Operational Plan 2017/19 (Refresh 2018/19)

Transcription

1 Operational Plan 2017/19 (Refresh 2018/19)

2 Table of Contents 1 Introduction Relationship to the STPs Delivering the nine must dos Develop/deliver Sustainability and Transformation Plans Financial Sustainability Primary Care Urgent and Emergency Care Referral to Treatment Times and Elective Care Cancer Mental Health People with learning disabilities Children and Young People Mental Health Services (CAMHS) Maternal and Infant Health Complex Care and Personal Health Budgets RightCare Priorities Quality Engagement Workforce Risks

3 1 Introduction The 2017/19 Operational Plan is a two year plan written to provide NHS England with assurance that Sandwell and West Birmingham CCG has plans in place aligned to the Black Country Sustainability and Transformation Plan (STP) and that it is designed to deliver the nine must dos, the NHS Constitution and the CCG Improvement and Assessment Framework. In line with the Refreshing NHS Plans for 2018/19 guidance published in February 2018, we have reviewed our two year plan. This document forms part of our refreshed submission and supports the finance and activity submission for 2018/19. The content of this document is designed to be succinct so as to clearly demonstrate the progress we have made over the last 12 months to deliver the 2017/19 Operational Plan. It clearly outlines our plans for 2018/19 to deliver the nine must dos, the NHS Constitution and the CCG Improvement and Assessment Framework. The refreshed plan is written within the context of the wider Sustainability and Transformation Partnership (STP) plans for the Black Country and Birmingham, the Transforming Care Partnership plans, the CCG Transformation Area plan, the submitted Strategic Demand Management plan, the CCG General Practice Strategy, CAMHS Local Transformation plan and the Better Care plans. 3

4 2 Relationship to the STPs Operational Plan In Sandwell and West Birmingham, people are living longer with evermore complex conditions. Modern lifestyle issues such as obesity are causing an increase in long term conditions, alongside progress in treatments and medical techniques resulting in an increase in associated costs and raising public expectation. To address these pressures and ensure a sustainable health and care system fit for the future, we must transform local services and the way we commission them. For the past 12 months we have provided leadership and operational support to the development of the Black Country STP whilst playing a very active role within the Birmingham STP. Through these partnership forums we have co-designed strategic programmes designed to: Improve the health and wellbeing of the local people. Improve the quality of local health and care services. Deliver financial stability and efficiencies throughout the local health care system. Working with partners across the Black Country STP and the Birmingham STP (where we are also an associate commissioner), we aim to change the way we spend money and use our limited resources to make the most of modern healthcare, innovation and best practice. Working together we aim to ensure patients who need hospital care, receive the highest quality care (with less variation), where specialist interventions are delivered in the right place and at the right time. Together we are also developing local placed based models of care that will shift demand away from our hospitals to a more community centred approach. Over the last 12 months we have continued to develop the local placed based models of care, learning from national and local pilots, including the two local Vanguards. Over the next year and beyond, the placed based approach will continue develop and address growth in the burden of illness and unwarranted clinical variation. The placed based models will be continuing to work on achieving integrated continuity of care for people complex health and care needs, improved access to primary care, and reducing unscheduled admissions through improved community services and personalised care. 4

5 3 Delivering the nine must dos 3.1 Develop/deliver Sustainability and Transformation Plans The Black Country STP plan sets out a strategy for the transformation of health and care across the Black Country and west Birmingham footprint. The STP has no statutory powers but it is a collaboration of the 18 organisations providing primary care, community services, social care, mental health and acute and specialised services for the population of the four Black Country Clinical Commissioning Groups. As a key delivery partner of the STP we have aligned our operational plan priorities with the delivery of the STP plan. Through extended collaboration across the providers, the STP will continue to improve the quality of services in the Black Country through the work of the STP Clinical Leadership Group and the provider alliances. In particular we will continue to: Ensure that there is sufficient resilience in the urgent care network. Deliver the NHS England priorities. Drive the delivery of the National Cancer Strategy through aligning commissioning responsibilities across the Cancer pathway. Enable further collaborative working across providers. Support the Transforming Care Together programme, to redesign and operationalise evidence based mental health services. Ensure, collectively, that we deliver value for money and the priorities of the Five Year Forward View for Mental Health, including continuing to ensure people with learning disabilities and autism can lead fulfilling lives with developed community based services as part of the Transforming Care Partnership plans. Build on the existing partnerships with individual Local Authorities and the West Midlands Combined Authority to take effective action on prevention and the wider determinants of health by understanding the economic impact of healthcare spending and identifying the impact of mental health on demand for health services. Build on the ambition of the Black Country Provider Partnership to offer a first class accredited pathology service across the Black Country and West Birmingham that ranks in the top quartile nationally on a range of quality, efficiency and outcome measures. Implement the Black Country Local Maternity Strategy following consultation with stakeholders. Identify other areas where greater efficiency can be delivered at a scale not available to individual organisations. Assess our readiness against the Integrated Care Systems framework to demonstrate our ability to take collective responsibility for financial and operational performance and health outcomes. 5

6 3.2 Financial Sustainability To achieve sustainability in local health and care services, the Black Country STP needs to take significant action to reduce both the projected growth in demand and the costs of the services provided. The STP challenge equates to avoiding spending of 512m by 2020/21 across the Black Country and West Birmingham. With an indicative national Sustainability and Transformation Fund allocation of 99m in 2020/21, the STP challenge equates to 413m. The Sandwell and West Birmingham CCG retains its organisational responsibility for the delivery of its annual savings, efficiency targets and compliance within the updated business rules for 2018/19, which are: Maintaining a minimum of 0.5% contingency. The non-recurrent utilisation of 0.5% has been lifted for 2018/19. No benefit to the bottom line from the business rule regarding the 0.5% CQUIN. Strict adherence to the CCG two year allocations that have been issued. Robust inflation and growth assumptions based on historic and future plans. National Investment Standard Requirements around Mental Health and Child and Adolescent Mental Health Services. Demonstrate the use of the 3 per head for GP Forward View. A requirement to confirm adherence to the national must dos coupled with delivery of the relevant elements of the national 10 point efficiency plan. Income In 2018/19, the CCG will receive an allocation of m (including the brought forward surplus and an in year drawdown of 2.4m). This represents a growth increase of 2.4% when compared with recurrent allocation in 2017/18. Further non-recurrent allocations may become available in year. However, at present these amounts are unknown and it would be imprudent to rely upon their receipt. Expenditure A full analysis of the cost pressures facing the CCG in 2018/19 has been undertaken. The assessment has included: Expected growth in healthcare contracts. Pressures from national policies. Pay and price inflationary pressures. Planning guidance requirements. 6

7 The main assumptions used in formulating the CCG s financial plan are summarised as follows: Table 1 - Key Planning Assumptions The CCGs expenditure is estimated to be 784m in 2017/18, which is summarised below. Table 2 - CCG Expenditure Summary 2018/19 7

8 Overview of Expenditure by Programme Area The acute commissioning portfolio remains our biggest area of spend accounting for nearly half the CCGs annual spend. Acute commissioning combined with prescribing, mental health, community services and primary care co-commissioning equate to over 90% of our total spend. Graph 1 Planned Expenditure 2017/18 Underlying Position The underlying financial position is a key metric when considering the long-term financial sustainability of an organisation. The underlying surplus is calculated by taking the planned financial position, adjusting for the full year effect of expenditure commitments/savings and removing non-recurrent items. The underlying surplus (as submitted in our plan to NHSE in February 2018) is 1.9% of total expenditure in 2018/19. Table 3 - CCG Underlying Position 8

9 Contract Position The CCG has used the planning assumptions contained within this paper to estimate the contract values for 2018/19. The assumptions include adjustment for: demand growth, demographic growth, patient flows, national tariff, the new Midland Metropolitan Hospital trajectory and new investment. It also includes estimations for efficiencies and demand management. The CCG is currently negotiating its contracts for 2018/19. Where applicable, we will agree contract variations for the 18/19 contracts in line with national guidance. The progress will be updated in plans as appropriate. Primary Care Co-Commissioning The budget in respect of primary care co-commissioning is included within our financial plans and the attached GP Forward View plan. The allocation received in respect of primary care co-commissioning is 79.7m in 2018/19. Activity Growth Growth on activity has been determined by taking into account underlying historical growth trends, future demand and capacity, consideration of demand management initiatives and QIPP alongside the required delivery of the national Referral To Treatment (RTT) target. Quality, Innovation, Productivity, Prevention (QIPP) The financial plan has identified the gap between available resources and predicted levels of expenditure in 2018/19. The annual challenge is set out in the table below: 9

10 Table 4 In order to tackle the growing financial challenge in future years, a working group has been established with a programme focused on the RightCare opportunities that have been developed and recently published by NHSE. This tool again identifies where the CCG is an outlier in terms of expenditure, but also attempts to indicate the health benefit to patients. The above QIPP values exclude health economy wide price efficiency savings that equate to a further 20m. Running Cost Allowance In 2017/18, the CCG had a Running Cost Allowance of 11.5m. However, the CCG is forecasting to only spend 10.6m in this year. In 2018/19, the CCGs Running Cost Allowance will reduce to 11.4m. While the running costs of the CCG are still predicted to be affordable and within the Running Cost Allowance, the level of underspend will reduce. This expected increase in cost is caused by inflation (pay and non-pay) and incremental drift. Despite the additional growth in the CCGs allocation, the CCG faces some significant challenges during 2018/19 and there are some significant risks that need to be managed diligently in order that the statutory break even duty can be achieved in future years. The CCG takes these challenges seriously and has robust systems in place to address the situation. 3.3 Primary Care In our operating plan we articulated our intentions to invest in Primary Care above and beyond the core General Medical Contract. At the heart of our plans is the improvement of Primary Care via the Primary Care Commissioning Framework (PCCF). This is now entering its third year of commissioning and has been our main vehicle for incentivising and supporting general practice. An independent evaluation of the PCCF identifies that it is delivering tangible outcomes for our patients such as 10

11 improved access, reductions in strokes due to the detection of atrial fibrillation and higher detection and management of diabetes. We remain committed to delivering the GP Forward View (GPFV) and addressing the significant challenges faced by primary care as well as delivering the ambitious modernisation agenda and new care models. This refresh outlines the CCGs progress and achievement against the previously established ambitions detailed in the Operating Plan Ambition 1 - Improved Access From 1 September 2017, our member practices have been providing extended access to GP services, including evenings and weekends, for 100% of our population. This includes the commissioning of extra capacity to ensure access is available during peak times of demand, including bank holidays, Easter, Christmas and New Year periods. The CCG has been assessed for assurance in January 2018 by NHS England. These changes have been progressed in tandem with the CCGs Engagement team who are delivering an extensive communication package that highlights the extended GP access and listening to patients experiences. Ambition 2 Workforce In addressing workforce challenges we are: Actively collaborating with CCGs in the Black Country STP to develop the Primary Care Workforce Strategy. This entails recruiting our STP share of 129 Doctors allocated to us by NHS England. It is being delivered over the next two years using a variety of methods, including the use of the NHS England International Recruitment Programme. Working with our acute partner Sandwell and West Birmingham NHS Trust to develop a local scheme to enable clinically trained refugees to join the NHS locally. Aiming to retain a significant proportion of retirees and add to the current clinical fellowships we currently offer. By retraining the local medical/clinical refugee population we anticipate that this will ensure an adequate supply of GPs within our STP footprint. Supporting our practices that have been successful in applying for two schemes under the NHS England Clinical Pharmacists in General Practice programme. Focusing on new roles within General Practice. 23 of our member practices have trialled new roles such as Clinical Pharmacists and Physiotherapists through successfully using the Sustainability and Resilience and Vulnerable Practices funding in This budget was fully spent during Increasing the number of Physician Associates in primary care. Anticipating further information from NHS England in relation to the recruitment of Mental Health Therapists into primary care. 11

12 Continuing to deliver the Community Education Provider Network (CEPN). The CCG has strategies in place to recruit to new entry level posts, strengthen the skills of the current primary care workforce and attract an experienced workforce. The CEPN is the vehicle through which we commissioning education and training to meet the needs of the GPFV. Partnering with the Local Workforce Action Board (LWAB) to influence Primary Care workforce matters at STP level. Ambition 3 - Transformation Funding We have a robust plan for the utilisation of the 3 per head transformation fund which will be monitored via our Primary Care Commissioning Committee. Ambition 4 Primary Care Networks We are supporting our practices to galvanize themselves into populations of 30,000-50,000 patients in order to deliver new Primary Care Networks (PCN). Each PCN will have a bespoke development plan to help support their progression to mature provider groups who are able to work in partnership with other and often larger system providers. We have hosted a members event with national guest speakers, to promote the local and strategic benefits of developing Primary Care Networks and working in partnership to design local solutions to improve the outcomes of our patients. The Networks will identify local health challenges and co-design solutions in partnership with key stakeholders including patient representatives, social care and the voluntary sector. 12

13 Ambition 5 - Estates and Technology Transformation Fund (ETTF) We have received significant funding from the Estates and Technology Transformation Fund and progress against spend and delivery is monitored through the GP Forward View Monitoring Group, the Strategic Commissioning and Redesign Committee (SCR) and the Primary Care Co-commissioning Committee (PCCC). We have an agreed Estates Strategy and a delivery programme which includes timescales with identified additional revenue funding. The delivery of the plan is overseen by our bi-monthly Strategic Estates Review Group (SERG) which continuously monitors opportunities and the delivery of ETTF funding. Ambition 6 - High Impact Actions (Time to Care) With regards to our high impact actions we have: Used this framework to ensure that practices are using referral models for patient self-care and managing reductions in Did Not Attend (DNA s) as part of implementing the Time 2 Care programme. Gone out to tender for an organisational partner to deliver workflow optimisation training for all of our member practices. Procured a training provider to deliver training places for care navigation/active signposting. This training is aligned to the HEE bronze framework. Facilitated several member practices to delivering social prescribing models. Commissioned effective telephony training to clinicians to support the implementation of new consultations models. Commissioned an App called My GP to support patients in their self-care. Continue the use of the NHS Standard Contract and its new legal requirements for acute hospitals and community providers to relieve some of the administrative burden on GP practices. These changes are impacting positively in primary care. Ambition 7 - Primary Care Provider Development We continue to proactively work with our member practices and have held several focus groups to agree local solutions that will not only support general practice but also deliver the primary care transformation outlines in the GPFV. We have established a robust governance programme for the GPFV and it has two Clinical Lead sessions per week used to drive transformation in general practice. The GPFV Monitoring Group meets on a monthly basis and exists to assure Primary Care Commissioning Committee (PCCC) of delivery and forecast against financial spend and monitor all the component areas of the GPFV, 13

14 such as access, care re-design, workload, workforce, estates and information transformation. A quarterly stakeholder bulletin on the GPFV progress is made available for all members along with an update in our member s news electronic newsletter. This is supplemented through direct engagement with all member practices. 14

15 Ambition 8 - Delegated Primary Care Commissioning We are entering our third year of delegated primary care commissioning. The PCCC, which meets on a monthly basis, provides assurance that the CCG is discharging its statutory delegated functions. We have 82 General Medical Services (GMS) contracts and three Alternative Provider Medical Services (APMS) Contracts. Ambition 9 - Medicines optimisation for care home residents Our Medicines Quality team is working in collaboration with the other medicines management teams across the STP to develop a networked infrastructure comprising commissioners, providers, regulators, professional bodies and patient groups. Our plans for 2018/2019 We aim to: Build on the progress and achievement from 2017/2018. Continue to commission improved access for 100% of our patient population. Continue to listen to patient experience and use this valuable insight to improve services. Continue to improve primary care through the Primary Care Commissioning Framework (PCCF) as the main vehicle for incentivising and supporting general practice. Commission the investments planned against the 3 per head of population general practice transformation support. Continue to actively work with our Primary Care Network groups and assist in their growth and development. Work with our Acute partners at Sandwell and West Birmingham NHS Trust to develop integrated systems across primary and secondary care. Support practices to apply for the sustainability and resilience funding via NHS England. We anticipate any funds from these budgets for 2018/2019 will be fully committed and spent by 31st March Continue to commission and deliver on schemes that support the 10 high impact actions such as: workflow optimisation; care navigation/active sign posting; online patient self-care package; social prescribing, partnership working and stream lining of back office functions. Deploy self-service kiosks in to general practice to assist with workload. Continue to establish new roles in primary care and increase the workforce as a whole. Working across the STP deliver our share of GPs required to ensure sustainability in local general practice. Continue to work with our acute partner Sandwell and West Birmingham NHS Trust to develop the local scheme to enable clinically trained refugees to join the NHS locally. 15

16 Continue to contribute as a partner on the Local Workforce Action Board (LWAB) and influence primary care workforce matters at STP level. Invest in schemes such as commissioning training and education for Nurses, Practice Managers, and HCAs, whilst supporting additional apprenticeships (including dual role apprenticeships supporting receptionists to become HCAs). Commit transformation monies into Information Technology to assist our member practices to trial alternative ways of ways of working. Commission the rollout of solutions to support the delivery of online consultations. Increase practices capacity management and facilitate remote working through the rollout of new digital telephone systems. Upgrade GP practices to Docman 10 to facilitate a more collaborative and streamlined working practices. Continue with CEPN as the vehicle through which we are commissioning significant levels of education and training to meet the needs of the GPFV. Deploy a team of pharmacists and pharmacy technicians in collaboration with the CCGs across the STP footprint who will link with the Local Authority and deliver the aims of the Managing Medicines in Care Homes NICE guideline and quality standards and the Enhanced Health in Care Homes (EHCH) framework for care home residents. This is dependent on the bid to Pharmacy Integration Fund being successful. 3.4 Urgent and Emergency Care Local acute providers continue to struggle to achieve the 95% 4 hour target performance target. In the 2017/19 Operating Plan we explained the multifactorial reasons for the poor performance in A&E. It included changing patient behaviours, a rising number of unfilled shifts at a trust level, reliance on bank and agency staff in ED, delays in clinical decision making, above predicted ambulance conveyances, higher than predicted attendances at A&E, internal patient flow delays and wider system issues such as, the pace of establishing community care packages and placements. During 2017/18 we have worked with urgent care system partners to address these issues. Specifically we have: Made good progress towards reducing Delayed Transfers Of Care (DTOC), by working with local authorities partners to reconfigure community step down services. Increased our Continuing Health Care discharge to assess capacity. Worked in partnership with the local urgent care system (via the A&E Board) to address the systems underperformed. The changes have included a 59% increase of patients streamed for emergency departments (ED) to medical assessment in December, the adoption of national best practice models such as red to green, consultant of the week, push/pull models. Despite these initiatives the West Midlands Ambulance Service (WMAS) conveyances to ED remains above plan and predicted contract performance. Increased numbers of NHS 111 contacts receiving clinical support and piloted direct booking into GP Practices. 16

17 Reviewed the local walk in centre services and the local transformational plans to assess the potential future service model. The current contracts expire in March Delivered the winter plan, which includes additional community capacity. Supported whole-system reviews of stranded patients. In partnership, have established a multidisciplinary Nursing Home Team to improve the quality in independent residential and nursing homes for older adults (rated requires improvement) and reduce risk of further market failures. Increased the capacity in the local Short Term Assessment and Reablement (STAR) service to make this the default service home. Continued to work towards 20/21 target of all acute hospitals having Mental Health crisis and liaison services (for all ages) and deliver Core 24 MH liaison standards for adults in 50% of hospitals, subject to successful recruitment. Ensured 100% of the population have appropriate access to enhanced services via the Integrated Urgent Care 111 Clinical Assessment Service. Met the 50 % of 111 calls receiving clinical input. Implemented the Ask NHS App. Our plan for 2018/19 Building upon progress made in 2017/18, we will continue to work with providers to ensure that the four priority clinical standards for seven day services and the five elements of the A&E Improvement Plan and progress with the development of Integrated Urgent care are achieved. We will: Stratify the patient cohort and develop local plans to address the needs of particular groups, for example there has been a 6% increase of emergency admissions for people aged 80 and over, they are more complex and experience excessive lengths of stay (over 21 days) which accounts for 15.6% of all emergency bed days. Continue to work with partners to ensure that aggregate performance against the four-hour A&E standard is at or above 90% by the end of September 2018, and 95% by March

18 Refine specifications for ambulatory care units at City/Sandwell in line with national best practice and local need. Also to ensure an interface with the NMC programme to support a stronger primary/community offer for urgent care sensitive conditions. Build on the mobilisation of the new Integrated Urgent Care service to ensure patients can access clinical advice and support and can be provided with certainty and choice through pre-booked appointments at appropriate services. Expand take up of the NHS 111 Online App service and develop web based version. Develop pharmacy services from the Clinical Assessment Service (CAS) including electronic prescribing. Develop in conjunction with Mental Health, 111 and NHSE, a new Mental Health crisis assessment module. Implement region-wide direct access for paramedics to the Clinical Assessment Service to obtain advice to reduce conveyances to A&E and increase see and treat rates. Work closely with 999 and IUC providers to maximise potential benefits offered by the new Ambulance Response Programme standards and IUC models of care. Work with system partners to refine plans for the new emergency and urgent care services and ensure a robust communications plan is in place supporting patients to choose the rights points of access. Support self-care - development of a proposal via the West Midlands Urgent & Emergency Care Network to deliver a more tailored approach to self-care via Integrated urgent care and local adoption and implementation of these plans. Implement the urgent care demand management project with CCG membership. The pilot scheme already completed will be introduced across the CCG to proactively develop care plans for patients. Improve mental health services to better meet the needs of people accessing emergency services with a mental health illness. Through the Sandwell and Birmingham Better Care programmes, continue to develop plans for the implementation of the joint Sandwell and West Birmingham Strategy for Intermediate Care, which aims to address timely planning for discharge, supporting patients in their own home and promoting Independence. Continue to work towards 2020/21 deliverable of all acute hospitals having Mental Health crisis and liaison services (for all ages) and deliver Core 24 MH liaison standards for adults in 50% of hospitals, subject to successful recruitment. Continue to make progress to ensure technology is enabled to support direct booking from IUC CAS into local GP systems by March 19 and 50% of UTCs by May Designate UTCs in 2018/19 to meet the new standards and operate as part of an integrated approach to urgent and primary care. Work with local Ambulance Trusts to ensure the new ambulance response time standards are met by September 2018 and handovers between ambulances and hospital A&Es do not exceed 30 minutes. 18

19 Continue to make progress on reducing delayed transfers of care (DTOC), reducing DTOC delayed days to around 4,000 during 2018/19, with the reduction to be split equally between health and social care. Continue to work with partners to focus specifically on reducing inappropriate length of stay for admissions, including specific attention on stranded and super stranded patients who have been in hospital for over seven days and over 21 days respectively. Continue to work towards the 2020/21 deliverable of all acute hospitals having mental health crisis and liaison services that can meet the specific needs of people of all ages including children and young people and older adults; and deliver Core 24 mental health liaison standards for adults in 50% of acute hospitals, subject to hospitals being able to successfully recruit. Continue to develop out of hospital discharge to assess capability to deliver less than 15% of NHS continuing healthcare full assessments take place in an acute setting. Continue to increase the number of patients who have consented to share their additional information through the extended summary care record to 15% and improve the functionality of e Summary Care Record (escr) by December Working with the CCG Engagement team to consult on the future service model for improved primary care access and same day access (walk in centre activity). 3.5 Referral to Treatment Times and Elective Care Over the last three years we have initiated a range of programmes to support effective demand management of planned care: 2013/15 General practice peer reviews 2013/15 Referral management services (for groups of practices and specific long term conditions) 2013/16 Commissioned a range of primary care led speciality services (i.e. cardiology, dermatology, gynaecology) 2014/15 Audited every practice access and productivity flows and initiated individual project plans 2014/16 The establishment of 10 Population Management Pilots sites covering a total population of 210,000 (pre the initiation of the West Birmingham Vanguard) 2015/16 Developed and expanded the West Birmingham New Model of Care Vanguard Connected Care Partnership) 2015/16 The development of an acute led Consultant Advice and Triage Service 19

20 2016/17 Initiated a new Primary Care Commissioning Framework to improve horizontal integration between practices, reduce variation in access, increase community diagnostic provision and proactively target the health and wellbeing of carers, people with enduring mental health illness and people at risk of coronary heart disease, stroke and diabetes. With the exception of the Primary Care Commissioning Framework, which is a long term strategy designed to support General Practice work towards delivering new integrated placed based models of care, all the above initiatives have had a marginal positive impact and/or increased costs. Lessons learned from our attempts to manage demand clearly show that in order to manage demand effectively we need to balance the aspirations of providers, with an incentive structure that supports transformation, aligns to quantifiable patient outcomes and is supported by a workforce with the required capacity and capability. Our plan for 2018/19 Continue to listen to the experience of our patients and use this valuable insight to improve the quality of services. To continue the agreed trajectory to halve the number of 52 week breaches. To have invested in and have robust plans to maintain minimum waiting lists at the March 18 position. To actively encourage and facilitate the formation of partnership working between Acute providers and Primary Care Networks, so that they can codesign care pathways that focus resources on prevention, self-care, enhanced community care and reduced reliance on care in an acute setting. New Models of Working We have long since understood that patient experience needs to be at the heart of what we do, but that functional organisational form behind this doesn t always work. We need to find a way of making all providers (at every level) work more closely and reduce any silo provision which can create a transactional rather than transformational experience for patients. Following significant involvement in both the local vanguard and understanding lessons learned by other vanguards on a national level, we realised that there was not one answer to solve this issue. Rather, we need to work from both a bottom up and a top down basis simultaneously in order to really achieve meaningful system change - something that would be truly felt by patients in the operational delivery of their health and social care requirements on a day to day basis. In order to achieve this, we have: Completed a listening period to ascertain what our patients think about their health care services. 20

21 Worked as a partner organisation with Care Connected Partnership in order to obtain the learning required from a Vanguard area, to replicate this across the entire CCG area and to ensure equity of care provision for our patients. Worked with the national teams to learn from other vanguards across the country. Contributed to the national discussions on how this should be funded and what would be most appropriate for the patients of Sandwell and West Birmingham. Commenced strategic discussions with statutory organisations across locality, including health and social care partners, to explore and progress integrated care provision for our patients. Engaged with the Acute Trusts, community based Providers, mental health providers, primary and care has been initiated at two separate system wide stakeholder events. This has also commenced with the Third sector. Developed a place based strategy for Sandwell and West Birmingham. Fostered close working relationships across both health and social care business intelligence departments to facilitate a system wide response rather than the traditional silo working. Extensively scoped and explored procurement options and identified associated risks. Subsequent discussions identified the desire to foster and progress closer working relationships with existing providers to allow a truly integrated response to the needs of the local community rather than a fullscale procurement. Written a draft outcomes framework which is due to be shared with both statutory and voluntary providers. Our Plans for 2018/19 Continue extensive engagement with statutory providers and all other stakeholders towards the delivery of an integrated provision. Undertake further work with the Third Sector to allow community-based mapping to be progressed. This will facilitate the Primary Care Networks to appropriately utilise social prescribing. Continue to develop the local outcomes framework with providers and patients. Continue working in conjunction with the newly formed Birmingham and Solihull CCG to ensure most appropriate place-based provision for the people of Western Birmingham. Further develop the local placed based model of care and rollout of the final version of the placed based strategy. Encourage the Primary Care Networks to actively engage their patient representatives in the co-design service improvements. The delivery of an integrated placed based model of care designed to meet the needs of the local population is a key component of our local strategic plans to ensure the health and care system is sustainable when the new Midland Metropolitan Hospital opens. 21

22 3.6 Cancer We have an established Cancer Steering Group bringing together multidisciplinary stakeholders to focus on and drive the cancer agenda across the local economy. This group has provided the direction, support and challenge across the local system to enable stakeholders to effectively collaborate and deliver a range of initiatives that are positively impacting on patient oriented and co-ordinated care, improving service performance and contributing to our ambition of better cancer outcomes for patients. In our Operational Plan we set out our ambition for cancer and in this refresh we outline our progress against these ambitions. Each ambition is outlined followed by a summary of progress and/or achievement. Ambition 1 - Work with Public Health to address the causes of cancer, particularly reducing smoking prevalence to less than 13% by 2020 Public Health is embedded as a core member of the cancer steering group. Several joint media campaigns / messages have been implemented over the past year. Collaboration with public health to explore significant event audits (SEAs). Ambition 2 - Increase screening rates through work by the Cancer Research UK (CRUK) facilitator and other activities The CRUK facilitator has now visited 70% practices, prioritising practices with the lowest screening uptake and those who had a high number of emergency presentations. GP practices have been supported to develop action plans outlining how gaps will be addressed, particularly around screening uptake. GP practices are revisited at six, nine and 12 months to explore progress and offer support. The facilitator has encouraged GP endorsement and e-communications sign up and both have significantly increased over the past year. Public Health has developed several media campaigns to encourage screening uptake. The Cancer Steering group established a screening sub-group meeting who have developed an action plan to outline what they key priorities are in 2018/19. The Primary Care Commissioning Framework (PCCF) has been updated to ensure screening still remains a priority and to support GP endorsement / e- communications sign up and to identify Cancer Champions. A non-clinical education event has been planned for May 2018, aimed at practice administration staff and Practice Managers. This will ensure a basic awareness of the cancer support available. 22

23 Ambition 3 - Increase in cancers diagnosed at an earlier stage through screening and other activities In addition to the activities described in point two: Implemented electronic referral service (ers) for all two week waits. Developed and implemented new two week wait forms with referral criteria included. Developed and implemented new two week wait patient information leaflets. Collaborated with Sandwell and West Birmingham NHS Hospitals Trust (SWBHT) to agree and implement Straight to Test approaches commencing with Straight to Test for Suspected Colorectal Cancer. Ambition 4 - Increase in one year survival rates through increase in screening, earlier diagnosis and work with the Macmillan Primary Care Facilitator (Holistic Needs Assessments, Treatment Summaries, Cancer Care Reviews etc). Establishing current/baseline position with respect to living with and beyond cancer. Mapping current services providing support to people living with and beyond cancer to identify gaps in current service provision and in order to develop a directory of services. Commenced the development of a joint living with and beyond strategy with SWBHT to include a detailed action plan to address any identified gaps. Applied to Macmillan for a nurse facilitator to work with and support primary care. Further work is being undertaken on the bid following feedback to 23

24 consider what support is needed, including ensuring good cross-over between both primary and secondary care. Supported the roll out of a Macmillan-funded Citizens Advice Bureau (CAB) service providing welfare and benefits advice to those living with and beyond cancer. Ambition 5 - Raise patient awareness through a structured communication and engagement plan covering all of the 3 strategic priorities (early diagnosis, living with and beyond cancer, breaches) A plan has been developed including key communication and engagement activities across priority areas. The final draft is to be presented at the Cancers Steering Group meeting in March Ambition 6 - Monitor the achievement of the two week wait, 31 day and 62 day standards Performance sub-group established with representatives from quality, contracting, commissioning and SWBHT. Also performance monitoring 104 day breaches and inter-provider transfer breaches (onward tertiary referrals after day 38). For every 62 or 104 day breach SWBHT are conducting a breach reason analysis and a breach action plan, identifying lessons learned and identifying whether or not the patient came to any harm as a result of the breach. SWBHT very rarely breach, however we are now exploring opportunities to collaboratively work with other commissioners / trusts to assess if we can further reduce the number of CCG breaches. Ambition 7 - Implement ers for two week wait referrals Completed as outlined in point 3. Ambition 8 - Develop direct access to diagnostic approaches as appropriate Straight to test for suspected colorectal cancer to be implemented in March

25 Ambition 9 - Support the SWBHT to implement the inter-provider breach allocation policy Partially implemented, ongoing system challenges regarding Oncology and information technology are impacting on progress. Ambition 10 - Explore initiatives for breast and prostate follow up pathways Stratified breast pathway implemented and is to be reviewed. Prostate pathway not yet implemented as we are awaiting publication of the best practice pathways via the Accelerate, Co-ordinate, Evaluate (ACE) schemes. Additional work that has been undertaken in 2017/18 not outlined in the original operating plan for Jointly established and participated in collaborative cancer commissioning groups across the Black Country and BSOL STP areas to ensure a more joined up approach. Maintained participation on peer reviews at SWBHT to confirm, challenge and ensure awareness of local issues. Participated in system discussions regarding the provision of Oncology care in the future. Our plans for 2018/19 Build on the progress and achievements from 2017/18. Implement our comprehensive communications and engagement plan for Cancers. Strengthen collaboration and partnership working with SWBHT and partners across the STP footprint to design, develop, implement and review pathways, including diagnostics; based on national guidance / best practice to ensure that the 28 day Faster Diagnosis standard can be achieved by Implement the straight to test pathway for suspected colorectal cancer. Explore opportunities to further increase screening take-up. Explore the opportunity for lung health checks for those at risk of developing lung cancer. Complete the gaps analysis and directory of services for the living with and beyond (LWAB) cancers workstream. Complete and implement the LWAB strategy. Submit revised Macmillan bid to increase support those living with and beyond cancer. Work with primary care, secondary care, facilitators and other stakeholders to fully implement the recovery package. Continue to monitor and address any breaches in the eight waiting time standards. Implement the communications and engagement plan. 25

26 Support the development of long term plans for local Oncology provision (12 15 months) through experience led commissioning approaches and patient engagement/ consultation. 3.7 Mental Health In the Black Country and West Birmingham, men and women with severe and enduring mental health problems in contact with mental health services have a lower life expectancy than the rest of the population. Further, mental health service users experience higher mortality rates across all major disease groups. Whereas cancer is the leading cause of death for the population as a whole, circulatory disease is the most common cause of death for mental health service users. Approximately 1 in 5 of all A&E attendances and emergency admissions relate to mental health service users. Tackling inequalities for people with mental health illness requires concerted effort. It is therefore our intention to commission mental health services in collaboration with other Black Country STP commissioning partners. As one commissioner we will substantially reduce the current unwarranted variations in the quality of care, we will standardise services, and create an environment in which our providers can maximise resources and workforce through better skill mix utilisation. This approach will build on the Transforming Care Together (TCT) partnership vision to create synergies and improve the experience of Black Country and West Birmingham residents affected by Mental Health and Learning Disabilities (MHLD). By sharing best practice and aligning to the work of other agencies we will reduce variation, improve access, choice, quality and efficiency and collaborate to develop new highly specialised services in the Black Country and West Birmingham (eg Children s Tier 4, secure services and personality disorder services). Overall, our approach to harmonise and standardise will: Simplify access to services improving health and wellbeing for users, families, staff and communities. Put in place common, responsive and standardised all age Early Intervention services. Combat variation in care and service delivery across the Black Country and West Birmingham. Ensure clear, simplified pathways for users, ensuring most effective use of resources, achieve economies of scale for providers and reduction of duplication. Improve utilisation in front line services through better skill mix usage and reduction in temporary and locum costs. To date we have: Developed an Early Intervention in Psychosis (EIP) service specification at STP level. Current performance of 83% in SWB above target. Ensured that health checks are embedded in the PCCF. 26

27 Planned a pathway review for crisis care in mental health working with Black Country Partnership Foundation Trust (BCPFT) and Sandwell Local Authority. This incorporates crisis care, community treatment, crisis care at home as well as a community place of safety. Planned a case for change and defined a delivery model for Improving Access to Psychological Therapies (IAPT)- integrating physical and mental health through primary care. Completed a comprehensive service review of mental health well-being services. Undertaken high-level discussions with local authority on the planning requirements for suicide prevention. Working with the Engagement team, have used a co-design approach to review mental health and wellbeing services which reached over 100 service users and providers. We also used outreach sessions to reach seldom heard communities. These insights will have a significant influence over the commissioning of future services. Our plan for 2018/19 To sustain EIP performance throughout 18/19 (minimum of 60% by 2020/21 required). Ensure all GP practices signed up to health checks for mental health by April To work towards and proactively deliver the One Commissioner approach for mental health services across the Black Country STP. Working at STP level, to define the pathway and delivery model for integrated crisis care (based on integrated urgent care model), by June 2018, incorporating acute mental health liaison plan/investment, referral pathway for MH/well-being, transition plan for Midland Metropolitan. To complete the case for change for IAPT Long Term Conditions with the planned implementation of IAPT with Diabetes Respiratory Clinics by September This will ensure that the 19% target is met by March To successfully procure the mental health well-being service. Mobilise a new service specification for carers support. Work with SMBC to complete the draft of the suicide prevention strategy. Continue to progress the working relationship with Birmingham Joint Commissioning Team (MH) to ensure alignment for West Birmingham. To commission additional psychological therapies integrated within primary care. To reduce out of area placements for non-specialist acute care. To increase crisis support and supporting those in crisis who present to A&E. To improve the dementia diagnosis rate in line with the national diagnosis rate of at least two thirds of estimated local prevalence, with due regard to the forthcoming NHS implementation guidance on dementia focusing on postdiagnostic care and support. To work in partnership with voluntary organisations to develop community support post diagnosis for patients and carers. 27

28 3.8 People with learning disabilities We have engaged with people with learning disabilities, their families and carers as part of the Transforming Care Programme. We are also working with Community Catalysts a project to support people with Learning Disabilities to lead a good life once they leave hospital. The project focuses on what people can do rather than what they cannot do. Feedback to date has been positive from both the project and people with learning disabilities who are leaving assessment and treatment beds in hospital. Working in partnership, we have established a Black Country STP one commissioner approach to deliver the Transforming Care Plan. By working as one commissioner alongside providers and NHS Specialised Commissioning, we have made progress towards delivering the vision set out in Building the Right Support and the National Service Model by: Building on existing collaborative commissioning arrangements, to commission at sufficient scale, to manage risks, to strategically commission for a relatively small number of people whose care packages are complex and very expensive. Facilitating improved local health services for people with a learning disability and/or autism. Working collaboratively to deliver Building the Right Support (the National Plan) across the STP footprint, to reduce reliance on inpatient care. Improving quality of outcomes for people with learning disabilities and/or autism through the development of standardised outcome measures, care pathways and clinical services. Strategically decommissioning inpatient assessment and treatment beds and decreasing the dependence on inpatient services across CCG and NHSE commissioned beds from 119 in December 2016 to 70 in February Continuing to work towards improving health care for people with a learning disability so that by 2020, 75% of people on a GP register to receive an annual health check. We have commenced a GP register cleanse to ensure they are up to date and families/carers understand the importance of health checks. This has been supported by learning events for primary care. Working with other health care providers to ensure reasonable adjustments are taken to enable people with learning disabilities to have equity of access to services. Reviewing the costs of care packages and out of area placements in order to improve sustainability and utilisation of local inpatient units. Working with the Engagement team, we have provided learning events for primary and community staff. Working with the STP to develop a new clinical community model which incorporates two new services: the Community Forensic service and the Community Intensive Support service. Both of these are designed to support complex patients within their own homes and community rather than in a hospital setting. 28

29 Working with Black Country Partnership Foundation Trust (BCPFT), utilised the Care and Treatment Review (CTR) process, to ensure all hospital admissions are appropriate. Continuing to implement findings and recommendations from the Bristol University Learning Disability Mortality Review Programme (LeDeR) in relation to reducing premature mortality rates. Our plan for 2018/19 We continue to work towards reducing the national aggregate level of admissions by 35% to 50% by March To achieve this improvement we are placing particular emphasis on reducing the number of long-stay inpatients, the number of inappropriate admissions and improving equity to health to reduce premature mortality. We will continue to: Improve access to healthcare for people with a learning disability, so that the number of people receiving an annual health check from their GP is 64%, higher than in 2016/17. Provide training for primary care to improve care management, reasonable adjustments and the quality of the annual health check. Invest in community teams to avoid hospitalisation, including the use of the Transformation Fund and the mobilisation of the two new community specifications (Community Forensic and Community Intensive Support). Utilise the CTR process to reduce admissions, by providing alternatives to hospital admission. Ensure more children with a learning disability, autism or both get a Community Care, Education and Treatment Review (CETR) either before admission ore immediately post admission, so that other options are considered before they are admitted to hospital. To tackle premature mortality by supporting the review of deaths of patients with learning. 3.9 Children and Young People Mental Health Services (CAMHS) Significant progress has been made in respect of CAMHS and our commitment to fully transform local services in line with both the FYFV & FIM by We have: Commissioned a NICE compliant Eating Disorder (ED) service and developed a single ED service specification across the STP footprint. Made progress to ensure that we achieve the access target for children and young people by additional 35%. A project, supported by the STP has commenced between the Local Authority and Third Sector partners to address the existing data gap and to ensure that all the CAMHS activity is captured irrespective of the where provision is accessed. Refreshed our 2017 Local Transformation Plan (LTP).This was submitted in October 2017 and gained full assurance from NHSE. Continued to expand the children and young people IAPT programme with additional funding being provided by NHSE/HEE. 29

30 Reduced the numbers of children and young people requiring Tier 4 admission as a direct impact of the new Crisis Intervention and Home Treatment service (CIHT) as they are now more likely to be supported with treatment packages within their own home. Seen the positive impact of the Early Years Psychology post (supporting ASD diagnosis) which has successfully reduced the waiting times for CYP assessment and diagnosis of ASD via the MAA (Multi Agency Assessment). Our Plan for 2018/19 Robust monitoring of the national ED waiting times standard of 95% (referral to treatment). Undertake a comprehensive service review of the ED service, in collaboration with Black Country STP commissioning colleagues, with a focus on NICE compliance and quality. Ensure that all CAMHS activity is captured via the MHDS, which will help us to monitor progress against the access target. Continue to support the CYP IAPT programme with the East Midlands consortium and ensure all allocated funds from NHSE/HEE are utilised. Increase the Early Years ASD post from 0.6WTE to 1WTE to further support assessment and diagnosis of ASD - local evidence identifies increased demand on the MAA. Prepare for the CAMHS LTP refresh. The request from NHSE is expected in August Maternal and Infant Health The Operational Plan highlighted why improving maternal and infant health is a local priority as well as a national must do. For our CCG, the following is the case: Our outcomes are worse than comparator areas, resulting in more local demand for services. We have higher levels of low birth weight babies. This typically results in longer hospital stays and increased likelihood of neonatal intensive care use. We have higher rates of low birth weight babies, which increases the likelihood of emergency admissions for lower respiratory tract infections and gastroenteritis in the first months. Obesity and diabetes is increasing in the women of childbearing age, and the use of fertility services are all increasing. These factors increase the risk of a safe birth for both mother and baby. We have a higher than national average infant mortality rate. We have high levels of deprivation, teenage conceptions and smoking, all of which contribute towards the poor maternal, infant and child outcomes. In this refresh we outline our actions we have taken during 2017/18 to address local poor maternal and infant health outcomes. Each ambition is outlined followed by a summary of progress and/or achievement. 30

31 We have established a Maternity Voices Group and held maternity coproduction events. The voices of our patients have informed the development of the Maternity Strategy and driven the changes we have made. We have worked with partners across organisational boundaries to review and develop a maternity pathway that supports personalisation, safety and choice, has access to specialist care whenever needed. Through partnership working we have developed a new maternity service specification. Working with partners we have developed a single view of maternity and neonatal service capacity, and the implementation of the national Better Birth recommendations. This will support the improvement in the quality of care, make care safe, as well as giving women greater control and more choices. Together we will engage with the people who use these services and create a more person-centred and sustainable model of care for maternity and neonatal services. We have used contractual tools to improve performance within our providers to address obesity and smoking in pregnancy. We have worked with partners across the Local Maternity System to deliver a local maternity plan which outlines how the system will deliver improvements in safety towards the 2020 ambition to reduce still births, neonatal deaths, maternal death and brain injuries by 20% and by 50% in The plan includes the full implementation of the Saving Babies Lives Care Bundle by March We have developed a new perinatal mental health service model. We have focused on the flow of communication between providers particularly between primary care and maternity services, by advancing the mobilisation of Badgernet. We have commissioned the Bethel Doula project to support hard to reach and vulnerable women. Our plan for 2018/19 Maternal and infant health is dependent upon a multitude of economic psychosocial factors which need to be addressed in partnership. Over the next year we will: Continue to develop solutions with our partners specifically our main maternity provider and Public Health teams. Increase the number of women receiving continuity of the person caring for them during pregnancy so that by March 2019, 20% of women booking receive continuity. Continue to increase access to specialist perinatal mental health services, working with providers to align services across Birmingham Women s Hospital and the Black Country. This includes applying for national funding to support the change in the model of care. If successful the funding to be allocated to the CCG baseline in 2019/20. Work with providers to ensure delivery of the new maternity and perinatal mental health models across the Black Country and West Birmingham. Continue to engage patients. We will facilitate two Whose Shoes events across Local Maternity System. 31

32 We will continue to work with Clevermed (the provider of Badgernet) to develop a cloud based system to improve access and enable women to access their records electronically. Continue to align maternity specifications and performance indicators across the Black Country STP. We will review of the homebirth services to increase women choice. Develop the Infant Mortality Localised Integrated Plan with associated performance indicators. Review and develop localised pathways to signpost to key services. Work in collaboration with Sandwell and West Birmingham hospital to secure Baby Friendly status. Develop a Community Midwifery Hub model (which is interdependent on the development of pathways across the Local Maternity System (LMS). As a partner of the LMS sub-committee we will deliver the Local Maternity System Plan which aims to develop clinical pathways, revision of the payment system and address workforce planning/ multi-professional training. 32

33 4 Complex Care and Personal Health Budgets Personal Health Budgets (PHBs) We began 2017/18 with a very low baseline of personal health budgets (PHB). To address this and achieve the CCG trajectory towards the Mandate targets, a multifactorial approach was taken which involved: Reviewing current continuing health care patients and assessing the likely benefit to the individual of a PHB. Care package characteristics identified via the CONI QA patient management system were used to facilitate a targeted approach. Allocating potential recipients to a case manager. Dedicating a lead nurse responsible for delivering the PHB project. Training staff and providing supervision to ensure consistent capability and confidence across the clinical team. Developing and distributing accessible information to promote the benefits of PHB. Enabled patients to make an informed choice. As a result the CCG has increased the uptake of PHB to 33 and is on track to meet the planned trajectory of 55 cases. The 2018/19 planned trajectory is a further increase of 28 cases, bringing the trajectory to 83. Our plan for 2018/19 Further increases in activity volumes will be achieved through expansion of PHB into patient groups not eligible for CHC, by identification of target groups and engagement with lead commissioners for these areas. As funding of care for individuals will fall outside existing CHC provision, analysis of existing block contract arrangements will be required to determine potential funding mechanisms; this is likely to delay full implementation until 2018/19. Actions to achieve required governance improvements for the larger cohort resulting from these interventions will include the ratification of a revised PHB policy to provide a governance framework that encompasses all patient groups as well as the procurement of an expanded brokerage provision, completed via a procurement exercise or framework mechanism. In addition, revised KPIs for CCG and external functions will be implemented to enable effective performance management of all aspects of service delivery, with data reported via the CCG s Quality and Safety Committee. 33

34 Continuing Healthcare (CHC) In 2017/18 we continued to improve performance and responsiveness of the Continuing Healthcare function by optimising capacity and improving engagement with the wider health and social care economy. This was achieved by: Increasing available capacity in the clinical and administrative team. Implementing an enhanced IT functionality to support paperless working and increase efficiency within the assessment process eg tablet technology. Increasing discharge to access capacity. Introducing a pool staffing model which can be flexed during periods of high demand. Introducing provider self-billing/mandated payments to reduce invoice processing time and improve efficiency. Working collaboratively with local authority colleagues to ensure issues and concerns are addressed quickly. At the beginning of 2017/18, 60% of CHC assessments happened in an acute hospital setting, the CCG has made steady progress to improve its performance and move toward the target of not more than 15% CHC assessments conducted in hospital. We have also improved our timescale-to-decision performance, the national average is 58% and the CCGs quarter three performance was 76%. Our plan for 2018/19 In 2018/19 we will: Continue to work with providers and local authorities to improve the early identification and co-ordination of assessments. Continue to develop robust integrated care pathways between health and social care partners to reduce the use of CHC assessment as a gateway mechanism for non-chc health funding. This approach will support provision of care to those with needs below the CHC threshold at an earlier stage, potentially reducing the reliance on other services, while increasing responsiveness and capacity for assessment and case management for those individuals whose needs are of a nature, complexity, intensity, and unpredictability that would confer eligibility for CHC. Focus on education of health and social care professionals to increase the identification of eligible individuals. Training to primary care professionals will be delivered via established protected learning time mechanisms, with targeted interventions for individuals in partner organisations delivered to both raise awareness and address operational issues as they emerge to support referral quality. Raise patient and carer awareness of their rights to an assessment through engagement with local voluntary organisations and advocate groups, and through development and distribution of printed information to key health and social care locations. Implement a discharge home pathway for those patients who are deemed appropriate to return to a home environment. Interim health funding providing 34

35 domiciliary care will be prior to assessment (set at Social Services level of care provision to avoid transfer of care issues for patients not meeting CHC eligibility). Continue to improve our timescale to decision performance, the national average is 58% of assessments are completed with 28 days. The CCGs aims to achieve and maintain 80% by the end of 2017/18 and continue throughout 2018/19. 35

36 5 RightCare Priorities Sandwell and West Birmingham CCG is participating in the national NHS RightCare programme. The CCG and NHS England agreed on the following three programmes areas to be prioritised in 2017/18: 1. Endocrine (diabetes) 2. Respiratory 3. Cancers Endocrine (diabetes) There are 39,540 people diagnosed with diabetes in the Sandwell and West Birmingham CCG population (QOF 2016/17). 9.1% of the CCG adult population (17 years and over) are diagnosed and living with diabetes. This is an increase of 1,268 patients (3.3%) diagnosed with diabetes in the last 12 months based on GP practice registers. Public Health England estimates suggest that the number of people living with diabetes in the CCG population is 50,123 (2017) suggesting there are an estimated 10, 583 people currently undiagnosed. It is important that diabetes is diagnosed, to prevent disease progression and associated symptoms, as well as prevent further complications associated with diabetes. A key aspect of the diabetes pathway is preventing disease. The risk factors associated with type 2 diabetes are well known, particularly lifestyle factors including exercise, diet and weight management. The CCG are actively working with public health colleagues in local authority who commission lifestyle and well-being services to optimise the impact and benefit of these services for our population. SWBCCG participate in the National Diabetes Prevention Programme (NDPP) which aims to positively influence and impact on people classed as pre-diabetic (recorded as having a raised blood glucose but below diabetic levels). The following points summarise the progress that has been achieved in 2017/18 against the plans outlined in the Operating Plan The diabetes steering group have led the development and delivery of the diabetes strategy and plans, incorporating the opportunities identified by NHS RightCare. We have collaborated with public health colleagues to optimise the utilisation of commissioned lifestyle services to prevent or delay the onset of diabetes in people identified of being at risk. GP practices have referred 3,340 patients in 2017/18 to the NDPP exceeding the anticipated activity by 9%. Approximately 50% of patients referred attend the programme which is in line with national performance. The Primary Care Commissioning Framework (PCCF) for 2017/18 includes a standard for diabetes that encourages GP practices to proactively assess, diagnose and appropriately manage diabetes, including actively referring newly diagnosed patients to structured education programmes locally. All GP practices 36

37 have access to a care plan template developed by the diabetes steering group with local clinical input. The percentage of diabetic patients achieving the three treatment targets (blood pressure, blood glucose and cholesterol) stated in the Improvement and Assessment Framework (IAF) is 44.1% (2016/17) an increase from 43.6% (2015/16). The CCG remain above the England average of 41.1%. Diabetes in Community Extension (DiCE) service continued to provide joint and virtual clinics between primary and secondary care clinicians. The impact of this service is currently being evaluated. 98.9% of our GP practices (90 of 91) participated in the National Diabetes Audit (NDA) in 2016/17. This is an improvement from 83.2% in 2015/16 (84 of 101). Attendance at structured education programmes by newly diagnosed diabetic patients has improved with 2.6% of type 2 diabetic patients attending a programme within 12 months of diagnosis (2015) from 1.3% (2014). However, this remains below the national average of 7.4% (2015). The CCG have worked with the service provider to encourage improved patient participation by offering sessions at a wider range of locations and times. A number of clinical educational events have been held to support GP practices to improve the proportion of referred patients converting to attendances. 37

38 Our plans for 2018/19 Assess and review the current diabetes pathway with local stakeholders to develop an optimised pathway locally. Continue to work in partnership with public health colleagues in local authority to embed and maximise opportunity available to prevent diabetes through the provision of lifestyle services. Build on the initial success of people being referred and attending the NDPP. Collaborate with service commissioners to ensure that the service has the capacity to meet the need for the service locally. A revised diabetes standard will be embedded within the PCCF to build on the success of previous years. The standard will have a focus on supporting the delivery of opportunities identified through NHS RightCare that primary care can influence. Structured education enables newly diagnosed patients with diabetes to be empowered regarding the condition. A review of the current service offering and an assessment of how we can deliver services to significantly improve uptake of structured education will be undertaken to meet the needs of patients. Analysis of primary care prescribing will be undertaken to explore opportunity highlighted within NHS RightCare. A formal evaluation of DiCE will be completed to assess the impact of the service. Quarterly diabetes clinical education events are planned on focused topics to support local clinical colleagues. Respiratory The latest NHS RightCare commissioning for value information shows that respiratory represents our most significant opportunity in terms of outcomes, spend and the two elements combined. The opportunities relating to outcomes include; improved diagnosis, improved disease management and reduced premature mortality. There are also indicative spend opportunities relating to non-elective admissions and primary care prescribing. Respiratory as a programme covers a range of conditions, however asthma and chronic obstructive pulmonary disease (COPD) are the two most significant conditions in terms of the number of people living with the conditions and the utilisation of healthcare services. In 2016/17 there were 32,214 people diagnosed with asthma (5.8% of the population) and 8,510 people diagnosed with COPD (1.53% of the population). Public Health England estimates suggest that there is a significant proportion of our population living with these respiratory conditions who remain undiagnosed. A proportion of respiratory conditions and exacerbations of respiratory conditions can be prevented through interventions, education and chronic disease management. Examples of interventions include smoking cessation support, influenza and pneumonia vaccination and jointly agreeing self-care management plans. 38

39 The following points summarise the progress that has been achieved in 2017/18 against the plans outlined in the Operational Plan We have collaborated with NHS RightCare to rollout and implement the COPD GRASP tool in all GP practices to support the diagnosis and management of patients on GP registers. This enabled GP practices to implement the elements requested within the respiratory standard of the PCCF. Due to unforeseen circumstances this software has been superseded by a local software solution. GP practices now have a clinical management plan template embedded in their practice systems that has been jointly developed by local stakeholders. A series of six educational training events where held for primary care staff on asthma and COPD. GP practices have undertaken medication reviews of patients with asthma and COPD. This has included reviewing the choice of inhaler and active ingredient, to ensure good compliance and the supply of cost-effective options. Joint respiratory clinics between primary care and community/secondary care have been piloted. SWBHT have commenced a Consultant of the Week scheme. This scheme enables a respiratory consultant to attend the medical assessment unit to review patients presenting with respiratory problems, provide care plans where appropriate and potentially avoid unnecessary hospital admissions. SWBHT have commenced monthly MDTs to review frequent respiratory hospital attenders. A care plan is agreed with input from a number of service providers including; hospital and community respiratory teams, palliative care, social services and communication to GP practice. Our plans for 2018/19 Collaboratively develop and deliver with community and secondary care bespoke education sessions for primary care. Progress the development of clinical templates for primary care clinical systems. Review and optimise respiratory pathways with stakeholders to ensure locally we deliver the right care, at the right time, in the right place. Revise the PCCF respiratory standard to support primary care to deliver optimal respiratory care. Develop an integrated respiratory service to effectively manage patients who are frequently admitted to hospital with local partner organisations. 39

40 NHS RightCare priorities 2018/19 The CCG and NHS England agreed on the following three programmes areas to be prioritised in 2018/19: 1. Circulation 2. Musculoskeletal 3. Neurology We will develop delivery plans with local stakeholders for the three programmes. The learning gained from developing the delivery plans for the three priorities in 2017/18 will be embedded in the process moving forward. 40

41 6 Quality Quality Goals Our local framework for quality is informed by national policy and is set against three main drivers: Planning for high quality services Developing and commissioning high quality services Assuring the services we have commissioned deliver a quality service. Our priorities build on national policy, the Health and Wellbeing Strategies of Birmingham and Sandwell, our commissioning strategy, the NHS Five Year Forward plan and areas of higher risk and identified concerns. Our quality goals will contribute to the delivery better care and better health for the population of Sandwell and West Birmingham for better value. Our overarching strategic quality goals are: Goal 1 - Compliance with National NHS Constitution Expectations We are fully committed to maintaining the minimum standards of care set out in the NHS Constitution. Where these are not being delivered by local providers we will instigate our established arrangements for recovery. These will be reviewed annually to enable us to improve our performance year on year. Goal 2 - Delivery of Local Quality Improvement Objectives We recognise that one of the most significant contributions to the improvement of the quality of services will be to transform the local health and social care system. In some instances such changes will need to be significant in scope. As part of this transformation we will prioritise a set of quality improvements we expect from our local providers and describe these in detail with specific measures and goals in our local CQUIN arrangements. Achievement of these quality improvements is monitored on a quarterly basis by the quality and safety committee. Goal 3 - Delivery of a Quality Team Operational Work Plan A quality team operational work plan will be developed to ensure delivery of our quality strategy and to sustain and improve our existing structures. It will be refreshed annually and outcomes monitored by the quality and safety committee through twice yearly reports. 41

42 Arrangements for Quality Assurance We have a system of quality assurance and early warning processes in place which provides information about the safety, effectiveness and patient experience of services we commission. This system enables us to be proactive in identifying early signs of concerns and take action where standards fall short. It also helps to inform our commissioning decisions at all stages of the commissioning cycle. Using Data to Assess and Improve Quality We monitor provider quality information and data for trends and themes, compliance with local and national requirements for all providers of NHS care including: Acute hospitals Care homes that provide nursing and residential care within the categories of elderly frail, mental health, learning disability, dementia, physical disability and brain injury for older and younger adults Community services Mental health services Independent hospitals Out of hours services such as NHS 111 WM Ambulance services Domiciliary care agencies GP providers Our customer care approach, through the Time2Talk team, has enabled us to significantly improve the way in which we manage concerns and complaints and use this softer intelligence and patient experience to drive quality. We do detailed analysis, interpretation of hard and soft intelligence to support a continuous improvement approach with services. The team triangulates the information from provider data, Time2Talk data and from regular announced and unannounced visits to providers, to inform Key Lines of Enquiry (KLOE) for follow up with providers at quality review meetings and where necessary to escalate any immediate or emergent issues and concerns. Monthly Quality and Performance Reporting We provide a monthly combined quality and performance report that highlights key areas of trends about our main providers of NHS care. This report is presented to the Quality and Safety committee and the CCG governing body. Serious Incidents and Never Events Serious Incidents (SIs) are reported by providers to the quality team in an agreed timeframe. For services where the CCGs are not the lead commissioner we work with the lead commissioner to ensure we are informed of incidents that affect our population. In primary care any incident reported to the CCG are shared with NHSE. 42

43 All SIs have a Root Cause Analysis and lessons learnt are shared across the CCG. SIs are analysed for trends and reported to the Quality and Safety Committee. The Learning from Experience Group Committee discusses key learning from incidents and how the learning can be embedded across our providers and our member practices. When SI s occur in provider organisations we review the initial findings. We review all investigation reports and ensure all resulting actions have been implemented via the Clinical Quality review meeting and assurance that learning is being embedded across the organisation where necessary. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We take these extremely seriously and ensure that contractual penalties are applied should they occur. A Never Event Assurance Committee with our acute provider has worked to ensure that learning is being embedded across the organisation, and looking at early warning serious incidents and trends. Quality Impact Assessments (QIA) The quality team supports the programme office by overseeing the organisation s approach to QIAs ensuring that these are completed to a high standard and sharing best practice. The quality team also ensures the implementation of the DH guidance on QIAs in regards to provider efficiency and QIPP plans to ensure that efficiencies are not having an adverse impact on the quality care. Review of Mortality Data Mortality review analyses and identifies trends/areas of concerns which are presented to the Clinical Quality Review Group. Safeguarding Adults and Children We ensure that our providers have arrangements in place to safeguard and promote the welfare of adults and children in line with national policy, guidance and locally identified areas of concern. Providers identify safeguarding issues relevant to their area and we challenge providers to demonstrate that policies and procedures are in place and implemented. We review staff training to ensure staff are appropriately trained, supervised and supported and know how to report safeguarding concerns. The CCG requires providers to inform them of all incidents involving children and adults including death or harm whilst in the care of a provider. We monitor our own staff training. Full information can be found in our Safeguarding Policy. We work closely with our partners to participate in Serious Case Reviews and Domestic Homicide Reviews and ensure findings are included in our triangulation of data. We lead institutional safeguarding investigations for health funded clients within nursing care homes and those receiving domiciliary packages of care. 43

44 We are active members of both the Birmingham Safeguarding Children and Adults Boards, and the Sandwell Safeguarding Children and Adults Boards. Staff, Capabilities and Culture The importance of staff, capabilities and culture is all too clear in the learning from Mid-Staffordshire NHS Foundation Trust and Winterbourne View Inquiries. As part of our assurance processes we carry out site visits to services in order to test the culture that exists within various services using our agreed quality visit process. Other key sources of information that we will draw together are: Staff satisfaction surveys Staff vacancy data and attrition rates Staff training information Workforce/patient dependency skills and capabilities Whistleblowing information Responses and implementing of workforce related policy such as Compassion in Practice Local Education and Training Board (LETB) and General Medical Council (GMC) training surveys Early identification of provider issues We collate and analyse all of the information as outlined above in order to make informed judgments relating to quality and outcomes for patients to identify emerging areas of concern by: Generating trend profiles relating to organisations and service areas based on soft and hard intelligence. Using trend profiles to inform a targeted and measured approach to assurance eg risk stratification informing the nature and frequency of site visits. Using trend profiles to support decisions relating to improvement plans and/or decommissioning care. Working closely with Primary Care colleagues. Working with our NHS England Area Team; other commissioners and partners as part of a wider geographic response to managing risks through the Quality Surveillance Group, rapid responsive reviews and risk summits. Reviewing Quality in all our providers where we do not have a regular monthly meeting through the annual Clinical Quality Review Self-Assessment and visit programme. Operating Plan The following points summarise the progress that has been achieved in 2017/18 against the plans outlined in the Operating Plan : To provide assurance on the quality of all NHS commissioned services. 44

45 To ensure that data and information will be analysed and utilised intelligently at all stages of the commissioning cycle. To ensure quality is integrated into all aspects of the commissioning cycle. To improve patient safety across the health economy. To monitor primary care CQC reports and support practices. To improve patient experience of NHS care across the health economy. To ensure that the incidence of healthcare associated infections such as MRSA and Clostridium difficile are reduced, emerging infections are appropriately managed and that cleanliness in our healthcare premises meets the highest standards. To ensure the continued improvement of quality in primary care. To ensure the quality impact of seven day services is monitored. To develop a monitoring system to monitor quality in care homes across Sandwell and West Birmingham. To support the implementation of learning across provider organisations and member practices through the Learning from Experience Group. To develop the Quality team working in the Co-commissioning team. To continue to support the Safeguarding Children and Adults agenda. Our plans for 2018/19 To continue to provide assurance on the quality of all NHS commissioned services. To continue to ensure that data and information will be analysed and utilised intelligently at all stages of the commissioning cycle. To continue to ensure quality is integrated into all aspects of the commissioning cycle. To improve patient safety across the health economy. To continue to monitor primary care CQC reports and support practices. To improve patient experience of NHS care across the health economy. To ensure that the incidence of healthcare associated infections such as MRSA and Clostridium difficile are reduced, emerging infections are appropriately managed and that cleanliness in our healthcare premises meets the highest standards. To ensure the continued improvement of quality in primary care. To ensure the quality impact of seven day services is monitored. To develop a monitoring system to monitor quality in care homes across Sandwell and West Birmingham. To continue to support the implementation of learning across provider organisations and member practices through the Learning from Experience Group. To develop the Quality team working in the Co-commissioning team To continue to support the Safeguarding Children and Adults agenda. 45

46 7 Engagement The CCG has a well-developed engagement model. With a dedicated Engagement team we continue to deliver on our robust model of engagement centred around our Patient and Partnership Advisory Group and localised patient networks which provide 20 meetings a year giving local people and partners the opportunity to have their say on the commissioning of local healthcare services. We have also during 2017/18, engaged extensively on the pathway changes in line with the Sustainability Transformation Partnership (STP) plan and in the design of the new model of care. To date we have: Led co-design events to facilitate the redesign of mental health well-being services. Led an extensive engagement activity with year olds around how we commission services in the future. We used a modified camper van and visited several venues to listen to the thoughts of 1200 young people. Co-developed a social media marketing campaign to reduce the attendance of year olds at Birmingham City Hospital. The campaign was designed along with the target age group, through detailed research to understand behaviours and motivators which led to an emoji style creative with high impact messaging. Led the consultation on prescriptions and medicines which ran for 16 weeks and included 42 meetings and events reaching 985 patients and partners. We used these insights as assurance to review our guidance on the use of medicines with insufficient evidence of clinical benefit. Hosted the Sandwell and West Birmingham Equality Awards with more than 140 people from across local NHS, statutory and voluntary sectors. The awards programme brought together local people and organisations to recognise and celebrate the outstanding work to address inequalities in health and well-being in the community a key focus for our equalities strategy. Celebrated the expertise and success of our GPs and our staff by organising annual award programmes. Set up a local Maternity Voices Partnership a group that brings together local mums, professionals and commissioners in order to directly influence our maternity strategy and the delivery of the local maternity service. Hosted an annual safeguarding conference on Female Genital Mutilation (FGM). Professionals from health, social care, police and community groups met to share best practice and ideas together with provider organisations which support survivors of FGM. Our plan for 2018/19 The Black Country and West Birmingham Sustainability and Transformation Partnership (STP) is committed to involving stakeholders in the development of proposals to improve health and care for local people. Since the publication of the sustainability and transformation plan, the STP has been working hard to keep local people informed and up to date with developments within the programme. Over the 46

47 coming year, the STP will be carrying out a series of stakeholder roadshows aimed at engaging local patients, partners and the voluntary and community sector. The roadshows will provide people an opportunity to find out about the partnership and how they can get involved in improving health and care services in the Black Country and West Birmingham. Locally we will: Ensure that robust communications and engagement is integral to the CCG s commissioning processes. To continue to build on our model of communication and engagement reaching out to emerging communities. Rebuild our website increasing its functionality and making better use of it as a platform for communicating and engaging our population. 47

48 8 Workforce During 2017 we have worked with other Black Country CCG s to develop an ambitious workforce plan for Primary Care at STP level. Our CCG workforce plan for primary care strategy is the delivery of the STP for the practices with the CCG membership. Our STP Primary Care Workforce Strategy sets out our vision for the workforce in General Practice and describes in detail how the STP and the LWAB will support and equip member practices with the necessary skills, workforce and infrastructure to deliver an efficient, resilient and sustainable service for our local population using three key priorities: Recruit, Retain, Transform. The scale of the workforce challenge is difficult to fully predict therefore the Black Country STP has set its assumptions based on two possible workforce scenarios as shown in the table below for the whole of the STP Primary Care workforce. We recognise that there will be a requirement for some local application of the strategy however the key success factor for our practices is the delivery of the STP plan. Scenario modelling on Baseline and Five year demand for GPs Best case Worst case assumption FTE assumption FTE Baseline adjusted to include estimated GPs from practices which did not return workforce data 768 no adjustment 709 Reductions to numbers Retirements 100% at % at Net other leavers & joiners 2% turnover 70 3% turnover 106 Increases in numbers Newly Qualified GPs national share less 36% (based on NHSE analysis) 136 adjusted 10% 122 Retention schemes per plan % of plan 63 Attraction to Black Country per plan 14 50% of plan 7 Local fellowship schemes per plan 10 50% of plan 5 International recrutiment national share 57 50% of plan 29 Refugee recruitment STP plan to none 2020 Supply The Black Country STP general practice workforce position has been informed through the NHS Digital workforce returns including: NHS Digital experimental data (June 2017), practice level indicators (March 2017), and HEE Midlands and East GP Supply Forecast Model (September 2017). In addition SWB CCG has used some of the local workforce analysis completed in 2016 for our practices. 48

49 Having GPs attracted to the Black Country STP, and therefore our CCG, is of paramount importance and the plan identifies 14 new GPs who will be attracted after new ways of working are deployed at primary care network level. This includes a range of different measures such as: additional support roles, which in turn ameliorates workload and pressure; integrated system working such as the MCP/Vertical integration which is designed to improve the way in which Primary Care is organised and delivered; other development schemes such as leadership and primary care initiatives such as workflow optimisation. The STP is also considering retention and attraction salary arrangements, which will be considered throughout 2018 for implementation. Our STP includes a number of other attraction schemes to encourage an increase in the GP workforce: 10 clinical fellowships across the 5 places within the STP GP international recruitment in February 2018, will bring in another 57 GPs by 2020 Our scheme to develop local refugees into the STP will further create 12 new GPs by Irrespective of the scale of the problem the STP will tackle the workforce challenges by focusing on the training and education of new and existing staff, recruitment to existing and new roles, retaining the skilled people we have, coupled with managing demand and embracing a culture fit for the future. All of this will enable us to commission new models of care focussing on Primary Care networks and changing service delivery to meet demand. Providers are no longer required to share their workforce plans with commissioners, we are therefore unable to give NHSE assurance that they have robust plans in place. However the CCG is working in partnership with the local Trust to consider where partnership working will support the workforce planning and strong integration of the Sandwell and West Birmingham healthcare Trust will further build the understanding of the workforce plans of providers to enable us to provide further assurance to the workforce planning for the future. We are also fully engaged, and in some instances leading, the STP workforce strategy. The STP workforce strategy considers all workforce within the STP and the 18 partners. The Strategy focusses on 5 key themes that will be collectively delivered throughout 2018/19 and will support the assurance and support commissioners can provide to NHS England. Workforce capacity Workforce innovation and change Recruitment and retention Working stronger together Leadership and education 49

50 9 Risks We have worked throughout to ensure controls and mitigation are in place to minimise risks. The principal risks are built into our Board Assurance Framework, which is subject to internal audit scrutiny and reviewed regularly by the governing body. Looking forward into 2018/19 there have been several risks identified. There are risks to quality and continuity of services as a result of the collapse of Carillion and subsequent delays to the completion of the Midland Met Hospital. The additional investment made by the CCG to provide additional services to Asylum seekers will have a financial impact on the CCG and subsequently the services commissioned for the patients of Sandwell and West Birmingham. The national primary care workforce issues remain a concern for SWB CCG and its ability to successfully commission and sustain primary care. The CCG will need to reduce expenditure and investment plans in order to deliver the total QIPP value required. Any risks identified are added to the risk register and are reviewed and actioned by the constitutional committees with oversight from Audit and Governance Committee and the Governing Body. 50