Planned Care Strategy 2013-2016 Executive Summary Page 1 of 16
To deliver high quality and effective services, safely, in the right setting with the right professional. Vision Values Strategic Planned Care Executive Summary Prioritised We will continually improve the quality of the services we commission both now and in the future Partnership working will be a key factor to ensuring the success of the strategies developed with our neighbouring CCG's and trusts. Patients will be at the centre of all the decisions that we make Primary Care Development and Demand Management Capacity Modelling Delivering Care in the Community by Service Redesign /Service Improvement Developing New Entrants in the market place Patient Choice and assisting patients in making informed decisions Patient Experience Consultant to Consultant Referrals Choice and Referral Centre New: Follow up Ratios Primary Care Demand Management Identify Demand v Capacity mismatches Source alternative providers Research Community Models of care Clorectal Surgery (Rectal Bleeding) Urology Cardiology Neurology Ophthalmology Pain Management Community Physiotherapy Community E.N.T. Community Dermatology:- B.C.C.'s Lung Cancer Pathway Source Local Providers A.Q.P. Tender Services Named Consultant Diagnostics Community Services to secondary care interface Appointment selection for Primary and Secondary Care Clinical Assessment Services A.Q.P. Management Management of Demand v Capacity mismatches (e.g. Spinal, Colorectal) Quarterly Monitoring of Patients Experiences Local Real time feedback systems (SNAP surveys, Outpatient Kiosks) Patient Experience CQUINS PPI Strategy Creating of Patient Congress Page 2 of 16
VISION To deliver high quality and effective services, safely in the right setting with the right professional This planned care strategy sets out a plan of service redesign and delivery that aims to deliver a variety of services, at higher quality and better value for money, in settings that are as close to the patients home as possible, and delivered in the community where clinically appropriate. This strategy will promote services that are delivered as part of integrated pathways across primary, community and hospital services where the evidence proves that this is the right thing to do. We understand that in many circumstances care delivered in hospital is the optimum model although provider capacity will sometimes present challenges. Therefore commissioners will need to understand the capacity and demand modelling and source other provision where appropriate in order to deliver national targets on 18 weeks. Stoke on Trent CCG is committed to sourcing new entrants into the market in order to create more capacity in a current market place that lacks alternative providers and hence choice for our patients. This strategy also has to recognise the important role that commissioners have to play in supporting established hospital trusts, especially University Hospital of North Staffordshire, to progress to Foundation Trust status. As we develop patient pathways we have to bear in mind both the sustainability of acute services as well regulations pertaining to procurement in the Health and Social care act. The Fit for the Future project included principles for the health economy to collaboratively commission healthcare for the people of Stoke on Trent and North Staffordshire. Whilst this project is now complete Stoke CCG still want to work in cooperation with our partners to deliver services. There are however some concepts that need to underpin this approach both in terms of service design and delivery. The drive for improvement cannot be impeded where providers are unwilling, or unable, to meet core undertakings or where they use their current dominance in the local health economy to obstruct progress. In terms of service design we expect our providers to: Help shape the vision Deliver promises Share data and intelligence Be open and transparent Have realistic and competitive pricing Deliver Quality Assist in safe clinical pathways. In terms of service delivery we expect our partners to: Meet Key Performance Indicators Meet national targets Deliver best value for money Provide best possible: o Patient safety o Patient experience o Clinical effectiveness o Quality of service Have robust capacity / capability Page 3 of 16
Where a provider is unable to meet the criteria above then we would look to seek alternative provision with providers who share the above principles. Commissioners will work with acute providers, private providers and our primary care clinicians to ensure that planned care delivered in the acute setting is delivered effectively and safely. Patients tell us they want access to local services because it is easier for them. The CCG faces higher demand for healthcare than ever before with high levels of activity across the healthcare system but especially in secondary care. We believe that providing alternatives to secondary care will be critical if the local health economy is to deliver a sustainable health service in the future. Care in hospital should be limited to specialist services and those it is not possible or practicable to provide outside a hospital setting. Those services will often be for people that require Consultant intervention or surgery. Services will be delivered in a community setting if they: Comment [SF1]: The extra paragraph needs to go after this.. Are of equal or improved quality compared to existing hospital provision Are cost effective and provide value for money Are acceptable to patients Promote choice and improve access Do not present risks that undermine the sustainability of the whole health economy once all risk mitigation strategies have been deployed. Much of this strategy will be delivered through the design and commissioning of effective care pathways. In delivering this strategy we will:- Ensure all service redesign is clinically led, strengthening links with existing clinical forums, localities, and working collaboratively with our CCG colleagues and primary and secondary care clinicians. Ensure all programmes of work deliver better value for money through closer joint scrutiny by clinical and financial leads Deliver quality and equity of access to all of our redesign pathway programmes. Deliver high patient satisfaction levels from all completed pathways. Page 4 of 16
CONTEXT Population Demographics The registered population of Stoke on Trent CCG is 280,282 spanning over 53 practices. Primary Care registers show patients are registered as having the following top 7 conditions within Stoke on Trent: Register sizes as at Jan Clinical Domain 2013 Coronary Heart Disease 10933 Hypertension 45424 Diabetes Mellitus (Diabetes) 15443 Asthma 17218 Depression 17047 Obesity 33681 Smoking 71407 Fact and Figures from the JSNA Stoke-on-Trent is ranked as the 16th most deprived area in England (Index of Multiple Deprivation), with 61% of the population living in areas classified as the most deprived 25%in the country. There is a population bulge predicted among older age groups. From 2010 to 2015, a 29% increase in the 65-74 year age group (around 3,000) and an 18% increase in the over 85s (around 400) are predicted. This will raise significant health and social care needs. The new census data will provide greater accuracy. Black and Minority Ethnic groups (BME) comprise 7% of the population. The city is becoming more ethnically diverse, with 20.6% of children in the city s schools being non-white Average life expectancy (2007 to 2009) for males is 75.4 years (national average 78.3 years) and for females is 79.9 years (national average 82.3 years). Men and women born in the least deprived areas of Stoke-on-Trent can expect to live respectively 8.1 and 5.2 years longer than their counterparts born in the most deprived areas. The overall death rate in the city is 24% higher than the national average: 76.7% of all deaths in the city are a result of three main diseases: cancer (30.5% of deaths), circulatory disease (28.6%) and respiratory disease (17.6%). Mortality from cancers is 36.4% above the national average (in the city s more deprived areas, people are 30% less likely to survive 5 years after diagnosis than in more affluent areas). Mortality from lung cancer is nearly 55% above the national average (in the most deprived areas of the city, this rate was nearly twice as high). Numbers of deaths from circulatory disease have more than halved in the last 10 years but the mortality rate remains 16.7% higher than the national average (the main cause of death is coronary heart disease).it is estimated that in 2006-08, Page 5 of 16
27.6% of the adults of the city were obese (national average 23%); a similar pattern is evident among the children of the city. Smoking is the single biggest contributor towards health inequalities. Smoking causes 40% of all male deaths and 25% of all female deaths (90% of all lung cancers are attributable to smoking; one in four of all cancers are attributable). Around 25.1% of adults in the city smoke (national average 21.2%), with a significantly higher incidence in the more deprived wards (2009/10). Public and Patient Engagement This strategy is designed to deliver the aims and objectives outlined in Stoke on Trent CCG PPI Strategy 2012/13. In this strategy it summarises that patients want: More ownership of local services by patients and public and communities Services in Stoke on Trent are designed and adapted to respond better to people s needs. Greater communication with patients, the public and communities; and service users are better informed Moderate inappropriate patient demand Increase patient satisfaction with our commissioned services Encouraging patients more appropriate use of services Lead to more cost-effective outcomes Help monitor the effectiveness of services Comparative patient perspectives to professional /commissioning managers viewpoints One of the core principles of the new NHS (Equity and Excellence) is putting patients at the heart of decision making.. Patient and public expectations of health services are at their highest. Patients are more aware of the choices available to them, more understanding of the NHS s obligation to deliver those choices, and more able to challenge when things go wrong. We welcome this increased patient power. This strategy will build on the picture drawn following consultation the priorities contained in Stoke on Trent CCG PPI Strategy. We will build on established mechanisms of involving patients and the public to ensure that commissioners continue to be updated about what people want and what they think about the services we commission on their behalf. General stakeholder engagement programmes will be established to capture broad themes; targeted service specific programmes will be run as a contribution to all service transformation and reconfiguration programmes. Page 6 of 16
National and Local Priorities The NHS White Paper Liberating the NHS (2010) - sets out a number of high level strategic objectives for the NHS. We must do more to put patients and the public at the heart of decision making about their care and about how services are commissioned and delivered on their behalf. We must improve health outcomes and incentivise for better quality in favour of contracting for activity. Local healthcare professionals and providers will have more autonomy locally to shape the way health services are designed and delivered, in turn they will be held more closely to account for what they do. And all of this must be achieved whilst significantly reducing the numbers of non-clinical staff hitherto engaged in supporting delivery of the health service agenda (target reduction of 45% in management costs over the next 4 years). Lord Darzi: High Quality Care for All: - Lord Darzi s final paper gave a vision of what healthcare should look like in 10 years time. The paper suggests that there should be more rights and control for patients with their own healthcare. Extending choice and empowering patients to have more informed choices in deciding upon their health care. Focusing on improving health as well as treating sickness, introducing polyclinics and new GP practices. Quality should be at the heart of the NHS by reducing health associated infections, setting quality standards and clinical priorities as well as systematically measuring what quality looks like. Fit for the Future Programme (2006-2013)- This ambitious programme sets out to deliver a smaller local hospital on one site with the creation/upgrading of several Primary Care Centres/Health Centres around the local health economy (LHE). From these centres will be housed 120,000 outpatient appointments, a series of diagnostic interventions, and primary care services that will and can be delivered closer to patients homes. Stoke on Trent CCG Clear and Credible Plan (2012) This paper sets out the vision and strategy of Stoke on Trent CCG over the next three years. The PCT s financial position going forward is of key importance going forward. There are significant pressures on the economy at present from Non elective activity and there is a real concern that financial balance will be a challenge. Finance and Activity The CCG going forward is facing significant challenges as stated above and needs to make savings in order to achieve its financial targets. Activity and Spend for Planned Care at UHNS for NHS Stoke on Trent 2010/11 2011/12 2012/13 Apr-Jan 2012/2013 FYE Point of Delivery Activity Cost Activity Cost Activity Cost Activity Cost Planned Same Day 27130 19,385,386 25665 16,832,786 18161 13,285,921 21793 15,943,106 Elective 5436 13,438,732 5001 13,353,179 4267 10,812,574 5120 12,975,088 First OP 62508 10,686,030 76556 11,762,060 60008 8,711,484 72010 10,453,780 FU OP 136090 12,558,729 175007 13,860,962 134706 9,685,167 161647 11,622,200 PbR Proc OP 17390 2,417,208 21322 3,196,741 18068 2,864,729 21682 3,437,675 Total 248554 58,486,085 303551 59,005,727 235210 45,359,874 282252 54,431,849 Page 7 of 16
Financial Impact per speciality. Treatment Specialty of Planned Care at UHNS for NHS Stoke on Trent 8,000,000 Planned Inpatient by Specialty 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 2010 / 2011 2011 / 2012 2012/2013 FYE Page 8 of 16
HRG Chapter Perspective of Planned Care at UHNS for NHS Stoke on Trent QIPP Plans (Quality, Innovation, Productivity, Prevention) All NHS organisations were charged with cumulatively delivering 20 Billion of savings directly linked to QIPP. The table below shows the Planned Care contribution to Stoke CCG s target.( 000 s) INITIATIVE TITLE 2011 2012 2012 2013 2013 2014 Total Improved Productivity in Community 250 500 250 1,000 MSK Pathway Redesign 248 248 Ophthalmology Redesign 270 270 First to Follow up Ratios 400 TBA 400 Standardised Admission Rates 1,541 1,541 Direct Access Diagnostics 46 46 Minor Hand Surgery 70 70 Day case to Outpatient Procedure 334 399 733 Community Gynaecology Service 45 43 88 Community E.N.T. Service 70 70 Community Dermatology Service 46 46 Decommissioning Dermatology/E.N.T. 148 148 Decommissioning Dermatology Service CAS 17 17 Phlebotomy Service 33 33 Total 4,710 Page 9 of 16
The challenges for Planned Care in Stoke on Trent are clear for all to see. Based on the information presented in this paper so far, there is a need to devise a strategy that will embrace the national and local priorities, deliver a sustainable programme of planned care services and strive to continually improve the quality and patient satisfaction around them. From the challenges already stated, there are six goals that must be focussed upon in order to deliver the vision. They are: 1. Primary Care development and Demand Management in Secondary Care 2. Capacity Modelling. 3. Delivering care in the community for services or part services by Service Improvement/Redesign. (including QIPP). 4. Developing new entrants (providers) into the market place. 5. Patient Choice and assisting patients in making an informed choice. 6. Patient Experience. 1. Primary Care development and Demand Management in Secondary Care We are a membership organisation and one of our strengths should be maximising the potential of primary care for the benefit of patients. This should include improved quality of care, enhancing the workforce and care closer to the patient. GP referrals are created as a result of either clinical necessity or clinical uncertainty. GPs will generally attempt to manage patients in primary care and only refer when either they need access to more detailed diagnostics or feel the patients need specialist assessment. As practice evolves there has been a trend that more complex conditions that were previously the domain of acute care have migrated to general practice. While GP competencies have progressively increased we need to recognise that operational capacity in primary care is significantly constrained. We also need to acknowledge that there are significant variations in GP referral activity to secondary care. We need to work with the primary care development teams to understand the reasons for the variability and provide support to drive up quality. One of the core principles for this strategy is the need to make sure that GP referrals follow best practice and use new pathways as they become available. We can promote this through education, service redesign and promoting referral management tools. These tools should include referral guidelines but we should also promote integrated electronic systems aligned to GP systems where possible. The CCG needs to promote the development of primary care to provide services in a federated model to facilitate care closer to home and increased choice for patients. Consultant to Consultant Referrals (C2C) The CCG will work with UHNS Trust colleagues to reduce the C2C referral numbers currently associated with the UHNS contract activity. Contract levers and speciality meetings with trust colleagues will be used to drive the current figure of 27% down to under 20% within three years (2016). Page 10 of 16
Choice and Referral Centre Stoke on Trent CCG have employed a small team to offer informed choice to patients who are referred on to secondary care as a result of community services that deem the patient to be moved on for further treatment. Another role of the team is to manage a Clinical Assessment service for specialities that triage referrals before sending on to either a community service or secondary care. Currently the following are triages through the CAS: General Surgery. Bariatrics. Colorectal Surgery Funny Turns (Neurology). Plastics. They also coordinate the primary care services that equally reduce the onward referrals to secondary care, e.g. Community Diabetes, Vasectomy/ED, Community COPD, Community Respiratory and Continence service. Stoke on Trent CCG will endeavour to utilise this team further to improve other services that would benefit from specialist triage and other services that will be put into the community as a Tier 3 service (i.e. a specialist service, usually Consultant led, that delivers more specialist care than a GP can offer but not requiring a surgical intervention or secondary care procedures.) New: Follow up Ratios per speciality Stoke CCG will pro-actively work with the UHNS to deliver an acceptable and safe follow up activity level that is consistent with other like trusts and ensure there is a continual improvement ethos in place to ensure minimised follow ups and therefore increasing patient satisfaction levels. Follow up appointments that can be delivered in the community as opposed to cyclic secondary care input will be mapped out and commissioned, consistent with the care closer to home policy. This should result in the current ratio of 1:2.3 being reduced by 20%. 2. Capacity Modelling Contract activity is currently based upon the previous years activity plus projected growth with any QIPP aspirations deducted. This is mainly due to the inability of providers to produce an accurate, effective capacity model. This has led to issues in the past where providers have ran into difficulties with delivering their contracted activity and have temporarily closed services as a consequence (e.g. Spinal service, Ophthalmology) or failed to deliver 18 week RTT Targets(with increased waiting times for surgery) Consequently, commissioners have had to source other provision with very short notice to ensure continuity of delivery for that service. Also, commissioners have had to fund transfers for patients on Inpatient waiting lists at UHNS to other providers. In order to ensure that commissioners can identify specialities that will present as capacity & demand mismatches, Stoke on Trent CCG will ensure that agreements are made with our main providers (e.g. UHNS, SSOTP) specifying accurate capacity models as a minimum requirement. We will also require our main providers to be registered with the NHS Benchmarking service to assess efficiency and quality. Page 11 of 16
3. Delivering care in the community for services or part services As part of the Fit for the Future strategy services were identified that could be brought in to the community and delivered safely closer to patients homes. Similarly, other services that have either been temporarily closed or specialities that require additional capacity injected into the LHE have also been placed in a community setting. Such services not only generate additional capacity but they also create competition for other services to improve. Examples of current community (Tier3) services are: MSK Service GP Direct Access to X-Ray and Ultrasound Community Gynaecology Service Community Dermatology Service Community E.N.T. Service Community Ophthalmology Service. Audiology :- Choice of several providers to choose from in Stoke on Trent Minor Hand Surgery in the community for Carpal Tunnel and Trigger Finger. Stoke on Trent CCG intend to continue to deliver further community services in the next three years. The following services are already in the pipeline and other services will be added as capacity and demand mismatches are highlighted to commissioners. Colorectal (Rectal bleeding clinics) Urology Cardiology Neurology Also, the current services provided in the community will be subject to improving the services further and increasing the range of services they currently provide. E.g: Community Gynaecology will have more interventions (e.g. Hysteroscopy, ablation) Community Dermatology will perform BCC and lesion removal. More Hand procedures to be performed in the community. Cataract Surgery to be delivered in a community setting. Service Improvement / Redesign Service improvement will be an on-going strategy with all services that are being provided in the community. All services being commissioned in the community are subject to a series of Key Performance Indicators (KPI s). Where this is not the case for older commissioned services), then a series of KPI s will be developed with the provider and reporting on them will occur once monthly with a meeting between the provider and commissioner. Stoke on Trent CCG have identified services that are currently commissioned that are not being delivered satisfactorily. These services will be subject to further improvement and redesign if required. As stated previously all service redesign will be subject to Capacity Page 12 of 16
modelling and failure to demonstrate to commissioners that the provider can deliver the demand to the required KPI s, then the service will be tendered subject to approval of the localities and CCG Board. Similarly, where there have been gaps in service provision highlighted to the CCG, commissioners will work with stakeholders with a view to closing this gap and procuring a redesigned, improved or new service. Services/part services that have been identified as requiring service improvement/redesign are: Community and Trust Physiotherapy Community E.N.T. Pain Management. Lung Cancer Pathway Heart Failure Pathway 4. Developing new providers into the Market. Clearly commissioners need to make local choice more meaningful by developing new local providers. As a response local commissioners (Stoke-on-Trent CCG and North Staffordshire CCG) are developing the approach of taking those pathways which UHNS are struggling to deliver, and thus effectively excluded from the partnering agreement, to develop service specifications suitable to tender. We have procured new providers for community gynaecology, hand surgery, dermatology and ophthalmology. These have been delivered largely by external providers with excellent wait times, one stop shop appointments where possible, and high levels of patient satisfaction. In all cases patients have been at the heart of the service redesign and pathway development. The intention is that we continue to actively seek new provision for redesigned services and where the local choice of provision is limited 5. Patient Choice and assisting patients in making an informed choice Choice is a Department of Health & NHS approach to healthcare which aims to give patients greater control over what healthcare they receive, where and when. For some types of surgery, for example this will mean the freedom to choose the provider and a named consultant through Choose and Book at GP level. The Operating Framework 2012/2013 stated that PCT clusters should drive forward improvements in patient choice. During 2013/14 this means continuing the implementation of: Choice of named consultant Patients will have the opportunity on Choose and Book to select a named consultant if they so wish. This could mean that patients wait longer for their 1 st appointment and the 18 week RTT could be compromised. Page 13 of 16
Choice of diagnostic test provider Patients will have the opportunity at GP practice level to have the choice of 2 providers for x-ray and non-obstetric ultrasound. If referred to secondary care diagnostic tests will be provided as part of the outpatient consultation if required. Phlebotomy Although the current provider is the University Hospital of North Staffs, patients have the opportunity to choose how and where walk in s and outreach clinics Choices post-diagnosis including choice of treatment Stoke CCG operate a Choice & Referral Centre offering the following: Clinical Assessment and onward referral to Tier 3 & Tier 4 services within selected specialities offering choice of Tier 4 provider and named consultant if required Onward referral from Tier 3 to Tier 4 within selected specialities offering choice of provider and named consultant if required Manage the appointment bookings within selected Tier 3 services Transfer patients from local provider to Independent Sector providers within selected specialities Where capacity issues are identified at the local provider offer choice of alternative providers within selected specialities Contact point for GP Practices offering support & guidance on Choose and Book issues Stoke CCG intend to promote the use of the Choice and Referral Centre further in the future which will enhance patient choice further as more services come on line. Any Qualified Provider The Department of Health are promoting the use of the procurement process by utilising Any Qualified Provider model. This is to generate more choice for patients to choose where and which provider they choose to receive their care from. There is currently an AQP procurement process for the following that will be implemented by September 2012. Adult Hearing Services Podiatry Continence There is an expectation that other services will follow in the near future to generate the need for better choice for patients to use e.g. Fertility. Page 14 of 16
6. Patient Experience Each patient s experience is the final arbiter in everything the NHS does. The Health Service Ombudsman s report, Listening and Learning, set up an inconsistent and at times unacceptable approach by some NHS organisations to complaints handling. Good complaints handling is vital in ensuring a culture in the NHS where patients are listened to and organisations learn from mistakes. NHS organisations must actively seek out, respond positively and improve services in line with patient feedback. This includes acting on complaints, patient comments, local and national surveys and results from real time data techniques. Patients and carers should feel that services are integrated and co-ordinated and this should form part of survey questions. The Government announced in its response to the NHS Future Forum on 20 June 2011 that it would introduce a Duty of Candour, a new contractual requirement on providers of NHS funded care to be open and transparent with patients and service users in admitting mistakes. The CCG is therefore seeking assurance as a way forward of ensuring the Patient Experience is a satisfactory one by ensuring the following: Quarterly monitoring of patient experience incl. A&E established as 11/12 SLA metric for routine reporting by Provider to Commissioners. Local real-time patient feedback systems in place (OPD/A&E kiosks, plans in place to roll out to other providers SNAP surveys, quality visits) feeding into CQRM meetings with Providers. Quality report to Board includes patient experience feedback including improvements made. Patient experience CQUINS are to be put in place. The CCG has a PPI strategy and group with Practice PPGs, Locality PPI group and Patient Congress in development. Page 15 of 16
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