Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Transcription

1 Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups 2019/20 COMMISSIONING INTENTIONS 1

2 Contents 1. Introduction 2. Population overview 3. Our objectives and priorities for 2019/20 4. Overview of National and North East London Commissioning Alliance (NELCA) Priorities 5. Preparing for an Integrated Care System 6. NHS Financial Recovery within the context of an Integrated Care System 7. Delivering our Constitutional Standards and High Quality Care 8. Our Commissioning intentions a. Prevention b. Primary Care c. Planned Care d. Urgent Care e. Older People, Frailty and End of Life Care f. Long Term Conditions g. Mental Health h. Maternity and Children and Young People (including CAMHS) i. Medicines Optimisation j. Cancer k. Integrated Care l. System Enablers (Workforce, Digital and Estates) 9. Appendices a. Detailed Commissioning intentions b. Glossary of terms 2

3 Introduction Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs) commission Health Care services for 767,500 people in Outer North East London. The health economy has been the site of a number of ground-breaking innovations (Health 1000, our Community Treatment Team model) but faces a number of significant challenges. To overcome these challenges will require us to work differently. Against a number of key health outcomes we don t perform as well as similar CCGs, partly due to local demographics and historic underfunding (particularly of primary care and community services) but also due to how the NHS services in our patch interact with each other and respond to the changing needs of our population. Since the CCGs formed in 2013, we have faced a growing financial pressure, the demand for care continues to increase and the funding we receive has not always been sufficient to meet that demand which when combined with an inability to achieve the financial efficiencies required to meet the financial challenges has led to us being placed into financial special measures, legally requiring us to take certain steps to deliver a financial recovery plan. Our Local Acute Trust, Barking, Havering and Redbridge University Hospital Trust, faces similar growing financial pressures and has just been placed into financial special measures, having within the last year come out of special measures following a CQC review. Outer North East London is growing; all boroughs are expecting local populations to increase over the next five years, due to improving transport links, large housing developments, such as Barking Riverside, and relatively low house prices (compared to Inner London). While this presents a number of exciting opportunities for North East London as a whole, it will mean increased pressure on local health services. In order to faces these challenges we need to work differently, not just in terms of how we operate as CCGs but how we work with our partners across Barking and Dagenham, Havering and Redbridge to provide health care. We have already started on this journey through development of an Integrated Care System, a journey which we expect to revolutionise how we provide NHS services starting in shadow form from We extend this approach of innovation and transformation to our 2019/20 Commissioning intentions which will be produced collaboratively with patients, our membership and our key NHS and Local Authority partners. This document contains our vision, as CCGs, of our commissioning priorities for the upcoming year. We want to move past the traditional approach of this being a solely commissioner-led process; we want to meaningfully engage and collaborate with our partners and the public to help shapes our plans, to not only improve them but as a further way to bring us closer to true system working. This document is the starting point in the conversation we want to have across BHR about how we, and our partners, shape the future of Health Care in North East London. 3

4 Population Overview Redbridge has a growing and mobile population and is the largest of the three BHR boroughs. The proportion of younger people is higher than for London and England. The population is very ethnically diverse: most of the population is from black and ethnic minority backgrounds with the largest group being of South Asian origin. There is wide variation across the borough in terms of deprivation, with some wards predominantly in the lowest two quintiles for deprivation and some in the highest two quintiles. In London, Redbridge has the: 1. Second highest proportion of people aged Second highest rate of people with diabetes 3. Third highest proportion of people from black and minority ethnic groups 4. Highest rate of children whose first language is not English. Since 2001, Barking and Dagenham has seen rapid population growth, linked to both to new housing developments and increasing birth rates. The population structure has changed significantly with particularly large increases in the numbers of younger people living in the borough. There has also been a rapid shift in the proportions of various ethnic groups, with a large decrease in the white British ethnic group and a large increase in the black African ethnic Annual report and accounts: 2017/18 9 group. Our population faces a range of major health challenges and health outcomes are poor for many local people because of a combination of poverty, deprivation and lifestyle. We have higher numbers of deaths from the major diseases (heart disease, stroke, cancer, diabetes and chronic lung disease) compared with the London average. Our residents also experience more ill health and disability during their lifetimes. There is a strong correlation between poverty/deprivation and poor health, for many reasons that include poor diet/nutrition and unhealthy living and working conditions. In general, those who live in areas of high deprivation suffer the most from poor health and wellbeing. In London, Barking and Dagenham has the: 1. Highest proportion of people aged Highest rate of unemployment 3. Lowest male and female life expectancy 4. Second highest rate of teenage conception 5. Third highest rate of mortality from preventable causes Barking and Dagenham Council has developed a vision for the borough that seeks to maximise the opportunities for growth and regeneration, linked to new housing developments (Barking Riverside) and the strategic location of the borough: One borough; one community; London s growth opportunity. The Joint Health and Wellbeing Strategy sets out how this will help make the borough a healthier place and tackle the poor outcomes currently experienced. There are over 250 thousand people living in Havering and they are generally fairly healthy. Life expectancy is long and residents and visitors to the borough benefit from plenty of high quality parks and open spaces. The borough is one of the most ethnically homogenous places in London, with only around 16% of residents from a black or minority ethnic background. Almost 90% of the population were born in the United Kingdom. Just under 70% of the population in Havering are home owners. This is one of the highest proportions across London boroughs. Housing in the borough is mainly 4

5 Victorian and Edwardian. Houses are generally large with an average of 2.8 bedrooms per household (higher than both London and England). In London, Havering has the: 1. Highest proportion of people aged Lowest proportion of people from black and minority ethnic groups 3. Highest amount of green space (at just under 60% of the borough). Our older population means we need a particular, though not exclusive, focus on services that can help keep older people healthier and independent for longer and help them avoid hospital admissions wherever possible. This puts a real strain on our services and resources, but we won t let this compromise the quality of care that our patients receive. Earlier identification of dementia is also a key priority for the CCG and we are working closely with the local authority on this work. Improving access to and experience of these services and making more available in localities, closer to people s homes, is a priority for the CCG. Barking and Dagenham Havering Redbridge Greater London England Estimated population (2017) 209, , ,200 8,835,500 55,609,600 % of population aged 0-15 (2015) 27.2% 19.3% 22.8% 13.9% 19% % of population aged 65+ (2015) 9.7% 18.4% 12.2% 12.5% 17.7% % of population from BAME groups (2017) 49.5% 15.7% 62.7% 42.5% --- Unemployment rate (2015) 11% 5.3% 7.9% 6.1% 5.1% Male life expectancy ( ) Female life expectancy ( ) Teenage conception, per 1,000 aged (2014) Childhood obesity ( ) Prevalence of diabetes, age Mortality from preventable causes, per 100, Table 1 - BHR population statistics - as reported in 2017/18 5

6 Our objectives and priorities for 2019/20 Our objectives for 2019/20 remain: 1. The delivery of high quality, safe and compassionate care through all commissioned services. Ensuring that we are delivering better outcomes for local people 2. Transforming care and meeting constitutional standards through building on our current programmes for planned and unplanned care with a cross-cutting focus on key population and priority groups, such as older people and those with long term conditions. 3. Development of our integrated care system, through a collaborative population based solution to our system challenges of quality and resources. 4. Secure financial recovery, meeting our control total agreed with NHSE, and agreeing a realistic plan to achieve financial balance 5. Continued implementation of our agreed Primary Care Transformation Strategy, recognising primary care as the foundation of our integrated care system To ensure we deliver our objectives we are establishing 7 key Transformation Boards focused on the key cohorts of patients we serve and these are detailed below: Older People, Frailty and EOL Children and Young People Long Term conditions Mental Health Medicines Optimisation Maternity Cancer These clinically led boards will develop and manage delivery of improvements for key care settings and for key cohorts of patients as outlined in Figure 1 below. They will bring together the currently disparate QIPPs (Quality, Innovation, Productivity and Prevention) Schemes of the CCGs and QCIPs (Quality & Cost Improvement Programmes) for Providers to ensure a coordinated approach. These groups are expected to remain in place for the longer term and will report into the Health Care Cabinet and in time to the Integrated Care Partnership Board. Figure 1 also shows the aligned priorities agreed by the BHR Joint Commissioning Board and proposed to be accepted by the Integrated Care Programme Board. 6

7 Figure 1 - Our Transformation Boards 7

8 National and North East London Commissioning Alliance (NELCA) Priorities National NHS England (NHSE) launched the NHS Five Year Forward View (FYFV) in The FYFV described how the NHS should change, in order to meet the needs of a changing population that is living longer through increased usage and reliance on the NHS. It identified three improvement opportunities: a health gap, a quality gap, and a financial sustainability gap that would need to be addressed for the NHS over the next five years. The FYFV also proposed an ambition to deliver triple integration of primary and specialist hospital care, of physical and mental health services, and of health and social care. In NHSE released an update to the FYFV titled Next Steps on the NHSE Five Year Forward view this included as assessment of progress to date, and outlined its priorities over the next two years: Improving A&E performance. - This also requires upgrading the wider urgent and emergency care system so as to manage demand growth and improve patient flow in partnership with local authority social care services. Strengthening access to high quality GP services and primary care, which are far and away the largest point of interaction that patients have with the NHS each year. Improvements in cancer services (including performance against waiting times standards) and mental health common conditions which between them will affect most people over the course of their lives. (Chapters Four and Five) North East London Commissioning Alliance The North East London Commissioning Alliance, of which BHR CCGS is a member, will develop a Commissioning Strategy by September. This plan will focus on the following areas: 1. Collation of current plans from local systems and East London Health and Care Partnership (ELHCP) programmes that require contractual or service change. These will be brought together across NEL to ensure consistency in our narrative and dealings with providers. 2. High level vision/principles relating to how we want to do commissioning differently in the future (which will be developed further following strategic review below) 3. Sections on the integrated care system framework and finance/activity/contract form This Commissioning Strategy will be reported to the ELHCP Joint Committee in September. 8

9 Preparing for an Integrated Care System 2015, Barking and Dagenham, Havering and Redbridge (BHR) Partners comprised of NELFT, BHRUT, London Borough of Havering, London Borough of Barking and Dagenham, London Borough of Redbridge and BHR Clinical Commissioning Groups submitted a successful bid to NHS England to explore the benefits of Devolution and the establishment of an Integrated Care System. Following the publication of the BHR Strategic Outline Case to test the benefits of Integrated Care in January 2017, the BHR Integrated Care Partnership Board have; Signed up to a clear vision for BHR to accelerate improved health and wellbeing outcomes for the people of Barking & Dagenham, Havering and Redbridge and deliver sustainable provision of high quality health and wellbeing services delivered by an integrated system with the following aims: o o o o Enable and empower people to live a healthy lifestyle, to access preventive care, to feel part of their local community, to live independently for as long as possible, to manage their own health and wellbeing, which creates an environment that encourages and facilitates healthy and independent lifestyles. Where care is: organised around the patient s needs, involves and empowers the patient, is integrated between agencies, with a single point of access, is provided locally where possible, meets best practice quality standards, and provides value for money. In which organisations: share data where appropriate, work collaboratively with other agencies and maximise effective use of scarce/specialist resources. Where artificial barriers that impede the seamless delivery of care are removed, bringing together not only health and social care, but a range of other services that are critical to supporting our population to live healthy lives. Strengthened partnership governance arrangements through the Integrated Care Partnership Board with the establishment and continued development and evolution of a Joint Commissioning Board and Provider Alliance. Undertaken a significant amount of research and preparation for the development of an Integrated Care System, including workshops to explore contracting and commissioning options with Hempsons, research on best practice with UCL Partners and participation in the UCL Partners / Dartmouth Institute Place Based Care Network development programme producing a proposal to take forward the development of place based care. Identified key transformation areas and priorities for integrated care, which align to the BHR NHS Recovery Plan approach: o older people, frailty and end of life (including the place-based care frailty proposal which is being taken forward by the Provider Alliance) o children and young people o long term conditions o place-based care development including Barking Riverside o Mental health. Whilst 2018/19 has seen the establishment of the new form partnership, the development of system priorities and operating principles including a new contract form with BHRUT, in 2019/20 the intention is to operate a shadow integrated care system including a shared system control total and joint assurance process. 9

10 Figure 2 - BHR roadmap to an Integrated Care System NHS Financial Recovery within the context of an Integrated Care System The BHR system is under significant and growing financial pressure. Since 2014/15 the financial position has worsened from a 25m deficit to a 72m system wide deficit. As of 2017/18 BHRCCGs have reported a 21.1m deficit, while BHRUT have reported a deficit of 60.9m. NELFT are currently the only NHS organisation reporting a surplus, however this is due to one-off transactional benefits. In 2017/18 BHR CCGs were placed by our regulators into financial special measures, a legally mandated process requiring us to developed a balanced financial recovery plan. In 2017/18 CCGs were required to deliver 45m of efficiency savings (our QIPP programme), of which 32M was achieved. For 2018/19 we are planning to deliver a further 32m, with a further 60m to be delivered in efficiency savings between 19/20 and 20/21. 10

11 During 18/19 BHRUT have also been placed into financial special measures, due to the reported 17/18 deficit position and issues raised through the Grant Thornton report into financial governance. The organisation has produced a financial recovery plan which will require a significant savings programme (CIP) to be delivered in 18/19 and in subsequent years. System Deficit 2014/15 v 2017/ BHR CCGs BHRUT NELFT SYSTEM DEFICIT / /18 Figure 3 -System Deficit 2014/15 v 2017/18 This has been caused by a range of factors including; A historic under-funding across the BHR system (mostly now resolved) that led to under-investment in Primary Care contributing to increasing activity in secondary care. In addition there has been a lack of infrastructure for partners to work together The BHR health economy cannot deliver financial balance, unless we work together to address the deficit. As described in the previous section; our longer term solution to the financial pressure within the system is development of an Integrated Care System, however we have begun to make a number of changes to our governance to support joint ownership of the system financial challenge. The ICS will need a different approach to decision making and an open approach to financial planning that will involve all of the partners within the ICS. It will also see the partners speaking collectively with both NHS regulatory bodies and with the democratically elected bodies responsible for BHR. The formation of the ICS will break down organisational boundaries, ensure decisions that affect multiple organisations can be made and will ensure that risks and costs are not inappropriately moved around our local system. We are now regulated as a system, with our respective regulators (CCGs -NHS England, BHRUT and NELFT NHS Improvement) and our progress will be measured against a system financial control total, as opposed to individual the individual organisational position. We have set up an NHS Financial Recovery Board (which met for the first time in August), which provides a forum for NHS 11

12 partners to discuss how we plan collectively to address the financial position. This Board will bring together the senior NHS leadership (clinical and managerial) from across our system to discuss common issues and to make collective decisions. This group will also ensure we are speaking as a single voice to our regulators around assurance. This is a temporary group (provisionally for one year) to secure a system recovery plan. Over time it is expected that the Joint Commissioning Board will assume some of the responsibility for delivering the system recovery plan across the wider system. Part of creating the right environment for financial recovery through transformation is to have contract forms that enable parties to work together effectively. During 2017/18 we have begun the process of changing contract forms with our key providers, to support financial recovery and begin to test approaches towards contracts ahead of the ICS. 12

13 Delivering our Constitutional Standards and High Quality Care It is important that the BHR systems delivers all Constitutional Standards for the services we provide. The Constitutional standards are monitored through evidenced based performance indicators, variance from defined thresholds can indicate that our patients may be receiving a lower quality of care than we would expect. During 2019/20 we expect all providers of services to be fully compliant with all constitutional standards and associated monitoring processes. Should any provider fail to deliver any standard, we would expect the provider to fully cooperate with commissioners by complying with our performance escalation processes and ensuring robust recovery plans are developed and implemented. We aim to deliver High Quality, compassionate and safe care for all commissioned services. This will be achieved through refreshing our Quality Strategy, confirming our quality priorities for 2017/20: Implementation of the system pressure care improvement plan Comprehensive quality impact assessments on all proposals/business cases forming part of the Financial Recovery plan Strengthening collaborative commissioning of care for people living in care homes Addressing key quality concerns such as; reducing the number of people who die from treatable conditions, and improved infection and prevention control Implementation of the SEND recommendations for children and the Wood Review requirements for safeguarding (working with local safeguarding children boards). 13

14 Our Commissioning intentions Prevention The NHS treats a growing number of patients with preventable illnesses each year and this is expected to continue to rise in the future. Illnesses such as Diabetes and COPD, can have debilitating impacts on our population s health and overall quality of life and can require significant use of NHS time and resource to manage effectively. Reducing our incidence of preventable diseases would mean that our population is healthier and has a better quality of life while reducing current pressure on NHS resources. This can be achieved by enabling and empowering people to live a healthier lifestyle will help avoid preventable illness. The NHS is an integral part of our society and the services that we provide need to reflect the needs of that society. We treat patients dealing with a range of societal issues, which impact on their health. These issues, ranging from inequality to domestic violence, require a joined up approach from both the NHS and Local and National Government to support those affected. The BHR system is committed to working with our partners to develop plans to support our population to live a healthy life style and ensure that they have access to preventative care and live in an environment that supports our population to achieve this. Each Local Authority has a responsibility for the development of a prevention strategy. We will work closely with our Local Authority colleagues to support the local prevention agenda within each of the boroughs within the BHR system. What we want to achieve: Intention 1: For children to best prepared to start school by the age of 5, by: Supporting the development of Language and Communications skills to enable children to achieve their potential when starting school Helping to influence behaviour of children and parents to improve Oral Health, and thereby reduce the number of dental caries manages in A&E Increasing completion of Health Checks for 2 year olds, providing early insight into physical development and of vocabulary and communication skills Improve the rate of Childhood Immunisation across all boroughs Intention 2: To increase healthy life expectancy by increasing early diagnosis and intervention in four key areas: Increasing awareness of the symptoms of Cancer and the importance of testing Ensuring patients diagnosed with Long term Conditions (LTCs) feel supported to manage their conditions Intention 3: Supporting Community resilience, by: Ensuring all residents to have an awareness of domestic violence and abuse, and to feel comfortable disclosing domestic violence and abuse if it occurs Increasing the number of practices offering social prescribing, to increase the number of patients receiving care in a holistic way addressing their needs Intention 4: Enable and empower people to live a healthy lifestyle, to access preventive care, to feel part of their local community, to live independently for as long as possible, to manage their own 14

15 health and wellbeing, which creates an environment that encourages and facilitates healthy and independent lifestyles, by: Providing Mental Health and emotional wellbeing support have parity and emotional wellbeing is supported and improved for Frail and Elderly patients Supporting greater functional independence and thereby avoid unnecessary or lengthy acute stays which can have impact on mobility and outcomes for Frail and Elderly patients 15

16 Primary Care Primary Care The majority of the public s interaction with the NHS is through Primary Care and GPs are the gate keepers of a patient s journey through our services, acting as constant point of contact and care. Nationally; The NHS Five Year Forward view recognised that Primary care has been proportionally underfunded compared to Secondary care, and this is also true within the BHRUT health economy. This underfunding has contributed towards an increase in secondary care activity, which could be managed appropriately in alternate settings. BHRCCGs have developed a five year strategy ( ) which aims to transform how we deliver primary care services allowing us to: Meet the health needs of our diverse population, in which an increasing number of patients live with one or more long-term conditions Improve health outcomes and reduce inequalities Meet national and regional quality standards for care Support the delivery of our system financial recovery plans This will be achieved by working with our local system of GP Federations, Networks and practices to deliver transformational programmes which improve the following areas of primary care provision within BHR: 1. Develop a GP workforce plan, which creates an attractive working environment to enable our system to recruit and retain GPs and other staff such as practice nurses working in primary care. 2. Improve existing infrastructure (IT and Estates) to enable primary care to effectively manage the patient pathway and provide care in premises that are fit for purpose 3. To systematically improve the quality of care provided in primary care, and support GPs to improve their productivity enabling more time to care. 4. Ensure the patient experience is positive, joined up and cost effective, while increasing access to GP appointments for patients 5. Ensure primary care significantly contributes to increasing health outcomes across BHR, and delivers local and nation standards. What we want to achieve: Intention 1: CCGs will continue to implement the recommendations of specific National Primary Care Programmes: National Diabetes prevention programme Continued implementation of the National Diabetes Prevention programme focussing on identifying at risk patients of developing Diabetes and supporting them to live healthier lifestyles. LBTI NHSE Screening programme Continuation of the LBTI screening programme (the last year of a five-year programme), which aims to increase identification of TB and contribute to a reduction in the number of active TB cases within BHR 16

17 Intention 2: Continued implementation of NHSE General Practice Forward View, London Commissioning Strategic Framework for Primary Care Transformation in London and London Health Commission s Better Health for London, and BHR s System Resilience programme and 5 Year Strategy Continued focus on primary care at scale, Federation and network maturity, supporting GP Federations and networks to develop and deliver high quality services that meet patient need. Musculoskeletal (MSK) Pilot scheme B&D only - To pilot a Barking and Dagenham primary care musculoskeletal scheme with the Federation and networks which will deliver integrated general practice/physiotherapy clinics to patients, enabling increased value for money, increased patient satisfaction and decreased A and E and Outpatient attendance for MSK problems. Frailty- Redbridge only Continued implementation of a scheme managed by Redbridge Federation (part funded in 2018/19) to identify and case manage those patients with moderate frailty in Redbridge. Outcomes include quality improvement in patient care, maintenance of health and prevention of deterioration, and a reduction in A&E attendances /unplanned admissions. Long Term Conditions (LIS) Continuation of the LTC LIS in 2019/20, to be provided be provided by the three respective Federations on behalf of all practices across BHR to achieve improved outcomes in relation to: CVD, COPD and Diabetes. Intention 3: to support the Primary Care Provider development agenda, through the delivery of specific projects focused on business and workforce resilience, workload and workflow, delivery at scale, and new models of care. The following areas will be of specific focus during 2019/20: Equalisation of GP PMS/APMS funding B&D Programme to equalise PMS/APMS funding and support the delivery of local priorities. An additional 1 will be made available in 2019/20 for Local Premium general practice across all B&D GP practices with the option of delivery via an at scale provider, the local focus will be determined through negotiations taking place during September to October Equalisation of GP PMS/APMS funding Redbridge - Redbridge CCG currently commission pwp of local primary care services via 42 GP practices in Redbridge (29 GMS 12 PMS and 1 APMS); this funding is committed to remain within Primary Care as part of the GMS/PMS equalisation process. The current schemes are: o Access Opening Hours 2.20 o Access Consultations 4.30 o Wound Care 1.00 o End of Life 1.00 o Practice Development 2.28 E-Consult Support the practice usage of the E-consult tool. Consultations hosted via a e- consult will count towards the PMS review and assist practices achieving the top level of transitional funding over the next three years J-MOG Redbridge and Havering only Evaluation of the J-MOG messaging tool, to understand the scope for reduction of DNA across Primary Care Advice & Guidance BHR wide. Increase and improve the usage of Advice and Guidance services for general practice, to prevent unnecessary outpatient appointments for patients, 17

18 when care can be effectively delivered with consultant expert guidance, by the patient s own GP. Shared Care (LIS) BHR wide. Working with partners to develop shared care processes and protocols for the management of specialised or complex medication and associated phlebotomy/and or diagnostic requirements. General Practice Nursing Leadership To commission a nursing leadership structure across the three CCGs. Designed to support the development of practice nurses, reduce variation in recruitment process and increase retention of Practice Nurses within BHR. House bound flu (LIS) An initiative designed to reduce the number of community acquired pneumonia infections, for house bound patients. Practices will be asked to arrange a home visit to each house bound patient during which they will need to check against the range of criteria shown below o Blood pressure o AF screening o Flu immunisation status o Pneumococcal Immunisation status Intention 4: Quality improvement, comprising projects focused on reducing variation in outcomes across practices, access to data to track quality, and development of skills and capability in quality improvement. Quality Improvement Programme To implement a sustainable and supported Quality Improvement programme across each CCG which fulfils the GPFV High Impact Action outcomes, as well as supporting BHR to create efficient ways of working Peer Review of referrals Implementation of a system of peer review of referrals designed to support GP learning and improve referrals, reducing unwarranted variation in referrals and avoiding referral where clinically appropriate. This will link with the Improving Referrals Together Programme (see Planned Care) and the quality improvement programme. Cancer (LIS) (Havering and Redbridge only) Implementation of a LIS focused on improving the quality of cancer care reviews and the clinical outcomes of those practices where cancer has been diagnosed and ensuring that a cancer care review takes place months after diagnosis. 18

19 Planned Care Compared to other CCGs across North London, our patients are more likely to be treated in an acute setting and the cost for that treatment tends to be higher. This increased pressure on services and can lead to longer waiting time for patients. Where possible and appropriate it is more effective and efficient to treat patients in settings other than hospitals, which frees capacity to manage those patients whose need is greatest. We have been expanding the number of community services we offer, and during 2019/20 will seek to work with our partners to continue to identify services we could commission differently to ensure we provide high quality, timely care to patients in the appropriate setting. Significant work has been undertaken within the BHR economy to improve patient waiting times and ensure consistent delivery of the RTT constitutional standards. This work will continue in to 2019/20 ensuring patients are managed in the appropriate setting, increasing the range and usage of community services. This will include focused work on repatriation of activity back to BHRUT to support the Trust in more effectively manage demand and capacity. We will continue to work closely with our partners to ensure appropriate pathways of care are developed, implemented and adhered to. We have a jointly managed programme with BHRUT (Improving referrals Together) which transform how we manage planned care pathways and support our clinicians to more effectively manage patients care. What we want to achieve: Intention 1: Implementation of year 2 of the Improving Referrals Together (IRT) programme. Improving Referrals Together is a joint programme between BHRUT and BHR CCGs designed to improve referral quality across the borough by redesigning pathways, increasing communication between clinicians and supporting the learning and development of GPs. This is expected to reduce outpatient activity through the reduction of inappropriate referrals. Intention 2: To develop and commission Community services, designed to move appropriate activity into the community, delivering improved care for patients in a more efficient setting. During 2019/20 CCGs will commission (or continue to commission) the following Community services: ENT Service launched on the 1 st of July 2018, managing Ophthalmology Service to launch on the 2 nd of December 2018 Urology Service specification under development, service launch TBC Community Pain Management service - Service specification under development, service launch TBC Gynaecology TBC Gastroenterology New service to launch April 2019 Diabetes Community Services Redbridge only TBC Integrated Anticoagulation Services Community Diagnostics Intention 3: Develop a single point of access model, with BHRUT and where a community service model exists, to ensure referrals are made to the appropriate setting and not accepted in Secondary Care where this is not the case. A single point of access model is being developed for the following specialities, with further models to be developed: ENT 19

20 Ophthalmology MSK Gastroenterology Dermatology Intention 4: Review our existing model of Community MSK provision and implement the findings. BHR CCGs implemented a Community MSK triage model in 2016/17. In addition CCGs are exploring a potential bid to NHSE to pilot A First Contact Practitioner model. CCGs expect both elements will support the achievement of further reductions in Secondary Care MSK activity. Intention 5: Implementation and re-design of physiotherapy provision within the community using a provider alliance model involving BHRUT, Barts Health and GP federations Intention 6: To engage on the outcomes of the London Choosing Wisely Programme, which will propose revised policies for Procedures of limited Clinical Effectiveness Intention 7: To develop a consistent service specification across BHR for simple wound care provision, implement the outcomes of the ongoing complex would care review. This may require the need for a potential procurement of Lymphedema services. Intention 8: The repatriation of activity from other settings to BHRUT, to support BHRUT effectively manage Demand and Capacity. This will include a specific workstream focusing on IVF treatment. Intention 9: Commission an Insulin pump service across BHR Intention 10: Continue the implementation of the Diabetic foot care MDT, to improve patient outcomes and meet NICE requirements. 20

21 Urgent Care NHS and social care staff in Barking and Dagenham, Havering and Redbridge (BHR) are working together to deliver the best possible urgent and emergency care (UEC) to our community, but our system is under increasing pressure. Too many people still go to A&E for treatment or nonemergency or life threatening conditions, despite ongoing investment in community urgent care services designed to manage this demand. Local people have told us that our current Urgent and Emergency Care system is confusing and fragmented. This has meant increasing A&E attendances in the system. Due to this pressure and inefficiencies in how our services run, we do not meet the 4-hour A&E trajectory at BHRUT. Our Urgent Care Centres have low throughput and do not always provide a consistent experience across sites. Too few patients in the UCC setting are redirected to other care settings and instead pass into A&E. These factors mean that too many patients experience longer waits that they should or end up admitted into Hospital when they could have been treated more effectively at home, through the support of community services. We want to ensure that our patients are effectively treated, in a timely manner in the most appropriate setting based on their need, this will require the usage of streaming and triaging process consistently across the system. What we want to achieve: Intention 1: Comply with FYFV and commission an Integrated Community Urgent Care offer across BHR and to commission Urgent Treatment Centres at the front of Queens and KGH hospitals. The procurement of the Integrated Community Urgent Care Service contract will commence in December 2018 and replace the following contracts: Harold Wood Walk in Centre (WIC) South Hornchurch WIC Barking Community WIC Loxford WIC 7 GP hubs 3 GP out of hours services Intention 2: Ensure consistent and effective streaming protocols are in place at the front door of all Urgent Care services. This will include the redirection and booking of patients into GP practices. This is expected to reduce A&E attendance and increase utilisation of other Urgent Community and Primary care services. Intention 3: Work with the London Ambulance services to ensure the full implementation and use of Appropriate Care Pathways (ACPs) across BHRUT to reduce Conveyances to Hospital and increase the number of patients being managed in appropriate alternate settings. Intention 4: Ambulatory Care Work with BHRUT to determine the pathways to be commissioned and the hours of operation of the service in order to reduce pressure in A&E and ensure the right care for patients. This work will include a review of the current tariff. Intention 5: GP Home visiting We intend to work with colleagues across the NEL CCGs to commission a GP Home Visiting service to cover the NEL geography. 21

22 Intention 6: Stroke services We will work with BHRUT, NELFT, the voluntary sector and patients to review the recommendations from the previous Stroke consultation and look to commission a more integrated pathway to improve outcomes for patients. 22

23 Older People, Frailty and End of Life Care Our population is growing older, which means that we expect to see an increase in the number of patients requiring treatment for conditions, such as dementia, which increase in prevalence with age. At the same time more of our patients are reaching older age with a number of Long Term Conditions. Within the BHR system; Frail and older people have a higher incidence of admission into Hospital and tend to stay in Hospital for longer which can lead to further deterioration. This can lead to an increased need for support from Health and Social care services along with a loss of independence. The BHR system needs to ensure that it delivers services which support older people to live independently and healthily for as long possible, in accordance with their wishes. In order to do this we need to work collaboratively across our system, to identify frail and older patients and ensure they receive holistic care based on their needs, at as early a stage as possible. Where frail and older people are admitted to Hospital we need to ensure that they receive appropriate support to return to their normal place of care and retain the same (or better where possible) quality of life they had before their admission Recent work has demonstrated that our population, as with the wider UK population, has expressed a preference to die at home rather than in hospital, however currently too few BHR patients are able to die at home in accordance with their wishes. As a system we need to more effectively empower patients, their families and carers to have and enact an End of Life care plan in accordance with the patient s wishes. What we want to achieve: Intention 1: Commission an integrated nursing home service that provides multi-disciplinary support to nursing homes in BHR including through extended hours, to reduce avoidable admissions from nursing homes. Intention 2: Develop a falls prevention programme, which identified patients at risk of falling and develops a holistic support plan to reduce incidences of falls. Intention 3: By 31 December 2019 all Type 1 EDs trusts to provide an acute frailty service for at least 70 hours per week with input from physiotherapists, occupational therapists, case managers (typically a nurse specialist) and pharmacists to provide multidisciplinary (MDT) assessment, reducing length of stay for frail and older patients. Intention 4: Review the commissioning of end of life care beds within local nursing homes for patients identified as having end of life care needs, ensuring the care homes are signed up to a trusted assessment model so discharges from the acute hospitals are as efficient as possible Intention 5: Review the enhanced community nursing offer (community matrons/nurses) commissioned to provide EOLC Intention 6: Increase the usage of the Electronic Frailty Index (EFI) system to identify frail patients in primary care and support management of their conditions. Intention 7: Ensure the system wide usage of Coordinate my Care (CMC) for the identification of EOL patients 23

24 Long Term Conditions An increasing number of people across BHR are living with Long Term Conditions (LTCs). Conditions such as COPD and Diabetes can have a debilitating impact on patients and can exacerbate if not continuously managed. This can lead to Hospital admission and poorer health outcomes and overall quality of life. Failure to effectively manage the increasing prevalence of long terms conditions will adding increasing strain on the NHS while guaranteeing poorer outcomes for our patients with Long Terms Conditions. Since 2015/16 there has been an approximate 27% increase in GP referrals linked to LTC related specialities, costing the NHSE approximately 200K more in 2017/18 (a 29% increase). Across BHR, we tend to have a lower observed prevalence of LTC conditions than we would expected for our population, for example our observed prevalence of Atrial Fibrillation is %%, while the expected prevalence is %. This indicates that a significant proportion of our population are living with Long Terms Conditions, without effective management of that condition, this increases the likelihood of complications arising. We are committed to developing a strategy for the management of patients with LTCs which brings together all partners across the Health economy, to support and treat patients holistically to improve outcomes and reduce our overall spend on LTC conditions. Through our Long Term Conditions Transformation Board we will be developing a LTC strategy which will seek to improve outcomes for patients living with LTCs. The Board will focus on the following conditions as a priority: Diabetes Atrial Fibrillation (AF) Chronic Obstructive Pulmonary Disease (COPD) Chronic Heart Disease (CHD)/Cardiovascular Disease (CVD)/Heart Failure (HF) Chronic Kidney Disease (CKD)/ Acute Kidney Injury (AKI) Hypertension What we want to achieve: Intention 1: To develop a three year strategy for the management of Patients with Long term conditions, which will improve outcomes for patients, reduce the cost of care for this cohort of patients and support patients to more effectively manage their condition(s). Intention 2: Continue to implement the work addressing Diabetic prevalence, leading to a reduction in acute spend related to diabetes and improve identification rates Intention 3: Improvements in the identification and treatment of patients with AF and COPD as part of the LTC LIS 24

25 Mental Health We want to ensure that the services for those needing support in relation to their mental wellbeing are responsive to patients at their point of need and that patients are treated in the least restrictive setting of care close to home. It is critical that patients who present with a mental health related crisis are seen quickly with the appropriate level of support. One of the key principles of the Five Year Forward View for mental health is the recognition that mental health often sits in isolation to physical health and we want to address the need for greater parity of esteem between mental health and physical health. It is therefore important that all layers of the treatment pathway are optimised. We want to ensure that there are robust and effective services at the primary care level as well as a comprehensive emergency/urgent treatment pathway to ensure the best management of crisis. This year s commissioning intentions for mental health will build upon some of the commitments in previous years with a view to moving more towards a treatment system that is better equipped to cope with the increasing demands on the system and deliver care in the most appropriate settings for patients. We need to ensure that we meet the constitutional standards, on an ongoing basis, to ensure that our patients are not disadvantaged or care affected. What we want to achieve: Intention 1: Increased usage of the IAPT services as way to support patients with Long Term conditions. This will require an increase in access to IAPT services and reduction in waiting times for subsequent treatments. Intention 2: Design and implementation of a Psychiatric Liaison service and agree the steps required to reach core 24 model by 2021, as per the mental health Five Year Forward View Intention 3: To work with NELFT to develop a Mental Health Primary Care Programme, to be phased in over 3 years. This programmes aim to reduce the number of patients with Mental Health issues being managed within secondary care where alternate settings of care are available Intention 4: To review the NELFT case for a Clinical Decisions Unit, which would be positioned between the Inpatients services and the Home Treatment to reduce the number of patients admitted to inpatient services where this can be avoided through the use of alternate care settings Intention 5: Improve the physical health and reduce the gap in outcomes of patients with SMI through the introduction of a system to carry out physical health checks in secondary care Intention 6: To review the current scope and effectiveness of the Street Triage team to understand if any improvements can be made to the existing service model. 25

26 Maternity and Children and Young people (including CAMHS) The BHR system expects to see an increasing population of 0-19 year olds over the next five years, and many within this group are expected to have additional complications linked to ongoing health needs (Asthma, Diabetes) as those related to social issues such (deprivation etc.) Effective provision of Health and Social care services can have a significant positive impact on young people and enable them to not only experience a high quality of life throughout childhood, but also ensure that they have the best possible start to life. We are committed to working closely with our partners, including Public Health, Education and the NHS, to ensure that we provide a multi-agency response to delivering services for the 0-19 age group. This will extend to the joint commissioning of services, which we will continue to develop with our partners. We will focus on the CAMHS Wellbeing Hubs to ensure that the deliver the outcomes we have planned. This will mean working closely with providers to ensure effective performance and contracting processes are in place, and we work jointly to effect change where required. A growing proportion of the 0-19 age group are living with long term conditions, such as Asthma and diabetes. Effective management of these conditions is key to ensuring that those conditions don t exacerbate and cause additional complications. We ensure existing services models deliver best practices service models. For Maternity we will deliver the ELLMS Maternity programmes including Neighbourhood Midwifery, shared specifications and continuity of care. What we want to achieve: Intention 1: Deliver the transformation of 0-19 services, through the implementation of a hub based service model based on the delivery of family centred care. This will require multi agency commissioning work between the NHS and Public health, interfacing with education, early years and CAMHS programmes and stakeholders. Intention 2: Develop robust services specification for Children s and Young Peoples therapies to reflect the Service Level Review outcomes and the Joint commissioning agenda. Intention 3: Review outcomes form pilots focussing on reducing Paediatric A&E redirection to understand what elements can be included in the Paediatrics Urgent Care pathway. Intention 4: For NELFT to continue to facilitate the provision of the NEL Child Sexual Abuse hub, located in Chadwell Heath, ensuring this meets all relevant clinical guidelines Intention 5: To work collaboratively with NELFT to develop Emotional Health and Wellbeing Services for Children and Young people, which will contribute to the delivery of the 35% access target by 2019/20 Intention 6: Work with Specialised Commissioning, Local Authorities and Providers to deliver a Place of Safety for Children and Young people Intention 7: To roll out across all of BHR the CAMHS LTP action, including the commissioning of nonrecurrent pilots to move existing schemes into business as usual Intention 8: For NELFT to implement and adhered to the Health in Justice Service specification, KPIs and reporting structures 26

27 Intention 9: BHRCCGs will continue to ensure it maximises the efficiency of the Equipment and Wheel Chair Services, ensuring that both meet the requirements of services users Intention 10: To work with partners to Commission specialist Nursing role(s) in schools across BHR Intention 11: To review the following services to ensure they are delivering the planned outcomes and comply with agreed pathways and services specifications for Children and Young people: Dietetics Epilepsy Audiology Asthma Intention 12: Finalise and implement a revised service specification for Looked After Children (LAC) Intention 13: SEND/EHCP TBC Intention 14: Maternity TBC 27

28 Medicines Optimisation The medicines management commissioning intentions for 2019/20 build on existing work to drive improvements in quality and efficiency through effective medicines use. The aim is to enable budgetary planning for specialist medicines and NICE technology appraisal guidance with a focus on prescribing of medicines, the prescribing and drugs budget, access to high-risk and high-cost medicines and elements of safety. BHR CCGs want to ensure the maximum cost-efficiency and safety in relation to medicines across the health economy. What we want to achieve: Intention 1: To work with Acute partners to ensure Secondary Care prescribing compliance with agreed BHR Medicines Management policy and process. Specific areas include: Biosimilar (Cytokine Inhibitors) To ensure providers comply with existing arrangements regarding pricing for Infliximab, Etanercept, Rituximab and Adalimunab and this is reflected in Trust SLAM submissions. For newly launched (or future Cytokine biosimilars) BHR CCGs will only pay the lowest acquisition biosimilar prices (based on LPP or equivalent price) PBR excluded Medicines CCGs will only fund High Cost Drugs in line with NICE Guidance and NICE Indications. BHR CCGs will mandate the usage of the Blueteq application for applications for PbR excluded drugs and expects Trusts to comply with this process Administration charge for Homecare and VAT CCGs will continue to pay VAT on PbR excluded drugs supplied by the Trust, however CCGs will not pay VAT on PbR excluded drugs supplied via the Homecare arrangements. BHR CCGs will support the Trust with administration costs relating to the supply of PbR excluded drugs via Homecare to the value of 50 per Homecare patient per year. Intention 2: For all ophthalmology indications involving the use of Ranibizumab (Lucentis) and Aflibercept (Eylea), BHR CCGs will no longer accept top up charges for these PbR excluded drugs. The Trust should charge the CCGs lowest acquisition cost price for these drugs Intention 3: CCGs will continue to work with BHRUT to support the increased uptake of any biosimilar Insulin Intention 4: BHRCCGs require all patients discharged from secondary care on Oral Nutritional Supplements to have an agreed management plan included in the discharge communication. All patients requiring Oral Nutritional Supplements must be discharged with a powdered supplement in line with BHR CCGs recommendations Intention 5: In line with the outcomes from the Spending Money Wisely consultation, BHR CCGs expect the Trust to comply with the prescribing restrictions, and prescribe in accordance with the associated policies Intention 6: BHR CCGs and Trust to agree and implement an electronic platform for the hosting of the BHR wide drug formulary 28

29 Cancer Cancer CIs are developed at an STP level and this information has not yet been received, as such this section will be updated over coming weeks. The current list of Intentions related to BHR specific issues related to performance and quality. These will be included in the overarching STP level CIs. What we want to achieve: Intention 1: For BHRUT to complete internal validation for all tumour sites for cancer as per the National Quality Surveillance programme. This should include commissioning and patients representation as part of the panel Intention 2: BHRUT to carry out an audit to understand why BHR CCGs are the worst performing CCGs in London, in regard to immediate reconstruction surgery following mastectomy, and jointly develop a recovery plan with commissioners to address current performance Intention 3: BHRUT to move to 50% of all patients being given a cancer diagnosis (or all clear within 28 days of their GP referral as per the Faster Diagnostic Standard. This is to be achieved by 2020 Intention 4: Trust to move to 100% patients being transferred to a tertiary provider within 38 days. Intention 5: implementation of the timed pathways for lung, colorectal and prostate. 29

30 Integrated Care Early in this document we described the progress we have made in our journey towards the development of an ICS model across BHR. 2019/20 will be a crucial year for the BHR system as we begin to implementing our plans which have been in development since We believe that through implementation of an ICS we can accelerate improved health and wellbeing outcomes for the people of Barking & Dagenham, Havering and Redbridge and deliver sustainable provision of high quality health and wellbeing services delivered by a system with the following aims: Enable and empower people to live a healthy lifestyle, to access preventive care, to feel part of their local community, to live independently for as long as possible, to manage their own health and wellbeing, which creates an environment that encourages and facilitates healthy and independent lifestyles. Where care is: organised around the patient s needs, involves and empowers the patient, is integrated between agencies, with a single point of access, is provided locally where possible, meets best practice quality standards, and provides value for money. In which organisations: share data where appropriate, work collaboratively with other agencies and maximise effective use of scarce/specialist resources (e.g. economies of scale). Where artificial barriers that impede the seamless delivery of care are removed, bringing together not only health and social care, but a range of other services that are critical to supporting our population to live healthy lives. Further person focussed outcomes will be co-developed through engagement with local people, key stakeholders and grass roots staff, building on the work that has already taken place. What we want to achieve: Intention 1: To work with the Provider Alliance during 2019/20 to develop and implement the Integrated Care Service as agreed in the ICS SOC. The following areas have been identified as priority areas by the Integrated Care Programme Board for the coming year: The Barking Riverside Healthy New Town Development Place based Frailty pilots Development of Long Term conditions strategies for Diabetes and AF (as per the LTC strategy) Children and Young People Mental Health Intention 2: To work with Local Authority partners as part of the Joint Commissioning board to explore opportunities for integrated commissioning and pooling of commissioning budgets to achieve greater outcomes. This may include the commissioning of place-based models of care from a single lead provider through and alliance contract. 30

31 Key Information AREA Prevention CLINICALLY RESPONSIBLE OFFICER (CRO) SENIOR RESPONSIBLE OFFICER (SRO) National, NEL or BHR BHR BHR BHR Specific Intentions (please include actions require by provider) Best Start in Life Supporting the development of Communication and Language skills All healthcare practitioners should consider how they can influence behaviour to improve the oral health of children as part of making every contact count (MECC). Expected Impact Increase the number of children ready for school by the age of 5 and long-term impacts on resilience Reduce the number of A & E admissions for dental caries (0-4 years) BHR Increase completion of 2 year old health visitor health checks Early insight into vocabulary and communication, and physical development BHR Early Diagnosis and Intervention BHR Increased awareness of signs and symptoms of cancer and Increased screening programmes importance of testing BHR Support provided by patients diagnosed with long-term Increased number of patients who feel conditions supported by services BHR Resilience BHR Awareness of signs of domestic violence and abuse in staff Increase the number of domestic violence across all partner agencies and abuse referrals through the NHS Increased knowledge of advocacy services Implementation/completion date TBC TBC TBC TBC TBC TBC Increase the number of Practices adopting social prescription to ensure that many more people receive support that looks at their needs holistically as a way of linking patients in primary care with sources of support within the community Medication use before and after referral date between those referred to social prescribing Social prescribing schemes may lead to a reduction in the use of NHS and care services 31

32 BHR Frailty Mental Health and emotional wellbeing support have parity and emotional wellbeing is supported and improved Greater functional independence; avoid unnecessary/lengthy acute stays which can have impact on mobility Social prescribing seeks to address people s needs in a holistic way to increase resilience by supporting individuals to take greater control of their own health. Increase % of adult care users who have as much social contact as they would like (decrease in loneliness) Increase confidence in managing own health Reduction in percentage adults 65+ inactive Reduction in Unplanned hospitalisation Reduction in new long term packages of care 32

33 Key Information Primary Care Transformation CLINICALLY RESPONSIBLE OFFICER (CRO) Dr Anil Metha National, NEL or BHR Specific Intentions (please include actions required by provider) Expected Impact BHR CCGs - Redbridge only GMS/PMS equalisation funding Redbridge CCG currently commissions per weighted population (pwp) of local primary care services via 42 GP practices in Redbridge (29 GMS 12 PMS and 1 APMS); this funding is committed to remain within Primary Care as part of the GMS/PMS equalisation process. The current schemes are: Access Opening Hours 2.20 Access Consultations 4.30 Wound Care 1.00 End of Life 1.00 Practice Development 2.28 Total The Wound Care Premium service for , funded at 1 per patient for all Redbridge patients is due to finish on 31 March Planned care in the process of reviewing commissioning options for wound care services; therefore, agreement is required as to whether this practice level service is required for 2019/20 or whether this service should continue. Also under the review an Opening Hours component was commissioned at 2.20 pwp this also needs review given the strengthen approach by commissioners in tackling practice opening hours. Option of delivery via an at scale provider (i.e. GP federation subject to being legally permissible and agreement with lower level providers). Notice required to general practice providers by 1 October 2018 The review process for potential replacement services commences in September 2018 to be ready for Jan 2019 allowing practices 3 months implementation time possible services already identified to replace these are signposting and self-care, and/or continuation of cancer detection. SENIOR RESPONSIBLE OFFICER (SRO) Sarah See, Director, Primary Care Transformation The initial scoping of the selfcare specification encourages increased provision of information advice and signposting via non-clinical staff to relieve the burden from clinicians. It will combine the increased use of practice websites, the services directory and care navigation to raise awareness together with the establishment of at least 2 self-care condition management groups at the practice. Further discussions with relevant transformation programmes required. Investment: 282k Financial Savings: TBC Implementation/completion date Implementation- 1 April 2019/20 Individual Practice Management 33

34 BHR CCGs - Barking & Dagenham only GMS/PMS equalisation funding. An additional 1 pwp available in 2019/20 for Local Premium general practice across all B&D GP practices with the option of delivery via an at scale provider (i.e. GP Federation subject to being legally permissible and agreement with lower level providers). Potential services (TBC in September/Oct 2018) End of Life Care / cancer service (to ensure consistent approach across all three CCGs). This will need to be negotiated between September and December 2018, to enable commencement from 1 April EOL LIS 2018_2019 Final.docx This specification acknowledges far more patients would prefer to die at home than do - rewards practices who provide a coordinated approach to EOLC - patients are offered greater choice and have access to high quality co-ordinated care ensuring every patient has an Advanced Care Plan describing the patient s preferred place of death. Meticulous record keeping ensures all aspects of the care package are being achieved, and avoids duplication of care Investment 220k Implementation 1 April 2019/20. Individual Practice Management BHR CCGs 3.50 Provider Development funding Long Term Conditions LIS (this is a continuation of the programme implemented from September 2018/19). This LIS will be managed through the use of a NHS Standard Contract, by the three respective Federations on behalf of all practices across BHR to achieve outcomes in relation to: CVD, COPD and Diabetes. It is intended to look at a contract schedule variation from September/October 2019 (work up from April 2019) to ensure that LTC outcomes continue to be stretched over 2019/20 with the implementation of additional stretch from September/October March 2020 (6 month period). Financial Savings: to be considered Quality Improvement related to LTCs within Primary Care Cost Savings model prevention and admission avoidance. Investment 2,658,403 (Financial total from FYE 2018/19. This level of funding may vary) Financial saving total to be confirmed- circa 3 million Implementation of the LTC LIS will be from September/ October 2018/19 for a period of 3 years with a proposed completion date September contract schedule variations each year will enable stretch Federation Management BHR CCGs - Over 75 Assessment: Frailty LIS (this is a continuation of the programme Quality Improvement, Implementation. 34

35 Redbridge CCG only BHR CCGs - Barking and Dagenham only implemented in 2018/19) Redbridge CCG Scheme, part funded in 2018/19 to identify and case manage those vulnerable with moderate frailty in Redbridge. Continuation of this funding to enable a full year effect and to ensure outcome delivery with savings identified. Outcomes include quality improvement in the management of this cohort, maintenance of health and prevention of deterioration, and a reduction in A&E attendances / unplanned admissions. Outcomes also include A&E and Unplanned Admission Avoidance. Scheme Cost FYE- 980,239 / PYE - c 350,425k (2019/20) MSK Pilot Scheme To pilot a Barking and Dagenham primary care musculoskeletal scheme which will deliver integrated general practice/ physiotherapy clinics to patients, enabling increased value for money, increased patient satisfaction and decreased A and E / OPD attendance for MSK problems. Patients able to be dealt with at source. Integrated physiotherapy in Primary Care Data intelligence, feedback and learning: Virtual Lifestyle management support: prevention of health deterioration within this cohort. Savings from acute. Investment 350,425 PYE* Check if accrual can continue with finance. Savings FYE 1,194, * (FYE- September 2018/19- August 2019/20) The main focus of the service will be: Relieving pain, preventing and managing impairment or disability, and achieving highest possible function. Relieving pain, preventing and managing impairment or disability, and achieving highest possible function. Improving and maintaining movement independence and physical performance Promoting injury prevention and overall health and wellness Ultimately improving quality of life. September-March 2018/2019 April - August 2019/20- Completion date (evaluation required May 2019 re further extension) Federation Management Pipeline implementation. This pilot scheme requires work up in tandem with the B&D Together First Federation, Planned Care and support of primary care team. Time lines for 2019/20 and thereafter to be considered. Federation Management Investment TBD Savings TBD BHR CCGs Advice and Guidance LIS Financial Investment to be confirmed. Implementation from October

36 BHR CCGs Implementation of a LIS to support the uptake of Advice and Guidance services for general practice, to prevent unnecessary outpatient appointments for patients, when care can be effectively delivered with consultant expert guidance, by the patient s own GP. Peer Review Referrals Implementation of a programme of Peer Review of Referrals, Linked to Improving Referrals Together. Further scoping work required in September Investment to be confirmed. PID in development Financial Investment to be confirmed. Investment to be confirmed. Completion date March move to BAU. Federation Management Implementation date TBC Federation Management.BHR CCGs Shared Care LIS Implementation of a Shared Care LIS for specialised and complex medication management and associated phlebotomy management and / or other diagnostics required between acute and primary care. PID in development Investment to be confirmed Savings to be confirmed Implementation date - April 2020 (may start within 2018/19) Federation Management BHR CCGs A working group has been setup to design/develop the scheme which GP practices will sign up to. The development team includes CDs, consultants, acute chief pharmacists, Meds management and Planned Care teams Housebound Flu Scheme (LIS) Implementation of a Housebound Flu LIS. The rationale of the scheme is to reduce the need for patients to attend secondary care and NEL admissions owing to community acquired pneumonia and also act as an incentive to give the vaccination to patients that are housebound. Practices will be asked to arrange a home visit to each house bound patient during which they will need to check against the range of criteria shown below Blood pressure AF screening Flu immunisation status Pneumococcal Immunisation status Modelling in the PID has shown that this scheme could potentially prevent up to 32 housebound patients acquiring community acquired pneumonia, up to 11 hospital admissions for CAP and up to one death from CAP. Research papers have suggested that immunisation against flu can prevent hospitalisation from CAP Implementation in 2019/20. Same principles to be applied. Federation Management 15 per vaccinated housebound patient (query uplift to payment in line. To improve outcomes and numbers vaccinated, query whether to move this scheme under Modelled Investment by CCG is 36

37 Federation management for 2019/20. Barking and Dagenham 8,822 Havering 14,555 Redbridge 15,254 BHR CCGs 1.50 Provider Development GPN Leadership Structure To commission a nursing leadership structure across the three CCGs. Proposed structure is 1 x 0.8 WTE Band 8b Strategic Nurse Lead and 3 x 0.6 WTE Band 7 GPN borough Leads (1 per borough). Proposed funding stream for this is from the 1.50p/h provider development monies (to be agreed). It is proposed that this structure is hosted by BHR GP solutions. Proposed costs are as below (scheme is planned to commence in October 2018 subject to PID approval) Barking and Dagenham 25,732 PYE 2018/19 ( 51,464 FYE) Havering 25,732 PYE 2018/19 ( 51,464 FYE) Redbridge 25,732 PYE ( 51,464 FYE) Further modelling in the PID highlights that there is a potential cost pressure of approx. 20,854 from carrying out this scheme across BHR CCGs Support structure for GPNs across the system, improved and more structured training and improved support for continuing professional development peer support at practice level, uniform recruitment practices including testing and interview support for practices. Decrease in vacancies and attrition rates across BHR, increased job satisfaction. Engagement at the BHR and NEL level.increase in clinical quality via improved training and development. Improved workforce data keeping. Planned implementation in October 2018 Continued Funding 2019/20 Hosted management by BHR GP Solutions Investment 154,392 FYE 2019/20 Savings N/A BHR CCGs Quality Improvement To implement a sustainable and supported local level QI programme across each CCG Investment resource for each CCG area. Planned implementation in October

38 which fulfils the GPFV HIA outcomes, as well as supporting BHR to create efficient ways of working including return on investment (ROI) where appropriate; Through QI the federations will be able to identify programmes of work that support the CCG in terms of quality improvement, financial efficiency as well as through alignment with the GPFV, Transformation Plans and High Impact Actions (HIA). This programme of work aligns and supports the Transformation plans and its assurance around QI (currently underway in each CCG with the Federations). 3X PT 8a 0.6wte. Cost (midpoint). Backfill for 2 sessions per month for 14 QI leads QI (course) programme for 6 QI leads in B&D cost awaiting Continued Funding 2019/20 Federation Managementmatrix working with the CCG lead for QI. BHR Havering and Redbridge CCGs BHR-Havering and Barking and Dagenham CCG Cancer Local incentive Scheme (incl. Macmillan Toolkit) This local incentive scheme (LIS) seeks to strengthen the CCGs approach to early detection and diagnosis of cancer and to improve the quality and clinical outcomes for patients once they have been diagnosed with cancer. PID approved February 2018: REDBRIDGE 96,350 in 2017/18 209,400 in 2018/19 209,400 in 2019/20 plus any agreed uplift 209,400 in 2020/21 plus any agreed uplift From 2019/20 onwards, subject to any national QOF changes. HAVERING 121,880 in 2017/18 311,520 in 2018/19 Further years subject to confirmation of funding and from 2019/20 onwards, subject to any national QOF changes. Nursing Home Scheme To be decommissioned and replaced by the Integrated Nursing Health Scheme, led by Unplanned Care. Investment Total- TBC Savings - TBD This LIS focuses on improving the quality of cancer care reviews and the clinical outcomes of those practices where cancer has been diagnosed and ensuring that a cancer care review takes place months after diagnosis. Investment Redbridge 209,400 Havering 311,520 *subject to QOF changes Savings - none identified Funding of existing LIS being transferred as part of new INHS Implementation- await QOF changes before consideration given to recommission Change management to Federation? Notice to be given to existing providers October BHR CCGs - M-JOG (text messaging) This service has had an impact 38

39 Havering and Redbridge BHR CCGs - Redbridge and Barking & Dagenham only Funded NHSE To commission a two-way text messaging service which enables appointment reminders, health campaigns, Friends and family tests, QOF etc. Both Redbridge and Havering will have to undertake an evaluation of the scheme to determine whether the scheme is successful in reducing the rate of DNAs. Havering: Cost: 52, Redbridge Cost: TBC LBTI Screening Programme. To use available PHE funding to support areas of high active TB incidence where introduction of LTBI screening so specifically eligible cohort has been shown to be cost effective method of reducing incidence of active TB. Redbridge and Barking & Dagenham consistently reported as areas of High TB incidence. on reducing DNAs. When a patient replies to cancel an appointment via text, this is automatically removed from the clinical systems and made available to other patients improving access. Q1-86k worth of cancelled appts. Need to ascertain impact on overall DNA rates to understand practice efficiencies / system gains from lost appts By screening prospectively and 5 years retrospectively incidence of active TB expected to reduce As this is the final year of a five year strategy funding in 2019/21 may be expected to be less than previous years. Implementation and completion dates June 2018 June 2019 Dependant on funding offer from PHE TB strategy LTBI screening programme for 2019/20. Barking & Dagenham B2.pdf NHSE Investment TBD Savings TBD Could move to Federation Management BHR CCGs Funded NHSE National Diabetes Prevention Programme Continued implementation of the National Diabetes Prevention programme, a part of Healthier You. Programme to be Provided by the emerging ICS (also providing across various sites within East London) Programme will target 1100 recruited participants to pilot across two distinct cohorts. 1) NDH 2) obese/overweight. Participating practices across BHR (B&D 9 practices; Havering 5 practices; Redbridge Evaluation of multi-approach longer-length fitness programmes. Local Population: reduced population of at-risk-ofdeveloping diabetes. Outcomes measures: recorded NDH results & weight/bmi NHSE Programme which is expected to run for several years 39

40 15 practices) Referrals accepted by LIVA from Dec 17 till September 28 th (inclusive for national extension offered by NHS E to all pilot sites) Provider = LIVA (also providing in Humber coast and Vale.) Offering pre-diabetic support as an alternative to shorter currently running borough programmes, i.e. Healthy Lifestyles, etc. programme includes various elements to encourage behavioural change, including one2one sessions with a health coach, counselling, light exercise and nutrition educational sessions, with six and nine month one2one progress reviews. recorded at baseline, 6 months and 12 months (by GP practice). All data fed into national evaluation report. Cost of Programme Patient sign-posted (by ICS) upon graduation to further services if needed (i.e. if greater health need has been identified). BHR CCGS NHSE All BHR practices are participating in the programme. B&D go live date 02/07/2018. Havering & Redbridge go live date 01/08/2018 e-consult Implementation of E-Consult, a web based patient triage programme designed to manage demand and free up both GP and admin capacity. E-consult is run via a web link banner which sits on the practices website and is currently used by 380 practices This contract, funded by NHSE, commenced on the 1st May 2017 and will run for three years (with a twelve month break clause should either party request this) Consultations via e-consult will count towards the PMS review and assist practices achieving the top level of transitional funding over the next three years. Cost of programme Implementation Date May 2018 May

41 Key Information National, NEL or BHR BHR Planned Care CLINICALLY RESPONSIBLE OFFICER (CRO) Atul Aggarwal Specific Intentions (please include actions require by provider) Delivery of year 2 of Improving Referrals Together programme clinically agreed pathways, referral templates and discharge templates to be agreed in key specialties. Work has commenced during 2018/19 (although is currently behind plan). This is a joint project between BHRUT and BHR CCGs. SENIOR RESPONSIBLE OFFICER (SRO) Louise Mitchell Expected Impact Reduction in outpatient activity within secondary care providers Implementation/completion date Underway two year programme BHR Achieving the full year impact of Advice and Guidance implementation at GPs Reduction in outpatient activity September 2018 TBC (saving of 1 in 3 assumed) BHR ENT: Reduction in outpatient activity Deliver the Full Year Impact of ENT Community Service re-procurement, new service went live 1 st July 2018 within secondary care providers Underway - 30 th June 2019 Implementation of Single Point of Access (work currently underway with BHRUT) TBC BHR Ophthalmology: Reduction in outpatient activity Achieving the full Year Impact of Ophthalmology Community Service reprocurement, new service due to go live 2 nd December 2018 within secondary care providers 2 nd December st December 2019 Full year impact of implementation of Single Point of Access (work currently underway with BHRUT) TBC Pathway for cataract follow up patients to be agreed (pilot currently underway with community provider, outcome will be known by November 2018) BHR BHR BHR Full Year Impact of Ocular Coherence Tomography Scans carried out for patients with Diabetes as part of the annual eye screening test where required. CCGs intend to develop a proposal to implement a Urology Community service. The proposal is currently being worked through. Implementation is provisionally scheduled to occur with 19/20 Potential to implement Pain Community service currently being worked through. The proposal is currently being worked through. Implementation is provisionally scheduled to occur with 19/20 MSK: Review of MSK Triage Service underway due to current contract expiry (in Reduction of OCT scans carried out in secondary care for this cohort. Reduction in outpatient activity within secondary care providers Reduction in outpatient activity within secondary care providers Potential further reduction in outpatient activity with Implementation: November 2018 Implementation: August 2018 TBC TBC 41

42 early 2019) outcome likely to be known by end August Potential bid to NHSE for pilot of First Contact Practitioner Full year impact of full implementation of Single Point of Access (work currently underway with BHRUT) secondary care providers September 2018 onwards TBC TBC 42

43 Key Information National, NEL or BHR BHR in line for FYFV National in line with FYFV BHR BHR BHR BHR BHR URGENT CARE CLINICALLY RESPONSIBLE OFFICER (CRO) Dr Jagan John Specific Intentions (please include actions require by provider) To Commission an integrated community urgent care offer across BHR which will replace the current contracts for: Harold Wood WIC Hurley Group South Hornchurch WIC Hurley Group Barking Community WIC - NELFT Loxford WIC Healthbridge 7 GP Hubs GP Federations 3 GP out of hours services PELC Procurement will commence in December 2018 To Commission UTCs at the front of Queens and King George hospital To ensure Consistent streaming at the front door of all urgent care services and appropriate redirection and booking in to GP practices. The streaming will be commissioned as part of the urgent care procurement but the booking will require engagement with GP Federations/ GP practices. Ambulatory care TBC Embed the use of Electronic Frailty Index (EFI) in primary care to support identification and management of frail patients and manage risk, as part of the GP Networks/Primary Care services Commission integrated care home support to reduce conveyances and A&E attendances/ admissions GP home visiting TBC SENIOR RESPONSIBLE OFFICER (SRO) Sharon Morrow Expected Impact Increased use of 111 Reduction in A&E attendances Increase in booked appointments Reduced conveyance, attendance, admission and reduce delays on discharge Implementation/ completion date October

44 BHR To embed the system wide usage of Coordinate my Care (CMC) to enable sharing of End of Life care plans across the system to improve patient experience and care and increase the number of patients supported to die in their place of choice Improved patients care and reduction of deaths in hospital BHR Stroke services TBC Improved care for patients and pathway to improve rehabilitation and reduced care costs BHR To fully implement and use of ACPs across BHR to reduce conveyance to hospital and resulting A&E attendances. To be delivered by London Ambulance Service Reduced conveyance to A&E and attendances 44

45 Key Information National, NEL or BHR BHR BHR OLDER PEOPLE, FRAILTY AND END OF LIFE CLINICALLY RESPONSIBLE OFFICER (CRO) Specific Intentions To Commission an integrated nursing home service that provides multi-disciplinary support to nursing homes in BHR including through extended hours Placed based care TBC SENIOR RESPONSIBLE OFFICER (SRO) Sharon Morrow Expected Impact Reduction in emergency admissions Increase in number patients dying in their place of preference BHR To commission a Falls prevention service to across the system Reduced admissions due to falls BHR To develop a consistent approach to the identification and management of frail patients in primary, community, secondary and social care. National By 31 December 2019 all Type 1 EDs trusts to provide an acute frailty service for at least 70 hours per week with input from physiotherapists, occupational therapists, case managers (typically a nurse specialist) and pharmacists to provide multidisciplinary (MDT) assessment. Reduction in length of stay BHR Review the commissioning of end of life care beds within local nursing homes for patients identified as having end of life care needs, ensuring the care homes are signed up to a trusted assessment model so discharges from the acute hospitals are as efficient as possible. Reduced length of stay BHR Review the enhanced community nursing offer (community matrons/nurses) commissioned to provide EOLC 45

46 Key Information Long Term Conditions CLINICALLY RESPONSIBLE OFFICER (CRO) Atul Aggarwal SENIOR RESPONSIBLE OFFICER (SRO) Louise Mitchell National, NEL or Implementation/completion Specific Intentions (please include actions require by provider) Expected Impact BHR date BHR Development of LTC 3 year strategy TBC Underway December 2018 BHR Continuation of work within primary care to address rising Diabetic prevalence Reduction in acute and Ongoing community diabetic service and improved detection rates. Longer term impacts on complication/co-morbidity levels BHR Improvement in identification and treatment of patients with AF and COPD (in collaboration with primary care) as part of the LTC LIS Reduction in outpatient appointments within secondary care TBC (dependant on PID approval) 46

47 Key Information National, NEL or BHR BHR BHR AREA (IE PREVENTION) CLINICALLY RESPONSIBLE OFFICER (CRO) Dr Raj Kumar Specific Intentions (please include actions require by provider) To increase reach of IAPT into long term conditions and further development of digital solutions. CCGs require: NELFT to work with commissioners to determine which LTCs will yield the most benefit NELFT to continue to embed the offer of digital solutions within the IAPT service NELFT to work with commissioner and agree the steps required to reach core 24 mode by As per the mental health Five Year Forward View SENIOR RESPONSIBLE OFFICER (SRO) Expected Impact Sharon Morrow Increase in IAPT access rate Decrease in waits for 2nd and subsequent treatment Decrease breaches in the 4 hour metric due to MH patients Implementation/completion date 1 st April 2019/ 2021 May 2019/September 2019 BHR To carry out a gap analysis and determine the distance from core 24 model To outline the staffing skill mix and the balance of coverage across different sites Primary Care MH NELFT to work with commissioners to set out a phased development of a mental health primary care programme over 3 years. Decrease in the number of patients in secondary care April March 2022 BHR NELFT will need to set out, in collaboration with commissioners, what can be achieved in year 1. NELFT to work with commissioners to identify the cohort to be considered NELFT to present a business case for a Clinical Decisions Unit (CDU) The CDU would sit in-between Inpatient services and Home Treatment Team and better ensure most appropriate patients for inpatient admissions. Decrease of patients being admitted to a ward that can be managed elsewhere. September 2019-September 2020 NHSE Requirement BHR NELFT to carry out modelling work to determine the benefit of the CDU to the inpatient pathway NELFT to put forward a case for change Physical Health Checks for patients with SMI NELFT is to work with commissioners to set up a system to maximise the opportunity to carry out health checks in secondary care. Street Triage - NELFT to work with commissioners to scope the current cover and effectiveness of Street Triage and explore whether any changes need to be made. NELFT to look at the demand on the service at different times of the day To quantify and qualify the impact of not having full cover Children and Maternity Improve the physical health of patients with SMI Decrease the gap in health outcomes for patients with SMI Improve the out of hours offer for patients with a mental health crisis Free Ambulance time A + E avoidance Admission avoidance January 2019 September 2020 April 2019 September

48 Key Information National, NEL or BHR BHR 0-19 Transformation CLINICALLY RESPONSIBLE OFFICER (CRO) Jacqui Himbury Specific Intentions (please include actions require by provider) Multi agency joint commissioning work over 2 years to develop a fully integrated 0-19 service encompassing all services commissioned by PH and Health and interfacing with education, early years and CAMHS to deliver a hub based service model delivering seamless family centred care in the correct place and with accompanying cost benefits SENIOR RESPONSIBLE OFFICER (SRO) Louise Mitchell Implementation/completion Expected Impact date An agreed model for future Q4 2019/20 delivery of seamless 0-19 services and with demonstrable efficiencies Reductions in unplanned admittances and A&E attendances Outcomes from Local Area SEND inspections taken into planning along with best practice skills mix and working models Senior contribution to the Transformation Boards and supporting governance Maximisation of resource through skills mix and multi-agency working BHR Paediatric Therapies Work towards revised and robust service specifications for all CYP therapies to reflect SLR outcomes and requirements of the Joint Commissioning agenda and the future design of the 0-19 service Fit for purpose service specifications delivering SMART data returns and mapping against the likely 0-19 model Q4 2019/20 Ensure that additional non recurrent investment maps against SLR work to confirm recurrent funding NEL / BHR A&E Re-direction Consideration of previous pilots to place HV within Paeds ED to screen <5 activity and / or Paeds UC. Integrate with 0-19 and CCNT re-design and work with LA partners and providers on commissioning and clinical supervision Validated model of ED activity avoidance eventually linking in to a revised and integrated 0-19 service Q2 2019/20 NEL NEL Child Sexual Abuse Hub NELFT will continue to facilitate the provision of an equipped CSA Hub in Chadwell Heath and to work with partners to ensure delivery of a Paediatric rota meeting clinical guidelines Outer NEL CSA Hub meeting working with dedicated emotional support teams to deliver seamless service to vulnerable cohort and reduce lifelong health activity Q3 2018/19 Q1 2019/20 48

49 BHR NEL BHR Emotional Health and Wellbeing (EHWB / CAMHS) NELFT will work collaboratively to develop EHWB services delivering MH / physical health parity and equity of delivery pan BHR whilst robustly contributing to attainment of the 35% access target for 2019/20 Section 136 Suite CYP MH Place of Safety Work with Spec Comm, LA and providers to deliver a S136 CAMHS Local Transformation Plans (LTP) Roll out of all BHR CAMHS LTP actions and with full sign off from LTP Board. Commissioning of non-recurrent pilots and actions to validate existing schemes into business as usual funding Costed solutions to equity of delivery across BHR utilizing MH parity funding Attainment of the NHSE 35% Operating plan target for EWMH therapeutic contacts All CYP with MH Act S2 and S3 will have a Place of Safety in accordance with best practice and learning outcomes from previous CeTR s Delivery of a LTP Board supported set of schemes with agreed outcome measures informing future commissioning to meet national and local targets Q2 2019/20 Q2 2019/20 Q4 2019/20 National BHR BHR Health in Justice (collocated NHSE funded additions) NELFT will work collaboratively to ensure the service specification, KPIs and reporting structures are adhered to, the teams are co-located and that work is conducted to provide validation for Year 3 Business as Usual funding Equipment The BHR CCGs, integrated community equipment service across BHR health and social care services has gone live from February 2018 BHR CCGs will wish to see the continued development of the equipment provision to maximise efficiency, making the best use of staff resource and capacity and ensuring a consistent service to people receiving community health services Wheelchair Services Confirm that the new service is working to agreed budgets and service user requirements 2018/19 issues require rectification on-going work to strengthen collaborative working Agreed Service Specification and supporting reports delivering demonstrable physical and MH outcomes for CYP in the YOS Mature functioning of integrated systems delivering expected efficiencies A service delivering to cost and quality assumptions Q2 2019/20 Q2 2019/20 Q2 2019/20 49

50 BHR BHR NEL / BHR BHR BHR Specialist Nursing in Schools and Schools provision Commissioners to commission specialist nursing role (s) in schools across BHR, linked to the wider work with schools leading to an updated specification and clarification of what is expected from the service. Multi agency work on funding to support expanded SEMH and AP capacity Explore how community health services work with schools including co-location of services, workforce allocation, demand and capacity planning, clear service offer and joint working and single assessment processes across health, education and social care Dietetics Commissioners will continue to monitor and review this service to confirm outcomes resulting from 2018/19 122K investment for two paediatric specialist & technical dieticians Epilepsy Work to review and implement HLP best practice Audiology Commissioners have met with NELFT (B&D and Havering) and BARTs (Redbridge) to review and update the paediatric audiology service specification and pathway. Commissioners will expect NELFT and partners to continue to develop the service, review pathways and finalise the service specification Asthma Adoption of the London Asthma Standards for CYP and to integrate with NELFT and key partners to work, review and implement best practice Multi agency agreement on funding and support for expanded workforce Demonstrable returns on investment as per business case Costed and agreed model reflecting multi agency best practice Fully functioning service supported by robust specification and reporting lines Costed and agreed model reflecting multi agency best practice Q3 2019/20 Q4 2019/20 Q3 2019/20 Q3 2019/20 Q3 2019/20 BHR Looked After Children (LAC) Completion of revised service specification reflecting multi agency agreement and delivering timely and high quality Assessments and on-going health support for LAC including CAMHS Integration of EHCPs into IHA and RHA desktop review An agreed service specification delivering efficient and effective services for LAC Q2 2019/20 50

51 BHR SEND / EHCP Cross agency working via the DCO to establish learning packs for standardisation of EHCP narratives Clear understanding of mutiagency input to EHCPs including agreement on areas of responsibility Q2 2019/20 Action on outcomes from the Local Area Inspections (OFSTED/CQC) including robust specification on transition and wait times for therapies Confirmation of system design to maximise oversight of individual CYP with EHCP Significant progress on standardised early transition protocols Significant progress on interface with LAC systems NEL Maternity Continue strong working relationships with the ELLMS A sector wide shared vision delivering and monitoring best practice Q4 2019/20 Commissioning of a shared programme of engagement with Maternity Voices Partnership (MVP) and / or CCG supported professionalization of the Chair role interfacing with CQRMs A robust MVP reflecting service user experience into governance structures ELLMS wide consideration of a Neigbourhood Midwifery model ensuring that the impact is not disproportionate on one provider site A shared specification allowing equality of access and delivery Development of shared Midwifery KPIs informing ELLMS priorities such as continuity of care and personalised care plans Shared work on Maternity Specifications 51

52 Key Information National, NEL or BHR BHR BHR BHR BHR AREA (IE PREVENTION) Medicines Management Secondary Care Prescribing CLINICALLY RESPONSIBLE OFFICER (CRO) SENIOR RESPONSIBLE OFFICER (SRO) Dr A Tran, Dr G Kalkat, Dr S Raza Jacqui Himbury Specific Intentions (please include actions require by provider) Biosimilars (cytokinine inhibitors) current arrangements Current biosimilar PbR excluded drugs BHR CCGs will continue to only pay the lowest acquisition costing biosimilar price (based on LPP or equivalent prices) for the following drugs: 1. Infliximab 2. Etanercept 3. Rituximab 4. Adalimumab Prices are available through BHRUT Pharmacy or directly through the LPP The Trust is to charge the CCGs the lowest acquisition cost price for these drugs via SLAM monthly Biosimilars (cytokinine inhibitors) future arrangements BHR CCGs will only pay the lowest acquisition costing biosimilar price (based on LPP or equivalent prices) for any newly launched biosimilar PbR excluded drugs The Trust is to charge the CCGs the lowest acquisition cost price for these drugs via SLAM monthly Age Related Macular Degeneration (ARMD) BHR CCGs no longer accept top-up charges for all ARMD PbR excluded drugs The Trust is to charge the CCGs the lowest acquisition cost price for these drugs via SLAM monthly Blueteq BHR CCGs intend to implement the use of blueteq to manage applications for PbR excluded drugs Applications for new patients to be made via blueteq from April 2019 All existing patients to be transitioned through blueteq by October 2019 BHR CCGs can support the Trust with the introduction of blueteq for CCG commissioned PbR excluded drugs Expected Impact Continuation of current agreement to ensure maximum cost-efficiency for these high cost drugs across the health economy Correct price charges will reduce the administrative burden of SLAM challenges for BHR CCGs and BHRUT Trust to change to newer biosimilars as released to ensure maximum cost-efficiencies for these high cost drugs Trust to charge only the agreed drug price via SLAM for ARMD drugs Reduction of the administrative burden of SLAM challenges for BHR CCGs and BHRUT Trust will apply for funding for all PbR excluded drugs via blueteq software Provision of an audit trail of each drug application that will allow accurate and efficient validation of invoices Tracking of patient clinical outcomes based on agreed criteria of blueteq forms Implementation/completion date On-going from 2018/19 Adalimumab biosimilar expected Dec 18 After 1 month of launch of new biosimilar On-going from 2018/19 Implement for new patients from April 19 Existing patients to be transitioned by October 2019 National/BHR Administration charge for Homecare Vs VAT Trust to charge for VAT correctly On-going from 2018/19 52

53 BHR BHR National BHR/national BHR BHR CCGs will continue to pay Value Added Tax (VAT) on PbR excluded drugs supplied by the Trust BHR CCGs will NOT pay Value Added Tax (VAT) on PbR excluded drugs supplied via Homecare arrangements BHR CCGs will support the Trust with administration costs relating to the supply of PbR excluded drugs via Homecare only BHR CCGs will agree to pay an administration cost of 50 per Homecare patient per year These administration charges are expected to be charged quarterly ( 12.50) as a separate charge through SLAM for each patient Biosimilar insulin BHR CCGs Commissioners continue to work with the Trust to support the uptake of any biosimilar insulin Oral Nutritional Supplements All patients discharged on an Oral Nutritional Supplement must have a malnutrition management plan included in the discharge communications BHR CCGs expects the Trust to discharge ALL patients, requiring Oral Nutritional Supplements, with a powdered supplement in line with BHR CCGs recommendations PBR exc medicines compliance BHR CCGs will only fund High Cost Drugs where used in line with NICE Guidance and NICE Indications Decommissioning of medicines from FP10 BHR CCGs expects the Trust to support primary care with prescribing restrictions made from the Spending NHS Money Wisely local consultations and NHS England consultation outcomes for conditions for which over the counter items should not routinely be prescribed in primary care BHR CCGs expects the Trust to support primary care with prescribing restrictions made from the NHS England consultation outcomes for low value medicines, which should not routinely be prescribed in primary care BHR wide drug formulary BHR CCGs and Trust to agree and implement an electronic platform for hosting the BHR wide drug formulary via monthly SLAM reducing the administrative burden of SLAM challenges for BHR CCGs and BHRUT Trust to charge per quarter per Homecare patient as a separate charge through SLAM to support the Trusts administrative costs for this activity Trust to discharge patients on a biosimilar insulin where clinically appropriate to ensure maximum cost-efficiencies Malnutrition management plans are to be included with patient discharge communications Powdered Oral Nutritional Supplements to be provided on discharge to ensure maximum costefficiencies Continuation of current agreement Trust is expected to both prescribe and recommend primary care to prescribe in line with recommendations/ restrictions that are in place to enable costavoidance across the health economy Formulary available in electronic format for all prescribers including highlighted Hospital Only Drugs From 1st April 2019 Continuation of current agreement Continuation of current agreement On-going from 2018/19 To start April 2019 with expected completion October

54 NEL/BHR Interface prescribing and joint working BHR CCGs expects the Trust to adhere to the hospital only list recommendations that is agreed across NEL STP BHR CCGs expects the Trust to agree relevant Shared Care guidelines/agreements with them BHR CCGs expects the Trust to send the signed locally agreed Shared Care guidelines/agreements to BHR practices for all new requests for prescribing drugs agreed for share care BHR CCGs expects the Trust to retain prescribing of medicines where a practice does not agree to share care BHR CCGs expects the Trust to prescribe in line with agreed joint formularies and agreement with BHR CCGs APC recommendations BHR CCGs expects the Trust to make no requests to BHR GP practices to prescribe non-formulary drugs BHR CCGs expects the Trust to support medicines management decisions agreed at the APC The BHR CCGs expects all future Medicines Management plans for are documented and linked to a dedicated contract schedule With regard to STP priorities, the BHR CCGs will require the Trust to comply with the outputs of Medicines Optimisation East London Health and Care Partnership Steering Group and the NEL clinical senate and Shared Care Agreements Continuation of current agreement Reduction of GP and Trust queries and complaints related to nonadherence Agreed Medicines Management contract schedule in place to benefit working across the interface NEL wide implementation of agreed initiatives to provide costeffective and safe medicines optimisation High Level Outcomes Key Risks & issues Other Information To ensure maximum cost-efficiency in relation to medicines across the health economy Medicines Management Team (MMT) and BHRUT Pharmacy Capacity to ensure all intentions are actioned and monitored. Business case for additional resource Lack of communication between BHRUT Pharmacy and Finance to ensure prices are agreed and released to commissioners. Finance + Contracting + BHRUT Pharmacy department and MMT meeting to discuss and agree a way forward On-going from 2018/19 54

55 Key Information National, NEL or BHR National Cancer (Planned Care) CLINICALLY RESPONSIBLE OFFICER (CRO) Atul Aggarwal Specific Intentions (please include actions require by provider) BHRUT to complete internal validation for all tumour sites for cancer, as per the national Quality Surveillance programme. To include a commissioning representative and patient as part of the review panel SENIOR RESPONSIBLE OFFICER (SRO) Louise Mitchell Implementation/completion Expected Impact date Trusts and commissioners to TBC have a clear understanding of quality within cancer services. An opportunity for the Trust to reflect on key achievements and challenges for the previous year within each specialty and to plan for the following period. BHR Trust to carry out an audit to understand why BHR CCGs are the worst performing in London in regard to immediate reconstruction surgery following mastectomy and jointly agree action plan to address.` To identify causes of inequity and to develop an action plan to address them. TBC National Trust to move to 50% of all patients being given a cancer diagnosis or all clear within 28 days of their GP referral, as per the Faster Diagnosis Standard which needs to be achieved by 2020 Incremental move towards meeting the 2020 ambition of all patient being given a diagnosis or all clear by Incremental move towards required levels 1 st April st March 2019 National Trust to move to 100% of patients being transferred to a tertiary provider within 38 days. TBC - Action plan awaited High Level Outcomes Key Risks & issues Other Information Improved patient experience Cancer CIs are developed at an STP level and this Improved staff satisfaction information has not yet been received, as such this Sustained delivery of Cancer list will need to be updated over coming weeks. Waiting Time standards 1) Urology pathway (prostrate) to UCLH is under pressure. Mitigation: work underway at an STP level to address this issue which is common across NEL. 2) Capacity constraints. Mitigation: Work with BHRUT collaboratively to identify any capacity issues given knock on effect to RTT 55

56 Key Information National, NEL or BHR Integrated Care CLINICALLY RESPONSIBLE OFFICER (CRO) TBC Specific Intentions (please include actions require by provider) Work with the Provider Alliance during 2019/20 to develop and implement the integrated care system (new place based model as set out in the ICS SOC). The following areas have been identified by the ICPB as priorities for the coming year: SENIOR RESPONSIBLE OFFICER (SRO) Jane Gateley, Director of Strategy and Integration Implementation/completion Expected Impact date BHR - Barking Riverside Healthy New Town Development, a new and innovative model of care and wellbeing framed around promotion of wellbeing, linked to the wider determinants of health - Placed based frailty pilots 2 per borough (proposal developed through programme supported by UCLP/Dartmouth Institute, to be led by the Provider Alliance) (we could add details of resource commissioners are providing for this but I would need to check with Ceri what she has agreed) - Diabetes and AF (presume this are picked up in the LTC response Mark?) - Children and young people (tbc) - Mental health (tbc) More streamlined, person centred high quality services with improved outcomes for local people BHR Explore integrated commissioning opportunities with the local authorities through the Joint Commissioning Board via expansion and evolution of the Better Care Fund and further pooling of budgets. This may include commissioning of place-based models of care from a single lead provider through an Alliance contract etc. Reduction in variation across BHR, improved utilisation of scare resources. Economies of scale achieved where possible to improve sustainability 56

57 DRAFT v DRAFT City and Hackney Clinical Commissioning Group System Commissioning Intentions onwards August-September 2018 Part 1: Context Our vision for the City and Hackney health and social care system Our local vision for Hackney and the City of London is that local residents and patients have the healthiest, happiest lives possible. By 2022, we will have a single approach across City and Hackney that supports people and their families to the live the healthiest possible lives. For our patients and residents this will mean: - More support for patients and their families to get healthy be active and stay well and be as independent as possible - Easier ways for patients to be involved in decisions about their care - Joined up physical and mental health that meets patients physical, mental health and other needs - Neighbourhoods where people and communities are actively supported to help themselves and each other - High quality GP practices, pharmacies and communities services which offer those who use them more support and closer to their homes - A thriving local hospital there when our patients and residents need it Our 2019/20 system commissioning intentions are shaped by our vision and the impact of our programme will be measured through our systems outcomes framework currently under development. The Integrated Commissioning Programme Integrated Commissioning (IC) is a partnership to improve health and wellbeing outcomes for Hackney and City of London residents through closer joint working and integration between local health and care organisations. The Programme has brought together three commissioning organisations: London Borough of Hackney, the City of London Corporation and the City and Hackney Clinical Commissioning Group, alongside a wide range of providers. We want to improve health and wellbeing outcomes in our boroughs, by planning and delivering health, social care and public health services together. By working together better, we can make the most of our joint local knowledge and achieve our common goals, can better involve our service users are at the centre of everything we do, and better tailor services to the needs of our diverse communities. We can also make the most of every Hackney and City pound in the context of increasing pressure on sector budgets. We have established four workstreams, with members from commissioning organisations and local providers and patients/residents to work together to more effectively plan how to improve services and care for local people, these include Planned Care, Unplanned care, Prevention and Children Young People and Maternity Services. We have also established a Transformation Board and two Integrated Commissioning Boards (one for Hackney, one for 57

58 DRAFT v City of London) to oversee the work of the workstreams. These Boards have meetings in common. In addition, there are two other cross-cutting commissioning elements that feature across all of these workstreams including: Primary Care and Mental Health; we are passionate about making sure mental health is given the same priority as physical health and transforming our Primary care services through our Neighbourhoods Programme To support the continuing development of the workstreams there are five enabler groups that provide them with essential input: - Estates Enabler Group; - Information Technology Enabler Group; - Community Provider Education Network; - Engagement Enabler Group; - Primary Care Quality Enabler Group. Our partners The key organisations that commission) health and social care in Hackney and City are joint partners on IC: - NHS City and Hackney Clinical Commissioning Group (CCG); - City of London Corporation; - London Borough of Hackney. - The commissioners are partnering with the organisations that provide services and support in our area: - City and Hackney GP Confederation (GPC); - City and Hackney Health and Social Care Forum (HSCF); - City and Hackney Local Pharmaceutical Committee (LPC); - City and Hackney Urgent Health Care Social Enterprise (CHUHSE); - East London NHS Foundation Trust (ELFT); - Healthwatch City of London; - Healthwatch Hackney; - Homerton University Hospital NHS Foundation Trust (HUHFT). Our Priorities In City and Hackney we are working together with our patients and providers to commission and deliver an integrated, effective and financially sustainable system within the systems control total that meets the population s health and wellbeing needs. To tackle the problems we face, we are taking a place based approach working in partnership with clinicians and practitioners, residents and patients, local authority members and other stakeholders. We want to really join up public services, make better use of our collective estates and take a new approach to prevention. Our Strategic Framework, signed up to by all partners, sets the background for our systems workstream commissioning intentions and our aims for our population. Our priorities are: Improve the health and wellbeing of local people with a focus on prevention and meeting the aspirations and priorities of the 2 Health and Wellbeing strategies; Ensure we maintain financial balance as a system and achieve our financial plans in line with agreed system financial controls 58

59 DRAFT v Deliver a shift in focus and resource to prevention Deliver proactive community based care closer to home and outside of institutional settings where appropriate Address health inequalities and improve health and wellbeing outcomes, using the Marmot principles in relation to the wider determinants of health and focusing on social value; Ensure we deliver parity of esteem between physical and mental health Deliver integrated care that meets patient s physical, mental health and social needs Ensure we have tailored offers to meet the different needs of our diverse communities; Promote the integration of health and social care through our local delivery system as a key component of public sector reform; Build partnerships between health and social care for the benefit of the population; Achieve the ambitions of the NEL STP. Over the course of 2019/20 and beyond, each workstream will contribute to the establishment of an integrated care system across Hackney and the City which achieves our system aims and objectives. To do this, the partners in each of the workstreams, supported by the enabler groups, will take collective responsibility for: Overseeing contractual performance and proposing changes to contractual arrangements Service redesign and organising service delivery to achieve integration Ensuring provider collaboration in service redesign and delivery Developing and embedding innovative front line practice and delivery Implementing transformation initiatives Achieving local ambitions and those of NEL STP Delivering improvement in population health outcomes Delivering NHS Constitution and other standards and metrics Maintaining financial balance and delivering savings plans Working together in a truly integrated way to address shared issues/common outcomes. This will be achieved through work with clinicians, resident/patient and other stakeholders to develop and implement robust and integrated delivery plans across local providers. Principles We will deliver our plans adhering to the following principles: Addressing the wider determinants of health to address underlying health inequalities, focusing both on direct service commissioning and influencing and advocacy in the wider system Development of Neighbourhoods across City and Hackney with planning and delivery of care at a neighbourhood level where this would improve care and outcomes re Empowered patients equipped with skills and information to help them self-manage, access the right services when needed, make informed decisions on the evidence and options for their care and who are active in the co-design of our service delivery arrangements and pathways Strong safe local hospital care delivering: o o High quality 7 day services, integrated with mental health resources and networked with other local hospitals where necessary. Fewer face to face outpatients - replaced by digital solutions. 59

60 DRAFT v o o o o o o Support and expert advice to primary and community care. Demand management of tertiary service. Reductions in variations between teams. Minimal length of stay, thanks to good primary and community based services which command universal clinical confidence. Aligned clinical and practitioner behaviours across primary, community, secondary and social care, which see the community / home as the default and support the delivery of resident care plans. Preventative interventions. How this aligns to our STP ambitions The Five Year Forward View has set out the ambition to provide new models of care to patients and to join up services between health and social care. The NEL STP has put this ambition into deliverable outcomes. These outcomes include, improved health and wellbeing outcomes for the people of north east London, sustainable services built around the needs of local people, and the development of new ways of working in partnership to deliver services and prevent ill health. We share the same ambitions and are committed to doing our bit to support the delivery of the NEL STP. Our devolution plan will direct the practical delivery of the Five Year Forward View and STP ambitions across City and Hackney. With our local plans we will now be able to go further in delivering the STP ambition, by empowering local solutions for our population. Strong leadership, mature relationships and a track record of integration Our system is built on strong and mature relationships across Hackney and the City and Leaders across the system have been working closely together since 2013 as well as across the broader north East London health and social system. We build on a history of collaboration which has resulted in some real improvements for local people and a sustainable health and care system. Strong commitment to system planning and shared financial risk management Delivering our vision is set against a context of existing health and wellbeing challenges within the borough, and financial challenges facing our system of health and social care. We are clear that the only solution for these current and emerging challenges is through a radically different system, continuing to further develop integrated commissioning and build on our collaborative approach We are in a relatively strong position financially, with high quality provider performance and a history of innovation and significant care and outcome improvements which have come about from our local partnership working. Therefore, we start from a relative position of strength which unifies the partners. We are working towards a 3 years systems control total for City and Hackney. Work on this has begun with the CFOs of the key partner organisations and we will be holding a financial scenario workshop in to develop a better understanding of how this could be achieved across the care workstreams. We have been working through the NEL STP to understand our local five year affordability challenge across health and social care and achieving and maintaining financial balance across our system is a key driver for our local devolution plans. We want to ensure our new models of care are sustainable in the longer term and this can only be achieved through changes to the way we currently commission and deliver services. 60

61 DRAFT v Our commissioning intentions for 19/20 and beyond are set in the context of the financial challenge that City and Hackney could face across health and social care is between 20m and 78m by 2020/21 and there is considerable volatility within these estimates. Challenges include but are not limited to: Policy changes - Impact of Brexit on economy and domestic policy - Proposals to move Attendance Allowance responsibility to Local Authorities - Introduction of system wide control totals within NHS - Ongoing welfare reform - Potential implementation of the Housing and Planning Act Successful management of existing pressures within the system - Ongoing delivery of savings across health and social care - Management of growth in demand and changes in acuity and complexity of need - Impact of pressures on providers such as national minimum wage, recruitment and retention - Continuing care market in distress [To be updated] Finance and forward planning How the integrated commissioning programme supports performance The integrated commissioning structure supports improved performance by enabling us to take a system-wide view of performance pressures across our provider organisations. This means that we can identify any wider system issues that may lead to performance pressures within a given provider, and also allows us to work as a system to deliver a resolution, if that is required. This is particularly important to deliver access standards and DToC targets, where a multi-agency approach is required to support improvements. Future Plans for Integrated Commissioning There are many plans in place for Integrated Commissioning to design and improve local services for residents and patients. Our commissioning intentions are a reflection of the future plans we have in place - The move to a neighbourhood model for the delivery of all prevention, health and social care community-based services will continue at pace; - A innovative redesign of community services including the services in our current community health contract - Looking at how to support partners to work even more closely together to deliver new models that are developed; - Continued planning to meet the financial challenges and budget reductions to ensure that any impact is minimised on the work of the Integrated Commissioning work streams; - An innovative approach to prevention making use of all our existing staff Making Every Contact Count - More health and care budgets from across Local Authorities and the CCG will be pulled together to ensure that spend can be undertaken more efficiently and effectively. 61

62 DRAFT v Patient and public voice across the system We have patient and public representatives on all of the care workstreams and project teams as equal partners in decision-making; their role is to raise issues important to local residents and patients, comment on issues from a public perspective, challenging and providing an impartial and independent view. We will also provide opportunities for patients and service users to contribute to the service-redesign work through a design lab approach and have adopted co-production charter that informs all our work as a system. In addition, we have an Engagement Enabler Group co-chaired by the Director of Healthwatch Hackney and the CCG s Lay Member for Patient and Public Involvement and additional support for public events and for our engagement work has been fully funded. The Enabler Workstream acts as a critical friend to the programme and supports the driving principles for public involvement, including: open and informed debate; opportunity and time to form, inform and consider proposals; deepening the partnership between residents and those delivering services; co-design through effective resident and service user involvement. Our clear ambition is to embed these principles in the new model of integrated commissioning that emerges from our work. [To be updated] Our Local Need Key Workstream achievements to be added 62

63 DRAFT v Part 2: Our Proposed NEL STP Commissioning Intentions This year, we are required to submit items which we envisage could be commissioned at an STP level that could be considered for inclusion in the North East London (STP) Commissioning Strategy. The below are a summary of the items we are currently considering for commissioning on the NEL level: Workstream Area Unplanned Care Item An cross-borough Hospice at Home Service for patients nearing the end of life A cross-borough approach to commissioning the Mildmay Community Centre Planned Care Potential to commission some Cancer services via cross-borough arrangements Implementation of the recommendations from NHSE re: Not prescribing OTC medicines in primary care for 35 minor, short-term conditions, medicines Not prescribing from a list of 18 medicines considered to be of low value Children Young People and Maternity An STP wide perinatal mental health offer is being piloted, alongside proposals for some elements of maternity A North East London Child House (multi disciplinary support for children who have experienced sexual assault) Agree an approach to service user involvement (Maternity Voices Partnership and PPI) Look at developing a shared specification across maternity with some shared and some local KPIs Jointly commissioned Audiology Service 63

64 DRAFT v Peer Mentoring Project for Young People with Sickle Cell Ongoing work with CAMHS specifically around standards of CYP crisis with improved interfaces across tier 4 beds Prevention Proposal that the preventing ill health by risky behaviours [alcohol and tobacco] CQUIN target is included across KPIs at an NEL level 64

65 DRAFT v Part 3: Our 2019/20 System Commissioning Intentions 2019/20 System Commissioning Intentions Our local commissioning intentions for 2019/20 and beyond are set in the context of the financial challenges that City and Hackney face across health and social care and the priorities set out in Section in Part 1 above. The 2019/20 system commissioning intentions across the four care workstream portfolio areas are summarised below; During 2019/20 the care workstreams will be the main vehicle for the delivery of commissioning activities and system savings. There will be full patient engagement on the commissioning intentions both at workstream and system level Unplanned Care System Commissioning Intentions Commissioning Intention Activity Outcomes including the impact on patient care Urgent Care Deliver a new, more integrated GP Out of Hours service which integrates our current OoH service with the Primary Urgent Care Centre (PUCC) The new service will mean patients will have one destination for urgent OoHs care and will be able to receive OoH care via the Homerton Hospital who have a strong track of delivery of urgent care and are consistently in the top one or two in London for A&E four hour wait performance. Improve our falls response and prevention services by: - developing a falls prevention exercise service (OTAGO), - reviewing the expansion of the paradoc service to include a falls response element (this service has been running since April 2018) These activities will support the creation of a more integrated and less fragmented offer for patients, and will have the following system wide outcomes: - We expect this service to reduced A&E attendances and emergency admissions from falls / injuries related to falls - Reduce orthopaedic services including surgery & outpatients - Reduce social care costs as a result of a reduction in volume and level of support - (the review will ensure that the Falls Paradoc service is fit for purpose 65

66 DRAFT v Ensure that we are maximising the opportunities for ambulatory care for our emergency admissions Neighbourhoods - Continue to develop and begin the implement the Neighbourhood Model across City and Hackney. Activities will include: - Planned engagement with local residents - Further work to integrate services at a local level - Plans to include Neighbourhood Working in local contracts The Homerton Ambulatory Care unit was opened in April 2017 as an alternative to admission for emergency patients, the unit also supports expedited discharge from inpatient wards. We will be undertaking a review of the service in 2018, which will inform a revised specification and potential tariff change from 2019 onwards. Part of the review will be ensuring that we are maximising the opportunity that ambulatory care models offer and learning from best practice in other areas. The Neighbourhoods Model will create 8 neighbourhoods across City and Hackney to organise health and care services around the patient rather than the hospital. The long-term impact will be: - Services that are more resilient, joined up by partners working collaboratively - Better accessible for patients and responsive to their needs - Less duplication of effort/resources/time - Reduction in emergency attendances and admissions through appropriate evidenced based interventions. - Improvement in patients experience of care and other patient measure - Improvement in staff recruitment and retention Discharge Deliver the Discharge to Assess (D2A) Pilot; this service will enable patients to receive assessment for any ongoing care needs after discharge from hospital in their usual place of residence. Our pilot will establish whether this model is effective at managing patient discharge We will continue to bring together system partners to deliver improvements to the discharge process and better support patients at a time that is often life-changing for them. - City and Hackney patients will benefit from a better quality of assessment and improved access to the services that they require post-discharge Patient will receive care in the best settings for them D2A will reduce the number of Delayed Transfers of Care in the City and Hackney system and will support patients in leaving hospital when they are medically ready (as long stays in hospital can have a negative impact on a patient s health). Recommission the Integrated Independence Team (IIT) contract, including provision to make Patients that require intermediate care beds have to be sent out of the borough to receive this service. Developing our own service within the borough will provide a service closer to home for 66

67 DRAFT v improvements to our intermediate Care Service by sourcing suitable space for 4 Intermediate care bed our residents. We can also design the new service, with resident involvement, to meet our local needs. We will work collaboratively across the Hackney system to agree any changes to the contract specification to ensure that the service is still fit for purpose. One of the changes will be to include delivery of a bed based service as described above. Work with Age UK to expand the Take Home and Settle on a 1 year non-recurrent basis (initially) This service assists elderly / vulnerable patients in the smooth transition from the hospital back home, and prevents them being readmitted to hospital through linking them with community services. The expansion of this service will increase its reach and will ensure some of our most frail and vulnerable residents able to link in with existing community services which can support them. Deliver a high quality, effective primary care service to our nursing home populations End of life care We will be undertaking a review of our primary care nursing home contracts in The outputs of this inform a new service specification from 2019/20 We will ensure that those patients nearing the end of their life and their families are Commission a City and Hackney Hospice at Home service as a one year pilot to test the benefits of the service, this service will be provided by the St Joseph s Community team As we currently have no urgent out of hours response service for patients approaching the end of life in City and Hackney, patients and their carers have to rely on non-specialist services with slow response times or turn to 999/A&E/hospital. We will create and provide a person centred, holistic and sensitive service to fill this gap. This new service will support City and Hackney patients nearing the end of life in the following ways: - Improved patient/carer assessment of quality of care at the end of life - Reduction unnecessary admissions to hospital - Reduction in the number of patients dying in hospital - An increase the number of patients dying in the preferred place and with their preferred care package in place Mental Health 67

68 DRAFT v Improve our offer for patients with Dementia including: - Increasing Dementia diagnosis rates - Harmonising dementia registers across providers - Explore expanding the Dementia Memory Clinic and the Dementia Navigator role - Work towards creating CMC care plans for 100% of dementia patients at the point of diagnosis - Understand and assess wider resources across the Community Mental Health teams to ensure value for money. The proposed activities will support the creation of a more alignment across Dementia services leading to increased prevention, a reduction in crisis, and an increased offer across providers. We will support crisis prevention services to work together more closely. This will support better sharing and co-ordination of care plans across organisations We expect that the proposed activities will lead to a reduction in inappropriate acute hospital bed usage and a reduction in A&E presentations. Pilot integrated pathways for frequent attenders including those patients who use A&E, 111 and London Ambulance Service (LAS) frequently and whose behaviour has a suspected psychological causation. There will be no requirement for patients to have a mental health diagnosis The pathways will have a focal point in the HPM Psychiatric Liaison service, and will have a small frequent attender team which will be close linked other services engaged in frequent attender work including substance misuse, TPFT and VSO peer support. Based on the outcome of the pilot we would be looking to commission the service recurrently. We expect that this service will support a reduction in frequent attendance 6 months prior to, and 6 months after for A&E, 111 and LAS and will deliver a reduction in costs associated with frequent attending across the system. The service will support improved service user psychological wellbeing. Use the outcomes of the Health Based Places of Safety (HBPOoS) options appraisal to devise a new staffing model for ELFTs HBPoS sites The staffing model will ensure that patients are able to access better quality built environments which are safe and private and appropriate for the type of support they require. As part of the new model staff receive training to broaden their skill set including physical health assessments to reduce unnecessary A&E referrals. Work with ELFT to review inpatient usage of This review has the potential to impact the number of beds, the locations of beds and the 68

69 DRAFT v Psychiatric beds as part of a review into inpatient usage against recent increase investment in crisis services distribution of savings arising from bed reductions or the use of local beds by non-city & Hackney patients across the borough. The impact on patient care will be determined by the outcomes of the review. Pilot a Mental Health Neighbourhood Blueprint in 2019/200 As part of the Neighbourhoods Programme, we will be piloting a Mental Health Neighbourhood Blueprint which will engage Mental Health Alliances and will build on existing primary care mental health services. Long term, patients will benefit from improved access to mental health services and more integrated ways of working. Prevention Care Workstream Commissioning Intentions Commissioning Intention Activity Outcomes including the impact on patient care Incorporate the NHS Health Check schedule into the Primary Care at Scale contract These activities should have a positive impact on the performance of both services monitoring of NHS Health Check outcomes will be improved (including follow-up and referrals), and identification of high risk patients for effective primary care management will be enhanced. Update the Long Term Conditions schedule within the Primary Care at Scale contract to: update KPIs, enable case findings for COPD and asthma and implement recommendations from the asthma audit Continual improvement of primary care management of people with long-term conditions through early identification and earlier intervention (key Prevention workstream priorities) building on successes which have led to our GP practices being among the highest performers in the country. 69

70 DRAFT v Re-commission Social Prescribing Contract to reflect outcomes of a review of care navigation roles across City and Hackney to identify opportunities for integrated commissioning Patients who are better able to support improved self-management and access to preventative community-based activities. Embed the following 2018/19 (acute) CQUIN targets as service KPIs: preventing ill health by risky behaviours alcohol and tobacco (screening advice/support & referral) Consider this service for inclusion in the community health services contract. Work at a system level to review the substance misuse service Complement smokefree policies and build capacity for the trust to meet Five Year Forward View requirements to tackle unhealthy behaviours in the NHS. Skill up workforce to identify and provide very brief advice to patients who smoke and/or higher risk drinkers. Embed treatment of tobacco dependency in NHS services, as recommended by London Clinical Senate. Improved outcomes for people with a dual mental health/substance misuse diagnosis, with benefits for the wider system. Prevention Mental Health Embed the following 2017/19 CQUIN targets are to be embedded as service KPIs: - cardio metabolic assessment and treatment for patients with psychoses - EIP BMI outcome indicator and EIP smoking cessation outcome indicator - Preventing ill health by risky behaviours alcohol and tobacco (screening, advice/support & referral inpatients). KPIs for substance misuse screening/referral also to be included. Embedding these KPIs in our contracts will support: - Upskilling of the NHS workforce to identify and provide very brief advice to patients who smoke and/or higher risk drinkers. - Embed treatment of tobacco dependency in NHS services Patients who are visiting some NHS services will be provided a low level intervention to support them in better manage their problem drinking and to quit smoking. Long term, this will improve patient health outcomes across the borough - in the medium term it will reduce demand on services through preventative action. 70

71 DRAFT v Work at a system level with ELFT, Westminster Drug Project to review how we can improve access to psychological support for substance misuse clients We will be reviewing substance misuse services as part of a joint strategy. We will also be reviewing the case for a joint contract which has a greater focus on the role of psychological interventions. The joint strategy will improve the access to psychological therapies for people who are substance misusers regardless of whether they have a mental health diagnosis. It will endeavour to improve recovery rates and outcomes for people with a dual mental health / substance misuse diagnosis, with benefits for the wider system. Planned Care System Commissioning Intentions Commissioning Intention Activity Outcomes including the impact on patient care Planned Care Continue our Outpatients Transformation Programme [until March 2020] The impact of this programme will: Support a number of functions including: Preventing unwarranted first attendance and referral, improving GP education and training, Improving guidance for patients, including patient self-management and improving triage for community primary care and other pathways Reduce unnecessary face-to-face follow ups-by creating patient centred tools to enable self-management and follow up via virtually/ via the telephone Optimise what should be done in secondary care and by whom This includes reducing consultant consultant referrals, making us of e-consultation in patient home, group consultations, practitioners/specialist nurse for targeted follow up Develop an online tool for patients which will enable them to refer into the Physiotherapy Service This tool will provide patients with advice, exercise, telephone and face to face appointments depending on an algorithm and questionnaire, the tool will improve patient access and support a reduction in the number of presentations to GP Practices for referrals 71

72 DRAFT v Recommission the current Minor Eye Condition service to provide: a specialist referral review, advice on GP treatment, and referrals to the Minor Eye Condition service and to secondary care The new service will create an improved offer for our patients and supports a reduction in secondary care activity; It is estimated that 1400 routine referrals could be reviewed and a minimum of 600 or 40% would not be referred to secondary care (monitored on SEM activity) Work with colleagues at LBH and CoLC to create a Women s Health Community Service encompassing: Gynae, Pelvic Floor Continence, Linked Sexual health, Fertility, Contraception, Breast and Menopause The new service will create an improved offer for our patients and supports a reduction in secondary care activity Work with the Prevention Workstream to develop and implement an Obesity Pathway for City and Hackney This service will be jointly commissioned by two Integrated Commissioning Workstreams, the new service will include provision to prevent and manage obesity Undertake review of the Teledermatology Service, due to start in 2018/19 and its impact on community services Upskill practices nurses so they can better support parents of children with eczema The review will ensure that the service is fit for purpose and will support the introduction of any improvements The new service will create an improved offer for patients and supports a reduction in secondary care activity; an audit in 2017/18 indicated that 25% of referrals to HUHFT Paediatric dermatology was for low level eczema management. This will be delivered working closely with the CYPM workstream Reduction in unnecessary Pathology and Radiology testing This will free up capacity in HUH laboratories and will lead to a financial saving for the CCG 72

73 DRAFT v PSA Monitoring Shared Care: monitoring activity of stable prostate cancer patients moved to GP Practices from the Homerton This will free up capacity in Homerton Urology and will lead to a financial saving for the CCG Cancer Continue to work towards cancer targets with our providers, including: specialist within 7 days, referral-to-treatment in 62 day target and ITT to be completed in 38 days We will implement the following to ensure patients are seen, supported and receive their treatment as quickly as possible: - Implement rapid assessment and diagnostic pathways for lung, prostate and colorectal cancers - Begin to implement 28 day FDS compliant pathways - Increasing access to early diagnostic tests and improving the response times to improve upon the national targets from referral to treatment started (62 days) - Resolve any issues with cancer services we commission Recognise living with cancer as a long term condition We will roll out a recovery package including treatment summaries and health and well-being events to provide more ongoing support to patients and families Better recognition of those requiring 2 week colorectal cancer referral We will implement new testing colorectal cancer in primary care which will support a reduction in the number of patients needing endoscopies and the number of people who require this type of referral Learning Disabilities Continue to develop and deliver the Integrated Learning Disabilities Service (ILDS) model of integrated working including co-production Our objectives this year will be to improve some of the back office processes and procedures, to ensure we have permanent staff in place and that they have a clear shared direction of travel and purpose. Long term, an integrated service will provide a more streamlined and less fragmented services for people with a learning disability 73

74 DRAFT v Undertake the following actives to ensure positive outcomes for people with LD: - Implement a joint funding model for clients accessing health and social care, - Strengthen links with the emerging Neighbourhood model - Develop the Shared Lives Scheme, - Develop a co-produced Learning Disabilities Charter - Review day service provision - Undertake an Accommodation review to ensure suitable support and accommodation in the borough with more personalised services. We want to ensure that people with a learning disability are: - An active part of their community; through working with multi-disciplinary partners such as Hackney Works and Hackney Job Centre we will support people to access employment and training opportunities - Are enabled to achieve independence where possible - Have somewhere to call home: we will support the creation of targeted, specialist housing provision for local people with LD through our accommodation review - Are able to access the health care they need; through strengthening links with primary care and the Neighbourhoods Programme, mainstream health staff will be skilled, confident and better able to work with service users - Support all services for people with a learning disability being more accessible CHC Extend our CHC domiciliary care and nursing home providers with a 2-year extension. We will be reviewing the service specification and the KPIs in the contracts and reviewing rates jointly with NEL Commissioning Alliance and LBH/CoL and will confirm changes with contractors before March 2019 This programme of work will support the following: - Allow KPIs to be updated to reflect changes that have recently been made within the national and London AQP (Any Qualified Provider) contracts. - This will include reporting to provide assurance about quality of care provided to service users with detail on the latest CQC inspection rating, registered manager changes, reporting punctuality and a variety of metrics relating to: service user safety, continuity of care, service feedback, punctuality of care, EOLC service delivery, service integration - A review of rates with partners will enable better collective engagement with the market. Consideration whether to join the Domiciliary Care AQP contract for 2019/20 Review the options for provision of a CHC brokerage function to support the Homerton The Domiciliary Care AQP is a collaborative commissioning contract for London CCGs which means CCGs will avoid individual procurement costs. Detailed analysis of provider costs supports commissioners to set prices that represent value for money, support market sustainability and promote quality care. We have made clear commitments to further existing joint funding arrangements and pooled budgets across the London Borough of Hackney (LBH) and City of London (CoL) and the CCG. Our health and social care team s commission and place with a majority of the same providers, so 74

75 DRAFT v CHC team and the options for delivery of care within people s homes overnight to residents with CHC and fast track requirements Review the options for delivery of care within people s homes overnight to CHC and fast track patients. there are synergies to work together around contracts, quality monitoring and also brokerage of packages of care. Integrating functions, starting with a brokerage post, will align with the wider Planned Care strategic approach to progress joint funding and joint commissioning arrangements. A night owl or hospice at home service will enable a more responsive, flexible and cost effective service. Review commissioning arrangements for local care homes beds across the system. We want to develop a strategy for our bed base, which would allow greater flexibility for placements including interim, intermediate, residential and nursing care. Having greater flexibility with our bed base will help ensure that: a. Patients can be discharged from hospital more quickly once their medical needs have been met. b. As an individual s needs change over time, they do not necessarily require a move from their current home. We will also deliver CHC assessment in placements to facilitate faster discharge from hospital care, Mental Health Work with IAPT to develop the following: - more integrated pathway structures and systems across HUH psychological therapies to link together IAPT interventions and HMP with more complex and specialised intervention, also link with a clear identification of frequent attenders - expand the service to cover a broader range of LTCs - improve equity in access and recovery rates - expand the uptake of online therapies online access rates by 30% This programme of work with IAPT would support the following: - Greater integrated alignment in Mental Health - Addressing the current unmet MH needs for people with LTCs in line with national strategy. - Improved contractual performance in relation to the delivery of recovery and clinical improvement - Improving the breadth of offer to patients who may have difficulties accessing services - Increase cost / effectiveness owing to improvements in productivity. Patients will benefit from service which better meets their needs and supports equity off access 75

76 DRAFT v Create a secondary care psychological therapies offer which includes psychotherapy, psychology and arts therapies This programme of work will support the following: - reducing the backlog of waiting lists and waiting times and meeting national standards of 18 week RTT - the regular reporting of activity and outcomes - ensuring greater availability of open access psychological support for crisis - the development of clear structures and pathways that support local integrated care strategies including the emergent neighbourhood model. Patients will benefit from an improved service offer with reduced waiting times Working collaboratively with the CCG and the local authority, review existing mental health accommodation contracts as part of a joint accommodation strategy This work will be led by the Mental Health Co-ordination Committee and the Planned Care Workstream, and will form part of the joint 3 year mental health strategy. This work will support the following: - A joined up health and local authority approach to mental health accommodation - Increased use of floating support - Greater throughput in the system with reduced numbers and reduced lengths of stay in high needs areas - Greater service user autonomy - Improved value for money. Work with ELFT, to jointly develop a specification for Primary Care Liaison which will include: Links to EPC and improving the step up functions of EPC, other mental health pathways Links to neighbourhoods Protocols for supporting anti-psychotic prescribing in primary care. These activities will support the following: - A clear Primary Care Liaison specification - Improved primary care integration - Anti-psychotic protocols. 76

77 DRAFT v Pilot the use of Personal Health Budgets in including: Extending our PHB offer to all CHC eligible patients receiving care at home to receive a notional PHB with further promotion of the option for people to receive direct payments This programme of work will support the following: - Will ensure we are compliant with national PHB target by Q Will support greater service user autonomy and choice - Will provide improved support for people with more severe mental health problems. - Will provide incentives to service users to improve mental and physical health. The psychological Therapy and Wellbeing Alliance will pilot PHBs for patients frequently attending A&E due to Mental Health concerns The Homerton Hospital Wheelchair service will pilot a PHB offer over the later part of with a full rollout by 2019 Prescribing Undertake reviews across the following areas: Opeoids, Pregabalin and Gabapentin, Sip Feeds, Care Homes Respiratory, Atrial Fibrillation, hospital only drugs and specials, not prescribing OTC medicines in primary care for 35 minor, short-term conditions, medicines, not prescribing from a list of 18 medicines considered to be of low value Medication areas for review include: Hypertension, Polypharmacy Eye Drops, Dual Antiplatelet This programme of work will:: - Support patients to use medications appropriately and reduce hospital admissions related to avoidable medicine issues - Reduce variation between our GP practices & will help ensure all funding for drugs is being utilised in an optimum manner by practices - Improve our compliance with NICE guidance / - Support practices and pharmacists to work together effectively - Identify areas for improved communication between primary and secondary care - Provide opportunities for education and training of prescribers - (Medication Reviews) Optimising & simplifying medicines regimes. - Reduce of waste, Polypharmacy and side-effects. - Improve outcomes of therapy. Support GPs to undertake, and increase patient awareness of medication reviews; increase the 77

78 DRAFT v number of reviews undertaken by Practice Support Pharmacists Undertake audits across the following Nonclinical areas: Repeat prescribing and 7 day prescriptions Audits will support safer prescribing across the system, support a reduction in medicines wastage and will ensure patients understand their medications and support greater self-management Review the following programmes: Antimicrobial Stewardship for improving quality and cost efficiency, Implementation of Shared Care Guidance with compliance and monitoring Ensure we support ongoing management of safety Continue to review the prescribing of Sodium Valproate in women and children of girls of child bearing potential These reviews will have the following outcomes: - Antimicrobial Stewardship) Improve knowledge of AS, support the development of new antibiotics, conserve and steward the effectiveness of existing treatments, - (Shared Care) Improve quality and safety of prescribing of higher risk drugs & a better experience for the patient when discharged This programme of work will support: - The identification of patients at risk will reduce medication errors. - Cost savings realised by reducing health-care use resulting from minimising adverse drug events Continue to update the medication profile of the prescribing decision support tool Deliver training for the following: the use of eye drops, Prescqippa and Bespoke webinars for prescribing [e.g. Opeoids], implement respiratory audit training recommendations Our training programme will support: - Excellent education - Competent and capable staff - Flexible workforce receptive to research and innovation - NHS values and behaviours - Widening participation The service will also improve safety and patient care 78

79 DRAFT v Run Discharge to Pharmacy project, ensure meetings between Community Pharmacies and GP Practices are facilitated These projects will support: - Improved communications between secondary care and community pharmacies which will improve accuracy and support improved outcomes for patients - Effective management of issues in a timely and effective way - Share good practice Introduce a Biosimilar CQUIN Cost savings for the system which will be invested in HUH s clinical services to improve outcomes for patients Children Young People and Maternity (CYPM) System Commissioning Intentions Commissioning Intention Activity Outcomes including the impact on patient care Maternity Work with HUHFT to refresh KPI s to reflect financial year and CQC August 2018 report Recommendations to include: Caesarean section rate benchmark, LSCS data, Consider Elective caesarean section without medical indication POLCV, Obstetric staffing/midwifery staffing/anaesthetic staffing monitor. Agree mechanism with HOM to look at Birth rate plus report findings, Monitor the maternity service risk register, hand hygiene, equipment check/emergency boxes Improve the overall governance and safety and ensure the women accessing services at the Homerton are receiving optimal care. HUHFT Maternity CQC rating is currently good aim for outstanding at next inspection. Improved experience of women using maternity services through HUHFT Continue to monitor compliance with NHSE recommended Continuity of Carer (CoC) model, including: This will improve outcomes for women who use HUH maternity services: Women who receive CoC have better physical and emotional experience of pregnancy, birth and postnatal wellbeing physical and emotional experience of pregnancy, birth and postnatal wellbeing. 79

80 DRAFT v Implement a new transformational model of working % monitor from Q1, % of all women to have CoC in 2019/20. - Work to up skill the workforce - Host an MDT and for all women included those who are high risk. Maintain focus on reducing infant mortality including avoidable admission of term neonate to NICU The main focus on the delivery of the Maternity Strategy and action log monitor Q alongside the CQC recommendations listed above which include recommendations arising from staffing reviews, for midwives obstetric and the named healthcare professional. Part of NHSE Specialised commissioning: we've identified that over 20% of admissions of full term babies to neonatal units could be avoided. By providing services and staffing models that keep mother and baby together we can reduce the harm caused by separation. We want all maternity and neonatal services to work together to identify babies whose admission to a neonatal unit could be avoided and to promote understanding of the importance of keeping mother and baby together when safe to do so. Agree three clinical audit topics which could potentially include: - Deliveries with complications : Tariff Coding audit for intrapartum care - Emergency caesarean section - Diabetes care These clinical audits will improve quality across service areas. Continue to ensure as many women as possible uptake the flu vaccination and pertussis We will ensure that from 16 weeks gestation women are offered the flu and pertussis. Vaccinations, and that we will offer at 20 week anomaly scan for all women booked at the Homerton. 80

81 DRAFT v This will support a healthier City and Hackney population. Implement the following system transformation activities via CQUINS: - Continuity of Carer model of care to be offered to all high risk women. - Review of emergency caesarean section decision making Continuity of Carer for high risk women by an obstetric and midwifery led team model may lead to a reduction in elective caesarean section for women in this cohort. Reviewing of emergency caesarean section decision making will ensure the obstetric trainees will learn about the decision making process and optimal management of a woman s care when in labour. Community Paediatrics Work with HUHFT to continue commissioning and delivery community paediatrics including: - Developing community baby clinics - Review referral pathway for school referrals to Community paediatrics - Contribute to re-design of Health of Looked After Children s service - Contribution to NEL CSA hub Paediatrics rota (as below) This programme of work will enhance joint working between community paediatrics and primary care, and will support the development of a consistent high quality offer across NEL Monitoring of Community Health Services workforce and vacancies Transparency of staffing vacancies and impact on performance / value for money of block contract services Specific issues in 2018/19 regarding CCNT and Community paediatrics Work as a system to clarify paediatric dietetic provision Work as a system to re-specify the Continuing Care Nurse Service This programme of work will clarify the Tier 3 dietetic provision for children and young people, and will be scoped in light of new system wide provision on children s healthy weight This programme of work will create an improved service offer which includes a Brokerage function. 81

82 DRAFT v Commission a respiratory specialist nurse Embed primary care liaison across A&E and Primary Care role to assess impact in reducing unplanned attendances and admissions Agree areas for Clinical Audit across the children s portfolio Develop a mechanism to support patients transitioning between adults and children s diabetes services This service will provide equity in access to local provision and to specialist nurses in the community and will support better communication between the Trust and Primary Care supporting holistic management of and support for patients in the community Recommission the Looked After Children s service as a system The re-commissioned service will provide an improved offer to patients Child and Adolescent Mental Health Service (CAMHS) Contribute to objectives as interpreted locally in the City and Hackney CAMHS transformation plan. support with developing the Phase 3 including a. Schools b. Transition c. Parenting d. Crisis e. Mapping work priories (set by CAMHS Alliance) Our programme of work with CAMHS will support the following: a) Increasing access rates from 25% in 2014/15 to 35% by 2020/21 (an extra 70,000 children and young people nationally). b) Assessment target of 2,068 in 2019/20 Phase 3 Transformation Plan, one of our main focuses of growth in 19/20 will be in non-health care settings. Primarily this will be schools, through the deployment of CAMHS workers because there is an opportunity to work both with the CYP directly and also indirectly through the teaching staff and whole school culture. Other community settings will also be used where appropriate. We will continue to report against all national targets in a timely manner. We will be increasing the assessment and early 82

83 DRAFT v identification of Mental Health problems in CYP. Transitions out of Children and Young People s Mental Health Services (CYPMHS). There are three components of this CQUIN: a. 1. A case-note audit in order to assess the extent of Joint-Agency Transition Planning; b. 2. A survey of young people s transition experiences ahead of the point of transition (Pre-Transition / Discharge Readiness); c. 3. A survey of young people s transition experiences after the point of transition (Post-Transition Experience). Perinatal Mental Health The commissioning intention is to work collaboratively as a system to deliver the objectives agreed in the implementation of the perinatal bid & contribute to all Five Year Forward View objectives on perinatal mental health including: - Supporting at least 30,000 additional women nationally each year to access evidence based specialist perinatal mental health treatment. This will increase access and reach of perinatal mental health services across City and Hackney. 83

84 Newham Clinical Commissioning Group 2019/20 Commissioning Intentions Strategy 84

85 Contents Page Introduction Page 3 Population Overview Page 4 CCG Priorities for 2018/19 Page 6 National and North East London Commissioning Alliance (NELCA) Priorities Page 9 Integrated Care System (Newham Health and Wellbeing Partnership Summary of Commissioning Intentions for 19/20 Appendix 1 Further detail to 2019/20 Commissioning Intentions.Page 11.Page 13.Page 21 85

86 1. Introduction NHS Newham Clinical Commissioning Group (CCG) is a membership body, made up of local GPs, that plans and buys public healthcare services for over 343,500 people in Newham. We plan healthcare by identifying the health needs of the population and forecasting what services might be needed in the years to come. Newham CCG s long term strategies set out how we aim to meet local healthcare challenges by transforming local services and the way that they are provided, which is why this is such an exciting time to be commissioning healthcare services in Newham. As we become more innovative and forward thinking in how we approach health and healthcare, and develop closer working relationships across the health economy to ensure that we can deliver on our vision of improving health and health outcomes and reducing health inequalities, we need people who are as excited as we are about the future of healthcare in Newham. We are a high achieving organisation and are proud of our ongoing accomplishments and determination to do the absolute best in commissioning high quality health services for the people of Newham. Our mission, values and aims have been developed to encapsulate what we believe are the key challenges and behaviours that will enable us to deliver real transformational change in the provision of patient-centred healthcare in Newham. Our commitment to delivering improved patient care in partnership with local people, partners and healthcare providers in order to meet local health needs rests at the heart of everything we do. 86

87 2. Population Overview The current population of Newham is young and diverse as defined by ethnicity and religion. As the current population ages, the demand for both social care and health can be expected to increase. It therefore would be prudent to use the current opportunity to promote and maintain healthy behaviours. Supporting local employers to implement the evidence based workplace health promotion charter workplace through workplace health network as implemented in some counties could be considered. This would align with the health and economic resilience agenda. Newham with an estimated resident population of 340,700 is the 18th largest borough in the country and fourth largest in London. The population served by Newham clinical commissioning group (NCCG) is estimated to be 332,800. The adult population is 75% of the total population at 256,100 for resident population and 249,000 for registered population. It is the fifth youngest borough in the country with a median age of 30.8 years and second youngest in London. It is the most diverse community with 75% of the population from Black and Asian communities (BAME) which is the highest in the country. For the adult population BAME communities form 70% of the population. The rest of the population is White British (15%) and White other 14%). The estimated projections based on natural change (births and deaths) and internal and international migration suggest an increase of 15% for adult population from 2016 to The greatest percentage increase is expected in the years age group (27%) and lowest in the years group (8%). The greatest increase is expected to occur in the other ethnicities, (28%) British Asian (20%) with other White (15%) and all mixed (14%) and British Black (6%). The British White are estimated to decrease by 14%. The expected housing developments in parts of the borough will have a great impact on the population size and structure and this information will be under review. 2a. Wider determinants of health The population of Newham face multiple challenges. The most pressing challenge is related to low income and housing affordability. One of the consequence is people living in overcrowded and poor housing conditions. Crime is a concern for many residents and reducing crime and fear of crime and this should be one of the areas for further improvement. Whilst local policies are in place, regional and national policies should be more supportive of improving the income, housing affordability and crime in historically poor areas such as Newham. Newham has moved its ranking from being the second most deprived borough in England in 2010 to the 25th most deprived in 2015, which now places it in the second most deprived decile (20% most deprived) compared with most deprived decile (10% most deprived) as measured by the Index of multiple deprivation (IMD). As these measures are relative and not suitable for time trends, it cannot be said for certain how much of it is absolute change. Based on the 2015 IMD, Newham is performing well on education similar to other London boroughs, and falls in the middle range for employment and health based on proportion of 87

88 small areas in Newham falling in the 10% most deprived decile in the country. It ranks lower in the income and ranks the worst for crime and barriers to goods and services. About 20% of all adults and 25% of all older people were income poor. The median annual household income in Newham was 28,780 (2012/13) which was 10,000 lower than the London average but comparable to that of North West England. Historically, Newham has had very low median income and even with the 60% increase in income from 2002/3, it remains comparatively low. The low income combined with higher house prices in London results in poor housing affordability for most of the residents. Newham ranked 4th worst in the country for housing deprivation. Newham along with its neighbouring Tower Hamlets and the City of London had the highest proportion of households living in overcrowded conditions. About half of all the households living in private housing live in overcrowded conditions and 20% in social housing. 2b. Newham population Characteristics The median age is 30.8 years (mid-2015) 52.3% of the population are male and 47.7% female (mid-2015) 25.2% (83,800) of the population are under 18 years, 67.8% (225,600) are aged 18 to 64 years and 7% (23,400) are aged 65 years and older (mid-2015) o By 2021 Newham s population is projected to be over 367,900 (SNPP). o Ethnic or cultural background of residents: 46.5% Asian/Asian British, 26.5% White, 18.1% Black/Black British, 4.9% mixed/multiple ethnic group and 4.0% any other ethnic group. These figures are based on the mid-year 2017 GLA ethnic group projection. 40% of residents are Christian, 32% Muslim, 8.8% Hindu, 2.1% Sikh, 1.2% part of another religious group, 9.5% were not religious and 6.4% did not state their religion (2011). 88

89 3. CCG Priorities for 2018/19 Strategic Priorities The Newham CCG Boards view was that the commissioning of a borough integrated health and care system remained a priority as did the commissioning of high quality GP services and to this end the following draft Strategic Priorities were broadly agreed: 1. To commission a Newham-based integrated health and care system which delivers high quality services for the people of Newham, in accordance with statutory requirements. 2. To commission and develop GP services that are modern, accessible and fit for the future in caring for the local population. Enabling Priorities The Board also agreed that a set of enabling priorities must be in place that enable, support and provide the CCG with the band width to deliver against the Strategic Priorities. These have been developed with our workforce through the Staff Conference earlier in the year, which are: 1. Securing financial stability 2. Making sure our governance is fit for purpose 3. Valuing and enabling our staff, Board and Clinical Leaders to learn and develop thereby enabling them to deliver against the CCG Priorities 4. Ensuring we maintain our performance across the key business areas. CCG Outcomes A set of outcomes, that are measurable have been agreed with the Quality, Performance and Finance Committee which will measure how the CCG is performing in delivering the Strategic and Enabling Priorities which are as follows: 1. We will spend the Newham pound wisely, ensuring value for money and maintaining financial balance 2. We will have a borough based Integrated Care System that is utilised, understood and valued by our residents 3. We will ensure we plan, design, and commission accessible high quality services for our residents with our residents 4. We will improve access to, and, the quality of, Primary Care 5. We will clearly be able to demonstrate how we have improved outcomes for our residents 6. We will support our entire CCG workforce to deliver what we need to for our residents 7. We will promote equality as a commissioner of health services and as an employer. 89

90 Golden Thread This shows how the Strategic Priorities, the Enabling Priorities and the CCG Outcomes will drive the work of the Committees and ensure the Governance regime of the Committees and the Board will support their delivery. 90

91 19/20 Commissioning Intentions link to CCGs Strategic and Enabling Priorities This shows on a page, of how our 19/20 Commissioning Intentions links with the CCGs Strategic and Enabling priorities. While the CCG does not have 19/20 priorities at this stage of the year, we expect the theme of the 18/19 priorities will continue into 19/20. 91

92 4. National and North East London Commissioning Alliance (NELCA) Priorities National and North East London Commissioning Alliance (NELCA) Priorities National Following the announcement of the of the NHS funding settlement in June 2018, the NHS 10 year Long Term Plan is being developed nationally and is expected to be published in mid-november However it is anticipated that the plan will build upon the NHS Five Year Forward View (FYFV). The FYFV described how the NHS should change, in order to meet the needs of a changing population that is living longer through increased usage and reliance on the NHS. It highlighted three gaps that need to be addressed to deliver the vision of a sustainable NHS, tax-funded, free at the point of use and fully equipped to meet the evolving needs of its patients: The health and wellbeing gap The care and quality gap The funding and efficiency gap The FYFV also proposed an ambition to deliver triple integration of primary and specialist hospital care, of physical and mental health services, and of health and social care. In 2017 NHS England released an update to the FYFV titled Next Steps on the NHSE Five Year Forward view this included as assessment of progress to date, and outlined its priorities over the next two years: Improving A&E performance - This also requires upgrading the wider urgent and emergency care system so as to manage demand growth and improve patient flow in partnership with local authority social care services. Strengthening access to high quality GP services and primary care, which are far and away the largest point of interaction that patients have with the NHS each year. Improvements in cancer services (including performance against waiting times standards) and mental health common conditions which between them will affect most people over the course of their lives. Ahead of the publication of the 10 year Long Term Plan for the NHS, national working groups have been established bringing together local and national system leaders, partners and stakeholders to shape what the plan will focus on. Working groups include; Prevention and Personal Responsibility Healthy Childhood and Maternal Health Integrated and Personalised Care for People with Long Term Conditions and the Frail and Elderly Cancer Cardiovascular and Respiratory Learning Disabilities and Autism Mental Health North East London Commissioning Alliance The North East London Commissioning Alliance, of which Newham CCG is a member, will The 20 organisations across North East London (NEL) worked together as part of East 92

93 London Health and Care Partnership (ELHCP) to develop and now implement the NEL Sustainable Transformation Plan (STP). The plan identifies six key priorities which need to be addressed collectively in NEL: 1. Ensure we have the right health and care services in the right place to care for our growing population 2. Transform the way care is provided: encourage self-care, offer care close to home and ensure secondary care is high quality 3. Secure the future of our health and social care providers 4. Improve specialised care 5. Work together to tackle challenges, identify solutions, make decisions and improve the health of local people 6. Use our buildings better: maximise the use of infrastructure so that it supports the vision To implement the STP vision we have developed a set of transformation programme workstreams built around our commitment to person centred, place-based accountable care systems for the population of NEL. Collectively, the three core elements of our transformation programme are: Promoting prevention and personal and psychological wellbeing Promoting independence and enabling access to care closer to home Ensuring accessible, high quality acute services for people who need it Transformation workstreams are: UEC MH Cancer Maternity Outpatients Primary Care Prevention Meds Optimisation Children and young people End of life care Transforming Care CHC/ PHB Elective Estates Workforce Digital 93

94 5. Integrated Care System (Newham Health and Wellbeing Partnership) Newham has agreed a vision for developing an integrated community, health and social care model of provision based on a population healthy need, the NWP is aligning its programme of activities to deliver this. The Newham Wellbeing Partnership (NWP) is made up of commissioners and providers of acute, community, mental health, social care and primary health services, represented by the following organisations: o Bart s Health NHS Trust (BH) o East London Foundation Trust (ELFT) o London Borough of Newham (LBN) o Newham Health Collaborative (NHC) o NHS Newham Clinical Commissioning Group (NCCG) The NWP priorities build on and take account of: o Newham CCG s (NCCG) strategic priorities but also reflect the aspirations of partners and providers o National and local priorities including delivery of NHS Constitution standards, the NHS Mandate, the NHS Outcomes Framework and NHS England s Five Year Forward View refresh o Joint working with London Borough of Newham and the Health and Wellbeing Board and their associated plans o Better Care Fund plans developed jointly with the London Borough of Newham o The CCG s financial plans and associated measures and actions designed to deliver an improved and sustainable financial position for the health and social care system. The Newham Wellbeing Partnership will: o Ensure community health services are responsive, located at the heart of our communities and able to meet the current and future needs of the population through the delivery of its Building Healthier Communities approach o Develop a primary care system that is modern, accessible and robust enough to care for the local population now and into the future supported by its Primary Care Home work stream o Ensure our population can access effective, high quality urgent and emergency care in and out of hospital which will be delivered via an Alliance Agreement and the Urgent Care Pilot o Develop a strong and sustainable acute system that places the needs of the patient at the heart of its design o Be central to a whole system approach working across traditional boundaries to effectively tackle health inequalities and make a positive impact on the health and social care economy of east London o Ensure staff and clinical leaders are equipped with the skills and expertise to enable the delivery of the CCG s priorities and commissioning agenda o Deliver an Integrated Commissioning Function between Newham CCG and the London Borough of Newham which will be in place from 1st April

95 6. Delivering our Constitutional Standards and High Quality Care It is important that the Newham CCG systems delivers all Constitutional Standards for the services we provide. The Constitutional standards are monitored through national performance indicators. Variance from defined thresholds can indicate that our patients may be receiving a lower quality of care than we would expect. We expect all providers of services to be fully compliant with all constitutional standards and associated monitoring processes. Should any provider fail to deliver any standard, we would expect the provider to fully cooperate with commissioners by complying with our performance escalation processes and ensuring robust recovery plans are developed and implemented. Delivering improved patient care to meet local health needs rests at the heart of everything we do at NHS Newham CCG through our Commissioning for Quality Strategy. Newham CCG has systems in place to measure and monitor quality of services delivered by providers to influence and improve standards. This includes: o Clinical quality review meetings; these allow us to hold providers to account for the quality of their services o Quality performance and finance committee; where we review quality based on our approach to commissioning for quality strategy, as well as request and receive reports pertaining to the quality of services and provide assurance to the Governing Body as a result contractual levers; which are used to drive up quality in areas where improvements have taken some time to come to fruition. This has been done through supportive or facilitative processes o Quality assurance visits; these are undertaken with our providers through a structured framework, enabling us to see first-hand any improvements made and understand the quality of services o Quality key performance metrics; these are based on national/regional and local standards and inserted into contracts with providers whose performance is then monitored on a monthly basis o Feedback from member practices; carried out through an automated system called amber alerts. o A GP practice is able to alert us to a potential quality issue in a provider organisation and we seek outcome responses from the provider for each of these alerts. Any trends are monitored and then taken to a clinical quality review meeting for discussion with providers, with the intention of improving patient experience, patient safety and overall quality. o Patient feedback; this is invaluable in providing intelligence that is used in conjunction with other quality information to form a picture of services. This helps to determine if there are any potential areas of concern we need to explore. 95

96 7. Summary of Commissioning Intentions for 19/20 The table below provides a summary of Newham CCG 2019/20 commissioning intentions. Further information to the intentions is provided on Appendix 1. Area of intention Maternity, Childrens and Young People Background As commissioner for the youngest population in England, the CCG will secure leading quality maternity and paediatric services and a healthy start in life for its children and young people. List of intentions 1. Commissioning arrangements for MVPs being reviewed across NEL STP to ensure fit for purpose and best use of resources. 2. Review of outcomes in Maternity Mates voluntary sector service supporting vulnerable pregnant women in Newham. 3. Re-model the Diana team and scope within the children s community nursing service (CCNS). 4. Resolving the gap in community services for 16 and 17 year olds. 5. Pilot designated medical / clinical officer (DMO/DCO) for special educational needs and disability (SEND) for 1 year. 6. Development of community asthma services to prevent inappropriate and preventable use of unscheduled care. 7. Review of sickle cell and thalassaemia pathway in pregnancy including what organisation takes lead on partner testing and discussion of pregnancy options as appropriate for parents to be. 8. Review of tariffs across various TOP providers to ensure best value for money. 9. Review of commissioning arrangements for hospice care across NEL to ensure equity and in line with doings things once in NEL as appropriate. 10. Consider inclusion of hospice respite in personal budgets for children. 11. Ongoing development of home based hospice offer. 12. Extension of contract for audio vestibular consultant (AVC) as interim solution while we develop Bart Health resource within the wider audiology service. 13. Provider to develop a cost effective solution for providing in house audio vestibular consultant (AVC) resource with clear timeframes to ensure timely implementation 96

97 Area of intention Medicine Management Background The Newham Medicines Management team supports Newham CCG s aim and mission to work in partnership with our community and local health stakeholders to improve the health of Newham population by delivering medicines optimisation in the new health and social care system to meet the needs of patients. We aim to achieve this by ensuring improvements in health outcomes through: O Promoting safe, evidence based and cost-effective use of medicines o Providing up-to-date, unbiased information about medicines, treatments and care pathways o Supporting practitioners and patients to make best use of medicines o Minimising the harm caused by medicines o Developing local guidelines and care pathways to optimise the use of medicines and management of conditions O Collaborating with local hospital trusts and other healthcare providers to support these. List of intentions 1. ELFT to continue to review patients prescribed doxepin for depression in line with NICE guidelines. The CCG expects that prescribing levels are further reduced to levels comparable to neighbouring CCGs. 2. The CCG in line with other NEL CCGs expects that ELFT adhere to the two NHS England guidance listed below which being fully implemented by the CCGs. 3. The CCG wishes to work with ELFT community services to develop a model for centralised supply of dressings by community and Tissue viability Nurses. 4. The CCG would like to develop and implement a patient-centred, IT supported continence and stoma service that will ensure appropriate appliance and cost-effective prescribing. 97

98 Area of intention Unscheduled Care Background NHS and social care staff in Newham CCG are working together to deliver the best possible urgent and emergency care (UEC) to our community, but our system is under increasing pressure. Too many people still go to A&E for treatment or non-emergency or life threatening conditions, despite ongoing investment in community urgent care services designed to manage this demand. Local people have told us that our current Urgent and Emergency Care system is confusing and fragmented. This has meant increasing A&E attendances in the system. Due to this pressure and inefficiencies in how our services run, we do not meet the 4-hour A&E trajectory at NUHT. Too few patients in the UCC setting are redirected to other care settings and instead pass into A&E. These factors mean that too many patients experience longer waits that they should or end up admitted into Hospital when they could have been treated more effectively at home, through the support of community services. We want to ensure that our patients are effectively treated, in a timely manner in the most appropriate setting based on their need, this will require the usage of streaming and triaging process consistently across the systemhealthcare providers to support these. List of intentions 1. To work collaboratively with the un-scheduled care pilot to achieve a shift of type 1 activity equalling a 60:40 split UTC/ED 2. To review the implemented model for ambulatory emergency care. This CI was in place for 2017/2018. The intention is to review the service and local tariff to ensure the service is treating the right patients at the right time, i.e. reference the AEC Directory of care. 3. To undertake a review of the first year of contract and implement subsequent recommendations. This includes SPA, Outpatient and diagnostic activity and inpatients. 4. We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the UTC to meet the national guidelines. 5. To undertake a review for face to face and home visiting attendances in the context of meeting national guidelines for integrated urgent care. This review to potentially work at scale across STP to commission a home visiting service. 6. We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the Rapid Response service to re-locate and work to support the ED/UCC with regard to attendances that would be supported by the rapid response service. 7. To operate in the un-scheduled care pilot pathway, testing pathways for patients who are presenting and discharging on unscheduled care pathways. 98

99 Area of intention Transforming Care Programme - Learning disabilities Long Term Conditions Background Transforming Care aims to improve life for people with learning disabilities and people with autism who have challenging behaviour. It comes in the aftermath of the Winterbourne View enquiry that found these most vulnerable people often living in institutional and poor quality, unsafe services, far from family and friends. Our plan is to give the right support in the right place at the right time with each person. Newham CCG s aim and vision to work in partnership with our community and local health stakeholders to improve the quality of life for people with long-term conditions. We aim to achieve this by ensuring improvements in health outcomes through: o Promoting safe, evidence based practice o Supporting the development of local guidelines and care pathways to ensure patient centred care. o Working across the diabetes care pathway supporting diabetes service providers in improving patient outcome through practice based facilitation, audit, education & training. List of intentions 1. Work with providers to understand the capacity and demand of the Community Learning Disability Team, in order to identify what is working well and any gaps in current provision. 2. Design and implement action plan in relation to the findings of the deep-dive service review of the Community Learning Disability Team 1. Supporting the delivery of NEL Diabetes transformation bid 2. Supporting uptake of the National diabetes prevention programme (NDPP) 3. Commitment to review multi-disciplinary diabetes foot team 4. Re-design of transition services 5. TB Review the service delivery models across 7 CCGs 99

100 Area of intention Patient and Public Engagement/ICS Mental Health Primary Care Background As a commissioner it s important to view the services through the eyes of the patient s perspective. This enables the commissioner to identify areas where service improvement can make the biggest difference to patient experience which is one of the areas of focus both nationally and for the CCG. Nationally, poor mental health represents around a quarter of the total burden of ill health, and can represent a significant barrier to gaining and maintaining employment. Improving mental health and wellbeing for residents is therefore a core part of Newham s goal to build resilience. Newham CCG will be reviewing its placement and support services and commission services for patient who live out of the borough. Here at NHS Newham CCG (NCCG) we are continually working to improve local health services and local health outcomes. In 2013 we launched our five year primary care strategy setting out how we expected to support the delivery of high quality primary care for residents of Newham. Since the launch of this document a lot has changed across the NHS landscape, which is why we have developed a refreshed version of the strategy that supports the development of sustainable List of intentions 1. Development of a bespoke PPG training programme for GPs. 2. Build a patient and public voice platform. 3. Deliver a series of engagement events to garner public opinion of services. 1. We intend to review the provision of IPS services across the borough in 2019/20 in order to develop commissioning intentions beyond the period covered by NHSE funding. 2. Intend to contract with NELFT to deliver care to Newhamregistered patients who live out of borough. 1. Review of existing an AQP provider arrangements completed in December Review the impact of EPCS and LIS. 3. Provision of language and translation services to patients attending a GP Practice. 4. Outcome measures/kpis were offered to PMS practices with effect from 1 July 2018, as a result of the PMS review process. They will be offered to GMS and APMS practices on a phased implementation as part of a four year transition process. 5. Primary Care Seven Day Access: CCGs have a responsibility to commission Enhanced Access to General Practice. This is distinct from Extended Access, which comes under a Directed 100

101 Primary care services, which can meet demands now and into the future. Enhanced Service. 6. Commission weekday provision of access to pre-bookable and same day appointments to general practice services from 6:30pm 10.00pm 7. Commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs. 8. Provide robust evidence, based on rates of use, for the proposed disposition of services throughout the week. 9. Appointments must be provided on a hub basis with practices working at scale. 10. Commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to 45 minutes per 1000 population. 11. Ensure usage of a nationally commissioned new tool to automatically measure appointment activity by all participating practices, both in-hours and in extended hours. 12. Ensure services are advertised to patients, including notification on practice websites, notices in local unscheduled care services and community publicity, so that it is clear to patients how they can access these appointments and associated service. 13. Ensure ease of access for patients including all practice receptionists able to direct patients to the service and offer appointments to extended hours service on the same basis as appointments to core hour s services. Patients should be offered a choice of evening or weekend appointments on an equitable basis to core appointments. 14. Use of digital approaches to support new models of care in general practice, direct booking from GP practices, NHS111 and unscheduled care services. 15. Issues of inequalities in patients experience of accessing general practice identified by local evidence and actions to resolve these put in place. The CCG will have achieved consistent availability of urgent and routine primary care 101

102 appointments Monday Friday until and at weekends in line with assessed patient need across the entire patient population in a way that integrates with the other components of our primary and unscheduled care pathway. 16. Under the NHS Primary Medical Service regulations, the CCG (in its role as delegated commissioner) is required to commission a Violent Patient Scheme (VPS) or Special Allocation Scheme (SAS) for its area. 17. Social Prescribing 18. Nursing Homes Primary Medical Support. QIPP and CIPs Building Healthier Communities Programme Developing QIPP Schemes for 19/20 to drive quality improvement and at the same time find efficiency benefits. Newham CCG continue to be committed to improve the provision of care through the Building Healthier Communities Programme, following patient feedback over the last four years. Over this period of time patients have raised the following concerns: Unclear about what services exist and what is right for patients Minimal transparency through the pathway for patients Little or no information around access and eligibility for services available Potential duplication and not enough integration Not enough focus on prevention and selfcares In order to deliver this, patients have suggested that there needs to be an improved pathway integrating the services 1. Development of QIPP schemes and joint QIPP/CIP schemes with our providers 1. ELFT to continue to demonstrate strengthened integrated working practices with the GP clusters including circulating upto date ensuring that the EPCT service is further embedded into primary care 2. ELFT will continue with the rollout to staff working in the community will have access to mobile electronic record keeping devices (ipad/laptop) in order to limit the requirement for double note entries in EMIS and paper records 3. ELFT should actively promote the role of independent prescribers - looking for opportunities within each service area around how this function can enhance care. ELFT should undertake quarterly prescribing audits which should be shared with the CCG and implement changes to ensure service progression 4. CCG intend to commission additional rehabilitation capacity in a community setting, with the objective of providing a broader range of interventions and integrated therapies. This will avoid duplication across the system, with an anticipated reduction in 102

103 across the sectors (Primary, Community and Secondary Care). The BHC Programme has been designed to ensure that patients play an integral role in redesigning the services involved. During 2019/20 NCCG intends to implement a new service model with your involvement to design the most appropriate service model, using your extensive knowledge and experience of providing healthcare for the residents of Newham. Further work will continue to design the future service provision and contract models during the remainder of 2018/19 to ensure the delivery occurs. waiting times, DTOCs and LOS, particularly for neuro-rehab patients 5. The CCG intends to start to shift our focus towards outcomes for Newham residents. 6. St Joseph s Hospice and CCG to develop its approach to ensure appropriate use of Community Palliative Care and Specialist. 7. Mildmay and NCCG to ensure outputs of any audit or review of the specialist HIV pathway are incorporated into the BHC developments. 8. Community Links - The CCG will be considering ways to incentivise the provider to increase in screening uptake from Newham population to meet the strategic aims of the East London Health and Care Partnership (ELHCP, formerly the STP) in relation to Bowel Scope screening. 9. Audiology - there is a need for the CCGs and Barts Health to identify potential efficiencies within this contract and to consider a universal offer that allows for patients and staff to work across the East London Health and Care Partnership and deliver efficiencies within this area that would be seen through a standardised approach. This will require an alignment in terms of contract following a development to deliver community adult and children services 103

104 Appendix 1 Further detail to 2019/20 Commissioning Intentions Link to national/regional/n ELCA or local strategy Five Year Forward View - New care model -modern maternity services NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Maternity Five Year Forward View - New care model -modern maternity services NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Maternity Scheme name Review support of Maternity Voice Partnership (MVP) to ensure it is fit for purpose and best use of resource Review outcomes of Maternity Mates to inform commissionin g Scheme details Patient and public engagement and support of Maternity Voice Partnership (MVP) Maternity Mates voluntary sector service supporting vulnerable pregnant women in Newham Scheme development stage Commissioning arrangements for MVPs being reviewed across NEL STP to ensure fit for purpose and best use of resources Review of outcomes in progress in liaison with Tower Hamlets CCG We will inform provider of intentions to recommission by 31st March 2018 Action Re-tender or bring tasks in house Possible 6 to 12 month contract extension to ensure sufficient time for remodelling Review outcomes of contract for impact to inform commission ing after 09/19 Provider s impacted Social Action for Health (current provider of support to MVPs in three CCGs Newham, WF & TH) Women's Health and Family Services Years (start and end) Contract runs 01/05/201 6 to 30/04/201 9 Contracts runs 01/10/201 6 to 30/09/201 9 Activity Impact TBC Supports up to 125 women p.a. Financial Impact Current contract value is 22,000 p.a. Possible savings if commissio n service differently Contract value p.a. 90,000 Suggest 10% saving of 9000 if continue after 09/19 104

105 Link to national/regional/n ELCA or local strategy NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream Scheme name Re-model the Diana team and scope within the children s community nursing service (CCNS) Resolving the gap in community services for 16 and 17 year olds Scheme details Re-model the Diana team and scope within the children s community nursing service (CCNS) Resolving the gap in community services for 16 and 17 year olds Scheme development stage Service reviewed and options being provided to NCCG SMT September 2018 for discussion and sign off. 6 to 12 month required to implement new model ELFT delivered transition panel pilot to identify needs and provide findings of panel to CCG. This has taken place for 6 months from April 2018 and will report in Action Remodel Diana service and amend service specificatio n via contract with ELFT CHS Amend as necessary the appropriate service specificatio ns (adult and children) based on findings Provider s impacted ELFT ELFT Years (start and end) Contract runs 01/05/201 7 to Contract runs 01/05/201 7 to Activity Impact TBC ELFT reporting on findings Sep 2018 Financial Impact Current contract value is 35,375,5 35 p.a. Potential to withdraw up to 1m for packages of care budget but expect c. 250k savings to be realised by ELFT prior to this Current contract value is 35,375,5 35 p.a. Financial impact TBC 105

106 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage September 2018 Action Provider s impacted Years (start and end) Activity Impact Financial Impact NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream Pilot designated medical / clinical officer for special educational needs and disability (SEND) for 1 year Development of community asthma services to prevent inappropriate and preventable use of unscheduled care Pilot designated medical / clinical officer (DMO/DCO) for special educational needs and disability (SEND) for 1 year Development of community asthma services to prevent inappropriate and preventable use of unscheduled care Identification of additional medical, therapeutic or nursing lead to deliver designated role in 2019/20 At scoping stage Job description, reporting requirement s and contract variation ELFT Contract runs 01/05/201 7 to TBC ELFT Contract runs 01/05/201 7 to TBC TBC ideally reduction in unschedul ed care activity and costs Current contract value is 35,375,5 35 p.a. Value for DMO/DC O is up to 38,421 p.a. Current contract value is 35,375,5 35 p.a. Investmen t funding to realise wider savings in health economy TBC 106

107 Link to national/regional/n ELCA or local strategy NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream Five Year Forward View - New care model -modern maternity services NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream Scheme name Review of sickle cell and thalassaemia pathway in pregnancy including what organisation takes lead on partner testing and discussion of pregnancy options as appropriate for parents to be Provision of termination of pregnancy (TOP) services (and some aligned sexual health services STI testing and contraception) Scheme details Review of sickle cell and thalassaemia pathway in pregnancy including what organisation takes lead on partner testing and discussion of pregnancy options as appropriate for parents to be BPAS - Provision of termination of pregnancy (TOP) services (and some aligned sexual health services STI testing and contraception) Scheme development stage At discussion stage Review of tariffs across various TOP providers to ensure best value for money Action Provider s impacted Years (start and end) TBC ELFT Contract runs 01/05/201 7 to Extend contract for one further year Possible AQP in 2020/21 BPAS (and other TOP providers including Barts and NUPAS) Contracts runs 01/05/201 6 to 30/04/201 9 Activity Impact TBC may realise efficiencie s or savings in service N/A Financial Impact Current contract value is 35,375,5 35 p.a. Any efficiencie s or savings are TBC Budget for BPAS in 18/19-262,000 Possible savings if we renegotiat e cheaper tariffs 107

108 Link to national/regional/n ELCA or local strategy Five Year Forward View - Why does the NHS need to change? NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Transforming Care Five Year Forward View - Why does the NHS need to change? NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Transforming Care Scheme name To understand the capacity and demand of the Community Learning Disability Team Implement action plan from the capacity and demand review of the Community Learning Disability Team Scheme details Community Learning Disability Team Community Learning Disability Team Scheme development stage We intend to work with the provider to understand the capacity and demand of the CLDT, in order to identify what is working well and any gaps in current provision Design and implement action plan in relation to the findings of the deep-dive service review Action Undertake a deep-dive service review To be informed by the findings of the deepdive service review Provider s impacted ELFT (CHN Contract) ELFT (CHN Contract) Years (start and end) Activity Impact 2019/20 To be confirmed 2020/21 To be confirmed Financial Impact To be confirmed To be confirmed 108

109 Link to national/regional/n ELCA or local strategy National Guidance on the special educational needs and disability (SEND) Scheme name 1. Review of commissionin g arrangements for hospice care across NEL to ensure equity and in line with doings things once in NEL as appropriate. 2. Consider inclusion of hospice respite in personal budgets for children Scheme details 1. Review of commissioning arrangements for hospice care across NEL to ensure equity and in line with doings things once in NEL as appropriate. 2. Consider inclusion of hospice respite in personal budgets for children 3. Ongoing development of home based hospice offer Scheme development stage 1. At scoping stage 2. At scoping stage 3. In progress Action Extend contract for further year while we scope NEL opportunitie s during 2019/20 (potentially via new CYP STP work stream) Provider s impacted Richard House Hospice Years (start and end) Contract runs 01/04/201 6 to 31/03/201 9 This is across 6 out of 7 CCGs in STP (not Havering) Activity Impact TBC Financial Impact Current contract value is 147,500 p.a. for Newham Possible savings if review tariffs and allocations across NEL NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation 3. Ongoing development of home based hospice offer Extension of contract for audio vestibular consultant (AVC) as interim Extension of contract for audio vestibular consultant (AVC) as interim solution while we develop Barts Initial scoping and exploration between commissioner and provider (Barts) completed Extend contract by one further year (2019/20) (Newham Hearline - communit y AVC provider Contract runs 01/04/17 to 31/03/19 TBC Contract value is 76,500 p.a. for Newham Savings 109

110 Link to national/regional/n ELCA or local strategy Workstream - Provider Productivity NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Provider Productivity Scheme name solution while we develop Barts Health resource within the wider audiology service Provider to develop a cost effective solution for providing in house audio vestibular consultant (AVC) resource with clear timeframes to ensure timely implementatio n Scheme details resource within the wider audiology service Provider to develop a cost effective solution for providing in house audio vestibular consultant (AVC) resource with clear timeframes to ensure timely implementation Scheme development stage Initial scoping and exploration between commissioner and provider completed Action are lead commission er, with TH and C&H associate commission ers) Amend 5- year contract via contract variation by (Newham are associate to TH led community contract with Barts, C&H also associate commission er) Provider s impacted Barts communit y audiology services Years (start and end) Contract runs 01/04/17 to 31/03/22 Activity Impact TBC Financial Impact may be possible by moving from private provider to NHs provider Contract value is p.a. for Newham Savings may be possible by moving from NHs provider to non NHS Provider (third or private sector) 110

111 Link to national/regional/n ELCA or local strategy Five Year Forward View - New care model -urgent and emergency care networks NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Urgent and Emergency Care Scheme name To work collaboratively with the unscheduled care pilot to achieve a shift of type 1 activity equalling a 60:40 split UTC/ED Scheme details To work collaboratively with the unscheduled care pilot to achieve a shift of type 1 activity equalling a 60:40 split UTC/ED Scheme development stage The CCG will work with the Provider to develop an activity model for the Urgent Treatment Centre that will be based on a 60:40 UCC/ED split. The CCG will work with the Alliance Agreement Group to ensure activity is streamed away from the UCC to Primary Care at Newham Hospital Action A new UTC contract would be issued for 2 year Pilot Provider s impacted Barts Health Main contract ED type 1 activity UTC Contract Type 3 activity Years (start and end) Activity Impact Nov-18 Reduction in patient Flow in emergenc y departme nt & urgent treatment centre Financial Impact Not known at this stage. 111

112 Link to national/regional/n ELCA or local strategy Five Year Forward View - New care model -urgent and emergency care networks NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Urgent and Emergency Care Scheme name To review the implemented model for ambulatory emergency care. Scheme details To review the implemented model for ambulatory emergency care. This CI was in place for 2017/2018. The intention is to review the service and local tariff to ensure the service is treating the right patients at the right time, i.e. reference the AEC Directory of care. Scheme development stage At the time of writing a local tariff is being agreed with Barts Health. The specification has a range of KPI s and therefore the proposed review will be based on these. This CI was in place for 2017/2018. The intention is to review the service and local tariff to ensure the service is treating the right patients at the right time, i.e. reference the AEC Directory of care. Action Potential variation to local tariff and model of care Provider s impacted Barts Health Main contract Ambulator y Care Years (start and end) Main Barts contract Activity Impact Reduction to emergenc y admission s Financial Impact Not known at this stage. 112

113 Link to national/regional/n ELCA or local strategy NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream- Provider Productivity Five Year Forward View - New care model -urgent and emergency care networks NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Urgent and Emergency Care Scheme name To undertake a MSK review of the first year of contract and implement subsequent recommendati ons. This includes SPA, Outpatient and diagnostic activity and inpatients. We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the UTC to meet the national guidelines. Scheme details To undertake a review of the first year of contract and implement subsequent recommendation s. This includes SPA, Outpatient and diagnostic activity and inpatients. We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the UTC to meet the national guidelines. Scheme development stage Agree scoping document and terms of reference. SMT to approve either a partial or full review A kick off meeting has been held with an outline of the commissioning approach. A timetable has been released with regard to contract negotiation. Action Outcome of review will determine the rest of the contractual term. Re-design of UCC Provider s impacted Barts Health MSK contract Barts Health Urgent care contract Years (start and end) August 2017 July 2022 Ends November 2018 Activity Impact Reduction in acute referrals Reduction to ED activity, Increase in UCC activity, increase in streaming away activity Financial Impact Not known at this stage. 113

114 Link to national/regional/n ELCA or local strategy Five Year Forward View - New care model -urgent and emergency care networks NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Urgent and Emergency Care Scheme name To undertake a review for face to face and home visiting attendances of out of hours, in the context of meeting national guidelines for integrated urgent care. This review to potentially work at scale across STP to commission a home visiting service. Scheme details To undertake a review for face to face and home visiting attendances in the context of meeting national guidelines for integrated urgent care. This review to potentially work at scale across STP to commission a home visiting service. Scheme development stage The CCG will work with the Provider to develop a service model that is aligned to the Integrated Urgent Care model to ensure where appropriate, patients have a face to face appointment with clinicians including where necessary at the patients place of residence. Action New 6 months contract to be issued Provider s impacted Newham GP OOH Years (start and end) Activity Impact Oct-18 Reduction in OOH activity Financial Impact Not known at this stage. The service model will be provided in an environment that promotes effective care 114

115 Link to national/regional/n ELCA or local strategy Five Year Forward View - New care model -urgent and emergency care networks NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Urgent and Emergency Care Five Year Forward View - New care model -urgent and emergency care networks NELCA Commissioning Strategy 2019/20 - Scheme name We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the Rapid Response service to relocate and work to support the ED/UCC with regard to attendances that would be supported by the rapid response service. To operate in the unscheduled care pilot pathway, testing pathways for patients who are presenting Scheme details We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the Rapid Response service to relocate and work to support the ED/UCC with regard to attendances that would be supported by the rapid response service. To operate in the un-scheduled care pilot pathway, testing pathways for patients who are presenting and discharging on un-scheduled Scheme development stage A letter of contract variation is due to be released in year. Our expectation for is to pilot the pathway and learn from the arrangement. The CCG will work with the Alliance Agreement Group to develop an unscheduled care pathway which would be Action Contract variation. Remodelling of rapid response service. Evaluating and Testing will inform future commission ing requirement s Provider s impacted ELFT Rapid Response Newham Health Collaborat ive Years (start and end) Activity Impact Nov-28 Not known Reduction in patient Flow in emergenc y departme nt & urgent treatment Financial Impact 0 to staffing Not known at this stage. 115

116 Link to national/regional/n ELCA or local strategy 2021/22 - Commissioning Priorities & Transformation Workstream Scheme name and discharging on unscheduled care pathways. Scheme details care pathways. Scheme development stage evaluated and tested. Action Provider s impacted Years (start and end) Activity Impact centre Financial Impact NHS Five Year Forward View - Getting serious about prevention NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Prevention Supporting the delivery of NEL Diabetes transformation bid Supporting the delivery of NEL Diabetes transformation bid through Clinical leadership Clinical engagement Delivery against milestones The bid includes four interventions Type 1 and young people, pre-conception, virtual patient record reviews and a NEL dashboard Milestones agreed by providers and executives of trusts Funding secured Governance in place MOUs detailing expected delivery signed for drafted for Re-model / pathway redesign, enhance current provision in each CCG areas NELFT ELFT BARTS BHRUT Homerton CEG Commenc ed Minimal impact on acute activity Improved outcomes for people living with diabetes Outcome targets improved Reduced variation Shifting of work between settings Increased PBR activity Long term financial gain through reduction in admission s and complicati ons associate d with diabetes e.g. blindness, amputatio n 116

117 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - Getting serious about prevention NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Prevention NHS Five Year Forward View - Getting serious about prevention NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Prevention Scheme name Supporting uptake of the National diabetes prevention programme (NDPP) Commitment to review Multidisciplinary diabetes foot team Scheme details Supporting uptake of the National diabetes prevention programme (NDPP) Clinical leadership Clinical engagement Commitment to review Multidisciplinary diabetes foot team Clinical leadership Clinical engagement Scheme development stage National service specification written Provider in place Engagement undertaken MOU signed with NHSE including recruitment of staff to support the delivery of the interventions NEL partnership group in place NEL foot care network in place MDT bid document produced could be used as a base to understand required provision and gaps Action Delivery of contracted activity Clinical pathway redesign Provider s impacted General practice NELFT ELFT BARTS BHRUT Homerton General practice Years (start and end) Activity Impact Targets reached as outlined by national programm e Reduction in variation Financial Impact Long term financial gain through delay or prevention of Type 2 diabetes Long term financial gain through reduction in LOS, admission s and complicati ons associate d with foot disease e.g. amputatio 117

118 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact n NHS Five Year Forward View - Getting serious about prevention NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Prevention Re-design of diabetes transition services Re-design of transition services NEL type 1 network in place Service specification developed Clinical pathway redesign BARTS BHRUT Homerton ELFT NELF Reduction in variation Long term financial gain through reduction in LOS, admission s and complicati ons associate d with Type 1 & Type 2 diabetes Improved psychologi cal outcomes 118

119 Link to national/regional/n ELCA or local strategy NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Medicine Optimisation NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Medicine Optimisation Scheme name TB Review the service delivery models across 7 CCGs ELFT to continue to review patients prescribed doxepin for depression in line with NICE guidelines Scheme details TB Review the service delivery models across 7 CCGs ELFT to continue to review patients prescribed doxepin for depression in line with NICE guidelines on depression as CG90 does not mention doxepin and advocates SSRIs and newer generation of antidepressants. The CCG expects that prescribing levels are further reduced to levels comparable to neighbouring Scheme development stage Initial scoping to develop local model of delivery Benchmark against local CCG performance to consider replication Identify gaps in services Continuation from previous CIs Action To be determined Remodel of the service will be required to standardise Provider s impacted BHRUT BHT HUH Primary Care ELFT Years (start and end) Activity Impact 2019/20 TBD Currently there is a need to consider the most appropriat e model before being able to document the impact Improved patient care and health outcomes. Reduced prescribin g spend enabling resources to be invested in prioritised care, new medicines and technolog y Improved Financial Impact TBD Currently there is a need to consider the most appropriat e model before being able to document the impact Included in QIPP programm e 119

120 Link to national/regional/n ELCA or local strategy Scheme name Scheme details CCGs. Scheme development stage Action Provider s impacted Years (start and end) Activity Impact patient care and health outcomes. Financial Impact NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Medicine Optimisation The CCG in line with other NEL CCGs expects that ELFT adhere to the two NHS England guidance s. The CCG in line with other NEL CCGs expects that ELFT adhere to the two NHS England guidance listed below which being fully implemented by the CCGs. o Items which should not be routinely prescribed in primary care o Conditions for which over the counter items should not routinely be prescribed in primary care Commenced but needs to be leveraged through contract ELFT Barts Improved patient care and health outcomes. Reduced prescribin g spend enabling resources to be invested in prioritised care, new medicines and technolog y Improved patient care and health Included in QIPP programm e 120

121 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage Action Provider s impacted Years (start and end) Activity Impact outcomes to be invested in prioritised care, new medicines Financial Impact NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Medicine Optimisation Develop a model for centralised supply of dressings by community and Tissue viability Nurses. Develop a model for centralised supply of dressings by community and Tissue viability Nurses. Business case to be developed The plan is to start discussions and scoping in 2019/20 but implementation may not start till Q4 or 2020/21 ELFT Improved patient care and health outcomes. Reduced prescribin g spend enabling resources to be invested in prioritised care, new medicines and technolog y Improved patient Included in QIPP programm e 121

122 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage Action Provider s impacted Years (start and end) Activity Impact care and health outcomes to be invested in prioritised care, new medicines Financial Impact NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Medicine Optimisation Develop a model for centralised supply of dressings by community and Tissue viability Nurses. GPs are experiencing significant increased workload generated from the request to prescribe dressings by community nurses. Develop a model for centralised supply of dressings by community and Tissue viability Nurses. GPs are experiencing significant increased workload generated from the request to prescribe dressings by community nurses. Business case to be developed The plan is to start discussions and scoping in 2019/20 but implementation may not start till Q4 or 2020/21 ELFT Improved patient care and health outcomes. Reduced prescribin g spend enabling resources to be invested in prioritised care, new medicines and technolog y Improved patient Included in QIPP programm e 122

123 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage Action Provider s impacted Years (start and end) Activity Impact care and health outcomes to be invested in prioritised care, new medicines Financial Impact NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Mental Health Review of Individual Placement and Support (IPS) Commission NELFT to deliver care to cross-border patients in need of MH services Individual Placement and Support (IPS) mental health and employment Cross-border patients in need of MH services We intend to review the provision of IPS services across the borough in 2019/20 in order to develop commissioning intentions beyond the period covered by NHSE funding We intend to contract with NELFT to deliver care to Newhamregistered patients who Service review will determine next steps Activity review in 2018/19 will inform method of contracting for 2019/20 Mind in Tower Hamlets and Newham, ELFT North East London Foundatio n Trust (NELFT) 2019/20 TBC TBC 2019/20 TBC TBC 123

124 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage live out of borough Action Provider s impacted Years (start and end) Activity Impact Financial Impact NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Development of a bespoke PPG training programme for GPs Development of a bespoke PPG training programme for GPs Build a patient and public voice platform Deliver a series of engagement events to garner public opinion of services. This programme is coming to the end of year 1 of a 3 year contract. The PPG development programme is about to commence training at the 10 GP practices identified. It is anticipated that all 10 will be complete by the end of The back end of the PVP is in development. Completion expected October 2018 Contract to continue with close monitoring. Following delivery of the PPG training, the completion of the PPG resources pack and face to face visits to all practices listed the CCG anticipates that the PPG element of this contract to cease March Therefore, the intention is for the Intelligent Health Limited Start 13th November 2017 End 12th November

125 Link to national/regional/n ELCA or local strategy Scheme name Scheme details Scheme development stage Action CCG to decommissi on this element of the contract. Provider s impacted Years (start and end) Activity Impact Financial Impact NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Review of Any Qualified Provider (AQP) AQP: The CCG has commissioned a number of services to be delivered using the Any Qualified Provider (AQP) contracting route since October The commissioned AQP services are able to deliver a number of predetermined, clinically defined, low-risk Review of existing arrangements completed in December Service specifications, gap analysis and communication and engagement plan nearing completion A new contract would be issued for three years following procuremen t Patient First Social Enterprise 1 April 2019 to 31 March 2022 TBC Local tariff payment per procedure, per service 125

126 Link to national/regional/n ELCA or local strategy Scheme name Scheme details procedures as part of these contracts. The four services that are currently included in the contract are: 1. Cardiology 2. Dermatology 3. Gynaecology 4. Minor Surgery Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact 126

127 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Scheme name Review of the 14 EPCS and LIS services Scheme details EPCS and LIS: In 2018/19, the CCG commissioned fourteen EPCS: Primary Prevention CVD risk and pre-diabetes Atrial Fibrillation Post-Cardiac Review Diabetes and CVD review Chronic Obstructive Pulmonary Disease Chronic Kidney Disease Mental Health Services Latent TB Cancer ECG Referral Pathway Service Scheme development stage The impact of this four year programme is required to inform arrangements for 2019/20 and beyond Action A new contract would be issued for one year Provider s impacted Newham GP Practices Years (start and end) 1 April 2019 to 31 March 2020 Activity Impact TBC Financial Impact Local tariff payment per service The CCG also commissions a Local Incentive Scheme to support practice engagement with 127

128 Link to national/regional/n ELCA or local strategy Scheme name Scheme details monthly cluster meetings, quarterly commissioning events and monthly PM Forum meetings Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact 128

129 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Scheme name Provision of language and translation services to patients attending a GP Practice Scheme details Provision of language and translation services to patients attending a GP Practice Scheme development stage This service is currently commissioned from Language Shop until 31 March 2019 under a Service Level Agreement. Language Shop will be presenting their offer to partners/commi ssioners in September Action A contract will be offered to Newham Health Collaborativ e to provide the contract manageme nt of practice utilisation Provider s impacted Newham GP Practices / Newham Health Collaborat ive Years (start and end) Activity Impact Financial Impact Local tariff payment for service The CCG intends to commission the contract management of the utilisation for this service from Newham Health Collaborative 129

130 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Scheme name Outcome measures/kpi s w offered to GMS and APMS practices on a phased implementatio n as part of a four year transition process. Scheme details Newham Outcome Measures: These outcome measures/kpis were offered to PMS practices with effect from 1 July 2018, as a result of the PMS review process. They will be offered to GMS and APMS practices on a phased implementation as part of a four year transition process. Scheme development stage This programme is currently commissioned from all PMS practices and on a phased implementation from GMS and PMS practices. Following a review of fitness-forpurpose and impact, new Outcome Measures may be substituted for current ones from 2019/20 onwards Action NHS Standard contract in place for PMS and GMS practices; and included in APMS contracts under existing contract arrangemen t as a variation Provider s impacted Newham GP Practices Years (start and end) 1 July 2018 to 30 June 2021 Activity Impact TBC Financial Impact Local tariff payment 130

131 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Scheme name Commission Primary Care Seven Day Access Scheme details Primary Care Seven Day Access: CCGs have a responsibility to commission Enhanced Access to General Practice. This is distinct from Extended Access, which comes under a Directed Enhanced Service. Timing of Appointments: Scheme development stage This service is currently commissioned under pilot arrangements until 31 March 2019 Action A new contract would be issued for two years following procuremen t, subject to GP Forward View funding Provider s impacted Newham Health Collaborat ive Years (start and end) 1 April 2019 to 31 March 2021 Activity Impact 41,600 appointme nts per year Financial Impact 1,100,00 0 Commission weekday provision of access to prebookable and same day appointments to general practice services from 6:30pm 10.00pm Commission weekend 131

132 Link to national/regional/n ELCA or local strategy Scheme name Scheme details provision of access to prebookable and same day appointments on both Saturdays and Sundays to meet local population needs. Provide robust evidence, based on rates of use, for the proposed disposition of services throughout the week. Appointments must be provided on a hub basis with practices working at scale. Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact Capacity: Commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to 45 minutes per

133 Link to national/regional/n ELCA or local strategy Scheme name Scheme details population. Measurement: Ensure usage of a nationally commissioned new tool to automatically measure appointment activity by all participating practices, both in-hours and in extended hours Advertising and Ease of Access: Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact Ensure services are advertised to patients, including notification on practice websites, notices in local unscheduled care services and community publicity, so that it is clear to patients how they can access these appointments and associated 133

134 Link to national/regional/n ELCA or local strategy Scheme name Scheme details service. Ensure ease of access for patients including all practice receptionists able to direct patients to the service and offer appointments to extended hours service on the same basis as appointments to core hour s services. Patients should be offered a choice of evening or weekend appointments on an equitable basis to core appointments. Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact Digital: Use of digital approaches to support new models of care in general practice, direct booking from GP 134

135 Link to national/regional/n ELCA or local strategy Scheme name Scheme details practices, NHS111 and unscheduled care services. Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact Inequalities: Issues of inequalities in patients experience of accessing general practice identified by local evidence and actions to resolve these put in place. The CCG will have achieved consistent availability of urgent and routine primary care appointments Monday Friday until and at weekends in line with assessed patient need across the entire patient population in a way that 135

136 Link to national/regional/n ELCA or local strategy Scheme name Scheme details integrates with the other components of our primary and unscheduled care pathway. Scheme development stage Action Provider s impacted Years (start and end) Activity Impact Financial Impact 136

137 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Scheme name Commission a Violent Patient Scheme (VPS) or Special Allocation Scheme (SAS) for its area. Scheme details Special Allocation Scheme: Under the NHS Primary Medical Service regulations, the CCG (in its role as delegated commissioner) is required to commission a Violent Patient Scheme (VPS) or Special Allocation Scheme (SAS) for its area. Due to the specialist nature of the service and relatively small numbers of patients involved, it is likely that this service will be procured at scale (STP-wide or London wide) Scheme development stage Service specification in development and due to be completed by 30 September 2018 Notice to current provider required in September 2018 Service to be procured between October and December 2018 Provider to be appointed in December 2018 Service mobilisation January to March 2019 Commenceme nt of new service 1 April 2019 Action A new contract would be issued following procuremen t Provider s impacted The Orient Practice (current provider) Newham GP Practices Years (start and end) 1 April 2019 duration yet to be determine d, but may be 5+5 years Activity Impact Financial Impact TBC 20,

138 Link to national/regional/n ELCA or local strategy NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care NHS Five Year Forward View - New Models of Care NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Primary Care Scheme name Review of Social Prescribing Review of Primary Medical Support to Nursing Homes Scheme details Social Prescribing Nursing Homes Primary Medical Support Scheme development stage SDIP required to be implemented Further work to be undertaken on increasing uptake to the scheme Inclusion criteria being reviewed with a view to expansion Current scheme being reviewed with a view to introduce a transformation al scheme that would be open to all care home residents. Action The scheme falls under the wider BHC umbrella so will be considered as part of the wider programme A contract will be issued based upon the agreed future delivery route following a procuremen t Provider s impacted West ham United Foundatio n Five or six Newham GP Practices Years (start and end) Activity Impact Mar-19 The scheme is payable on a block basis with activity chargeabl e No contract end date as this is delivered under a section agreemen t Block 380k split 50% with LBN Activity variable tariff Care home bed occupanc y based on registered beds Financial Impact 143k split between providers based on bed occupanc y 138

139 Link to national/regional/n ELCA or local strategy NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Provider Productivity Scheme name Development of QIPP schemes and joint QIPP/CIP schemes with our providers. Scheme details Development of QIPP schemes and joint QIPP/CIP schemes with our providers. Scheme development stage Developing QIPP Schemes for 19/20 to drive quality improvement and at the same time find efficiency benefits. Action Develop 19/20 QIPPs. Share and agree QIPPs with providers. Provider s impacted Barts Health ELFT And potentially all other providers. Years (start and end) April 2019 to March 2020 Activity Impact Will be developed as part of QIPP planning where appropriat e. Financial Impact Will be developed as part of QIPP planning NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Provider Productivity Implementing a checklist for Anticoagulation patients Implementing a checklist for Anticoagulant patients being passed onto pharmacists and resulting dashboard to be shared on a quarterly basis with commissioners To work with our providers on joint QIPP/CIPP plans. Developed as part of the 18/19 QIPP process. Contract Variation Barts Health April 2019 TBC TBC 139

140 Link to national/regional/n ELCA or local strategy NELCA Commissioning Strategy 2019/ /22 - Commissioning Priorities & Transformation Workstream - Provider Productivity Scheme name Consider trialling of OCT pilot with Moorfields Scheme details Consider trialling of OCT pilot with Moorfields Scheme development stage Contract Variation Action Contract Variation Provider s impacted Moorfield s Years (start and end) Activity Impact 2019 TBC TBC Financial Impact 140

141 Providers impacted Service Area Service details Scheme development stage Activity Impact/Outcome Financial Impact How does it link to 5YFV Barts - Acute Diabetes Re-design of transition services NEL type 1 network in place. Service specification developed Reduction in variation Long term financial gain through reduction in LOS, admissions and complications associated with Type 1 & Type 2 diabetes. Improved Integrating care locally, psychological outcomes new models of care Barts - Acute Diabetes Supporting the delivery of NEL Diabetes transformation bid through Clinical leadership Clinical engagement Delivery against milestones The bid includes four interventions Type 1 and young people, pre-conception, virtual patient record reviews and a NEL dashboard Milestones agreed by providers and executives of trusts Funding secured Governance in place MOUs detailing expected delivery signed for drafted for Minimal impact on acute activity. Improved outcomes for people living with diabetes. Outcome targets improved. Reduced variation. Shifting of work between settings. Increased PBR activity Long term financial gain through reduction in admissions and complications associated with diabetes e.g. blindness, amputation Integrating care locally, new models of care Transforming care, Long Term Conditions Diabetes & TB / JSNA priority Barts - Acute Barts - Acute Urgent & Emergency Care/Integrated Care Urgent & Emergency Care/Integrated Care ED type 1 activity. UTC Contract Type 3 activity To work collaboratively with the un-scheduled care pilot to achieve a shift of type 1 activity equalling a 60:40 split UTC/ED Ambulatory Care -To review the implemented model for ambulatory emergency care. This CI was in place for 2017/2018. The intention is to review the service and local tariff to ensure the service is treating the right patients at the right time, i.e. reference the AEC Directory of care. The CCG will work with the Provider to develop an activity model for the Urgent Treatment Centre that will be based on a 60:40 UCC/ED split. The CCG will work with the Alliance Agreement Group to ensure activity is streamed away from the UCC to Primary Care at Newham Hospital At the time of writing a local tariff is being agreed with Barts Health. The specification has a range of KPI s and therefore the proposed review will be based on these. Reduction in patient Flow in emergency department & urgent treatment centre Reduction to emergency admissions Barts - Acute Urgent & Emergency Care/Integrated Care To commission a Minor eye conditions service in the community. Newham CCG will work with stakeholders to develop a Community MECS service model that would repatriate patients from the Acute hospital Reduction in A&E attendances and 1 st outpatient discharge Barts - Acute Urgent & Emergency Care/Integrated Care To undertake a review and re-commission minor ENT services. Newham CCG will work with Providers to develop an activity model to understand the ENT activity. Review options to assist with the commission of a community ENT service Reduction in ENT outpatient activity Barts Urgent & Emergency Care/Integrated Care Demand and Capacity Management Newham CCG will seek to work closely with Providers to manage the capacity within the current financial envelop. This will require full engagement from the Providers to support service change and redesign in the development of cost effective pathways. Barts Barts -Acute and Newham GP practice Urgent & Emergency Care/Integrated Care Elective Care Diabetes Commitment to review Multi-disciplinary diabetes foot team provision and clinical care pathway Clinical leadership Clinical engagement Barts - MSK Planned Care To undertake an annual review of the MSK Collaborative Service Newham CCG will seek to work with providers of elective care to agree models that are sustainable for the health system. We would seek the Provider s support to assist Primary Care with the demand (referral) management agenda. NEL foot care network in place MDfT bid document produced could be used as a base to understand required provision and gaps Newham CCG will work with Providers to undertake a review on activity and finance and jointly agree changes to pathways Reduction in variation Long term financial gain Integrating care locally, through reduction in LOS, new models of care. admissions and Transforming care, Long complications associated Term Conditions with foot disease e.g. Diabetes & TB / JSNA Barts - MSK Urgent & Emergency Care/Integrated Care To undertake a review of the first year of contract and implement subsequent recommendations. This includes SPA, Outpatient and diagnostic activity and inpatients. Agree scoping document and terms of reference. SMT to approve either a partial or full review Reduction in Acute Referrals Barts - Outpatient Urgent & Emergency Care/Integrated Care Commission a peer review/triage for Outpatient referrals in Newham Newham CCG will work with Providers to develop an activity model to understand the demand on first and follow up. Work with clinical lead to develop possible schemes to assist with triaging outpatient referrals Reduction in outpatient referral activity into acute

142 Providers impacted Service Area Service details Scheme development stage Activity Impact/Outcome Financial Impact How does it link to 5YFV Barts - THT Community Health Services Children and Young People and Adults There is a need for the CCGs and Barts Health to identify potential efficiencies within this contract and to consider a universal offer that allows for patients and staff to work across the East London Health and Care Partnership and deliver efficiencies within this area that would be seen through a standardised approach. This will require an alignment in terms of contract following a development to deliver community adult and children services. Provider to develop a cost effective solution for providing in house audio vestibular consultant (AVC) resource with clear timeframes to ensure timely implementation Contract value is 1,176,000 p.a. for Newham Barts - Urgent Care Centre Urgent & Emergency Care/Integrated Care We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the UTC to meet the national guidelines. A kick off meeting has been held with an outline of the commissioning approach. A timetable has been released with regard to contract negotiation. Reduction to ED activity, Increase in UCC activity, increase in streaming away activity Budget for BPAS in 18/19-262,000 British Pregnancy Advisory Service Maternity Provision of termination of pregnancy (TOP) services (and some aligned sexual health services STI testing and contraception) Review of tariffs across various TOP providers to ensure best value for money Possible savings if we renegotiate cheaper tariffs ELFT Children and Young People Development of community asthma services to prevent inappropriate and preventable use of unscheduled care At scoping stage Ideally a reduction in unscheduled care activity and costs Investment funding to realise wider savings in health economy TBC ELFT Children and Young People Re-model the Diana team and scope within the children s community nursing service (CCNS) Service reviewed and options being provided to NCCG SMT September 2018 for discussion and sign off. 6 to 12 month required to implement new model ELFT Children and Young People Resolving the gap in community services for 16 and 17 year olds. ELFT delivered transition panel pilot to identify needs and provide findings of panel to CCG. This has taken place for 6 months from April 2018 and will report in September 2018 ELFT reporting on findings Sep 2018 ELFT Children and Young People SEND. Pilot designated medical / clinical officer (DMO/DCO) for special educational needs and disability (SEND) for 1 year Identification of additional medical, therapeutic or nursing lead to deliver designated role in 2019/20 Value for DMO/DCO is up to 38,421 p.a Whilst we continue to develop any significant transformation through the BHC programme there are elements within your contract we would like to your continued support in developing and will welcome your continued support in improving care for our patients within Newham. ELFT to continue to demonstrate strengthened integrated working practices with the GP clusters including circulating up-to date ensuring that the EPCT service is further embedded into primary care ELFT will continue with the rollout to staff working in the community will have access to mobile electronic record keeping devices (ipad/laptop) in order to limit the requirement for double note entries in EMIS and paper records ELFT should actively promote the role of independent prescribers - looking for opportunities within each service area around how this function can enhance care. ELFT should undertake quarterly prescribing audits which should be shared with the CCG and implement changes to ensure service progression CCG intend to commission additional rehabilitation capacity in a community setting, with the objective of providing a broader range of interventions and integrated therapies. This will avoid duplication across the system, with an anticipated reduction in waiting times, DTOCs and LOS, particularly for neuro-rehab patients ELFT ELFT Community Health Services Diabetes Building Healthier Communities To extend the provision of education of Type 1 diabetes education outside of any DAFNE provision The CCG intends to start to shift our focus towards outcomes for Newham residents. Education provision currently commissioned ELFT Diabetes Commitment to review Multi-disciplinary diabetes foot team and local care pathway Clinical leadership Clinical engagement in NEL network NEL foot care network in place MDfT bid document produced could be used as a base to understand required provision and gaps Reduction in variation Long term financial gain through reduction in LOS, admissions and complications associated with foot disease e.g. Integrating care locally, amputation new models of care

143 Providers impacted Service Area Service details Scheme development stage ELFT Diabetes Supporting the delivery of NEL Diabetes transformation bid through Clinical leadership Clinical engagement Delivery against milestones The bid includes four interventions Type 1 and young people, pre-conception, virtual patient record reviews and a NEL dashboard To support the redesign of the DSN service provision through utilisation of transformation monies Milestones agreed by providers and executives of trusts Funding secured Governance in place MOUs detailing expected delivery signed for drafted for Activity Impact/Outcome Minimal impact on acute activity Improved outcomes for people living with diabetes Outcome targets improved Reduced variation Financial Impact Increased PBR activity Long term financial gain through reduction in admissions and complications associated with diabetes e.g. blindness, amputation How does it link to 5YFV Integrating care locally, new models of care ELFT Diabetes To extend the provision of education of Type 1 diabetes education outside of any DAFNE provision Education provision currently commissioned ELFT Learning Disabilities Community Learning Disability Team ELFT Learning Disabilities Community Learning Disability Team We intend to work with the provider to understand the capacity and demand of the CLDT, in order to identify what is working well and any gaps in current provision Design and implement action plan in relation to the findings of the deep-dive service review This links to the Transforming Care Programme (TCP) This links to the Transforming Care Programme (TCP) ELFT Maternity/Children and Young People Community sickle cell and thalassaemia pathway Review of sickle cell and thalassaemia pathway in pregnancy including what organisation takes lead on partner testing and discussion of pregnancy options as appropriate for parents to be ELFT Medicines Management The CCG in line with other NEL CCGs expects that ELFT adhere to the two NHS England guidance listed below which being fully implemented by the CCGs. o Items which should not be routinely prescribed in primary care o Conditions for which over the counter items should not routinely be prescribed in primary care Improved patient care and health outcomes. Reduced prescribing spend enabling resources to be invested in prioritised care, new medicines and technology Improved patient care and health outcomes. Get best value out of medicines and pharmacy: Implementing NHSE Medicines Value Programme ELFT Medicines Management Develop a model for centralised supply of dressings by community and Tissue viability Nurses. Business case to be developed. The plan is to start discussions and scoping in 2019/20 but implementation may not start till Q4 or 2020/21 Improved patient care and health outcomes. Reduced prescribing spend enabling resources to be invested in prioritised care, new medicines and technology Improved patient care and health outcomes. Get best value out of medicines and pharmacy: Implementing NHSE Medicines Value Programme

144 Providers impacted Service Area Service details Scheme development stage Activity Impact/Outcome Financial Impact How does it link to 5YFV ELFT Medicines Management Develop a model for centralised supply of dressings by community and Tissue viability Nurses. GPs are experiencing significant increased workload generated from the request to prescribe dressings by community nurses. Improved patient care and health outcomes. Reduced prescribing spend enabling resources to be invested in prioritised care, new medicines and technology Improved patient care and health outcomes. ELFT ELFT Medicines Management Urgent & Emergency Care/Integrated Care ELFT to continue to review patients prescribed doxepin for depression in line with NICE guidelines on depression as CG90 does not mention doxepin and advocates SSRIs and newer generation of antidepressants. The CCG expects that prescribing levels are further reduced to levels comparable to neighbouring CCGs. Rapid Response - We will commission a UTC through operating a pilot pathway through the local health community alliance. The requirements will be for the Rapid Response service to re-locate and work to support the ED/UCC with regard to attendances that would be supported by the rapid response service. Continuation from previous CIs Our expectation for is to pilot the pathway and learn from the arrangement. Contract variation. Re-modelling of rapid response service. Get best value out of medicines and pharmacy: Implementing NHSE Medicines Value Programme Contract value is 76,500 p.a. for Newham Hearline Ltd Children and Young People Extension of contract for audio vestibular consultant (AVC) as interim solution while we develop Barts resource within the wider audiology service Initial scoping and exploration between commissioner and provider (Barts) completed Savings may be possible by moving from private provider to NHS provider Intelligent Health Mildmay Mission Hospital Patient and Public Engagement Community Rehab - HIV Development of a bespoke PPG training programme for GPs Build a patient and public voice platform Deliver a series of engagement events to garner public opinion of services. Mildmay and NCCG to ensure outputs of any audit or review of the specialist HIV pathway are incorporated into the BHC developments Mind in Tower Hamlets and Newham, ELFT Mental Health Individual Placement and Support (IPS) mental health and employment NELFT Mental Health Cross-border patients in need of MH services Newham GP Practice and Barts Newham GP practice Diabetes Diabetes Supporting the awareness of the uptake of the National diabetes prevention programme (NDPP), Working in partnership to identify evidence based diabetes prevention strategies Clinical leadership Clinical engagement Supporting uptake of the National diabetes prevention programme (NDPP) & other diabetes intervention programme Clinical leadership Clinical engagement Review of Primary Prevention EPCS This programme is coming to the end of year 1 of a 3 year contract. The PPG development programme is about to commence training at the 10 GP practices identified. It is anticipated that all 10 will be complete by the end of The back end of the PVP is in development. Completion expected October 2018 We intend to review the provision of IPS services across the borough in 2019/20 in order to develop commissioning intentions beyond the period covered by NHSE funding We intend to contract with NELFT to deliver care to Newham-registered patients who live out of borough National service specification written Provider in place Engagement undertaken MOU signed with NHSE including recruitment of staff to support the delivery of the interventions NEL partnership group in place National service specification written Provider in place Engagement undertaken MOU signed with NHSE including recruitment of staff to support the delivery of the interventions NEL partnership group in place EPCS service Targets reached as outlined by national programme Targets reached as outlined by national programme Long term financial gain through delay or prevention of Type 2 diabetes Integrated Care System (Newham Wellbeing Partnership) There is a FYFVMH target linked to the number of people accessing IPS services NELFT will supply services that are mandated by the FYFVMH to Newhamregistered patients Prevention Transforming care, Long Term Conditions Diabetes & TB / JSNA priority

145 Providers impacted Service Area Service details Scheme development stage Newham GP practices Newham GP Practices Diabetes Primary Care Supporting uptake of the National diabetes prevention programme (NDPP) & other diabetes intervention programme Clinical leadership Clinical engagement Review of Primary Prevention EPCS EPCS and LIS: In 2018/19, the CCG commissioned fourteen EPCS: Primary Prevention CVD risk and pre-diabetes Atrial Fibrillation Post-Cardiac Review Diabetes and CVD review Chronic Obstructive Pulmonary Disease Chronic Kidney Disease Mental Health Services Latent TB Cancer ECG Referral Pathway Service The CCG also commissions a Local Incentive Scheme to support practice engagement with monthly cluster meetings, quarterly commissioning events and monthly PM Forum meetings National service specification written Provider in place Engagement undertaken MOU signed with NHSE including recruitment of staff to support the delivery of the interventions NEL partnership group in place EPCS service The impact of this four year programme is required to inform arrangements for 2019/20 and beyond Activity Impact/Outcome Targets reached as outlined by national programme Financial Impact Long term financial gain through delay or prevention of Type 2 diabetes Local tariff payment per service How does it link to 5YFV Prevention Links to demand management to support the shift of services closer to home and away from secondary care to primary care Newham GP practices Primary Care Newham Outcome Measures: These outcome measures/kpis were offered to PMS practices with effect from 1 July 2018, as a result of the PMS review process. They will be offered to GMS and APMS practices on a phased implementation as part of a four year transition process. This programme is currently commissioned from all PMS practices and on a phased implementation from GMS and PMS practices. Following a review of fitness-for-purpose and impact, new Outcome Measures may be substituted for current ones from 2019/20 onwards Local tariff payment Links to General Practice Forward View; Mental Health 5YFV and JSNA health priorities Newham GP Practices (Five or six) Nursing Homes Primary Medical Support Current scheme being reviewed with a view to introduce a transformational scheme that would be open to all care home residents. Care home bed occupancy based on registered beds 143k split between providers based on bed occupancy Care closer to home Newham GP Practices. Newham Health Collaborative Primary Care Provision of language and translation services to patients attending a GP Practice This service is currently commissioned from Language Shop until 31 March 2019 under a Service Level Agreement. Language Shop will be presenting their offer to partners/commissioners in September The CCG intends to commission the contract management of the utilisation for this service from Newham Health Collaborative Local tariff payment for service The Orient Practice (current provider) Newham GP Practices Primary Care Special Allocation Scheme: Under the NHS Primary Medical Service regulations, the CCG (in its role as delegated commissioner) is required to commission a Violent Patient Scheme (VPS) or Special Allocation Scheme (SAS). for its area. Due to the specialist nature of the service and relatively small numbers of patients involved, it is likely that this service will be procured at scale (STP-wide or London wide) Service specification in development and due to be completed by 30 September 2018 Notice to current provider required in September 2018 Service to be procured between October and December 2018 Provider to be appointed in December 2018 Service mobilisation January to March 2019 Commencement of new service 1 April Newham Health Collaborative Urgent & Emergency Care/Integrated Care To operate in the un-scheduled care pilot pathway, testing pathways for patients who are presenting and discharging on un-scheduled care pathways. The CCG will work with the Alliance Agreement Group to develop an unscheduled care pathway which would be evaluated and tested. Reduction in patient Flow in emergency department & urgent treatment centre Integrated Urgent Care

146 Providers impacted Service Area Service details Scheme development stage Activity Impact/Outcome Financial Impact How does it link to 5YFV Primary Care Seven Day Access: CCGs have a responsibility to commission Enhanced Access to General Practice. This is distinct from Extended Access, which comes under a Directed Enhanced Service. Timing of Appointments: Commission weekday provision of access to pre-bookable and same day appointments to general practice services from 6:30pm 10.00pm Commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs. Provide robust evidence, based on rates of use, for the proposed disposition of services throughout the week. Appointments must be provided on a hub basis with practices working at scale. Capacity: Commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to 45 minutes per 1000 population. Measurement: Ensure usage of a nationally commissioned new tool to automatically measure appointment activity by all participating practices, both in-hours and in extended hours Advertising and Ease of Access: Ensure services are advertised to patients, including notification on practice websites, notices in local unscheduled care services and community publicity, so that it is clear to patients how they can access these appointments and associated service. Ensure ease of access for patients including all practice receptionists able to direct patients to the service and offer appointments to extended hours service on the same basis as appointments to core hours services. Patients should be offered a choice of evening or weekend appointments on an equitable basis to core appointments. Digital: Use of digital approaches to support new models of care in general practice, direct booking from GP practices, NHS111 and unscheduled care services. Inequalities: Issues of inequalities in patients experience of accessing general practice identified by local evidence and actions to resolve these put in place. The CCG will have achieved consistent availability of urgent and routine primary care appointments Monday Friday until and at weekends in line with assessed patient need across the entire patient population in a way that integrates with the other Newham Health components of our primary and unscheduled care pathway. Collaborative Primary Care This service is currently commissioned under pilot arrangements until 31 March ,600 appointments per year 1,100,000 This work stream responds to the core requirements of the General Practice Forward View (GPFV) for delivery of Enhanced Access to General Practice and new models of care Newham GP OOH Patient First Social Enterprise Urgent & Emergency Care/Integrated Care Primary Care To undertake a review for face to face and home visiting attendances in the context of meeting national guidelines for integrated urgent care. This review to potentially work at scale across STP to commission a home visiting service. AQP: The CCG has commissioned a number of services to be delivered using the Any Qualified Provider (AQP) contracting route since October The commissioned AQP services are able to deliver a number of predetermined, clinically defined, low-risk procedures as part of these contracts. The four services that are currently included in the contract are: 1. Cardiology 2. Dermatology 3. Gynaecology 4. Minor Surgery Review of commissioning arrangements for hospice care across NEL to ensure equity and in line with doings things once in NEL as appropriate. The CCG will work with the Provider to develop a service model that is aligned to the Integrated Urgent Care model to ensure where appropriate, patients have a face to face appointment with clinicians including where necessary at the patients place of residence. The service model will be provided in an environment that promotes effective care Review of existing arrangements completed in December Service specifications, gap analysis and comms. and engagement plan nearing completion. Reduction in OOH activity Local tariff payment per procedure, per service Current contract value is 147,500 p.a. for Newham Links to Demand management to support the shift of services closer to home and away from secondary care to primary care Richard House Children and Young People Consider inclusion of hospice respite in personal budgets for children Ongoing development of home based hospice offer Hospice at Home is in development. Other schemes are at the scoping phase. Possible savings if review tariffs and allocations across NEL Social Action for Health Maternity Patient and public engagement and support of Maternity Voice Partnership (MVP) Commissioning arrangements for MVPs being reviewed across NEL STP to ensure fit for purpose and best use of resources Current contract value is 22,000 p.a. Possible savings if commission service differently. PPI engagement and support of Maternity Voice Partnerships (as per NEL CIs)

147 Providers impacted Service Area Service details Scheme development stage St Joseph's Hospice The Whittington Health NHS Trust Community End of Life End of Life Care Commissioners to support Newham GPs and Care Homes to improve capacity and confidence through EoL Care to ensure that the community palliative care service is used appropriately and that non specialist palliative care is delivered at GP and Community Nursing level. STJH and CCG to develop its approach to ensure appropriate use of Community Palliative Care and Specialist Children and Young People The Michael Palin Centre -Stammering and Dysfluency Service 2-year contract to be issued to this provider Previously NCA Commissioners from Newham CCG and the London Borough of Newham, wish to continue working with the West Ham Foundation in implementing actions from the Service Development Improvement Plan (SDIP), including; Activity Impact/Outcome Financial Impact Contract value of 54,000 represents a potential saving of 11k on previous years expenditure. How does it link to 5YFV West ham United Foundation Diabetes Social Prescribing. Women's Health and Family Services Maternity Maternity Mates voluntary sector service supporting vulnerable pregnant women in Newham Implementation of the online reporting (IT) system Targeted practice visits to increase the number of eligible referrals coming through the programme Improved and increased marketing of the service to improve uptake Inclusion of Gestational Diabetic patients to the scheme Revised and improved invoicing processes Regular service reviews will enable both commissioner and provider to review the potential of extending the access criteria. Review of outcomes in progress in liaison with Tower Hamlets CCG. to inform commissioning after September 19 The scheme is payable on a block basis with activity chargeable. Block 380k split 50% with LBN. Activity variable tariff Contract value p.a. 90,000. Suggest 10% saving of 9,000 if continue after 09/19. Health Prevention, selfcare and management of LTC Links to better births Maternity 5YFV and providing enhanced and tailored support for pregnant women including those experiencing perinatal mental health needs

148 Service Area Diabetes Providers impacted Service details Scheme development stage General practice Barts Supporting the awareness of the uptake of the National diabetes prevention programme (NDPP), Working in partnership to identify evidence based diabetes prevention strategies Clinical leadership Clinical engagement National service specification written Provider in place Engagement undertaken MOU signed with NHSE including recruitment of staff to support the delivery of the interventions NEL partnership group in place Action (De-commission/ contract variation/issue a new contract/procurement). Delivery of contracted activity Years (start and end) Activity Impact/Outcome Financial Impact How does it link to 5YFV Targets reached as outlined by national programme Long term financial gain through delay or prevention of Type 2 diabetes Prevention Transforming care, Long Term Conditions Diabetes & TB / JSNA priority Diabetes Commitment to review Muti-disciplinary diabetes foot team provision and clinical care pathway Clinical leadership Clinical engagement NEL foot care network in place MDfT bid document produced could be used as a base to understand required provision and gaps Clinical pathway redesign Reduction in variation Long term financial gain through reduction in LOS, admissions and complications associated with foot disease e.g. amputation Integrating care locally, new models of care Transforming care, Long Term Conditions Diabetes & TB / JSNA priority Diabetes Supporting the delivery of NEL Diabetes transformation bid through Clinical leadership Clinical engagement Delivery against milestones The bid includes four interventions Type 1 and young people, pre-conception, virtual patient record reviews and a NEL dashboard To support the redesign of the DSN service provision through utilisation of transformation monies Milestones agreed by providers and executives of trusts Funding secured Governance in place MOUs detailing expected delivery signed for drafted for Re-model / pathway re-design, enhance current provision in each CCG areas, Minimal impact on acute activity Improved outcomes for people living with diabetes Outcome targets improved Reduced variation Shifting of work between settings Increased PBR activity Long term financial gain through reduction in admissions and complications associated with diabetes e.g. blindness, amputation Integrating care locally, new models of care Transforming care, Long Term Conditions Diabetes & TB / JSNA priority Diabetes ELFT Commitment to review Multi-disciplinary diabetes foot team and local care pathway Clinical leadership Clinical engagement in NEL network NEL foot care network in place MDfT bid document produced could be used as a base to understand required provision and gaps Clinical Pathway Redesign Long term financial gain through reduction in LOS, admissions and complications associated with foot disease e.g. amputation TB BHRUT BHT HUH TB Review the service delivery models across 7 CCGs Initial scoping to develop local model of delivery Benchmark against local CCG performance to consider replication Identify gaps in services To be determined Remodel of the service will be required to standardise 2019/20 TBD Currently there is a need to consider the most appropriate model before being able to document the impact TBD Currently there is a need to consider the most appropriate model before being able to document the impact Prevention Transforming care/long term conditions Diabetes and TB Primary Care 148

149 2019/20 High Level Planning and Commissioning Intentions Update N.B These are a high level DRAFT at this stage Warwick Tomsett, Joint Director of Integrated Commissioning Damian Panesar-Gipson, Head of CCG PMO September #TH2GETHER 149

150 Planning and Commissioning Intentions Considerations /20 Tower Hamlets Together (THT) is a partnership of commissioners and providers working towards the shared aim of improving the health and wellbeing of people in Tower Hamlets THT has developed three life course workstreams which have been delegated the task of developing collective, system wide commissioning intentions for 2019/20 and beyond The CCG and the local authority are forging ahead with integrated commissioning, as the best means of meeting the financial challenges ahead and this is supported by the appointment of a Joint Integrated Director of Commissioning to lead this process THT are beginning to move to the alignment of system wide planning and commissioning processes as an enabler to developing integrated system intentions The priority for THT in developing 2019/20 commissioning intentions is to take a collaborative, co-development approach to removing costs out of the system, joining up service delivery, improving quality and moving away from the commissioner-provider split It is acknowledged that this is a developmental year for the THT workstreams in moving towards a system wide joint process to planning and commissioning. 150

151 North East London Commissioning Strategy is currently in development In addition to the local THT system commissioning priorities development, the North East London Commissioning Alliance (NELCA) are developing a commissioning strategy across NEL The strategy will be outlining the overarching vision, strategic priorities and scope of the 2019/20 process to cover NEL, WELC and dovetailing with local commissioning priorities In addition, the strategy will outline the 13 main workstreams across NELCA that will need to have synergy with local plans The strategy is expected to outline a collaborative framework approach to commissioning with the major providers across North East London something which THT has already started with the multiagency workstreams tasked with developing commissioning plans Individual Boroughs should ensure that local commissioning development is in alignment with the overarching NEL commissioning strategy and its 13 work streams, whilst allowing for local interpretation, collaboration and innovation It is anticipated that the commissioning strategy will be coming to the THT Board in October for engagement 151

152 Scene Setting: High Level Principles for THT System Wide Commissioning The following criteria was agreed by THT in June to support the workstreams to develop commissioning ideas 1. All money is public money and that all staff work for the benefit of our local population 2. Every penny counts, that there is no duplication of services between different agencies 3. Services meet the identified needs of our local population 4. We will review and reconfigure services and budgets where necessary to ensure that we achieve the maximum health and care improvements from our collective resources. 5. Start with ensuring that money in the system is being efficiently utilised as there is no new investment and we are expect to see reductions in budgets. 152

153 High Level Commissioning Ideas - THT The following slides outline the high level draft commissioning intentions outputs from the 3 life course work streams and the cross cutting, enabler themes These have been developed during July and August It is clearly acknowledged that this is a snap shot of progress so far and that more work refining and development is needed during the next few weeks 153

154 Born Well and Growing Well high level plans 2019/20 Title High level description Allergy/Asthma/Eczema Maternity and Neonatal system transformation CHC Children's Adolescent Health Early Years language acquisition project Coordinate the care of children with allergy/asthma/eczema, with a focus on reducing admissions to hospital for children with eczema. This programme to address the significant challenges faced in Tower Hamlets and across Barts Health, Homerton and BHR footprints. In addition to optimising the midwife-led pathway, this may involve work on jaundiced babies and follow ups, home birth provision, and strengthening the transitional care community outreach Alignment with adults pathway Development of an adolescent health hub - with a prototype in one of the four localities Inspired by the Well Centre this would initially consist of embedding a GP in a current youth service, running drop in clinics in collaboration with youth workers, sexual health and mental health support and other key partners. Develop he early years language acquisition offer for children in an integrated early years language service offer. Locate Barts Speech and Language Therapists in children s centres for an agreed period each month Hospital at Home Audiology Tier 3 service. Development of a Hospital at Home offer to integrate care between CCNT/Inpatient and Outpatient care To augment the existing T1/2 CHS audiology service we will be looking to market test for an audiologist led - T3 service with consultant input as required. 154

155 Living Well high level plans 2019/20 Title High level description Dermatology Community ENT Direct Access MRI Virtual Biologics Clinic Outpatients MSK Physical activity and nutrition in adults An integrated information offer to support health and wellbeing A strategic approach to social prescribing A whole system approach to reproductive health Outpatient and inpatient episodes coded digestive Health Checks Review secondary care dermatology pathway, increase capacity at Barts Health and explore triage options through ERS and RAS Increase the use of RAS, Advice & Guidance and other virtual models. Explore community ENT options Reduce the number of direct access MRIs Implement a virtual MDT model in the biologics clinic Reduce the number of outpatient appointments through increased use of RAS and Advice & Guidance, and reduce follow up appointments through improved use of technology Review the pathway locally in partnership with Public Health and LBTH obesity pathways as well as linking with the opportunities across WEL. Coproduction of new targeted programme to support physical activity and healthy nutrition in adults Work in partnership across the council, NHS and non statutory sector to align resources to provide people in Tower Hamlets with easy access to information around health and wellbeing and connection to local assets and services (including integrating SPAs and alignment to Mental health information and access processes) Proposal is to take a strategic view of social prescribing and align approaches across sectors (council, NHS and non statutory) link across to Promoting Independence workstream Identifying opportunities to streamline the pathway and potential cost savings. This is the QI project for this workstream. Explore opportunities to redesign the pathway to prevent inappropriate referrals and identify potential savings Review/evaluate/potentially re-scope Health Checks to see how these could be used more effectively for prevention and with a wider focus 155

156 Promoting Independence high level plans 2019/20 part 1 Title High level description Personalisation Developing Care Coordination Continuing healthcare (CHC) Heart Failure Pooled Budgets Domiciliary Care Community services review Review of employment pathways and outcomes Older adults pathways Developing a refreshed personalisation strategy across Tower Hamlet moving towards mainstreaming personal budgets within learning disabilities and mental health. Improve the personalisation offer for adults and children and young people with long term conditions and complex needs, including continuing healthcare and continuing care Revisiting our approach to the commissioning of community based support, Identifying options for sustaining personalisation across the system in 2020/21 and beyond Strengthen integrated care MDT working across the primary, community, secondary and social care interface (QI Project) Block contracting of nursing care home beds (with LBTH) in borough to secure an adequate supply of CHC bed provision (including for discharge to assess D2A) Looking at opportunities for pooled budgets where appropriate Pathway review looking at medicine optimisation and/or proactive patient finding and intervention Explore bed based and domiciliary care pooled budgets Review of existing day services, and information and advice community services including recovery college, well-being and recovery and mental health user led grants; review to inform future model and pattern of services. Procurement required for new services to be in place by July 1st 2019 Review of existing employment services to inform future pattern or services in the context of work path and IAPT Employment advisors pilot; review to inform future model and pattern of services. Procurement required for new services to be in place by Apr- Jul 2019 Initial scoping of the opportunities for developing community provision as an alternative to the current CHC inpatient provision at Thames ward for those with more complex needs associated with dementia. This will primarily explore community support models and an enhanced nursing care offer for this small group of patients. 156

157 Promoting Independence high level plans 2019/20 part 2 Title High level description Social Prescribing Respiratory CHC and Learning Disability Deliver Mental Health (MH) 5 Year Forward View (5YFV) requirements Care at home Improved physical health for those with SMI Accommodation pathways Strategic development, learning disabilities (LD) Transforming Care: Building the Right Support Programme Co-design integrated model of information, advice and social prescribing (linked with Living Well) There is a significant opportunity for Tower Hamlets to improve our spend and outcomes in the area of respiratory. Respiratory nonelective admissions are particularly high, with the two main drivers of this appearing to be obstructive airways disease and influenza and pneumonia. We will be working with system partners to understand why this may be and work collectively to develop plans to begin to address the opportunities that have been identified. Accommodation pathway and spend review Review of mental health crisis pathways in Tower Hamlets to deliver key requirements of 5YFV Increasing skills in home care workforce to provide a range of health interventions Review current delivery against 5YFV, develop workforce, develop monitoring dashboard Review of current resettlement capacity and recommendations for future model LD Partnership Board (LDPB) to meet every 2 months to oversee implementation of Strategy and monitor implementation of delivery plan and outcomes framework Sustain promotion of annual health checks and health action plans and distribution of accessible information about health improvement Review needs of people in registered care out of borough back into borough and plan to bring them back with increased development and use of supported local accommodation Develop a service model to support people with challenging behaviour to participate in local activities Deliver training to staff in all services about positive management of people with challenging behaviour 157

158 Cross Cutting Themes high level plans 2019/20 Title URGENT CARE High level description Urgent Care and 111 Physician Response Unit Frequent Attenders Ambulatory Emergency Care Consolidation of UTC and 111 to increase streaming, assessment and triage into UTC and redirection as appropriate to primary and community care Extension of operating hours to provide out of hospital response, with improved co-ordination with rapid response and admissions avoidance services Implement model for early identification, management and intervention to support medium risk cohort Embed model to investigate and treat patients attending A&E without the need for a hospital admission and reduce potential of becoming complex frequent attenders PRIMARY CARE Primary Care model for the mostly healthy APMS Review PMS Review/Reinvestment NIS Review Homeless Services To implement a new model of primary care for the mostly healthy cohort that utilises digital technology to provide accessible and convenient primary care services Review of General Practice APMS contracts Agree investment against released PMS funds To review the NIS outcomes to ensure they align with the THT outcomes framework Stretch NIS targets to include metrics with broader system impact Implementation of the new service model for homeless services 158

159 Cross Cutting Themes high level plans 2019/20 Title PRIMARY CARE ESTATES High level description Reduction of NHS void space to reduce direct cost to THCCG and the wider NHS Work with practices to reduce the remaining historic debt and other complications Strategic and operational delivery of renewal/expansion of THCCG primary care estate THCCG commissioners to consider estates costs (direct to the particular and indirect to the wider NHS) Resolve historic debt owed to NHS Property Services by working to resolve the outstanding service charge issues at practices Improvement and increased cost effectiveness of primary care in TH. APMS contract renewal to consider estates issues PRIMARY CARE ICT AND INFRASTRUCTURE Update the CV CoIN (N3) to HSCN S106 IT funding for GP Practices EMIS Video Consult Better interoperability within services on the HSCN, greater bandwidth, upgrade the infrastructure from ADSL lines to Ethernet for future proofing of the network Telephony solutions at better value which are fit for purpose Access to Ipad s, patient online, local practice services, PODs for patient registration services, apps that support video communication Enable GP s to adopt remote working practices leading to time saved, patients with barriers accessing GP services to remotely access services equality of access 159

160 THT Commissioning Intentions sign off and engagement timeline Month CI Stage THT Board JCE SFIC Born Well Growing Well August 2018 CI Development September Commissioning Intentions Sign off THT FINANCE SUMMIT RECOMMEND CI SHORTLIST TO SFIC + JCE CI PROCESS SHARE AGREE SHORTLIST CI PROCESS SHARE SIGN OFF CI SHORTLIST (for GB approval) Commissioning Intentions Letters Sign off & Send by end of Sept CI SHORTLISTING WORK ON MEDIUM TERM PRIORITIES SUPPORT BC DEV Living Well CI SHORTLISTING WORK ON MEDIUM TERM PRIORITIES SUPPORT BC DEV Promoting Independence CI SHORT LISTING No meeting October 2018 November 2018 Develop & Sign off Business Cases UPDATE ON SCHEME DEVELOPMENT RECOMMEND BUSINESS CASE APPROVALTO SFIC UPDATE ON SCHEME DEVELOPMENT UPDATE ON BC DEVELOPMENT SUPPORT BC DEV SUPPORT BC DEV Initial business case proposals for savings schemes (QIPP and LA) to be progressed as appropriate REPORT ON BUSINESS CASE PROGRESS SIGN OFF BUSINESS CASES No meeting REFINE 19/20 WORK PRIORITIES SUPPORT BC DEV REFINE 19/20 WORK PRIORITIES Collaborative System Negotiation - Agree QIPP and LA Savings programmes and contract negotiation/changes December ALL BUSINESS CASES APPROVED REPORT ON BUSINESS CASE PROGRESS SIGN OFF BUSINESS CASES REFINE 19/20 PRIORITIES REFINE 19/20 PRIORITIES REFINE 19/20 PRIORITIES Jan 2019 Feb 2019 Contract Negotiations + Submit Operating plan FINALISED QIPP + LA SAVINGS TBA FINALISED QIPP + LA SAVINGS TEST PRIORITIES TBA TBA /20 WORK PLAN TEST PRIORITIES /20 WORK PLAN TEST PRIORITIES /20 WORK PLAN

161 Planning Governance 2019/20 - Sign off process reminder System Management Committee Oversee 2018/19 delivery Receives recommendation from THTB for final sign off Health and Well Being Board Joint Commissioning Executive LBTH CCG (SFIC) Receives recommendations from Workstreams - final sign off for THT Tower Hamlets Together Partnership Board Development of commissioning intentions & workstream endorsement Promoting Independence (complex adults) Living Well (healthy adults) Born Well & Growing Well (Children & young people) Involvement Centre of Excellence User & Stakeholder Engagement Test ideas with the people of TH Workstreams to check off and/or develop ideas with LHWC NE Health & Wellbeing Committee NW Health & Wellbeing Committee SW Health & Wellbeing Committee SE Health & Wellbeing Committee 161

162 Commissioning Intentions - next steps Life course work streams to continue work to refine commissioning intentions (Commissioning Leads) Commissioning leads to review the NELCA commissioning strategy and against local plans to look for synergies, scale and to avoid duplication Business case templates for appropriate savings schemes circulated (CCG PMO/LA) A central master spreadsheet capturing progress of all commissioning intentions to be circulated to commissioning leads (CCG PMO) 162

163 Waltham Forest Better Care Together ICS: During 2018 the Waltham Forest commissioning system have established an Integrated Strategic Commissioning Function from the 1st April This will involve us over the next 12 to 18 months to integrate commissioning portfolios across London Borough of Waltham Forest and Waltham Forest CCG commissioning portfolios in a phased way. Enablers and functions of the Integrated Commissioning Function: Community Equipment Carers Contracting of Integrated Care Systems Registered Care Market Prevention Waltham Forest Integrated Commissioning Function Personilisation Autism Children and Young People Maternity Learning Disabilities Mental Health - Engagement and coproduction - Voluntary Sector Development - Staff Development and Engagement - Contracting Approach and Governance - Contracting for an Integrated Care System - Development of an Integrated Care System Within Waltham Forest the system has formally established three provider led Integrated Care Sub Systems, which are: Communities Integrated Care System, Integrated Urgent Care and, End of Life Integrated Care System. 163

164 Waltham Forest - Journey Towards an Integrated Care System - v.5 System 1 b - Community Care with a focus on discharge support and optimising the use of acute and community beds Integrated provision that re-connects residents to community based care and support following an admission to hospital. Aims to stream patients into the most appropriate pathway depending on their needs and potential for rehabilitation and reablement. High degree of collaboration between professionsals for residents who are likely to need 'transitional' support to maximise independence following an acute episode. Likely that the system will span the interface between acute and community care and that some specialist resources for rehabilitation and re-ablement will be delivered on a partnership basis. The scope of this work includes optimising the use of acute and community beds across the system. Communities ICS with a focus on optimising community care following a crisis or admission to hospital Three Gateways to Community Based Services Communities ICS with a focus on prevention and early intervention (i.e. promoting independence and wellbeing) System 1 a - Community Care with a focus on early intervention and prevention (i.e. promoting independence & wellbeing) Builds on existing Managed Network of Care & Support Includes prevention and early intervention services, as well as planned care pathways delivered by community based health and social care providers/professionals. Aims to keep residents well at home, living as independently as possible. Ambition is to reduce dependence on the 'crisis' end of statutory services, where appropriate. End of Life Care Integrated Urgent Care System 3 - End of Life Care Creates an 'accountable care model' for residents who are approaching the end of life. The system is based on a 'hospice at home' approach and integrates provision across all care settings (i.e. primary, community, urgent/acute and community & voluntary sector). The ambition is to shift the focus away from 'treatment' towards the effective management of symptoms, providing compassionate care in a familiar and supportive setting. System 2 - Integrated Urgent Care (unplanned care) Integrated provision of services where an immediate response is required (e.g. urgent or crisis situations) Aims to deliver highly coordinated services where professionals collaborate to determine the right pathways/outcomes for residents who must be supported without delay. The ambition is to bring together various providers (e.g. NHS111, Rapid Response, OOH, UCC, LAS, appropriate LBWF teams) within a single system that has a shared operating model & some shared governance. Within Waltham Forest each ICS sub-system has a dedicated Senior Responsible Officer from provider organisations and multi-agency, multi-disciplinary leadership teams in place. The partners to these systems include: - NELFT - Barts - Waltham Forest GP Federated Network - LBWF - WFCCG. All partners have signed a Memorandum of Understanding that sets out the principles and approach to working together to develop integrated care systems. Each of the systems have evolving outcome measures and priorities which are detailed below: Urgent Care System The commissioning priority is to procure a single Urgent Care System for the Whipps Cross footprint via a contractual mechanism by April 2018 which encompasses all urgent and emergency care services to support improved clinical and patient outcomes for the system. The agreed objectives of the ICS are: 164

165 The commissioning expectation is that the following services, through a phased process, will be included within the final contract: Urgent Care Centre Rapid Response Services Ambulatory Care Primary Care Extended Access Social Care in ED Admissions Avoidance Team Emergency Department, Minors and Majors (Inc Eye Treatment Centre) Frail elderly assessment service AAU Psychiatric Liaison Service The aim of the ICS is to focus attention on the improvement of key outcome measures that will drive quality improvement within the system. The proposed outcomes are described below: ACS Urgent Care Outcomes Proposed Outcome Rationale Risks/Limitations Next steps 1. Reduced A&E attends per pop. (no increase) Right Patient Right Place Right Time An objective of the ACS is to reduce inappropriate A&E attendances and reduce the pressure on the Emergency Department at Whipps Cross associated within increasing demand Large elements of demand outside the scope of the ACS including routine primary care and social care. Might be easier to target reduction in ED attendances. The WX system population is complicated as it includes Redbridge and Essex. Benchmark ACS performance 165

166 2. Reduced emergency admissions per pop Right Patient Right Place Right Time The WX system population is complicated as it includes Redbridge and Essex. Benchmark ACS performance Reduced emergency admissions is a key measure of quality of patient care. 3. Improved patient experience (across all ICS services) ICS Objective: Quality Not captured consistently at the moment across all services. FFT currently captured in ED but is this a robust metric? TBC / Agree how to measure and implement systems for monitoring 4. Develop the local workforce Proxy measures: Staff satisfaction/ WTE permanent staff/ agency staff rate/ turnover rate ICS Objective: Workforce Alternatives include total WTE workforce employed/ use of agency TBC / Agree how to measure and implement systems for monitoring It is expected that the contract for the ICS will be primarily focused on the achievement of these outcomes, rather than the large number of operational measures that are currently used. End of Life Care Partners in Waltham Forest have developed a vision for improving care and choice at the end of life, so that: the system is better able to recognise patients approaching the end of life, record their wishes and provide care that enables their wishes to be met, allowing more to die in their preferred place of death; the general community nursing offer is enhanced and integrated with specialist nursing; there is 24-hour access to clinical advice at an appropriate level; care is well co-ordinated around patients and avoids delays in transfers of care at the end of life; generalist community and primary care services are supported to deliver end of life care, in particular GPs and care homes; and the whole end of life care system is brought together in Waltham Forest to maximise the impact of its component services. A Memorandum of Understanding has been agreed and signed by all partners on how new investment will be managed to improve outcomes for patients across the system and identify benefits for further integrated systems. Communities The communities Integrated Care System is the largest and most complex system developing in Waltham Forest which encompasses a significant area of commissioning 166

167 spend and provider delivery. This system covers a wide range of statutory provider services from both health and social care but also the voluntary sector and registered care market. The pathway and system re-design priorities include: Mainstreaming and connecting community prevention pathways, Supporting a stable residential care market, Developing an integrated rehabilitation & reablement system, Managing transfers of care, Developing safer homes and hubs and networks. Some of the anticipated system benefits to this system include: Improved outcomes for our target populations of 18+ who have ongoing complex support needs which require input from a range of stakeholders and/or our care and support workforce who predominantly live and work in Waltham Forest Value peoples independence and recognises individuals wants and needs Ensuring our residents are well, independent, safe, resilient & prospering Active investment in local communities to enable residents & families to support and help themselves Maximising residents ability to live independently in their own homes by delivering joined-up care & health services in the community Home first ethos No assessments for long term care in an acute setting Support people to stay at home and reduce dependence on unplanned acute episodes 167