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Context Our 2015-17 operating plan represents the second and third year of delivering our Five Year Strategic Plan for Wolverhampton (Figure 1). The intent and strategic direction remains the same, though there are many new elements that shape our local landscape and the national picture: Approval of our Better Care Fund plans. The Dalton Review. The Five Year Forward View. The 2014/15 Operating Plan was produced prior to agreement of our Five Year Strategic Plan. Figure 1 Outline of the Five Year Strategic Plan for the Wolverhampton Health and Social Care Economy. Our 2015-17 Operating Plan therefore reflects these changes, and ensures that our strategic intent remains cohesive and relevant to our local population. The vision of our organisation is to commission the right care, in the right place, at the right time within the context of a finite set of resources, in order to deliver our statutory responsibilities. The challenge is to commission services that offer the best quality and value for money. In order to ensure that we focus our effort where it is most effective, we need to target resources that: Facilitate the right care for people who are ill, in particular those who are very young, very old and/or who have a life limiting condition. Page 2 of 48
Ensure that services are safe, reliable and have the confidence of the people of Wolverhampton. Deliver services seamlessly, so that patients are seen by the appropriate professional at the right times. Help people to stay healthy for as long as possible, reducing health inequalities. Critical areas for delivery 2015-17 We recognise the imperative to maintain quality of care whilst working within our financially challenged health and care economy. For the coming two years, our three priorities are: 1. To continue to commission the most valuable healthcare for our population, maintaining the highest levels of quality, safety and esteem, whilst maintaining financial balance. 2. To ensure the operations of the CCG align with, support and augment transformational change in the way services are delivered, via the Better Care Fund and co-commissioning of primary care services, to further the preventative and public health agenda and opportunities for early intervention and proactive care through greater integration. 3. To maintain our continued delivery of Quality, Innovation, Productivity and Prevention (QIPP), by aligning our commissioning intentions and decisions with our pre-agreed ambitions. To deliver these priorities, our strategic objectives will be to: i. Deliver our Better Care Fund (BCF) plans, to improve integration between health and social care, and improve our ability to enhance protective and preventative interventions with patients. ii. Develop our integrated commissioning capability: We are coterminous with our local authority, acute and mental health providers. We have worked together closely to produce our BCF plans and have established clear governance arrangements through the Health and Wellbeing Board. Our pooled BCF budget, presently circa 70m (subject to final sign off by governing body and cabinet) provides a mechanism for this. We are developing front line teams who have increasingly aligned incentives, structures and processes for joint working. iii. Ensure delivery against our QIPP schemes, protecting quality of service whilst taking avoidable cost out of the system. iv. Negotiate an affordable contract with our acute and community providers, so they can work with us to develop and deliver new models of urgent and planned care and ensure systemwide sustainability. v. Continue to develop and strengthen our leadership capacity and capability as a CCG, including: Managerial bandwidth. Clinical leadership. Support structures How care will be different by 2017 and how we support change New models of care The focus is on building the infrastructure in community settings to support patients to manage long term conditions (LTCs) proactively. We will develop processes and structures (e.g. locality meetings) which will build stronger relationships with primary care, to engage in co-development of new Page 3 of 48
models, and influence referral patterns and the means of managing demand in primary care settings. In particular, our progressive program of GP practice support visits will contribute significantly to improved demand management. Our appetite for new models of care is evident in the community hub model which ran through our BCF plans and our further development of community-based services to accelerate design and implementation of these new ways of working. Integrate our commissioning with the local authority and neighbouring CCGs We are proud of our Better Care Fund plan (approved without conditions) and it holds a central focus for our work with Wolverhampton City Council. We presently hold circa 70m in a pooled budget to implement our four schemes, and reduce emergency admissions by 3.5% in 2015/16. Our non-elective ambition has not changed from that stated in our approved BCF plan. This is a separate indicator from our ambition to reduce A&E attendances. To deliver this, we will be in a position to implement our delivery and benefits realisation plans from 1 st April 2015. The four work streams are already established, governance arrangements are through our Health and Wellbeing Board (including acute provider membership), and we will take a rigorous approach to programme management. System-wide engagement will be ongoing, to work through the operational practicalities. We are also working more closely with Staffordshire CCG on our acute contract, to achieve greater alignment of strategies and services and simplify the requirements placed on our shared acute provider, The Royal Wolverhampton NHS Trust (RWT). Focused prevention and public health interventions Wolverhampton suffers from high levels of deprivation and inequality. Preventative healthcare is one of the key pathways within our Primary and Community Care work stream. We are working closely with Wolverhampton City Council, RWT and local voluntary organisations to develop robust, integrated pathways that support a focus on prevention. We also work closely with Public Health colleagues, who are now beginning to input into the direction and content of our Practice Support Visit programme. Our greatest areas of concern are being addressed through targeted work: Infant mortality is amongst the highest in the country. A working group has been established and 2015/16 will see the implementation of the resultant action plan. Obesity is being addressed through a whole systems approach that aims to tackle the wider determinants of health, alongside the modifiable risk factors for obesity. Our Director of Public Health released a call to action via the Public Health Annual Report, and is now receiving pledges from local organisations to address the challenge, as well as recognition at a national level. Improving financial sustainability Our Five Year Strategic Plan sets out our intent to put the health and care economy on a sustainable footing, through developing community-based services and addressing the default of receiving care in acute settings. This is also in the context of Wolverhampton City Council needing to save in excess of 120m over 5 years. To address this, we will be working in partnership, and the CCG will focus on increasing capacity in primary care. Page 4 of 48
We have piloted GPs making more routine visits to residential homes to address health concerns as they arise, and reduce avoidable admissions to hospital. We have also tested having in-reach teams from hospitals into care homes. We will shortly be in a position to review the six month results of this project, looking at potential avoidance of admissions and ambulance conveyances. To deliver on our existing QIPP schemes (see Appendix 1), we need to ensure alternative provision is available so that high quality care remains in place, giving us the confidence to take cost out of the system. Developing mental health services Our expenditure on mental health is higher than other comparable areas and we are committed to delivering parity of esteem, so that mental health is given equal priority to physical health (see section Parity of Esteem ). However, we know that we need to derive greater benefits and improve clinical outcomes by changing our services, particularly by caring for long term service users more effectively. We are therefore developing a clear planned care pathway, and a distinct urgent care pathway for mental health services. We want to build on the positive impact of existing schemes, for example the Rapid Assessment Service, where clinicians from the mental health trust (Black Country Partnership NHS Foundation Trust) are based in the acute trust emergency department. We are also focussing on repatriating out-of-area placements, as a means of improving patient experience and contributing to greater financial sustainability. Wolverhampton s Health Needs Estimated population 252,900 (249,470 at 2011 census). Age distribution Average age: 39 (close to the average for England). High proportion of under 16s. Ethnic background White: 68% (with a growing population from Eastern Europe). BME: 32% (higher than the national average of 14.3%). Population growth High number of new arrivals (e.g. 2700 traveller families in 2012). Growing number of over 65s (but a lower growth rate than national and regional averages). Life expectancy Based on 2010-12 figures: Males: 77.4 years. Females: 81.7 years. 2 years lower than national average. Quality of life Disability-free life expectancy: 58 years (3 years lower than national average). 61 years (2 years lower than national average). Deprivation 21 st most deprived local authority and expected to worsen. 51.1% of population amongst the 20% most deprived nationally. Most deprived: North East Wolverhampton (Figure 2). Least deprived: South East Wolverhampton. Life expectancy gap between the most and least deprived: Males: 7 years. Females: 3 years. Morbidity 27.7% suffer from one or more LTCs. Single greatest cause of years of life lost: Cardiovascular Disease. Infant mortality 7.7 per 1000 live births (Highest in England. England average - 4.3). Page 5 of 48
Figure 2 Map illustrating Index of Multiple Deprivation (IMD) quintiles across Wolverhampton. Consultation and Engagement with Our Stakeholders Consultation and participation are central to what we want to achieve we will continue to communicate, engage and involve our staff, our GP members, our commissioning partners and patients/the public throughout 2015-17. Our participation vision is Right information, Right conversations, Right decisions and our mission is to promote openness and understanding of the CCG to our people and partners, by bringing to life what the organisation is all about. Our key engagement principles, against which we will hold ourselves to account as we deliver the 2 year operating plan: Trust and know-how - We will engender confidence and provide reassurance that we are good custodians of the local NHS. We will always explain who we are and what we do. Our website will be a one-stop shop for all of our documents, activities and participation opportunities. Timely and easy-to-understand - We will communicate in a timely manner, using easy-tounderstand language. Participation wherever possible - We will involve people in everything that we can, promoting the opportunities people have to get involved widely and arrange them to suit different interests and lifestyles. We won t ask questions for the sake of it. We will always use feedback to help us make decisions and show people how they have influenced the CCG. Quality surveillance - We will gather patient experience themes through all that we do, supporting us to act and respond in line with our duties. Inclusive - We are committed to equality and diversity in all aspects of employment and service delivery. We will work towards eliminating discrimination, advancing equality of opportunity and fostering good relations in the course of our work. Working together, not in competition - We will work with our partners and use their knowledge and experiences to help guide our work. The CCG and its partners will always aim to speak with one voice. High quality and fulfilling our statutory duties - Our communications and participation will meet statutory requirements, such as the NHS Act 2006, section 242 (duty to engage on changes to services), as well as best practice, such as the NHS Institute s Engagement Cycle. Page 6 of 48
Participation Framework Our Participation Framework (Figure 3) will wrap around all the work we do and allow us to: 1. Determine our local health priorities and develop an overall strategy to address the needs of people in Wolverhampton. 2. Improve the way services work together. 3. Draw-up detailed specifications for the services we wish to commission 4. Continuously monitor and improve services by learning from people s experience and feedback. Figure 3 Our Participation Framework. Sitting at the top of our Participation Framework is the Joint Engagement Assurance Group (JEAG), which includes multi-agency representation from stakeholders including patient groups, providers, public health, Local authority, Healthwatch and our strategy team. Its mission is to ensure the CCG is an accountable care organisation that delivers meaningful participation in commissioning. We meet quarterly with a diverse range of representative groups including residents, patient participation groups, community groups, clinicians/health professionals, and Healthwatch, and will report throughout the commissioning cycle to demonstrate the value of our participation work. We work with the city s Equality and Diversity Forum to reach the seldom heard and we evaluate our self-selecting Patient Partner membership against the city s demography statistics (Census 2011) to ensure they are representative. Our communications and engagement strategy refresh will address under-represented members of our community. We will work closely with patient groups to understand delivery. We support a Citizens Forum, which has patient leads for disease-specific groups including Cancer, Diabetes, Mental Health, Stroke, Learning disabilities, Sickle Cell Disease and Dementia. We will also work with local community leaders from a range of diverse groups to understand their experience. We will continue to support Patient Participation Group Chairs to share problems with services and their ideas for improving practices. Page 7 of 48
Transformation, Reconfiguration and Reprocurement Joint commissioning Primary Care We have carefully assessed the approach we take to the commissioning of primary care. As a result, we have decided to move towards a joint commissioning model with the NHS England Area Team, on the basis of an ambition to move towards fully delegated responsibility in the future (see Appendix 2). Joint commissioning will give us an opportunity to plan more effectively and improve the provision of out-of hospital services, with the option to pool funding for investment in primary care services. It will allow us to develop our in- house expertise, with access to the knowledge and experience housed within NHS England. Joint commissioning will act as a significant enabler in developing integrated out-of-hospital services based around the diverse needs of our local populations, through a shift of investment from acute to primary and community services. Greater alignment of primary and secondary care commissioning will also allow us opportunities to develop more affordable services, through efficiencies across the patient pathway and greater synergy between commissioning budgets. We will therefore establish a joint committee with the Area Team in order to commission primary medical services, for the next 12 months as a minimum, before pursuing the opportunity of full delegation. We will work closely with NHS England in order to deliver an effective transition of responsibilities in a systematic and collaborative way. New Models of Care Our vision for health and social care services for the Wolverhampton community is underpinned by the city s jointly agreed and developed Health and Wellbeing Strategy. In response to the Five Year Forward View and building on our plans for primary care joint commissioning, we will shift activity and investment from acute/hospital settings to primary and community facing services in 2015-17. This will be phased, and mindful of system-wide stability. We will need to explore the implications of different operating models, based on the needs of Wolverhampton s population and evidence of improvements in quality and outcomes. Our acute and community provider Our community services are predominantly delivered through a contract with The Royal Wolverhampton NHS Trust (RWT). The majority of community facing healthcare services are in scope for redesign and development via the BCF Primary and Community Care Work stream. As RWT are also our main acute provider, we have a valuable opportunity to cut across traditional boundaries to achieve integration through service redesign. We continue to engage our providers with our work programmes, with a reinforced expectation that BCF metrics will be delivered through redesign and enhancement of community-facing services. This will be delivered through our commitment to building a neighbourhood approach which generates self-care, early identification and screening, integration and resilience of communities and neighbourhoods across primary and community services. Strengthening primary care capacity and capability We need to be deliberate about improving the links GP practices have with the wider primary healthcare and community services teams, particularly District Nursing and Health Visiting. We Page 8 of 48
need to improve consistency in the coordination and integration of care for patients with ongoing health needs, working together with carers and voluntary sector services. This will allow us to improve patient experience and outcomes, whilst reducing pressure on healthcare professionals. Better co-ordination means it becomes more feasible to offer services closer to patients homes. There is strong appetite for transformational change and integration in Wolverhampton. We will support the exploration of emerging care delivery operating models, for example: Multi-specialty community provision. Super- clustering of practices for shared care purposes (federated models) e.g. building upon our current primary care in-reach programme for residential care homes. Practice merger opportunities. The aim is to produce neighbourhood-facing services that offer improved access and greater coordination of care. We are organising a major development session in the near future with our GPs and practice managers to confirm our shared vision and discuss mechanisms for delivery. Responses to the financial challenge There is no availability of any significant new money to invest in the delivery of new community and primary care services. We must therefore impact on the activity and spend incurred in acute care to release funds for the investment needed. This approach is underpinned by the metrics identified in the BCF programme and our commitment to influence through design and procurement, the outcomes we are able to achieve. For primary and community care services this means adopting a collaborative and integrated approach to the delivery of services. Wolverhampton will develop community neighbourhood teams, which will be wrapped around a locality cluster of GP practices that can provide an integrated primary and community care model. The new neighbourhood teams will focus on: Person-centred support. Living well with one or more LTC. Single point of access and single assessment. Wraparound care coordination. Extending the role of primary care. Reducing social isolation, alongside building enhanced community assets which support living well and staying well. Better Care Fund Update Agreed plans and our commitment The BCF remains central to our ambitions and delivery mechanisms to generate transformational change in the way care is delivered, and is reflected in the second of our three highest priorities as a CCG. The overarching plan is illustrated in Figure 4. Page 9 of 48
Figure 4 Overarching plan for delivery of our BCF schemes. There are four core whole-system work streams (Table 1) which have been established by the Health and Wellbeing Board and focus on the delivery of the strategic vision i.e. integration and care delivered as close to home as possible ( home as hub ). This is aligned to our Five Year Strategic Plan. Work stream Programmes delivering in 2015-17 Community and Primary Care Dementia Community and Primary Care Redesign Programme Integrated Care Pathway Design Programme Mental Health Mental Health Urgent and Planned Pathway Design Programme Intermediate Care & Intermediate Care Pathway Redesign Programme Reablement Table 1 Better Care Fund work streams and delivery in 2015-17. We presently have circa 70m committed in a pooled budget with Wolverhampton City Council for 2015/16 to deliver these schemes. Page 10 of 48
How care will be different in the next two years through delivery of the Better Care Fund plans Over 2015-17, we will transform health and care provision to reflect the following delivery model: Building community capacity to improve health and reduce social isolation. A material shift from episodic care and support, to interventions being wrapped around the individual so as to maximise independence. Fully integrated mental health, dementia, community health and social care neighbourhood teams and urgent care pathways that support person-centred care and provide communityfacing alternatives to admission. Care that is better co-ordinated across different organisations, regardless of how complex a patient s needs are. Improved approaches to accelerated discharge planning and post discharge support. Consistent and responsive community access and effective support in a crisis. Clear, agreed and defined health and social care outcomes. Innovative approaches to the co-design and commissioning of services. Through more integrated, proactive, community-based services for the people of Wolverhampton, this will deliver: Reduced non-elective admissions by 3.5%. Reduced permanent residential admissions by 32. Reduced delayed transfers of care by 110. Increased effectiveness of re-ablement by 30. At least 90% of those living with frailty and/or complex health and care needs in a care home will have a care plan. All patients in designated care or nursing homes will have access to a GP on a weekend. All patients who are over 75 and with one or more LTC will be assigned a care co-ordinator. Seven day working for hospital pharmacies, with a senior medic available in trusts over the weekend to ensure seven day discharging can take place. Progress on developing and delivering our BCF plans Since submission and approval of our BCF plans, further work has developed: A detailed implementation plan A robust benefits realisation plan These will be reviewed by the Health and Wellbeing Board in March 2015, concluding the planning phase, thereby enabling us and our partners to move into delivery from day 1 of the 2015/16 financial year. We are making good use of our integrated governance and delivery structures, including key partners such as Wolverhampton City Council and The Royal Wolverhampton NHS Trust (Figure 5). We have strengthened our GP representation on our four work streams. Page 11 of 48
Figure 5 Governance, delivery structure and responsibilities for the Better Care Fund. To ensure delivery of our schemes and realise the benefits, we will be strengthening our approach to programme management, with the sophistication to work across organisational boundaries, track and respond to dependencies and resolve issues quickly and effectively. We are shaping our primary care model to realise our ambitions: 2015/16 options appraisal of possible models (e.g. multi-specialty providers, GP cooperatives, federated approach, condition-specific clusters) piloting and establishing proof of concept agree level of ambition move into implementation by end of 15/16 2016/17 full implementation changes complete and services running by end of 16/17 Revising our ambitions With regards to revising our BCF ambitions, there have been significantly fewer non-elective admissions than predicted over the reference period used for pay for performance (Q4 2013/14 to Q3 2014/15, see Table 2). We remain committed to our ambition to reduce non-elective admissions by 3.5% over the performance period (Q4 2014/15 to Q3 2015/16), in line with national guidance. However, given the 9.2% difference in actual activity over the reference period, this equates to a Page 12 of 48
drop in 951 admissions rather than the initially agreed 1048. We intend to retain reduction of nonelective admissions by 1048 as our target for improvement, which will be discussed at forthcoming meetings of our Health and Wellbeing Board. This is separate from our ambition to reduce A&E attendances by 3044. Forecast non-elective admissions in submitted BCF plan Actual non-elective admissions over reference period Percentage Difference Q4 13/14 7102 6354-10.5% Q1 14/15 7736 7073-8.6% Q2 14/15 7393 6572-11.1% Q3 14/15 7696 7165-6.9% Total 29927 27164-9.2% Table 2 Forecast versus actual non-elective admissions over the BCF reference period. Children s and Maternity Commissioning We are developing a model of children s and maternity commissioning that will be in keeping with our main strategic objectives for integration throughout 2015-17. In order to improve the provision of services, together with Wolverhampton City Council we will: Address the significant outlier status of infant mortality in the city, working with Public Health colleagues and primary care services to implement an action plan (see below for further details). Reduce the number of cases and period of time children with complex health, social and educational needs are placed out of area. Reduce the numbers of Looked After Children (LAC) in the city and ensure this group has timely assessments and reviews. Ensure joined-up children s commissioning services, including transfer of health visiting commissioning responsibility to the local authority. Continue implementation of the Children and Families Act 2014 for children with special educational needs and disabilities (SEND). This includes: o Maintaining our Local Offer. o Introduction of personal health budgets. o Contributing to Education Health and Care plans. o Development of a SEND strategy. o Joint commissioning arrangements with the local authority. Improve transition arrangements for young people moving from child to adult-based health services, so that early and seamless support is in place. Ensure GP engagement in the safeguarding agenda including provision of timely medical reports. Contribute to the personalisation agenda and personalised care plans. Review CAMHS, to ensure responsiveness and alignment to the national review of CAMHS specialised services. Address the high rate of children with ambulatory care sensitive conditions through our Urgent Care strategy review, in order to move towards national benchmarks. Transfer to Payment by Results (PbR) tariff for maternity pathways. Provide meaningful choice in maternity services by engaging with different cultures to ensure access to early pre-natal care. Page 13 of 48
The Joint Strategic Needs Assessment (JSNA) does not currently provide data on children and young people with disabilities. We have commissioned Public Health to conduct a needs analysis which will be incorporated into the refresh of the JSNA and will inform our SEND strategy (due in May 2015). This will address the need to implement person-centred planning to improve health outcomes for this group. We will also work closely with the Wolverhampton Children s Trust Delivery Board to achieve their ten-year priorities for health, aiming for fewer children to be obese, more children to survive infancy, fewer parents to suffer from mental ill-health and fewer children and young people to misuse substances. Infant mortality The infant mortality rate in Wolverhampton remains the highest in England. It has steadily increased between 2009 and 2012 and is a major contributor to the gap in life expectancy within Wolverhampton compared to the national average. Public Health has identified risk factors that may contribute to the high rates of infant deaths in Wolverhampton. These include: High smoking rates throughout pregnancy and at delivery, which lead to a much higher risk of infant death. Prematurity, in particular infants under 1500g. Mothers aged between 40 44 years. Mothers from deprived communities. Mothers from black ethnic groups. An infant mortality working group meets, chaired by our Director of Public Health and consisting of obstetricians, midwives, neonatologists, paediatricians, health visitors, health trainers, and representation from our CCG and Public Health. A draft action plan has been produced, consisting of a broad range of analyses and interventions, aimed at: Reducing the proportion of women smoking during and after pregnancy. Ensuring a smoke-free hospital stay. Promoting a smoke-free home environment. Ensuring a whole school approach to smoking prevention/cessation to decrease smoking initiation and maximise referral to smoking cessation services for school children. Improving antenatal detection of foetal growth restriction. Improving maternal nutrition during and after pregnancy. Promoting exclusive breastfeeding in the first 6 months of life. Combatting the risk factors for Sudden Unexpected Death in Infancy to prevent postpartum deaths up to one year. Assessing the effectiveness of gender-specific pregnancy prevention programmes. Ensuring pregnant women under 19 years are supported to make healthy choices during pregnancy and beyond. Ensuring vulnerable women are supported during pregnancy. Commissioning Cancer Services To improve early diagnosis for cancer, we will establish a programme of work to be led by our Macmillan Primary Care Nurse Facilitator and overseen by our Macmillan GP Facilitator. This work includes: Promoting cancer awareness training for staff in primary care. Reviewing practice level data on Cancer referrals and diagnosis to support practices to improve timely referral. Page 14 of 48
Championing the Primary Care Cancer Audit. Enhance cancer-related significant event audits in primary care practices. Improve cancer screening uptake through campaigns and initiatives to improve early diagnosis. The work plan for the nursing post will include a range of projects to improve early diagnosis for cancer and track outcomes such as one-year cancer survival rates. We will use national cancer peer review reports to aid our local understanding, as well as drawing upon the insights of our patient representatives. We track 1-year cancer survival data from the Local Cancer Intelligence website provided by Public Health England. Furthermore, the National Cancer Intelligence Network Cancer Commissioning Toolkit will publish 1-year and 5-year survival rates for breast, lower GI and lung cancers. We will analyse this data at a practice level to identify outliers and our Macmillan GP Facilitator will work with practices to support improvement to these figures. Commissioning our acute providers The Royal Wolverhampton NHS Trust (RWT) is our largest provider of acute services, with a contract value worth 89.8% of our portfolio, followed by The Dudley Group NHS Foundation Trust at 2.7%. The transfer of Cannock Hospital to RWT will offer the trust greater flexibility in managing activity within secondary care. However, it is recognised that there will be a transitional stage as the trust integrates systems and staff to ensure a consistent approach to pathways and clinical practice across sites. The Cannock Hospital site will offer an opportunity for reconfiguration of services and ability to up and down-scale to meet demand at times of pressure and ensure that peaks in emergency/urgent care do not impede the provision of elective care. Financial and performance improvement plans Overspend on the contract with RWT has resulted from underperformance on QIPP plans and increases in activity far beyond expectations. We are currently in contract negotiations for the coming year, but it is clear that service redesign at the trust will be necessary in order to remain financially viable. The trust has not been able to meet the A&E four hour 95% target in 2014/15, with winter proving particularly challenging. This is similar to neighbouring trusts. A Systems Resilience Group (SRG) recovery plan is well-established, and the SRG convenes weekly to ensure a timely response and action where needed to manage peaks in demand. The majority of delays in A&E for Wolverhampton are as a direct result of increased emergency admissions and a lack of sufficient numbers of available beds. In an attempt to manage this pressure, the SRG has redirected funds to increase flow co-ordinators within the hospital, place GPs in the emergency department, provide additional step down facilities in the community and support earlier discharge/reduce length of stay by investing in the Third Sector. The trust are on a trajectory to hit the headline target for Referral to Treatment Times, but it is notable that specialties such as general surgery and trauma & orthopaedics have been failing to reach this target all year. We have used national monies to support the trust in meeting requirements, but the increase in non-elective bed activity over winter has affected this adversely, making it more difficult to complete elective work. Ambulance hand over delays (>30 mins and >60 mins) in Wolverhampton are the lowest in the Black Country, highlighting the whole-system approach to managing flows of patients throughout the Page 15 of 48
urgent care system, rather than the emergency department alone. 12 hour breaches have also been avoided for the winter period to date, and whilst a number of acute trusts across the region declared an EMS Level 4, Wolverhampton managed to consistently manage at EMS Level 3, despite the fluctuations in demand. It is essential that the operating plan for the whole CCG is not compromised by the pressure on Urgent Care Services and the consequences this has on Referral to Treatment times. The System Resilience Group will develop a robust local capacity and demand plan, to target resilience funds to address vulnerable points in the system. The learning from 2014/15 is paramount in planning for 15/16: The planned Winter Washup took place in March 2015. We have undertaken a planned Length of Stay Review facilitated by Emergency Care Intensive Support Team (ECIST) at the end of March 2015. We will be evaluating the effectiveness of existing schemes. ECIST have undertaken a planned review of urgent care services at RWT at the end of March 2015 in the form of an urgent care whole system walk through. Following these assessments, the SRG will apportion funding and establish key practices accordingly. Delivery of 7 day working will also be factored in. As a result, the capacity and demand plan for Urgent Care will be aligned to the operating plan, to ensure resilience across the system in 2015-17. The CCG has set aside 1.7m of resilience funding in its baseline for 2015-16 this funding is currently the subject of SRG discussion as to its most effective use in the coming year. Demand Management We have modelled potential growth in demand for healthcare services by assessing changes in population size, the age profile and age-specific health status over the next 5 years. We have assumed an increasingly health challenged and aging population, with greater complexity and comorbid conditions. Our findings indicate the absolute need to adopt an early intervention, self-care and management and prevention approach. The outputs are being used to help identify how we should respond to the predicted growth in demand and the likely range of services we should commission. We are developing all activity plans in consultation with provider activity plans. Discussion and challenge meetings are taking place regularly between the CCG and providers throughout the contracting/modelling and planning process, to ensure activity plans are consistent and have been mutually agreed. Our likely activity levels are illustrated in Tables 3 and 4. Table 3 Likely Activity Levels 2015/16 Elective: * Trust Elective Spells All specialties The Royal Wolverhampton NHS Trust 24,103 The Dudley Group NHS FT 1,220 Other Contracts (less than 5m) 1,811 Non NHS Providers 205 Total 27,339 Table 4 Likely Activity Levels 2015/16 Non-elective: * Trust Non-elective Spells All specialties The Royal Wolverhampton NHS Trust 31,731 The Dudley Group NHS FT 814 Page 16 of 48
Other Contracts (less than 5m) 1,483 Total 34,028 * Values are correct as of 02.04.2015. These are likely to change as discussions for 15/16 activity plans continue with providers. The three Locality Boards (South West, North East and South East) have recently taken on a more strategic agenda, with GPs taking greater responsibility for the performance of Localities, with use of the QIPP and Finance Report reviews. It is hoped this will influence demand for acute services at a GP Level, and will expand as Locality Boards further develop their scope and managerial capability. Working with Primary Care There are three strands in primary care that we will work towards in order to ensure accuracy in capacity and demand planning for acute services: 1) GPs will be encouraged and enabled to critically review their referral management, especially A&E and Outpatient Attendances. 2) GPs will have access to the Information System from April 2015, providing more accurate acute activity and cost information, to ensure practice utilisation of acute services is appropriate to levels of clinical need. 3) Annual Practice Support Visits (commenced August 2014) provide a two-way review of areas for improvement for both the CCG and practice in the development of primary care. They include consideration of how acute services are used, aiming to reduce or avoid the need to refer, through development and use of primary and community services. Workforce Planning Despite our focus on continuous improvement, the stretched and finite capacity of primary care and insufficient number of GPs remain a challenge for the foreseeable future: Consultation rates have almost doubled in the last decade from nearly three to six times per year. Patients over 65 consult their GP on average more than twice as frequently as those aged 15-44 years of age. In the last 12 months, the number of consultations rose by 3.5%, GP numbers rose by 0.2% full time equivalent in the same period. We will undertake workforce planning analysis to determine current workforce requirements against demand and develop workforce succession planning. This will include recruitment and retention planning and consider alternative ways of increasing access within primary care. The CCG is represented on the Local Education and Training Board, and is a portfolio lead. We are sighted on provider workforce plans and it is anticipated these will be approved prior to confirm and challenge by Health Education West Midlands (HEWM). We are working hard to develop our collaboration with the Local Education and Training board to ensure staffing and workforce plans are affordable and support our strategies for transformation. Nursing and midwifery revalidation comes into full effect by December 2015. We are in the process of mapping our providers who employ registered nurses and midwives. A CCG focus group will be monitoring and progressing the work required to meet the deadline, working alongside the subregion team. Engagement is already well underway, discussing the implications with practice managers, locality teams, practice nurses and at various quality forums. Developing the workforce Page 17 of 48
We will work with the West Midlands Deanery and other educational organisations to develop the workforce, so that it is more flexible and able to undertake a greater range of healthcare interventions. Given the time lag in recruitment, skills development and building a strong pipeline, we are mapping local trends in terms of retirements and recruitment/ retention issues, both for primary care and community services. NHS England will help us to assess the scale of the workforce problems through the collation of workforce data. We understand that there is a national shortage of general practitioners and aim to move towards a more multidisciplinary model for delivery. This could include a strengthened role for nurse practitioners, physician assistants and more involvement of pharmacists in primary care. We are working closely with the head of our local pharmacy network in order to ensure that our objectives are aligned. An example of how this is already working is the use of advanced nurse practitioners and pharmacists for our residential care home in-reach program, which works to reduce unnecessary hospital admissions. Development of new models of primary care will consider the existing workforce strengths and constraints, and take steps to address any medium-term gaps. We will continue to promote and provide clinical training and education in order to maintain high clinical standards and skills within the workforce, including Team W events (a local education and engagement forum). We will also work to ensure support and development mechanisms for other key staff groups, such as practice nurses and practice managers. Access The consistent message from our member practices is that workload in primary care has become increasingly difficult to manage within existing capacity and is in danger of compromising the quality of service offered. Difficulty in getting appointments continues to be the most important concern for our patients in primary care. Wolverhampton reports a rate of 86% for patients being satisfied with ease of telephone access (compared to the national average of 82%) with 79% satisfied with their ability to make an appointment (compared to the national average of 80%). The overall consultation rate in Wolverhampton has increased by approximately 1.5 over the last 15 years. For a practice of 10,000 patients, this represents an additional 15,000 consultations per year which need to be accommodated. This rise in demand has not been matched by an increase in resource within primary care. Improving access to Primary Care We plan to create capacity in primary care to help reduce pressure on practices and improve access for patients. We will: Ensure practices operate robust telephone booking systems (as this is the preference of the majority of patients) whilst supporting implementation of more flexible and responsive booking systems. Assess the need for extended time appointments for complex patients and for patients with an LTC. Support provision of demand and capacity exercises to better understand access. Page 18 of 48
Support greater continuity for patients, as 40% of patients prefer to see or speak to a particular GP. Work to develop access to primary care and emergency services to non-english speaking patients. Encourage practices to offer extended opening hours, via an NHS England-commissioned enhanced service to improve access to GP services, whilst planning towards 7 day opening across services. Develop an approach to practice federation to allow greater capacity and flexibility of service. This will draw upon a broader skill mix for delivery where appropriate (including nurses and pharmacists). Be proactive in the way we commission local improvement schemes/local Enhanced Services (LES), by planning ahead and ensuring adequate primary care engagement. Implementing the Urgent and Emergency Care Review Both nationally and locally, urgent care services continue to be a high priority. Wolverhampton continues to experience increasing admission rates and national benchmarked data suggests that there are higher than expected numbers of patients attending the emergency department with conditions that could be readily treated in primary care. We are committed to implementing the Urgent and Emergency Care Review and have ensured our urgent and emergency care strategy and plan for primary care is aligned to its findings. Our review of urgent and emergency care services has taken into consideration the impact on all providers from a financial and activity perspective, with modelling and review of current provision across the city, including walk-in centres, GP access in primary care, out-of-hours services and emergency department activity. The overarching aim is to build an urgent care system that meets patients needs and provides services that are high quality, value for money and sustainable. The health economy undertook an extensive and inclusive three month consultation with the public on our vision for Urgent and Emergency Care provision in Wolverhampton. Our approach was overwhelmingly supported, with over 90% of those surveyed responding that they Agreed or Strongly Agreed with our plans. The strategy for urgent and emergency care was subsequently approved and implementation plans have progressed without delay. A new Emergency Care Centre RWT is constructing a new, purpose-built Emergency Care Centre which will house both the new Emergency Department (ED) and the new Urgent Care Centre (UCC). The new ED will have significantly increased capacity and opens in November 2015. The UCC will be GP-led, open 24 hours a day/7 days a week and sited directly above the new ED. It will incorporate the entire GP Out of Hours service, the Showell Park Walk-in Centre and manage all primary care-type activity that currently presents to the ED. The plan to open this in April 2016 is on target. Patients who present to the ED will be directed to the most appropriate service for their clinical need, while those who are aware of the Urgent Care Centre and the services it provides, can self present. The UCC will work closely with local GPs, especially where patients frequently attend the ED and UCC, to encourage reduced attendance. We will support effective signposting to help patients choose the right service for their need. The UCC will actively encourage patients to return to their GP for follow-up. Page 19 of 48
We are currently out to procure for a provider to run the Urgent Care Centre, in line with strict procurement rules and guidance. The service specification has a strong focus on quality and value for money, as well as close working with Healthwatch to ensure excellent patient experience and outcomes. This will be measured using a number of metrics, including the Friends and Family Test. The specification will also target inequalities, particularly around dementia and those with language barriers, whist ensuring that those experiencing mental health problems can access pathways with ease. A patient reference group has been established with oversight of the service specification, to ensure it meets the needs of our population. A major issue raised during consultation is that patients would prefer to see their own GP, but for a number of reasons have been unable to. They also reported that they find the current urgent care system complex and difficult to navigate. 111 services are being reviewed and re-procured in line with national requirements and changes, to ensure the service integrates across all health care and voluntary sectors. We will work in conjunction with the new service provider to ensure integrated care to all patients across the city with the benefit of access to a GP to avoid hospital attendance or admission. The work to develop the Primary Care Strategy will run alongside this, focussing on ensuring that patients are seen in primary care where clinically appropriate. The CCG will work in collaboration with thecritical Care Network, the stroke reconfiguration group and the Operational and Strategic Urgent Care Networks in relation to further developing the Urgent Care Networks regionally. System Resilience and Marginal Rate Emergency Threshold monies The SRG will be following an agreed process for evaluating schemes funded during 2014/15 from both system resilience money and Marginal Rate Emergency Threshold (MRET) money. This will inform decisions where: i) Schemes need continued funding from either System Resilience money or MRET from April 2015. ii) Schemes require funding part year to target predicted peaks in demand. iii) No further funding is required as little benefit was realised from the scheme. iv) There are new areas spend. A high level review of existing schemes took place during February 2015. SRG review and agreement on high level plans took place in March 2015, in preparation for submission in April 2015. Once the baseline plan is agreed, the SRG will continually review activity against demand and predictions, to ensure that funds are invested where the greatest impact can be realised, with a focus on quality of care, value for money and achievement of key performance targets. Meeting the NHS constitution standards We are committed to meeting the NHS constitution standards and NHS Mandate Commitments in 2015-17. We will provide assurance of this by ensuring Key Performance Indicators (KPIs) relating to the Constitutional requirements (including A&E waits, Cancer Wait Targets, Referral to Treatment, Diagnostic Waits, Quality Performance measures and Mental Health Measures) are carefully monitored at the required frequency. Performance will be assured during review, discussion and challenge when reported to Finance and Performance Committee, Quality and Safety Committee, our Senior Management Team and also Contract Review Meetings within the organisation. Additional assurance on our commitment to meet constitutional obligations will be provided to NHS England, during regular KPI update requests and CCG assurance visits. Page 20 of 48