NHS Bradford Districts CCG Commissioning Intentions 2016/17 Introduction This document sets out the high level commissioning intentions of NHS Bradford Districts Clinical Commissioning Group (BDCCG) for 2016/17. They provide the context for constructive engagement and indicate to our current and potential new providers how, as a commissioning body, we intend to shape the system that provides health services for the population of Bradford. Our CCG population is approximately 339,500, served by 40 practices that are responsible for the commissioning of health services. The key health and well-being challenges for our CCG remain chronic conditions and cancer, and the outcomes relating to these. Social, economic and environmental factors either have a direct impact on health status or exacerbate existing ill health, which can be seen in our population. A powerful driver across all service provision, and in developing our policies, will be encouraging healthy choices that promote wellbeing as the default option across a system much wider than health alone. The CCG is genuinely clinically led. Our constant clinical focus will be on improving quality and outcomes. Central to this is the significant engagement in commissioning from our member practices and the wider clinical community, who have been active in setting the key strategic priorities to improve the health of our population. These commissioning intentions build on and take account of: BDCCG s strategic priorities but also reflect the aspirations in the Bradford District and Craven Five Year Forward View (2014-2019) for the healthcare system, developed with partners. National and local priorities including delivery of NHS Constitution standards, the NHS Mandate, the NHS Outcomes Framework and NHS England s Five Year Forward View. Joint working with the Local Authority and the Health & Well-Being Board and associated work plans. Better Care Fund plans developed jointly with Bradford Metropolitan District Council The CCG s financial plans and associated measures and actions designed to deliver an improved and sustainable financial position for the health and social care system BDCCG is responsible for commissioning the following services for the people of Bradford Districts: Urgent & Emergency Care Out of hours primary care Planned hospital care Services for people with learning disabilities Rehabilitation services Mental health services Children s healthcare services Maternity and new-born services Community health services NHS Continuing healthcare From April 2015, the CCG has also been responsible for the commissioning of Primary Medical Care Services (i.e. excluding dental, community pharmacy and ophthalmic services). BDCCG will take responsibility for the commissioning of bariatric surgery in 2016/17, previously commissioned by NHS England.
BDCCG is not responsible for commissioning: Specialist services e.g. retinopathy Specialist services e.g. transplants Public health services e.g. health visiting Other commissioning organisations such as NHS England, Public Health England and local Public Health (part of the Local Authority) are responsible for commissioning these services for our local population. At times we will also work in partnership with these organisations to commission services together via pooled or aligned budgets. Overarching principles and direction of travel Bradford Districts CCG has a clear, concise and well-recognised vision of better health for the people of Bradford. Our strategy for greater integration and improving people's experiences of the services we commission remain at the heart of our ambition for sustainable, high quality and efficient health services. BDCCG will contribute to the delivery of the Five Year Forward View and to enable us to do this we will focus on the nine key must do s as outlined in the planning guidance 1 : 1. Develop a high quality and agreed Sustainability and Transformation Plan, and subsequently achieve our most critical milestones for accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View. 2. Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through implementing the RightCare programme in every locality. 3. Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. 4. Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through making progress in implementing the urgent and emergency care review and associated ambulance standard pilots. 5. Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. 6. Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-onyear improvement in the proportion of cancers diagnosed at stage one and stage two; and 1 https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf
reducing the proportion of cancers diagnosed following an emergency admission. 7. Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. 8. Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. 9. Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts. The above will be delivered across our unit of planning (Bradford, Airedale, Wharfedale and Craven) as we move towards place-based commissioning. There will also be different commissioning footprints, some very local e.g. community based, others wider, at either West Yorkshire or Yorkshire and Humber level. System transformation The main strategic focus for BDCCG is to develop new models of care that achieve the triple aim of improved population health outcomes, high quality experience of care and at a good value per capita cost. As a system we have signed up to the design and delivery of an accountable care system as being one, albeit significant, lever in achieving these aims. We expect to be operating within an accountable care system by 2020/21 and we are planning major steps in the design of this in 2016/17. We believe that by establishing an accountable care approach, we will be able to commission holistic care for our population, taking into account the care they will need for their whole life, and for the whole person, rather than commissioning separate services. We will commission services that wrap around them, to provide co-ordinated consistent and high quality services across organisational boundaries. This approach will be outcome based. We are not interested in merely counting activity and inputs, rather, we want to know that the care received by our population is of high quality, safe and of best value and that we commission interventions that improve the population s overall health outcome To achieve this, in 2016/17 we are testing our capability (and providers capability) to work collaboratively to achieve a common purpose. We are undertaking a structured collaboration approach to commissioning diabetes services and the prevention of diabetes. Structured collaboration is a process where we as commissioners will work with existing providers, patients/service users and the public to establish a new approach to the delivery of transformed services. This means that we expect the providers to work together collaboratively, rather than in competition with each other. Such collaboration between commissioners, providers and patients/service users and the public will be conducted with the aim that, over time, the emphasis can shift away from secondary prevention of disease and delivering services to meet acute care needs towards primary prevention and self-care We want to enable and empower our population to make decisions around their illnesses and, where possible, to support them to prevent or delay the onset of some diseases altogether.
There are a number of key steps involved in using structured collaboration to commission and contract for services differently. This work commenced in 2015/16 and will continue into 2016/17 and beyond. This includes the providers and commissioners working together with other stakeholders to establish robust governance arrangements, agree the scope of services, and for commissioners to set clear key outcomes. There are a number of gateways set out over time which the providers, together as one entity, will be required to meet. BDCCG has recognised that it would be extremely difficult to go from the current commissioning arrangements to a whole accountable care system in one step, which is why in 2016/17 we are concentrating on diabetes. We believe this will support the overall aim by 2020/21.We intend to approach the commissioning of a complex care system for people with long term conditions (ranging from people who self-care to those who are in a stable condition managed in primary and community services to those who have escalating needs, are unstable or have acute care requirements) utilising the same methodology. This work is being implemented in partnership with Bradford City CCG. This will allow for the development of the provider landscape and the embedding and progression of the new commissioning approach over the next 5 years to facilitate the realisation of an accountable care system across Bradford District and Craven. To further support the overall strategic aim of delivering an accountable care system by 2020/21, as well as undertaking the diabetes and complex care work outlined above, we will continue to deliver change via our key work programmes: Bradford Beating Diabetes Bradford s Healthy Hearts Improving Patient Experience Maternal and Child Health Mental Health Learning Disabilities Urgent and Emergency Care Planned Care Out of Hospital Care (Primary and Community Care) Self-care and prevention There will be continued focus on parity of esteem between mental health and physical health and delivery of the Crisis Care Concordat. We will continue to work with our partners on the roll out of the Future in Mind plan to improve the care delivered to children and young people with mental health issues. The CCG will have a key focus on Learning Disabilities in 2016/17 with the finalisation and commencing roll out of the Transforming Care Plan, aiming to make key changes to services to better meet the needs of our population. Three significant cross-cutting themes that also underpin the wider system wide transformation programmes have also been identified by the CCG as essential enablers to delivering change. These are system wide workforce development, estates and better use of technology. The system has traditionally struggled with recruitment and retention issues, and is focused on using its current workforce more effectively and developing a clear workforce strategy. The Digital Roadmap will set out our plans to become paper free by 2020, with the detail to be included in our Sustainability and Transformation Plan. The CCG is working with Bradford Districts CCG and Airedale, Wharfedale and Craven CCG alongside key partners to develop a system wide estates strategy in 2016/17. It is also anticipated that the CCG will submit an application against the national Primary Care Transformation Fund to support the sustainability of primary care. We continue to invest in the development of
primary care at scale and, in line with the accountable care development work, are continuing to support new models of primary care which see greater collaboration both between general practices and within the wider health system. Our short term strategy for improving general practice focuses on improving access and challenging variation. We will also engage with other areas of work taking place over a wider footprint to enable system transformation which are already underway and which will offer opportunities in the future. Examples include the West Yorkshire Urgent and Emergency Care Vanguard, and the Airedale Care Homes Vanguard. Funding for future transformation plans will be accessed via our Sustainability and Transformation Plan. Patient experience and engagement The poorest care is often experienced by those least likely to provide feedback, make complaints, exercise choice or have family speak up for them. Patient experience is one of the elements of quality, alongside clinical effectiveness and patient safety. There is an incomplete picture of the patient experience across the range of services and breadth of patient groups. The CCG will continue to build capacity and capability in ourselves and our partners and providers to act on patient feedback by building the skills and tools to analyse different sources of feedback, identify key issues that need to be addressed and then implement plans that deliver an improved experience. Engaging local people in a meaningful way is central to the way we work and to understanding the needs and experiences of people who use our services. We have built up our relationships with local people by establishing a number of ways in which people can influence our decision making and work with us to co-design pathways and services. We have patient groups and networks to strengthen people s voices and these have supported the development of the People s Board a body designed to build on the strong foundations of patient and public involvement already in place and strengthen and champion participation and co-design. We gather views in a wide range of ways including through our website, social networking, public events, surveys or working with the voluntary sector and other partners. These experiences feed into our Grass Roots report where themes and trends are identified and feed into our programmes of work to inform the way ahead and improve local people s experiences of the services we commission. Commissioning for quality, outcomes and value As outlined above, BDCCG will commission against the NHS Outcomes Framework and also the CCG Outcomes Framework, the Adult Social Care Outcomes Framework and the Public Health Outcomes framework. The CCG will also further develop and refine its approach to outcome based commissioning, and will be continuing to work with providers and partners to consider innovative approaches to its contracting frameworks that will incentivise providers to deliver improved outcomes. Initially this will focus on diabetes and complex care. As a CCG we need to balance the need to improve and maintain quality with ensuring value for money and producing efficiencies. The NHS Right Care programme supports this approach, and NHS England and Public Health England are taking forward the Right Care approach through new programmes to ensure that it becomes embedded in the new commissioning and public health agendas for the NHS. BDCCG will continue to use and adopt the approach in 2016/17, focussing on clinical programmes and identify value opportunities, moving away from commissioning focused on organisational boundaries. Value exists where our health economy is an outlier and therefore will
yield the greatest improvement to clinical pathways. The CCG will deliver value to our population by reviewing available indicative data on quality, spend and outcome to highlight the top priorities and opportunities for transformation and improvement. These reforms will be those that give us the highest value healthcare improvement. The Right Care programme areas that offer the greatest opportunity in terms of both quality and spending are circulation disorders, genito urinary endocrine, musculoskeletal and mental health problems. A key element of improving the quality, outcome and value of the services we commission will be the improved use of technology and information. We expect over 2016/17 and future years to see an increasing use of technology to support both direct patient care and better efficiencies. We will expect any future service to have interoperability with other relevant services and that data sharing when appropriate is standard practice, so patients receive safe care and only have to give information once, rather than to every care provider. Tackling Inequalities BDCCG has acknowledged that the tackling of inequalities requires a targeted approach at some of the underlying determinants of poor health. Whilst some of this level of thinking is picked up in the commissioning of new models of care for diabetes and complex care, there is a significant shortfall in strategic attempts to address inequality. BDCCG will play a full and active part in partnership arrangements such as the health and Wellbeing Board and seek to leverage action to directly address the underlying causes of health inequalities. The approach to commissioning community based services through bodies such as the VCS is also being reviewed with the intention of securing local community and voluntary services as first base not as an unplanned recipient of non-recurrent resources and mainstream slippage. These services are core to our delivery of self-care and prevention and ultimately all our new models of care to achieve better population health outcomes. BDCCG wants to ensure that every contact counts to allow us to deliver health and wellbeing improvements to our population. Whichever part of the health service our patients come into contact with we want them to be supported to make improvements to their health. This will mean a focus on commissioning health improvement interventions rather than commissioning standard treatment options. For example, in 2016/17 we need to start thinking differently about how to tackle obesity issues, smoking in pregnancy, malnutrition in our children and young people, and improving the health and wellbeing of our population with mental health and learning disabilities. Financial Context In 2016/17 the CCG plans to spend just under 500 million on health care. The key areas of spend include services from acute hospitals, mental health, community services, primary care, and prescribing. However, there is also the need to identify cost saving opportunities. The QIPP Programme for 2016/17 will be based on intelligence led identification of opportunities and local discussions about prioritisation and utilisation of resources. With resources in Bradford health and social economy diminishing, the CCG is choosing an approach that targets areas where there is evidence of unwarranted variation in the CCG s benchmarked performance and one that builds upon existing service change initiatives and underpins our direction of change. At this stage the CCG has assessed its savings programme requirements for 2016/17 to be in the region of 10.5m although increased demand within elements of existing contracts suggests that this position could deteriorate.
In recognition of the constrained financial environment across Bradford s Health and Social Care system, difficult decisions will need to be explored around possible disinvestment from and decommissioning of services. The CCG with its partners will therefore be ensuring a clear and transparent process for this is in place, and stakeholders and patients are involved. Next steps The CCG recognises it has a significant programme of work and that choices will need to be taken in implementing commissioning intentions and determining the CCG s programme of work. The CCG will work with partners over the next year on our transformation programmes, shifting business as usual from our existing commissioning and provider delivery patterns to an accountable care approach.