Hull 2020 NHS Hull CCG Strategic Plan 2014/15 to 2019/20

Hull 2020 NHS Hull CCG Strategic Plan 2014/15 to 2019/20 Date June 2014 Hull 2020 CCG Strategy 1

Document Control Sheet Programme Hull 2020 Document Title CCG Strategy Version Draft 0.6 Project Reference Author Struan Coad Date 19 th June 2014 Document History Version Date Author Comments 0.1 22 nd May 2014 SC Redraft of CCG strategy 0.2 16 th June 2014 SC Inclusion of team comments 0.3 17 th June SC JM comments 0.5 18 June 2014 JM Final revision and comments 0.6 19 th June 2014 SC Final edit 0.7 19 June 2014 JM Offender health and final, final edit Hull 2020 CCG Strategy 2

Contents Document Control Sheet 2 Contents... 3 1. Executive Summary... 4 2. Introduction... 5 2.1. Purpose of the document... 5 2.2. Business Need and Current Situation... 5 2.3. Strategic Fit... 7 2.4. Service Context Overview... 11 2.4.1. Planned Care... 11 2.4.2. Unplanned Care... 12 2.4.3. Children and Young People... 12 2.4.4. Mental Health and Learning Disability... 13 2.4.5. Co-Commissioning... 14 2.4.6. Overview of the Provider Landscape... 20 3. Strategy Overview... 22 3.1. The Vision... 22 3.2 Aims and Objectives... 23 3.3 Scope... 24 3.4. Key Business Benefits... 25 3.5 Stakeholders... 30 4. Implementation... 32 Hull 2020 PMO Function Diagram... 34 4.1. Governance... 36 4.2. Programme Plan... 37 4.3. Risk... 37 5. Appendix... 38 5.1. Work stream overview... 38 6. Appendix 2 Work Stream Participation 46 Hull 2020 CCG Strategy 3

1. Executive Summary NHS Hull CCG has established a programme for integrated service transformation in Hull, working alongside public sector organisations. This is a time of unique challenge in public funded services which brings with it an opportunity to radically change the services are offered to meet the needs of the whole population and work towards a better and healthier future for the people of Hull. The Hull 2020 vision is: In 2020 we will work together better to enable the people of Hull to improve their own health and wellbeing and to achieve their aspirations for the future. This strategy document outlines the rationale for the Hull 2020 programme and demonstrates how it is embedded in the context of clear delivery of healthcare commissioning and greater integration with social care. The Hull 2020 programme builds on the extensive health and social care commissioning activity that is in place and broadens that to work with organisations such as the Police and Fire services. It is reaching beyond the proposals that are being developed by the Better Care Fund to incorporate greater collaboration across public services as well as private, voluntary, and charitable sectors within Hull. This Transformation Strategy is ambitious and all the partner organisations across Hull recognise that significant change is essential in order to ensure that sustainable, high quality services are available to meet the needs of the population. To achieve these ambitions all involved must continue to nurture the current relationships and work with partners and the people of Hull to deliver this agenda. The defined outcomes of the Hull 2020 programme are: Clearly defined, equitable and quality 7 day services available on the basis of need People are aware of the services available to them, and confident that they can access what they need when they need it. Information is shared across public services to speed up and coordinate care and support and reduce duplication A single system that removes traditional organisational boundaries enabled by integrated governance and partnership Making the best use of the available money in Hull public services, to meet the needs of local people. A workforce that is fit for the future to meet the needs of the population A Programme Management Office has been established, based in the CCG, to drive the implementation of the strategy and demonstrate the impact of wide collaboration. All participants have signed a Memorandum of Understanding to contribute to the programme and to contribute to the service delivery and enabling work streams that have been mobilised. Hull 2020 CCG Strategy 4

2. Introduction 2.1. Purpose of the document This document demonstrates how the NHS Hull CCG strategy and the Hull 2020 programme are aligned to deliver the CCG vision of Creating a Healthier Hull in the context of the three priorities of the CCG, which are Developing 21st century primary care, Integration and Next generation healthcare. This provides the evidence and business justification alignment of the Hull 2020 programme with the CCG strategy. 2.2. Business Need and Current Situation The business need has been generated through extensive discussion across partners and analysis of the evidence base. The city of Hull is ranked as the 10th most deprived in England. Hull s Black and Ethnic Minority population is estimated to have risen fast, from 8,500 in the 2001 census to 28,700 by 2009. Between 2010 and 2030, ONS estimate that Hull s population will increase from 266,100 to 311,900 residents, an increase of 17%. The figure below shows the population of Hull (2011 Census Data). Figure 1 Population of Hull Hull is an area with marked health inequalities, for example: 34% of adults across the city smoke, compared to 20% in England 1 70% men and 61% women are overweight or obese, compared to 66.6% among men and 57.2% among women in England 2 The crime rate for Hull was 111 per 1,000 resident population during 2009/10, decreasing slightly (by 9%) to 101 per 1,000 resident population during 2010/11. 1 Statistics on Smoking: England, 2013, HSCIC, Aug 2013 2 Statistics on Obesity, Physical Activity and Diet: England 2014, HSCIC, Feb 2014 Hull 2020 CCG Strategy 5

Life expectancy is low, at an average of 75.7 years for men and 80.2 years for women, compared with the national averages of 78.6 and 82.6 years respectively Increasing numbers of older people requiring more complex and individualized support to remain in their own homes with the care they need Survey responders in Hull s 2011-12 Health and Lifestyle Survey, which involved over 13,500 residents, were asked about their religion, sexual orientation, as well as general health. In terms of self-reported health, 28% reported that their health was fair or poor and 29% reported that they had long-term illness or disability that affected their daily living. In Hull, the educational attainment of year 11 pupils (15-16yrs) is lower compared to England. The percentage of 15-16 year olds achieving five or more A-C grade GCSEs (or equivalent) is 50% compared to 54% for England. 26% of children live in households where the household income was less than 60% of the median income before housing costs compared to 21% for England. In addition to the local population needs, there are a number of local priorities to be addressed: There is a need to address a perceived culture of dependency in some parts of the community The cost of services and the complex challenges the system currently faces needs to be clearly explained, in meeting ever increasing need and demands The current structure of services and organisations does not lend itself to supporting individuals; instead it is based around fragmented core services. These services should be built around the needs of individuals. For example, health services are currently too focused on who is providing the service, rather than reflecting the need to operate in a more joined up way to reduce duplication and confusion In terms of public expectations, there is a need for more informed lifestyle choices among members of the public but this will require an understanding by commissioners and service providers of an individual s life choices and their aspirations. There is a need to explore options which enable people to solve their own problems as well as provide community resources Public health messages need to evolve to be more do rather than do not, supported by open and honest conversations with the public regarding the cost of services There is a need to improve frontline, day to day communication between professionals in order to deliver a seamless blend between service providers and service sectors In terms of the resources available, there is a need to improve efficiency and deliver services for the 21 st century. In addition, a major challenge is to recruit and retain a highly skilled workforce - in particular primary care services face major challenges in recruiting and retaining staff. The public sector is the largest employer in Hull and being proactive with schools can encourage local people to train and work in Hull to deliver excellent public services. Measures and metrics for performance of services should be cross-sector and jointly owned. The role of the Hull Health and Wellbeing Board will be a critical enabler for change, particularly with regards to driving forward the integration agenda Hull 2020 CCG Strategy 6

The political environment, particularly the pace of change and fluctuating priorities, is a core risk and a steep learning curve for the Hull 2020 Programme. There is a clear requirement to engage more with political partners to find a balance of sustainability and change 2.3. Strategic Fit NHS Hull CCG is the NHS body responsible for commissioning many of the health services for the people of Hull. The CCG vision is to Create a Healthier Hull, and in order to achieve this we work in close collaboration with our partners to improve health, reduce health inequality and secure excellent services for all of the communities in Hull. The CCG is a clinically-led organisation, which brings together 57 local GP Practices and other health services to plan, design and buy services to meet local patients' needs. The GP Practices serve a registered population of 288,000 across 23 wards. The CCG currently directly employs 38 Whole Time Equivalent staff (excluding embedded Commissioning Support Unit employees, GP members and Lay members), across specialisms of Commissioning, Contracting, Business Intelligence, Engagement, Governance and Finance teams. The recurrent healthcare funding allocated to NHS Hull CCG for 2014/15 is 360.3m (a 2.14% increase over 2013/14). Although the CCG has a significant level of non-recurrent funds, and is currently able to balance recurrent funds against expenditure, it will become increasingly challenging to maintain this position going forward. This is in the context of an increased level of demand from an aging population whilst the level of recurrent funding remains relatively static. The below table sets out the summary financial plan for the CCG in 2014/15: this includes the CCG investment programme, incorporating schemes approved by the CCG Planning and Commissioning Committee and unavoidable cost pressures. Recurrent ( m) Non Recurrent ( m) Total ( m) Resources Baseline Allocation 360.3 0.0 360.3 Return of Prior Year Surplus 0.0 9.0 9.0 Running Cost Allocation 7.0 0.0 7.0 Total Resources 367.3 9.0 376.3 Expenditure Acute (inc Ambulance) 186.1 1.3 187.4 Mental Health 34.4 0.2 34.6 Community Services 48.8 2.8 51.6 Continuing Healthcare 28.6 0.0 28.6 Primary Care / Prescribing 49.6 1.9 51.5 Corporate / Other 3.9 1.4 5.3 Contingency 0.0 1.9 1.9 Running Costs 6.4 0.0 6.4 Total Expenditure 357.9 9.4 367.3 Surplus / (Deficit) 9.4 (0.4) 9.0 Hull 2020 CCG Strategy 7

The NHS Hull CCG boundary is coterminous with Hull City Council the Council being the 10th most deprived in the UK. Hull is an area with marked health inequalities, for example increasing numbers of older people requiring more complex and individualized support to remain in their own homes with the care they need. However, there are areas where progress has been made: Hull s teenage pregnancy rate is now at the lowest it s been since 1969 The celebrated Fit Fans weight management programme has supported 2,000 people completing the course to lose a combined total of 13,770.2 lbs Access to a NHS dentist in the city is now widely available The 2012-2015 Health Strategy set out how the organisation intended to take forward "Creating a Healthier Hull", this was described as:..working toward our strategic aims which have been determined by the health needs of the city, patients expectations and the aspirations of clinical leaders, to deliver sustainable services and improve health outcomes There are a notable number of achievements against the strategy over the past 18 months, which include, amongst many others: The End of Life Fast Track Pathway has enabled more people to fulfil their wish to end their life in a location and with the support of their choosing The Healthier Hull Community Fund has enabled a considerable number of individuals, small teams through to established large groups to utilise modest sums of money to generate local health and wellbeing benefit that far outweighs the upfront investment Commissioned a Community Pain Management Service An investment in a scheme to expand the Emergency Department and agreed a model for co-located services including Primary Care Progressed Health and Social Care Reablement services for the elderly, including Thornton Court and established an integrated Early Supported Discharge Service for stroke patients in partnership with Hull City Council On-going development of Telehealth that has successfully empowered a growing number of people with long term conditions to manage their care closer to home Self-Care and Social Prescribing have been forefront in the primary care agenda leading to successful partnerships with the local voluntary, community and social enterprise organisations in the city The Health Bus/Listening Events have evolved from a specific screening initiative to a wider agent of general health and wellbeing campaigns with excellent feedback from members of the public In addition to these achievements, there are also a vast number of major programmes underway, including work to establish the East Hull Community Integrated Care Centre and a range of re-procurements, including community services. Hull 2020 CCG Strategy 8

That strategy was fit for purpose when it was written but it is unlikely to address the challenges faced up to 2020 with much of it already delivered. The current national policy landscape has given a clear indication of the required direction for commissioners and providers of health and social care. A Call to Action and The Better Care Fund guidance, among other policy guidance, have outlined the case for rigorous integration arrangements, increased collaboration and public engagement, not just between healthcare services but across the broader care and public provider landscape. All service providers have a part to play in improving community wellbeing and health outcomes. Care focused on the individual begins with wrap around services for those who need it, delivered through aligned interventions (i.e. health or social care) supported by systems and infrastructure (e.g. signposting to community services or equipment services) to enable healthy productive lives. In particular primary care services will be fundamental to delivering integrated care and care closer to home. NHS Hull CCG is exploring with NHS England, the scope for co-commissioning of primary care services in order to develop primary care so it is able to provide a 21 st Century service. It is expected that co-commissioning will evolve from the current position in 2014/15, where there is limited CCG involvement in the NHS England Area Team commissioning decisions, to one of greater CCG leadership and involvement through joint commissioning arrangements to delegated authority. It is anticipated that from 2015/16 delegated commissioning arrangements will be in place with the CCG carrying out some defined functions on behalf of NHS England where this enables the achievement of the NHS Hull CCG strategic objectives as set out in Hull 2020. The co-commissioning arrangements will align with joint commissioning arrangements with Hull City Council through the existing Joint Commissioning Forum for Adults, the Better Care Fund arrangements and the Hull Children and Families Board. The local vision for Better Care is that people in Hull will expect better care, and better care will be organised around them. The aspiration is, that local health and social care services will change significantly over the next 5 years; Health and Social Care organisational boundaries will be broken down to ensure that care is co-ordinated across different care settings. The initial two year plan for the Better Care Fund (BCF) in Hull is focused on the needs of our population of older people, people with mental health conditions and people with physical disabilities. Better Care will be a delivery vehicle for Hull 2020 and is designed to integrate services in order to ensure easier access to care at the point of need delivered in local communities. People in Hull will expect better care, and better care will be organised around them Hull 2020 CCG Strategy 9

The shared vision across Hull is for whole system integrated care and to have support aligned to the three interdependent strategies for the City: the NHS Hull CCG led transformational programme Hull 2020, Hull s Health and Wellbeing Strategy (2013-16) and the City plan which bring together key partners signed up to an improvement programme which will influence the wider determinants of health such as housing and jobs. These local documents provide the blueprint for whole system transformation and reinforce a shared commitment to improve care, quality and access to resources, as pictured below. Figure 2 Local Context There is the need for further prioritisation of collaboration across the public sector in Hull to ensure sufficient capacity and capability to deliver the needs of the population, which the Hull 2020 Transformation Programme had been established to address. Unit of Planning The NHS Hull CCG led transformational journey to Hull 2020 - working towards a year of health and wellbeing for the City; celebrates a vision where we will work together better to enable the people of Hull to improve their own health, resilience, wellbeing and aspiration for the future. The City Plan for Hull, the Hull Health and Wellbeing Board Strategy and the Hull 2020 strategy all support and reinforce Hull as a population base that is destined for improvement - based on the wider determinants of health; part of which will be celebrated in 2017 as Hull comes out of the shadows as the City of culture. NHS Hull CCG is a key stakeholder and city partner - hence the unit of planning for strategic purposes in terms of health. Hull 2020 CCG Strategy 10

2.4. Service Context Overview 2.4.1. Planned Care NHS Hull CCG is exploring opportunities to transform care pathways and the management of patient care in high volume (outpatient) specialties and aims to provide patients with a choice of services that improve their experience of assessment, diagnosis and treatment based on personal, seamless, convenient, safe and reliable clinical services. The optimal model is that patients will no longer wait to be seen but will be able to choose when and where they receive their care at a time that is convenient to them. A fundamental aim is to, wherever possible, shift away from providing planned care in a hospital towards providing it in a primary care setting. Too many diagnostic tests, outpatient appointments and elective procedures are occurring in hospital, when they could be done nearer to a patient s home, at lower cost and high quality in the community. In addition, we want to bring about a closer integration of services; that means hospital and primary care services working more closely together to ensure that patients receive diagnosis, treatment and care at the right time, in the right place from the right person. NHS Hull CCG will achieve a shift of activity out of hospital by having more specialist services in the community, facilitated by primary and community health and care services that are accessible, understandable, effective and tailored to meet local and individual needs. The productive elective care work stream has enabled GPs and hospital consultants to identify patients where:- follow up is not clinically necessary only one follow up appointment is required on-going care can be managed in primary care via shared care arrangements on-going care can be managed in primary care with additional support or clinical guidelines The NHS Constitution contains the following right for patients: You have the right to start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions. NHS Hull CCG is analysing referrals to high volume areas by GP practice in order to understand how the Referral To Treatment (RTT) 18-week pathway is under constant pressure. We are working with GPs and other healthcare professionals to understand the referral process and to consider alternative pathways and service provision for patients in order to avoid secondary care referrals. This will also give the CCG the opportunity to change pathways for patients to ensure they receive the optimum clinical treatment for their episode of care and a key feature will be the use education, where appropriate, to support variation in primary care. Hull 2020 CCG Strategy 11

Specific initiatives that are being developed in 2014/15 include: Productive Elective care NHS ereferral Rightcare 2.4.2. Unplanned Care Systems and processes need to be able to work 365 days a year to avoid the crises seen over the past few years, commonly known as winter pressures, however the crises are now a yearlong feature, although the causes may be different. Systemised delivery of urgent interventions to meet patients perception of an urgent need will ensure a more managed approach to urgent care and mitigate the risk of surges of activity impacting on capacity across health and social care. A year round surge and escalation framework has been developed and is managed by a multi-agency discharge hub on the Hull and East Yorkshire Hospitals NHS Trust, Hull Royal Infirmary site. This model will be developed further in order to ensure the safe transfer of care, move towards discharge to assess and increase the number of people enabled to return to their own home. Process working 7 days a week across all sectors will lead to effective patient care, both in terms of quality and cost thus leading to efficient patient flow throughout the NHS. There are three main areas of the NHS that respond with urgent interventions - Secondary Care (Acute), Primary Care (GPs) and Community Care. Service development is being taken forward under the direction of the Hull & East Riding Unplanned Care Board, particular initiatives include: Ambulatory Care Acute Frailty Pathway Integrated primary care (GP) in A&E Combining Out of Hours Service (OOHs) and Minor Injury Services (MIU) 2.4.3. Children and Young People NHS Hull CCG has a strong focus on children and young people as the next generation. The recent review of maternity services and the development of a 5-year maternity services strategy had a significant impact on this work stream and there is an opportunity to build upon and align services and activities in order to improve the lives and outcomes of the children and young people of Hull. This includes the work of the Hull Children Safeguarding Board, the Hull Community Safety Partnership and harnessing the work with partners such as Academies, sports and community groups. Hull 2020 CCG Strategy 12

The NHS Hull CCG approach therefore includes services from pre-conceptual care and maternity through to early years, education, learning and employment with a focus on supporting the most vulnerable groups such as those children who are looked after, have a disability and/or mental health need, those Not in Employment, Education or Training (NEET), and in or on the fringe of being in the youth justice system. 2.4.4. Mental Health and Learning Disability NHS Hull CCG has a track record in supporting mental health and learning disability service developments which supports the Parity of Esteem principle by which mental health must be given equal priority to physical health. It was enshrined in law by the Health and Social Care Act 2012; organisations are required to work for parity of esteem to mental and physical health through the NHS Mandate. The CCG has an on-going programme of initiatives to develop and support local services. For example, a new model has been recently developed for Child and Adolescent Mental Health Services (CAMHS). The model identifies how all statutory agencies are required to work together to ensure that the holistic mental health and wellbeing needs of children and young people are met. The model has a continuum approach - recognising that children, young people and families may move along the continuum in either direction at various points in their life. There is a Hull Emotional Health and Wellbeing Strategy for children and young people that is supported by an action plan which will ensure that the required changes are implemented. The CAMHS (non-specialist) service specification has been finalised incorporating changes with regards to early support and intervention and targeted support. Other initiatives that NHS Hull CCG is delivering include: The Headstart project - Jointly working with Hull City Council on responding to an invitation to submit an application to the BIG Lottery fund for projects to improve resilience and emotional wellbeing in children and young people aged 10-14 Dementia Action plan - To review existing support for carers of people with dementia and recommend the development of alternative forms of support in conjunction with improved diagnosis rates Mental Health Front Door Service this has involved the redesign of access to secondary care mental health services, reflecting the requirement to offer timely access to assessment, clustering and progression to active treatment. This will include the disaggregation of the access to IAPT services with the implementation of the new Depression and Anxiety Service from 1st October 2014 Responding to Winterbourne NHS Hull CCG recognises that case management for individuals is crucial to delivering appropriate care and support, especially for those patients who are placed out of the Hull area. The CCG commissions specialist case managers who play a key role in coordinating services from across the mental health system, as well as other service systems (e.g. criminal justice, specialist hospital care, secure hospital placements). Hull 2020 CCG Strategy 13

2.4.5. Co-Commissioning Primary Care NHS Hull CCG is committed to the development of primary care services since new models of care will be required to deliver 21 st Century services. The CCG has undertaken work across a number of areas to develop primary care these include: A review of all previously commissioned local enhanced services, now called Extended Primary Care Medical Services which included the development of new service specifications and the re-procurement of services using the NHS Standard Contract The development of Map of Medicine as a tool to support primary care in the evidence-based management of conditions and to provide easily accessible local information on services and referral processes Commissioning of a single integrated telehealth service to support the management of an increasing number of patients with heart failure and chronic obstructive pulmonary disease (COPD) The development of a multi-disciplinary team (MDT) community-based model, involving a range of clinicians, medicines management and social care, in order to support practices in the management of high risk complex patients, often with multiple long term conditions The re-design and re-procurement of the Community Ophthalmic Referral Refinement scheme (CORRS) from community optometric practices Support to the Hull City Council Public Health Team in the commissioning of the NHS Health Check Undertaking a Listening to the Workforce consultation exercise with practices, to obtain feedback on the current state of future challenges for general practice, which resulted in the development of a CCG action plan addressing the following areas: o Cross practice/partnership working o Attitudes to the CCG o Working environment o Workforce o Training and development o Patient engagement Support to practices in preparing to meet the requirements of the 2014/15 Avoiding Unplanned Admissions DES In response to the NHS England invitation for expressions of interest in co-commissioning, NHS Hull CCG has submitted a proposal to work with the Area Team to jointly commission and ultimately take delegated responsibility for the commissioning of GP primary care services. This is seen as vital to enabling the CCG to realise its ambitions for the Hull 2020 CCG Strategy 14

development of new models of primary care and the future sustainability of primary care services in Hull in the context of rising demand and needs. The benefits of co-commissioning are expected in the following areas: Integration of health and care services Raising standards of quality and reducing unwarranted variation Enhanced patient and public involvement in the development of services Addressing health inequalities Specialised Services Specialised services are predominantly relatively high cost and low volume, and tend to be located around catchment populations of more than one million people, mostly in hospital Trusts within major towns and cities. The number of patients accessing these services is small, and therefore a critical population mass is needed in each treatment centre in order to achieve the best outcomes for patients and maintain the clinical competence of NHS staff. The commissioning of Specialised Services came together in a single organisation, NHS England, in April 2013 and forms part of the NHS England Direct Commissioning responsibilities. The CCG has a responsibility to co-commission specialised services (amongst others) with NHS England in order to ensure that local priorities are fairly, adequately and appropriately reflected within a national context. The Top 5 specialised commissioning areas, by spend, are: Renal including hospital and home dialysis and transplantation. Mental health services Chemotherapy and rare cancers Cardiac surgery and complex invasive cardiology Specialised children s services, including neonatal and paediatric intensive care These are relatively common areas of treatment and care which are fundamental to the improved health, wellbeing and life expectancy of the people in Hull. The health of children across Yorkshire and the Humber is comparatively worse than England; this is a particular issue for Hull too. Poor health starts before birth with higher smoking rates during pregnancy and high rates of teenage pregnancy; then at birth with proportionately less initiation of breast feeding. This has implications for the commissioning of specialised children s services, in particular neonatal services. The delivery, by all commissioners, of the actions within the NHS Hull CCG led Maternity Services Work-plan, are crucial to ensuring the best start in life. Hull 2020 CCG Strategy 15

A range of lifestyle factors puts the population of Hull at greater risk of developing poor health and long term conditions such as diabetes, heart disease, hypertension, stroke, and cancer. All of these conditions impact on the demand for specialist services, in particular cancers, specialised cardiology and cardiac surgery services. Partnerships, through co-commissioning and a range of forums such as the Health and Wellbeing Board, with specialist services commissioners are important in ensuring that population health risk factors are impacted upon at all stages across the life-course. This is central to the Hull 2020 vision of a much more joined up and integrated wider health and social care system in the context of place. The centralisation of specialised services commissioning aims to raise the standards of care and outcomes for all patients receiving treatment for rare and specialised conditions by ensuring that local issues are much more closely aligned with national priorities, that service specifications are standardised across providers and that teams are working closely to maintain consistent approaches throughout the commissioning cycle the CCG cocommissioning role. Hull and East Yorkshire Hospitals NHS Trust is our local provider of a range of specialised services and has a catchment area population of around 1 million people within the Humber and North Yorkshire. Specialised services are currently being delivered out of too many sites, with too much variety in quality and at too high a cost in some places. In the Yorkshire & Humber region, 31.4% 3 of services across all providers were subject to derogations for non-compliance with service specifications at April 2014. A significant number of these derogations are to do with the population critical mass required to meet the specifications. The aim of the derogation policy is to ensure an open and objective dialogue between commissioners and providers, to support clear communication to stakeholders on any agreed variation to national requirements. Of the 67 specialised services provided by Hull and East Yorkshire Hospitals NHS Trust; 16 services (23.9% 4 ) are subject to derogation. Balancing the conflicting issues of improved quality and outcomes through centralisation versus the need to maintain equity of provision and access for local residents, based on the geographical nature of the patch, within a single operating model with national specifications and policies, that are inflexible compared to local determination and a degree of flexibility, will remain an on-going challenge for commissioners, co-commissioners and provider hospitals. However, NHS Hull CCG and its wider public sector partners are committed to that challenge in the pursuit of improved health, wellbeing and longer life expectancy for the people of this City. 3 Source: NHS England South Yorkshire and Bassetlaw Area Team operational plan submission as at 02 April 2014 4 Ibid Hull 2020 CCG Strategy 16

Armed Forces and Veteran Health The NHS England long term vision is to obtain the best heath benefit from the available resources by commissioning high quality, safe and effective care for the Armed Forces community 5 in accordance with the Armed Forces Covenant and the NHS Constitution. Society s obligations are set out in the Armed Forces Covenant, a framework for the duty of care Britain owes its Armed Forces. In terms of healthcare, the key principle is that armed forces staff and their families experience no disadvantage in accessing timely, comprehensive and effective healthcare; and that they, and veterans, will also receive bespoke services in some agreed areas for their particular needs or combat-related conditions. The obligations and expectations within the Armed Forces Covenant in relation to CCG commissioning will be honoured by NHS Hull CCG where they apply. NHS Hull CCG does not host any active armed forces base but recognises the needs of those medically discharged and veterans. The Armed Forces Covenant obligations and expectations are: When posted somewhere new, serving personnel and their families should retain their relative position on NHS waiting lists to remove any disadvantage Continuity of care for all wounded, injured and sick serving personnel on medical discharge from the armed forces when transitioning to civilian life Bespoke veteran mental health improving access to psychological therapy (IAPT) services delivered by a provider with a specialist understanding of armed forces culture Veterans should receive priority treatment where it relates to a condition which results from their service in the Armed Forces, subject to clinical need NHS Hull CCG supports the long term vision of NHS England of improving health outcomes for patients, and NHS Hull CCG will work collaboratively as a co-commissioner in order to ensure that the those patients covered by the Armed Forces Covenant receive equitable and consistent health care provision, tailored to meet the local need. NHS Hull CCG will work closely with NHS England Area Teams to focus assets in the local communities, working in co-production with patients, families and carers and collaborating to improve outcomes. More specifically the needs of those medically discharged and veterans need to be a focus for local commissioning in Hull. There is evidence of musculo-skeletal (MSK) problems being a health need for serving personnel and there is a perception that the Armed Forces community have a range of 5 Definition of Armed Forces Community - serving members of the Armed Forces, Reservists, Veterans and all of their families. Hull 2020 CCG Strategy 17

mental health problems and in particular suffer from Post-Traumatic Stress Disorder (PTSD). However in 2009, the Academic Centre for Defence Mental Health undertook a useful review of evidence on the health and social outcomes, and the health service experiences - of UK ex-service personnel, which found that the ex-service population has comparable health to the general population and a broadly similar prevalence of mental health-related conditions. NHS Hull CCG has recently re-commissioned both the community MSK service and the depression and anxiety services for the population of Hull; which will ensure that equitable and consistent access is provided for the wider armed forces community, as necessary. Offender Health We know that prisoners, and others in touch with the criminal justice system, experience significant health inequalities they often have low health aspirations, poor expectation of services, complex needs, chaotic lifestyles that make it difficult to access and navigate the healthcare system, and are at an increased risk of developing mental health problems. In terms of health needs, offenders are more likely to smoke, misuse drugs and/or alcohol, and/or suffer mental health problems, report having a disability, self-harm, attempt suicide and die prematurely compared to the general population. Up to 25% of the prison population are thought to have a borderline personality disorder; up to 30% of adults within the criminal justice system have ADHD, which remains undiagnosed and/or untreated, and a similar number report having experienced emotional, physical or sexual abuse as a child. Two thirds of offenders live in the community the health and wellbeing needs of offenders in the community are worse than those in custody, and within the general population - premature death rates are significantly higher. Access to primary health care is often an issue both in terms of social exclusion and their chaotic lifestyles, which do not fit with attending regular appointments and taking part in screening programmes. There are clear links between the wider social determinants of poor health and reoffending such as sustainable housing or employment - drug users are responsible for between 33-50% of acquisitive crime (treatment can cut the level of crime they commit by about half) and alcohol is a factor in an estimated 44% of violent crime (evidence from A&E data shows that targeted interventions can reduce alcohol related disorder by around 25%). NHS Hull CCG continues to support the successful partnership working in the context of not unnecessarily criminalising people in the city. There are both effective and innovative schemes to triage young people, those affected by mental health problems, substance dependency (drug and alcohol) and women ensuring that they receive appropriate care, support and treatment, where necessary and appropriate, to address the underlying cause of offending. Hull 2020 CCG Strategy 18

The CCG has supported the development of a responsive facility provided by Humber NHS Foundation Trust, in order to support the timely and appropriate assessment, care and treatment under Section 136 of the Mental Health Act in partnership with Humberside Police (Hull Division). We have worked with the Probation Service within the Multi-Agency Public Protection Arrangements (MAPPA) to support the care and treatment of high risk offenders ensuring that their holistic needs are addressed. The CCG provides a specialist case management service staffed by clinically qualified professionals who case manage a small number of individuals within this cohort; there contribution is valued and respected, both in their field and within the multi-agency, multi-disciplinary arrangements. NHS Hull CCG has recently re-commissioned a Depression and Anxiety Service for Hull a focus on the newly commissioned service is the access to services and outcomes (recovery rates). We acknowledge that there can be difficulties for offenders in gaining access to the full range of mental health services, such as those based on CBT approaches. We will be working with our partners to ensure that this area of healthcare need is addressed for the local population. Through The Gate there is a need to ensure that pathways are in place as patients are released from prison in order to ensure continuity of healthcare, particularly around ensuring access to primary care. Whilst this is currently an NHS England responsibility, NHS Hull CCG has a desire to assume delegated authority for this area of commissioning, and would therefore be in a position to support local developments. NHS Hull CCG is a core member of the Humberside MAPPA Strategic Management Board and maintains regular and professional links with the Probation Service so is well informed in relation to the reforms to the prison estate as part of the wider Transforming Rehabilitation policy. An outcome of these reforms should ensure that more prisoners are released from prisons closer to home and that more prisoners receive supervision and support from Community Rehabilitation Companies to support them to access appropriate health services on release. NHS Hull CCG welcomes the opportunity to work more closely with prisons and the Community Rehabilitation Companies as well as maintaining links to the National Probation Service. We know that NHS England (West Yorkshire Area Team) has commissioning plans for 2014/15 with regard to re-commissioning the healthcare service in prisons in Hull and the East Riding; we look forward to working with our colleagues as co-commissioners in this regard. Hull 2020 CCG Strategy 19

2.4.6. Overview of the Provider Landscape Hull & East Yorkshire Hospitals NHS Trust (HEYHT) provides a comprehensive range of acute hospital, specialist and major trauma services for approximately 1.25 million people. Services delivered relating to a large acute general hospital are used by people predominantly living in the Hull, the East Riding and Northern Lincolnshire; with the wider population of Yorkshire accessing specialised services. HEYHT provides networked services with other providers in the area, including; major trauma, major vascular, neurosciences, cardiology, oral surgery urology, cancer services, and a range of screening services. The only major services not provided locally are transplant surgery, major burns and some specialist paediatric services. The Trust employs approximately 8,664 staff working across the hospitals and community, with an annual turnover of 495m. Hull Royal Infirmary Hull Royal Infirmary is based in the centre of Hull. With 709 beds, it is the emergency centre for the Trust. The A & E department sees 120,000 people each year, and is currently being upgraded with support from NHS Hull CCG. The site also consists of a dedicated Renal Dialysis unit, an Eye Hospital and the Women s and Children s Hospital; there is a clinical skills facility that supports training and education across all healthcare sectors. Castle Hill Hospital Castle Hill Hospital, Cottingham is located 6 miles outside of Hull in the NHS East Riding CCG. It provides predominantly elective care, with 610 beds. This site includes the awardwinning Queen's Centre for Oncology and Haematology, the Centre for Cardiology and Cardiothoracic Surgery (bringing diagnostic and treatment facilities in one state-of-the-art building on the site), and the Centenary Building (Breast Surgery and ENT). National thinking around hospital based care has been influenced through high profile reviews such as the Keogh review of Mid-Staffs, and the Berwick and Cavendish Reviews; the recommendations and responses from these reviews have influenced commissioners. In his review of hospital services, Sir Bruce Keogh recommended that serious or life threatening care should be delivered from centres of excellence, with the best expertise and facilities to maximise chances of survival and recovery. National recommendations to move the commissioning of serious, life-threatening emergency care and rare services to centralised locations, in order to ensure clinical and cost efficiencies are maximised, may have an impact for the services provided by HEYHT. NHS Hull CCG along with other collaborative CCGs and co-commissioners would need to carefully consider the impact of any changes on the sustainability and resilience of locally commissioned services. Hull 2020 CCG Strategy 20

NHS services will continue to go through a process of transformation over the next five years, with the whole health economy needing to change in order to meet the increased demand for healthcare services arising as a result of demographic change, technological and pharmacological advances, increased demand for healthcare services and the requirement for integration across the health and social care sectors. Hull and East Yorkshire Hospitals NHS Trust (along with all other local providers) is a full member of the Hull 2020 Transformational Programme Board; they are integral to the partnership approach adopted by NHS Hull CCG, and working collaboratively, we have a collective opportunity to ensure that we make a better future together. All local providers are members of the Unplanned Care Board through which the details of the Better Care Fund (BCF) plans have been shared and shaped. The BCF plan projects will invest significantly in an improved health and social care system, changing the way that health and social care services are commissioned and delivered to drive service improvements for elderly and vulnerable people. The plans have been signed off through the NHS Hull CCG Board and the Hull Health and Wellbeing Board, and are overseen and supported by the BCF Steering Group which includes healthcare provider representatives. The BCF plans and other urgent intervention initiatives arising from Hull 2020 will resource a joined-up 7-day health and social care service, shifting the balance of care from a hospital environment to a home or community settings where it is safe to do so, promoting self-care and independent living. Provider organisations will need to rise to the challenge of transforming services in response to the primary and community care needs, and support their staff who will need to work differently and across organisational boundaries to deliver seamless integrated care. Planned interventions (elective care) will be modernised across primary and secondary care to deliver service improvements and efficiencies whilst providing clinically safe services. This will improve the quality of services, reduce variation and improve patient experience and outcomes. Working with all local providers, NHS Hull CCG will ensure that GPs and secondary care doctors have access to technology to support communications between clinicians; pathways are agreed and shared using the Map of Medicine; community based diagnostics will support diagnosis and work-up in primary care so that only those patients who need to be referred to an acute provider will be referred. In summary, NHS Hull CCG has established its vision to Create a Healthier Hull and is working with local stakeholders (both commissioners and providers) to achieve the transformational service change required at scale and pace. It is expected that provider responses will involve a range of different options for delivery of services, including reconfiguration, collaboration, alliances and clinical networked approaches within a range of contractual frameworks. Hull 2020 CCG Strategy 21

3. Strategy Overview 3.1. The Vision The vision for the Hull 2020 Programme is: In 2020 we will work together better to enable the people of Hull to improve their own health, resilience, wellbeing and to achieve their aspirations for the future. This vision will be delivered by public services collaborating to enable access to the right services at the right time. This will allow individuals access to a range of interventions, which might include mental wellbeing and personal resilience support to meet their aspirations and expectations. This will require the understanding of the local population and incentives (for the service providers and the public) will be used to inspire individuals and communities to work towards a common purpose. The model for delivering this vision is based on several key objectives: A. Public focused services that recognise the needs of the individual (access to service, experience of service, safety, quality) B. Driven by the people of Hull as well as professionals, expert staff, and partners in recognition of the need for local answers for local issues C. Addressing the process and system issues - reducing waste, inefficiency and frustration D. Maintaining a sustainable skilled workforce to meet wider public need E. Making best use of partnerships across all sectors, particularly through the voluntary sector and exploration of options regarding community owned initiatives F. Co-ordinating initiatives and building on existing infrastructure to develop a consistent approach to working across Health & Social Care. These objectives link directly those agreed as part of the Better Care Fund Plan to be delivered across Hull. o BCF 1. Permanent admission of older people (aged 65 and over) to residential and nursing care homes - Reducing inappropriate admissions of older people (65+) in to residential care o BCF2. Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services - Increase in effectiveness of these services whilst ensuring that those offered service does not decrease Hull 2020 CCG Strategy 22

o BCF3. Delayed transfers of care (delayed days) from hospital - Effective joint working of hospital services (acute, mental health and non-acute) and community based care in facilitating timely and appropriate transfer from all hospitals for all adults o BCF4. Avoidable emergency admissions - Reduce emergency admissions which can be influenced by effective collaboration across the health and care system o BCF5. Patient/service user experience - To demonstrate local population/health data, patient/service user and carer feedback has been collated and used to improve patient experience. To provide assurance that there is a co-service design, delivery and monitoring putting patients in control and ensuring parity of esteem o BCF6. Injuries due to falls in people aged 65 and over Given the current and predicted financial challenges across public services demonstrating the clear impact of the Hull 2020 programme in the services provided will be crucial. 3.2. Aims and Objectives When Hull 2020 vision is delivered it will be underpinned by a single system of partnership beyond traditional organisation boundaries. The Outcomes that will be achieved by the Hull 2020 programme are: 1. Clearly defined, equitable and quality 7 day services available on the basis of need 2. People are aware of the services available to them, and confident that they can access what they need when they need it. 3. Information is shared across public services to speed up and coordinate care and support and reduce duplication 4. A single system that removes traditional organisational boundaries enabled by integrated governance and partnership 5. Making the best use of the available money in Hull public services, to meet the needs of local people. 6. A workforce that is fit for the future to meet the needs of the population A significant element of the CCG strategy that is being delivered through the Hull 2020 programme is the desire to support people in Hull to care for themselves, accessing public services that are easy to navigate. Hull 2020 CCG Strategy 23

The diagram below shows the characteristics of people accessing the different type of services. Figure 3 Care Continuum Arranging public services in the most suitable way will help support people with their own resilience and wellbeing, while reducing the amount progression of complex multi-need care. Resilience and Wellbeing addressing the wider social determinants of health, and improving the aspirations of the people of Hull Self-Care and Carer Support enabling individuals to take ownership of their own care and development, in order to pursue happier, healthier and more independent futures Early and Intensive Intervention - developing resources to prevent rapid deterioration in health or wellbeing, in order to reduce the need for formal intervention Complex Care - better planning, reduced duplication and better integration across public services, resulting in seamless care supported by single points of contact 3.3. Scope The Hull 2020 Programme has been established to deliver cross public sector collaboration that impact upon the lives of people in Hull. The role of the programme is to establish the opportunities for collaboration based on the five principles, which are: Integration Care closer to home Community hubs Single Care navigator Community designed and owned Hull 2020 CCG Strategy 24

The role of Programme Management Office is to drive through the collaborative projects to achieve the identified impact on the population. The scope of the Hull 2020 programme is not designed to deliver all projects that are to be delivered across the public sector in Hull. In 2014/15 the currently identified specific interventions that the Hull 2020 Programme Team is facilitating are: 1. Development and roll out of Community Hubs across Hull 2. Establishment of Wi-Fi connectivity for all staff across all public sector offices in Hull 3. Use of cold alarm technology to support cross sector winter planning and specifically to increase the level of prevention 4. Creation of a single portal for people in Hull to access information about the services available to them In 2014/15 each organisation that is collaborating with the Hull 2020 Programme has its own delivery plan for individual projects, however whilst the Hull 2020 PMO is tracking these projects as part of the overall programme, the PMO is not responsible for their delivery. For example, the NHS Hull CCG team is currently delivering the following key initiatives in 2014/15, while the Hull 2020 PMO is aware of these projects, the CCG team is project managing the projects: Procurement of Depression and Anxiety Services for Hull Re-procurement of Community Musculo-skeletal (MSK) Services Co-location of Urgent care in the Emergency Services Department The development of Map of Medicine to support clinicians in primary care follow evidence-based best practice and to provide easily accessible updated local service information A summary of all the Hull 2020 Work streams, including their scope is included in Appendix One. 3.4. Key Business Benefits When the Hull 2020 vision is delivered, it will be underpinned by a single system of robust integrated governance and partnership beyond traditional organisational boundaries. The best use will be made of the whole Hull public service pound, and options will be explored regarding public service funds becoming community earned and community owned. Hull 2020 CCG Strategy 25

Financial Benefits The NHS Hull CCG element of the Hull 2020 programme is contributing to the following QIPP plan for 2014/15, which has been approved by the NHS Hull CCG Board: Description m's QIPP Demand Management; better management of pathways through early support and intervention, right care first time (3.5) QIPP Reduced Outpatient 1st to follow up ratio (1.1) QIPP End of Life (0.7) QIPP Improving Access to Psychological Therapies reprocurement (0.5) QIPP Day Case to Outpatient Conversion (0.3) QIPP Medicines Management (prescription costs) (0.4) QIPP Better Care Fund/Shared Care Monitoring/Dementia Assessments (0.4) Total Saving (6.8) There is further work underway to model the opportunities for financial contributions to the CCG and other agency efficiency programmes through the Finance enabling work stream. The Hull 2020 approach may include investment to ensure that existing systems will not be a barrier to the provision of integrated care. This will also develop contractual levers that improve co-ordination of care and incentivise providers to work together. This will be specified in joint contracts that ensure that there is accountability for the outcomes achieved for individuals regardless of the provider and that payment is more outcomes focused rather than just for specific activities. The intent is to create mechanisms that allow funding to flow to the point of need in order that the shift of care is mirrored by a shift in resource; it is expected that the impact of this to be measured by the movement of investment from secondary to primary and community care and primary prevention. The figures below represent the potential activity shift over the next six years as a result of transformational initiatives across the City of Hull, from base case activity to activity following the implementation of initiatives. Hull 2020 CCG Strategy 26

NB: the charts are purely indicative at this stage Figure 4 Base Case Activity Figure 5 Post Initiative Activity The Hull 2020 approach is clear that centralisation of health and care services will not save money; as in many cases the same number of patients would need to be treated. There is as yet insufficient evidence to support centralisation on the basis of cost benefit; it may even cost more to move and run services from one location. Centralisation considerations are to improve quality, safety and individual outcomes. Hull 2020 CCG Strategy 27

Outcomes Benefits The table below sets out how the key interventions that will be delivered in 2014-15 by the Hull2020 programme will support both the Hull 2020 and the BCF outcome frameworks. These Outcomes are detailed in Section 3.1 above. Hull2020 Interventions in 2014/15 Relevance to Hull2020 Outcomes Alignment to BCF Development and roll out of Community Hubs across Hull Establishment of Wi-Fi connectivity for all staff across all public sector offices in Hull Use of cold alarm technology to support cross sector winter planning and specifically to increase the level of prevention Creation of a single portal for people in Hull to access information about the services available to them A,B,C,D,E,F, A,B,C,D,E,F, A,B,C,D,E,F, A,B,C,D,E,F, BCF1, BCF2, BCF3, BCF4, BCF5, BCF6. BCF5. BCF1, BCF2, BCF3, BCF4, BCF5, BCF6. BCF5. The Ambition for Improving Outcomes detailed in the Better Care Fund Plan are aligned to the outcomes expected to be delivered by the Hull 2020 programme. These are contained in the table below: Workforce Benefits With a demanding set of financial and health challenges for the city, the NHS Hull CCG workforce, working with colleagues from other agencies, will be the single most powerful differentiator in enabling the required transformational changes to the way healthcare is commissioned, led, delivered, quality assured and assessed across the Hull 2020 workstreams. The NHS Hull Organisational Development strategy is designed to: Underpin and support the delivery of the NHS Hull CCG Hull 2020 transformation project, harmoniously aligned with the attendant Commissioning for Quality, Communications, Engagement and the development of CCG-centric workforce development plans Hull 2020 CCG Strategy 28

Set out how we will achieve the desired capability and culture required to become a high performing, thought leading commissioning authority, delivering the stated business strategy of Creating a Healthier Hull and underpinned by the outcomes set out in the Hull 2020 strategy Ensure we have the right people in the right roles with the right knowledge skills and potential to implement the three key strategic aims of 21st Century primary care, Integration, and Next Generation in a dynamically stable organisational culture. Central to enabling the CCG to deliver this agenda, is the enablement of its workforce to innovate and deliver differently through creative thinking and agile implementation. Creating the conditions for these organisational behaviours will require inspirational and visionary leadership. Research and Development NHS Hull CCG is committed to promoting research, service evaluation and innovation when addressing the healthcare priorities of the population in Hull in order to ensure that the commissioning decisions are based on best available evidence. The CCG recognises that maximising the quality and effectiveness of patient care is best realised through a strategic approach in taking part, attracting and funding research studies that best match the population characteristics in Hull as well as working towards attracting more high quality commercial studies into this area. Maximising the benefits of research through innovation, income, knowledge improvement are key to improving patient/public outcomes. NHS Hull CCG continues to be at the forefront of making the promotion of research, and the use of research evidence part of its core work, and demonstrates a high level of research and development (R&D) activity, by sponsorship of local projects, working with partner organisations in securing national bids and more recently the establishment of a R&D Steering group. The CCG aims to positively engage with the research agenda and be an evidence driven organisation, utilising research methodologies to: 1. Improve the health of patients/public by commissioning research that supports the development of best evidence, innovation and commissioning priorities 2. Develop a research culture characterised by increased patient and public involvement and engagement in research studies both as participants and researchers 3. Increase knowledge and understanding of specific treatments and care delivery to determine if service provision is effective in terms of improved outcomes and value for money 4. Inform commissioning, service provision and identify gaps in the evidence base Hull 2020 CCG Strategy 29

The objectives of this work for NHS Hull CCG are outlined below: Identify CCG Research Champions to assist in identifying research topics in line with commissioning priorities Strengthen and support a culture of evidence based commissioning underpinned by research, innovation and clinical effectiveness Ensure the inclusion and opportunities for patients to be involved in research through our main providers contractual requirements Develop proactive engagement with partners for knowledge transfer, the translation of research and innovation into practice and rapid implementation. For example NICE, PHO, CLARHC s, AHSN s, The Cochrane Library, local Higher Education Institutions Meet the responsibilities to promote and support research including excess treatment costs associated with non commercial research Support the engagement of patients and public in research both as participants and researchers The CCG will develop an action plan to deliver against these objectives, which will further enhance and build on the Research and Development agenda underpinned by the interdependent strategies for Hull. 3.5. Stakeholders This vision will be delivered by public services collaborating to bring about an integrated approach to health and social care, informed by an on-going dialogue with the people of Hull. To deliver the vision the partners across Hull have committed to a set of partnership working principles signed up to within a Memorandum of Understanding, as detailed below: Principles of Partnership working Partnership organisations will work collaboratively and support each other over the period of transformation. Individual members will ensure the Hull 2020 strategy is aligned with their own organisations strategies and business development plans. Partners will be open, transparent and act in good faith to each other. Partners will work in the interests of the population of Hull rather than current organisations and look to make all decisions on a 'best for Hull 2020' basis. Open, straight and honest communication, understanding and respecting other people's perspectives within the Participants and with all key stakeholders. As far as possible commit to try and resolve all issues within the Participants. Partners will commit their resources appropriately to support a timely delivery of the agreed programme objectives. Recognition that this is an iterative programme. Partners will use their influence to support the Hull 2020 programme Hull 2020 CCG Strategy 30

The Hull 2020 Strategy has been developed to guide the rapid adoption of more integrated models of care that are sustainable and focused on meeting the needs of the public; these needs will continue to be identified by an on-going dialogue with the people of Hull. As well as the organisation stakeholders that are involved in Hull 2020 the people of Hull are influencing the programme through community champions. These champions are part of the NHS Hull CCG Ambassadors, provider membership groups, the Hull People s panel (Hull City Council and Hull CCG) as well as working with a wide range of voluntary and charitable organisations, such as the Goodwin Trust and Age UK. An example of the how this engagement has informed the developed of Hull 2020 is the use of the Tale of Two Wards, which has reviewed the difference in life expectancy of ten years between the St Andrews and Beverley wards. The outcome of this project is informing the location and approach to the new model of care being delivered by community hubs, supported by on-going engagement. A significant transformation agenda will require robust programme management and shared governance across the participating organisations. The use of change management techniques and integrated partnership working will be the key enablers for successful delivery of the Hull 2020 vision. This strategy will be reviewed annually to ensure it continues to reflect the on-going needs of the people of Hull beyond 2020. The partners we are working with to deliver Hull 2020 are: Has responsibility for the commissioning of health services to meet the needs of the people of Hull; clinically led with a membership comprising 57 local GP practices Unitary Local Authority for the City of Kingston upon Hull; it is responsible for delivering Social Care and Public Health services; it is also the local education authority Provides medical and surgical services for the people who live in the Hull and East Riding of Yorkshire area; has two main sites at Hull Royal Infirmary and Castle Hill Provides a comprehensive range of mental health, community services, learning disability and addictions services to people living in Hull and the East Riding of Yorkshire Hull 2020 CCG Strategy 31

Provides community services across Hull, such as children and young people s services, adult nursing care, out of hours GP services, minor injuries and some primary and dental care Provides 24-hour emergency and healthcare services to a population of more than five million across the county of Yorkshire Focused on reducing crime, disorder and road casualties. Covers the districts of North East Lincolnshire, North Lincolnshire, and the East Riding of Yorkshire, along with the urban area of Kingston Upon Hull Provides an emergency fire and rescue service covering the districts of North East Lincolnshire, North Lincolnshire, and the East Riding of Yorkshire, along with the urban area of Kingston Upon Hull Healthwatch Kingston upon Hull is the independent consumer champion for the community, influencing all local health and social care services. 4. Implementation A Programme Management Office has been established to co-ordinate the programme of work that has been developed for Hull 2020. This team is responsible for driving through the collaborative projects to achieve the identified impact on the population. Programme management for the Hull 2020 Programme is based on a simple three step approach: Hull 2020 CCG Strategy 32

This approach has been used in recognition that Hull 2020 is a five year programme with multiple work streams working across multiple organisations. The Hull 2020 Programme will be developed iteratively and be reviewed and refreshed on an annual basis with formal sign off by the Hull 2020 Programme Board. The purpose of the Programme Management Office (PMO) is to maximise the benefits delivered by the programme. The PMO should bring a level of decision making and review, which would not be possible at the project level. For example, determining priorities (e.g. relating to resources), and determining which projects are delivering maximum contribution to key business objectives. Often it is not possible or desirable to make sound decisions on these factors at the individual project level. The purpose of the PMO is not to duplicate the function of delivering projects it is to: Provide focus on the strategic goals, objectives and benefits and ensure these are evident or maximised Provide input to project planning to maximise the achievement of the business objectives Communicate with stakeholders and sponsors and support Project Managers where required with this task Ensure the sum of the deliverables from across the programme meet the business needs Ensure that benefits are actively planned, optimised and realised Ensure that wider business risks are recognised and being addressed Provide direction relating to priorities and resources When programme management is carried out in a regular structured and disciplined manner, the following benefits can be achieved: Projects can be accelerated, slowed down, or stopped in line with overall priorities Resource priorities can be assessed across projects Issues and risks can also be assessed and provided with direction in line with business needs Interdependencies can be identified and controlled The PMO provides the link between strategic planning and the benefits that will be delivered, ensuring the optimisation of the benefits delivered. Hull 2020 CCG Strategy 33

Hull 2020 PMO Function Diagram HULL 2020 Programme Structure The diagram below provides an overview of the service development work streams that have been established and the approach to mobilising the activities of each project. There is a project manager from the Hull 2020 PMO assigned to each work stream to provide coordination and resource to develop the activities of each project. Hull 2020 CCG Strategy 34

The work streams below are the enabling work streams that have been mobilised to support the service development activities. These work streams include participants from across the Hull 2020 organisations in order to ensure that the infrastructure to deliver future services in being developed in parallel with the service initiatives. The diagram below indicates the leadership of each of the Principles of Delivery within the Hull 2020 programme. These work streams are led by senior Directors from each of the main partner organisations and are focused on ensuring that integration is coherent. Hull 2020 CCG Strategy 35

4.1. Governance Programme governance is managed by ensuring senior level engagement and leadership in the work streams and in championing the programme s Principles of Delivery. This is secured via a Programme Board that reports to all individual partner organisation Boards and the Hull Health and Wellbeing Board; Emma Latimer, Chief Officer of NHS Hull Clinical Commissioning Group is the Programme Sponsor. The Clinical & Professional Reference Group will provide clinical oversight and advice. The Communications and Engagement Group will ensure public involvement in developing the programme. The partner organisations have agreed a Memorandum of Understanding for collaborative working that ensures all parties work together to deliver this programme. Appendix Two provides a summary of the stakeholders engaged with each work stream. The PMO uses three tools across the programme and for all work streams: Risk Register Issues Log Programme Plan A standard report format is also used for all communication; this is provided in the form of a blog for all partner organisations and stakeholders. Hull 2020 CCG Strategy 36