Aylesbury Vale Clinical Commissioning Group Innovation & QIPP Report, October 2013 1. Introduction Programme Activity Finance Milestones InPACT (Urgent Care) Chronic diseases (LTCs) Early Years (Children s) Care (Right Care) Localities Joint care This report highlights the key issues and risks in the 2013/4 QIPP Plan during Month 6 (September), although much of the supporting data analysis relates to month 5. The table to the left provides a high level assessment of current and forecast delivery of the QIPP challenge in 2013/14 for each of the constituent programmes. Assessment of QIPP programme delivery is made on achievement of the required activity reduction aligned to delivery of the QIPP projects (activity and finance) and the assessment of delivery from the highlight reports (milestones). The body of the report provides a summary highlight report for each programme including the high level Key Performance Indicators (KPIs) for each programme where these have been agreed. Where they have not, work continues with programme managers to identify KPIs and these should all be in place by October (some services do not start until later in the year). More detailed highlight reports are available from the programmes.
2 Summary of QIPP Delivery - QIPP Finance Aylesbury Vale CCG QIPP savings summary Annual Budget Year to Date Budget Year to Date Year to Date Achieved Year to Date 000 000 000 000 % Impact Rating Achievem ent 000 000 % - INPACT 1,089 313 240 (73) 77% Amber 705 (384) 65% Red - Chronic Disease 1,837 907 709 (199) 78% Amber 1,417 (420) 77% Red - Early Years 109 33 0 (33) 0% Amber 0 (109) 0% Amber - Care 1,361 454 277 (176) 61% Amber 1,031 (330) 76% Red - Localities 600 300 0 (300) 0% Red 263 (338) 44% Red - Joint Care 598 299 299 0 100% Green 598 0 100% Green Total Gross s 5,594 2,306 1,525 (781) 66% Red 4,014 (1,581) 72% Red Mitigtion - BHT - Use of Headroom 339 339 Blue 678 678 Blue Total Net QIPP Programm 5,594 2,306 1,864 (442) 81% Blue 4,692 (903) 84% Blue Key: High Impact/Risk of not achieving plan (variance 25%/ 250k or over Medium Impact/Risk of not achieving plan (variance against plan belo On target or marginally positive Red Amber Green Positive variances against plan Blue Risk Rating Table One (left) provides a summary of Month 6 QIPP achievement by programme and a forecast position for year end in financial terms. reported position was 1,525k savings against a plan of 2,306k (66% achievement). This is partly off-set by 339k mitigation from underspend on budgets not covered by QIPP schemes The mitigated QIPP position is an under achievement of 442k (19%) The forecast position is a year-end delivery of 84% of the plan. It should be noted that it is assumed that delivery has been achieved on budgets that are currently showing as being on Plan in Prescribing and Joint Care, and for those elements that will be delivered under the risk sharing rules established within the BHT contract.
3. QIPP Programmes 3.1 InPACT CLINICAL LEAD: DR KEVIN SUDDES RAG rating Activity Finance Milestones Table 2: Delivery of savings against plan by project InPACT Table 2 (left) shows that the InPACT programme is estimated to be delivering 240K of its expected 313k (77% achievement). Summary For AVCCG, admissions at all providers are lower than last year but above plan at Buckinghamshire Healthcare Trust (BHT). However, these figures exclude patients who are treated or observed in the Clinical Decision Unit (CDU), Surgical Assessment Unit (SAU) and the cardiac and stroke receiving unit which have been implemented by the Trust in 2013/14. An audit of patients treated and discharged from these units without onward admission has been conducted and is being reviewed with the trust to understand the pathway, associated activity and cost. Key Performance Indicators (KPIs): Activity trends for emergency admissions, A&E attendances CDU admissions are well above plan and would lead to a significant rise in overall cost of urgent care at BHT. The Trust and Commissioners are reviewing the associated costs and charges of the CDU. Although these changes at SMH have benefited patents and the Trust achieved its A&E 4 hour standard consistently from April, the situation has deteriorated and it has not achieved this standard since the end of August. BHT describe this as being due to difficulty in discharging patients who have a long length of stay. The OOH service has improved its performance in the percentage of urgent calls triaged in 20 minutes and the percentage routine calls in 2 hours although it is still not achieving the 100% target. Winter plans have being collated and submitted to the NHS England TV Area Team, to demonstrate how
Buckinghamshire will manage the expected demand within existing resources. These are using more sophisticated activity modelling from the ambulance service and also BUC this year, and highlight the significant additional resources that these services require on the Friday between Christmas and New Year. Primary Care capacity at this time of year for urgent appointments is particularly valuable in minimising risks to patients. Key achievements last month: Shared Patient Notes deployment supported by Urgent Care JET to enable Practices to utilise for QP work NHS111: finalised report process for repeat callers for OOH s MAG s: 46 practices signed up for MAGs, and 2 new Care Coordinator posts filled Centaur project for rapid community response: Continued to engage with GP practices in order to increase referral rates MIIU activity for all CCGs Key next steps for next month: Comms: Production of material for winter messaging. OOH re-procurement: Develop options for a contractual model MuDAS: Commence audit of patients admitted within 30 days of being seen in MuDAS, to identify lessons learnt. Children s Urgent Care: Roll out of D&V and Head Injury pathways Brokerage to facilitate hospital discharge for self funders: Revised proposals for sign off by Bucks CC and NHS.
3.2 Care (Right Care Steering Group) CLINICAL LEAD: DR CHRISTINE CAMPLING RAG rating Activity Finance Milestones Table 3: Delivery of savings against plan by project: Care Project Title & Brief Description (categorised by workstream type) Net s Net From Plan Revised '000 '000 '000 '000 '000 '000 '000 New approach to follow ups 1,361 454 277 176 1361 1,031 330 1,361 454 277 176 1,361 1,031 330 Key Performance Indicators: Follow-ups and elective admissions The Right Care programme is delivering the agreed milestones. However the forecast over performance (at BHT) against key areas in planned care has led to mitigation plan for Care. Two thirds of the QIPP savings expected from the reduction in follow-ups are being generated (Table 3). The programme is delivering the agreed milestones, however the majority of reductions will be realised in quarters 3 and 4. The right care programme is working closely with the CCG planned care leads to improve reporting and in turn to support decision making and prioritisation, and links to locality working. A mitigation plan (a combined action plan to review areas of over performance and agree where actions can be taken to improve delivery) has been discussed and provisionally agreed with the Trust. The key areas for escalated action are radiology unbundled and direct access. There are still significant anomalies between cost and activity. Further analysis is in progress. First outpatient activity from GPs is level, however consultant to consultant driven activity (C2C) has risen. An audit is taking place looking at C2C against the agreed protocol. BHT are being asked to look at outpatient waiting times with a view to extending waits as appropriate to 9-11 weeks. The Dermatology project is exploring providers for teledermatology and community dermatology services with a view to present at the November meeting. An interim solution that will be accelerated is the use of advice and guidance by GPs. This has been agreed by BHT. It is expected that this will reduce outpatient appointments whilst a longer term model is developed. Elective activity is being reviewed and steps taken through the
general surgical, ophthalmology and gynaecology actions in the mitigation plan. MSK will form the biggest business case for the 14/15 commissioning intentions process. As part of this the current efficacy of the MSK pathway will be reviewed to inform this and to support the mitigation plan as part of 13/14 work. Pathology Price on Ice is a joint Right Care and medicine management project and the planned communication will include guidance and top tips. This forms phase l of the project and will live from November 2013. Further developments are expected as ongoing work. 3.3 Chronic Diseases (Long Term Conditions LTCs) CLINICAL LEAD: DR STUART LOGAN RAG rating Activity Finance Milestones Table 4: Delivery of savings against plan by project: Chronic Diseases Project Title & Brief Description (categorised by workstream type) Net s Net From Plan Revised '000 '000 '000 '000 '000 '000 '000 Long Term Conditions 1,068 523 0 523 1068 0 1,068 Long term conditions The Primary Care Long Term Conditions Programme covers the Psychological Therapies 'Live Well', AIM, and diabetes and respiratory skills projects. QIPP savings for these schemes are not yet being met as work to date has mostly been preparatory, or in too early stages of implementation. Medicines Management 769 385 709 (324) 769 1,417 (648) 1,837 907 709 199 1,837 1,417 420 This programme covers the Psychological Therapies Project 'Live Well', text messaging AIM Project, and diabetes and respiratory skills projects. Live Well clinics have run for 10 weeks. 39 patients referred so far. Plans are in place to drive increase in referrals. ACG Tool issue now resolved. AIM first patients recruited and training and support for practices on-going. Activity in line with plan.
Key Performance Indicators: to be confirmed for LTCs and to be finalised for medicines management but will be in the areas of dexa scan and pathology test rates by practice. Medicines management Review of Medicines Management Diabetes nurse work to date complete, business case for continued funding submitted to Exec teams Review of Medicines Management dietician work to date complete, business case for continued funding submitted to Exec teams Anticoagulation Service Specification drafted Submission made for Waste project funding
3.4 Early Years (including Children s Urgent Care) CLINICAL LEAD: DR JULIET SUTTON RAG rating Activity Finance Milestones Table 5: Delivery of savings against plan by project: Early Years Project Title & Brief Description (categorised by workstream type) Net s Net From Plan Revised '000 '000 '000 '000 '000 '000 '000 Paediatric urgent care 36 11 0 11 36 0 36 Paediatric urgent care 73 21 0 21 73 0 73 109 33 0 33 109 0 109 KPIs: Emergency admissions for under 5s and fever pathway (from September) plus other pathways as they come on stream. Chart CYP1: Admissions to main 3 acute hospitals (BHT, MKH, OUH) of children aged 0-19 by month Table 5 (left) shows that the Early years programme is not delivering it s expected 33k of savings to date, however emergency admissions for children are below prior years. Paediatric urgent care To date, fever is the only pathway that has been rolled out (due to delays in the others) so this is the only one where an impact would be expected. The number of paediatric admissions from AVCCG practice to the main acute providers is shown in the charts CYP1 and CYP2 opposite (all admissions 0-19 years and admissions for fever 0-4 years). There was a reduction in August but this is consistent with seasonal variation in previous years (See charts CYP3 and CYP4). Monitoring admissions over the next few months will demonstrate if there is a reduction in admissions. Achievements this month Activity on finalising and ensuring governance of subsequent pathways (D&V and Head injury and Bronchiolitis) has been underway this month. An offer has been made to all localities to share the pathways to help embed them locally. A 5 CCG collaboration around analysis of data has been created by the incoming Intelligence lead which will usefully allow us to share lessons learned across that wider area. 1. Governance process for next 3 pathways - The 3 remaining pathways were taken to the Children s JET meeting (5th Sept) for approval. D&V is now with the Quality Committee whilst Bronchiolitis is going through the Trust (BHT) Governance process and then will go the Quality Committee. 2. Minor Neonatal Conditions pathway following a meeting on 26th September further joint work is required. 3. Asthma/Wheeze pathway work has been undertaken will now be further refined by HWP and our GP /Community Asthma Nurse lead at the 17th October meeting. 4. Common Childhood illnesses website hosting arrangements and dedicated website address agreed expected role ouot in November. 5. Children s Programme Board meeting (12th Sept) new
Chart CYP2: Admissions to main 3 acute hospitals (BHT, MKH, OUH) of children aged 0-4 with Fever by month format this was attended to ensure that the urgent care issues are fed into Commissioners discussions around families and children (chaired by the Clinical Lead for Children). 6. Head Injury pathway use of appropriate scales was discussed and it was agreed to use AVPU. 7. Self harm pathway The upskilling/training group met early in the month and working on the ELearning Quiz and Training resources. The first meeting of the Overview group was held on 11th Sept which was well attended. A new chair (teacher) of the Non Clinical Resources group has taken over the group. Children & Young People s Joint commissioning Unit Chart CYP3: non-elective spells for all providers for Buckinghamshire practices against original target trajectory, 2011/12; 2012/13; 2013/14 0-2 attachment project: Project is moving into operational phase. Day to day project management has been transferred to Oxford Health (OH) as the lead provider. Clinical consultant has been recruited. Dates for training for officers from the Children in Need teams are scheduled for October, with early referrals expected in Nov for pre-work. CAMHS Re-commissioning: Project initiated with four phases planned. Phase 1 preparation (Oct Dec 13), phase 2 specification development (Jan Apr 14), phase 3 tendering process (May- Nov 14), phase 4 mobilisation (Dec Apr 15) Chart CYP4: non-elective spells at BHT for Buckinghamshire practices against original target trajectory, 2011/12; 2012/13; 2013/14 New projects have been established: CYP Physiotherapy: undertake service review of CYP Physiotherapy service needs analysis Maternal Mental Health Mapping & Scoping Project This clinically led project will identify the needs and services available for women who may develop, or have developed, mental ill health during pregnancy or in the post natal period up to 1 year. The final report will make recommendations regarding quality provision for the prediction, detection and treatment of mental ill health in women during this critical period (expected completion March 2014)
3.5 Joint Care: CLINICAL LEAD: DR KAREN WEST RAG rating Activity Finance Milestones Table 6: Delivery of savings against plan by project: Joint Care Project Title & Brief Description (categorised by workstream type) Net s Net From Plan Revised '000 '000 '000 '000 '000 '000 '000 Reduce Grow th 598 299 299 0 598 598 0 Total 598 299 299 0 598 598 0 The following key performance indicators have now been agreed and will be monitored from the date specified. KPIs Referrals to memory clinics (from October); Number of people with a learning disability receiving a health check (from September (ie September data) data being sought from practices); The QIPP savings generated through the joint care programme are related to reducing and containing growth. Projects covered by the programme are: Autism; Dementia; Neuro-rehab services review; Stroke support. Key achievements this month were: IAPT Richmond Fellowship & Relate contracts signed; contract finalised and with provider Maternal and Infant MH scoping project commenced Education and training group established with GP clinical leadership Equal Access to Psychological Therapy (EAPT) group formed. Initial focus on Deaf, Deafened and Deaf Blind AVCCG reviewed Live Well project and intentions (LTC /IAPT) Specialist community review: OHFT are on target with the review of CMHTs, assertive outreach, crisis/home treatment services. Pathway design is shaping up for two locality teams - covering the two CCG areas, with sub-team structures. Dementia: Governance structure redeveloped and confirmed including the dementia board and the whole systems group New memory clinics in Buckingham, Haddenham, Hawthornden and Burnham Memory Advice Service run by Age UK continues to plan Primary Care Worker Pilot (north locality Buckingham and Winslow) review shows success in achieving required outcomes Physical Disabilities review: Review is complete and business case is being drafted PIRLS: Project manager has been put in place by OHFT Finance has been signed off by the CCGs and service is about to be implemented.
Targets for next period: IAPT o Relate and Richmond Fellowship outstanding invoices paid o Final push to ensure Chesham Post Natal Depression happens o Continue to work with provider and CSU to resolve issues arising from new data reporting systems. o LTC Clinical leads to meet to discuss IAPT priorities for county o IAPT PbR pilot in Buckinghamshire proposed - awaiting national response previous meeting cancelled o Opportunity to have x2 trainee GPs in IAPT to be pursued Specialist community review o Dementia: o Dementia friendly community post to be progressed. o Discussion regarding set up of neighbourhood return scheme required o BHT MRI Scans agree protocol for Dementia patients. o Memory assessment closer to home to be fully embedded in pathway Physical Disabilities review Agreement needs to be reached of funding levels for the continuation of the service post April 2014. Figures require double checking PIRLS Implementation to start
3.6 Localities: CLINICAL LEADS: DR CHARLES TODD & DR MALCOLM JONES RAG rating Activity Finance Milestones Table 7: Delivery of savings against plan by project: localities Project Title & Brief Description (categorised by workstream type) Net s Net From Plan Revised '000 '000 '000 '000 '000 '000 '000 New Outpatients 1st Referrals 231 116 0 116 231 116 116 Diagnostics 77 39 39 77 19 58 New Outpatients 1st Referrals 112 56 0 56 112 56 56 Diagnostics 37 19 0 19 37 9 28 New Outpatients 1st Referrals 107 54 0 54 107 54 54 Diagnostics 36 18 18 36 9 27 Total 600 300 0 300 600 263 338 Key Performance Indicators: First out-patient attendances and first outpatient attendances which are GP referred; diagnostic activity exact KPI to be agreed. First out-patient attendances are above plan year to date and referral activity is above allocation but has shown a reduction compared to 2012/13 of approximately 4% across all localities. Practices in localities are being encouraged to review specialties with high referral patterns as part of the QP process in 2013/14 to support the CCG to reduce utilisation of acute care. The locality meetings in October and November will be used to undertake peer review to support practices to challenge each other as to proposals to improve referral management. Central locality in particular has engaged with the use of QP to support mitigating the CCGs activity position. Strengthened Parental Care for Sick Children This project is now being supported by the Communications Lead; engagement events for mothers and children are being planned for November through to June. A toolkit to support the engagement events (including information for parents, promotional materials for parents/children and presentations for clinicians) are being developed. Supporting media and social media activity including Facebook advertising, text messaging and information for public screens is in development. Leg Ulcers Oxford Health NHS FT have been awarded the contract to deliver this 6 month pilot scheme aiming to go live in November. The service will deliver training to Practice Nurses in order to introduce a consistent approach to the effective management of leg ulcers and to implement integrated treatment pathways in partnership with practice nurses, district nurses and the tissue viability team. Within each locality, a nurse will be identified as the clinical champion for this area of care. These nurses will act as a resource for colleagues and ensure best practice is maintained. This is an AVCCG-wide project and support is required to encourage takeup across all our practices. In the long run this should lead to improved patient outcomes and reduced use of nurse time.
Milton Keynes Discharge Coordinator Discharge coordinator has been in post for three months, work is on-going to strengthen communication between acute, social care and primary care to support improved patient care and quality of discharge. This includes ensuring appropriate access to information and patient records. Practices are contacted on admission to identify patients with current care packages along with additional requirements when discharged. Electronic Discharge notes are being shared between the trust and primary care. The Coordinator has identified a cohort of patients who are regular users of services across the healthcare system and is working with partners to understand drivers for usage patterns and solutions to support both the patients and the services. The Coordinator has highlighted an issue around patients being delayed discharge to Buckingham Community Hospital and is working with the CCG and other providers to find a patient focused solution. Primary Care colleagues have welcomed the support from the discharge coordinator. Care Home Matron A launch event for the care homes matron project was held on 19th September with South Locality practices to introduce the service. The project is now moving forward to provide support on the ground to care homes and practices.