REPORT TO CROYDON CLINICAL COMMISSIONING GROUP GOVERNING BODY Meeting in Public 30 April 2013 Title of Paper: CONTRACT PERFORMANCE AND MANAGEMENT: NON ACUTE CONTRACTS Lead Director Report Author Contact details Committees which have previously discussed/agreed the report. Committees that will be required to receive/approve the report Purpose of Report Stephen Warren, Director of Commissioning Stephen Warren, Director of Commissioning Stephen.warren@croydonpct.nhs.uk Croydon Clinical Commissioning Group (CCG) Senior Management Team (SMT) on 16 April 2013 None Discussion and noting Recommendation: The Governing Body is asked to note the report. Executive Summary: The report provides an update on non-acute contracts for the fourth quarter of /13, highlighting key issues. Key Messages and Issues (making reference to paragraph within report) The overview of mental health contact with South London and Maudsley (section 2) reflects increased demand on IAPT services which has led to increased waiting times. Some Intermediate Care Services (section 3) reflect higher onward referral and/or follow up activity. The Croydon Health Services (CHS) community contract (section 7) was subject to a rebasing exercise during the latter part of the financial year. The rebasing process will now be taken forward into 2013/14. Specific services within the block, mainly school nursing health promotion, sexual health and contraception transferred to Public Health from the 1 st Page 1 of
April 2013. Future reports will provide more detailed activity and financial information. Discussions are currently underway on the realignment and enhancement of community nursing services to support the CCCs Transformation Strategy and development of Long Term Conditions QIPP. Governance: PEC Comments where appropriate Financial Implications Implications for other CCGs Equality Impact Assessment Information Privacy Issues Reputational Issues Communication Plan N/A Identified in each section None Undertaken as part of individual work streams None identified None identified N/A Page 2 of
Report on Non Acute Contracts 1. Introduction This report provides an update on non-acute contracts for the fourth quarter of 20/13. 2. Mental Health Contracts This summary is based on South London and Maudsley (SLaM) contract reports and monitoring at month 11. Month reports will not be available until later in April. 2.1 Activity: Outside the main block there is continued over-activity in adult acute inpatient services. The rate of activity has reduced since April (and the last few months of 2011/) but has remained well above commissioned levels. In specialist services, activity in CAMHS Tier 4 reduced to budgeted levels by M11, but the QIPP target was not met. Over-activity in inpatient addictions services to (M6) was managed down well below contract levels from M7 and this progress has been maintained to M11. Expenditure was 344,850 in the first six months and 82,346 in the next five months to February 2013, mostly brought about by more rigorous challenge through a joint NHS and local authority panel. 2.2 Performance: All of the highest priority quality requirements in the contract are being met and performance in Key Performance Indicators (KPIs) for crisis resolution / home treatment and early intervention is well over target. Performance in the Care Programme Approach (CPA) 7 day follow ups, KPI is just above the level of the year to date target. Performance in the five SLaM Commissioning for Quality and Innovation Incentives (CQUINS) has generally been disappointing, in Croydon and in all four CCGs that co-commission from SLaM. Croydon s end of year deal ensured that financial rewards were appropriately limited. The four CCGs are adapting their CQUIN schemes for SLaM in 2013/14. Performance in QIPP programmes has been mixed. Almost all of the 600k savings target for forensic secure placements was reached. The target for savings in Continuing Care for Older Adults with mental health problems was comfortably exceeded, but other targets were not met, or only partially met. 2.3 Service Developments: A business case for the re-design of adult acute inpatient services, including the introduction of a triage ward, is still in discussion and further clarification has been requested from SLaM. Good progress has been made on the Project Initiation Document (PID) Quality, Innovation and Prevention and Productivity (QIPP) project to commission a Low Intensity Treatment (LIT) Team, and to pilot an intermediate service. The new Page 3 of
Primary Care Mental Health Support Service (intermediate service), incorporating a new mental health Locally Enhanced Service LES, commenced in April 2013. Discussions have started on a more comprehensive re-design of older adult services and a project consultant (joint funded by the CCG and Council) has been working on the development of specific proposals since January. 3. Intermediate Care Services Intermediate Services Update AQP procurements In 2013/14 there are a number of AQP procurements are planned to take place, these are: - Community Spirometry - ENT - Diabetes Education. The AQP process remains the same as last year with the Department of Health undertaking section 1 compliance checks and then the CCG undertaking its own localisation checks. It should be noted that with any AQP re-procurement there is the possibility that the existing service provider may not choose to bid and therefore, will not continue to provide the service. Activity and spend to date Service Planned Activity (M1-11) F/FU s/procs Actual Activity (M1-11) F/FU s/procs Planned Spend to date(m1-11) Actual Spend to date (M1-11) ENT 6,860 3,817 595,320 307,071 Dermatology 5,921 6,495 607,595 445,890 Gynaecology 5,354 3,220 526,428 330,780 OP Gynaecology Hysteroscopy 355 521 108,001 249,421 ENT The Intermediate ENT service comprises 3 community providers. The service was tendered as an Any Willing Provider contract from the 1 st July 20 for a one year period. Performance reports for months 1-11 indicate activity is below plan (although underperformance may appear overstated due to better than planned first to follow up ratios in the community provider. The project lead continues to work with practices to raise referral levels as an alternative to referral to secondary care. It is hoped that the Croydon Referral Support Service (CReSS) will increase referral rates. Page 4 of
Performance Commissioners meet on a bi monthly basis with all providers to discuss performance issues. There are no major concerns with the providers. However onward referral rates are higher than anticipated for some providers and are being monitored. An audit on patients referred onwards to Secondary Care was undertaken which assured the commissioners that the referrals were appropriate. ENT guidelines have been developed to ensure that more activity is undertaken in primary care before being referred to the intermediate services. Dermatology This service was commissioned via Any Qualified Provider process in 20, with one provider bidding for the service. Service activity figures are slightly skewed as one service component (minor surgery) does not have a plan attached and is therefore low. The service is currently under plan in terms of actual spend as some procedures will no longer be carried out in the intermediate service. Performance Commissioners meet bi monthly with the provider to discuss activity and monitor performance against KPIs. Expansion Commissioners tried to expand the scope of the Dermatology service in /13 to include additional outpatient procedures such as phototherapy and patch testing. Due to concerns expressed by CHS clinicians about the suitability of provision in a community setting and lack of clarity from the British Association of Dermatologists commissioners are not perusing this activity at this time. There have however recently been positive discussions with CHS clinicians about diverting unnecessary low level activity such as eczema away from the hospital. On occasions extreme cases of paediatric eczema have been admitted and with better prevention and management this should be avoidable. Gynaecology The gynaecology service was procured in April 2013 via the Any Qualified Provider process. There were 2 providers who bid for the service; both have been approved, one subject to financial accounts. Actual activity is lower than plan. Commissioners continue to work with practices to maximise appropriate utilisation of this service. Clinical guidelines have also been developed with hospital consultants in order to redirect patients back to primary care where appropriate therefore avoiding unnecessary activity. Performance Commissioners meet with the providers on a bi-monthly basis to discuss activity, performance and quality. Community Ophthalmic Development The community ophthalmic service (CORS) continues to see an increased number of patients, with referrals into the service generally increasing month on month. In Page 5 of
addition the triage service is redirecting referrals into CORS where it is more appropriate for the patient to be treated in the community than the hospital, resulting in a faster service for the patient and a cost reduction when compared with the Hospital service tariff. Data to date: TRIAGE: Referrals from GPs TRIAGE: Referrals from OPTOMs TRIAGE: Referrals onto CORS Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 1 2 3 4 5 6 7 8 9 10 11 18 69 65 57 148 144 226 278 269 234 206 28 189 166 248 216 214 281 358 272 356 414 Jan- 13 Feb- 13 0 64 82 9 143 138 177 231 155 141 225 Totals 1,714 2,742 1,485 1st OP 318 271 296 309 304 295 338 329 306 252 430 3,448 CORS Activity Advanced 1st OP 6 0 7 7 2 7 8 9 0 0 7 FUp 50 58 39 39 67 27 48 58 54 46 66 552 Onward Referral 109 93 70 89 92 2 111 105 88 0 166 53 1,045 For the 2013/14 year the intention is to tender for a single community service to encompass the following: - Primary Care Triage - Current CORS service - Glaucoma Referral Refinement - Ocular Hypertension Assessment - Cataract Pre-assessment Additionally, a market testing exercise will commence shortly for integrated hospital and intermediate care services as an integrated service. 4. Croydon Referral Support Service (CReSS) This service is provided by Brighton and Hove Integrated Care Service (BICS). 4.1 Activity and spend to date Referral activity through CReSS to date, whilst increasing, remains lower than the estimated plan. This has been due to: the initial delay to roll out of the CReSS over-estimates on referral activity and unintentional errors by practice staff in the early stages of using CReSS Page 6 of
The plan for M1 M11 was 52,253 referrals at a cost of 1,117,615. The current activity to date stands at 33,631 referrals at a cost of 649,502. 60 out of 61 practices are now live on CReSS. The remaining practice is experiencing technical difficulties and BICS is working with them to resolve the issues. Commissioners continue to work with the local acute trust and local intermediate service providers to triangulate referral data monthly, to ensure that practices that are live on CReSS do not bypass the service. Where practices are not utilising CReSS fully, the commissioner and provider (BICS) work together with the practice to understand reasons for poor utilisation and put changes in place to remedy. 4.2 Performance Commissioners hold fortnightly teleconference meetings with BICS and face-face contract meetings on a bi-monthly basis. In months 7 and 8 of the contract BICS failed to meet 2 out of 7 of the KPI s set out in the contract. As per contractual requirements, BICS provided commissioners with a recovery action plan which committed to improvements in March and full recovery for April. It has been agreed that BICS may exclude any referrals that have breached the KPI due to external influence, where for example: 1) Breaches due to admin and clinical referrals on hold where the practices has not responded within the set time frame to BICS queries and referral has therefore been breached. 2) Delays / System failure at Connecting 4 Health which slows or stops Choose and Book functions so that referrals cannot be picked up or processed. Croydon CCG has requested that BICS provide a detailed report to show which referrals have breached due to in-house delays and those that are to be exempted due to external factors. Actions have been taken to increase capacity at BICS, to ensure that referrals on hold for clinical reasons are dealt with and several communications have been sent to practices requesting that they deal with queries on a daily basis. 4.3 Complaints There have been 3 complaints to the service since its commencement in July. These have all been fully resolved within contracted timeframes and lessons learnt shared amongst the team. BICS hold a quarterly Clinical Quality Review (CQR) meeting where complaints, incidents and feedback from clinicians are discussed. All three complaints have been signed off through the CQR and at the bi-monthly contract meeting. 4.4 Service Developments for 20/13 BICS have developed a central hub, based in Croydon (Greenside Group Practice), to house a small number of admin staff who will be able to provide practical and face Page 7 of
to face support to practices where necessary, and to enable GP triagers to work in partnership and support one another. 4.5 Other issues IT support remains a central risk to this project. IT support such as Smart Card access was provided by the South West London Sector team who approve access to GP systems. This team is likely to be based in London after transition and this local support going forward will need to be kept under review. 5. Direct Access Diagnostics Over the course of 20/13 we saw a significant reduction in direct access activity via InHealth and an increase in activity being delivered in CUH, to take advantage of the unbundling arrangement negotiated with CUH. Across 2013/14 there will be a continuation of the work undertaken in 20/13 plus: - The introduction of consultant triage across some diagnostic referrals at CUH, this should help to reduce inappropriate or unnecessary referrals - The production of a number of referral guidelines to aid referrers in making referrals in the correct manner and to the correct service. Development going forward will need to focus on strengthening the learning loop back to practices on referrals, supported by effective Peer Review. 6. Anticoagulation Since implementation of the service in 2007 approximately 1100 stable patients have been transferred from CUH to one of four community providers; Parchmore Medical Practice, Selsdon Park Medical Practice, A-z Pharmacy and Fishers Pharmacy. As at month 11 commissioners had successfully discharged 269 patients in the year against a plan of 240 resulting in cumulative savings of 41,576.00 against a plan of 40,117.00 New patients discharged Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 13 1 2 3 4 5 6 7 8 9 10 11 Plan 0 0 0 30 30 30 30 30 30 30 30 240 Actual 9 15 17 9 9 34 28 43 44 33 28 Feb- 13 Total 269 Page 8 of
In the year 2013/14 there will be significant developments to the service: It is proposed that the current community providers will be issued with NHS standard contracts for a period of 6 months, extendable to 9 months, to cover the time it takes to procure the new community service (See below) To procure a new community service via a competitive tender process. The proposal is to contract between 4-8 local community providers to expand the service to other patients who may benefit from being treated in the community. 7. Croydon Health Services Community Contract Work was undertaken to rebase this contract in /13 and Commissioners agreed with CHS part of the impact of this exercise as part of agreeing on end of year position for /13. The end of year agreement forms the baseline for discussion on the negotiation of the 2013-14 contract. 7.1 Performance Pulmonary rehab services are underperforming and regular planning discussions have now commenced with CHS about how the service may be utilised more effectively around the needs of people with long term conditions. Discussions have been continuing throughout the final contract quarter on the future provision of community nursing services. These will extend to include more specialist nurses and be aligned more effectively around the GP networks to better address the needs of those with LTC s in the community. Increased activity in community nursing is said to be partly attributable to a sizable increase in phlebotomy referrals and CHS have been asked to provide more detailed information about the source of these referrals. 7.2 Other Issues There remain concerns in respect of some aspects of quality of service as well as over and under performance across services. Commissioners have been in discussion with CHS around the provision of Community Diabetes services and have brought back the Enhanced Services element of this contract back to the CCG for onward management and alignment with the review of Locally Enhanced Services for Long Term Conditions. Page 9 of
The intermediate service will be re-procured in 2013/14 with a view to a new service commencing in April 2014, against a revised service model. Diabetes education will be re-procured through the AQP process. Discussions are currently underway on the re-alignment and enhancement of community nursing services to support the transformation strategy and development of the Long Term Conditions QIPP. 8. Equipment Services Commissioners continue to consider the merits of whether Croydon will be part of the London-wide procurement process. CHS have expressed the wish to return the budget and its management, allocated to them for equipment to the CCG, but have yet to formally express this as a contract notice. The draft Independent Procurement Hub (IPH) contract, which replaces the current Section 75 agreement has been scrutinised by CCG Solicitor s, and the comments and suggested amendments have been shared with the local authority for their consideration. 8.1 Performance The contract at end Qtr 3 has a predicted over spend of 400k across the LA and CCG funded service. As joint commissioners we have written to all Operational Leads and Clinical Prescribers to request consideration when ordering special equipment and encouraging use of the Generic Catalogue which will help to reduce spend without impacting on quality. Quarter 4 data will be imminently available to enable commissioners to evaluate the impact within 1 quarter. 9. St Christopher s Hospice This is a multi-lateral contract which is led by Bromley PCT, which is for the delivery of End of Life Care. Since the last report there has been a Legionella outbreak at St Christopher s preventing the use of the inpatient facility and thus Croydon patients have been transferred to Linden Ward at Lewisham Hospital. Some patients have chosen not to use the Lewisham venue because of the geographical distance and St Christopher s staff have managed these patients through an extended community outreach approach which has not resulted in any known quality issues for patients, although it has contributed to an increased use of the night sitting service. As the service had been underperforming there are no financial implications at this stage. 10. Reablement Joint LA and CCG Funded The Reablement Programme is commissioned jointly with the Local Authority and through the Reablement Board via a Section 256 agreement and has several levels of investment, aimed at supporting early discharge or preventable admissions. The performance of this programme is currently being discussed with the Council, who lead on the commissioning of the services. The CCG has requested up to date expenditure and outcome information in order to inform discussions for the next fiscal year. Page 10 of
It is important to ensure that the programme aligns with the service transformation agenda and also supports QIPP. The management of telehealth has now reverted back to the CCG by mutual agreement and following review, has identified specific actions to increase the use of existing equipment and to actively engage with primary care. 11. Urgent Care Contracts 11.1 Harmoni 111 Performance In parallel with national concerns regarding the performance of the 111 service, there have been significant issues with Harmoni, the local provider. Over the Easter period the 111 service was extremely stretched by incoming call volumes resulting in unacceptably long call waiting times and delays in call-backs from clinicians. This trend has continued during the remainder of April and has been escalated via CCG CO s to NHS England and the Department of Health. On-going discussions are taking place with a view to resolving this issue as a matter of urgency. Other Issues Going forward there is further work to do on the Directory of Services and analysis of dispositions to the LAS, which have allegedly increased. The latter is not entirely borne out by the latest data but continues to be closely monitored. Serious Incidents and Complaints There have been no SIs. 11.2 Virgin Urgent Care Centre and GP Out of Hours (PC24) Performance Virgin has continued to improve and sustain performance and is generally meeting the contracted performance requirements. Staffing levels have continued to improve with the use of staff grades to supplement GPs in the Urgent Care Centre (UCC) and the use of its own direct locums on performer contracts has stabilised the service and contributed to positive changes in the service model. Communication with the ED is now good, especially on a clinical level, and continues to support joint working to improve CUH A&E performance which has been below the required levels for the whole of Q4. Other Issues The model for paediatric triage is still to be resolved and further discussion between the CCG, CHS and Virgin is underway. CHS have committed to responding to the Page 11 of
CCGs requirements in respect of this service, potentially being provided by CHS rather than it sitting in the Virgin Contracts by the end of April. Urgent Care Strategy It should also be noted that the current Urgent Strategy is currently being refreshed and an Emergency Care Pathway summit will be organised shortly with stakeholders to ensure that it has wide ownership across the local health economy. This will also include the outcome of a review of the development of Urgent Care in primary care. 11.3 The Practice, Walk In Centre, Edridge Rd Performance The lack of reporting from Edridge Road continues to be a concern. The Urgent Care lead is actively following this up with the NHS England London Primary Care Team and directly with The Practice PLC.. Recommendation The CCG Governing Body is asked to note the report. Author: Title: Stephen Warren Director of Commissioning Date: 30 th April 2013 Page of