LEICESTER, LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUPS OPERATIONAL PLAN

Transcription

1 LEICESTER, LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUPS OPERATIONAL PLAN Final 23 rd December 2016 NHS East Leicestershire and Rutland Clinical Commissioning Group NHS Leicester City Clinical Commissioning Group NHS West Leicestershire Clinical Commissioning Group

2 Contents Foreward 3 Challenges 4 Key Actions 5 Finance 6 Activity 9 Quality 11 Engagement 15 Workforce 16 Governance 17 Project Documentation for key actions 18 Appendicies Appendix 1: Mapping of the Nine Must Dos Appendix 2: ning Trajectories Appendix 3 Risk and Mitigations Appendix 4: General Practice Five Year Forward View Operational

3 Foreward Our organisations commission and provide health and care services for over a million people in Leicester, Leicestershire and Rutland. Every day our services support people to stay healthy and lead independent lives. When people are ill our services are there for them, their carers and families. Over the next five years, the services we are accountable for will need to adapt and transform in order to ensure that they remain clinically and financially sustainable. How we will do this is set out in our Leicester, Leicestershire and Rutland Sustainability and Transformation (STP). The latest version of our STP sets out the actions that we will need to take in order to balance the various pressures of continued growth in patient demand from an ageing and growing population, a requirement to recover and maintain delivery against national access and quality standards, at a time of historically low levels of financial growth in the NHS and substantial pressures on social care funding. Our STP builds on the work of our Better Care Together programme, the plans of which were already well advanced and articulated in many areas. This Operational s for 20 and 20 set out how Leicester City CCG; East Leicestershire and Rutland CCG; and West Leicestershire CCG will work together with provider and local authority partners to deliver the next two years of the STP. The financial challenge facing the NHS nationally over the next five years is well recognised. In LLR we are no different and in order to achieve system and organisational financial control totals over the next two years will require considerable transformational change. To achieve this we need to work together as a system while at the same time ensuring a tight grip on each CCG s financial position. Our governance arrangements for delivery of both transformational change and QIPP are set out in in this plan, (page x). Our drive is to deliver high quality care and as a result of the actions set out in our STP and this Operational we would expect by 2020/21 that: Patients will have more of their care provided in the community by integrated teams with the GP practice as the foundation of care. Patients will only go to acute hospitals when they are acutely ill or for a planned procedure that cannot be done in a community setting. More people will be encouraged to lead healthy lifestyles to prevent the onset of long term conditions. Screening and early detection programmes will enable more people to be diagnosed early to enable improved management of disease and to reduce burden. Professionals will have access to a shared record to improve the quality and outcome of patient care. General Practioners will increasingly use their skills to support the most complex patients and routine care will be delivered by other professionals. General Practice will be increasingly working in networks to improve resilience and capacity. The system will be in financial balance and be achieving its performance Services will be delivered from fit for purposes premises. Sue Lock Managing Director Leicester City CCG Karen English Managing Director East Leicestershire and Rutland CCG Toby Sanders Managing Director West Leicestershire CCG 3

4 Challenges The challenges that LLR face are detailed in our STP where we have undertaken an analysis to identify solutions, against the three gaps of health and wellbeing; care and quality and finance and efficiency. Many of these solutions require implementation in the next two years and as such form part of our Operational for 20 and 20. A summary of these gaps and challenges are set out below. NHS Constitutional Standard Performance As a system there are a number of NHS Constitutional targets where performance remains below expectation. The areas are: A&E 4 hour target Ambulance Response Times Ambulance Handover Times Cancer 62 day wait The plans to address this under performance are part of the key action section of this Operational. There will be ongoing focus to ensure continued compliance with the 18 week referral to treatment time and that demand can be effectively managed. Health and Wellbeing There is variation in health outcomes, including life expectancy, across LLR. Much of this variation is in areas that are affected by life style, early detection and ongoing management of long term conditions. Our solutions around Integrated Teams and Long Term Conditions and Cancer should support improvements in these areas. Care and Quality We have identified that we need to make improvements across a number of areas which are addressed in this Operational including improving independence; ensuring primary care is more resilient; improving outcomes for mental health and continuing to work with providers that are rated as Required Improvement by the CQC. Finance and Efficiency In order to achieve system and organisational financial balance in 20 and 20 there is a QIPP requirement of 50m in 20 and 42m in 20. The key actions within this plan set out how this will be achieved. 4 Getting contracting right to enable deliver STP There is a commitment across the CCGs and main providers within LLR to seek to change the terms of trade in order to align more effectively the incentives across all parts of the system. Effectively what we are seeking to do is construct a local two year system deal that hardwires the distribution of the LLR pound to the strategic transformation model and direction set out in the STP. This would result in substantially lower levels of financial growth over the period into the acute hospital sector than has been the case over the recent years in order to enable a greater proportionate shift of resources into primary care and out of hospital services. Seeking to develop such an approach will require a balance to reflect the relative control over the drivers that impact on demand and delivery. Many of the plans set out in this Operational will support this approach including ned Care and Urgent Care.

5 Key Actions The key actions set out in this Operational are designed to deliver: The STP solutions to close the financial gap (20 and 20); and Address the Nine Must Dos in the ning Guidance. The Operational is aligned with our STP including solutions, finances and workforce. Given the alignment to the STP we are working collaboratively across the three CCGs in development of this joint Operational. Therefore the majority of the key actions set out in this section of the plan are LLR wide and as such all three CCGs are working together to implement and deliver these. For each key action we have developed a high level Project Document which sets out the key deliverable; outcomes; baseline activity and trajectories (where this is appropriate); investment required; savings to be achieved; activity changes; and a high level plan. Each key action is detailed in a Project Document at the end of this. The key actions have been through a confirm and challenge session to ensure the robustness of the plans. The majority have detailed project plans and or business cases in place. The focus now is to concentrate on the implementation and delivery of the key actions. Each of the key actions has a lead CCG and it will be their responsibility to implement and deliver on behalf of all three CCGs and the LLR system. To support this each key project has a Chief Executive/Accountable Officer lead; an Executive SRO; a clinical lead(s) and an implementation manager. More information on our governance can be found in later in the plan. A Programme Management Office is also in place to support delivery and provide information to partners on progress. In addition at a system level the new System Leadership Team made up of Chief Executives/Managing Directors from across the health sector together with clinical leaders from the NHS organisations and very senior representation from Local Authorities which will oversee delivery of the STP solutions. At a CCG level the delivery of the QIPP schemes set out in this Operational will be overseen by the LLR QIPP Delivery Board which is made up of Executives from each CCG. Where progress is not on track than this will be reported to the System Leadership Team. The following table gives an overview of how the key actions map to the STP solutions and the Nine Must Dos. More detail on how our plans map to the Nine Must Dos can be found in Appendix 1. LLR Key Action STP Must Do LLR1 ned Care LLR2 Home First LLR3 Urgent Care LLR4 Integrated Teams LLR5 Primary Care LLR6 Medicine Optimisation LLR7 CHC LLR8 Cancer LLR9a Adult Mental Health LLR9b Children Mental Health LLR10 Learning Disabilities LLR11 Long Term Conditions LLR12 Childrens, maternity, neonates LLR13 End of Life Care LLR14 SelfCare & Prevention LLR15 Reviewing minor services LLR16 CCG Efficiencies LLR17a Acute Reconfiguration LLR17b Community Hospital Reconfiguration 5

6 Finance This section outlines the financial plans for West Leicestershire CCG, East Leicestershire and Rutland CCG and Leicester City CCG for the financial years 20 and 20. It outlines the context within which the plans have been produced and also provides specific details on plans for investments and savings. It provides confirmation that the CCGs intend to deliver financially against key NHS England requirements. Overall, since the (Leicester, Leicestershire and Rutland) LLR CCGs operate within limited financial budgets, they have a duty to ensure that allocated funds are spent on efficient and effective health care services for the population ensuring value for money and appropriate use of NHS funds. Context All of the health and social care organisations in LLR face financial challenge, as demand and demographic growth for services outstrip the increased resources available year on year. Without developing new ways of working the impact of increased demand creates a financial gap for health and social care across LLR of 399.3m by 2020/21. The health gap is 341.6m and the social care gap is 57.7m. The LLR system has been aware of this continuing demand and resource gap for some years and has produced a 5 year Sustainability and Transformation (STP), the latest draft version of which was submitted to NHS England on 21 st October The CCGs two year financial plans represent the detailed plans for years 2 and 3 of the STP. The Financial In line with NHS England requirements for 20 and 20, the CCGs plan to deliver against all business rules: A minimum cumulative 1 surplus Investment into mental health services at least in line with our allocation growth ( parity of esteem ) Holding an uncommitted contingency of fund half to remain uncommitted and half available for nonrecurrent investment Remain within Running Cost Allocation Delivery of significant QIPP savings to fund required investment The table below summarises, at a high level, the increased funding which the CCGs will receive in 20 and 20 and how it is utilised in the current expenditure plans: 6 Financial Summary 20 LC CCG ( 000) WL CCG ( 000) ELR CCG ( 000) Recurrent Baseline 9,087 9,105 7,329 Growth CoCommissioning 1, Growth Reduction in running costs allocation (10) (3) (12) Non recurrent 68 (1,805) 291 allocations Impact of HRG4 1, (158) Impact of IR Changes (1,264) (1,611) (1,362) NET CHANGE IN 10,698 6,888 6,501 FUNDING Recurrent Impact 5,243 5,031 5,505 from 2016/17 Demographic Growth 2,683 3,088 1,904 Non Demographic 8,259 9,351 7,461 Inflation 7,559 7,179 6,229 Efficiency (7,199) (6,839) (5,932) QIPP (22,420) (19,198) (16,801) Cost Pressures 11,383 3,444 3,984 Increase/(Decrease) in (541) surplus Investments: QIPP Other 3,064 2,356 1,991 Replacement of 2,483 2,378 2,066 Contingency Reserve Increase in 1 Fund Change in CQUIN 71 (33) (13) NET CHANGE IN 10,698 6,888 6,501 EXPENDITURE

7 Financial Summary 20 LC CCG ( 000) WL CCG ( 000) ELR CCG ( 000) Recurrent Baseline 8,677 8,758 7,247 Growth CoCommissioning 1, Growth Reduction in running costs allocation (12) 0 (10) Non recurrent (968) 1,278 1,479 allocations Impact of HRG4 1, (160) Impact of IR Changes (1,285) (1,636) (1,384) NET CHANGE IN 9,571 9,707 7,749 FUNDING Recurrent Impact (968) 1,243 1,177 from 20 Demographic Growth 2,685 3,084 1,909 Non Demographic 9,194 8,702 6,731 Inflation 7,638 7,156 6,227 Efficiency (7,274) (6,815) (5,931) QIPP (17,199) (15,914) (14,262) Cost Pressures 15,043 11,797 11,544 Increase in surplus (400) Investments: QIPP Other Movement of Contingency Reserve Increase in 1 Fund Change in CQUIN (68) (96) (91) NET CHANGE IN EXPENDITURE 9,571 9,707 7,749 Quality, Innovation, Productivity and Prevention (QIPP) Last year the LLR CCGs planned, implemented and delivered a number of QIPP schemes. These were designed to change various elements of care pathways in order to improve either quality of care, productivity or prevention. A number of the schemes were designed to change services in such a way that funds could be moved from one care setting to another or from one service to another and in so doing, delivering increased volume and or quality of care for the same cost. The STP requires an unprecedented level of QIPP savings in 20 (c 51m c3.6) and 20 (c 46m c3) to be delivered across LLR CCGs to support financial stability across the system. These schemes are intended to involve service transformation such as New Models of Care, Service Configuration and Redesigned Pathways. QIPP projects have been developed in partnership across LLR as part of the STP process and have undergone a rigorous challenge process to ensure they are clinically safe, move the CCG towards its goals and have been developed in conjunction with the local clinicians. 7 There is 7.6m of unidentified QIPP within the LLR plans for 20. During the financial year further work will be undertaken across LLR to identify new schemes to mitigate this shortfall. A list of potential new QIPP schemes is in place and will be further developed over the coming months. Investments Due to the financial challenge faced by the CCGs there is little funding available for investments during 20 and 20. The majority of investments will be spent in the following 4 areas: To reinstate the 0.5 contingency reserve to manage risk during the financial year. To achieve the General Practice 5 Year Forward View To support the delivery of QIPP savings To achieve mental health parity of esteem and make suitable transformation of Mental Health services

8 Other assumptions The LLR CCGs financial plans are aligned with latest planning guidance received from NHS England and others, specifically including the following: Tariff Inflation is applied at a net level of 0.1 for both financial years. Whilst BCF plans for and are in the final stages of agreement, all CCGs have assumed the minimum level of funding will be fully spent. CHC Non demographic Growth has been based on historic levels of growth preqipp. Acute growth has been calculated to account for demographic changes. Nondemographic growth is also factored into these plans to reflect the ageing population and the impact this has on healthcare required. this is nearly double of the savings generated in recent financial years. Mitigation against this and other financial risks within the plan is as follows: A 0.5 Contingency will be set aside to guard against adverse risks Further QIPP schemes will be developed and implemented during the financial years to ensure delivery of the required surpluses 1 Nonrecurrent funds will be set aside and half will remain uncommitted until the CCGs are satisfied that risks are successfully being managed. Risks and Mitigations The major financial risk is the delivery of QIPP at the targeted level 51m across LLR CCGs 8

9 Activity LLR CCG Activity plans have been developed using the NHSE process via the plan build template. 2016/17 national forecast outturn and growth calculated by the template 2015/16 outturn. Activity then has been taken out by Point of Delivery (POD) by QIPP scheme. The following table sets out the schemes that have an impact on acute activity by POD: Scheme Key Action POD Reduction in Outpatients and Follow Up across 20 across 32 specialties Low Priority Treatments LLR1 ned Care LLR1 ned Care LLR1 ned Care EM 7 All referrals G&A EM 8 all 1 st OP consultant appointments EM 9 Follow up consultant appointments EM 7 All referrals G&A EM 8 all 1 st OP consultant appointments EM10 total elective spells Day Case and Inpatient EM 9 Follow up consultant appointments Scheme Key Action POD Reducing further followups Reducing activity in low value treatments Urology Remote Monitoring Cardiorespiratory Integrated Team Stroke/Neuro Rehabilitation MH triage Car Eye Casualty Inter practice Referrals BCF Rutland PINCER Meds optimisation Children s Short Stay Admissions Children s Short Stay Admissions Primary Care LLR 1 ned Care LLR1 ned Care LLR 11 Long Term Conditions LLR Long Term Conditions LLR 3 Urgent Care LCCCG specific scheme WLCCG Specific Scheme ELRCCG Specific Schemes 9 EM 9 Follow up consultant appointments EM 9 Follow up consultant appointments EM11 Non Elective Spells EM11 Non Elective Spells EM12 A&E Attendances EM12 A&E Attendances EM7a GP Referrals EM 8 all 1 st OP consultant appointments EM11 Non Elective Spells Scheme Key Action POD Vanguard Stream 1 activity changes at A&E / front door ED / LRI Streaming reduction green ambulance 50 previously transferred currently 11 of OOH advice told to attend A&E currently 6 of home visits from OOH LLR3 Urgent Care EM11 Non Elective Spells EM12 A&E Attendances Below summarises by CCG the percentage change by each POD against the 2016/17 FOT demonstrating the shift in activity and the impact of the planned QIPP. Our plans have been through an assurance process with NHS England.

10 Leicester City CCG West Leicestershire CCG East Leicestershire and Rutland CCG Code Activity Line Annual Annual Growth 16/17 FOT to to Forecast Growth E.M.7 Total Referrals (General and Acute) 102, , E.M.7a Total GP Referrals (General and Acute 71,920 73, E.M.7b Total Other Referrals (General and Acute) 30,287 27, E.M.8 Consultant Led First Outpatient Attendances 95,604 95, E.M.9 Consultant Led FollowUp Outpatient Attendances 155, , E.M.10 Total Elective Admissions 36,374 38, E.M.11 Total NonElective Admissions 38,625 38, E.M.12 Total A&E Attendances excluding ned Follow Ups 124, , Code Activity Line Annual Annual Growth 16/17 FOT to to Forecast Growth E.M.7 Total Referrals (General and Acute) 119, , E.M.7a Total GP Referrals (General and Acute 78,365 80, E.M.7b Total Other Referrals (General and Acute) 41,374 40, E.M.8 Consultant Led First Outpatient Attendances 96,640 96, E.M.9 Consultant Led FollowUp Outpatient Attendances 178, , E.M.10 Total Elective Admissions 44,422 46, E.M.11 Total NonElective Admissions 34,779 35, E.M.12 Total A&E Attendances excluding ned Follow Ups 79,601 80, Code Activity Line Annual Annual Growth 16/17 FOT to to Forecast Growth E.M.7 Total Referrals (General and Acute) 102, , E.M.7a Total GP Referrals (General and Acute 68,136 69, E.M.7b Total Other Referrals (General and Acute) 34,659 34, E.M.8 Consultant Led First Outpatient Attendances 83,132 80, E.M.9 Consultant Led FollowUp Outpatient Attendances 151, , E.M.10 Total Elective Admissions 41,570 43, E.M.11 Total NonElective Admissions 28,575 28, E.M.12 Total A&E Attendances excluding ned Follow Ups 117, , Activity in this plan will be expressed in Point of Delivery, as follows: EM7a EM7b EM7 EM8 EM9 EM10 EM11 EM12 GP Referrals (G&A) Other Referrals (G&A) Total Referrals (G&A) All 1 st Outpatients Consultant Led Follow Up Outpatient Consultant Led Total Elective Spells (Inpatient and Day Case) Non Elective Spells A&E Attendances excluding follow up 10

11 Quality The aim of Leicester, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCG s) is to commission high quality, safe and effective health services that meet the needs of our people; to ensure that the right services are commissioned for patients to be seen at the right time, in the right place by the right professional. In relation to quality we encompass the three equally important parts that include: Care that is safe, Care that is clinically effective and Care that provides a positive experience for people. Our focus is on the following areas. Patient Experience: Ensure the patient and service user voice and improving patient experience is considered using various methods to engage with the public, patients and carers to receive feedback about the commissioned services that includes: Experience Led Commissioning (ELC) to codesign new services and inform the new service procurements. Receive and review monthly complaints reports and review quarterly patient experience reports to identify areas for improvement by providers. Monitor the contractual requirement in respect of Duty of Candour for all Patient Safety Incidents where there has been moderate or severe harm. Undertake as part of the NHS Standard contract and quality requirement regular quality visits to our provider organisations that will include review of patient experience utilising our CCG Patient Leaders. Use markers of patient experience within general practice such as national patient experience survey and NHS Choices to triangulate data and inform actions for improvement. Work collaboratively with our Health and Wellbeing Boards via the Enter and View visits to gain an understanding of patient experience and actions for improvement. Patient Safety: Ensure a commitment to improve collaboration to multiagency working across health and social care to address patient safety concerns for patient safety incidents and a patient safety culture across all our providers of services. In addition we will: Via the Learning Lessons to Improve Care (LLtIC) work to ensure system wide clinical leadership across the health community to lead and drive safety, support the patient and staff engagement, listening and action, continue the drive for effective care across interfaces between providers of health services, focus on transforming emergency care in our wards, hospitals and communities, and transforming End of Life Care (EoL). Monitor Serious Incidents from our providers to identify any safety concerns or harms in light of the current system issues and pressures on our local urgent care system that includes in particular the LRI Emergency Department and EMAS provider. Participate in the annual publication of findings from reviews of deaths including the annual publication of avoidable death rates and actions to reduce deaths related to problems in healthcare. Infection Prevention and Control: Work in partnership with infection prevention teams across the local health economy to implement established measures and develop innovative methods to ensure the incidence of healthcare associated infection is reduced to achieve the best outcomes for our population and keep them safe. We will: Focus on antimicrobial prescribing across our range of providers and compliance 11

12 with the LLR antimicrobial resistance strategy. Review investigations into incidents of C Difficile and MRSA to ensure that learning is incorporated into business as usual and changes made to practice. Continue to work towards a zero tolerance ambition of MRSA bloodstream infections. Work with our colleagues across public health, primary and secondary care, and social care on reducing key infections such as community acquired pneumonia, urinary tract infections and sepsis. Provide a focus for improvements in the recognition, management and reduction in HCAIs. Ensure training and education in infection prevention and control, and medicine optimisation via support of our Care Home Pharmacist to reduce incidents of HCAI s. Ensure antibiotic stewardship lead across each CCG. Ensure all providers implement the Sepsis guidelines and tools to ensure early identification and management. Safeguarding: The LLR Chief Nurses will be supported with their statutory duties in safeguarding by Designated Nurses, a Designated Doctor and the LLR CCG Hosted Safeguarding Team. In 20 our safeguarding priorities will include: Assurance that there are a range of services in place to safeguard children and adults, evaluated by the CCG s using suite of monitoring tools supported by audit. Assurance via regulated inspections e.g. CQC. Working with providers to ensure that we have multiagency collaboration and communication in place. Ensuring the performance monitoring of the safeguarding vulnerable people element of the NHS Contract (SC32 Safeguarding, including PREVENT) is delivered by health provider organisations. Supporting the Safeguarding Children and Adult Board programme groups and work streams (supporting the delivery of LLR Children and Adult Boards Business s). Support patients subject to DoLS and CoP requirements. Workforce and Organisational Development: The LLR CCG s will continue to drive a new generation within the health and social care workforce to work across organisational boundaries, and with a greater focus on out of hospital service and integrated working. In response to workforce challenges we will: Establish a clear baseline of our current workforce and undertake workforce modelling and capacity planning. Getting the detail right by reviewing and refining the skill mix of teams to better understand the types of work that needs to be done in new settings to better enable, people to move around the system quickly efficiently and effectively. Implement the LLR General Practice Nurse Recruitment and Retention Strategy PreRegistration Nurse Placement, Return to Practice Scheme, Rotational Placements, Developing Advanced Nurse Practitioner role, and Assistant Practitioner (HCA) role and Nurse Associate Role and their development facilitated by the LLR Training Hubs led by General Practice. Provide an annual General Practice Nursing Conference. Demonstrate nurse leadership in the STP via the new nursing framework: Leading on Change, adding Value, with focus on: health and wellbeing, care and quality and funding and efficiency. 12

13 Promote System Workforce development (UHL and LPT work), Piloting the New Nurse associate role, to include HCA from General Practice. Support training for General Practice Nurses. Research and Innovation: LLR CCGs will meet its statutory responsibilities to promote research and innovation, to use research evidence and to follow policy with respect to excess treatment costs for noncommercial research studies. The participation of local patients in funded research will be supported through an R&D Office, which hosts a service for the three Leicester, Leicestershire and Rutland (LLR) CCGs. We will work closely with the regional Clinical Research Network (CRN) to support study delivery. All East Midlands NHS R&D Leads, and Primary Care Research and Innovation Leads meet regularly to discuss research progress across the region, resolve any issues and share developments in the Health Research Authority s Approval process. Primary Care Quality: We have adopted a holistic approach to monitoring quality in Primary Care; which has been designed to develop an environment where learning from both success and adverse events can be shared with the aim of continually striving to improve the quality and experience of healthcare for both patients and our Primary Care workforce. A key area of learning has been from our General Practice that have been in Special Measures following CQC reviews, and where we have developed support and programmes to ensure practices understand and develop robust clinical governance, systems and process to demonstrate services that are well led and of high quality. We will: Promote and Support the Supporting Vulnerable Practices programme that will offer insight to human factors and driving improvement through leadership and positive culture for quality improvement. Utilise our governance arrangements that are in place within each CCG for Information Sharing with NHSE to enable a systematic process for the determination of risk in General Practice relating to quality and safety. Reward our practices via the Quality and Outcome Framework (QOF) for the provision of quality of care and helps to standardise improvements in the delivery of clinical care. Utilise our Primary Care Quality Dashboards: that provide a high level view of an individual practice in terms of quality and safety. 13 Utilise our clinical leads for General Practice both medical and nursing to drive and champion continuous quality improvement and clinical governance in General Practice. Contract Quality Assurance: In 20 and 20 and as part of the LLR STP we will lead on and drive continuous quality improvement in our new and emerging service developments and at the same time maintain our robust quality monitoring and assurance processes of our existing services to ensure provision of high quality services across LLR. We will: via the Commissioning for Quality and Innovation (CQUIN) Payment Framework: drive quality improvement that focuses on system working, and integration. via the Contract Quality Review process ensure robust monitoring of all provider organisations via the Quality Schedules to ensure compliance with essential standards of care and quality focusing on particular: Safer Staffing and staffing shortages, waiting delays in the urgent care services, waiting list delays in UHL and Pressure Ulcer care.

14 undertake both announced and unannounced Quality Visits of all our provider organisation to ensure direct sight of patient care and patient experience. support organisations to improve in the event that they are subject to CQC special measures. Urgent Care Support the urgent care activities for physical and mental health to reduce pressure across the system ensuring that patients and services remain safe. Patient Care Work with commissioning support unit to ensure high quality services for patients requiring continuing healthcare and SEND. Lead Care and Treatment Reviews to ensure effective implementation of the Transforming Care agenda, working to reduce inpatient capacity by March 2019 to

15 Engagement There are a number of transformational schemes within our STP that will require consultation during the next two years. The key consultation topics will be: Changes to community hospital reconfiguration as a result of a Home First approach including site specific proposals. Changes to acute reconfiguration, including the impact of care closer to home and separating planned care from emergencies. Changes to maternity services, moving obstetric led care to one site (Royal Infirmary); a midwife led unit colocated at the Royal Infirmary; and views on a midwife led standalone unit at the General Hospital. Engagement has been integral to the STP process and the associated Better Care Together Programme (BCT). A wide variety of stakeholders have been involved ranging from statutory bodies, elected officials, local authorities, the voluntary and community sector, right through to patient and public groups. During spring of 2015, a large scale public campaign was launched across LLR which explained the current position of health and social care services in the area, and to ensure that the priorities of the local communities and other stakeholders, matched the direction of travel of the BCT programme. Over 1000 responses were received, and a population reach of over 375,000 was achieved through various engagement techniques. The data was used to inform our proposals for change. Our wider engagement has included: s shared with partner boards. Commissioning of voluntary sector to engage with each of the protected characteristics. Patient and Public Involvement representatives via monthly meetings and the wider patient and public involvement network, and the Leicester Mercury Patients panel. Voluntary, Community and Faith sector networking events and virtual forum. Staff engagement events, briefings, protected learning time, and a dedicated staff webpage. Briefings for councillors and MPs. Public facing website and associated social media for people to feedback on and interact with. Regular updates and briefing at Health and Wellbeing boards and HOSC s. Timescale for formal consultation Once we have received formal feedback from NHS England on our STP we will commence the process of moving towards formal consultation on the proposals. The key dates are detailed below. Action Date Formal approval of STP by Boards Complete Publish STP Complete Prepare consultation materials Winter 2017 Commence consultation February 2017 Finish consultation April 2017 Consider responses Spring 2017 Proposals to partner Boards Summer 2017 Commence implementation Summer 2017 The consultation will comprise of the following activities: LLR wide advertising (radio, billboard, social media and newspaper) An electronic, paper easy read version of the consultation document Programme wide level briefings across LLR to key stakeholders Public events and engagement at both a programme wide and community level.

16 Workforce The transformation change set out in our STP and the two years of implementation set out in this Operational will require significant change to the workforce in LLR. As part of the BCT programme each workstream has identified the workforce issues and challenges and our Workforce Strategy sets out how we will respond to these. Our Workforce Strategy has been developed by the BCT Workforce Group who have worked closely with Health Education England East Midlands as part of regional approached and programmes, as well as determining local activity and solutions to respond to the challenges we face. The challenges we face are common with the national picture and include: An ageing workforce Recruitment and retentions issues Attracting people into certain roles across health and social care New models of care requiring new roles Demand for workforce is growing faster than population The need to work across boundaries to support new models of care. The following changes will continue to be refined and tested as we go through implementation. Workforce Implications of our plans (5 years) Change in Numbers Urgent Care Integrated Teams 120 in acute Primary Care 154 over 4 yrs 77 for 7 day services 166 in community 24 GPs 211 Other Service Reconfiguration To be confirmed ned Care 1433 in elective and therapy 24 in Alliance Change in Roles Increase in ECPs and ANPs Use of specialists in the community and more foundation level roles Increase in ANP; ECP and Physician Assistant roles Increased use of pharmacist in practice Change in Numbers Learning Disabilites 18 4 bed reduction Mental Health Adults and Children 17.3, mental health triage; CAMHS; HLP Long Term Conditions 113 across LTC Overall Impact Primary care up /17 (2271) and 2020/21 (2505) Change in Roles Provider down /17 (19805) and 2020/21 (18169) 16

17 Governance To deliver the plans set out in this Operational requires strong leadership during the implementation phase to ensure plans are delivered and at the right pace. There are different levels of governance that are in place within LLR to ensure delivery. At a system level: The overall delivery of the STP will be overseen by a new Senior Leadership Team made up of Chief Executives from providers; CCG Managing Directors; very senior representation from local authorities; and a clinical lead from each of the NHS organisations. It is intended to have a member from the SLT overseeing the delivery of key schemes outlined in this Operational and the STP. This will be determined at the December 2016 meeting of the SLT. At a scheme level each has: A member of the System Leadership Team (SLT) having responsibility for overall delivery (for key schemes), post SLT December 2016 meeting. An Executive Senior Responsible Officer to ensure conditions for delivery. For clinical workstreams there is a lead clinician and in some schemes such as Long Term Conditions there are clinical leads from primary and acute. An implementation manager to oversee the day to day implementation of the scheme. A group that oversees the development and implementation. The Better Care Together/STP PMO is in place and in the future they will monitor progress of delivery and report this to the System Leadership Team. At CCG Implementation level: Each CCG has a lead area of responsibility on behalf of the three CCGs and is responsible to delivering the LLR schemes that relate to that area. For example Leicester City CCG lead on ned Care; West Leicestershire CCG lead on Integrated Teams; and East Leicestershire and Rutland lead on Continuing Healthcare. Where there is a risk of delivery than escalation will take place through the PMO arrangements already described to the System Leadership Team. A LLR QIPP Group meets on a monthly basis to monitor progress against QIPP schemes and to take corrective action where necessary or escalates to the Managing Directors Meeting. This group is made up of Executives from the three CCGs. Each organisation has processes in place to assure delivery which feeds into the monthly LLR QIPP meeting. Once a month QIPP delivery is discussed at Managing Directors meeting to ensure corrective action can be taken quickly if needed. A LLR QIPP tracker is in place which is used to monitor progress both by individual organisations and the LLR QIPP group. 17

18 Priority: LLR 1 ned Care Nine Must Do STP Priority Relationship to other plans: QIPP Opportunities Key Deliverables: The ned Care worksream will focus on 34 specialities over the next four years: Reducing demand of New Outpatients: driving down secondary care demand for new outpatients referrals by 20 through the use of referral management tools (i.e.prism), Advice and Guidance, development of a LLR referral and triage hub focused on the high demand specialities and pathway redesign. Reducing Outpatient FollowUps: driving down Outpatient followups by reducing clinical variation, removing unnecessary followups, using virtual clinics, non face to face appointments and through open access referrals. Low Value Treatments: reducing activity in areas of Low Clinical Priority and Low Value treatments through review of existing policies, identification of additional low priority treatments and the consistent application of policies. Pathway redesign: moving activity into lower cost settings either in community or primary care to deliver care in the right setting and ensure utilisation of community assets. In 20 and 20 the plan is to work on 12 specialities (34 over four years). This will include ensuring diagnostic support if available in the right place. RTT: continue to deliver the NHS Constitution for Referral to Treatment Times, using our Cancer and RTT to drive delivery. Integrated MSK Physiotherapy Services: development of an integrated (acute and community) MSK Triage and Treat Hub to include all MSK and Spinal triage. This will improve wait times; improve efficiencies in the service and deliver savings of 1.2m across LLR. Demand Management s: Demand Management s which set out actions to reduce GP elective referrals. Many of the actions are part of our ned Care work and are detailed above. In addition, there is a focus on working with General Practice to peer review referrals; increasing awareness of wait times and alternative providers to enable them to support patient choice; and with patients to support their decision making on which provider to choose. RightCare: The three CCGs will be part of the Wave 2 RightCare programme. Having reviewed the refreshed October 2016 Commissioning for Value Packs the priority areas for LLR in relation to planned care are shown below, we will use this to prioritise our planned care work. Baseline Position (2016/17) RTT Performance LLR KPI or Trajectory Target Apr16 May16 Jun16 Jul16 Aug16 Sep16 YTD See Appendix 2 page 2. ELR West City LLR Improvement Opportunity (spend) Electives LC ELR WL Cancer and Tumours CVD Diabetes MSK Neurological Trauma and Injuries Gastrointestinal Genito Urinary Respiratory Outcomes (Impact) Achieve RTT targets. Reduce by a minimum of 20 referrals into acute settings through improved GP electronic referral, process, referral and triage hub and advice and guidance. Less overnight stays in hospital by increasing outpatient procedures and day case surgeries. Provide more services closer to patients homes, improving patient outcomes and experience and eliminate waste through redesigned pathways. Ensure patients are seen and treated in accordance with national standards. Reduce unnecessary appointments that currently offer little benefit to patients, freeing up clinical space and time. Better use of technology to help support the delivery of the programme. Patients will not have treatment where the clinical value has no or little evidence to support it. Reduce follow ups by a minimum of 30. Deliver a minimum of 8m of savings in 20 and 20.

19 Investment required Savings to be achieved Change in activity Impact on beds CCG LC 213,328 ELR 204,364 WL 197,308 Total 615,000 CCG LC 3,964,513 2,884,283 ELR 3,406,686 2,594,600 WL 3,285,026 2,827,604 Total 10,656,225 8,306, LC ELR WL EM7a EM7b EM EM EM EM ned care will contribute a 22 bed reduction within UHL over the next four years with the movement of more elective day case and minor procedures into community settings and the impact of low value treatments. 20 LC ELR WL EM7a EM7b EM EM EM EM In addition to the above activity CCGs and UHL have agreed, as part of the STP, to work collaboratively on reducing elective care followups further. This has not yet been agreed contractually but is forming part of the ned Care Workstream plans. 19

20 Key Actions 16/17 Reducing demand for New Outpatients, Reducing Outpatient Follow Up, Pathway Redesign Dermatology / General Surgery / Gastroenterology / Rheumatology / Urology / ENT / Cardiology / Ophthalmology / Gynaecology / Pain Management / Musculoskeletal Services / Musculoskeletal Services Triage / Musculoskeletal Services Physio / Diagnostics (Cardiac and Respiratory) Diagnostics (Cardiac and Respiratory) Plastic Surgery / Nephrology Clinical Haematology / Neurology / General Medicine Integrated Medicine / Hepatology / Allergy / Integrated Medicine General Medicine / Thoracic Medicine / Diabetic Medicine / Endocrinology / Chemical Pathology / Clinical Oncology / Medical Day Case Breast Surgery / Infectious Diseases / Geriatric Medicine / Audiology / Clinical Immunology / Respiratory Physiology / Gynae Oncology / Medical Oncology / Spinal Surgery / Sports and Exercise Medicine Referral Hub Agree specialties / Agree CPIG Principles Agree Manpower(where is it coming from for triage) / Agree Admin / Agree location and management / Agree sign up to plan for all organisations / Agree IT Actions / Agree KPI and Monitoring Implement in agreed 5 specialties Low Value Treatment Policies Set up CPIG / Review existing thresholds and low value treatment policy / Agree a plan with UHL to reinvigorate the policies and procedures with all consultants in relevant specialties / Review where current thresholds and procedures are held on PRISM checking polices are updated and patient letters are available / Undertake a review of other health economy policies and procedures / Review of Right Care CCG packs to ascertain areas for possible improvement to take us to the top 25 centile / Undertake data review of our performance against these thresholds comparing us with other health economies / Agree a set of principles to support the implementation of CPIG with clinicians and managers across CCG s and Providers / Develop a work programme for Undertake work programme to facilitate the introduction of new thresholds and low value treatments Implement new thresholds and low value treatment policies To monitor impact of new thresholds and guidelines Support Regional EMACC Process Integrated MSK Physiotherapy Service 16/17 20

21 Priority: LLR2 Home First Nine Must Do STP Priority Key Deliverables: The overarching model of care across LLR is the home first model. This model was originally highlighted by Dr Ian Sturgess in the 2014 Sturgess Report on the Urgent Care Pathway in LLR. However, the principles of home first are not only applicable to an urgent presentation but define our approach for integrated care across LLR. This approach requires all teams and individuals whether in secondary, community or primary care to ask Why is this patient not at home? or How best can we keep them at home? If an emergency admission to hospital does occur, then the home first principle applies. Namely, that if someone is admitted to hospital and after necessary interventions and treatment, the system s primary aim will be to return that person to the home address from which they came. If there is a need for ongoing assessments around decisions for further care, these take place within the persons usual environment where they are likely to function at their best. This is to avoid crisis decision making about the long term care from a hospital bed. A recognition that remaining in Hospital when there is no longer any acute or sub acute need to remain in Hospital, in particular, for people with frailty risks the development of deconditioning, which can worsen outcomes. Likewise in the community, teams will be required to place patients and their carers at the centre of the design and delivery of care. This requires a move away from organisationally driven provision to integrated placed based provision. The principles underpinning this model are: Patients, carers and family are at the centre of this model. The patient will be known by their registered GP and that a medical management plan and care plan is consistently transferred between settings of care. Rehabilitation and reablement should be undertaken at home or in a community care setting. Inpatient beds should be utilised for acute and sub acute care. The need to optimise and maintain independence for as long as possible. Deliver a Trusted assessment concept which is central to the application of this model. The Discharge to assess concept underpins the Home First model. Baseline Position (2016/17) Baseline to be developed in Quarter /17 Relationship to other plans: New models of care, QIPP Opportunities The home first model is based on transforming services for all patients but is particularly urgent priority for the rising number of patients with long term and complex conditions. It requires a fundamental shift towards care that is coordinated around the full range of an individual s needs (rather than care based around single diseases) and care that truly prioritises prevention and support for maintaining independence. Achieving this will require much more integrated working to ensure that the right mix of services is available in the right place at the right time. Many of the services that are required to support this model are already in place through our BCF plans, discharge pathways and our Intensive Community Support service but we need to consistently use and apply them and understand capacity gaps. Outcomes (Impact) Reduced length of stay in acute hospital to reduce deconditioning More patients receiving care in their home with increased patient experience Patients with a sub acute care will be cared for in community hospital if clinically appropriate Improved health outcomes through case management and optimising independence for as long as possible Assessment for ongoing care will take place outside of hospital after a period of rehabilitation where this is appropriate thus maximising independence Reduction in the number of community beds and resultant financial savings KPI or Trajectory KPI s to be developed in Quarter /17 21

22 Investment required Savings to be achieved Change in activity Impact on beds None From Community Beds CCG LC 289,000 ELR 501,000 WL 511,000 Total 1,301,000 The impact of this project will be to reduce the number of beds required in community hospitals. The impact of Phase one of Home First model contributes to the overall reduction of 53 community hospital beds as set out in the Community Rehabilitation document 17b. There is potential for further reductions once the model has been embedded. Unidentified QIPP CCG LC 821,000 1,800,000 ELR 1,424,000 1,500,000 WL 1,454,000 1,700,000 Total 3,699,000 5,000,000 Key Actions 16/17 Phase 1 Preparatory Phase : Undertake settings of care gap analysis with regard to current service provision/ interventions aligned to proposed model Agree clinical case,model and pathway Define the programme scope and interdependencies with wider STP Programmes (Urgent care, Integrated Locality Teams,LTC) Establish programme Board etc Develop PID and Programme Delivery Establish stakeholder Comms and Engagement Phase 2 Implementation Develop implementation plan,identifying priority areas for service enhancement development Commence reduction in community hospital beds Phase 3 post implementation and evaluation 16/17 22

23 Priority: LLR 3 Urgent and Emergency Care Nine Must Do STP Priority Relationship to other plans: New models of care Key Deliverables: we will deliver a system which provides responsive, accessible personcentred Continue to improve compliance with the 7day services priority clinical services as close to home as possible. Services will wrap care around the individual, promoting selfcare and independence, enhancing recovery and reablement, through integrated health and care standards within the acute hospital, within the available financial and manpower resources. services that exploit innovation and promote care in the right setting at the right time. Develop a realtime demand and activity model to improve management of Urgent care services in LLR will be consistently available 24 hours per day, 7 days a week in operational resource and capacity. community and hospital settings. Clinical triage and navigation is a central part of the new Implement new discharge pathways to provide an integrated, discharge to integrated urgent care offer, reducing demand on ambulances and acute emergency services. The assess model which is based on the principle of home first. following diagram identifies the components of our integrated system. Implement SAFER and Red/Green Days in both community and acute inpatient New Urgent Care System settings. Support the development of integrated clinical teams and enable shared approaches to risk. Improving NHS Constitutional Performance We have developed an A&E Recovery, there are five intervention areas for LLR. Those in addition to the actions stated above are listed below: The main changes which will be delivered by the new service model are: The creation of a clinical navigation service, providing telephone advice, assessment and onward referral for people calling NHS 111 and 999. The clinicians working in the service will have access to patients primary care records and care plans, where relevant, and will be able to directly book patients into primary and community urgent care services. The service will include warm transfer callers to specialist advice for mental health, medication and dental issues. Future plans for the navigation hub include bringing it together with a professional advice line and integration with a single point of access for social care. Extended access to primary care across LLR so that patients can access primary care services 8am to a minimum of 8pm every day of the week. Urgent Care Centres will offer a range of diagnostic tests and medical expertise for people with more complex or urgent needs, and we will strengthen community based ambulatory care pathways which can avoid admission without the need to referral to acute hospital. An integrated streaming and urgent care service at the front door of Leicester Royal Infirmary Emergency Department, staffed by senior GPs working within the rebuilt Emergency Department. 23 Managing demand for urgent care in order to minimise presentations at the Emergency Department: Ensuring those patients discharged from the Acute Trust with a PARR+ score of +5 are provided with adequate community support and increased utilisation of Intensive Community Service capacity to prevent acute activity. Improving Ambulance response times: including implementation of A&E Front Door Clinical Navigator and the mobile Directory of Service and sustain the current high levels of hear and treat. Improving flow within hospital: including the implementation of SAFER patient flow bundle, trail senior acute physicians in ED, reduce time from bed allocation to departure from ED, reduce handover time for medical and nursing teams, reduce delays for diagnostics, reducing overnight breaches, implement direct admissions from ED to specialties and learning from other systems Improving discharge processes: including reviewing the model of Intensive Community Support (ICS) for opportunities to increase usage and support a home first model, establish pathway of reablement patients and discharge to assess, implement an electronic solution to support a trusted assessment upon transfer of care, improve the pathway to support effective transfer of care for people with dementia and adapt acute SAFER flow bundle to address

24 A 24/7 urgent care home visiting service across LLR, including out of hours home visiting and an acute visiting service for people with complex needs or living in care homes. community hospital service requirements. Baseline Position (2016/17) ED performance UHL ED performance trajectory 2016/17 Agreed trajectory Actual National target Outcomes Reduced A and E attendances Reduced non urgent ambulance conveyances Increased numbers of patients treated and redirected by ED streaming Increased numbers of patients accessing ambulatory pathways Increase in NHS 111 calls closed with self care advice Reduced high volume service users presenting to NHS 111 EMAS and ED Reduced GP Urgents and reduction in quality variation across LLR Reduced admissions, especially short stay admissions Improvement in ED Floor performance Improved patient experience Increased discharge from wards before 11am and 1pm Reduction in number of patients assessed for CHC in acute setting Reduction in 30 days readmission of patients leaving the Trust (PARR score 5+) KPI or Trajectory See Appendix 2 page 5 For 20 the A&E 4 hour target has been set in line with guidance issued to deliver a 1 improvement month on month and achieve national standards by the Winter of Currently this means that there is a difference in trajectory between the commissioner and provider and we will work to reconcile this by April

25 Investment required Savings to be achieved Change in activity Impact on bed CCG LC 2,890,546 1,080,000 ELR 1,458, ,000 WL 1,554,106 1,020,000 Total 5,903,463 3,000, LC ELR WL EM EM Contributes to the 77 bed reduction in LLR17a for BCT Clinical workstreams Key Actions New LRI Front Door streaming service mobilised 24/7 enhanced clinical triage to targeted cohorts goes live New services mobilise (West & City) Review of evaluation findings to inform future model of HCP support Low risk ambulatory service implemented on CDU Full roll out of Rapid Flow across UHL Longer term planning for Pathway 3 commenced and agreed Trusted assessment live on UHL s Nervecentre platform and in use by key staff. Business case completed for phase 2 of electronic sharing across IT platforms Mental health triage car evaluated & procured Introduction of additional cohorts for advanced clinical triage LLR wide discharge policy and procedure communication messages implemented PSAU opens New services mobilise (East) Final procurement of clinical navigation hub Electronic sharing to support Trusted Assessment completed All LLR services available on the mobile DoS Findings of evaluation of Vanguard programme Pathway 3 delivered Implementation of Alliance Contract Core 24 service fully embedded Hub extended to include social care services 25

26 Priority: LLR4 Integrated Teams Nine Must Do STP Priority Relationship to other plans: New Models of Care; QIPP Opportunities Key Deliverables: Develop integrated teams across LLR to support our Home First Model. The new model of care focusses on four areas: Increasing prevention and selfmanagement; Developing accessible and responsive unscheduled primary and Our model of integration wraps around the patient and their GP practice, extending the care and support that can be delivered in community settings through multidisciplinary working, with the aim of reducing the amount of care and support delivered in acute settings, so that only care that should and must be delivered in the acute setting will take place there in the future. It is designed to improve health outcomes and wellbeing, increase our citizens, clinician and staff satisfaction and at community care; Developing extended primary and community teams and securing specialist support in the community. Working with leaders in the LLR system on prevention and self management, developing primary and community care and securing specialist support in non acute settings is key in the success of integrated locality teams. the same time moderate the cost of delivering that care. Focus of Integrated Teams As integrated teams develop they will be responsible and accountable for the care of all patients within their defined geographical place. However, the focus of the initial phase of our programme will be on those patients most at risk. The following priority cohorts of patients have been identified, via the Adjusted Clinical Groups (ACG) risk stratification system: Over 18 s with five or more chronic conditions All adults with a frailty marker, regardless of age but related to impaired function Adults whose secondary care costs are predicated to cost three or more times the average cost over the next twelve months. Where will the Integrated Teams be based? The geographical spread of integrated teams will be based on ten established localities across LLR with a population size of between 63,000 and 121,000. For some services there will sub localities, eighteen in total, which are circa 35,000 in size. Baseline Position (2016/17) Project Board in place, project documentation including KPI s and work plan are in draft form to be signed of in Quarter /17. Outcomes (Impact) Resources targeted effectively based on understanding of population need, demand, patient journeys and real time data Focus on prevention, individual responsibility for health and wellbeing, early diagnosis and selfmanagement Care delivered in the right place at the right time first time, home first principle and only acute care when patient cannot be treated in the community Improved health outcomes and wellbeing Increased patient, service user, clinician and staff experience and satisfaction Moderate the cost of delivering care across health and social care KPI or Trajectory Project Board in place, project documentation including KPI s and work plan are in draft form to be signed of in Quarter /17. 26

27 Investment required Savings to be achieved Change in activity Impact on beds CCG LC 1,200,000 2,160,000 ELR 870,000 1,800,000 WL 930,000 2,040,000 Total 3,000,000 6,000,000 This scheme will deliver a reduction in A&E attendances and emergency admissions the impact of which is currently being developed. Based on early modelling it is expected to deliver a reduction of 2,163 A&E attendances and 1,730 non elective admissions and work is ongoing realise these benefits. Integrated teams will contribute a 128 bed reduction within UHL over the next four years Key Actions 16/17 PHASE 1 Identify and assess the holistic care needs of the risk stratified cohort of patients. Design and prepare the ICT for pilot implementation in Q4. Ensure necessary support services and back office functions are aligned in support. Engage with and deliver training ICT. Implement one pilot ICT in each CCG area. Feedback and actions from pilot ICT in preparation of rollout. Engage with and deliver training ICT. Ensure necessary support services and back office functions are aligned in support. Mobilise ICT in care and residential homes Bring specialist support nearer to patients Feedback and actions from ICT for continuing development. Roll out Phase 2 16/17 Q 19 27

28 Priority: LLR 5 Primary Care Nine Must Do STP Priority Relationship to other plans: RightCare; Demand Management s, GPFV Key Deliverables: This project summary sets out the LLR vision for primary care as set out in the STP. This is much more about how general practice will need to evolve and adapt over the next few years to manage the demand and the changing nature of primary care. More detailed plans at a CCG and systemyjh level will be provided the GPFV in line with the national timeline of 24 th December The Model: Our model for primary care is based on the GP as expert clinical generalist working in the community with general practice being the locus of control, ensuring the effective coordination of care. The GP has a pivotal role in tackling comorbidity and health inequalities but increasingly they will work with specialist colocated in primary and community settings, supported by community providers and social care to create integrated out of hospital care. Key to supporting patients is the ability to provide a differential service according to need. Not every patient requires contact with a doctor or an appointment on the same day. A cohort of patients, especially those with multiple comorbidities who are at risk of admission for their complex condition require a more proactive offer that could involve a multidisciplinary team including social care, community nursing and specialist care. Integrated care combines a range of disciplines across health, social services and voluntary organisations to create personcentred care. This new model of general practice is demonstrated in the diagram below. Access: Through our design of urgent and emergency care we will be delivering extended hours in line with the national requirements. This access will not necessarily be from a GP, but a nurse, pharmacist, Advanced Nurse Practitioner, Extended Care Practitioner or other health professional according to need. This offer is intrinsically linked with the already developed plans, being piloted and evaluated now through the Leicester, Leicestershire and Rutland Emergency and Urgent Care Vanguard. By April 2017 this will have generated a new model of home visiting, OutofHours provision, clinical navigation, Urgent Care and enhanced primary care access, which in combination will provide a twentyfour hour service across LLR. Workforce: We have been working across the system and together with other partners such as HEE, LMC and LPC over the last two years to develop solutions to the workforce issues we face. Baseline assessments have been completed, three multidisciplinary training hubs have been established and Education networks are working across the footprint. This has resulted in new delivery models and extended roles including Clinical Pharmacists and Emergency Care Practitioners. This forms the basis for a longer term strategy to deliver the solutions for a sustainable service. Our STP sets out an increase of 10 in the primary care workforce (2271 WTE in 2016/17 to 2505 WTE in 2020). Estates and Technology: LLR has been successful in two technology bids from the ETTF programme for completion in 2016/17. In addition a number of practices have been successful in the ETTF for upgrading their estate; the CCGs will continue to support them in this process. To meet the needs of patients, now and in the future, the model of delivery will need to adapt. This adaptation is based around patient need and seeing the right health care professional for their condition. The evidence shows that patients with complex needs require a coordinated package of care that will require care planning, regular proactive interventions and support. This continuous care is best provided by a multidisciplinary team with the GP at the heart of that care. This level of service utilises a GPs skills to best effect and patients will be streamed accordingly. All other patients will have access with another appropriate health when needed, supported by a GP. 28 National Programmes: The CCGs are committed to ensuring that local practices get access to the national programmes that are available to support transformation and effectiveness and efficiency. Across LLR we have made a joint bid to the GP Practice Development Programme and a number of practices are being supported through the GP Resilience Programme. Actions Focusing on improvements in primary care, better integration of services through placebased teams. Deliver the Leicester, Leicestershire and Rutland Workforce to improve recruitment and retention of medical staff in primary medical care and develop the required skill mix to deliver the future model of primary care and support integrated placed based teams.

29 complex health needs. Support the development of Federations. Work with Federations to enable more collaboration between practices. Ensure access to extended primary care services in the evening and weekend outside of core GP opening hours in multiple sites across the geography. Develop integrated placebased teams with the general practice at the heart of care. Implement the local Digital Roadmap and the requirements set out in the GP IT Operating Model 2016/18. Support practices through the Estate and Technology Transformation Fund process based on the LLR Estate Strategy. Support practices to take forward the initiatives within the General Practice Five Year Forward View including the 10 High Impact Changes and the General Practice Development Programme. Submission of General Practice Forward View In line with the ning Guidance each CCG has developed a General Practice Five Year Forward View Operational, this is attached as Appendix 4. The plan has been produced based on the actions that we are taking at an LLR level and builds on the actions set out in this Project Document. In addition it provides an overview of finances for each CCG and how access in each area is being addressed. Use a range of professionals to deliver care particularly to those with less What Primary Medical Care will look like five years from now? If this plan is fully implemented, we envisage General Practice in LLR looking like this: General Practice with registered lists will remain at the heart of the model offering a comprehensive service to patients based on differential need according to condition and complexity. We will actively encourage practices to work together in networks or merge and provide services on multiple sites offering planned and unplanned services to meet patient s needs. This will reduce bureaucracy and enable economies of scale to enable greater clinical workforce focus. CCGs in LLR have already invested significantly into the development of formal legal GP Federations who do and will work as collective providers of services for patients such as enhanced services. These federations will be active partners in alliance partnerships or integrated teams supporting place based models of care. Place based care provided around geographically defined populations. This will support the adaptation of services for patients, which will act as a catalyst to new models of GP collaboration for core services. GPs will increasingly have portfolio careers. Baseline Position (2016/17) To be worked up as part of the General Practice Forward View Final. KPI or Trajectory To be worked up as part of the General Practice Forward View Final. 29

30 Investment required Savings to be achieved Change in activity Impact on bed Key Actions 16/17 Establish Project Board, Sub Groups and Governance Develop the model for the management of complex patients Develop the model for the management of non complex urgent work Develop to model for enhanced Update Workforce Strategy Complete ETTF Technology Schemes Support practices with ETTF funding to complete their schemes Ensure national programmes are supporting general practice in LLR 16/17 30

31 Priority: LLR 6 LLR Medicines Optimisation Nine Must Do STP Priority Key Deliverables: We recognise that more could be done to improve medicine optimisation by working collaboratively with our provider partners. For example nationally 6.5 of emergency admissions and readmissions are caused by avoidable adverse reactions to medicines; there is over 150m a year of avoidable medicines wastage and only 16 of patients take their medicines as prescribed. LLR Actions Consider the move to an LLR wide prescribing team and greater collaborative working across organisations. Better manage the high cost drug budget to support the growth in drugs with NICE Technical appraisals. Ensure that the medicine impact of both left shift and increased prevention are understood and accounted for. Maximise the use of the pharmacy workforce to support clinical services and staff and also increase the use of nonmedical prescribers. Work together to tackle waste across the system. Support patients to take an active role in medicines taking to increase compliance Promotion of the selfcare agenda to empower patients to manage themselves more effectively. Maximise the use of prescribing analysis support tools to reduce polypharmacy which leads to a reduction in preventable hospital admissions. Consider whether cost effective alternatives to medicines could be provided, for example coping strategies for some patients suffering pain. Blueteq/Homecare/High cost drug pharmacist Implement Blueteq which is a proven preverification and audit tool for all high cost drugs. Under take switches for Infliximab Biosimilar due to patent expires, this will need to be managed by a team pf pharmacists and healthcare professionals. Scope other areas for switches Increase the hours of the Embedded High Cost Drugs Pharmacist Develop SLA for pilot for provision of Domiciliary Medicine reviews Use Eclipse RADAR and IMPACT to: Provide real time prescribing data analysis functionality for the CCGs and its member practices. Relationship to other plans: QIPP Opportunities Provide a way to communicate prescribing efficiencies and patient safety projects to practices. Enable Medicines Optimisation teams to identify and prioritise efficiencies and patient safety issues at CCG level and at practice level and to further move towards a facilitation role to expand the scope of the team. Enable the CCGs to identify and facilitate the systematic review of reversible medicines safety and prescribing issues resulting in admissions for medicines related harm being reduced as with PINCER. (Eclipse covers the three PINCER iterations and more patient prescribing safety issues and can be expanded for the CCGs own patient safety agenda) Facilitate the delivery of more prescribing efficiencies in a more streamlined way for the CCG, the Medicines Optimisation team and the practices Allow the efficient audit and monitoring of progress and delivery of prescribing QIPP areas and patient safety issues using more realtime data, comparing practices within the CCG and CCGs with CCGs also using Eclipse Solutions Enablement of the CCG to meet its statutory requirements towards long term conditions Individual CCG specific actions West Leicestershire CCG Repeat Prescribing: Implement findings from review of the repeat prescribing process. This will be accompanied by a waste campaign. Catheters project: Implement the formulary developed during the pilot and undertake a product review in line with formulary. CRP: Implement CRPPOCT for respiratory tract infections using the Alere Afinion C reactive protein (CRP) test or the Eurolyser Cube C reactive protein (CRP) test, within the GP practice setting. Dietetic review for Oral Nutritional Support in primary care: A nutritional care plan put in place for patients by a dietician to promote food first or fortified food rather than ONS where appropriate. Prescribing incentive scheme: Support GPs to improve prescribing (WLCCG and ELR CCG) across at a minimum: Quality Indicators (e.g. antibiotics) High impact savings (areas with the greatest potential savings) Other indicators (areas which have been worked upon in previous years) 31

32 Stoma Project: A review of patients in line with formulary developed as part of pilot. Stoma specialist nurse to review patients in line with formulary choices and quantities guidance in Primary care. Leicester City CCG Care Homes: C ontinue our pharmacist led work with care homes to optimise patients medications to reduce medicine related harm and associated unplanned avoidable admission. Prescribing Switches and Reviews: this will be done through the continued use of a point of prescribing decision support tool installed in all practice and with facilitated pharmacist led prescribing support for practices on practice specific areas that are either efficiency; best practice or medicine safety. Prescribing systems processes reviews: expand the training of practice prescription and administration staff in relation to reducing avoidable waste from repeat prescriptions so each practice as two or more trained individuals. Following stakeholder engagement in 2016/17 we will develop revised policies and guidance for the management of repeat prescriptions across all sectors. In addition we will undertake a medicines waste campaign. Patient access schemes: engage with patient access schemes with pharmaceutical companies. OffPrescription procurement: explore a number of opportunities for off prescribing service procurement including stoma and incontinence products for full implementation in the latter half of 20. East Leicestershire & Rutland CCG Medication requests by third parties Restricting of ordering of medication by third parties. Dressings Rationalise the dressing s formulary to ensure the most costeffective prescribing. PINCER Practices signed up to be part of the national pharmacistled IT based intervention, shown to reduce rates of clinically important errors in prescribing and medicines management within general practice anticipated savings of 100,000 Baseline Position (2016/17) Nationally 6.5 of emergency admissions and readmissions are caused by avoidable adverse reactions to medicines There is over 150m a year of avoidable medicines wastage and only 16 of patients taken their medicines as prescribed. In 2016/17 LLR will spend 314.6m on Primary Care and Prescribing, 13 of the overall figure for health and social care Outcomes (Impact) Reduce spend on the areas of high costs drugs covered by the programme Improve the quality of care for patients through the review of prescribed medicines in line with local and national guidance and identifying medicines related harm issues Reduction in waste, individual needs of patients are met, product review in line with formulary Reduction in antibiotic prescribing, reduction in use of secondary care services and out of hours and a reduction in the number of unplanned admissions Patients prescribed in line with formulary, reduce inappropriate prescribing Electronic system of preapproval of high cost drugs Improved nutritional and pharmaceutical care for people in care homes contributing to independence and health outcomes Improve the rate of selfcare for minor illnesses To support care closer to home To reduce medicines related admissions This will: Reduce inappropriate prescribing and the associated costs with ONS, A reduction in waste Reducing the workload for GPs in the area of oral nutritional support KPI or Trajectory Maintain / increase the number of medicine switches Reduction in associated costs with oral nutritional supplements Increase the number of patients taking an active role in medicines taking to increase compliance and reducing waste Reduction in emergency admissions and A&E attendances due to adverse reactions to medicines 32

33 Investment required Savings to be achieved Change in activity Impact on bed LC 119,000 ELR WL 417,000 LLR 109,909 Total 645,909 CCG LC 1,919,000 1,800,000 ELR 1,500,000 1,500,000 WL 2,117,000 1,700,000 LLR 805, ,000 Total 6,231,091 5,000,000 Not applicable Not applicable Key Actions 16/17 Establish LLR Medicines Optimisation Group (LLR MOG) Scope out the work programme for the LLR MOG Mobilise Bluteq Increase the hours of the Embedded High Cost Drug Pharmacist Switches for Infliximab Biosimilar Scope out other switches Implement WLCCG QIPP 1 Implement WLCCG QIPP 2 Implement WLCCG QIPP 3 Implement WLCCG QIPP 4 WLCCG Quarterly Monitoring Care Homes Dietetics and pharmacy support LC CCG Drug Switches LC CCG Evidence based prescribing and self care LC CCG Prescribing system and processes LC CCG Patient access schemes LC CCG Real time prescribing data analysis LC CCG Off Prescription Procurement LC CCG Implement ELR CCG QIPP 1 Implement ELR CCG QIPP 2 Implement ELR CCG QIPP 3 Implement ELR CCG QIPP 4 ELR CCG Quarterly Monitoring 16/17 33

34 Priority: LLR 7 CHC Nine Must Do STP Priority Relationship to other plans: QIPP Opportunities Key Deliverables: A tranche of schemes that will collectively aim to reduce inefficiencies, drive consistency and streamline continuing healthcare (CHC) provision across Leicester, Leicestershire and Rutland CCG s. Building on work already commenced in 2015/16 and 2016/17, the schemes will aim to identify further financial savings in 20. Schemes include: The procurement of end to end CHC: end to end CHC process will be in place by April 2017 with new Provider identified. This will mean that across LLR we will have a more streamlined approach to the assessment and management of CHC including the contract management of specialist providers, care home providers and home care providers resulting in CHC savings. Application of the settings of care policy: during 2016/17 LLR CCGs have been developing the draft settings of care policy including engaging with service users with the aim of the revised policy coming into effect from April Continued expansion of Personal Health Budgets (PHB s): LLR CCGs will continue to incrementally increase the uptake of PHBs and for County CCGs there has been a significant impact on the uptake of PHBs due to the implementation of HTLAH. A similar process is being undertaken in the city. Full year effect of HTLAH: joint commissioning of home care with Leicestershire County Council. The new contract arrangements are now in place and there is an anticipated benefit as a result of the procurement of the new contract into 20. Robust management of high cost requests including case reviews: across the LLR CGGs a more robust process to manage high cost requests and case reviews with more involvement of the Nursing and Quality Teams to oversee the governance and clinical effectiveness process. Closer working relationship between Nursing & Quality Teams, CHC team and contract and commissioning teams. 3 month overdue reviews: this will be implemented to ensure that all packages of care are reviewed appropriately and timely so that they better reflect the needs of service users. CHC eligibility and funding authorisation: across LLR CCGs new governance processes have been put in place for the authorisation of CHC eligibility and funding. Full year effect of the impact of this is anticipated in 20. LD workstream: case note review of placements/developments of PHB s. Promoting PHBs as an enabler for transforming care. The CCGs are now in a position to offer PHBs to service users that are eligible through the transforming care programme. Baseline Position (2016/17) To be completed for final version City Joint Commissioning: LCCCG and Leicester City Council are jointly commissioning domiciliary care which will be mobilised from Oct Outcomes (Impact) Packages of care meet the needs of patients All packages of care are in place within 28 days 3 month and 12 month reviews are undertaken on time Increase proportionately the number of people on PHB Reduction in CHC spend and volume Reduction in the size of packages of care through application of Settings of Care and implementation 3 month overdue reviews Reduction in the number of new cases Fast track reductions will be delivered by end of life workstream Delivery of CHC National Framework in line with the Quality Premium Indicators relating to CHC this will be driven through the procurement of the end to end CHC and the robust process of CHC eligibility and funding authorisation. Increased efficiency Successful delivery of the project will also deliver measurable gains and benefits across the patient pathway i.e.: 34 Reduced LOS on acute episodes within the relevant age range Increased patient choice on care setting for required interventions and increased adherence to choice of place of care Improved patient experience and more personalised care plans Reduction in medical readmissions <30 days and <91 days Increased adherence to Expected Discharge Date Reduction in Delayed Transfers Of Care Effective use of resource KPI or Trajectory Reduction in the size of packages of care and costs Reduction in the number of new cases fast track/chc

35 Investment required Savings to be achieved Change in activity Impact on bed LC 226,522 ELR 148,748 WL 175,730 Total 551,000 CCG LC 3,466,522 2,880,000 ELR 2,622,998 2,400,000 WL 2,461,480 2,720,000 Total 8,551,000 8,000,000 Key Actions 16/17 Procurement of the remaining 3 Lots for HTLAH Implementation of End to End Pathway Outcome of Procurement and mobilisation of new specification Consultation on the revised Settings of Care Policy Implementation of New Settings of Care Policy Implementation of agreeing and signing off joint decisions Joint Procurement of the City Home Care Services 16/17 35

36 Priority: LLR8 Cancer Nine Must Do STP Priority Relationship to other plans: Cancer Recovery ; Achieving World Class Cancer Outcomes Key Deliverables: working with a range of stakeholders including the Cancer Alliance we will: Outcomes (Impact) Early Diagnosis (improving one year survival rates): work with Cancer Research UK to promote earlier diagnosis of cancer, increasing access to optimal treatment and thereby improving survival Increase the number of citizens partaking in bowel and cervical rates and reducing cancer mortality. Promoting the use of NICE approved Cancer Maps to support primary care in making appropriate referrals particularly lung cancer which has a very low survival rate currently. Continue the work started in 2016/17 to encourage participation in the national Bowel Screening programme and increasing first time take up. Upskilling healthcare professionals around cancer pathways. Current proportion of cancers diagnosed at stage 1 or 2 is 43.5 to 49.8 across LLR and needs to increase to 62 by Prevention: Commission additional screening initiatives for Bowel Cancer across LLR, through screening tests in LC and WL and maintain the high standards in ELR. For bowel cancer the current screening uptake is 45.4 in Leicester City CCG and 62.9 in West Leicestershire and 63.9 in East Leicestershire and Rutland CCG. The uptake rate needs to be 75 by For cervical both county CCGs are currently above the national achievable target. For Leicester City we above the national acceptable (70) but need to increase from 72.5 to 80 to meet the achievable target. engagement with religious and community leaders; translated materials, work with care homes and Raise awareness around cancer signs and symptoms. letters endorsed by primary care. Work with the Better Care Together Long Term Condition Group Over the next ten years decrease the number of people who develop to ensure LLR has effective smoking cessation programmes. We are also participating in an NHSE cancer through preventative programmes. national pilot to increase uptake of cancer services amongst BME communities. Identifying earlier (stage 1 and 2), individuals who may have cancer SelfManagement and Recovery Packages: Commission The Recovery Package to include holistic needs assessment; treatment summary; health and wellbeing events; and cancer care review. In Current proportion of cancers diagnosed at stage 1 or 2 is 43.5 to 49.8 across LLR and needs to increase to 62 by addition commission an exercise referral rehabilitation programme; and educational events to A decrease in gap between LLR CCGs and similar 10 CCGs based on the support with sustaining a patients recovery by empowering them to selfmanage. Atlas of Variation particularly in lung, bowel and lower GI. Review Pathways: review Urology, ENT and Lung pathways and develop remote monitoring for the Deliver the NHS Constitutional Standards for cancer care. for Thyroid and Prostate with the potential to develop into MGUS monitoring which can result in Every person will have access to a cancer recovery package by myeloma. We are also looking at stratifying breast cancer followups in line with the ning Guidance. Delivery of NHS Constitutional Standards: implement the Cancer Recovery Action to ensure all constitutional standards are met and or maintained this includes work on matching demand to staffing levels, increasing diagnostics and changes to pathways. Baseline Position (2016/17) KPI or Trajectory See Appendix 2 pages

37 Investment required Savings to be achieved Change in activity Impact on bed An application is being made to the STF funding process to support our cancer work. The Cancer Group is also seeking funding and or support from alternative sources. None None Not applicable Key Actions 16/17 Early Diagnosis training at PLT for healthcare professionals Early Diagnosis visits offered to all practices from Cancer UK facilitator Early Diagnosis promote the roll out and utilisation of Cancer Maps in primary care Prevention contact with non responders Prevention increase uptake in bowel screening through Birthday Cards Prevention bowel screening community engagement events Self management and recovery packages Review of pathways 16/17 37

38 Priority: LLR 9a Mental Health (Adults) Nine Must Do STP Priority Relationship to other plans: QIPP Opportunities Key Deliverables: We will work to achieve specific national planning guidance to move towards parity of esteem including achieving NICE and national mental health access standards, eliminate out of area placements by 2020 and reduce the incidence of suicide. Widen choice and effectiveness in crisis and acute response to reduce demand for beds: Remodel Community Mental Health Teams, review Psychiatric Intensive Care provision, strengthen; IAPT, Liaison Psychiatry, Perinatal and Eating Disorder services, developing NICE compliant services for First Episodes in Psychosis (including improving treatment and care pathways, improving access and develop all age services), Personality Disorder and autism. Working with Police, Ambulance, Acute Hospital and social care partners to provide triage and alternative community based responses or if required timely access to local brief admission. Increase timely clinical efficiency and partnership processes: to create alternatives to acute admission e.g. crisis café; enable timely flow through acute hospital beds; effective care management, evidence based care cluster pathways, access and support to mainstream and potentially bespoke accommodation. Reduce suicide and increase resilience and promote recovery and independence: to enable people to manage their health more effectively we will develop awareness, reduce stigma and support skills in the population, build on the benefits of improved children s Mental Health services and schools. We will develop integrated locality based recovery networks, social prescribing and supporting access to employment, accommodation and workplace health. All of our plans will contribute to reducing suicides. Meet recovery and rehabilitation needs locally: we will develop a local integrated offer enabling fewer placements out of area; conducting rigorous reviews so that people have appropriate care packages closer to home at reduced cost, using redirected investments to build local infrastructure with social care and housing partners IAPT: All three CCGs are planning to meet the new national targets of 16.8 in 20 and 19 in 20. We will work with our providers and the wider system to put the necessary plans in place to deliver our offer re focusing on supporting people retain or enter work and support people with long term conditions. Dementia: Work is ongoing across LLR practices to continue to improve early diagnosis of patients. This has included skilling up primary care clinicians and identifying dementia leads across the health and social care partners. As part of our LLR for Dementia we have reviewed our Memory Assessment Services and the shared Care model is in place. During 20 further work will be undertaken to remodel the service in order to improve capacity and access to the service. A review of Post diagnostic services has been undertaken during 2016/17 and scoping work to consolidate discrete service provision across health and social care in order to develop an integrated approach to post diagnostic support. The aim will be to develop an integrated community inreach service that supports service users and their carers affected by dementia within community and when they are in acute care settings. A business case has been developed with a view to jointly procure with LA an integrated community post diagnostic support service. Outcomes (Impact) A reduction in the numbers of out of county acute overspill placements and their cost of patients in secondary care mental health hospital placements A reduction in individual patient packages and thier cost An increase in the number of annual reviews A reduction in DToC and LoS to bring in line with national average. An increase of 17.3 WTE in 20 to support mental health triage, CAMHS crisis service and liaison psychiatry (LPT). Increase in access and recovery rates to IAPT Proactive early intervention through first episode in psychosis services and crisis teams to deliver the access targets and deliver better outreach particularly for people with complex or multiple needs during 20 Psychosis treated with a NICE approved care packages within two weeks of referral target to be achieved for 20 is 50 and 20 is 53 Baseline Position (2016/17) See Appendix 2 pages 612 KPI or Trajectory See Appendix 2 pages

39 Investment required Savings to be achieved Change in activity Impact on bed LC 28,350 ELR 18,480 WL 23,170 Total 70, LC 963,920 ELR 478,690 WL 639,390 Total 2,082,000 Unidentified QIPP LC 1,173,245 ELR 587,895 WL 783,860 Total 2,545,000 Key Actions 16/17 Reduce number of patients in OOC placements to 12 Reduce number of patients in OOC placements to 8 Reduce number of patients in OOC placements to 4 Reduce number of patients in OOC placements to 0 Reduce local DTOC & LOS rates in line with national average Meet Increasing IAPT targets Personality Disorder Pathway phase 1 Personality Disorder pathway phase 2 Autism Treatment service phase 1 Autism Treatment service phase 2 Initiate Recovery hubs Develop accommodation initiatives 16/17 39

40 Priority: LLR9b Mental Health Children Nine Must Do STP Priority Relationship to other plans: Future in Mind Key Deliverables: our Future in Mind transformational plan to improve the mental Outcomes (Impact) health and wellbeing of children and young people focuses on improving resilience; enhancing early support; improving access to the specialist CAMHS service; enhancing the community eating disorder service; developing a children s crisis and home treatment service and developing the workforce. We will: Provide more high quality mental health services for children and young people, so that at least 32 of children with a diagnosable condition are able to access evidence based services by April This includes full implementation by September 2017 of a crisis home treatment services; procuring for implementation by May 2017 targeted early help, improving the CAHMS pathway and ensuring a skilled and competence workforce to deliver Children and Young People Improving Access to Psychological Therapies (CYP IAPT) by Commission community eating disorder teams so that 95 of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases and reduce suicide rates by 10 against the 2016/17 baseline. Commissioners and providers will join the national quality improvement and accreditation network for community eating disorder services. Improvements in the last year have been made to enable100 patients to be seen by the service compared to 20 previously. Ensure the delivery of mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals Eliminate out of area placements for nonspecialist acute care by 2020/21 through regional collaborative commissioning and work with local providers. Improve access to CAMHS and deliver against 13 week target Decreased waiting times in line with the national standards Improved health outcomes and wellbeing More children and young people feeling supported to manage their mental health Children and young people cared for closer to home More children and young people able to access services Reduction in young people who attend the Emergency Department due to an acute mental health problem who have to wait more than four hours to be seen by a specialist Baseline Position (2016/17) See Appendix 2 page KPI or Trajectory See Appendix 2 page

41 Investment required Savings to be achieved Change in activity Impact on beds Not applicable Not applicable Not applicable Key Actions 16/17 Targeted Early Help Procurement Implementation of Targeted Early Help Implementation of phased Crisis and Home Treatment Service Implement reduction in waiting times plan Education and training for CYP IAPT Out of area placement 16/17 41

42 Priority: LLR10 Learning Disabilities Nine Must Do STP Priority Relationship to other plans: Transforming Care Partnership Key Deliverables: In line with national guidance on Transforming Care, we have a comprehensive plan to transform care for people with learning disabilities. By 20, Improve access to health care: we will continue to work with our primary care providers to deliver the target of 75 of people on a GP register are receiving an annual health check. our aim is to produce and deliver responsive, high quality, safe learning disability services and support that maximise independence, offer choice, are personcentred, good value and meet the needs and aspirations of individuals and their family carers. Reduction in Outcomes (Impact) premature mortality by improving access to health services, education and providing training to staff, and by making reasonable adjustments for people with learning The following workforce changes will be made as a result of developments in this area. disabilities and or autism. Agnes Unit Beds: to decrease the number of Agnes Unit inpatient beds by 4 and increase community support to prevent admissions and readmissions. Provide proactive, preventive care: with better identification of people at risk, and early intervention. We will empower people by expanding personal health budgets and through independent advocacy and a greater choice in housing. Provide specialist multidisciplinary support: in the community including intensive support when necessary to avoid admission to mental health inpatient settings through the provision of a refocused and enhanced Learning Disability Outreach Team which will reduce the need for inpatient beds. Improve health and wellbeing: of people with Learning Disability and their family carer(s) through reviewing short break provision and ensuring engagement with preventative health initiatives. Redesign pathways: to deliver improved outcomes for patients with learning disabilities. The work in our plan aim to support reducing reliance on inpatient care for people with LD or autism in order to meet the national standard. The resulting reduction of inpatient stays will mean a reduction of 18 WTE in 20 relating to the closure of 4 beds in the Agnes Unit (LPT). By 2020, 75 of people with learning disability on a GP register will have an annual health check. Increase in the number of personal health budgets taken by people with Learning Disabilities. Reduction in the number of admissions to inpatient beds. Improved health and wellbeing of people with learning disabilities. Meet the required national standards. Baseline Position (2016/17) TBC KPI or Trajectory The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and or behavioural healthcare needs, and whose bed is commissioned by a CCG. This will include all adults in inpatient wards that are not classified as low, medium or highsecure. The number of people from the TCP who have a learning disability and or autistic spectrum disorder that are in inpatient care for mental and or behavioural healthcare needs, and whose bed is commissioned by NHS England. This will include all adults in inpatient wards that are classified as low medium or highsecure, and all children and young people in Tier 4 CAMHS services. 42

43 Investment required Savings to be achieved Change in activity Impact on bed Included in Mental Health Adults savings None 4 beds on the Agnes Unit Key Actions 16/17 Closure of 4 beds at the Agnes Unit Review CTR processes and Discharge pathway Consult on respite and short breaks Increase Personal Health Budgets Implement agreed changes to short breaks Review Crisis Response 16/17 43

44 Priority: LLR11 Long Term Conditions Nine Must Do STP Priority Relationship to other plans: Key Deliverables: Our vision for long term conditions is person centred, integrated care utilising as its foundation the methodology of the Chronic Care Model which is proactive case finding; stratification of severity and complexity; circular pathways encompassing annual review; shared care planning; endto end whole disease pathways; cross cutting and prevention activity; and Learning from patients and carers. Our focus in 20 and Prevention: There are a number of prevention activities that we will consider undertaking should STF or alternative funding become available including roll out self managed rehabilitation programme for patients with Angina; deliver 8 COPD support groups in 20 in the community; targeted Familia Hypercholesterolemia Cascade screening; integrated Breathe Easy Groups for COPD patients; CKD and inpatient Smoking Cessation Service. 20 will be on: Provide Stroke and Neuro Integrated Rehabilitation service Integrated community based specialist rehabilitation service for stroke survivors and those with long term neurological conditions. A coordinated Multi Disciplinary Team service linking health, social care and the voluntary sector in addressing patient s needs. Advanced level of expertise in the assessment and management of patients. Provide Cardio and Respiratory Integrated Community Service Specialistled Cardio Respiratory service to manage and support patients with Long Term Conditions, including Asthma, COPD, Bronchiectasis, Hypertension, Angina, AF and Heart Failure in the community. A coordinated Multi Disciplinary Team service linking health, social care and the voluntary sector in addressing patient s needs. Provide seamless links to existing specialist services. Support primary care diagnostics; provide a crisis response service and single point of access for clinical triage. Baseline Position (2016/17) Stroke and Neuro 2014/15 approx 1200 stroke related emergency admissions 48 were discharged home or to residential care and referred for generic therapy offer or neuro therapy offer 64.6 of those referred to domiciliary therapy were seen within three days of referral Community bed cost of 3,732,807 Cardio Respiratory 15/16 cost of emergency admissions 13,119,277.84; 15/16 Cost of referrals 985, Outcomes (Impact) Stroke and Neuro Integrated Rehabilitation Service: Six monthly review for stroke patients in line with NICE guidance Reduced inequalities for patients and enable them to achieve maximum functional independence Targeted rehabilitation for patients as opposed to generic therapy offer Improved general health Reduced burden on carers Rehabilitation provided at patients home or preferred location Cardio Respiratory Integrated Community Service: Prevent avoidable hospital admissions Earlier discharge from hospital Improved earlier diagnosis Reduced use of secondary care Improved well being Care closer to home Increased patient education Reducing inequalities in health care provision Increased patient and carer satisfaction KPI and or Trajectory Stroke and Neuro: Assessment within 72 hours of referral ; Reduction in waits for rehabilitation Reduction in emergency admissions of neuro patients; Reduction in readmissions of stroke and neuro patients Reduction in LOS of Stroke and Neuro patients Reduction in CHC packages of care Reduction in discharge of stroke and neuro patients to com Hospital or rehab bed Cardio Respiratory Between 2080 of outpatient activity for cardiology and respiratory to be moved into community by end of year 3 44

45 Investment required Savings to be achieved Change in activity Impact on bed Long Term Conditions CCG LC 940, ,744 ELR 781, ,835 WL 646, ,574 Total 2,368, ,153 Long Term Conditions CCG LC 1,839, ,847 ELR 1,325, ,539 WL 1,639, ,744 Total 4,805,280 2, LC ELR WL EM Respiratory EM11 stroke & Neuro 20 EM Respiratory EM11 stroke & Neuro Stroke and Neuro: Close 11 stoke beds in Coalville (9), St Lukes (2) Key Actions 16/17 Stroke and Neuro Rehabilitation service Initiate recruitment process for Stroke and Neuro team Develop systems and processes for SPA and recording and reporting system Agree sub contracting arrangements between LTP and UHL All identified patients to receive their care from the integrated service Full delivery of the service 16/17 Cardio Respiratory Service Alliance Governance arrangements in place Integrate existing workforce Crisis Response Service Implemented Ambulatory Pathways for Breathlessness, Heart Failure, AF and chest pain Set up SPA Phase 2 Expansion of service 45

46 Priority: LLR 12 Children s, maternity, neonates Nine Must Do STP Priority Relationship to other plans: Better Births, Future in Mind Key Deliverables: Our focus is on improving outcomes in maternity, children s emotional health and wellbeing, young people and family services. This involves a range of organisations working together efficiently to improve productivity across universal, targeted and specialist services to improve outcomes for children and young people. Continue to improve the quality of maternity and neonatal services: improved access and outcomes for women and their babies based on the principles within Better Births including the formation of a Maternity Network and the development to of integrated pathways between primary and secondary care to provide continuity of care. In addition, and subject to consultation, all obstetricled inpatient maternity services will be delivered from one site, and options on the provision of midwifery led units will also be consulted on. See Service Reconfiguration Section. Work will be undertaken to further consolidate and develop the neonatal service to meet the responsibilities of being the lead centre for the Central Newborn Network. Delivery of Future in Mind: our transformational plan to improve the mental health and wellbeing of children and young people focuses on improving resilience; enhancing early support; improving access to the specialist CAMHS service; enhancing the community eating disorder service; developing a children s crisis and home treatment service and developing the workforce. See LLR9b Care in the right place at the right time: the population of children and young people with general and complex health needs that require clinical intervention is increasing. Work is underway to review The Children Hospital Model to meet the increasing demand, remodelling work will consider where services will be based; increasing the admission age to 18 and 365 days for those who have a complex condition and Special Educational Need; review pathways to consider the best environment for delivery; and deliver the Children s Emergency Care Pathway and the Single Front Door to ensure robust streaming and assessment and delivery of clear pathways for ambulatory care. One Child one Chair: we are exploring the impact of providing access to the right seating system for children with a neurodisability to improve their quality of life and reduce the amount of equipment required. Respiratory: we are exploring an increase the capacity within the Children s Diana Respiratory Physiotherapy Service to prevent regular admission, assist early discharge and reduce length of stay for children with complex respiratory disorders and neuro disabilities. This will be work through in year via a Business Case. SEND: review therapy service for young people aged 1618 years old to ensure young people transitioning to adult services have access to the appropriate provision; and ensure that personal health budgets are offered to children and young people with Continuing Healthcare Needs. Outcomes (Impact) Care in the right place at the right time More children being cared for closer to home One Child One Chair Reduced level of pain. Reduced severity and occurrence of pressure sores. Improved postural drainage which will reduce aspiration and chest infection and hence the need for hospital admission. Specific moulded hip and spinal support which will reduced postural deterioration in almost all cases and prevent complex and painful (Possibly repeated) spinal and hip surgery. Reduction in number of pieces of equipment to supply and maintain. This chair will be assessed to access the home, education and respite settings. In addition to a hoist to move from bath/shower/loo or bed to Chair there should be little need for additional equipment. Baseline Position (2016/17) KPI or Trajectory Review 50 children for One Chid One Chair 46

47 Investment required Savings to be achieved Change in activity Impact on bed CCG LC 27,667 ELR 23,056 WL 26,130 Total 76,853 None None Key Actions 16/17 One Child One Chair 16/17 Green QIPP form completed and business case Project plan in situ identifying time line for delivery, contractual requirements, etc. Project delivery group set up ( Including TOR, meeting dates, assurance processes identified) Agree new process in relation to delivery Pilot new process. Evaluate the pilot. Complete contractual changes including specification. Start date of new process Monitor implementation of new process and agree outcomes for ongoing monitoring Respiratory Physiotherapy Green QIPP form completed and business case Seek CCG finance agreement to proceed. 47

48 Priority: LLR13 End of Life Care Nine Must Do STP Priority Relationship to other plans: Home First; Integrated Teams Key Deliverables: Following a review of patients who died in LLR in 2012/13, we Outcomes (Impact) identified where improvements could be made to ensure high quality endoflife care based on two key areas unified care planning and coordinated 24/7 palliative care services. Our focus for will be on: Implement 24/7 Care Coordination navigation centre for those at the end of life and those closest to them. Implement 24/7 access for generalist and specialist EOLC services. Ensuring all patients to have opportunity for Advanced Care s with option to appoint a person with lasting powers of attorney. Establish and roll out Electronic shared care planning system via a Summary Care Record V2.1 rolled out as an EPacc solution. Develop an integrated approach across LLR on use of DNACPR documents. Develop and implement a LLR wide Training Strategy ensuring that 100 of staff delivering End of Life Care met a defined level of education and training using the existing training and education programmes and online tools. Ensure effective prescribing and access to medication out of hours. Patients on discharge will have a named GP in accordance with NHS England Guidance. More patients to receive care at home or in a hospice. Improved patient and carer experience Improved quality of care Joined up care with information sharing to reduce fragmentation of care Patient preferences will be shared with organisations providing care Staff delivering End Of Life Care meet defined standard of education and training Baseline Position (2016/17) Emergency admissions for patients in their last 2 weeks of life are higher than average. Many of these admissions occur outside of GP opening hours and are initiated by the Out of Hours Service, including 111, EMAS or ED. Patients, families and professionals report that current systems are difficult for them to understand and they do not always feel that they are directed to the most appropriate option. There are inconsistencies in the availability of services and level of care across LLR. There are limited community specialist palliative care services at the weekend despite this being a NICE recommendation for many years. Inappropriate delays for patients being discharged from hospital in last days of life resulting in patients dying in hospital while waiting for packages of care. KPI or Trajectory 100 of staff delivering End Of Life Care meet defined standard of education and training Increase in of patients dying in the usual place of residence Decrease in the number of patients receiving an inappropriate fast track POC Decrease in the number of inappropriate admissions to hospital Increase in the number of patients being identified as EoL and placed on the GP register Increase in the number and increase in the quality of Advanced care plans created by GPS 48

49 Investment required Savings to be achieved Change in activity Impact on bed CCG LC 199,596 ELR 109,935 WL 84,510 Total 394,041 CCG LC 959,399 ELR 528,425 WL 406,217 Total 1,894,041 Saving being released from reduced number of CHC packages None. Key Actions 16/17 Encourage a lead GP in each Practice Implementation plan to deliver Strategy to include scope, timescales, constraints etc. Develop a project plan for chosen system solution for EPaCCs to include scope, timescales, constraints etc. Develop a Service Specification for EOL/Palliative Care Develop Education & Training (form part of LLR Strategy) Clinical GP mentor in each of the three CCGs providing support to upskill GPs A lead EOL GP within every practice identified Training around the AMBER Care Bundle and One Chance to Get it Right for UHL and LPT staff Identify case studies to highlight beneficial changes of before and after Develop workforce plan (form part of LLR Strategy) Review Discharge for those in last few days of life Enact changes from review of those in last few days of life Incorporate improvements to EOLC into Integrated Teams workstream 16/17 49

50 Priority: LLR 14 Self Care and Prevention Nine Must Do STP Priority Relationship to other plans: Key Deliverables: Prevention is a key part of Better Care Together. Many factors which drive longerterm demand for social care and secondary care are preventable or could be managed more effectively. Prevention of illness may help people stay working, live independently, or continue caring for loved ones. This will help the health and social care economy to a sustainable position and support the wider economy of LLR. However this is fundamentally about helping people improve their quality of life. To support the STP prevention work a joint piece of work has been undertaken across the public health teams within LLR to identify the key issues that need to be addressed within the delivery of the various workstreams. These are detailed below: Rutland Leicestershire Leicester Giving children the best start in life Enabling people to take responsibilityfor their health Helping people to liver longer and healthier lives Tackling wider determinants of health Getting it right from childhood Improving mental health and wellbeing, and services for people with learning disabilities Giving childre the best start in life Reducing early deaths and health inequalities Improving mental health and wellbeing The prevention agenda is also focused on effective prevention interventions in the short to medium term which impact on lifestyle and behavioural change in risk groups and on reducing the risk of illness and death in people with established disease or risk factors. Actions Wider determinants of health: Create an environment that supports community health and builds health into the local area, making healthy behaviour the norm, working with planning, housing, air quality and transport to maximise health benefit and which in the long term will have an impact on mortality. Baseline Position (2016/17) To be developed in Quarter /17 50 Make better use of risk profiling: To target communities and places with the poorest health, developing our capability to use realtime data systems to better understand health need and to monitor and evaluate the impact of changes to services on service usage and associated costs. Detecting early: Programmes to support General Practice in identifying and recording actual prevalence and supporting patients through better management of Long Term Conditions. Early detection programmes and preventative public health strategies and programmes working closely with patientled groups, selfhelp groups and community and voluntary organisations. Primary prevention reducing incidence of disease before it occurs: Tackling unhealthy behaviours through effective communication with the public, building on approaches such as PHE s Sugar Swap campaign, Dry January and One You, alongside programmes to reduce alcohol consumption, obesity and support the availability of smoking cessations in acute and well as community settings, and the availability of advice and support through lifestyle hubs. Develop assetbased approaches to working with local communities, maximising their capabilities and resources to enhance health and wellbeing, improving their networks and resilience and developing social prescribing. Ensure that Making Every Contract Count is maximised. Secondary prevention reducing the impact of disease: Extend what we know works including better chronic disease selfmanagement, care management to support people with longterm conditions such as AF and hypertension, improved day to day management of patients with complex needs through the development of integrated placed based teams, early disease identification through programmes such as NHS Health Checks coordinated with lifestyle services, and the Diabetes Prevention and Structured Education Programme maximising numbers of patients on the schemes. Workforce health: Develop workforce capability by implementing new approaches to workplace health, maximising the crucial role that staff at all levels play in promoting health and wellbeing. KPI or Trajectory To be developed Quarter /17

51 Investment required Savings to be achieved Change in activity Impact on bed The programme of work is being managed within existing budgets. Not applicable Not applicable None Should STF funding become available, in line with our STP financial submission, there may be potential to increase funding in this area. To be developed. 51

52 Priority: LLR 15 Reviewing Minor Services Nine Must Do STP Priority Relationship to other plans: Key Deliverables: A tranche of schemes that will collectively aim to reduce inefficiencies, drive consistency and streamline community healthcare (CHS) provision across Leicester, Leicestershire and Rutland CCG s. Building on work already commenced in 2015/ /17, the schemes will aim to identify further financial savings in 20. Schemes include: Diabetic Foot Ulcers: currently all diabetic foot ulcers are referred to UHL however the majority of these could be moved to a lower cost setting within the community podiatry service by implementing a threshold for treatment within UHL, using the Texas wound classification scale and setting a benchmark at which point the patient is referred into UHL. All other activity could stay within a community setting. Podiatry: redesign Podiatry service to enable the service to become more efficient focusing on appointment times; procedures undertaken; level of staff undertaking procedures; and stopping interventions which are not clinically required. Orthotics: There is duplication in some of the orthotics offered by the CHS Podiatry Service and Blatchfords. Commissioning teams will review the services provided by LPT, Blatchford s and The Alliance and will consider any duplication of services offered prior to the reprocurement of the service. Community Therapy: undertake a full review of this service in line with the new services recently developed; Pathway 3, HTLAH and ICS beds. Falls clinic programme: review of service to ensure effectiveness and that its impact on reducing admissions. Children s audiology: full review of service including criteria for referral and number of follow ups; where actvity takes place; location and impact on acute activity. Children s SALT: full review of service including criteria for referral and number of follow ups; where activity takes place and location. Dietetics: full review of service including criteria for referral and number of follow ups; patient compliance; and location. MSK Foot and Ankle: currently only ~30 of activity referred from the podiatry service to UHL MSK foot and ankle requires surgery. The service is providing podiatric treatments and referring to the more expensive Blatchford s service. Treatment and semi bespoke insoles could be provided in a lower cost, community setting within the existing LPT podiatry service. The service will be reviewed to deliver efficiencies. Baseline Position (2016/17) To be developed in 20 Direct access to xray: currently patients attending the podiatry service who require an xray must be referred onto the foot clinic within UHL. This results in the patient receiving a duplicate assessment prior to xray. The LPT Hosted contract team are working with the UHL hosted contract team to review this with a view to altering the pathway to allow podiatrists direct access to xray. This would result in a saving from the UHL contract. Continence Nursing Service: review the service to develop a new specification and pathway and ensure efficiency of products. Phlebotomy: undertake a review of the service to ensure we have cost effective pathways taking into account areas such as DOACs that could impact on the model and the stopping of all INR and non caseload phlebotomy. Primary Care CoOrdinators Service: to review the model of primary care coordination to ensure efficiency and that it is targeted in the right areas of acute activity. METT Centre and Recovery College: review the service in light of our overall strategic direction for mental health services and the commissioning of recovery hubs. Outcomes (Impact) Reduction in activity Reduction in referrals to UHL Increased efficiency Reduction in home visits Reduced number of follow up appointments Reduction in appointment times KPI or Trajectory To be developed in 20 52

53 Investment required Savings to be achieved Unidentified QIPP Impact on bed From Phlebotomy; Primary Care CoOrdinators and METT Centre/Recovery College CCG LC 208,328 ELR 178,252 WL 207,420 Total 594,000 CCG LC 473,672 ELR 427,748 WL 507,580 Total 1, None Change in activity There will be a reduction in activity into community services. Key Actions 16/17 Podiatry savings identified Agree savings with LPT Identify project manager to review continence service Undertake review of Continence service Agree and roll out required changes Identify project manager to review phlebotomy service Undertake review of phlebotomy service Agree and roll out required changes Identify project manager to review Community Therapy Undertake review of Community Therapy Agree and roll out required changes Identify project manager to review Falls clinic programme Undertake review of Falls clinic programme Agree and roll out required changes Undertake review of Children s audiology Agree and roll out required changes Identify project manager to review Children s SALT Undertake review of Children s SALT Agree and roll out required changes Identify project manager to review Dietetics service Undertake review of Dietetics service Agree and roll out required changes 16/17 53

54 Priority: LLR16 CCG Efficiencies Nine Must Do STP Priority Relationship to other plans: Carter Review Key Deliverables: Outcomes (Impact) Corporate Estate Consolidation: This workstream will focus on identifying whether savings can be achieved from Leicester City CCG and West Leicestershire CCG moving office bases and particularly explore colocation opportunities with either local authorities or local health providers. Reducing IM&T costs: A review of IM&T provision across all three CCGS will be undertaken to consider whether costs could be reduced, for example by increasing the replacement period, or whether market testing would be beneficial. Shared Services: As part of our STP partners have committed to review back office functions to determine if a Shared Business Service for certain areas could be beneficial. The agreed scope of the project will be completed by the end of November 2016 with a target date of end of January 2017 for the completed Outline Business Case and for phased implementation from June 2017 onwards. CCG Joint Working: the three CCGs already have well established collaborative arrangements and a number of joint functions. However, there are areas that we undertake separately which adds duplicative costs into the system overhead. We will be working together to consider what else we could do jointly. Reduced running costs. Improved delivery through colocation. Improved delivery and stronger implementation of STP through further joint working. Baseline Position (2016/17) To be developed in Quarter /17 KPI or Trajectory To be developed in Quarter /17 54

55 Investment required Savings to be achieved Change in activity Impact on bed None identified The savings detailed below are at an LLR level. Not applicable Not applicable Area LC ELR WL Corporate 102,000 90, ,000 Estate Reduce 127, , ,000 IM&T spend LLR Shared 170, , ,000 Services CCG Joint 204, , ,000 Working Total 603, , ,000 Key Actions 16/17 Corporate Estates Reducing IM&T costs Shared services Joint Working 16/17 55

56 Priority: LLR17a Acute Reconfiguration Nine Must Do STP Priority Relationship to other plans: Key Deliverables. We know that Leicester is unusual in having three big acute hospitals Outcomes (Impact) for the size of the population we serve and this creates problems. Our specialist staff are spread too thinly, we duplicate and triplicate services across sites and it is expensive to run. Many planned elective care and outpatient services run alongside our emergency services and as a result when emergency pressures increase it is elective patients that suffer delays and last minute cancellations. And over the last two decades there has been significant and sustained under investment in the acute estate relative to most acute hospitals. We also know that too many patients, particularly elderly patients, spend too long recovering in hospital and potentially deteriorating as a result when they would be better served by rehabilitation services in their own home or in a community setting. As a system we plan to adopt a home first principle and many of our priorities support this including Integrated Teams and the new Rehabilitation Pathway. Our plans will therefore: Move from three acute sites to two: subject to consultation and the availability of capital funding move all clinical services onto two sites, the Leicester Royal Infirmary and the Glenfield. Maternity Services: subject to consultation and the availability of capital funding remodel maternity services to consolidate onto one site at the Royal Infirmary, and subject to preferences expressed during consultation provide a midwife lead unit at the General Hospital. Reduce the acute bed base: bed modelling has been undertaken to consider the above changes and those from other STP priorities and as a result the acute bed base will reduce to 1697 by 2020/21 from the current level of Improve clinical adjacency so that support and diagnostic services are close to where they are needed, promoting closer team working and providing better patient experience. Reducing delays to care by streamlining pathways. Reduce cancellations of elective care by protecting our elective beds by separating out emergency and planned care. This will be done by creating a planned ambulatory hub at the Glenfield as well as redistributing some of our services into the counties community hospitals. Improve the quality of the patient environment. At the end of the transformation programme it will contribute 25.6m savings per annum to support the sustainability of LLR. Improved mortality rates, waiting times and improved patient experience. Increase in type and volume specialist service provision. Baseline Position (2016/17) Bed Bridge Current to 2020/21 See Bed Bridge 56

57 Investment required Prior years 16/17 20/21 Total m m m m m m m Savings to be achieved Change in activity Impact on bed See Bed Bridge Reconfiguration programme Approved to date (50.7) (50.7) Internally funded (12.2) (4.5) (4.7) (9.2) (18.6) (10.8) (60.0) External funding requirement Site disposal (28.4) (28.4) PF2 (27.2) (70.2) (97.3) Welcome Centre (2.0) (10.0) (12.0) DH funding requirement (10.4) m per annum from 2020/21 after capital investment Key Actions * Subject to Consultation; ** subject to capital Delivery of Emergency Floor Move Vascular Services from LRI to GH Delivery of Emergency Floor Phase 2 Move L3 ICU and associated services from LGH to GH ** Move of EMCHC from GH to LRI (subject to continued commissioning) Delivery of Children s Hospital Phase 2 ** Delivery of Long Term ICU at LRI and GH ** Delivery of ned Care Hub at GH * ** Delivery of Women s Hospital at LRI* ** Final completion of Diagnostics Solution at LRI and GH ** Final Completion of Beds Solution at LRI and GH ** Final Completion of Theatres Solutions at LRI and GH ** 16/17 Qrt 1 20/21 Qrt 2 20/21 Qrt 3 20/21 Qrt 4 20/21 57

58 Priority: LLR17b Community Hospital Reconfiguration Nine Must Do STP Priority Key Deliverables: Due to increasing care being provided in patients home through our schemes such as Better Care Funds; Integrated Teams and Home First the need to community based inpatient beds have been reviewed. Our proposals subject to formal consultation and capital availability for each hospital are: Coalville Hospital Reduce rehabilitation beds by 3 Reduce Stroke Beds by 9 Outpatient services to remain Loughborough Hospital No change Hinckley and District Hospital Relocate outpatient and Day Case to Hinckley Health Centre Hinckley and Bosworth Community Hospital Create new endoscopy and day case suite Reduce rehabilitation beds by 18 Evington Centre Reduce rehabilitation beds by 5 Move Stroke beds for LGH to EC Melton Mowbray Hospital Increase beds from 17 to 21 Greater use of theatre for day case; expansion of outpatients and diagnostics Extended primary care Rutland Memorial Hospital Close inpatient beds Site to become a health and social care hub providing planned care; outpatients, therapy, diagnostics and wellbeing services. Extended primary care St Lukes Hospital Increase the beds by 6 Feilding Palmer Hospital Close inpatient beds Increase outpatients on the site but not necessarily in the existing hospital building Baseline Position (2016/17) Coalville 24 Stroke; 24 Rehab Loughborough 24 Rebab Hinckley 39 Rehab Evington/LGH 47 Rehab; 15 Stroke Melton 17 Rehab Oakham 16 Rehab Market 15 Rehab; 17 Stroke Lutterworth 10 Rehab Harborough Relationship to other plans: Home First; Integrated Teams Outcomes (Impact) More patients being cared for in their own homes Sustainable community hospital inpatient service capacity Transfer of stroke rehabilitation services from Leicester General Hospital Safer staffing levels on community hospital wards More patients receiving outpatient care closer to home More patients receiving diagnostics closer to home More patients receiving day case procedures closer to home Proposed by 2020/21 subject to formal consultation Coalville 15 Stroke; 21 Rehab Loughborough 24 Rebab Hinckley 21 Rehab Evington 42 Rehab; 15 Stroke Melton 21 Rehab Oakham 0 Market Harborough 21 Rehab; 15 Stroke Lutterworth 0 Note: The Home First model may see further reductions in rehab beds 58

59 Investment required Capital Savings to be achieved Change in activity Impact on bed 16/17 20/21 Total m m m m m m Lutterworth Reprovision Diagnostic/Primary Care Hub Hinckley (inc day case theatre) East ward reconfiguration Melton East ward reconfiguration Harborough CAMHS Relocation LGH stroke to Evington Rutland External Funding Requirement Disposals (6.0) (14.8) (20.8) Commercially funded (1.0) (1.0) Local Authority funded (2.0) (3.4) (1.0) (6.4) DH funding requirement See Home First and Long Term Conditions for savings related to reducing beds See proposals by 2020/21 See proposals by 2020/21 Key Actions 16/17 Coalville Hospital Loughborough Hospital Hinckley and Bosworth Community Hospital Hinckley Health Centre Evington Melton Mowbray Hospital Rutland Memorial Hospital St. Lukes Hospital Feilding Palmer Hospital 16/17 59

60 Appendix 1 Mapping the Nine Must Dos 1. STPs Implement agreed STP milestones, so that you are on track for full achievement by 20120/21. Achieve agreed trajectories against the STP core metrics set for Finance Deliver individual CCG and NHS provider organisational control totals, and achieve local system financial control totals. At national level, the provider sector needs to be in financial balance in each of 20 and 20. At national level the CCG sector needs to be in financial balance in each of 20 and 20. Implement local STP plans and achieve local targets to moderate demand growth and increase provider efficiencies. Demand reduction measures include: implementing RightCare; elective care redesign; urgent and emergency care reform; supporting selfcare and prevention; progressing populationhealth new care models such as multispecialty community providers (MCPs) and primary and acute care systems (PACS); medicines optimisation; and improving the management of continuing healthcare processes. Provider efficiency measures include; implementing pathology service and back office rationalisation; implementing procurement, hospital pharmacy and estates transformation plans; improving rostering systems and job planning to reduce use of agency staff and increase clinical productivity; implementing the Getting It Right First Time programme; and implementing new models of acute service collaboration and more integrated primary and community services. Key Action LLR 1 LLR 17 LLR 1 LLR 17 LLR 1 LLR 17 LLR 1 LLR 3 LLR 14 LLR 1 LLR 4 LLR 7 LLR 12 LLR 16 LLR 17 Actions Operational aligned to STP milestones Our STP builds on the work of our Better Care Together programme which is already well advanced in many areas. The financial plan shows a balanced plan for 20 and 20 QIPP projects developed in partnership across LLR as part of the STP process focus on demand management Evidence based change: Selfcare and Prevention projects, left shift of activity from acute with the development of Integrated Locality Teams, review of referral thresholds and low value clinical procedures, development of Integrated Teams, System wide medicine optimisation programmes, CHC procurement to improve current processes. s in train for estate rationalisation and sharing back office functions. Provider efficiencies in conjunction with CCGs include maternity services review, and integrated services. 3. Primary Care Ensure the sustainability of general practice in your area by LLR 5 Supporting practices to take forward the initiatives within the implementing the General Practice Forward View, including the General Practice Five Year Forward View plans detailed in Primary plans for Practice Transformational Support, and the ten high impact Care for submission on 23 rd December. changes. Ensure local investment meets or exceeds minimum required levels. LLR 5 In line with requirements General Practice Five Year Forward View 60

61 Key Action (Appendix 5) provides detail. Actions Tackle workforce and workload issues, including interim milestones that contribute towards increasing the number of doctors working in general practice by 5,000 in 2020, cofunding an extra 1,500 pharmacists to work in general practice by 2020, the expansion of improving Access to Psychological Therapies (IAPT) in general practice with 3,000 more therapists in primary care, and investment in training practice staff and stimulating the use of online consultation systems. By no later than March 2019, extend and improve access in line with requirements for new national funding. Support general practice at scale, the expansion of MCPs and PACS, and enable and fund primary care to play its part in fully implementing the forthcoming framework for improving health in care homes. LLR 5 LLR 9 LLR 9 LLR 4 LLR 5 Baseline assessments have been completed and Clinical Pharmacists and Emergency Care Practitioner roles are being developed. We have committed to an increase of 10 in the primary care workforce to 2505 WTE by We will work with our providers and the wider system to put the necessary plans in place to deliver the national IAPT targets Including funding for training practice staff and stimulate the use of online consultation systems Ensure access to extended primary care services in the evening and weekend outside of core GP opening hours in multiple sites across the geography. This access will not necessarily be from a GP but a nurse, pharmacist, ANP, ECP or other health professional according to need. Developing integration of services through placebased teams. We will continue our pharmacist led work with care homes to improve nutritional and pharmaceutical care for people in care homes contributing to independence and health outcomes and further develop support to Care homes through the development of Integrated Locality Teams. There will also be a 24/7 urgent care home visiting service across LLR, including out of hours home visiting and an acute visiting service for people with complex needs or living in care homes. 4. Urgent & emergency care Deliver the four hour A&E standard, and standards for ambulance response times including through implementing the five elements of the A&E Improvement. By November 2017, meet the four priority standards for sevenday hospital services for all urgent network specialist services. LLR 3 LLR 3 s in place to achieve constitutional standards. Improving Ambulance response times through the implementation of A&E Front Door Clinical Navigator and the mobile Directory of Service and sustain the current high levels of hear and treat; Streaming at the front door of LRI Emergency Department Manage demand for urgent care in order to minimise presentations at the Emergency Department; Improving flow within hospital; Improving discharge processes. Continue to improve compliance with the 7day services priority clinical standards by implementing a new pathway at the LRI Front door enhancing senior clinical presence and effective streaming to ensure patients are seen in the most appropriate setting; pathway redesign including enhanced services for ambulatory assessment in 61

62 Implement the Urgent and Emergency Care Review, ensuring a 24/7 integrated care service for physical and mental health is implemented by March 2020 in each STP footprint, including a clinical hub that supports NHS 111, 999 and outofhours calls. Deliver a reduction in the proportion of ambulance 999 calls that result in avoidable transportation to an A&E department. Initiate crosssystem approach to prepare for forthcoming waiting time standard for urgent care for those in a mental health crisis. Key Action LLR 3 LLR 3 LLR 3 LLR 9 Actions community settings; increasing specialist support in the community; the implementation of SAFER patient flow bundle, trail senior acute physicians in ED and learning from other systems By April 2017 a new model of home visiting, OutofHours provision, clinical navigation, Urgent Care and enhanced primary care access, which in combination will provide an integrated twentyfour hour service across LLR will have been generated Introducing clinical navigation to increase the numbers of people calling NHS 111 who receive clinical triage and advice Improved mental health crisis services for people of all ages, including psychiatric liaison, crisis support for children and young people, clinical triage from 111, a refurbished PSAU suitable for all ages and crisis cars in the community. Remodel Community Mental Health Teams, review Psychiatric Intensive Care provision, and strengthen; IAPT, Liaison Psychiatry, Perinatal and Eating Disorder services and develop NICE compliant services for First Episodes in Psychosis and Personality Disorder and to meet the national standards. 5. RTTs and elective care Deliver the NHS Constitution standard that more than 92 of patients on nonemergency pathways wait no more than 18 weeks from referral to treatment (RTT). Deliver patient choice of first outpatient appointment, and achieve 100 of use of ereferrals by no later than April 2018 in line with the 20 CQUIN and payment changes from October Streamline elective care pathways, including through outpatient redesign and avoiding unnecessary followups. Implement the national maternity services review, Better Births, through local maternity systems. LLR 1 LLR 1 LLR 5 LLR 1 LLR 9 62 Structure in place to manage performance through contracting teams Individual CCGs monitor progress through Finance and Performance meetings and escalate to Boards as necessary. At a system level the Provider Performance and Assurance Group (an LLR group made up of Executives; clinical leads and lay member) oversees provider performance including relevant NHS Constitutional Targets. Baseline Position (2016/17) RTT Performance target is 92, YTD (October 2016) is 92.8 Patient choice continues to be available and plans are in place to reach the national target for use of e referrals. Driving down Outpatient followups by reducing clinical variation, removing unnecessary followups, using virtual clinics, nonface to face appointments and through open access referrals. Improved access and outcomes for women and their babies based on the principles within Better Births including the formation of a Maternity Network and the development to of integrated pathways between primary and secondary care to provide continuity of care.

63 6. Cancer Working through Cancer Alliances and the National Cancer Vanguard, implement the cancer taskforce report. Deliver the NHS Constitution 62 day cancer standard, including by securing adequate diagnostic capacity, and the other NHS Constitution cancer standards. Make progress in improving oneyear survival rates by delivering a yearonyear improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancer diagnosed following an emergency admission. Ensure stratified follow up pathways for breast cancer patients are rolled out and prepare to roll out for other cancer types. Ensure all elements of the Recovery Package are commissioned, including ensuring that: o all patients have a holistic needs assessment and care plan at the point of diagnosis o a treatment summary is sent to the patient s GP at the end of treatment; and o a cancer care review is completed by the GP within six months of a cancer diagnosis. Key Action LLR 8 LLR 1 LLR 8 LLR 8 LLR 8 LLR 8 Actions Work with Cancer Research UK to promote earlier diagnosis of cancer, increasing access to optimal treatment and thereby improving survival rates and reducing cancer mortality. Promoting the use of NICE approved Cancer Maps to support primary care in making appropriate referrals. Continue the work started in 2016/17 to encourage participation in the national Bowel Screening programme and increasing first time take up. Upskilling healthcare professionals around cancer pathways. Implement the Cancer Recovery Action to ensure all constitutional standards are met and/or maintained this includes work on matching demand to staffing levels, increasing diagnostics and changes to pathways. Through GP learning events there will be upskilling around cancer pathways Patient information will be available through community engagement events and the bowel screening programme Patient information as part of the health recovery packages through health and wellbeing events There is a multi organisational cancer approach to improve cancer care for patients in LLR There is a multi organisational cancer approach to improve cancer care for patients in LLR 7. Mental Health Deliver in full the implementation plan for the Mental Health Five Year Forward View for all ages, including: o Additional psychological therapies so that at least 19 of people with anxiety and depression access treatment, with the majority of the increase from the baseline of 15 to be integrated with primary care; o More highquality mental health services for children and LLR 9 Commission community eating disorder teams to meet standards Widen choice and effectiveness in crisis response and reduce demand for beds by remodelling Community Mental Health Teams undertake a review of Psychiatric Intensive Care provision, and strengthen IAPT, Liaison Psychiatry, Perinatal and Eating Disorder services and develop NICE compliant services for First Episodes in Psychosis and Personality Disorder to meet the national standards. 63

64 o o o o young people, so that at least 32 of children with a diagnosable condition are able to access evidencebased services by April 2019, including all areas being part of Children and Young People Improving Access to Psychological Therapies (CYPIAPT) by 2018; Expand capacity so that more than 53 of people experiencing a first episode of psychosis begin treatment with a NICErecommended package of care within two weeks of referral; Increase access to individual placement support for people with severe mental illness in secondary care services by 25 by April 2019 against 20 baseline; Commission community eating disorder teams so that 95 of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases; and Reduce suicide rates by 10 against the 2016/17 baseline. Key Action Actions Increase clinical efficiency and partnership processes to create alternatives to acute admission and enable flow through acute hospital beds, including care management, access and support to mainstream and potentially bespoke accommodation. Reduce suicide and increase resilience and promote recovery and independence by enabling people to manage their health more effectively. We will develop awareness and support skills in the population and develop recovery networks, social prescribing and workplace health. Developing a local integrated offer enabling fewer placements out of area and by conducting rigorous reviews so that people have appropriate care packages closer to home at reduced cost, potentially using this redirected investments to build local infrastructure. Provide more high quality mental health services for children and young people, so that at least 32 of children with a diagnosable condition are able to access evidence based services by April 2019, including all areas being part of Children and Young People Improving Access to Psychological Therapies (CYP IAPT) by Commission community eating disorder teams so that 95 of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases and reduce suicide rates by 10 against the 2016/17 baseline. Commissioners and providers will join the national quality improvement and accreditation network for community eating disorder services. Ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals. Increase baseline spend on mental health to deliver the Mental Health Investment Standard. Maintain a dementia diagnosis rate of at least two thirds of estimated local prevalence, and have due regard to the forthcoming NHS implementation guidance on dementia focusing on postdiagnostic care and support. LLR 9 LLR 9 64 Improved mental health crisis services for people of all ages, including psychiatric liaison, crisis support for children and young people, clinical triage from 111, a refurbished PSAU suitable for all ages and crisis cars in the community. Our financial plan shows that we are meeting this standard. LLR 9 The standard dementia diagnosis rate for LLR is Upskill primary care clinicians and identify dementia leads across the health and social care partners Review of the Memory Assessment Service and the shared care model is in place. Further work will be undertaken to remodel the service in order to improve capacity and access to the service.

65 Eliminate out of area placements for nonspecialist acute care by 2020/21. Key Action LLR 9 Actions By conducting rigorous reviews so that people have appropriate care packages closer to home at reduced cost, potentially using this redirected investments to build local infrastructure. 8. People with learning disabilities Deliver Transforming Care Partnership plans with local government partners, enhancing community provision for people with learning disabilities and/or autism. Reduce inpatient bed capacity by March 2019 to 1015 in CCGcommissioned beds per million population, and 2025 in NHS Englandcommissioned beds per million population. Improve access to healthcare for people with learning disability so that by 2020, 75 of people on a GP register are receiving an annual health check. Reduce premature mortality by improving access to health services, education and training of staff, and by making necessary reasonable adjustments for people with a learning disability and/or autism. LLR 10 LLR 10 LLR 10 LLR 10 Support in reducing reliance on inpatient care for people with LD or autism in order to meet the national standard Our comprehensive plan will transform care for people with learning disabilities. By 20, our aim is to produce and deliver responsive, high quality, safe learning disability services and support that maximise independence, offer choice, are personcentred, good value and meet the needs and aspirations of individuals and their family carers. Reduction in premature mortality by improving access to health services, education and providing training to staff, and by making reasonable adjustments for people with learning disabilities and or autism. Intensive support when necessary to avoid admission to mental health inpatient settings through the provision of a refocused and enhanced Learning Disability Outreach Team. Decrease the number of Agnes Unit inpatient beds by 4 and increase community support to prevent admissions and readmissions. Working with primary care providers to deliver the target of 75 of people on a GP register are receiving an annual health check Practices sign up to the Learning Disabilities enhanced service. Education and providing training to staff is also offered. Better identification of people at risk, and early intervention through the provision of a refocused and enhanced Learning Disability Outreach Team and continuing to work with our primary care providers. 9. Improving quality in organisation s All organisations should implement plans to improve quality of care, particularly for organisations in special measures. LLR1 LLR 17 Improve collaboration to multiagency working across health and social care to address patient safety concerns for patient safety incidents and a patient safety culture across all our providers of services. In relation to quality we encompass the three equally important parts that include: Care that is safe, Care that is clinically effective and Care that provides a positive experience for people. Our focus is on the 65

66 Drawing on the National Quality Board s resources, measure and improve efficient use of staffing resources to ensure safe, sustainable and productive services. Participate in the annual publication of findings from reviews of deaths to include the annual publication of avoidable death rates, and actions they have taken to reduce deaths related to problems in healthcare. Key Action LLR1 LLR 17 LLR1 LLR 17 Actions following areas: Patient Experience; Patient Safety; Infection Prevention and Control; Safeguarding; Workforce and Organisational Development; Research and Innovation; Primary Care Quality; Contract Quality Assurance; Urgent Care and Patient care. We will continue to drive a new generation within the health and social care workforce to work across organisational boundaries, and with a greater focus on out of hospital service and integrated working. Monitor Serious Incidents from our providers to identify any safety concerns Undertake both announced and unannounced Quality Visits of all our provider organisation to ensure direct sight of patient care and patient experience via the Contract Quality Review process ensure robust monitoring of all provider organisations via the Quality Schedules to ensure compliance with essential standards of care and quality 66

67 Appendix 2 ning for /2019 Key Performance Indicators (KPIs) This section provides the Key Performance Indicators for each CCG submitted on 24 th November Weeks Referral to Treatment (RTT) trajectories: Incomplete Pathways (Monthly) Diagnostic Waiting Times trajectories (Monthly) Cancer 2 Week Wait trajectories & Cancer 2 Week Wait Breast Symptoms trajectories (Monthly) Cancer 31 Days First Definitive Treatment trajectories, Cancer 31 Days Subsequent Treatment Surgery trajectories, Cancer 31 Days Subsequent Treatment AntiCancer Drug Regimens trajectories & Cancer 31 Days Subsequent Treatment Radiotherapy trajectories (All required monthly) Cancer 62 Day Urgent Referral to First Treatment Waits trajectories, Referral from cancer screening service & for first treatment following referral from a consultant s decision to upgrade the patient s priority (All required monthly) A&E 4 Hour Wait trajectories (Monthly). Activity has been completed by Business Intelligence, and will be reported and discussed elsewhere by the CCG Mental Health Dementia Estimated Diagnosis Rate Mental Health IAPT Access Roll Out, Recovery & Waiting Times 6 Weeks & 18 Weeks Mental Health Psychosis 2 Weeks Children & Young Persons Mental Health Services Access Rate and Waiting Times 1 Week & 4 Weeks for Children EReferrals Coverage Personal Health Budgets Children Waiting > 18 weeks for Wheelchairs Extended Access (evenings & weekends) to GP Services LD/Autism Reliance on Inpatient Care (CCGs & NHS England) this will be completed by Nene CCG as Lead 67

68 RTT 18 Weeks National Standard 92 Leicester City Standard Monthly Diff. Tolerance RTT Incomplete Pathway / / E.B.3 Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways April May June July August September October November December January February March 18,115 18,723 18,839 17,763 18,488 18,582 18,076 17,755 19,382 18,596 18,380 19,001 18,832 19,487 19,731 18,764 19,796 19,636 19,450 19,000 20,901 20,012 19,722 20, ,773 20,283 20,228 19,748 19,854 21,385 21,942 21,928 21,363 21, East Leicestershire & Rutland Standard Monthly Diff. Tolerance RTT Incomplete Pathway / / E.B.3 Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways April May June July August September October November December January February March 14,576 15,285 15,704 15,740 15,950 15,901 15,691 15,581 15,025 15,509 15,826 16,050 15,092 15,878 16,328 16,491 16,906 16,761 16,657 16,539 16,001 16,499 16,831 17, ,556 16,531 16,772 16,566 16,382 17,696 17,759 18,055 17,842 17, ,376 16,434 16,708 16,511 16,421 15,929 15,830 15,718 15,207 15,680 15,996 16,294 17,799 17,862 18,160 17,945 17,848 17,313 17,206 17,084 16,528 17,043 17,386 17, ,471 16,529 16,805 16,607 16,516 16,022 15,922 15,810 15,295 15,771 16,089 16,388 17,902 17,966 18,265 18,050 17,951 17,414 17,306 17,183 16,624 17,142 17,487 17, West Leicestershire Standard Monthly Diff. Tolerance RTT Incomplete Pathway / / E.B.3 Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways Pathways < 18 Weeks Total Pathways April May June July August September October November December January February March 16,953 17,579 17,782 17,600 17,847 17,744 17,625 17,356 17,029 17,379 17,668 18,237 17,613 18,277 18,629 18,499 18,806 18,569 18,615 18,234 18,102 18,552 18,817 19, ,873 18,033 17,837 17,987 17,826 19,107 19,227 19,193 19,366 19, ,723 17,834 17,803 17,963 17,880 17,689 17,733 17,370 17,244 17,673 17,925 18,637 19,263 19,384 19,350 19,524 19,434 19,226 19,274 18,879 18,743 19,209 19,483 20, ,868 17,981 17,949 18,111 18,026 17,834 17,878 17,512 17,386 17,818 18,072 18,790 19,421 19,543 19,509 19,684 19,593 19,384 19,432 19,034 18,896 19,366 19,643 20,

69 Diagnostics Waiting Times < 6 Weeks National Standard 1 Leicester City Standard Monthly Diff. Tolerance Diagnostics Test Waiting Times / / E.B.4 Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting April May June July August September October November December January February ,525 5,702 6,040 5,848 5,951 6,048 6,129 6,311 6,091 6,204 6,696 6, ,594 6,741 6,626 6,392 6, March East Leicestershire & Rutland Standard Monthly Diff. Tolerance Diagnostics Test Waiting Times / / E.B.4 Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting April May June July August September October November December January February ,706 4,799 5,173 4,920 4,962 5,073 5,136 5,481 5,153 5,210 5,422 5, ,626 5,458 5,463 5,173 5, ,653 5,490 5,495 5,203 5,198 5,240 5,305 5,662 5,323 5,382 5,601 5, ,680 5,521 5,527 5,233 5,228 5,271 5,336 5,694 5,354 5,413 5,633 5, March West Leicestershire Standard Monthly Diff. Tolerance Diagnostics Test Waiting Times / / E.B.4 Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting Number Waiting > 6 Wks Total Number Waiting April May June July August September October November December January February ,597 5,779 5,835 5,709 5,464 5,650 5,761 6,047 5,767 5,857 6,063 6, ,143 6,010 6,188 6,358 5, ,185 6,059 6,239 6,410 5,841 5,850 5,965 6,261 5,971 6,064 6,278 6, ,228 6,109 6,290 6,463 5,889 5,898 6,014 6,312 6,020 6,114 6,329 6, March 69

70 Cancer 62 Day Waits National Standard 85 Leicester City Standard Monthly Diff. Tolerance Cancer Waiting Times 62 Day GP Referral / / E.B.12 April May June July August September October November December January Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen February March East Leicestershire & Rutland Standard Monthly Diff. Tolerance Cancer Waiting Times 62 Day GP Referral / / E.B.12 April May June July August September October November December January February March Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen West Leicestershire Standard Monthly Diff. Tolerance Cancer Waiting Times 62 Day GP Referral / / E.B.12 April May June July August September October November December January February March Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen Number Treated < 62 Days Total Number Seen

71 Cancer Waits All Indicators have been set at the National Standard as follows: Cancer 2 Week Wait National Standard 93 Cancer 2 Week Wait Breast Symptoms National Standard 93 Cancer 31 Day Wait National Standard 96 Cancer 31 Day Wait Surgery National Standard 94 Cancer 31 Day Wait Drug Regimen National Standard 98 Cancer 31 Day Radiotherapy National Standard 94 Cancer 62 Day Cancer Screening Service National Standard 90 A&E 4 Hour Wait National Standard 95 This is submitted by the Lead Commissioner on behalf of LLR Leicester City Standard Monthly Diff. Tolerance University Hospitals Of Leicester NHS Trust / / E.B.5 Number Waiting > 4 Hrs Total Attendances Number Waiting > 4 Hrs Total Attendances Number Waiting > 4 Hrs Total Attendances Number Waiting > 4 Hrs Total Attendances April May June July August September October November December January February March 1,391 1,578 1,379 1,433 1,715 1,768 2,131 3,632 2,833 3,694 3,670 4,585 18,357 19,135 18,729 18,363 18,216 18,320 19,166 19,895 19,058 19,602 18,540 20, ,549 4,227 3,771 4,652 3,859 18,924 20,983 19,462 20,149 19,

72 Dementia Diagnosis National Standard 66.7 Leicester City Standard Monthly Diff. Tolerance E.A.S.1 Number of people aged 65 or over diagnosed with dementia April May June July August September October November December January February March 2,238 2,242 2,358 2,376 2,410 2,437 Dementia Estimated Diagnosis Rate for people aged / Estimated prevalence of dementia based on GP registered population Number of people aged 65 or over diagnosed with dementia Estimated prevalence of dementia based on GP registered population Number of people aged 65 or over diagnosed with dementia Estimated prevalence of dementia based on GP registered population 2,694 2,694 2,694 2,694 2,694 2, ,909 1,909 1,909 1,909 1,909 1,909 1,909 1,909 1,909 1,909 1,909 1,909 2,861 2,861 2,861 2,861 2,861 2,861 2,861 2,861 2,861 2,861 2,861 2, ,943 1,943 1,943 1,943 1,943 1,943 1,943 1,943 1,943 1,943 1,943 1,943 2,913 2,913 2,913 2,913 2,913 2,913 2,913 2,913 2,913 2,913 2,913 2, East Leicestershire & Rutland Standard Monthly Diff. Tolerance E.A.S.1 Number of people aged 65 or over diagnosed with dementia April May June July August September October November December January February 2,782 2,773 2,835 2,849 2,879 2,886 March Dementia Estimated Diagnosis Rate for people aged / Estimated prevalence of dementia based on GP registered population Number of people aged 65 or over diagnosed with dementia Estimated prevalence of dementia based on GP registered population Number of people aged 65 or over diagnosed with dementia Estimated prevalence of dementia based on GP registered population 4,599 4,599 4,599 4,599 4,599 4, ,998 2,998 2,998 2,998 2,998 2,998 2,998 2,998 2,998 2,998 2,998 2,998 4,494 4,494 4,494 4,494 4,494 4,494 4,494 4,494 4,494 4,494 4,494 4, ,094 3,094 3,094 3,094 3,094 3,094 3,094 3,094 3,094 3,094 3,094 3,094 4,638 4,638 4,638 4,638 4,638 4,638 4,638 4,638 4,638 4,638 4,638 4, West Leicestershire Standard Monthly Diff. Tolerance E.A.S.1 Number of people aged 65 or over diagnosed with dementia April May June July August September October November December January February March 3,008 2,900 2,977 2,981 3,000 3,036 Dementia Estimated Diagnosis Rate for people aged / Estimated prevalence of dementia based on GP registered population Number of people aged 65 or over diagnosed with dementia Estimated prevalence of dementia based on GP registered population Number of people aged 65 or over diagnosed with dementia Estimated prevalence of dementia based on GP registered population 4,684 4,684 4,684 4,684 4,684 4, ,937 2,937 2,937 2,937 2,937 2,937 2,937 2,937 2,937 2,937 2,937 2,937 4,403 4,403 4,403 4,403 4,403 4,403 4,403 4,403 4,403 4,403 4,403 4, ,025 3,025 3,025 3,025 3,025 3,025 3,025 3,025 3,025 3,025 3,025 3,025 4,534 4,534 4,534 4,534 4,534 4,534 4,534 4,534 4,534 4,534 4,534 4,

73 IAPT Roll Out National Standard 16.8 for 20 & 19 for 20 Leicester City Standard Standard E.A.3 Q1 Q2 Q3 Q4 Number of people who receive psychological therapies 1,445 1,395 1, /16 Number of people who have depression and/or anxiety disorders 36,009 36,009 36,009 36, Number of people who receive psychological therapies 1, /17 Number of people who have depression and/or anxiety disorders 36, Number of people who receive psychological therapies IAPT rollout 1,513 1,513 1,513 1, Number of people who have depression and/or anxiety disorders 36,010 36,010 36,010 36,010 Number of people who receive psychological therapies ,712 1,712 1,712 1, Number of people who have depression and/or anxiety disorders 36,011 36,011 36,011 36, East Leicestershire & Rutland Standard Standard E.A.3 Q1 Q2 Q3 Q4 Number of people who receive psychological therapies 920 1,030 1,025 1, /16 Number of people who have depression and/or anxiety disorders 27,593 27,593 27,593 27, Number of people who receive psychological therapies /17 Number of people who have depression and/or anxiety disorders 27, Number of people who receive psychological therapies IAPT rollout 1,160 1,160 1,160 1, Number of people who have depression and/or anxiety disorders 27,594 27,594 27,594 27,594 Number of people who receive psychological therapies ,311 1,311 1,311 1, Number of people who have depression and/or anxiety disorders 27,594 27,594 27,594 27, West Leicestershire Standard Standard E.A.3 Q1 Q2 Q3 Q4 Number of people who receive psychological therapies 1,060 1,400 1,080 1, /16 Number of people who have depression and/or anxiety disorders 33,319 33,319 33,319 33, Number of people who receive psychological therapies 1, /17 Number of people who have depression and/or anxiety disorders 33, Number of people who receive psychological therapies IAPT rollout 1,400 1,400 1,400 1, Number of people who have depression and/or anxiety disorders 33,320 33,320 33,320 33,320 Number of people who receive psychological therapies ,584 1,584 1,584 1, Number of people who have depression and/or anxiety disorders 33,320 33,320 33,320 33,

74 IAPT Recovery National Standard 50 Leicester City Standard Diff. Tolerance E.A.S 2 Q1 Q2 Q3 Q4 The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 2015/16 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment , The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session 65 did not). 2016/17 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment. 240 IAPT Recovery Rate * The number of people who have finished treatment having attended 27.0 at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 20 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 20 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment East Leicestershire & Rutland Standard Diff. Tolerance E.A.S 2 Q1 Q2 Q3 Q4 The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 2015/16 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session 390 did not). 2016/17 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment. 695 IAPT Recovery Rate * The number of people who have finished treatment having attended 56.2 at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 20 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 20 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment

75 West Leicestershire Standard Diff. Tolerance E.A.S 2 Q1 Q2 Q3 Q4 The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 2015/16 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session 395 did not). 2016/17 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment. 825 IAPT Recovery Rate * The number of people who have finished treatment having attended 48.1 at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 20 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment The number of people who have finished treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not). 20 The number of people who have finished treatment within the reporting quarter (having attended at least two treatment contacts and coded as discharged) minus the number of people who have finished treatment not at clinical caseness at initial assessment

76 IAPT Waiting Times 6 Weeks National Standard 75 Leicester City Standard Diff. Tolerance /17 E.H.1 _A1 Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period Q1 Q2 Q3 Q IAPT Waiting Times 6 Weeks 20 * Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period East Leicestershire & Rutland Standard Diff. Tolerance /17 E.H.1 _A1 Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period Q1 Q Q3 Q4 IAPT Waiting Times 6 Weeks 20 * Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period West Leicestershire Standard Diff. Tolerance IAPT Waiting Times 6 Weeks / E.H.1 _A1 Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period * Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period Number of ended referrals that finish a course of treatment in period who received their first appointment within 6 weeks of referral Number of ended referrals that finish a course of treatment in period Q1 Q2 Q3 Q

77 IAPT Waiting Times 18 Weeks National Standard 95 Leicester City Standard Diff. Tolerance E.H.2_A2 Q1 Q2 Q3 Q4 Number of ended referrals that finish a course of treatment in period who received their first appointment within 18 weeks of referral /17 Number of ended referrals that finish a course of treatment in period 285 * 44.3 Number of ended referrals that finish a course of treatment in IAPT Waiting Times 18 Weeks 20 period who received their first appointment within 18 weeks of referral Number of ended referrals that finish a course of treatment in period Number of ended referrals that finish a course of treatment in 20 period who received their first appointment within 18 weeks of referral Number of ended referrals that finish a course of treatment in period East Leicestershire & Rutland Standard Diff. Tolerance E.H.2_A2 Q1 Q2 Q3 Q4 Number of ended referrals that finish a course of treatment in period who received their first appointment within 18 weeks of referral /17 Number of ended referrals that finish a course of treatment in period 760 * 98.6 Number of ended referrals that finish a course of treatment in IAPT Waiting Times 18 Weeks 20 period who received their first appointment within 18 weeks of referral Number of ended referrals that finish a course of treatment in period Number of ended referrals that finish a course of treatment in 20 period who received their first appointment within 18 weeks of referral Number of ended referrals that finish a course of treatment in period West Leicestershire Standard Diff. Tolerance E.H.2_A2 Q1 Q2 Q3 Q4 Number of ended referrals that finish a course of treatment in period who received their first appointment within 18 weeks of referral /17 Number of ended referrals that finish a course of treatment in period 895 * 98.6 Number of ended referrals that finish a course of treatment in IAPT Waiting Times 18 Weeks 20 period who received their first appointment within 18 weeks of referral Number of ended referrals that finish a course of treatment in period Number of ended referrals that finish a course of treatment in 20 period who received their first appointment within 18 weeks of referral Number of ended referrals that finish a course of treatment in period

78 EIP Psychosis National Standard 50 for 20 and 53 for 2018/18 (small numbers impact on percentages) Leicester City Standard Standard Diff. Tolerance E.H.4 Q1 Q2 Q3 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 12 2 weeks of referral. Q4 2016/17 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package 15 EIP Psychosis treated with a NICE approved care package within two weeks of referral 20 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package East Leicestershire & Rutland Standard Standard Diff. Tolerance E.H.4 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Q1 5 Q2 Q3 Q4 2016/17 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package 6 EIP Psychosis treated with a NICE approved care package within two weeks of referral 20 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package West Leicestershire Standard Standard Diff. Tolerance E.H.4 Q1 Q2 Q3 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 5 2 weeks of referral. Q4 2016/17 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package 7 EIP Psychosis treated with a NICE approved care package within two weeks of referral 20 Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended package care package in the reporting period within 2 weeks of referral. Number of referrals to and within the Trust with suspected first episode psychosis or at risk mental state that start a NICErecommended care package

79 Improve Access Rate to Children & Young People Mental Health National Standard 30 for 20 and 32 for 20 Leicester City 20 Standard 20 Standard E.H.9 16/17 Estimate* 16/17 CCG Revised Estimate* Q1 Q2 Q3 Q4 17 / 18 Q1 Q2 Q3 Q4 1a The number of new children and young people aged 018 receiving treatment from NHS funded community services in the reporting period. 40 1, Improve Access Rate to CYPMH Annual change for 1a The number of new young people receiving treatment from NHS funded community services 2a Total number of individual children and young people aged 0 18 receiving treatment by NHS funded community services in the reporting period. 2b Total number of individual children and young people aged 0 18 with a diagnosable mental health condition. Percentage of children and young people aged 018 with a diagnosable mental health condition who are receiving treatment from NHS funded community services. 16/17 to to 16/17 Final Estimate change change 1,200 1,412 1, /17 16/17 CCG Revised Q2 Q3 Q1 Q4 17 / 18 Q1 Q2 Q3 Q4 Estimates** Estimate** 75 2, , ,824 8,820 8,820 8,820 8, East Leicestershire & Rutland 20 Standard 20 Standard E.H.9 16/17 Estimate* 16/17 CCG Revised Estimate* Q1 Q2 Q3 Q4 17 / 18 Q1 Q2 Q3 Q4 1a The number of new children and young people aged 018 receiving treatment from NHS funded community services in the reporting period Improve Access Rate to CYPMH Annual change for 1a The number of new young people receiving treatment from NHS funded community services 2a Total number of individual children and young people aged 0 18 receiving treatment by NHS funded community services in the reporting period. 2b Total number of individual children and young people aged 0 18 with a diagnosable mental health condition. Percentage of children and young people aged 018 with a diagnosable mental health condition who are receiving treatment from NHS funded community services. 16/17 Final Estimate 16/17 Estimates** 16/17 to change to change /17 CCG Revised Estimate** Q1 Q2 Q3 Q4 17 / 18 Q1 Q2 Q3 Q , , ,805 5,639 5,639 5,639 5,

80 West Leicestershire 20 Standard 20 Standard E.H.9 16/17 Estimate* 16/17 CCG Revised Estimate* Q1 Q2 Q3 Q4 17 / 18 Q1 Q2 Q3 Q4 1a The number of new children and young people aged 018 receiving treatment from NHS funded community services in the reporting period Improve Access Rate to CYPMH Annual change for 1a The number of new young people receiving treatment from NHS funded community services 2a Total number of individual children and young people aged 0 18 receiving treatment by NHS funded community services in the reporting period. 2b Total number of individual children and young people aged 0 18 with a diagnosable mental health condition. Percentage of children and young people aged 018 with a diagnosable mental health condition who are receiving treatment from NHS funded community services. 16/17 Final Estimate 16/17 Estimates** 16/17 to change to change 900 1,068 1, /17 CCG Revised Estimate** Q1 Q2 Q3 Q4 17 / 18 Q1 Q2 Q3 Q , , ,188 6,827 6,827 6,827 6,

81 Mental Health Children & Young People Eating Disorders (ED) Waiting Times 4 Weeks National Standard 95 (small numbers impact on percentages) Leicester City Standard (to be achieved 95 by 2020) E.H.10 Q1 Q2 Q3 Q4 Diff. Tolerance Waiting Times for Routine Referrals to CYP Eating Disorder Services Within 4 Weeks Number of CYP with ED (routine cases) referred with a suspected ED that start treatment within 4 weeks of referral Number of CYP with a suspected ED (routine cases) that start treatment 5 Number of CYP with ED (routine cases) referred with a suspected ED that start treatment within 4 weeks of referral Number of CYP with a suspected ED (routine cases) that start treatment East Leicestershire & Rutland Standard (to be achieved 95 by 2020) E.H.10 Q1 Diff. Tolerance Waiting Times for Routine Referrals to CYP Eating Disorder Services Within 4 Weeks Number of CYP with ED (routine cases) referred with a suspected ED that start treatment within 4 weeks of referral Number of CYP with a suspected ED (routine cases) that start treatment 10 Number of CYP with ED (routine cases) referred with a suspected ED that start treatment within 4 weeks of referral Number of CYP with a suspected ED (routine cases) that start treatment Q Q3 Q West Leicestershire Standard (to be achieved 95 by 2020) E.H.10 Q1 Q2 Diff. Tolerance Waiting Times for Routine Referrals to CYP Eating Disorder Services Within 4 Weeks Number of CYP with ED (routine cases) referred with a suspected ED that start treatment within 4 weeks of referral Number of CYP with a suspected ED (routine cases) that start treatment Number of CYP with ED (routine cases) referred with a suspected ED that start treatment within 4 weeks of referral Number of CYP with a suspected ED (routine cases) that start treatment Q Q

82 Mental Health Children & Young People Eating Disorders (ED) Waiting Times 1 Week National Standard 95 Leicester City Standard (to be achieved by 2020) Diff. Tolerance Waiting Times for Urgent Referrals to CYP Eating Disorder Services Within 1 Week E.H.11 Number of CYP with ED (urgent cases) referred with a suspected ED that start treatment within 1 week of referral Number of CYP with a suspected ED (urgent cases) that start treatment 3 Q Number of CYP with ED (urgent cases) referred with a suspected ED that start treatment within 1 week of referral 3 Number of CYP with a suspected ED (urgent cases) that start treatment 3 3 Q2 Q Q East Leicestershire & Rutland Standard (to be achieved by 2020) Diff. Tolerance Waiting Times for Urgent Referrals to CYP Eating Disorder Services Within 1 Week E.H.11 Number of CYP with ED (urgent cases) referred with a suspected ED that start treatment within 1 week of referral Number of CYP with a suspected ED (urgent cases) that start treatment Q Number of CYP with ED (urgent cases) referred with a suspected ED that start treatment within 1 week of referral 2 3 Number of CYP with a suspected ED (urgent cases) that start treatment 2 Q Q3 3 Q West Leicestershire Standard (to be achieved by 2020) Diff. Tolerance Waiting Times for Urgent Referrals to CYP Eating Disorder Services Within 1 Week E.H.11 Number of CYP with ED (urgent cases) referred with a suspected ED that start treatment within 1 week of referral Number of CYP with a suspected ED (urgent cases) that start treatment Number of CYP with ED (urgent cases) referred with a suspected ED that start treatment within 1 week of referral 3 3 Number of CYP with a suspected ED (urgent cases) that start treatment 3 Q1 Q2 3 3 Q3 3 3 Q

83 EReferral Coverage National Standard 80 for 20 and 100 for 20 Leicester City 20 Standard 20 Standard Monthly Diff. Tolerance E.P.1 April May June July August September October November December January February March Total number of patients referred to 1st Outpatient Services (including twoweekwaits), via ers EReferral Coverage Overall number of patients referred to 1st Outpatient Services (including twoweekwaits) Total number of patients referred to 1st Outpatient Services (including twoweekwaits), via ers Overall number of patients referred to 1st Outpatient Services (including twoweekwaits) East Leicestershire & Rutland 20 Standard 20 Standard Monthly Diff. Tolerance E.P.1 April May June July August September October November December January February March Total number of patients referred to 1st Outpatient Services (including twoweekwaits), via ers 3,466 3,543 4,090 3,811 4,192 4,502 4,502 4,502 4,502 4,502 4,502 4,502 EReferral Coverage Overall number of patients referred to 1st Outpatient Services (including twoweekwaits) Total number of patients referred to 1st Outpatient Services (including twoweekwaits), via ers Overall number of patients referred to 1st Outpatient Services (including twoweekwaits) 5,776 5,536 6,015 5,293 5,516 5,627 5,627 5,627 5,627 5,627 5,627 5, ,648 4,677 4,900 4,898 5,326 5,660 5,660 5,660 5,660 5,660 5,660 5,660 5,810 5,568 5,568 5,324 5,548 5,660 5,660 5,660 5,660 5,660 5,660 5, West Leicestershire 20 Standard 20 Standard Monthly Diff. Tolerance E.P.1 April May June July August September October November December January February March Total number of patients referred to 1st Outpatient Services (including twoweekwaits), via ers 3,992 4,255 4,729 4,604 4,906 5,297 5,297 5,297 5,297 5,297 5,297 5,297 EReferral Coverage Overall number of patients referred to 1st Outpatient Services (including twoweekwaits) Total number of patients referred to 1st Outpatient Services (including twoweekwaits), via ers Overall number of patients referred to 1st Outpatient Services (including twoweekwaits) 6,654 6,648 6,955 6,395 6,455 6,621 6,621 6,621 6,621 6,621 6,621 6, ,367 5,631 5,899 5,931 6,248 6,676 6,676 6,676 6,676 6,676 6,676 6,676 6,708 6,703 6,703 6,447 6,508 6,676 6,676 6,676 6,676 6,676 6,676 6,

84 Personal Health Budgets National Standard 0.04 Leicester City E.N.1 Q1 Q2 Q3 Q4 1) Personal health budgets in place at the beginning of quarter (total number per CCG) ) New personal health budgets that began during the quarter (total number per CCG) ) Total number of PHB in the quarter = sum of 1) and 2) (total number per CCG) ) GP registered population (total number per CCG) 390, , , ,673 Personal Health Rate of PHBs per 100,000 GP registered population Budgets 1) Personal health budgets in place at the beginning of quarter (total number per CCG) ) New personal health budgets that began during the quarter (total number per CCG) ) Total number of PHB in the quarter = sum of 1) and 2) (total number per CCG) ) GP registered population (total number per CCG) 392, , , ,906 Rate of PHBs per 100,000 GP registered population East Leicestershire & Rutland E.N.1 Q1 Q2 Q3 Q4 1) Personal health budgets in place at the beginning of quarter (total number per CCG) ) New personal health budgets that began during the quarter (total number per CCG) ) Total number of PHB in the quarter = sum of 1) and 2) (total number per CCG) ) GP registered population (total number per CCG) 327, , , ,598 Personal Health Rate of PHBs per 100,000 GP registered population Budgets 1) Personal health budgets in place at the beginning of quarter (total number per CCG) ) New personal health budgets that began during the quarter (total number per CCG) ) Total number of PHB in the quarter = sum of 1) and 2) (total number per CCG) ) GP registered population (total number per CCG) 329, , , ,395 Rate of PHBs per 100,000 GP registered population West Leicestershire E.N.1 Q1 Q2 Q3 Q4 1) Personal health budgets in place at the beginning of quarter (total number per CCG) ) New personal health budgets that began during the quarter (total number per CCG) ) Total number of PHB in the quarter = sum of 1) and 2) (total number per CCG) ) GP registered population (total number per CCG) 383, , , ,781 Personal Health Rate of PHBs per 100,000 GP registered population Budgets 1) Personal health budgets in place at the beginning of quarter (total number per CCG) ) New personal health budgets that began during the quarter (total number per CCG) ) Total number of PHB in the quarter = sum of 1) and 2) (total number per CCG) ) GP registered population (total number per CCG) 386, , , ,378 Rate of PHBs per 100,000 GP registered population

85 Children Waiting Times 18 Weeks for a Wheelchair National Standard 92 for 20 and 100 for 20 Leicester City 20 Standard 20 Standard Diff. Tolerance E.O.1 Q1 Q2 Q3 Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service 50 Q4 2016/17 Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Children Waiting more than 18 Weeks for a Wheelchair 20 Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made East Leicestershire & Rutland 20 Standard 20 Standard Diff. Tolerance E.O.1 Q1 Q2 Q3 Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service 26 Q4 2016/17 Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Children Waiting more than 18 Weeks for a Wheelchair 20 Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made

86 West Leicestershire 20 Standard 20 Standard Diff. Tolerance E.O.1 Q1 Q2 Q3 Q4 Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service /17 Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Children Waiting more than 18 Weeks for a Wheelchair 20 Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made Number of children whose episode of care was closed within the reporting period where equipment was delivered in 18 weeks or less of being referred to the service Total number of children whose episode of care was closed within the quarter where equipment was delivered or a modification was made

87 Extended Access (evening & weekends) at GP Services No National Standard specified Leicester City E.D.14 Months 16 Months Number of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing prebookable appointments outside of standard working hours either through their practice or through their group. The criteria of Full extended access are: Provision of prebookable appointments on Saturdays through the group or practice AND Provision of prebookable appointments on Sundays through the group or practice AND Provision of prebookable appointments on weekday mornings or evenings through the group or practice Total number of practices within the CCG Extended access (evening and weekends) at GP services Number of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing prebookable appointments outside of standard working hours either through their practice or through their group. The criteria of Full extended access are: Provision of prebookable appointments on Saturdays through the group or practice AND Provision of prebookable appointments on Sundays through the group or practice AND Provision of prebookable appointments on weekday mornings or evenings through the group or practice Total number of practices within the CCG East Leicestershire & Rutland E.D.14 Months 16 Months Number of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing prebookable appointments outside of standard working hours either through their practice or through their group. The criteria of Full extended access are: Provision of prebookable appointments on Saturdays through the group or practice AND Provision of prebookable appointments on Sundays through the group or practice AND Provision of prebookable appointments on weekday mornings or evenings through the group or practice Total number of practices within the CCG Extended access (evening and weekends) at GP services Number of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing prebookable appointments outside of standard working hours either through their practice or through their group. The criteria of Full extended access are: Provision of prebookable appointments on Saturdays through the group or practice AND Provision of prebookable appointments on Sundays through the group or practice AND Provision of prebookable appointments on weekday mornings or evenings through the group or practice Total number of practices within the CCG

88 West Leicestershire E.D.14 Months 16 Months 712 Number of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing prebookable appointments outside of standard working hours either through their practice or through their group. The criteria of Full extended access are: Provision of prebookable appointments on Saturdays through the group or practice AND Provision of prebookable appointments on Sundays through the group or practice AND Provision of prebookable appointments on weekday mornings or evenings through the group or practice Total number of practices within the CCG Extended access (evening and weekends) at GP services Number of practices within a CCG which meet the definition of offering full extended access; that is where patients have the option of accessing prebookable appointments outside of standard working hours either through their practice or through their group. The criteria of Full extended access are: Provision of prebookable appointments on Saturdays through the group or practice AND Provision of prebookable appointments on Sundays through the group or practice AND Provision of prebookable appointments on weekday mornings or evenings through the group or practice Total number of practices within the CCG

89 Learning Disabilities Reliance on InPatient Care for People with LD/Autism E.K.1a Q1 Q2 Q3 Q4 Reliance on Inpatient Care for People with LD or Autism Care commissioned by CCGs The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs, and whose bed is commissioned by a CCG. This will include all adults in inpatient wards that are not classified as low, medium or highsecure. GP Registered Population of Transforming Care Partnership (18+ only) Learning Disability Inpatient Rate per Million GP Registered Population The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs, and whose bed is commissioned by a CCG. This will include all adults in inpatient wards that are not classified as low, medium or highsecure. GP Registered Population of Transforming Care Partnership (18+ only) Learning Disability Inpatient Rate per Million GP Registered Population E.K.1b Q1 Q2 Q3 Q4 20 The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs, and whose bed is commissioned by NHS England. This will include all adults in inpatient wards that are classified as lowmedium or highsecure, and all children and young people in Tier 4 CAMHS services Reliance on Inpatient Care for People with LD or Autism Care commissioned by NHS England 20 GP Registered Population of Transforming Care Partnership (18+ only) Learning Disability Inpatient Rate per Million GP Registered Population The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs, and whose bed is commissioned by NHS England. This will include all adults in inpatient wards that are classified as lowmedium or highsecure, and all children and young people in Tier 4 CAMHS services. GP Registered Population of Transforming Care Partnership (18+ only) Learning Disability Inpatient Rate per Million GP Registered Population

90 Calculated Summary of E.K.1a + E.K.1b Q1 Q2 Q3 Q4 The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs GP Registered Population of Transforming Care Partnership (18+ only) Reliance on Inpatient Care for People with LD or Autism Learning Disability Inpatient Rate per Million GP Registered Population The number of people from the TCP who have a learning disability and/or autistic spectrum disorder that are in inpatient care for mental and/or behavioural healthcare needs GP Registered Population of Transforming Care Partnership (18+ only) Learning Disability Inpatient Rate per Million GP Registered Population

91 Appendix 3 Operational Risks Risks Non delivery of required change and QIPP Can the plans be contracted System control totals will not be reached due to the Operational s not being aligned to the STP Relationships challenges providers and commissioners Cultural change required and change to working behaviours and skills not adequately addressed There is a disconnect between provider and commissioner plans The major financial risk is the delivery of QIPP at the targeted level 50m across LLR CCGs Pressures on the acute sector are not reduced and demand continues to grow Mitigation New governance arrangements are in place for delivery of the STP (see governance section). CCGs have formed an LLR QIPP group to oversee the delivery of LLR wide QIPP schemes. Individual CCGs have internal governance mechanisms to manage finance and performance issues. Contract envelopes have been issued and initial responses have been received from providers. Activity levels are being discussed with providers. There is ongoing dialogue between commissioners and providers with a view to agreeing contracts in line with the national timelines. The Operational is aligned with years 2 and 3 of the STP. Our local system has good working relationships and this is being further strengthened by the governance changes described in this document. Organisational Development for LLR agreed by the System Leadership Team on 17 th November Clinical Leadership Group in place which is taking forward the Organisational Development for LLR. The Operational is aligned to the STP. Work is ongoing to ensure that the activity assumptions in the CCGs two year operational plans align to provider plans. Providers are actively involved, and in some instances leading, the programmes of change. 1. A 0.5 Contingency will be set aside to guard against adverse risks. 2. Further QIPP schemes will be developed and implemented during the financial years to ensure delivery of the required surpluses Nonrecurrent funds will be set aside and half will remain uncommitted until the CCGs are satisfied that risks are successfully being managed. Our transformation plans have a strong emphasis on the development of out of hospital services to avoid admission and to enable patients to return home quickly. The redesign of Urgent and Emergency care across LLR will come into force from 1 st April Our plans around planned care are designed to manage demand and reduce unnecessary activity. 91

92 Non delivery of NHS Constitutional Targets Structure in place to manage performance through contracting teams; key groups such as the A&E Delivery Group and the RTT and Cancer Board who have active plans in place to pursue the achievement of the constitutional targets. Individual CCGs monitor progress through Finance and Performance meetings and escalate to Boards as necessary. At a system level the Provider Performance and Assurance Group (an LLR group made up of Executives; clinical leads and lay member) oversees provider performance including relevant NHS Constitutional Targets. 92

93 Appendix 4 General Practice 5 Year Forward View Operational Leicester, Leicestershire and Rutland (LLR) STP 93

94 Contents This plan sets out the initial ideas for how the Leicester, Leicestershire and Rutland (LLR) STP footprint intends to design, implement and deliver locally the elements of the General Practice Five Year Forward View set out in the NHS Operational ning and Contracting Guidance In LLR there is a specific work stream of the STP for the delivery of improved and resilient General Practice. This work is being progressed together as three CCGs working together with a common purpose and vision. This is reflected in the joint nature of this document for the key models and enablers. There are two sections on Access and Finance that are specific to each individual CCG to reflect the differing positions and progress made. Priority Work stream CCG Page No 1 Care Redesign LLR 95 2 Workforce LLR 97 3 Workload LLR IM&T / Estates LLR Access ELR Finance ELR

95 Priority 1: LLR General Practice 5 Year Guidance Ref: Forward View Care Redesign Annex 6) 1.3 Key Deliverables The overarching aim Is to deliver a sustainable model of general practice in which: The practice and primary healthcare team will remain the basic unit of care, with the individual practice patient list retained as the foundation of care. A significant proportion of care will be provided by practices coming together to collaborate; using their expertise and sharing premises, staff and resources to deliver care for and behalf of each other. The model is based on the GP as an expert clinical generalist working in the community, with general practice being the locus of control, ensuring the effective coordination of care. The GP has a pivotal role in tackling comorbidity and health inequalities but increasingly they will work with specialists colocated in primary and community settings, supported by community providers and social care, to create integrated out of hospital care. The key to supporting patients is the ability to provide a differential service according to need. A cohort of patients, especially those with multiple comorbidities, who are at risk of admission for their complex condition require a more proactive offer that could involve a multidisciplinary team including social care, community nursing and specialist care. Personcentred care recognises that an individual is best placed to make decisions about their own health, lifestyle and the level and location of treatment. All practices provide a level of urgent primary care access, as well as planned services, to support patients in selfcare management. Patients with complex needs require a coordinated package of care that will require care planning, regular proactive interventions and support. This continuous care is best provided by a multidisciplinary team with the GP at the heart of that care. This level of service utilises a GPs skills to best effect and patients will be streamed accordingly. All other patients will have access with another appropriate health professional, when needed, supported by a GP. Relationship to other plans: LLR Integrated Teams / ned Care / Long Term Conditions / Urgent & Emergency Care Outcomes (Impact) Active support of the core prevention agenda, whereby the population are empowered to make the right lifestyle choices to maintain their health, reducing the need for a visit to a GP surgery. Improve access to an extended range of services to our patients at scale. This access will not necessarily be from a GP but a nurse, pharmacist, or other health professional according to need. Active planning to prevent emergency admissions for complex or frail patients, and expedite discharge whenever a hospital stay cannot be avoided. The impact will be fewer unplanned admissions, due to proactive management, greater on the day access and a higher proportion of patients accessing selfcare. 95