Council of Members. 20 January 2016

Council of Members 20 January 2016

Feedback on election process: Council of Members Chair and Deputy Chair Malcolm Hines, Chief Financial Officer

Minutes of last meeting: 14 October 2015 Dr. Richard Proctor, Council of Members Chair

National planning guidance, CCG commissioning intentions and update on current PMS contract review Caroline Gilmartin, Director of Integrated Commissioning Dr. Jonty Heaversedge, Chair, Southwark CCG

NHS Planning Guidance 2016/17 2020/21 Delivering the NHS Forward View guidance recognises that local NHS systems will only become sustainable if they accelerate their work on prevention and care redesign. NHS England is requesting local systems quicken the pace of transformation early in 2016 to build momentum for future years. Planning by individual institutions will increasingly be supplemented with planning by place for local populations. The NHS is required to produce two separate but connected plans: 1. A five year Sustainability and Transformation Plan (STP), which is a local place-based blueprint for accelerating the implementation of the NHS Forward View. The footprint for Southwark is proposed to be south east London, consistent with the geography for Our Healthier South East London. 2. A one year Operational Plan for 2016/17, borough-focussed but consistent with the emerging STP. 5

NHS Planning Guidance 2016/17 2020/21 Whilst developing long-term plans for 2020/21, the NHS has a clear set of plans and priorities for 2016/17. There are 9 must do s for local systems in 2016/17: 1. Develop a high quality, agreed STP. 2. Return the system to aggregate financial balance. 3. Develop a local plan to address the sustainability and quality of general practice. 4. Meet standards for A&E and ambulance waits. 5. Ensure >92% of patients on non-emergency pathways are treated within 18 weeks. 6. Deliver the 62 day cancer waiting standard and improve one year survival rates. 7. Achieve the two new mental health access standards (50 % of people experiencing first episode of psychosis to access treatment within two weeks; and 75% of people with relevant conditions to access talking therapies in six weeks; 95% in 18 weeks). 8. Transform care for people with learning disabilities, improving community provision. 9. Improve quality and implement an affordable plan for organisations in special measures. 6

Financial context NHS England announced the NHS budget settlement on 17 December 2015. This covers a five year period, with the first three years fixed allocations being issued and last two years indicative figures. The settlement for Southwark of 3.05% in 2016-17 is below the national average of 3.4%. This is because Southwark is deemed to be some 4.2% above its spending capitation target level. Only Lewisham and Southwark CCGs are above target spend in south east London. Specialised commissioning budgets have been increased by 8% to allow for increased demand and new drug regimes. From 2017-18 onwards the Southwark budget increase drops to about 2.5% per annum and then goes back up in the last year (2020-21) to 3.7%. Our budget for running costs has also decreased by 120k, due to our ONS measured population decreasing by 7,000 to 292,000. This measure is contrary to our GP registered lists, which now stand at c.316,000, and are increasing annually by 1-2%. 7

Commissioning intentions bring together national, regional and sub-regional strategies Commissioning intentions for Southwark National England Regional London Sub-regional Southeast London Forward View Planning Guidance Allocations 13 programmes including Transforming Primary Six care pathways for improvement, including Community-Based Care Care 8

Aim of the CCG s commissioning intentions We are seeking a place-based approach that delivers timely access to services that are high quality, proactive & coordinated. When taken together our commissioning intentions reflect the need to secure: Timely access to services and a rapid return to delivery on constitutional standards. Safe and high quality services delivered consistently (over time and across providers). Proactive and preventative care that is coordinated between the various providers within a locality. Commissioning intentions require all providers of care to work as part of a coherent and place-based delivery system. Therefore we require significant transformation beginning in 2016/17 and including: Rapid development of Local Care Networks, including putting in place the commissioning changes to support formal joint working. Development of new care models in six priority service areas: urgent and emergency care, community-based care, cancer, children and young people, maternity and planned care. 9

CCG s commissioning intentions in context These intentions are consistent with our overall focus on populations, total system value and delivering the attributes of high quality care. We are changing the way we work and commission services so that we: Emphasize populations rather than providers Focus on total system value rather than individual contract prices Focus on the how as well as the what Arranging networks of services around geographically coherent local communities Moving away from lots of separate contracts and towards population-based contracts that maximize quality outcomes (effectiveness and experience) for the available resources Focusing on commissioning services that are characterised by these attributes of care, taking into account people s hierarchy of needs 10

Draft CCG commissioning intentions 2016/17

Commissioning intentions 2016/17: integration (children) Children and Young People Deliver the Southwark CCG and Council Joint Wellbeing (education, health & care) Children and Young People (0-25) Strategic Framework recommendations Prioritisation within pooled budgets on: Early years (0-5). Emotional wellbeing and mental health (transformation plan and working with schools on training). Reduce pressure on crisis services: Early Start Service and children s hospital@home. Long term conditions including mental illness, through Children and Young People s Health Partnership (CYPHP). Young people s health (10-25) risk behaviour. Vulnerable children and young people, including: carers, YOS, neglect, LD, SEND. Children and young people who are very overweight. Focus on brief intervention and strengthening services working with the Council. 12

Commissioning intentions 2016/17: integration (adults) Adult services Align Community Multidisciplinary Team (CMDT) approaches out of hospital embedding a sustainable CDMT framework that delivers improved coordinated care of patients in the community, reducing emergency attendances and admissions and outpatient attendances. Integrate consistent, sustainable support for people with mental health needs who are living with LTCs. This will replace models of social and psychological support which are specific to individual physical conditions. End of Life Embedding priorities of care (this replaces the LCP). Continued roll out and embedding of Coordinate My Care (CMC). Transforming Care Building the Right Support. Developing community services for people with learning disabilities and closing inpatient facilities. 13

Commissioning intentions 2016/17: integration (adults) Medicines Optimisation Medicines Optimisation and Pharmacy Workforce Strategy has been approved and will be implemented. QIPP, Prescribing Incentive Scheme and investments have been identified as part of the CCG s business planning process for 2016/17. Set up of an integrated service for patients with LTCs (cardiovascular, mental health, etc.) Pharmacy Workforce Transformation programme. Carers Working within the Children and Young People s Framework to develop a set of services that reflect the needs of a broad range of young carers, which delver a consistent and comprehensive approach, including early identification of young carers. Work with Southwark Council to ensure that we can promote activities that enable working age carers to stay in or return to work education or training, including promotion of consistent employment practices in NHS organisations and working with the wider system to roll these out. Improve and promote access to a range of mainstream services for carers, including health checks. Assist Southwark Council to increase the use of personal budgets, and increasing people access to services through access to information from local health care professionals. Promote the use of IAPT for carers. Ensure our health services such as ERR and Night Owls are responsive to the needs of carers. 14

Commissioning intentions 2016/17: mental health Implement Southwark CCG and Council Joint Mental Health Strategy, moving patients to less intensive inpatient settings of care as appropriate to their needs. Implementation of a 24 Hours Crisis Response (Psychiatric Liaison, 24 Hour Home Treatment, Crisis Line). Improve care and outcomes for patients with long-term conditions and mental health co-morbidities. Address the physical healthcare of people with mental health problems. Improve person-centred pathways by strengthening partnership working across health & social care. Develop a single point of access. Up-skill the primary care workforce and develop a primary care mental health services. Focus on perinatal and children and young people mental health concerns and support. Explore options for commissioning digital mental wellbeing services. Develop Enhanced psychological therapies service. 15

Commissioning intentions 2016/17: primary care Full delivery of Extended Primary Care Service: Consistent access at individual practice level. Evaluate model and implement changes including use of Skype consultations (or similar). Population health management delivery; reducing variation and early intervention: PMS Key Performance Indicators. Practice Dashboard development. Federation development. Focus resources supporting practices. Full use of systems including Coordinate My Care. Consider a move to delegated commissioning of primary care in 2016/17. 16

Commissioning intentions 2016/17: constitution standards Ensure that all commissioned services meet national standards, with a particular focus on improving A&E waiting times, Referral to Treatment and cancer treatment waiting detailed plans in place at sites and across the system. Implement a system-wide approach to demand management through maximising utilisation of DXS, single point of referrals, peer review, training and direct access diagnostics. Commission early diagnosis for cancer, increasing rates of screening and detection of cancer in Primary Care. Ensure that NICE guidance for 2 Week Wait pathways are implemented, including equitable provision of imaging and endoscopy services. Ensure local Maternity Services meet London Quality Standards. Develop a model of care that targets wellness, assessment of risk and assignment (to local community/lcn team or high risk team), access to acute assessment, and better transitions of care. Commission an Minor Eye Condition service from community optometrists to maximise patient experience and outcomes and release capacity within secondary care. 17

Commissioning intentions 2016/17: urgent care In partnership with South East London CCGs, procure an integrated urgent care service delivering high quality clinical assessment, advice, (formerly 111) and treatment (including Out of Hours GP services). Ensure local commissioned urgent care services are achieving the London Quality Standards and meeting to the pan-london Facilities Specifications for Urgent & Emergency Care System. Deliver of provider recovery plans and Southwark s Out of Hospital plan to improve performance against NHS operational standard of 95% of patients seen and discharged by A&E within 4 hours. Review access pathways for unscheduled care including Primary Care Access, Extended Primary Care Access, and Primary Care streaming in emergency departments. Re-specify Urgent Care Centre at Denmark Hill with King s College Hospital. 18

PMS Premium Draft Commissioning Intentions

PMS review and investing the premium NHS Southwark CCG is a level 2 co-commissioner of primary care in partnership with NHS England, who are leading the review of PMS contract across London. The contract is formed of different parts core / access specification and premium. The requirements for investing the PMS premium are: to fund demonstrable and measurable outcomes requirement to earn full available funding; to ensure delivery of services or outcomes that go beyond what is expected of core general practice; to support the CCG statutory responsibility to improve quality and reduce inequalities. NHS Southwark CCG s Five Year Forward View and Primary and Community Care Strategy have set an intent to move primary care towards transformation and collective incentivisation 20

Areas of focus For Southwark this means focusing on: access, prevention & early intervention, and proactive intervention with continuity of care for complex groups End of Life Transforming Primary Care: Strategic Commissioning Framework 3+ LTC 1-2 LTC People exposed to risk factors Mainly healthy Accessible Care Proactive Care Coordinated / Continuity of Care Effective Priority objectives Priority objectives Priority objectives Safe Equitable Cross-cutting themes about reporting incidents and open learning culture Cross-cutting theme about reducing variation in the offer and the outcomes Cross-cutting parity of esteem between mental health and physical health 21

The three parts to the PMS Premium Commissioning Intentions NHS England PMS Contract Sections Funding (pwp) Average Indicative 1. London Premium Key Performance Indicators (KPIs) PMS KPIs from NHS England to be negotiated at a London wide level. It has been requested that all PMS contracts include the screening, immunisation and vaccination KPIs to ensure an element of standardisation across London. There is flexibility in the choice patient experience KPIs from the GP Patient Survey and an optional access KPI. 2. London Premium Access Specification 3. Local PMS Premium commissioning intentions An options menu from NHS England London focused on improving access, including on line access, to primary care services. The CCG can chose which elements of the specification are commissioned by using the PMS premium funding providing justification to NHS England London for agreement Any other KPI / services that the CCG wishes to commission using the PMS premium funding to deliver services or outcomes that go beyond what is expected of core general practice. Over time KPIs will move to collective incentives. 19.84 Note: Core services are also being re-negotiated 22

Southwark CCG s proposed breakdown of premium funding PMS Proposed Premium Funding (indicative) PWP weighted Average available PMS premium funding 19.84 1. London Premium Key Performance Indicators 2. London Premium Access specification - 4.44* 3. Indicative premium funding for local commissioning intentions (Funding allocated to the London KPIs and premium access specification have been removed) 15.40 * = proposed costs dependent on final engagement 23

Collective incentive where possible Strategic fit of PMS Premium: local CIs Our local PMS Premium CIs focus on three areas; these fit within the wider system contracting and alongside existing local funding Better align contracts and incentives Actively resource and support new ways of working PMS Premium: Local CIs GSTT SLAM KCH PMS Premium 19.84 Premium: NHS England London s PMS KPIs Proposal Premium: NHS England London s Premium Access Specification Premium: CCG Local Commissioning Services: 15.40 Mental Illness Dementia Childhood Asthma Childhood Obesity Bowel Cancer Screening Wound Management Phlebotomy Management of LTCs System wide incentive Transformation funding (additional nonrecurrent funding) Shared system incentive: e.g. keeping people at home (PMS premium KPI to enable proactive intervention, with continuity of care, across the health system), aligned to other contract incentive funding) EPCS 2.3m annual value PHM 1.3m annual value 24

PMS KPIs supporting Local Care Network development How PMS KPIs will develop to support the transition to Local Care Network (LCN) working 5 Year Forward View 2015/16 2016/17 6 LTC KPIs Practice Premium Premium (21 self cert standards/ KPIs) P r e m i u m CCG collective achievement KPIs including system wide incentive CCG individual practice KPIs NHS England KPIs Principles: 1. Commitment to evidence-based interventions in KPIs. 2. Annual negotiation of premium KPIs. Core Core 3. Consultation period for 2017/18 to start in spring 2016. 4. Contract offer to be available to GMS practices and APMS practices (receiving less than current PMS premium value). Remove any duplication and shift to payment for collective delivery which is demonstrable and moves towards delivery of patient outcomes 5. Retain funding locally from any KPI underperformance, for primary care re-investment in local federations (or equivalent collective establishment) 25

Summary of Southwark s Proposed Local PMS Premium Commissioning Intentions KPI Proposal No. of KPIs Costing Funding Mental Illness Dementia Proactive Care - to support the identification, early referral and management of patients with mental illness Coordinated/Continuity of Care - to support the management of patients with dementia in the community and carer health and wellbeing. Childhood Asthma Proactive Care - to focus on early identification 1 2 50% Individual 2 Individual Individual Childhood Obesity Proactive Care - to focus on identification and offer of brief intervention 1 Individual Bowel Cancer Screening Wound Management Services Proactive Care - to support development of enhanced call and recall and improve performance. Coordinated/Continuity of Care - management of non-complex wounds for mobile patients 1 Individual 1 Collective Phlebotomy Accessible care - local access to phlebotomy in primary care for patients with Long Term Conditions (LTC) 1 25% Collective Management of LTCs Coordinated/Continuity of Care - to focus on management of 4 LTCs: Diabetes, Stroke, CHD and Hypertension. 4 Collective System wide incentive Focused on supporting patients with LTC through Local Care Networks. Approach in development across all local contracts 1 25% Collective CCG PMS KPIs Total 14 15.40 NHS England PMS Standard KPIs and Premium Spec Standard PMS KPIs and online access specification 10 + 4.44 TOTAL 24 19.84 Key: Within self -certification Current PMS KPI New KPI 26

Key Local Milestones 20 January: presentation local commissioning intentions to Council of Members 28 January presentation local commissioning intentions to Council of Members at Locality meetings Agree clinical evidence based KPIs with public health 3 February: provider and patient event 11 February: present final commissioning intentions for agreement by the Primary Care Joint Committee Regular meetings with Southwark LMC Individual meetings with practices July 2016: contract implementation 27

Questions and answers 28

Table discussion

Update on CCG Financial Position Malcolm Hines, Chief Financial Officer

Financial performance duties: month 8 2015-16 Duty YTD Target YTD Performance RAG Annual Target Forecast Performance RAG Achieve planned surplus (Expenditure not to exceed income) Capital resource does not exceed the allowance Revenue resource does not exceed the allowance Capital Resource use on specified matters does not exceed the allowance Revenue resource use on specified matters does not exceed the allowance Revenue administration resource use does not exceed the allowance 4,851k 5,049k 7,277k 7,477k N/A N/A N/A N/A 260,890k 255,841k 395,917k 388,440k N/A N/A N/A N/A N/A N/A N/A N/A 4,381k 4,183k 6,572k 6,372k Notes: 1. The above duties correspond to those reported in Note 42 of the Annual accounts, and represent the statutory duties of NHS Southwark Clinical Commissioning Group ( the CCG ). 2. To support the delivery of the above, an in-year QIPP programme of 7,982k has been established. QIPP monitoring information is included later in this report. 31

CCG programme budget summary: month 8 2015-16 Programme Budget Annual Budget ( 000s) Variance to Month 8 ( 000s) Predicted End of Year Variance ( 000s) End of Year Best Case Variance ( 000s) End of Year Worst Case Variance ( 000s) Acute 210,839 283 0 0-4,193 Client Groups 70,614-565 -199 160-574 Community and Primary Health Services 33,400-75 -140 0-225 Transformation 798 0 0 0 0 Prescribing 32,757-519 -350-300 -545 Better Care Fund 20,478 868 869 1,194 869 Corporate Costs 7,345-1,090-1,101-949 -1,169 Earmarked Budgets and Reserves 5,837 1,098 922 922 5,837 Planned Surplus 7,277 4,851 7,277 7,277 7,277 Total 389,345 4,851 7,277 8,304 7,277 Reserves not yet utilised in above position 4,915 4,915 0 Reserves not yet utilised in above position (month 7 for comparison) 5,261 5,326 0 Drawdown of prior year surpluses supporting 2015/16 position 0 0 0 0 0 Note: a red negative sign indicates budget overspend 32

CCG budget summary: month 8, 2015/16 The acute position shows a position that is forecast to worsen slightly over the remainder of the year. An overall year end agreement has been reached with King s College Hospital NHSFT and Guy s & St Thomas NHSFT, in line with the contractual agreements. This serves to limit the CCG s exposure. The overall position is nearly 5m adverse and assumes the outturn for King s and Guy s & St Thomas will exceed the contract tolerance and will therefore result in adverse variances. The running cost allocation is separate from the programme budget and is monitored separately. Running costs are currently underspent by 126k at month 5. This mainly relates to un-utilised budget for contract management. This area is expected to underspend by 200k at year end. Programme Budgets are achieving overall planned levels at Month 8, achieving the planned surplus level of 4,851k (expected to achieve 7,277k at year end). Total QIPP savings plans of 8,166k are in place for 2015/16. In order to achieve the plans, an investment of 184k on acute schemes has been made. This leaves the net QIPP value at 7,982k which is forecast to be delivered in full in 2015/16. 33

Question and Answers of the CCG Governing Body Dr. Richard Proctor

Any Other Business Dr. Richard Proctor

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