on our acute system, and ensure hospital-based care is only used where it is the most appropriate setting. 57 P a g e

NHS Bradford Districts CCG Commissioning Intentions 2016/17

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