Subject: 214-219 Strategic Commissioning Plan Meeting: NHS Milton Keynes CCG Board Date of Meeting: Tuesday 22nd July 214 Report of: Donna Derby, Director of Transformation & Delivery Alison Joyner, Head of Strategic Planning Is this document: Commercially Sensitive For the Public or Private Agenda To be publically available via the CCG Website N Public Y Introduction In order to respond to the significant challenges that the NHS is facing, CCGs must take a leading role in developing and implementing transformative long term strategies and plans for their commissioning of services. Following an earlier submission to the NHS England Area Team in April, the CCGs has further refined and developed its Strategic Commissioning Outline & 2 Year Operational Plan, to become a longer term 5 Year Strategic Commissioning Plan. The document has been enhanced in specific areas, based on feedback from the Area Team and national requirements as outlined in Everyone Counts: Planning for Patients 214/15-218/19. A draft version was required to be submitted to the Area Team by 2th June 214, and is attached for note. Summary The plan shows how the CCG will develop and implement service change and transformation over the next five years. It sets out the specific commissioning plans of the CCG for the next two years, which have been built up from our Commissioning Intentions, QiPP Plan and 5 Year Financial Plan. The plan also provides a summary of the CCGs Strategic Vision in the form of a Plan on a Page and an outline of five key areas in which we need to explore, agree and build new models of care delivery during the next 5 years. Namely: Citizen & participation empowerment Wider primary care, provided at scale A modern model of integrated care Access to the highest quality urgent and emergency care Page 1 of 2 NHS Classified
A step change in productivity of elective care. Sustainable Hospital Services The plan remains in draft form at this time, as there is still more work to do before the CCG can finalise it. A key aspect of this is the pending outcome of the MK/Bedfordshire Review which is currently still concluding, and the service options which will be agreed and published in the next month. Next Steps An executive summary is currently being developed, which will be available as a public facing document for stakeholders once the strategy is agreed and finalised. Key elements of the plan are being checked against, and included within the final documentation being developed as part of the MK/Bedfordshire Review. The findings/outcomes of the MK/Bedfordshire Review will need to be captured in the final Strategic Commissioning Plan, once the likely options are known. Recommendation The Board is asked to note the draft Strategic Commissioning Plan. NHS Classified Page 2 of 2
Strategy templates 214/15 218/19 5 Year Strategic Commissioning & Plan 214-219 Everyone counts: Planning for patients 214/15 218/19 1
Reader Information Version control 1.5 DRAFT Publication Date 19 th June 214 Lead Author Key Contributors Donna Derby Director of Transformation & Delivery donna.derby@miltonkeynes.nhs.uk Alison Joyner Joint Head of Strategic Planning Alison.joyner@miltonkeynes.nhs.uk This strategy builds on the Strategic Commissioning Outline & 2 Year Operational Plan, submitted to NHS England Area Team on 4 th April. It covers the period April 214-March 219. Description Contact Details Equality Impact Analysis This strategy has been informed by National Guidance, specifically the requirements of NHS England s Everyone Counts: Planning for Patients 214/215 218/219. It remains in draft form at this point and will be subject to further refinement and update based on the outputs of the Bedfordshire/MK Healthcare Review due to report in July. miltonkeynes.ccg@nhs.net We understand our responsibilities in relation to equality impact analysis; the reviews and projects that will arise as a result of this plan will each undertake their own equality analysis (as per MKCCG s Planning & Delivery process), and address any potential inequalities appropriately. 2
MKCCG: Plan on a Page Milton Keynes health economy is comprised of partners from MK CCG, MK Council, MK Hospital Foundation Trust and CNWL:MK Community Services & voluntary sector. Together, under the auspices of the Health & Wellbeing Board, we come together as a partnership to ensure an integrated & coordinated approach across NHS, social care & public health to improving the health & well-being of our population. Vision We will openly work with patients and stakeholders to plan and buy services that are high quality and provide the best health outcomes and experiences, whilst achieving value for money for our local community. We will listen and improve the health and well-being for everyone in Milton Keynes H&WB Priorities 1. Improve Wellbeing to enable residents to lead longer and healthier lives Values Aims Commission Services that are value for money 2. Reduce earlier deaths and tackle major diseases by focusing on prevention, early diagnosis and the quality of treatment services, including improved integrated services Involve Clinical Leadership to make a difference 3. Reducing health inequalities by addressing poverty, unemployment, education provision, transport and housing issues Develop Effective Engagement Improve Quality & Safety of Services Strategic Aim 1 Strategic Aim 2 Strategic Aim 3 Transforming Primary & Community Care Sustainable Hospital Services Quality & Inclusion Delivery Urgent Care High Impact Team for Care Homes/Domestic Commission Common Front Door/EMS Promote 111 Service Care Pathways & Primary Care Referral Management Service Pathway Reviews (Out of Hospital) Developing Primary Care & Community Services Integrated Health & Social Care Teams 24/7 Community Services Working Maternity, Children & YP Implement 5 High Impact Paediatric Pathways CAMHs Review Implementation of SEND Reforms Health Practitioner to Safeguarding Hub Mental Health & LD IAPT Specialist Outpatient Eating Disorder Services Inpatient Mental Health Service QIPP 214/15 11,688k 215/16 5,747k 216/17 4,666k 217/18 6,322k 218/19 1,425k Care Pathways & PC 4,78k Mental Health k Urgent Care 2,23k Children & Maternity 344k Contractual 2,k Prescribing 1,k Unidentified 1,541k Care Pathways & PC 4,114k Mental Health k Urgent Care 31k Children & Maternity 256k Contractual 2,k Prescribing 75k Headroom - 1,674k Care Pathways & PC 2816k Mental Health k Urgent Care 5k Children & Maternity 6k Contractual k Prescribing 75k Care Pathways & PC 3,55k Mental Health k Urgent Care 1,2k Children & Maternity 822k Contractual k Prescribing 75k Care Pathways & PC 6,5k Mental Health k Urgent Care k Children & Maternity 1,125k Contractual 2,5k Prescribing 75k
Table of Contents 1. Purpose... 5 2. Introduction... 5 3. Strategic Approach... 6 4. Health & Wellbeing in Milton Keynes... 7 5. System Vision... 8 6. Transformation & Delivery... 29 7. Governance... 33 8. Improving Quality & Outcomes... 34 9. Sustainability & Finance... 44 1. Integration & Partnership... 48 Appendix A... 53 Appendix B... 62 Appendix C... 7 Appendix D... 71 Appendix D... Error! Bookmark not defined. Appendix E... 72 Appendix F... 73 Appendix G... 74
1. Purpose This document outlines the Strategic Plan and direction for Milton Keynes CCG as the lead local organisation for commissioning health care services within the town. It is one of a suite of strategies which guides how we can ensure there is a high quality and sustainable healthcare system during the next 5 years. This document sets out the key health issues and commissioning priorities which will be addressed to improve the health and wellbeing of the population of Milton Keynes and to meet the objectives set out in the local Health & Wellbeing Strategy1. At this point in time it summarises the key operational commissioning intentions for 214/15 to 218/19 in detail and how these will contribute to meeting the NHS Outcomes framework and the national service indicators. The strategy also outlines the service transformation and reconfiguration that will be required over the next 5 years, both in terms of sustaining hospital services and delivering a significant level of care closer to home within primary and community settings. Finally, the plan describes the governance, performance monitoring, quality and safety assurance process and how financial resources will be used and the potential risks to delivery. 2. Introduction NHS Milton Keynes Clinical Commissioning Group (MK CCG) has delegated responsibility in 214/15 for commissioning services estimated at around 262 million. Which with population growth will rise to a value around 31m by 218/19. It has a geographic area of responsibility that covers all the wards in Milton Keynes Local Authority plus the wards of Great Brickhill and Newton Longville which are in Aylesbury Vale. Its members are 27 general practices organised into 4 neighbourhood groupings, geographically based in the north, south, east and west of Milton Keynes. Milton Keynes CCG is largely (95%) co-terminous with Milton Keynes Council and has a registered population of 252,42. The CCGs main acute provider is Milton Keynes Hospital NHS Foundation Trust, which accounts for approximately 62, admissions p.a. (85% of the total for that hospital). Mental Health & Community Services are provided locally by Central Northwest London NHS Foundation Trust. 1 2 H&WB Board, Milton Keynes Joint Health & Wellbeing Strategy: 212-215: April 213 Taken from Research & Intelligence Team at Milton Keynes Council using Population Bulletin 213/14 data. 5
As the primary organisation within Milton Keynes for commissioning health services to meet all the requirements of patients, the CCG will work collaboratively to ensure that it can meet the needs of the local population whilst living within its delegated resource limit. Improving the health of the local population is key to this aim, and is being delivered through the implementation of locally agreed individual commissioning strategies for Urgent Care 3, Mental Health 4, Older People 5, Dementia 6, Children & Young People 7. A Transforming Primary & Integrated Strategy 8 is also being developed, which lays out the ambition to commission a greater proportion of activity in community and home settings in order to rebalance the health economy and the Primary Care Development Strategy 9 which underpins how the CCG can support NHS England in the delivery of high quality of services in primary care. MK CCG is likely to oversee significant changes in acute care configuration within the next few years, with greater centralisation of specialist care, to achieve better patient outcomes. The provider landscape in Milton Keynes is evolving and will experience significant shifts over the next 2-3 year. NHS MK CCG will need to improve the use of the funding currently invested in the secondary care sector if it is to be able to commission the necessary resulting increases in breadth and volume of care provided in communities and primary care. Joint work in this area is currently underway across Milton Keynes & Bedfordshire via the review of acute hospital services, supported by Monitor, TDA & McKinsey. HealthWatch is a key participant in the review. The outcomes of this work will heavily influence the final version of this 5 Year Strategy for the CCG, once the review reports in July 213. 3. Strategic Approach MK CCG is committed to improving health, reducing health inequalities and ensuring that the public have access to safe, high quality services. As a commissioner, the CCG s intentions are to shift care from hospital to community settings where truly integrated care across a range of partners will be the norm, whilst maintaining sustainable hospital services for care that cannot be delivered elsewhere. There remains a compelling case to modernise services and to improve the degree of co-ordination with other partners, particularly in primary and social care. The MKCCG approach to creating a system which delivers high quality safe services for its population is shown in the diagram below. 3 MK CCG, Urgent & Emergency Care Strategy: 213-216: October 213 4 H&WB Board: Mental Health Strategy: 214-217: December 213 (draft, out for consultation) 5 H&WB Board: Older People s Strategy: 214-217: August 213 (draft, out for consultation) 6 H&WB Board: Dementia Strategy: 214-217: September 213 (draft, out for consultation) 7 MK CCG: Children & Young People s Strategy (in development) 8 MK CCG, Transforming Primary & Integrated Care: 214-219 (Working Draft), June 214 9 MK CCG Primary Care Development Strategy, 213-215, June 213 6
The CCG has organised delivery of its strategic approach and commissioning priorities through four interdependent Clinical Programme Boards, plus the Clinical Executive. The detailed focus for each board for 214/15 & 215/16 is summarised later in this document. 4. Health & Wellbeing in Milton Keynes According to the latest data, in 212 Milton Keynes Borough was home to 252,4 people, which is an increase of 37,3 (17.3%) since 21. The population is expected to continue to grow, rising by a further estimated 49,7 (another 19.7%) between 212 and 226 all of whom will require access to at least general practice and urgent care. In addition, an estimated 5, will develop long term conditions and need support and care to live well with their condition. The population is growing due to increasing life expectancy, a rising birth rate and inward migration: Average life expectancy at birth has increased steadily in recent years and is currently 78.1 years for men and 82.2 years for women. This is similar to the national average of England and Wales. The number of births has increased steadily between 21 and 212 from 2,83 to3,887 and estimated to be 3,943 births in 215. The number of people in each group is growing at a different rate. Most significantly, the population over 85 years of age is forecast to increase by 95% from 3,635 in 21 to 7,6 in 226. The population is ageing, with those aged 6 and over forecast to increase by 15% between 211 and 216 and by 26% between 211 and 221. The population of Milton Keynes is ageing faster than the national average. However the Milton Keynes population age profile is younger than that for England as a whole. 22.4% of the Milton Keynes population are aged under 16 compared with 18.9% in England. More than a quarter of people living in Milton Keynes Borough are from ethnic minority communities compared to about a fifth nationally. On average, the health of people in Milton Keynes compares favourably to the national picture and to the health of similar local authority populations. However, within Milton Keynes, there are wide gaps in health outcomes between the most and least affluent, and some small communities which are especially disadvantaged. As elsewhere in England, modern lifestyles are creating additional health problems, worse in more socioeconomically deprived areas. Obesity, smoking and alcohol misuse all place additional requirements on the NHS into the future. The major causes of death, premature death and disability in Milton Keynes continue to be cancer, cardiovascular disease and respiratory disease. Increasingly the Milton Keynes population are living with one or more Long Term Conditions. People with long term conditions are intensive users of health and social care services, including community, hospital and acute care services. The Health and Wellbeing Board is a partnership designed to ensure an integrated and coordinated approach across the NHS, social care and public health services in Milton Keynes. In its shadow form it produced the first Joint Health and Wellbeing Strategy 212 215, which will be refreshed next year. Locally, the collective system aim is to Improve the opportunities for children and adults to enjoy a healthy, safe and fulfilling life. By working together the partners aim to improve the opportunities for adults and children to enjoy a healthy, safe and fulfilling life. Drawing from the Joint Strategic Needs Assessment 213/14, the Social Atlas 211 and the latest 7
Director of Public Health Annual report1 the strategy identifies three strategic priorities that the system needs to jointly focus on over the next three years. To Reduce Early Deaths and Tackle Major Diseases To Improve Wellbeing To Reduce Health Inequalities Each priority has specific key objectives which describe the short, medium and longer term actions that are required to deliver against the priorities. The CCG has a role in supporting their delivery and this is reflected throughout this plan. The Health & Wellbeing priorities outlined in the strategy form the framework for NHS commissioning plans which the CCG needs to take forward, as its part, towards shaping how the health and care system will look in 5 years time. 5. System Vision The NHS is founded on a set of fundamental and enduring values: that the NHS should be a universal, tax-funded service, with equal access for all, free at the point of use and provided according to clinical need rather than the ability to pay. Naturally these values underpin all of the work of MK CCG, as we strive to ensure equity of access to appropriate high quality healthcare across our local population whether that healthcare be provided by an NHS body or another organisation. The challenge we face however is to ensure adequate provision of such care to meet all existing and future clinical need, within an extremely tight funding mechanism that has not always reflected the continuing growth of the Milton Keynes population. MK CCG wishes to plan and buy services that are high quality and provide the best outcomes, whilst achieving value for money for the local community. It has therefore set out four values/principles which will underpin its approach to achieving the vision set out above:- Commission services which are value for money Involve clinical leadership to make a real difference Improve quality and safety to positively impact on clinical outcomes and patient experience Develop effective engagement with stakeholders The overall vision for Milton Keynes is for a system that is as simple and straightforward as possible, with patients aware of and able to access appropriate high quality clinical care and support at the right time and in the right place, such that inequalities in access to this care are eliminated. The CCG is committed to commissioning a greater proportion of activity in community and home settings to support the required rebalancing of the health economy away from local acute services, with a real emphasis on care closer to home. This is necessary to support acute provider sustainability and to ensure that services are delivered in the best location. Far too many people currently access care in an acute hospital setting when they could be treated just as well within the community, often with less delay. Overuse of the acute sector is not sustainable because that specialist care is very expensive and as the population grows and demand rises with people living with one or more long term conditions11 it will increasingly 1 11 Milton Keynes PCT: DPH Annual Report 211, September 212 th MK & Bedfordshire CCGs: Bedfordshire & Milton Keynes Healthcare Review: A Case for Change; 9 April 214 8
become unaffordable. The current healthcare review across Bedfordshire and Milton Keynes indicates that current service provision is fragmented, difficult to navigate through and delivered through traditional models of care, emphasising the need for consideration of new ways to deliver NHS care that can deliver improved patient outcomes but within a tight financial environment. The CCG is also looking to understand where other care providers can offer support to the population at least as effectively as statutory providers. Greater emphasis on prevention and self-care are important long term strategies for the CCG. Helping those with long term conditions to take more responsibility for managing their care and using support networks outside of the NHS are important future options, and are reflected in the joint Better Care Fund Plan submission that sits alongside this plan. For those requiring on-going health and social care it will be important to further strengthen links between the statutory commissioners working closely through the Joint Commissioning arrangements. Our vision for how the whole health system should look and be working by the end of 219 is outlined in the detailed sections presented below. The results of these changes will mean:- 5.1 Improved access to and consistent quality of primary care for the population Better health and life outcomes for patients with more people able to live independently for longer with a higher quality of life. Reducing hospital admissions, particularly in the >75 age group and for ambulatory sensitive conditions Better use of the limited funding we have from the taxpayer to provide healthcare Citizen Participation & Empowerment Milton Keynes CCG is a membership organisation comprising the 27 GP practices that serve the population of Milton Keynes. Together, Board members, members of staff and patient representatives work to develop the strategic direction and to deliver the Group s commissioning plans and intentions. Being co-terminus with Milton Keynes Council supports close working with our Local Authority commissioners - this includes some joint commissioning arrangements and also public health advisers. MK CCG s Strategic Plan and specific commissioning changes are developed and implemented through four programme boards. Each board includes clinicians and patients in its membership and has a CCG member GP as Senior Responsible Owner (SRO), who is supported by a programme manager. Each programme board also meets regularly with appropriate local clinicians and managers from provider organisations as well as GP commissioners. The use of programme boards to oversee the development and implementation of the Strategic Plan and commissioning changes is in line with the NHS MK CCG approach on patient and public engagement, which is shown in the diagram below. 9
The CCG recognizes that its relationships with all our partners is evolving, including representative groups such as HealthWatch MK (the new independent consumer champion that gathers and represents the public view on health and social care services), Patient Congress (a body representing the Patient Participation Groups (PPG) that are based at GP Practices across Milton Keynes) and the Patient Advisory Forum. Additionally, work with member practices has developed ways in which to ensure they are informed and involved with the CCG work, including a Clinical Forum Group has been established. The CCG has continually strived to embed further co-operation with multi-agency partnerships where health commissioning makes a key contribution, such as the Safer MK Board which meets to assess and review joint programmes of work to reduce crime and make our city safe. The CCG has established strong relationships and close working with the Local Authority with arrangements in place for joint commissioning through the Joint commissioning Board and the Health and Well-being Board. The CCG has initiated and contributed to a number of Milton Keynes-wide forum events during the last 6 months including, as examples, the Big MK Debate, Here s HealthWatch and, more recently, a number of events as part of the Bedfordshire & Milton Keynes Healthcare Review. 5 Year Vision The CCG will be focused upon the creation of associations with key community groups and their networks, both in terms of specifically taking the Healthcare Review into the community and more broadly working in partnership with the community we serve on all areas that we commission. Through our approach to public engagement we will ensure that Milton Keynes CCG develops quality services, based around people s individual needs and aspirations and values the contributions they can make. 1
The CCG will concentrate upon: Joint working activity with MK Hospital Trust - during future public participation events and particularly with regard to clinical engagement ; Reaching a wider demographic (including those deemed as seldom heard stakeholders); Forging operational partnerships with key community groups who will enable access to their sector networks of followers, members and associates; Making use of under-used channels - such as the 27 member GP practices and their PPG groups and; Working closer with key stakeholder groups - such as Milton Keynes Council, Local Councillors, MPs and local press. We have a collective responsibility for consulting and involving the local community in the shaping and development of our services. We will work in partnership and develop our relationships with all groups and forums as an important mechanism of our engagement activity. To do this we will develop: A strong culture of involvement, improving and measuring Service user carer experience; More creative ways to capture insights and experiences From both individuals and communities; Approaches that are inclusive and accessible to all. This will ensure that the information on which we base our planning, commissioning decisions and service developments is: high quality reflective of the experiences of all service users and carers co-ordinated and centrally located skilfully analysed fed into strategic planning and service improvements acted upon fed back to all stakeholders 11
5.2 Wider Primary Care at Scale Primary care, and in particular care delivered by general practice has been a cornerstone of the NHS since its inception. Whilst GP services will be commissioned by NHS England, it will be imperative that Clinical Commissioning Groups support and encourage the development of primary care services and work jointly to ensure the way primary care is transformed fits alongside the wider aims of the overall strategic plan. Following the recent announcement by Simon Stevens12 MK CCG is submitting an expression of interest in developing an expanded role in primary care commissioning so that it can to drive up the quality of care, cut health inequalities in primary care, and help put their local NHS on a sustainable path for the next five years and beyond. It is anticipated that this co-commissioning approach will involve a mixture of the following options: A greater CCG involvement in influencing commissioning decisions made by NHS England Area Team Utilising joint commissioning arrangements for primary care with NHS England Area Team; making decisions together, potentially supported by pooled funding arrangements; Some delegated commissioning arrangements, whereby MKCCG would carry out defined functions on behalf of NHS England Area Team. Through its existing Primary Care Development Strategy13 and the Transforming Primary & Integrated Care Services Strategy14 MK CCG will therefore promote high quality and equitable primary care, creating patient pathways that are seamless, improve health outcomes and reduce inequalities, focusing on transformation which: Has a clear focus for improving overall quality. Establishes primary care at the heart of integrated care networks with other health and social care providers. Acts as the catalyst for encouraging practices to work together with a focus on enablement and empowerment, so that delivery at greater scale can be achieved. Maximises the role of information management technology to ensure practices are able to access high quality information in order to improve quality and value for money. Information drawn from the national GP Patient Survey15 indicates that locally we need to achieve improvement in:- 12 GP Access; (MK CCG currently ranked 28th out of 211 based on the ease of speaking to someone at your GP Surgery) Making Appointments; (MK CCG currently ranked in the bottom 4 CCGs in England on the proportion of patients rating their experience of making an appointment as Good) Last GP Appointment; (MK CCG ranked 2th out of 211 CCGs based on proportion of Milton Keynes stating that at their last appointment the GP was very good or good at giving them enough time) Overall Experience; (79.2% of respondents rate their overall experience of their GP Surgery as good. This compares to 86.2% nationally, 85.4% within Hertfordshire & South Midlands Area Team and 21st out of all 211 CCGs.) st NHS England Press Notice: Local Health Professionals to get more power to improve NHS Primary Care; 1 May 214 MK CCG: Primary Care Development Strategy: Achieving Excellence in Primary Care. 213-215; October 213 14 MK CCG: Transforming Primary & Integrated Care Services Strategy, 214-218 (draft); June 214 15 Ipsos MORI/NHS England: GP Patient Survey, January-March 213 13 12
Out of Hours; (Only half of patients said that they knew how to contact the GP Out of Hours Service. Just 56.7% of patient who had accessed the GP Out of Hours within the previous 6 months rated the service as very or fairly good. MK CCG was ranked 198th out of 211) Improving General Practice a) A Call to Action Interim Report This interim report describes NHS England vision for general practice, and the work needed to develop the necessary clinical and organisational models. It sets out the key ways in which this will be led locally, and then outlines the work underway nationally to support it. The report points out that in order to support its ambitions for health services, general practice will need to operate at greater scale and in greater collaboration with other providers and professionals, with parents, carers and local communities. It is suggested that such changes can be supported through networks, federations or super partnerships or more integrated models. This strategic approach supports the local ambitions set out in the CCG s Primary Care Development Strategy. Furthermore, the report sets out a number of intentions that will support the work of CCG including:1. Primary Care that can address barriers to access for vulnerable and hard to reach populations 2. Establishment of the National Network of Quality in Primary Care to develop metrics to describe quality in primary care 3. Joint arrangements between NHS England and CCGs for commissioning of general practice services including development of a national governance framework 4. Additional funding for CCGs to support accountable GPs 5. Greater clarity about different ways Area Teams and CCGs can make safe controlled investment in general practice services and variations in GMS, PMS or APMS contracts. 6. Toolkit to support CCGs and Area Teams in working with LETBs to implement workforce improvement strategies 7. Support efficient and effective use of existing community assets and the ability of CCGs to release revenue funding to support primary care developments. 8. Support practices to work through federations or networks 9. Publish a new framework to underpin decisions on practice premises in alignment with local CCG strategies 1. Improve information sharing across different providers through shared and summary care records. 11. Delegate responsibility for local operational management of general practice IT services to CCGs b) Co-Commissioning Particular emphasis of the co-commissioning relationship will be to:1. Work with NHS England to develop a remedial action plan for poor performing practices with appropriate use of contractual levers 13
2. Work with NHS England to develop a premises plan for Milton Keynes that recognises the constraints within the capacity and geography of current estates 3. Ensure the ambitions of the Enhanced Service for Reducing Emergency Admissions are fully aligned with the Transformation Funding available to primary care. The CCG expects to achieve the following through co-commissioning with NHS England: greater integration of health and care services to support more cohesive systems of out-of-hospital care raise standards of quality (clinical effectiveness, patient experience and patient safety) within general practice services, reduce unwarranted variations in quality, and, where appropriate, provide targeted improvement support for practices enhance patient and public involvement in developing services tackle health inequalities, in particular by improving quality of primary care in more deprived areas and for groups such as people with mental health problems or learning disabilities and those living in poverty. 5 Year System Vision Our vision is to create a sustainable primary care service operating on a single clinical system with collaborative working between practices. If we are to meet our overall strategic direction of delivering care closer to home then this will require a substantial shift of care from hospital to community settings. Evidence shows us that many people could be treated more locally;16 hospital based care is not necessarily the best way to care for people but with 9% of patients/users already using primary care services as their first point of contact with healthcare increased use of primary care and plans to develop 7 day working will require both additional capacity and capability, and funding. The CCG will therefore need to develop and reward innovation and quality improvement in primary care and promote and support mechanisms for improved integrated working. The NHS reforms put General Practice in a unique position as both provider and commissioner of healthcare services. There is a fine balance between these two and in Milton Keynes it is envisaged that primary care will increasingly both work collaboratively as providers of services, but also work within geographic neighbourhoods to commission appropriate range of care. The CCG is a membership organisation composed of its 27 constituent general practices. The fundamental purpose of the CCG is to improve the effectiveness of clinical care and patient experience, and develop care pathways using standardised processes where appropriate, through better understanding of activity and related costs. Member practices are encouraged to actively engage in the commissioning work of the CCG, by contributing to clinical pathway and service redesign, engaging with local communities and understanding local health needs. Services beyond core GMS will be delivered through a collaborative working approach. Like minded practices will federate to deliver an enhanced range services that move care close to home. Primary care at scale (to deliver 7days a week, 8am to 8pm) will be delivered through an integrated approach such as currently exists in MKUCS where our practices are currently members. GP as case manager / consultant at top of pyramid calling on others including nurse practitioners, Extended Scope Practitioners, mental health, social care. Single point of access to ensure coordinated response to health and social care needs. MK CCG s vision for developing excellence in primary care, delivered through the establishment of integrated Primary Care Hub & Spoke Models is shown below. 16 MK Public Health Team (S Godward); Urgent Care Needs Assessment; August 213 14
Easy access to high quality, responsive primary care Pro-active emphasis on keeping people healthy, preventing ill-health, self care and reducing health inequalities Simplified care pathways that can be delivered closer to home and promote independence Rapid Response to urgent needs so that fewer people need to access hospital emergency care Providers (social, health and third sector) working together, with the users at the centre Earlier & timely discharge planning meaning patients will spend an appropriate time in hospital when they are admitted 1 Transformed Primary Care, with Delivery at Scale North 2 Closer Integration of Community Services & Rapid Delivery 3 Elective Care Closer to Home East Community Hub Integrated Care (inc. Diagnostics/Specialists) Central Delivery Single Point of Access Health & Social Care Team Health & Social Care Team North East Hub & Spoke (inc. PCOCs & Diagnostics) Risk Stratification South South West West Practices Working Collaboratively Practice Teams Neighbourhood Delivery Source: MKCCG Alongside this is our vision for planned care which is to have a safer, more predictable and reliable planned health care system, providing a consistent quality of service that will support the delivery of more services close to patient s homes, and ensure that they are getting the right treatment for their condition. This will mean a focus on a range of methodologies that: Provide more efficient pathways for patients and ensure that they are seen in the most appropriate setting for their condition Build on the Practice Based Budgets system that was introduced in 213/14 Ensuring the right referrals putting in place systems to improve referral quality via active Referral Management System (RMS) Implementing systems that manage the whole elective care pathway. Upholding the principles of prevention, health education, self-management and informed decision making throughout. Developing and improving locally agreed guidelines and thresholds for treatments and interventions. Ensuring a much wider range of outpatient appointments is available within the community through the establishment of Primary Care Outpatient Clinics (PCOS). Encourage one stop shops which reduce significantly Follow Ups. Reduce cost of the pathways for the CCG and re-organise the clinical resource across the different care settings 15
All this means we need to commission a greater proportion of activity in community and home settings to support the required rebalancing of the health economy away from local acute services. This is necessary to support acute provider sustainability and to ensure that services are delivered in the best location. An illustration of how this would fit within the wider hub and spoke model is shown below. Primary Care Hub & Spoke Model NORTH NEIGHBOURHOOD Comprised of 7 Practices SPECIALITY Hubs for Outpatients/Treatments & Diagnostics: Urology/Urogynae/iMSK/Derma NPMC Cardiology - Oakridge MC All practices in this neighbourhood as spokes to refer the appropriate activity through RMS to the hubs in their neighbourhood SOUTH NEIGHBOURHOOD Comprised of 7 Practices SPECIALITY Hubs for Outpatients/Treatments & Diagnostics for: Gynae/Urogynae/Cardiology (already)/derma/respiratory - Whaddon MC imsk (Integrated MSK) - Parkside MC All practices in this neighbourhood as spokes to refer the appropriate activity through RMS to the hubs in their neighbourhood EAST NEIGHBOURHOOD SYSTEM WIDE Right Care, First Time and in the most appropriate settings MKCCG is planning to find efficiency gains from diverting appropriate secondary care activity to primary care,developing alternative pathways based on neighbourhoods for: Cardiology Ophthalmology Dermatology ENT Gynaecology Urology/Urogynae Gastroenterology Respiratory Musculoskeletal (integrated MSK) Comprised of 7 Practices SPECIALITY Hubs for Outpatients/Treatment & Diagnostics: Urology/iMSK/Derma - Broughton Gate Practice ENT, Gastro - MK Village MC All practices in this neighbourhood as spokes to refer the appropriate activity through RMS to the hubs in their neighbourhood WEST NEIGHBOURHOOD Comprised of 6 Practices SPECIALITY Hubs for Outpatients/Treatments & Diagnostics for: Gynae/iMSK/Cardiology FUs/Derma at Stony MC ENT at Hilltops MC Respiratory at Watling Vale MC All practices in this neighbourhood as spokes to refer the appropriate activity through RMS to the hubs in their neighbourhood Working Together Using a neighborhood approach, MK CCG will ensure that primary care can play a much stronger part at the heart of a more integrated system of community based services, including implementing new referral pathways and further integration of the primary secondary care interface. New models of care that better serve local communities in Milton Keynes will be considered and developed, specifically to:a) Improve Access By developing a joint approach between area team and primary care team to not only share the local practice audits but also to have a shared recommendations, action and facilitation plan for practices work is underway to develop this initiative further. The main focus will be to improve access and achieve better patient reported survey outcomes. Improved access will also be facilitated by the introduction and use of Practice Based Budgets (devolving of Planned Care 1st Outpatient activity and a monthly practice dashboard that gives a more complete picture of A&E usage, UCS In-Hours and OOH, 111 usage and community services usage. Practice visits to promote discussions on future models of care and proposed extensions to budgets will get practices thinking more about how they can offer their services with peer support within a more federated approach. The deep dive methodology being carried out across 4 practices (one for each neighbourhood) will help in our understanding and further planning on how access and quality of services drives demand and will also elaborate patient pathways for any improvement recommendations b) Provide Right Care First Time and in the most appropriate settings Achieving a step-change in the productivity of elective care is at the heart of our Transforming Primary & Integrated Care Services Strategy where the first tranche focuses on outpatient delivery. MKCCG is planning to find efficiency gains from 16
diverting appropriate secondary care activity to primary care and by potentially developing alternative pathways for Cardiology, Ophthalmology, Dermatology, ENT, Gynaecology, Urology/Urogynae, Gastroenterology, Respiratory, Musculo skeletal and Pain management (MSK). c) New methodologies This will provide more efficient pathways for patients and ensure they are seen in the most appropriate setting for their condition and will enable the acute setting to meet the RTT 18 week requirement, encourage one stop shops and reduce significantly Follow Ups, reduce cost of the pathways for the CCG and re-organise the clinical resource across the different care settings. d) Sharing of data and clinical records All 27 GP Practices of Milton Keynes are now on SystmOne which promotes the enhanced use of the system beyond its core functionality and a number of templates for referrals have been developed to reduce clinical variations in practice and supports care integrated around the patient. Further specialities are being considered across the next two years for updating pathways and referral thresholds e) Market development initiatives and patient choice - MKCCG plans to ensure local autonomy and flexibility with a number of pilots designed to instigate primary care as well as local providers in order to significantly improve quality and efficiency whilst increasing patient choice. A number of pathways and AQP models are being worked up as Primary Care Outpatient Clinics PCOCs f) Innovation and Research We are facilitating fresh perspective and partnerships which enhances primary care quality of services the rolling programme across the coming years of a single point of access for all elective referrals through a Referrals Management service (pilot) is one such initiative. This innovative approach, apart from ensuring right care first time, reduces clinical and referrals threshold variation and is facilitating the development of educational workstream to all GP Practices through clinical audit findings. Research and Evaluation is the cornerstone of this work and will facilitate the demonstrable evidence of improved patient outcome and integrated pathways of care. g) Improving the quality of primary care - Working in partnership with the area team of NHS England, through a Co-Commissioning model, MKCCG will define what represents a satisfactory quality standard for primary care, consult and agree this with practices and agree a clear procedure for managing unacceptable quality when it is not amenable to local facilitation and support. The Primary Care Development Team will also:i. Ensure regular monitoring and peer review through neighbourhood groups and to the CCG Board, working with the Quality Team to develop a suite of metrics / dashboard II. Pull together and share best practice sharing good ideas from elsewhere and celebrating local innovation and success h) Utilising Community pharmacy - There are 45 pharmacies in Milton Keynes. They provide services to patients who walk in without the need for registration. These services include dispensing, repeat dispensing, receipt of unwanted medicines for safe disposal, support for self-care, health promotion, signposting to other service provision and clinical governance.) Pharmacies are located across the area providing good access to all patients. Nobody in Milton Keynes has to travel more than 5 miles to reach pharmaceutical services and 9% travel less than 2 miles to a pharmacy. Pharmacies provide services across the week from early morning (6.am) until midnight Monday to Saturday and also over several hours on a Sunday. The extended opening of the five 1 hour pharmacies is valued. 17
The CCG will explore opportunities to work with community pharmacy to ensure it is an integral part of medicines optimisation, helping patients with long term conditions get the best out of their prescribed medicines and supporting patients to prevent ill health and treat minor illness. Specific areas of focus will include projects seeking to: Avoid inappropriate use of Urgent Care for forgotten repeat medication requests Avoid inappropriate use of Urgent Care for minor ailments, exploring the opportunity afforded by placing a pharmacist within the Urgent Care Service Facilitate timely discharge where complex medicines support is required Medicines optimization to support people to stay well and avoid hospital admissions Workforce The transfer of activity from acute hospital settings to the community, plus demographic changes will increase the workload in primary and community care. Activity going into services in these settings will increase and the workforce that will need to be in place to respond will increasingly become more multidisciplinary in nature. However GP resources as we know them now are likely to reduce over the next 5 years, leading to a potential shortfall. Addressing the projected GP shortage will require efficient and innovative ways of working, focussing on 3 key levers:1. A CHANGE IN SKILL MIX 2. UTILISE TECHNOLOGY SOLUTIONS TO INCREASE PATIENT FACING TIME 3. PROMOTING SELF-CARE What will it look like? From Transformed primary care & elective care closer to home Variations in performance and quality across practices Challenges in accessing primary care at times & location convenient to patients Fragmented Care Pathways and multiple patient hand-offs To Consistent quality regardless of where and how people access services Access to primary care services 7 days a week, 12 hours a day Pro-active care and support within the community and a focus on self-care The model will ensure delivery of beyond core GMS services, in a collaborative or federated arrangement. Enhanced services delivered through this model would include: Access to diagnostics Vertical integration across a continuum of care with Community nurses attached to practices; delivering same range and quality of acre Integrated health and social care teams comprised of health and social care professionals from primary and community care based around GP localities supporting patients with complex needs. Neighbourhood mechanisms for monitoring information, performance and quality developments. Seek to broaden training opportunities for nurse development and AHPs. 18
5.3 Modern Model of Integrated Care For the 5% of patients with multiple, often complex mental or physical long-term conditions, frequently compounded by being elderly and vulnerable, there needs to be a modern model of integrated care. Milton Keynes has a long history of joint working, and has a number of integrated services: Intermediate Care; Mental Health; Learning Disabilities; Integrated Community Equipment services and a Joint Commissioning team. Work is ongoing to further develop integrated services to better meet the needs of older people and those with long term conditions and/or physical disabilities. The whole system has agreed to support a specific programme focussing on services for Vulnerable Older patients and a joint system director post is in post. Implicit in the Joint Health and Wellbeing Strategy is the empowerment of Milton Keynes residents to be supported to help manage their own health and wellbeing through the commissioning and delivery of integrated, person centred services, which place the individual at the heart of service delivery. The Better Care Fund (BCF) is an opportunity for the CCG and Council, working in partnership, to transform local services so that people are provided with better integrated care and support. It encompasses a substantial level of funding to help local areas manage pressures and improve long term sustainability. Guidance on developing plans for the Better Care Fund were published by both NHS England and the Department of Communities and Local Government on 2th December 213 along with local allocations of the first full year of the fund in 215/16. A Milton Keynes BCF Plan17, outlining how locally we will use this initiative to deliver improved integrated care for the population was submitted on 3th April and further detail is outlined in Section 1. 5 Year System Vision Our vision for integrated care in Milton Keynes is to improve the experience of, and access to, health and social care services for citizens. More citizens will report that their quality of life has improved as a result of integrated health and care services. The number of citizens remaining independent in the community, including after hospital admission will increase with improved and seamless transfers of care. To deliver this vision we will undertake an extensive system wide programme of change that will see local services reshaped to deliver joined up care. The emphasis on integration will be focused on:- 17 Services that are configured to support people to live independently in their own home, within their local communities, wherever possible. This will be our default option for service delivery. Acute care as an inpatient, will be as short as clinically appropriate for that individual. Capacity will be developed in community health and social care services to meet the delivery of this objective and will be provided by a full range of statutory and voluntary and community organisations. More effective partnerships will be developed with housing providers, employment services, transport and leisure services to enable people to improve their quality of life and improve wellbeing. GPs will be central to organising the co-ordination of people s care and will work in a seamless integrated way with health and social care providers to better manage care and treatment of patients. This will be achieved through implementation of the national Enhanced service and the additional case management role that will be developed for the over 75 s. Self-care and self-management of an individual s health will be encouraged and people will be supported to develop strategies for managing their health and independence, including access to a range of preventative, early intervention services to support people to pro-actively manage their health. th MK CCG/MKC: Better Care Fund Plan 214-218: Final Submission; 3 April 214 19
Supporting services such as telehealth, telecare and community equipment will be strengthened to support independence. Rehabilitation and re-ablement will be offered to everyone. We are clear that everyone has the potential for restoring some level of physical and mental functioning. There will be integrated commissioning of services through a single pooled budget (facilitated through the Better Care Fund) and delivered through integrated health and social care teams. These teams will be configured so that they support people either on: a short term basis i.e. to deliver rehabilitation and reablement to help people regain confidence and previous levels of functioning or to provide support for physical health at home until reablement can be commenced. or on a longer term basis for people with more complex health and social care needs that may require more intensive support over a longer timeframe especially when they have an exacerbation of their condition. In the next five years it is expected that the demand for high cost secondary care (acute hospital) services will reduce as the service offer delivered in primary care, community care and social care settings will increase, as shown in the diagram below. Through the development of self-management and preventative services, ill health can be better managed at an earlier stage, and linked in to community based rehabilitation and reablement services to provide intensive support over the short term with a view to restoring people to independence. Integrated Model GP & Primary Care Rehabilitation Short Term (< 6 weeks) Hospital Discharge Integrated H&SC complex care teams (inc neuro); Res and Nursing care; Extra care Integrated Supportive Services On-going Care Longer Term (> 6 weeks) Individual s Home (e.g. Equipment, Wheelchairs, 3rd sector services, carers support services, Telehealth) Triage & Assessment? IH&SC Member Risk Stratification Including Intermediate Care; Social care and NHS integrated teams; Convalescence @home Workforce Delivering a new model of integrated care will require a significant shift in the make-up of the entire community workforce. Increasingly individuals and organisations providing care will need to work in cross-organisational teams, with a workforce equipped with skills to span traditional professional boundaries. Increases in nursing capacity 2
across both primary and community care will be required to deliver the models of care outlined, along with a more diverse range of support staff. Regardless of which organisation or provider staff members will be employed by, all will need to deliver care in the setting where it is needed and manage risk within a devolved structure. What will it look like? From Integrated Care for LTC & Frail Elderly To Fragmented services leading to duplication of effort and allowing people to fall through the cracks People kept longer in hospital because appropriate services are not in place for them to return home Pro-active support and a focus on self-care Fully integrated health, social and mental health teams to provide a seamless service to patients tailored to their needs Discharge planning commences at admission Range of home-based care & support services The model will help the system to move from fragmented services and delivery for people with long term conditions and vulnerable older people, to a system of integrated care providing seamless care that can be tailored to the needs of patients, and which supports significant admission avoidance and a proactive focus on self-care. Specifically it will: Reduce the demand for high cost secondary care (acute hospital) services as the service offer delivered in primary care, community care and social care settings will increase. Through the development of self-management and preventative services, ill health will be better managed at an earlier stage, and linked in to community based rehabilitation and re-ablement services to provide intensive support over the short term with a view to restoring people to independence. Configure services that support people in their own homes and local communities wherever possible, delivered on a 7 day a week basis. The use of services in the secondary care (acute) sector is essential for those people that need them where community, primary and social care services cannot meet the (acute) healthcare need. Delivery of a range of services, but with the following common objectives: Focused on improved outcomes, not solely on activity Promote individual independence for all Improving the experience of patients/service users and carers Reduce delayed transfers of care by the development of a range of community based services that can meet a range of needs for post-hospital support. The extension of rehabilitation and re-ablement to people with dementia The links between physical health and mental health are well known, although our services continue to work in silos. Services (Relationships) will be strengthened to deliver the objective of no health without mental health 21
A reduction in the rate of emergency admission to hospital and the number of permanent placements to residential and nursing care Support early intervention, identifying people who may need support before a crisis Case management and co-ordinating care to ensure people are cared for in the most appropriate environment by the most appropriate professional Partnership Delivery Initial delivery will be implemented under the auspices of the Better Care Fund Working Group (title to be confirmed) which will comprise of commissioners, service providers and key stakeholders. This working group will be responsible for the day-to-day management of the implementation of the proposals within the BCF and will report on progress to the Joint Commissioning Board, using established Programme and Project Management tools and techniques. It is also proposed to establish individual work streams for each of the proposals to ensure focused dedicated effort to implementation. The diagram below outlines the governance framework. The Health and Wellbeing Board will retain oversight of progress, and monitor performance and achievement of outcomes. Reports will be produced on a quarterly basis to outline progress, identify risks to delivery and outline mitigation action to ensure delivery remains on track. The CCG and Local Authority will satisfy themselves through their individual governance arrangements that they are meeting the BCF requirements and monitor performance and outcomes, and report any issues, risks, achievements to the Joint Commissioning Board The current Section 75 monitoring arrangements between Milton Keynes Council and Milton Keynes CCG to oversee Joint Commissioning will be reviewed to ensure that they are robust and able to meet the financial and governance requirements of the new fund. The Joint Commissioning Board will have the responsibility for ensuring the BCF proposals are delivered, risks identified and mitigation action specified and implemented. The JCB will also oversee the risk share agreements and monitor the progress on key specified performance indicators and report this to the Joint Health and Wellbeing Board. 22
5.4 Access to Highest Quality Urgent & Emergency Care Urgent and emergency care is the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly. Everyone in Milton Keynes deserves access to the highest quality urgent and emergency care. The report on the first phase Urgent & Emergency Care Review18 sets out an exciting vision for how we deliver NHS Services in a way that can complement current and future demand for and usage of these services. In line with that national vision, Milton Keynes CCG will need to develop a local approach that can treat an increasing proportion of people as close to home as possible, whilst recognising that greater specialism will mean significant changes to how current hospital based emergency care may be delivered. 5 Year System Vision The overall vision for urgent and emergency care in Milton Keynes is for a system that is as simple and straightforward as possible, with patients aware of and able to access appropriate high quality clinical care and support at the right time and in the right place, such that inequalities in access to this care are eliminated. Urgent and emergency care commissioning within Milton Keynes is currently implemented through a well-established Urgent and Emergency Care Working Group, and in line with its Urgent Care Strategy19. All citizens deserve access to the highest quality urgent and emergency care and local commissioning seeks to ensure that : Services are value for money Clinical leadership is involved to make a real difference Improvements in quality and safety are made that positively impact on clinical outcomes and patient experience Effective engagement is sought and undertaken with stakeholders The vision for urgent and emergency care provision going forward must incorporate economies of scale and improved integration to decrease the number of entry points into the system, whilst recognising and progressing the recommendations from the first phase of the national Urgent and Emergency Care 18 19 NHS England, Urgent & Emergency Care Review: November 213 MK CCG: Urgent & Emergency Care Strategy 213-216, October 213 23
review.2 Firstly, for those people with urgent care needs we should provide locally a highly responsive service that delivers care as close to home as possible, minimizing disruption and inconvenience for patients and their families. For those people with more serious or life threatening emergency care needs, we should ensure they are treated in centres with the very best expertise and facilities in order to maximise the chances of survival and a good recovery. This may need to be outside of Milton Keynes. The core care components required within the local urgent and emergency care system are shown in the diagram below. Local transformation of urgent care services within Milton Keynes during the next 5 years will focus on how organisations can translate local needs and national policy/guidance into local action to improve the value and quality of urgent and emergency care in Milton Keynes, specifically to: Increase the number of people who can be cared for in an out of hospital setting, by providing care closer to home Deliver further integration of health & social care provision Reduce the growing demand for urgent and emergency care presenting at hospital site. Reduce the variation in response to urgent and emergency care between in hours and out of hours. Improve quality and responsiveness of GP access across Milton Keynes primary care. Workforce Where emergency hospital care is required, the best healthcare systems provide access to highly trained clinicians who are exposed to the numbers and range of patients required to develop and maintain their skills. An increasing 2 NHS England: Urgent and Emergency Care Review, August 213 24
trend in how hospital based care is delivered will mean a reduction of general clinicians, and increasing numbers of specialist or sub-specialist staff concentrated in specific locations, allowing them to see sufficiently high number of patients and effectively utilise expensive equipment. The type and nature of workforce for urgent care services will therefore be heavily dependent on the patient pathway across the spectrum of urgent care. But greater urgent care skills will be required in more community based settings. What will it look like? From Rapid Response to Urgent Health Needs Multiple overlapping services leading to confusion over how to access care Limited access to non-acute services out of hours To Single point of access for urgent care services Access to a range of health and social care professionals depending on need The model will help the system to move from fragmented services, to a system in which it is possible to:- 5.5 Increase the number of people who can be cared for in an non-hospital setting, by providing care closer to home Deliver further integration of health & social care provision Reduce the growing demand for urgent and emergency care presenting at hospital site. Provide a common front door ) with appropriate services in close proximity for patients, such that, upon entry, they can be triaged by a healthcare professional to the correct pathway of care for their problem. Commission an ambulance service which triages patients who call their service, and can respond to these calls appropriately, but differently. Paramedics and Emergency Care Practitioners (ECPs) are in a prime position to clinically triage patients and bring in other health and social care professionals as required, rather than taking all patients to an acute hospital. Reduce the variation in response to urgent and emergency care between in hours and out of hours. Improve quality and responsiveness of GP access across Milton Keynes primary care. Increase Productivity in Elective Care For people who need episodic, elective care, access to those services must be designed and managed from start to finish removing error and maximising quality. For many existing patient pathways and referral routes into services, providers are not necessarily delivering them to extract maximum productivity and if we are going to transform hospital care, look to concentrate specialist services on fewer sites, and deliver more care closer to home then the CCG needs to review how to deliver routine elective care. The provider landscape in Milton Keynes is evolving and will experience significant shifts over the next 2-3 years. For example the outcomes of the Bedfordshire & Milton Keynes healthcare services review of acute services reconfiguration will undoubtedly mean future changes in locally provided acute services. Milton Keynes Hospital became a foundation trust in 27 but is increasingly competing with four other main hospitals 25
within 3 minutes drive of Milton Keynes, and with the national drive to concentrate services for less common disorders e.g. stroke, cardiac surgery, rare cancers in fewer centres of excellence, the traditional role of the District General Hospital is likely to be required to change. 5 Year System Vision Our vision for planned care is to have a safer, more predictable and reliable planned health care system, providing a consistent quality of service that will support the delivery of more services close to patient s homes, and ensure that they are getting the right treatment for their condition. This will mean a focus on a range of methodologies that: Provide more efficient pathways for patients and ensure that they are seen in the most appropriate setting for their condition Build on the Practice Based Budgets system that was introduced in 213/14 Ensuring the right referrals putting in place systems to improve referral quality via active Referral Management System (RMS) Implementing systems that manage the whole elective care pathway. Upholding the principles of prevention, health education, self-management and informed decision making throughout. Developing and improving locally agreed guidelines and thresholds for treatments and interventions. Ensuring a much wider range of outpatient appointments is available within the community through the establishment of Primary Care Outpatient Clinics (PCOS). Encourage one stop shops which reduce significantly follow ups. Reduce cost of the pathways for the CCG and re-organise the clinical resource across the different care settings All this means we need to commission a greater proportion of activity in community and home settings to support the required rebalancing of the health economy away from local acute services. This is necessary to support acute provider sustainability and to ensure that services are delivered in the best location. However, this is not simply a strategy to support a rebalancing of resources within the NHS the CCG is also looking to understand where other care providers can offer support to the population at least as effectively as statutory providers. MKCCG needs to find efficiency gains from diverting secondary care activity to Primary care and by developing pathways that offer an alternative to traditional hospital care for: Cardiology Ophthalmology Dermatology ENT Gynaecology Urology/Urogynae Gastroenterology Respiratory Musculo skeletal and Pain management (MSK) 26
Workforce Where planned hospital care is required, the best healthcare systems provide access to highly trained clinicians who are exposed to the numbers and range of patients required to develop and maintain their skills. An increasing trend in how hospital based care is delivered will mean a reduction of general clinicians, and increasing numbers of specialist or sub-specialist staff concentrated in specific locations, allowing them to see sufficiently high number of patients and effectively utilise expensive equipment. The type and nature of workforce for planned interventions will therefore be heavily dependent on the patient pathway across the spectrum of elective care. What will it look like? From Efficient Planned Care which is provided closer to patient s homes 5.6 To Fragmented pathways of care, with duplication of effort Inconsistent referral processes from primary into secondary care Overlapping service provision Streamlined care pathways and referral routes into services, with reduced patient hand offs. Increasing no. of elective services delivered in primary care settings Sustainable Hospital Services The most significant aspect of planning for the long term future of hospital services is the review of healthcare services across Bedfordshire and Milton Keynes. MK CCG is working with Bedfordshire CCG and three national partners (the NHS Trust Development Authority (NTDA), NHS England (NHSE) and Monitor) to conduct a review of hospital and community health services across Bedfordshire and Milton Keynes, with the aim of developing stronger, more resilient local healthcare. Health services in both areas are under pressure from an ageing and expanding population. Local people rely on hospitals that have faced clinical and financial challenges for many years. Both CCGs are already taking steps to deliver better integration of services, and to deliver more care closer to patient s homes. They have also made strides in putting patient and public views and experiences at the centre of decisions to commission and provide local services and local stakeholders now expect to be an integral part of plans and decision making around new and changed services. MKCCG recognises that the size and scale of the clinical and financial challenge at both local hospitals warrants the help of the national partners and international clinical experts who can work together to secure the future of local hospitals and health services. From January to July 214, all five organisations will work together to develop a set of models for healthcare provision that could offer safe, sustainable, high quality care for local people. 5 Year System Vision Local NHS hospital services have been built up incrementally in Milton Keynes, evolving gradually to deal with changing health needs, clinical standards and public expectations. This has produced some services and pathways that may now not be right for delivering the care patients need today or may need in the future. The Healthcare 27
Review21 being conducted across Milton Keynes & Bedfordshire is currently in its final stages and aims to produce a range of options for delivering affordable high quality healthcare, now and into the future, for the population. At its heart is the aim to transform and redesign services so that: People can be supported to take better care of themselves, lead a healthier lifestyle, understand where and when they can get treatment if they have a problem, understand different treatment options, and better manage their own conditions with the support of healthcare professionals if they wish Older, frailer people are supported on a 24 hours a day, seven days a week basis to maintain their health, dignity and independence at home When someone has an urgent healthcare need, they can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face to face consultations in local, easily accessible facilities as close to home as possible If they need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-ordinating the delivery of their health care If they need to be admitted to hospital, it will be only when they require acute specialist interventions that cannot be delivered in community settings, and then it will be to a properly maintained and up-to-date facility where they receive care delivered by highly trained specialists available seven days a week with the specific skills needed to treat them. When completed, the review will generate a set of options (possibly up to 5) for delivering sustainable, high quality services for the people of Milton Keynes and Bedfordshire that the CCGs will be able to put to public consultation. Specifically it will provide options for sustainable delivery healthcare for adults and children related to: Maternity & Childbirth Planned Care Modern Emergency & Urgent Care Workforce As currently organised, hospital services will find it increasingly difficult to meet the Royal Colleges standards for how to deliver high quality care and to recruit into the different clinical roles that currently exist. Workforce shortages and the current lack of effective integration between providers will mean that new models of working across clinical areas will need to be found and agreed. Specialist or sub-specialist staff are likely to be concentrated in fewer locations, this will have implications not only for hospital based care, but primary and community care too. What will it look like? From Sustainable Hospital Services for the future 21 Fragmented, inequitable service provision Variable quality of care and safety Clinical workforce shortages To GP Coordinated Care, increasingly supported by community level services Patients admitted to hospital only for acute specialist interventions Hospital care delivered by highly trained staff Bedford CCG/MK CCG/McKinsey: Bedfordshire & Milton Keynes Healthcare Review: A Case for Change, April 214 28
6. Transformation & Delivery MK CCG s commissioning, transformation and overall delivery is currently overseen and implemented through four clinical programme boards: urgent care board; care pathways & primary care board; mental & learning disabilities health board (jointly with MKC;) maternity, children & young people board; and also the clinical executive (for primary care). Each programme area is responsible for ensuring that both local and national focus is considered and acted upon. The CCG has established itself as a clinically led, innovative, forward thinking CCG with a culture committed to delivering high quality care to the communities it serves. However, fulfilling the long term ambitions of the NHS, as outlined in the latest planning guidance22 will mean that CCGs must drive forward a change in the way that health services are delivered. Therefore, given the local needs, system vision, strategic priorities and wider context set out above, the local focus for commissioning, transformation and driving continuous improvement by Milton Keynes CCG will centre on 3 key areas. They are:- 1. Avoiding time spent in/referrals to hospital, if it is not necessary 2. Improving patient flows within and through secondary care settings 3. Promoting independent living, with better, more integrated care outside of hospital Steps we take in transforming and developing services in the next couple of years must ultimately ensure that we have local models of care that will apply to the needs of the population in 5 years time. As a CCG, we are mindful of the 5 key themes for service development and change which have arisen from the NHS England s A Call to Action 23 programme. Our programme boards transformation and improvement intentions for the next 5 years are summarised within this section. Further detail is shown in Appendix A, along with their commissioning impact in terms of QIPP & activity changes. 6.1 Urgent Care Strategic Direction: MK CCG Urgent & Emergency Care Strategy 213/216 Principles for Change Ensure patients receive the right care, first time Improve the flow out of the hospital Reduce variation in response to care needs between in-hours and out of hours Aims of the Programme Board: 1. To improve the experience and outcomes for people who use urgent care services 2. To provide whole system leadership, assurance and ownership to ensure achievement of the 4 hour standard for A&E 3. To eliminate waste and improve overall quality 4. To increase integration 5. To review and redesign services 22 23 NHS England: Planning for Patients 214/15 to 218/19. NHS England: A Call to Action: July 213 29
Work Plan 214-219 includes: Commissioning Intervention/Intention Change Delivered from 1. Implement physical Common Front Door option for A&E and Urgent Care services Sept 214 2. High Impact Team for Nursing & Care Homes April 214 3. Reduction in ambulance dispatch using Hear & Treat & NHS Pathways Triage April 214 4. Structured Promotion of 111 & Self Care April 214 5. Improved Discharge Process across system April 214 6. High Impact Team for frequent fliers April 214 7. Adjusted Clinical Model for Urgent Care Services behind Common Front Door 216-217 6.2 Care Pathways & Primary Care Strategic Direction: MK CCG Transforming Primary & Integrated Care Strategy (currently in development) MK CCG Primary Care Development Strategy, 213-215 MKC & MK CCG Better Care Fund Plan, 214-218 MKC & MK CCG Older People s Strategy, 213-216 MKC & MK CCG Dementia Strategy Principles for Change Ensure patients receive high quality consistent care Ensure patients receive the right care, first time Bringing care closer to home Driving integration at scale and pace. Standardise and communicate what primary care should provide for patients with long term conditions. Commission pathways that are in line with NICE Guidance or for the best outcomes available. Commission a One Stop Shop approach wherever possible. Aims of the Programme Board are: 1. 2. 3. 4. 5. 6. 7. 8. 9. To improve the experience and outcomes of people who use our services To eliminate waste and improve overall quality To increase integration To review and re-design services Preventing people from dying prematurely Enhancing quality of life for people with long term conditions Empower patients to manage their own conditions Supporting people to recover from episodes of ill-health or following injury Enabling and supporting people in Milton Keynes to die in their place of choice 3
Work Plan 214-219 includes: a) Primary & Planned Care Commissioning Intervention/Intention Delivered by 1. Implementing a Referrals Mgt Gateway February 214 Onwards 2. Development & Improvement of MSK Pathways (including Pain Mgt & PLCV) June 214 3. Development of Managed Care for Ophthalmology May 14 4. Implement Practice Based Budgets January 214 onwards 5. Re-commission Patient Transport Services Dec 214 onwards 6. Introduction of Second Tier Pilot in Dermatology April 214 onwards 7. Improved efficiency in C2C and Follow Ups From April 214 8. Direct to Test Oscopies April 214 9. Primary Care Collaboration/Federated Working 216-219 1. Expansion of Elective Care/Diagnostics Closer to Home 217-219 b) Integrated Care Commissioning Intervention/Intention Delivered by 1. Review and implement changes to Respiratory pathways. March 215 2. Review and implement changes to Circulation pathways. March 215 3. BCF Integrated Health & Social Care Teams Pilot Model in 214/215 Full implementation by March 216 4. BCF 7 Day Working for Intermediate Care March 215 5. Assertive In Reach & Discharge Team Pilot Model in 214/215 Full implementation by March 216 6. Introduce a Year of Care Tariff 218-219 7. Vertical Integration of Services - Adults 216-219 6.3 Mental Health & Learning Disabilities Strategic Direction: MKC & MK CCG Mental Health Strategy, MKC & MK CCG Dementia Strategy 31
Principles for Change Commission a shift of care from acute inpatient care to preventative and recovery based wellbeing services in the community Commission pathways that are in line with NICE Guidance or for the best outcomes available Commission services that are increasingly focussed on individual packages of treatment and care Aims of the Programme Board are: 1. To improve the experience and outcomes for people who use services 2. To ensure that people can stay well 3. To ensure that when people become unwell, they receive the right care in the right place, getting better, quicker, effective and appropriate interventions delivered in a timely and personalised way. 4. To increase integration 5. To review and redesign services Work Programme for 214-19 includes: Commissioning Intervention/Intention 1. Early Intervention for Eating Disorders Local Service 2. Improving the Capacity and Quality of Inpatient Mental Health Services 3. Improving access to Psychological Therapies (IAPT) 4. Review of ASTI Specifications 6.4 Delivered by Initial benefits will be realised in first 12 months 31st March 214 Gradual increase in access numbers as capacity increases with achievement of target by end March 215 From April 214 Maternity, Children & Young People Strategic Direction: MKC Children & Young People s Plan, MK CCG Maternity, Children & Young People s Strategy (to be developed) Principles for Change Promote integration and collaborative working Commission pathways that are in line with NICE Guidance or for the best outcomes available Strengthen prevention to avoid the need for acute health and social care Aims of the Programme Board are: 1. 2. 3. 4. To improve the experience and outcomes for people who use services To deliver quality service that provide demonstrable value for money To benchmark services with best practice in comparable areas To commission care pathways that reflect the intent to avoid admissions to hospital and advice to allow children to be cared for in the community or close to home. 32
5. To focus on prevention and providing universal, accessible services with targeted care 6. To review and redesign services Work Programme for 214-19 includes: Commissioning Intervention/Intention Delivered by 1. Implementing 5 High Impact Pathways for children 2. Improving Local CAMHS Service 3. Implement Intermediate Gynaecology Services 4. Vertical Integration Children s Services 5. Review of Maternity Services 214/15 Q3 April 215 214/15 Q1 216-219 217-219 7. Governance MK CCG s commissioning changes are currently implemented through its programme boards - urgent care; planned & primary care; mental health & learning disabilities (jointly with Milton Keynes Council); children, young people and maternity; long term conditions and clinical executive support - and through work in the four neighbourhood quality & performance groups. Each board includes clinicians and patients in its membership and has a CCG GP as Senior Responsible Owner (SRO), who is supported by a programme manager. All programme SROs are accountable to the Commissioning Decisions Group (CDG) and through this to the MK CCG Board (see diagram below). Included within the remit of the programme boards is responsibility for the development of the annual QIPP, including monitoring of each programme board s delivery against their plan and provision of programme and project management advice to the clinicians and staff involved. The governance structure for delivery is shown below:- Clinical Federation of Member Practices NHS MK CCG Board NHS MK CCG Leadership Team EXTERNAL RESOURCES Stakeholders NHS MK Commissioning Delivery Group Commissioning Support Hub Joint Commissioning Team Advisory Service Providers Health & Wellbeing Board Clinical Networks Partner Organisations Patient Congress Practice Participation Groups Programme Management Office Mental Healthcare Learning & Disabilities Programme Board Healthwatch Care Pathways & Primary Care Programme Board Urgent Care Working Group Children Young People & Maternity Programme Board NHS Milton Keynes CCG Management Framework Internal Decision Making Structure The CCG is currently implementing a more formalised Programme Management Office (PMO) approach to monitoring implementation and delivery of its commissioning business. Part of the remit of the PMO is implementing Portfolio, Programme and Project Management (P3M) a best practice methodology employed widely by the NHS to support the integral part of its strategic process. P3M is a systematic approach that MK CCG will use 33
to deliver business strategy with visibility of financial, governance and quality/performance control. P3M links the business strategy with programmes and projects to drive strategic change. Working at various levels within the organisation the MK CCG PMO will underpin the project delivery mechanisms by ensuring that all key projects (especially QIPP & transformational change) are managed in a controlled way by providing: Governance: ensuring that decisions are taken by the right people, based on the right information. The governance role can also include audit or peer reviews, developing project and programme structures and ensuring accountability. Transparency: providing information with a single source of the truth. Information should be relevant and accurate to support effective decision-making. Reusability: stopping project teams from reinventing the wheel by being a central point for lessons learned, templates and best practice. Enabling project delivery maturity. Delivery support: Looking at streamlining project processes, providing training, mentoring and quality assurance. Management of Risk: working with project teams to identify risks at project level, sharing and escalation. Traceability: providing the function for managing documentation, project history and organizational knowledge. This will enable auditing and knowledge management. A simple tool, used by the PMO to track progress is shown in Appendix H. This will store all of the strategic projects mapping their progress against timelines, budget, change management and risks. This approach enables swift action/escalation when potential exceptions occur, and clearly shows when the project delivery is not on target. 8. Improving Quality & Outcomes The NHS Mandate to the NHS Commissioning Board was published on November 13th 212. This is structured around five key areas where the Government expects the NHS to make improvements: 1. 2. 3. 4. 5. Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring that people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm. These improvement priorities also represent the five domains of the NHS Outcomes Framework and the CCG will measure its progress through the nationally mandated indicator set alongside robust governance arrangements to ensure that operational progress is continually made and improved outcomes are delivered. 8.1 OUTCOMES AMBITIONS Within the five domains in the NHS Outcomes Framework, NHS England identified the measures best placed to provide assurance in planning and delivery, where CCG data exists and a baseline could be determined. Milton Keynes CCG is required to ensure delivery of the following seven outcomes ambitions, which have been determined based on local needs outlined in the JSNA. Performance against the following standards will be reported to the Commissioning Delivery Group (CDG) every month and CCG Board bi-monthly. In addition, the local Quality Premium ambition will also be monitored. The specific year trajectories for improvement are shown in Appendix B. 34
a) Securing additional years of life for the local population, with treatable mental & physical conditions measured by:potential Years of Life Lost (PYLL) from conditions amenable to healthcare b) Improving the health related quality of life of people with one or more long-term conditions measured by:health related quality of life for people with long-term conditions (EQ5D tool GP Survey) c) Reducing the amount of time people spend avoidably in hospital through better, more integrated care measured by:reduction in Emergency Admissions (composite rate) d) Increasing the proportion of older people living independently at home following discharge from hospital, measured by:no indicator currently available at CCG Level (tbc) e) Increasing the number of people having a positive experience of hospital care, measured by:patient Experience of Hospital Care Survey f) Increasing the number of people having a positive experience of care outside hospital in general practice and the community, measured by:patient Experience of Primary Care (composite rate) g) Making significant progress towards eliminating avoidable deaths in our hospital, caused by problems in care, measured by:indicator in development The importance of achieving these outcome ambitions in Milton Keynes, in relation to the needs of the local population as set out in the JSNA, the objectives of the Health & Wellbeing Strategy and how partners will work collectively together within the system to deliver key agreed milestones is shown in the diagram below. 35
H&WB Strategy Objective 3 INCREASE UPTAKE OF SCREENING INCREASE NO. OF NHS HEALTH CHECKS IMPROVE EARLY DIAGNOSIS & TREATMENT H&WB Strategy Objective 2 IMPROVE ACCESS TO PSYCOLOGICAL THERAPIES MOTIVATE PEOPLE TO ENGAGE IN HEALTHIER LIFESTYLES H&WB Strategy Objective 1 & 5 H&WB Strategy Objective 5 SUPPORT MANAGEMENT OF LTC PERSON CENTRED CARE PLANNING MOTIVATE PEOPLE TO ENGAGE IN HEALTHIER LIFESTYLES INTEGRATION OF HEALTH & SOCIAL CARE H&WB Strategy Objective 3 & 5 PERSON CENTRED CARE PLANNING INTEGRATION OF HEALTH & SOCIAL CARE H&WB Strategy Objective 3 INCREASE UPTAKE OF SCREENING PERSON CENTRED CARE PLANNING H&WB Strategy Objective 3 INCREASE UPTAKE OF SCREENING INCREASE NO. OF NHS HEALTH CHECKS IMPROVE EARLY DIAGNOSIS & TREATMENT Indicator E.A.1 Quality Premium Measure The latest performance data indicating progress of the CCG is shown in the table below. E.A.2 E.A.3 Description PYLL from Causes Considered Amenable to Health Health-Related Quality of Life for People w ith LTCs Improved Access to Psychological Services (IAPT) Roll-Out E.A.4 Emergency Admissions Composite Measure E.A.5 Patient Experience of Hospital Care (MKHFT) E.A.6 Friends and Family Test -Score (MKHFT) E.A.7.i Patient Experience of Primary Care -GP Services E.A.7.ii Patient Experience of Primary Care -GP Out of Hours E.A.8 Hospital Deaths Attributed to Problems in Care E.A.9 E.A.S.1 Target / Plan YTD Plan Latest Period YTD Below 2,96.5 1,926.9 (212) (211) baseline Above.75 (Jul11.76 (Jul12-Mar13) Mar12) baseline Above 3.75% in 2.52% 9.22% Q4 214/15 (Q4) Below 1,95. 197.2 (212/13) (211/12) baseline Below 172.8 181.5 (212/13) (214/15) 54 (Apr68 N/A 54 14) Above 83.1% 79.2% (Jan13(Jul11-Mar12) Sep13) Above 62.3% 56.7% (Jan13(Jul11-Mar12) Sep13) Indicator in development. Should be published Autumn 215. Trend Improving the Reporting of Medication-Related Safety Incidents Estimated Diagnosis Rate for People w ith Dementia Above 44.% (213/14) Above 5.% (214/15) E.A.S.2 Improved Access to Psychological Services (IAPT) Recovery Rate E.A.S.3 Proportion of People (65+) Still at Home, 91 Days after Discharge from Hospital into Reablement/Rehabilitation Services E.A.S.4 Healthcare Acquired Infection Measure (MRSA) E.A.S.5 Healthcare Acquired Infection Measure (Clostridium Difficile) 44 3 43.6% (212/13) 37.81% (Q4) 38.22% 7 (Apr14) 7 (Apr14) Trend Key: = Little or no change, = Improvement, = Deterioration 36
8.2 NHS CONSTITUTION MEASURES Milton Keynes CCG plans to ensure that the requirements of the NHS Constitution are delivered to the local population. The CCG has put in place robust governance arrangements to ensure that all performance measures required by the NHS Constitution are delivered and any performance issues addressed with providers in a timely fashion. Current CCG performance against these measures is shown below. Performance against the following standards will be reported to the Commissioning Delivery Group (CDG) every month and CCG Board bi-monthly. The activity measures against which CCGs will be monitored are contained in Annex C of Everyone Counts: Planning for Patients 214/15 to 218/19. Description YTD Target Lower Threshold Indicator Quality Premium Measure Activity Measures 358 N/A E.C.1 Elective Ordinary Admission First Consultant Episodes* E.C.2 Daycase First Consultant Episodes* 1,98 N/A E.C.3 Elective Finished First Consultant Episodes* 2,338 N/A E.C.4 Non-Elective Finished First Consultant Episodes* 2,344 N/A E.C.5 All First Outpatient Attendances* 4,172 N/A E.C.6 All Subsequent Outpatient Attendances* E.C.7 Number of Attendances at Type 1 A&E Departments 8,227 N/A E.C.8 Number of Attendances at All A&E Departments 14,46 N/A E.C.9 GP Written Referrals* 2,692 N/A E.C.1 Other Referrals for First Outpatient Appointment* 2,99 N/A E.C.11 Total Referrals* 4,791 N/A E.C.12 First Outpatient Attendances Follow ing GP Referral* 2,312 N/A Latest Period YTD +14.8% (Apr-14) -5.1% (Apr-14) +2.% (Apr-14) -6.8% (Apr-14) +14.9% (Apr-14) +14.8% (411) -5.1% (1,88) +2.% (2,385) -6.8% (2,184) +14.9% (4,794) W/E 18/5/14 W/E 18/5/14 +42.2% (Apr-14) +.8% (Apr-14) +24.5% (Apr-14) +28.6% (Apr-14) +2.7% (8,451) +7.7% (15,59) +42.2% (3,828) +.8% (2,115) +24.5% (5,967) +28.6% (2,973) Trend *Activity data relates to General and Acute specialties and w ill therefore be inconsistent w ith other activity based reports. NHS Constitution Measures The NHS Constitution sets out the universal rights and pledges for all NHS patients. The national requirements, in terms of operational standards expected from the NHS Constitution, are shown in Annex B within Everyone Counts: Planning for Patients 214/15 to 218/19. Supporting measures are denoted by E.B.S in the indicator reference number. 37
E.B.1 18 Week RTT Admitted Pathw ays <18 Weeks 9% 85% E.B.2 18 Week RTT Non-Admitted Pathw ays <18 Weeks 95% 9% 18 Week RTT Incomplete Pathw ays <18 Weeks 92% 87% Diagnostic Waits >6 Weeks 99% 94% E.B.3 Quality Premium Measure Lower Threshold Description Standard Indicator E.B.4 E.B.5 A&E Waits Seen Within 4 Hours 95% 9% E.B.6 Cancer 2 Week Waits -Suspected Cancer Referrals 93% 88% E.B.7 Cancer 2 Week Waits -Breast Symptomatic Referrals 93% 88% E.B.8 Cancer 31 Day Waits -First Definitive Treatment 96% 91% E.B.9 Cancer 31 Day Waits -Subsequent Treatment -Surgery 94% 89% E.B.1 Cancer 31 Day Waits -Subsequent Treatment -Chemotherapy 98% 93% E.B.11 Cancer 31 Day Waits -Subsequent Treatment -Radiotherapy 94% 89% E.B.12 Cancer 62 Day Waits -First Definitive Treatment -GP Referral 85% 8% E.B.13 Cancer 62 Day Waits -Treatment from Screening Referral 9% 85% E.B.14 Cancer 62 Day Waits -Treatment from Consultant Upgrade N/A N/A Ambulance Clinical Quality -Category A (Red 1) 8 Minute (SCAS) 75% 7% E.B.15.ii Ambulance Clinical Quality -Category A (Red 2) 8 Minute (SCAS) 75% 7% E.B.16 Ambulance Clinical Quality -Category A 19 Minute (SCAS) 95% 9% E.B.S.1 Mixed Sex Accommodation (MSA) Breaches 1 E.B.S.2 Cancelled Operations -Not Seen <28 Days (MKHFT) % N/A E.B.S.3 Mental Health Measure -Care Programme Approach (CPA) 95% 9% E.B.S.4 Number of 52 w eek Referral to Treatment Incomplete Pathw ays N/A E.B.S.5 Trolley Waits in A&E (MKHFT) N/A E.B.S.6 Urgent Operations Cancelled for a Second Time (MKHFT) N/A E.B.S.7 Ambulance Handover Delays (MKHFT)* 177 N/A E.B.15.i Latest Period 9.6% (Apr-14) 97.1% (Apr-14) 93.3% (Apr-14) 99.5% (Apr-14) 95.4% (Apr-14) 93.9% (Apr-14) 86.6% (Apr-14) 95.9% (Apr-14) 93.3% (Apr-14) 1.% (Apr-14) 83.3% (Apr-14) 82.4% (Apr-14) 92.3% (Apr-14) (Apr14) 81.6% (Apr-14) 77.3% (Apr-14) 96.5% (Apr-14) (Apr14) 8.1% (Q4) 91.2% (Q4) 4 (Apr14) (Apr14) (Apr14) 139 (Apr14) YTD Trend 9.6% 97.1% 93.3% 99.5% 95.4% 93.9% 86.6% 95.9% 93.3% 1.% 83.3% 82.4% 92.3% 81.6% 77.3% 96.5% 7.2% 93.9% 4 139 *Nationally it is expected that there are zero handover delays. NHS Patient Quality, Safety & Experience In recognition of the importance of patient safety, quality and experience this dashboard includes a range of indicators which do not feature in the NHS Outcomes Framework or NHS Constitution. This indicator set will expand in future months to encompass a wider scope of quality-based targets and priorities for the CCG. With the exception of VTE risk assessments, the indicators reported below are national CQUIN goals. As a minimum,.5% of the value for all healthcare services commissioned through the NHS standard contract is to be linked to the national CQUIN goals. 38
CQUIN Indicator Indicator Description Target / Plan YTD Plan 2..1 Friends and Family Test -Response Rate -A&E (MKHFT) 15.% N/A 2..2 Friends and Family Test -Response Rate -Inpatient (MKHFT) 15.% N/A 2.1 Safety Thermometer -All Pressure Ulcers (MKHFT)* 5.1% N/A 3.1 Dementia Assessments -Case Finding (MKHFT) 9% N/A 3.2 Dementia Assessments -Diagnostic Assessment (MKHFT) 9% N/A 3.3 Dementia Assessments -Referral for Specialist Diagnosis (MKHFT) 9% N/A Venous Thromboembolism (VTE) Risk Assessments (MKHFT) 95% N/A VTE Latest Period 1.6% (Mar-14) 27.6% (Mar-14) 5.% (Feb-14) 28.7% (Feb-14) 87.5% (Feb-14) 14.3% (Feb-14) 95.2% (Feb-14) YTD Trend.8% 25.3% 4.5% 28.2% 83.1% 42.% 95.9% *In the absence of a national target, performance is rated against the national average. 8.3 QUALITY PREMIUM Milton Keynes CCG is also required to ensure delivery of the national and local quality premium measures. The Quality Premium is intended to reward CCGs for improvements in the quality of the services that they commission and for associated improvement in health outcomes and reduction of inequalities. From April 214 the Quality Premium will be based on six national measures and one local measure, and the total amount payable for achievement will be 5 per patient. The relevant measures are shown below, with detailed trajectories outlined in Appendix A. Performance against the following standards will be reported to the Commissioning Delivery Group (CDG) every month and CCG Board bi-monthly a) Potential Year of Life Lost (PYLL) from amenable causes in 214/215 b) Avoidable Emergency Admissions (composite indicator) c) For IAPT, what proportion of people that enter treatment against the level of need in the general population are planned d) Friends & Family Test e) Reporting of Medical Errors Everyone Counts Planning for Patients 214/15 requires each CCG to identify one local priority against which it will make progress during the year. This priority will also be taken into account when determining if the CCG should be rewarded through the Quality Premium 214/15. For 214/215 the CCG has chosen the following indicator, which already underpins the delivery of the wider Health & Wellbeing Strategy and is also included in the 214/215 Implementation Plan. A detailed trajectory is shown in Appendix A. f) Admissions for stroke to an acute stroke unit, within 4 hours of arrival at hospital 8.4 MONITORING QUALITY MKCCG aims to commission the best possible healthcare for people within available resources with a focus on reducing health inequalities and improving outcomes. The CCG is committed to continuously improving the quality of care provided to people regardless of setting through a range of activities and interventions. The three elements of quality; patient safety, clinical effectiveness and patient experience, are considered as a basis of all commissioning decisions and will deliver the best outcomes for our community. The CCG uses a range of data to ensure the approach to quality is robust, with the on-going ability to learn. Independent sources of assurance include; Audit Commission National Quality Board 39
Internal Audit annual review of clinical quality processes External inspection agencies, e.g. Care Quality Commission and Ofsted Quarterly and Annual Assessment of the CCG by the Area Team of NHS England through the CCG Assurance Framework Safeguarding Children and Adult Boards The CCG will ensure that its quality priorities are aligned to the current and future health needs identified within the JSNA and are consistent with the Health & Wellbeing Board strategic priorities. All contract negotiations to improve quality take place in collaboration with other NHS commissioners and social care partners as required. The focus for quality improvement, going forwards, will be on:a) Patient safety The CCG has established risk management and patient safety process with providers, and provides leadership in reducing avoidable harm to patients. All serious incidents are reported and analysed, and action plans associated with the root causes of the incident are submitted. Monitoring of the application of the actions plans takes place to ensure that lessons are learnt and embedded within organisations to deliver overall improvements in patient safety within provider settings. Lessons learnt are also shared within the health economy wide serious incident groups to provide opportunities for whole system learning. The CCG will further strengthen systems in place to reduce health care associated infections through the investment in further Infection, Prevention and Control expertise. There is a strong focus on mortality rates with CCG and public health clinicians being part of the Milton Keynes Hospital Foundation Trust (MKHFT) mortality board and the establishment of a CCG led health economy wide mortality group. Mechanisms are embedded within provider contracts linked to Commissioning for Quality and Innovation (CQUIN) and Quality Schedules to further reduce patient harm, for example due to medication errors and falls. Zero tolerance of never events is established. To further improve patient safety the Quality team is supporting provider Directors of Nursing to implement the national safer staffing requirements and reporting in order to improve patient safety at ward level following the recommendations of the Keogh Review. We will further develop surveillance of patient safety to include equipment checks, safety procedures such as the use of the WHO surgical checklist, monitoring of early warning scores with links to mortality, and surgical infection site surveillance. b) Patient experience The CCG is committed to using systems and processes for capturing, understanding and improving patient experience to create effective care pathways. To embed this approach within commissioned services the Quality team has an experienced patient experience lead that works with providers to strengthen the collection of a range of patient experience information. This will ensure that the reporting of this information can be used to inform improvements in care and influence commissioning decisions.. Patient experience is a central component of all quality visits. We will further develop the focus on patient experience by ensuring that the full range of patient information is collated and triangulated to provide assurance concerning the quality of services from providers, including the focus on vulnerable and disadvantaged groups. We will build upon the CCG use of Experts by Experience in our Winterbourne view monitoring visits and team recruitment, to expand their use in other quality visits. A further priority will be working with the area team to improve patient experience in primary care recognising that the quality of primary care services impacts on care pathways for both acute and long term conditions. We will also further integrate the patient experience and patient and public engagement agenda. Reporting of trends in relation to complaints will be developed. Providers are required to review their 4
performance against the Equality and Diversity Delivery System outcomes, and agree with the CCG improvements to provider equality performance. c) Clinical effectiveness Leadership from the CCG membership ensures that clinical effectiveness and continuous quality improvement is at the heart of the CCG quality and commissioning plan. We want to ensure that the local community is provided with the most up to date clinical models of care associated with the very best outcomes. This is achieved through the search for and application of innovative models of care based on all relevant guidance including the NHS Outcomes Framework, and guidance from NICE and other clinical bodies. In order to support this, the CCG will be an active member of relevant strategic clinical networks and develop links further with local Academic Health Science Network in order to enhance and progress the application of evidence-based research into local practice. GP programme board chairs and clinical representation at programme boards ensure that the transformation agenda is clinically led, reflects evidence based practice and is outcome focused. d) Leadership for quality We have a duty to lead, drive and secure continuous improvement through the services we commission ensuring that high quality care is central to all commissioning decisions. In order to achieve this we will ensure that the potential of all staff is maximised through the appraisal and personal development plan process. Individuals are supported to undertake leadership programmes to strengthen the leadership with providers, and negotiation training to support the development of collaborative relationships which are more likely to result in the development of the best solutions which benefit patients when challenges arise. The CCG will lead whole system change including the development of joint outcome measures delivered across organisational boundaries. This is achieved through the CCG leadership of a number of health economy wide groups focusing on mortality, tissue viability, health care acquired infections and learning from incidents. The CCG will work collaboratively with a number of partner agencies including the Local Authority, other CCG s, the Area Team, Monitor and the Trust Development Authority, and be active members of the Health and Wellbeing and Safeguarding Adults and Safeguarding Children s Boards. The CCG Quality team will work closely with the Area Team Quality Collaborative to lead the development of improvements to address a range of quality priorities including HCAI rates, pressure ulcers and practice nurse development. e) Contractual levers MK CCG is incentivising providers to deliver the national CQUIN s and has negotiated the agreement of local CQUIN s to support reductions in urgent care acute trust attendances and improve patient flow. Locally agreed quality schedules with providers have a strong emphasis on improving patient safety and patient experience; and improving outcomes and reducing mortality relating to specific specialties such as stroke and respiratory pathways. CQUIN payments are profiled to incentivise initiatives that reduce overall risk to patient safety and support innovation. We will monitor the delivery of the outcomes detailed in the contract. Should the required outcomes fail to be delivered we will continue to support providers to improve using contractual levers if required in the form of development of improvement plans or the application of penalties. Providers will be held to account for the delivery of improvement plans within agreed timescales. f) Provider accountability All providers are held to account for the delivery of quality improvements. For the two main providers the CCG governance arrangements have reporting to the Quality Committee provider Clinical Quality Review Meetings (CQRM). The CQRM meets monthly as an operational group and quarterly as a strategic group. The strategic 41
meetings are to gain assurance and hold providers to account, while the operational meetings are to provide an opportunity for the CCG Quality team to support providers to deliver the required improvements. Quality contract monitoring, and reviews of CQC Quality and risk profiles takes place at the strategic CQRM. The CCG will further develop reporting to the CQRM to ensure that all provider quality issues are robustly monitored. This will in turn refine reporting to the quality committee and subsequently to the CCG Board and the Quality Surveillance Groups. The delivery of CQUINs will be closely monitored to drive up quality of care through the achievement of challenging but realistic targets. g) Cultural change A collaborative approach is taken with providers to support a culture of learning and patient focused care and compassion, with patients at the heart of decision making. This values based approach we believe will embed sustainable quality improvements and support innovation. The CCG receives assurance from providers of the implementation of the 6 C s relating to for example staffing levels, friends and family test and appraisals to ensure that the principles of the values and behaviours of Compassion in Practice are embedded in provider settings. Progress against provider Francis Enquiry action plans is also reported. h) Staff satisfaction The CCG is aware of the links between staff satisfaction and patient care and will continue to work with providers to drive improvements in staff satisfaction. Staff satisfaction is a critical element of all quality visits. National staff survey results will continue to be monitored and benchmarked against other similar providers and used within the triangulation of evidence to inform commissioning decisions. Performance against implementation of the staff friends and family test across all services monitored and providers supported to implement improvements as required. i) Assurance The CCG receives regular assurance that existing services meet acceptable standards, through the triangulation of a range of information - both hard and soft data through a number of resources. These include independent information sources, provider visits, evidence of historic progress, monitoring of outcomes, interactions with patents and carers, and provider dashboard reporting. A range of nationally published information is also scrutinised and monitored at provider and CCG level against the NHS Outcomes Framework, NHS Constitution, Local Priority indicators, patient safety, quality and experience measures, the Quality Premium and the CCG assurance framework. We will continue to utilise relationships and interactions with other regulators or agencies to be alert to concerns and drive improvements. The CCG will continue to have active clinical participation in Quality Surveillance Groups. Concerns about the quality of care provided are raised either through the CCG governance arrangements or directly with providers using a transparent supportive approach to achieving improvements. j) Measuring and publishing quality Continuous improvement is aided through effective measurement. The CCG, based on transparent relationships with providers, requires providers to share robust, relevant and timely information. Other information published nationally is reported monthly. This information will be shared and published to ensure accountability and support patient choice. 42
k) Safeguarding Our population has a right to live free from harm and abuse. Preventing and responding to the abuse of children and adults is essential to achieving optimum standards of health, safety and well-being. Safeguarding focuses on the most vulnerable members of our communities and is a priority for the CCG. MKCCG s approach to safeguarding is to make it integral to all aspects of commissioning through: 1. Working in partnerships 2. Seeking assurance that all our providers are delivering safeguarding responsibilities 3. Supporting all our providers to continually improve their safeguarding. 8.4 RESPONDING TO NATIONAL QUALITY CONCERNS The CCG is committed to responding to recommendations from national reports and ensuring that they are discussed with providers, and where appropriate corrective measures taken. A key focus for the CCG now and in the future will be ensuring the findings of the following are considered locally:a) Winterbourne View Close collaboration with Local Authority partners has delivered significant progress in our response to learning from Winterbourne View and government targets for people with learning disabilities to be cared for closer to home. The Milton Keynes multi-agency Winterbourne View monitoring group meets monthly, involving the Joint commissioning team, CCG, Social Care, the Community Team for Adults with a Learning Disability (CTALD), the CHC team and specialised commissioning. Whilst the monitoring group focuses on those people placed by the CCG out of area, it also includes a review of all out of area placements including those funded by specialised commissioning and social care. All out of area people, are visited and reviewed a minimum of every six months. In addition attendance at CPA reviews, MH Act tribunals, MH Act Managers hearings etc. results in people placed out of area being seen more often. Plans are in place to return MKCCG people to Milton Keynes as soon as they are clinically assessed suitable to do so. b) Keogh mortality review. The CCG has reviewed all activities in order to meet the recommendations of this enquiry. Provider action plans have been received and are monitored to ensure that all commissioned services have considered and responded to the recommendations of this report. The CCG works collaboratively with the acute trust to monitor mortality rates and has quality team and GP representation on the acute trust mortality board to focus on the full range of interventions to improve mortality from the implementation of care bundles in acute settings, to whole system pathway improvements. Further assurance is received through staffing level reports and quality visits. c) Berwick Report The CCG has been central to leading the development of a culture of learning within provider settings and has developed a number of senior roles within the CCG to strengthen reporting, assurance and learning processes. This will be further developed through the development of a culture of timely openness and transparency when things go wrong, holding providers to account for implementation of improvements, a clear focus on patient and public involvement, and full integration of learning across provider settings 43
9. Sustainability & Finance The NHS continues to face a period of unprecedented change and financial challenge, thereby increasing the need for both commissioners and providers to deliver both improved productivity and quality, but also to ensure that resources are targeted as effectively as possible to maximise patient treatment and care. Milton Keynes Hospital Foundation Trust, the main acute provider, is seriously financially challenged with a three year plan to achieve financial balance. Given the unprecedented scale of the financial position faced by the Trust, the CCG is developing contingency plans, in line with Monitor guidance, to ensure sustainability and continuity of services for Milton Keynes residents. Overall planning guidance for CCGs was issued in December 213, along with two year financial allocations to CCGs. This has been translated into a 5 Year Financial Plan. The strategic implications for the CCG of this are outlined below. 9.1 The CCG appears to have benefited from the late changes to the resource allocation formula to allow for greater impact of deprivation as its distance from target increased to 8% compared to circa 4% from the formula issued in the early autumn. MK CCG received the second highest allocation growth funding for 214-15 outside London at 4.3% compared to an average of 2.54% growth across NHS England. The growth funding received for 214-15 is 1.5m and for 215-16 1m, although this still leaves the CCG 7% away from its target allocation after the growth. Although overall levels of growth funding is anticipated to reduce, indicative allocations issued for 216-17 to 218-19 show that Milton Keynes should continue to benefit from a higher than average growth rate over these later three years in order to bring it closer to its target allocation. Running cost allocations for 214-15 have remained at the same levels nationally, although with the growth in population this is reflected in a lower value per head at 24.73 and in 215-16 a 1% reduction will be applied bringing the rate per head of population to 22.7. The CCG will be required to contribute part of its funding allocation in 215-16 to the Better Care Fund which will equate to 9.5m and increase this fund to 13.8m in total. The 9.5m is expected to come from existing resources and a reduction in emergency activity in the hospital setting. The planning guidance indicates an expected reduction of circa 15% but for inpatients alone this would only equate to circa 5m saving. The 214-15 increase in funding has already been top sliced by NHS England. After modelling the planning assumptions released in December the CCG anticipates a QIPP gap of 11.7m in 214-15 and 39m over the five year planning period. The high level of growth in allocation funding has been more than offset by the underlying pressure brought forward from the previous year and additional planning. PLANNING ASSUMPTIONS The following planning assumptions have been factored into the CCG plan: Budget pressures in 213-14 will continue. These include:- 44
Prior Year Pressures Acute & Ambulance Activity Overperformance Cquin underdelivery re-instated Loss of 5% contract penalty benefits & MRET adjustments Continuing Care Mental Health & LD Community Services Other Commissioning Prescribing Release of reserves 6,315 983 2,959 1,43 282 817 834 2,35-3,89 Total Prior Year Pressures 12,854 CCG surplus from previous years will be made available to re-invest non recurrently in the following year plan There will be a net deflationary reduction in provider contract prices ranging from 1.2% for the acute sector in 214-15 to 1.5% for non acute services Population and demand growth has been estimated at 3.14% in year 1 and between 3-5% in future years No additional funds have been set aside for investments Prescribing growth assumed at 5% per annum Continuing Care growth is assumed at 5.64% Running cost pressures assumed at 2%.5% contingency will be held each year 2.5% non recurrent reserve will be held in 214-15 decreasing back to 2% from 215-16 of which 1% will be available for transformation projects A 1% surplus will be delivered each year The CCG will hit the target each year to receive 75% of its quality premium from 214/215 onwards 1.4m will be ringfenced in 214-15 which equates to 5 per head of population (5% assumed to come from activity reductions) to support transforming the care of the over 75s as per planning guidance 9.5m will be ringfenced from 215-16 as an additional transfer to the Better Care Fund 9.2 FINANCIAL PLAN Based on the above planning assumptions the table below identifies the anticipated income and expenditure over the next five years and the more detailed schedule at Appendix C shows the changes year on year. Recurrent Funding Non Recurrent Funding Total Allocation Baseline Commissioning Expenditure Expenditure Growth Running Costs Total Net Expenditure (before QIPP) QIPP GAP CCG Surplus at 1% 213/14 Budget ' 251,19 5,172 256,362 229,876 29,861 6,51-266,247 1,885 1, 214/15 Plan ' 261,737 1, 262,737 232,218 34,666 6,542-273,426 11,688 1, 215/16 Plan ' 271,149 5,258 276,47 24,11 33,335 5,928-279,364 5,747 2,79 216/17 Plan ' 281,897 8,23 289,92 255,839 29,892 5,966-291,696 4,666 2,89 217/18 Plan ' 292,922 8,123 31,45 269,61 29,33 6,2-34,366 6,322 3,1 218/19 Plan ' 31,324 8,234 39,558 279,892 3,968 6,37-316,897 1,425 3,86 45
The plan assumes that the running cost expenditure will decrease by 1% in 215-16 in line with allocation reductions. Despite the higher than average allocation growth the CCG is still required to close a QIPP gap which equates to 11.7m in 214-15 and 39m over the five year planning period. This is in part due to the underlying pressures brought forward from 213-14 and also additional planning requirements for five years which include the following:o Population and demand growth o.5% increase in non recurrent fund o New investment in GP schemes for over 75s as identified in planning guidance o Requirement to hold aside funds for investment equivalent to the marginal rate reduction for emergency activity (MRET) and re-admissions penalty. o The Better Care Fund transfer in 215-216. 9.3 FINANCIAL RISKS AND MITIGATION This plan incorporates a number of risks which could impact on the financial forecasts as follows: Following a reduced surplus delivery in 214-14 the plan assumes that the CCG will deliver a 1% surplus each subsequent year and that this funding will be available non recurrently in the following year. The plan assumes that the CCG will deliver its QIPP targets each year with 5% on a recurrent basis. The ability of the CCG to deliver will depend on the engagement of both commissioners and providers of healthcare to deliver the changes required. In 213-14 the CCG delivered 59% of its QIPP plans, however there has been a lot of slippage on plans in year. The greatest area of risk relates to the assumptions applied to contract plans and demand. The starting point for hospital activity plans is the forecast outturn position for 13/14. The baseline plans for Milton Keynes Hospital Foundation Trust have been agreed with the Trust. The financial plans then include an element for growth in population and demand. However in previous years acute sector activity growth has risen in excess of plan. If activity and population growth vary from current assumptions then this could impact on the plan. A 1% variation in the assumptions equates to 75k. Other pressures brought forward from 213-14 relate to prescribing and continuing care. If these cannot be contained then there is a risk to the financial plan. The planning guidance indicates that CCGs will become responsible for funding provisions from 214-15 from within their allocated resource. This will be co-ordinated by NHS England through a risk pooling scheme. The CCG has set aside circa 1m from its non recurrent reserve to contribute towards this risk pool. The planning guidance indicates that CCGs will become responsible for Special Education Needs Commissioning from September 214. The financial plan assumes that this will be cost neutral. The CCG will also be required to implement personal health budgets from 214. It is assumed that this will be cost neutral. Additional investments will need to be funded from funds set aside for activity and population growth 46
It is assumed that the running cost reduction of 1% can be delivered There is a risk that the CCG may not achieve the targets for receipt of the quality premium The mitigations against these risks include the following: The financial plan has been set based on outturn from the previous year, assuming existing pressures will continue and include assumptions for population and demand growth Given the high level of inherent cost pressures brought forward the CCG is planning to deliver a reduced surplus of.4% surplus in 214-15 The CCG has agreed contracts with its two main providers for 214-15 which include realistic activity plans and embed the majority of QIPP plans into those agreements. The CCG has agreed with its main hospital provider that it will continue to pursue additional QIPP plans valued at circa a further 2m which have not been embedded into the contract. These are factored into the financial plan. For 214-15 a number of the QIPP plans have commenced in the final quarter of 213-14 and several pathway changes are in the latter stages of negotiation with providers, so the CCG is in a much better position to start the year. The budgets for prescribing and continuing health care are based on outturn plus growth at 5% and 5.64% respectively. A 3% and 3.7% QIPP saving have then been applied giving a net growth of circa 2% for both budgets which was not the case in 213-14. The use of the 1% transformation funds will allow the CCG to incentivise the delivery of change The remaining 1.5% non recurrent fund and the.5% contingency reserve will mitigate against any slippage on plans and in year pressures that have not been foreseen. 9.3 FINANCIAL PLAN 214-219 For the five year period of the plan the total difference between resources available and anticipated expenditure is 39m. This gap will be closed through the development of the CCGs QiPP Plan. In addition during 215-16 the CCG is required to reduce its running costs by 1% which equates to 745k. A number of the QIPP schemes started at the end of 213-14 so a full year of savings are anticipated. The contract value for community services has an agreement for a 2m reduction in 214-15 and a further 2m in 215-16 as a result of the TCS exercise. A further 1m will be saved through prescribing initiatives in 214-15 and.75m per annum in subsequent years. This leaves a balance for Programme Boards to address of 8.7m in Year 1 and 31m across the five year period. Delivery of Financial Balance will focus on: Delivery of the financial requirements of Everyone Counts: Planning for Patients 214/15 (the Operating Framework for 214/15) Ensure real shift within year of resources from Secondary Care to Primary Care and Community Services Implementation of the Bedford/MK healthcare review Enforce the standard terms of the new NHS contract, including the financial consequences for underperformance or failure to provide data on which to measure performance 47
More rigorous, evidence based, validation of tariff based activity and other claims for payment from Providers. In order to ensure that the CCG is paying the right amount for the right clinical care and that there is evidence of delivery before payment. Full contract coverage, with Minimum Datasets and Key Performance Indicators in place across-theboard Appropriate use of financial incentives and penalties in order to drive up quality of services Aligning CQUINs to the CCG s key priorities and programme objectives Agreeing an appropriate strategy for the commitment of and use of 2% Transformation Funds in a way that truly incentivises strategic change and improvement in the quality of services delivered Ensure that all providers have a demand management commitment i.e. that capacity is taken out as demand for services is reduced Ensure value for money from jointly commissioned funds and resources 9.4 QIPP PLAN 214-219 Based on the above financial planning assumptions the table below identifies a summary of the CCGs proposed QIPP Plan for the 5 years. A more detailed version of the QiPP Plan is shown in Appendix A and the monthly phasing for Year 1 is shown at Appendix D. 214/15 Costs Savings Care Pathways & Primary Care Mental Health Urgent Care Children & Maternity Other Contractual Changes Prescribing 1,351 1,57 678 898 4,78 2,23 344 2, 1, TOTAL SCHEMES 3,983 1,147 215/16 216/17 217/18 218/19 Net Net Net Net Net Costs Savings Costs Savings Costs Savings Costs Savings savings savings savings savings savings 4,43 1,621 4,114 785 2, 2,816 816 3,55 3,55 3,9 6,5 2,15-1,57 1,344 7 31 39 5 5 1,2 1,2-546 38 256 11 6 6 822 822 1,125 1,125 2, 2, 2, 2,5 2,5 1, 75 75 75 75 75 75 75 75 6,784 1,729 7,421 3,955 2, 4,666 2,666 6,322 6,322 3,9 1,425 QIPP TARGET 11,688 5,747 4,666 6,322 1,425 GAP(-) / Headroom (+) -1,541 1,674 6,525 Delivery of the QiPP schemes will be closely monitored on a monthly basis during 14/15 and 15/16 through the PMO. A detailed phasing of how the QiPP is to be achieved across the schemes is shown in Appendix D. 1. Integration & Partnership Milton Keynes has a long history of joint working, and has a number of integrated services: Intermediate Care; Mental health; Learning Disabilities; Integrated Community Equipment services and a Joint Commissioning Team. Work has been underway for some time to further develop integrated serves to better meet the needs of older people and those with long term conditions and/or physical disabilities. As part of this process, a number of workshops have been held with service providers and members of the public to discuss the development of integrated services. 48
1.1 Approach Implicit in the Joint Health and Wellbeing Strategy is the empowerment of Milton Keynes residents to be supported to help manage their own health and wellbeing through the commissioning and delivery of person centred services, which place the individual at the heart of service delivery. Through local health and social care teams we will work with local people in Milton Keynes to further develop our plans for integrated care and support to enable people to maintain their independence. Our vision for health and social care services in Milton Keynes is for services that are configured to support people to live independently in their own home, within their local communities, wherever possible. This will be our default option for service delivery. The aim of any intervention, especially acute care, will be to support people to realise this objective. Through effective utilisation of the Better Care Fund, capacity will be developed in community health and social care services to meet the delivery of this objective and will be provided by a full range of statutory and voluntary and community organisations. In February 214, Milton Keynes CCG hosted a system workshop to stimulate the planning and development of a pathway for Vulnerable Older Adults. There was cross sector attendance at this workshop and a commitment to working together as a health and social care system to deliver improved care for older people. By working together in this way, then the objectives of the MK Older People s Strategy and the Better Care Fund proposals will be delivered. GPs will be central to organising the co-ordination of people s care and will work in a seamless integrated way with health and social care providers to better manage care and treatment of patients. Self-care and selfmanagement of an individual s health will be encouraged and people will be supported to develop strategies for managing their health and independence, including access to a range of preventative, early intervention services to support people to pro-actively manage their health. Supporting services such as telehealth, telecare and community equipment will be strengthened to support independence. Rehabilitation and re-ablement will be offered to everyone. We are clear that everyone has the potential for restoring some level of physical and mental functioning. 1.2 Vision MK vision for its future model of integrated care is outlined below. We aim to configure services that support people in their own homes and local communities wherever possible, delivered on a 7 day a week basis. The use of services in the secondary care (acute) sector is essential for those people that need them where community, primary and social care services cannot meet the (acute) healthcare need. We aim to deliver services with the following objectives: Focused on improved outcomes not solely on activity Promote individual independence for all Improving the experience of patients/service users and carers Reduce delayed transfers of care by the development of a range of community based services that can meet a range of needs for post-hospital support. The extension of rehabilitation and reablement to people with dementia The links between physical health and mental health are well known, although our services continue to work in silos. Services (Relationships) will be strengthened to deliver the objective of no health without mental health A reduction in the rate of emergency admission to hospital and the number of permanent placements to residential and nursing care Support early intervention, identifying people who may need support before a crisis Case management and co-ordinating care to ensure people are cared for in the most appropriate environment by the most appropriate professional 49
1.2 Better Care Fund The Better Care Fund (BCF) will be fully deployed during 215/16, but joint plans have to be submitted to the Dept. of Health by February 14th 214. It will take effect from 214/15 under which a proportion of current CCG spend will transfer into a pooled fund with the Local Authority as a means of driving further integration between health and social care. The final allocation of the fund and any performance measures are still being debated at a national level. However, there are clear indications that part payment of the fund will be made against four principal conditions: 1. 2. 3. 4. Impact on acute care Protecting social care (eligibility) Seven day working Named professionals for at risk people The performance indicators around these conditions are related to: avoidable hospital admissions; delayed transfers of care; user experience; a developed local indicator. It is expected that an additional payment will be linked to both access and effectiveness of reablement, and the number of permanent admissions to residential and nursing care. Locally the BCF provides an opportunity to transform local services so that people are provided with better integrated care and support. It encompasses a substantial level of funding to help local areas manage pressures and improve long term sustainability. The Fund will be an important enabler to take the integration agenda forward at scale and pace, acting as a significant catalyst for change. The BCF Plan24 will support the aim of providing people with the right care, in the right place, at the right time, including through a significant expansion of care in community settings. There will be integrated commissioning of services through a single pooled budget and delivered through integrated health and social care teams. These teams will be configured so that they support people either on a short term basis i.e. to deliver rehabilitation and re-ablement to help people regain confidence and previous levels of functioning or to provide support for physical health at home until reablement can be commenced. or on a longer term basis for people with more complex health and social care needs that may require more intensive support over a longer timeframe especially when they have an exacerbation of their condition. In resource terms, for Milton Keynes the implementation of the local BCF Plan means that: In 214/15 an additional.8m will come out of NHS allocations in addition to the continued funding of 3.4m uplifted from the previous year. This has already been excluded from the CCG allocations announced in December. In 215/216 an additional 9.5m is estimated to come out of NHS allocations and into the BCF. This will make the total amount 14.6m. The CCG commissioning plans and local authority plans for social care have also been developed in the context of the JSNA and the Joint Health and Wellbeing Strategy, so there is a golden thread linking the health and social care high level strategic documents with the BCF service proposals. 24 st MKC & MKCCG, Better Care Fund Plan: 214-218: February 214 (1 draft) 5
1.3 Delivering Integration Collectively in Milton Keynes we will utilise the Better Care Fund to transform local services and pathways that will help us achieve the aims and objectives outlined above. It has been recognised that to move such significant funding into the BCF in such a short time frame will have significant implications, it has therefore been agreed for a phasing over a 5 year period (Appendix E), with 1.5m being earmarked for 15/16 and a further 2.m from 16/17, agreement needs to be reached for phasing from 17/18. The schemes build on the existing spend of 256 monies where appropriate. Full details of the proposed schemes to be funded via the BCF Plan are outlined in Appendix F, with a summary below. 1. Integrated Health & Social Care Teams Phasing: These will be a priority and the anticipated start will be during 14/15, with some phasing into 15/16 and beyond Two Complex Needs teams organised on a virtual basis, operating 7 days a week, involving a range of local authority, NHS and voluntary sector staff. These teams will offer on-going support to people with complex health and social care needs, identified by risk profiling, and managed by person centred care planning and case management using a virtual ward model by an applicable professional. Active involvement with this team will not be time limited, but patients will be discharged to receive the appropriate level of care and support, once the exacerbation of their illness has been managed effectively. The team will also provide 24/7 support to people who require support at the end of life. Extension of Intermediate Care Services to deliver effective reablement and rehabilitation 7 days a week for a period of up to 6 weeks by a team of therapists, nurses and reablement workers. This will be available for people following a period of acute hospital provision or as an alternative to emergency hospital admission and aims to restore confidence and levels of functioning following illness or injury. The rehabilitation and reablement will be delivered in a range of community settings, including the patient s home, and is currently being delivered on this basis. The BCF will be used to extend 24/7 working by this team. Assertive In reach and Supported Discharge Team to work on a time limited basis to in reach into acute settings and support the discharge of patients who don t yet meet the criteria for intermediate care and require a period of convalescence at home prior to rehabilitation e.g. non-weight bearing patients, those patients requiring support with wound care and nursing interventions. This service will be available 24/7 and will work with patients for a period of up to six weeks. Recruitment of Community Geriatricians and rehabilitation specialists to support the integrated health and social care teams Recruitment of additional social care staff to provide social care input into the completion of CHC assessments. These staff will work across the integrated health and social are teams above. Development of Community equipment, telehealth and telecare to be utilised by the integrated health and social care teams above as a tool to help support people at home. 1. The development of additional extracare housing schemes for older adults with dementia to provide longer term support as an alternative to permanent admission to residential/nursing care, 51
and offered on a tenancy basis with additional care support. Phasing: This is not likely to commence before 16/17. 2. The provision of an alcohol liaison service to support people presenting at A&E and who have an alcohol problem. This will focus on ensuring their physical health needs are met and that they are signposted on to a range of services that can help manage their alcohol need. Phasing: An existing pilot is being evaluated and continuation of this scheme in 15/16 will be dependent on positive evaluation. 3. To mainstream a High Impact Team to support residential and nursing homes to manage the fluctuating health needs of their residents, thereby avoiding admission to hospital. This team of nurses will work with those care homes identified as high referrers to A&E and higher than average ambulance call outs. Phasing: A proof of concept is being implemented during 14/15 and continuation of this scheme into 15/16 will be dependent on positive evaluation. 4. Investment in the falls prevention pathway to ensure the correct mix of lower level support and specialist services so that people who have fallen or are at risk of falling can access the relevant level of support. Phasing: To start implementation from 15/16 along with changed services from current providers. 5. Care Funding Calculator delivery through a sustainable team reviewing learning disability care packages and negotiating funding levels with providers.phasing: From 17/18. 6. Development of dementia pathway to support the implementation of the dementia strategy in Milton Keynes.Phasing: From 15/16. 7. Create an Autism Diagnosis Service to ensure appropriate diagnosis, signposting and information. Phasing: From 17/18. 8. Enhance our current approach to Experts by Experience in Learning Disability Services and roll out into other service areas. Phasing: From 17/18. 9. Undertake social isolation research to measure the effects on older people. This research will then inform future commissioning. Phasing: This will be in conjunction with the voluntary sector and scheduled for 17/18. 1. As an alternative to secondary (acute hospital) care we will ensure we have suitable and sufficient community nursing and residential care. This will be based around the provision of community beds supported by nursing and appropriate therapies. Phasing: From 17/18. 52
Appendix A Delivery & Implementation by Programme Board Urgent Care Programme Board Commissioning Interventi Actions on/intention Net Savings Net Savings Net Savings Net Savings Net Savings 214-15 215-16 216-17 217-18 218-19 1. Establish/Implement Common Front Door for A&E and Urgent Care services The system will deliver an integrated 28.6k front door to the hospital by co locating the Urgent Care Centre into the A/E dept. 2. Additional Support to Nursing & Care Homes (HIT) Full implementation through 2 1,15.7k 11.6k providers will occur during 14/15, a full evaluation regarding the effect on unplanned admissions will take place and if objectives are met then this will be procured permanently. Activity Reduction Area Lead Change Delivered from A&E attendances, emergency admissions Mark Cox A&E attendances, emergency admissions Peter Pentecost April 214 3. Reduction in ambulance Increase SCAS current ability in 49.6k dispatch using Hear & Hear and Treat (H&T) referrals. The Treat & NHS Pathways conveyance rates will be monitor to prove outcome from this service Triage change. Hear & treat; Hear See & Treat; Conveyance Steve Gutteridge April 214 4. Structured Promotion of 111 & Self Care A&E attendances Steve Gutteridge Through Marketing of the 111 service 38.9k to promote effective use will be maximized in 14/15. 149.k Sept 214 Urgent Care Programme Manager Urgent Care Commissioner April 214 Urgent Care Commissioner 53
5. Improved Discharge Process across system Redesign of processes will utilise learning from ECIST, national and best practice from neighbouring health systems. 6. High Impact Team to deal with frequent fliers Use Care Home HIT Team principles 299.9k to investigate transferability to patients in their own home. Emphasis will be on telephone contact and a service they can access not the Hospital. 41.1k* Reduced LOS April 214 Urgent Care Programme Manager A&E attendances, emergency admissions 5.4k Peter Pentecost April 214 Special Projects Lead 7. Adjusted Clinical Model Procurement of new, joined up for Urgent Care -Common clinical service model to sit behind Front Door physical Common Front Door TOTAL Mark Cox 5.k 2,22.8k 31.k 5.k 1,2.k A&E attendances, emergency admissions Mark Cox 216-217 Urgent Care Manager 1,2.k k Care Pathways & Primary Care Programme Board Commissioning Intervention/Intention Actions Net Savings Net Savings Net Savings Net Savings Net Savings 214-15 215-16 216-17 217-18 218-19 Activity Reduction Area Lead Delivered by 1. Implementing a Referrals Mgt Gateway Stage 2 roll out of next 4 specialities 136.4k 36.3k First outpatients/followup Asma Ali Programme Manager February 214 Onwards 2. Development & Improvement of MSK Pathways (including Pain Mgt & PLCV) Increase MSK referrals through triage to maximise use of alternatives to hospital services. Monitor through Practice based budgets. 1,119.k 468.3k First out-patients for Pain Mgt; Orthopaedics and Rheumatology. MSK Inpatient Procedures Liam Clarke Programme Manager June 214 54
3. Development of Managed Care for Ophthalmology Pathway to be finally agreed with provider 44.k 19.1k First Outpatients, Follow Up, O/P Procedures, daycases and inpatients Peter Pentecost May 14 4. Implement Practice Based Budgets Continue to promote practice based budgets to educate primary care to take some responsibility for the consumption of secondary care resources. 43.1k 117.3k Elective day-cases, first outpatients, In hours A/E and UCC attendances. Asma Ali Programme Manager January 214 onwards 5. Re-commission Patient Transport Services Re-commissioning of patient transport services as contract expires. Will incorporate journeys to NGH into block (as currently not) which will reduce the number of Extra contractual journeys and associated payments. Additionally SCAS data shows currently MKCCG underuse their block contract (22k journeys vs. payment for 27k) and therefore by retendering expect to improve efficiency. 19k 19k N/A Liam Clarke Asst. Programme Manager Dec 214 onwards 6. Introduction of Second Tier Pilot in Dermatology Agreed priority with the neighbourhood practice development. Monitor through practice based budgets. 314.k 77.4k First out-patient/followup/op procedure costs Asma Ali Programme Manager April 214 onwards 7. Improved efficiency in C2C and Follow Ups Agree final policy with secondary care consultants. 474.1k 119.3k First outpatients Follow Ups Asma Ali Programme Manager From April 214 8. Direct to Test Oscopies Increase awareness of pathway and monitor take up 225.9k 46.5k First outpatients Follow Ups Asma Ali Programme April 214 55
through Practice based budgets. Manager 9. Review and implement changes to Respiratory pathways. Aim to reduce referrals to the CCG cluster level, monitor through Practice based budgets 277.8k 738.6k Non Elective spells Sandra Vanreyk Care Pathways Manager March 215 1. Review and implement changes to Circulation pathways. Aim to reduce referrals to the CCG cluster level, monitor through Practice based budgets 172.8k 431.7k Non Elective Spells Dawn Garner Care Pathways Manager March 215 11. BCF Integrated Health & Social Care Teams Part of Better Care Fund Plan, initial increases will be commenced in 14/15 and effect will be monitored to inform intended full implementation in 15/16 158.9k 27.1k n/a Joint Commissioning Team/Jane Hainstock Pilot Model in 214/215 Full implementation by March 216 12. BCF 7 Day Working for Intermediate Care Part of Better Care Fund Plan This is weekend working for specific elements of ICS, particularly the ESD team. n/a n/a Joint Commissioning Team/Jane Hainstock March 215 13. Assertive In Reach & Discharge Team Part of Better Care Fund Plan This is particularly needed to supplement the internal hospital team, by combining the skill sets and knowledge of community services it is expected that more discharges will be achieved. 158.9k 27.1k n/a Joint Commissioning Team/Jane Hainstock Pilot Model in 214/215 Full implementation by March 216 14. Hyper Acute Stroke Service Streamline service and pricing between Providers 161.6k Non Elective Spells Sandra Vanreyk March 215 56
Care Pathways Manager 15. Pathology tariff deflator Contractual adjustment 218.1k 16. Continuing Health Care Review Review of placements 5.k n/a John Green, Contract Manager April 214 Jane Hainstock 17. Expansion of Out of Hospital Services 5.k 1,.k First Outpatients, Follow Up, O/P Procedures, daycases and inpatients Tbc 217-219 18. Up skilling Primary Care 216.k 35.k 55.k First Outpatients, Follow Up, O/P Procedures, Tbc 216-219 19. Vertical Integration Adult Services 6.k 6.k 6.k Economies across acute / community pathway Tbc 216-219 1,5.k 2,.k 2,1.k 3,9.k Non Elective Spells Joint Commissioning Team/Jane Hainstock 215-19 4,113.7k 2,816.k 3,55.k 6,5.k Net Savings 215-16 Net Savings 216-17 Net Savings 217-18 Net Savings 218-19 2. Better Care Fund TOTAL 4779.6k Mental Health & Learning Difficulties Programme Board Commissioning Intervention/Intention Evidence for Change Net Savings 214-15 1. Early Intervention for Eating Disorders Local Service Provision of specialist secondary level Out Patient Eating Disorder service in Milton Keynes. The inpatient facility is now commissioned by the NCB to be provided from Investme nt needed Activity Reduction Area n/a Lead Delivered by Tracey Chapman Senior Joint Commissioning Manager Initial benefits will be realised in first 12 months 57
Leicester. The OP service was previously provided from Oxford. The intention is for a community based eating disorder service to be provided locally, in MK, by CNWL. This will be an extension of the service currently provided by CNWL in London and is in line with NICE and commissioning guidance for Eating Disorders that the majority of patients with ED should be managed in the community close to home. 2. Improving the Capacity and Quality of Inpatient Mental Health Services Campbell Centre Business Case (Option 4) review of business case and options currently ongoing Investme nt needed Tracey Chapman Senior Joint Commissioning Manager 31 st March 214 3. Improving access to Psychological Therapies (IAPT) Increase access to talking therapies for people suffering from mild to moderate depression and anxiety to 15% of the prevalent population. Investme nt needed All Tracey Chapman Senior Joint Commissioning Manager Gradual increase in access numbers as capacity increases with achievement of target by end March 215 4. Review of ASTI Specifications Develop in line with Mental Health Strategy n/a Tracey Chapman Senior Joint Commissioning Manager From April 214 58
Maternity, Children & Young People Programme Board Commissioning Intervention/Intention Action Net Savings 214-15 1. Implementing 5 High Impact Pathways for children Review community paediatric nursing service; configuration and development of options for future provision taking into account acute and community services. Expect a decrease in admissions. 55.9k 2. Improving Local CAMHS Service CAMHS Review a) Review and revise emergency and out-ofhours pathway - 24/7 crisis support. B) Review CAMHS T2 and T3 provision in conjunction with MKC and jointly specify in line with needs Intermediate gynaecology service to support the early assessment of gynaecological problems through an effective intermediate gynaecology early referral/treatment for specified conditions (links with RMS triage) investment 3. Implement Intermediate Gynaecology Services 288.3k Net Savings 215-16 TOTAL Net Savings 218-19 159.k 6.k Maternity Pathway Review 344.2k Net Savings 217-18 97.4k 4. Vertical Integration Childrens Services 5. Net Savings 216-17 256.4k 6.k Activity Reduction Area Lead Delivered by A&E Attendances Emergency Admissions Fiona West Programme Manager 214/15 Q3 n/a Fiona West Programme Manager April 215 First outpatient/followup Hillary Jones Head of Quality 214/15 Q1 6.k 6.k Economies across acute / community pathway Tbc 216-19 222.k 525.k Maternity activity Tbc 217-19 822.k 1,125.k 59
Other Commissioning Intervention/Intention Action Net Savings 214-15 Net Savings 215-16 1. CNWL Contract TCS integration Requirements Efficiency Requirements embedded in three year contract 2,.k 2,.k 2. Prescribing Initiatives Various initiatives 1,.k 75.k Net Savings 216-17 75.k Net Savings 217-18 75.k 3. Year of Care Tariff Net Savings 218-19 Lead Delivered by n/a Contract Manager 213-216 75.k n/a Janet Corbett 2,5.k n/a Tbc TOTAL 3.k 275.k 75.k 75.k 3,25.k GRAND TOTAL 1,146.6k 7,421.1k 4,666.k 6,322.k 1,425.k Activity Reduction Area 218-19 6
61
Appendix B 5 Year Outcome Ambitions Ambition 1 (E.A.1): Potential years of life lost from causes considered amenable to healthcare. Definition: Rate of potential years of life lost from causes considered amenable to healthcare. Numerator: Annual ONS avoidable mortality for England. Denominator: ONS mid-year population estimates of the relevant age group and gender. Baseline year: 212 (Note that this is a Quality Premium indicator in 214/15). Planned Rate Persons Females Males Indicator Years of life lost GP registered population 29 21 211 212 2,964 2,984 2,85 2,441 134,48 134,48 134,48 134,48 Rate 2,41 2,432 2,255 2,48 Years of life lost 2,232 2,253 2,416 2,137 GP registered population Rate Years of life lost GP registered population Rate National average CCG Rank 133,566 133,566 133,566 133,566 1,782 1,837 1,933 1,85 5,197 5,237 5,221 4,578 267,974 267,974 267,974 267,974 2,77 2,135 2,97 1,927 2117 2172 2111 261 99 1 14 73 2.8% -1.8% -8.1% Yearly Growth 2,2 2,15 2,1 2,5 2, 1,95 1,9 1,85 1,8 1,75 1,7 213/14 214/15 215/16 216/17 217/18 218/19 1,865 1,847 1,828 1,81 1,792-3.2% -1.% -1.% -1.% -1.% E.A.1 Outcome Ambition 1: What is your ambition for securing additional years of life from conditions considered amenable to healthcare? CCG Plan England 29 21 211 212 213/14 214/15 215/16 216/17 217/18 218/19 Comments: To achieve the Quality Premium, the CCG must achieve a reduction of no less than 3.2% in the rate of potential years of life lost from amenable mortality between 213 and 214. The 213 baseline position will not be published until mid-214. 62
Ambition 2 (E.A.2): Health-related quality of life for people with long-term conditions. Definition: Average health status (EQ-5D) score for individuals who identify themselves as having a long-term condition. Numerator: The sum of weighted EQ-5D values for all responses from people identified as having a long term condition. Denominator: The weighted count from all people identified as having a long term condition. Baseline year: 212 Planned Rate Persons Females Males Indicator 211/12 212/13 213/14 214/15 215/16 216/17 217/18 218/19 EQ-5D per 1 Patients EQ-5D per 1 Patients EQ-5D per 1 Patients National average 74.7 75.2 72.9 73.1 75.5 75.8 76.1 76.4 76.7.4%.4%.4%.4%.4% CCG Rank Yearly Growth 77 77 76 76 75 75 74 74 73 73 72.7% E.A.2 Outcome Ambition 2: What is your ambition for improving the health-related quality of life for people with long-term conditions? CCG Plan England 211/12 212/13 213/14 214/15 215/16 216/17 217/18 218/19 Comments: The data source for this indicator is the GP Patient Survey. 63
Ambition 3 (E.A.4): Composite measure on emergency admissions. Definition: This is a composite measure of: Numerator: Unplanned hospitalisation for chronic ambulatory care sensitive conditions. Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s. Emergency admissions for acute conditions that should not usually require hospital admission. Emergency admissions for children with lower respiratory tract infections. Includes any admission matching the criteria in any of the 4 individual indicators published by the HSCIC. Denominator: The sum of population registered with each CCG s practices, October 213. Baseline year: 212/13 (Note that this is a Quality Premium indicator in 214/15). Planned Rate Persons Females Males Indicator 29/1 21/11 211/12 212/13 213/14 214/15 215/16 216/17 217/18 218/19 Emergency admisisons GP registered population Rate Emergency admisisons GP registered population Rate Emergency admisisons GP registered population Rate National average 1,879 1,927 1,95 1,97 1912 2 1996 254 2.5% 1.2% 1.% 1,968 1,965 1,96 1,959 1,957 -.1% -.2% -.3% -.1% -.1% CCG Rank Yearly Growth The chart below plots the proposed trajectory to reduce the growth in emergency admissions. E.A.4 Outcome Ambition 3: What is your ambition for reducing emergency admissions? 2,1 CCG Plan 2,5 England 2, 1,95 1,9 1,85 1,8 1,75 29/1 21/11 211/12 212/13 213/14 214/15 215/16 216/17 217/18 218/19 Comments: Achievement of the Quality Premium requires a reduction or zero per cent change in emergency admissions for these conditions between 213/14 and 214/15. In the absence of the 213/14 baseline plans have been submitted to achieve a.1% fall on the 213/13 position. 64
Ambition 4 (E.A.5): Patient experience of hospital care. Definition: Patient experience of hospital care, as reported by patients to the CQC inpatient survey. Numerator: Total number of poor responses. Denominator: Total number of respondents to the survey questions. Baseline year: 212 Planned Rate Persons Females Males Indicator 212/13 213/14 214/15 215/16 216/17 217/18 218/19 Poor responses Respondents Rate of poor experience Poor responses Respondents Rate of poor experience Poor responses Respondents Rate of poor experience National average 181.5 172.8 164.5 156.6 149.1 141.9-4.8% -4.8% -4.8% -4.8% -4.8% 142. CCG Rank Yearly Growth 19 E.A.5 Outcome Ambition 5: What is your ambition for increasing the proportion of people having a positive experience of hospital care? CCG Plan England 18 17 16 15 14 13 212/13 213/14 214/15 215/16 216/17 217/18 218/19 Comments: The latest available data places MKHFT in the top decile of providers based on poor hospital experience. The planned rate will improve patient experience to the current national average by the end of 218/19. 65
Ambition 5 (E.A.7): Composite indicator comprised of i) GP Services ii) GP Out of Hours Definition: Rate of responses of either fairly poor or very poor experience across General Practice and Out of Hours services per 1 patients. Numerator: Total number of responses of either fairly poor; or very poor experience. Denominator: Total number of respondents to the survey questions. Baseline year: 212 Planned Rate Persons Females Males Indicator 212/13 213/14 214/15 215/16 216/17 217/18 218/19 Patients dissatisfied Total responses Poor Experience Rate Patients dissatisfied Total responses Poor Experience Rate Patients dissatisfied Total responses Poor Experience Rate National average 9.8 9.3 8.9 8.2 8. 7.8-5.1% -4.3% -7.9% -2.4% -2.5% 6.1 CCG Rank Yearly Growth 11 E.A.7 Outcome Ambition 6: What is your ambition for increasing the proportion of people having a positive experience of care outside hospital, in general practice and the community? CCG Plan 1 England 9 8 7 6 5 212/13 213/14 214/15 215/16 216/17 217/18 218/19 66
National Target 1 (E.A.3): IAPT Roll-Out Definition: The proportion of people that enter treatment against the level of need in the general population i.e. the proportion of people who have depression and/or anxiety disorders who receive psychological therapies. Numerator: Total number of people who receive psychological therapies. Denominator: The number of people who have depression and/or anxiety disorders. (Note that this is a Quality Premium indicator in 214/15) Planned Rate 212/13 Indicator People w ith depression/anxiety 213/14 Q1 Q2 Q3 Q4 Q1 Q2 Q3 26,724 26,724 26,724 26,724 26,724 26,724 26,724 214/15 Q4 Q1 Q2 Q3 Q4 YTD 26,724 26,724 26,724 26,724 26,724 People w ho are referred for PT 794 886 1,23 1,44 1,56 967 1,14 1,126 1,375 1,46 2,394 6,356 People w ho have entered PT 355 28 382 384 545 476 42 548 561 575 1,2 2,686 Completed treatment Completed treatment and moving to recovery Completed treatment but did not achieve caseness People w ith depression/anxiety w ho receive PT 25 37 21 277 35 38 273 338 51 346 627 1,821 74 15 54 94 15 161 1 153 222 146 282 84 28 93 21 25 23 29 2 31 65 55 62 213 Proportion moving to recovery* 1.33% 1.5% 1.43% 1.44% 2.4% 1.78% 1.57% 2.5% 2.1% 2.15% 3.75% 1.1% 33.3% 49.1% 28.6% 37.3% 37.2% 45.9% 39.5% 5.% 5.% 5.% 5.% 5.% (213/14 shows latest data available) Comments: To achieve the Quality Premium in 214/15 the CCG must achieve an IAPT roll-out rate of 3.75% in quarter 4 and a recovery rate of 5%. 67
National Target 2 (E.A.S.5): Healthcare acquired infection measure (clostridium difficile) Definition: Number of Clostridium difficile infections (CDIs) for patients aged 2 or more; defined as a case where the patient shows clinical symptoms of C. difficile infection and has a positive laboratory test results for CDI recognised as a case according to the Trusts diagnostic algorithm. Providers are only attributed cases where the sample was taken post 72 hours of admission. 214/15 Indicator Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Planned Trajectory 3 3 4 6 6 5 8 7 7 5 4 5 63 Comments: The CCG was given a target of no more than 63 cases in 214/15. The target has been profiled based on historical activity. National Target 3 (E.A.S.1): Estimated diagnosis rate for people with dementia Definition: Diagnosis rate for people with dementia, expressed as a percentage of the estimated prevalence. Comments: The CCG has planned to achieve a dementia diagnosis rate of 67% by March 215 as mandated in Everyone Counts. Local Quality Premium Target: % admission to an acute stroke unit within 4 hours of arrival at hospital. Definition: People who have had a stroke who are admitted to an acute stroke unit within four hours of arrival at hospital. This is consistent with The National Institute for Health and Care Excellence (NICE) guidance, which recommends that all people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department. Numerator: the number of acute stroke patients whose first ward of admission is a stroke unit and who arrive on the stroke unit within four hours of arrival at hospital, except for those patients who were already in hospital at the time of new stroke occurrence, who should instead be admitted to a stroke unit within four hours of onset of stroke symptoms. Denominator: All patients admitted to hospital with a primary diagnosis of stroke, except, for those whose first ward of admission was ITU, CCU or HDU. The CCG Outcomes Indicator Set lists the data source as the Sentinel Stroke Audit Programme. This information has not previously been collected at CCG level and moreover will not be reported until December 214. This presents a 68
Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 challenge in terms of the formulation of a baseline and improvement trajectories. In the absence of robust commissioner-level data the CCG has chosen to base achievement of the target on delivery of the indicator at Milton Keynes NHS Foundation Trust. The Trust reports robust and timely stroke performance in the monthly Service Quality Performance Report. Historical performance is charted below. 7% 6% 5% 4% 3% 2% 1% % Stroke Patients Admitted to an Acute Stroke Unit Within 4 Hours of Arrival Between April 213 and January 214 25% of people who had a stroke were admitted to an acute stroke unit within 4 hours of arrival. The 6% reported in January is the worst performance since May 211. The CCG in discussion with the Health and Welling Board has set a challenging improvement trajectory of 7% for 214/15 with a view to stretching this target further in 215/16 to 95%, in order to ensure patients are assessed and receive specialist stroke care within a maximum of 4 hours of admission. 69
Appendix C 5 Year Financial Plan Milton Keynes CCG 5 Year Financial Plan 213/14 Budget setting ' 214/15 215/16 216/17 217/18 218/19 Plan ' Plan ' Plan ' Plan ' Plan ' Baseline Allocation 246,977 244,68 255,195 265,221 275,931 286,92 Revised baseline allocation 246,977 244,68 255,195 265,221 275,931 286,92 5,68-7,977 6,51 1,515 1,26 1,71 1,989 8,367 6,51 32 6,542-614 5,928 38 5,966 36 6,2 35 251,19 261,737 271,149 281,897 292,922 31,324 3,325 1,847 1, 4,258 1, 4,258 975 2,79 4,258 975 2,89 4,258 975 3,1 256,362 262,737 276,47 289,92 31,45 39,558 229,876 6,51 24,11 255,839 269,61 279,892 236,386 235,543-3,325 6,51-93 125 238,76 6,542-741 127 246,29 5,928-92 13 261,85 5,966-96 132 275,63 6,2-1 135 285,929 1,55 13,81 1,933 246,892 254,52 8,182 1,933-8,3 13,788 261,92 2,874 1,933 2, 268,611 2,333 1,933 2,53 281,859 3,161 1,933 3,5 294,523-4,69 3,663-3,663 3,767-3,783 3,865-3,865 4,35-4,35 4,186-4,186 4,329 Baseline expenditure 245,946 254,66 261,985 268,781 282,11 294,666 Provider Efficiency Requirement Provider Inflation Activity and Popn Growth Other Inflation (including prescribing) sub-total operational budgets -8,169 5,951 9,3 1,562 254,591-7,587 5,591 6,636 1,73 26,977-7,269 5,741 7,224 1,766 269,447-7,447 9,559 8,879 1,854 281,626-7,773 7,752 1,211 1,948 294,149-8,66 8,9 9,85 2,46 36,541 1,269 5,1 1,314 2,627 1,39 2,781 1,445 2,83 1,5 2,876 1,543 2,924 5,288 1, 3,941 3,867 7 1, 2,781 2,266 7 2,79 2,83 2,266 7 2,89 2,876 2,266 7 3,1 2,924 2,266 7 3,86 Total Gross expenditure 267,247 274,426 282,154 294,586 37,367 319,983 QIPP Gap (exp-allocn) -1,885-11,688-5,747-4,666-6,322-1,425 Total Net expenditure 256,362 262,737 276,47 289,92 31,45 39,558 4.33 4.47 2.12 1.66 2.16 3.46 Anticipated Allocations Growth In Year Changes - Recurrent Running Costs Running Cost allocation growth Recurrent Non recurrent Add Quality Premium (assumed 75%) Add surplus from prev year Total Anticipated Allocation Planned Expenditure Previous Year FOT (excluding reserves) Less Non Recurrent Spend Management Management Savings Required Management inflation sub-total baseline expenditure Previous years pressures 3% marginal rate activity revisions BCF Offset against existing spend Transfer to BCF baseline exp incl pressures Less CQUIN from previous year Add CQUIN for current year.5% Contingency Transformation fund @ 1% from 14/15 Non Recurrent Reserve (1.5% in 14/15 & 1% thereafter) Other reserves New Fund for over 75s investment Surplus at 1% Total Exp - Total Allocn QIPP as a % of recurrent allocation 7
Appendix D QiPP Plan Phasing Year 1 NHS Milton Keynes CCG 4F QIPP 214/15 Saving Profile ( ) Local Scheme Name (over.5m) Area of Spend (select from drop down menu) April May June July August Sept. Oct. Nov. Dec. Jan. Feb. March Total Transactional Productivity and Contractual Efficiency Savings Pathology Tariff Change Acute contracts -NHS (includes Ambulance services) (18) (18) (18) (18) (18) (18) (18) (18) (18) (18) (18) (18) (218) Continuing Care Package Tariff Continuing Care Services (All Care Groups) (42) (42) (42) (42) (42) (42) (42) (42) (42) (42) (42) (42) (5) Community & Mental Health Contract Agreement CH Contracts - NHS (167) (167) (167) (167) (167) (167) (167) (167) (167) (167) (167) (167) (2,) Prescribing Efficiency Prescribing (83) (83) (83) (83) (83) (83) (83) (83) (83) (83) (83) (83) (1,) Sub Total (31) (31) (31) (31) (31) (31) (31) (31) (31) (31) (31) (31) (3,718) Balance of Schemes under (.5m) CH Contracts - NHS (3) (3) (3) (3) (3) (4) (19) - - Balance of Schemes under (.5m) Total - - - - - - (3) (3) (3) (3) (3) (4) (19) Transactional Productivity and Contractual Efficiency Savings (31) (31) (31) (31) (31) (31) (313) (313) (313) (313) (313) (314) (3,737) Transformational Service Re-design and Pathway Changes Planned Care - Integrated Musculo Skeletal Service Acute contracts -NHS (includes Ambulance services) (8) (14) (26) (72) (73) (73) (26) (26) (26) (23) (367) Planned Care - Low Priority policy changes Acute contracts -NHS (includes Ambulance services) (1) (1) (1) (63) (63) (65) (65) (65) (65) (65) (65) (52) Planned Care - Referral Management Service & pathway Acute contracts -NHS (includes Ambulance services) (19) (47) (56) (64) (71) (71) (71) (71) (71) (71) (71) (71) (754) Planned Care - Other Practice Budget management Acute contracts -NHS (includes Ambulance services) (3) (9) (18) (27) (32) (33) (34) (36) (36) (36) (36) (37) (337) Urgent Care - High Impact team in Nursing Homes Acute contracts -NHS (includes Ambulance services) (67) (86) (86) (86) (86) (86) (86) (86) (86) (86) (86) (89) (1,16) Urgent Care - Improve discharges from hospital Acute contracts -NHS (includes Ambulance services) (34) (34) (34) (34) (34) (34) (34) (34) (34) (34) (34) (34) (41) Long Term Conditions - Reductions in Respiratory & circuacute contracts -NHS (includes Ambulance services) (66) (113) (136) (136) (451) Better Care Fund Investment in Integrated Health & SociAcute contracts -NHS (includes Ambulance services) (32) (72) (72) (72) (7) (318) Intermediate Gynaecology Service Acute contracts -NHS (includes Ambulance services) (9) (22) (33) (37) (37) (37) (37) (38) (38) (288) Planned Care - Direct to test endoscopy Acute contracts -NHS (includes Ambulance services) (6) (14) (18) (19) (19) (19) (19) (19) (19) (19) (19) (19) Urgent Care - High Impact team for frequent flyers Acute contracts -NHS (includes Ambulance services) (4) (15) (18) (29) (29) (29) (29) (29) (29) (29) (29) (31) (3) Investment for above projects CH Contracts - Other providers (non-nhs, incl. VS) 7 7 7 7 7 7 7 7 7 7 7 7 835 - - Sub Total (58) (129) (166) (213) (313) (371) (378) (412) (471) (518) (542) (544) (4,116) Balance of Schemes under (.5m) Acute contracts -NHS (includes Ambulance services) (18) (31) (53) (74) (81) (12) (123) (132) (142) (141) (141) (146) (1,22) Acute contracts - Other providers (non-nhs, incl. VS) (3) (7) (11) (24) (32) (32) (32) (25) (25) (25) (26) (242) Acute - NCAs (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (17) CH Contracts - Other providers (non-nhs, incl. VS) 35 35 35 35 35 35 35 35 35 35 35 35 416 Balance of Schemes under (.5m) Total 15 (1) (27) (52) (72) (119) (122) (131) (134) (133) (133) (139) (1,45) Transformational Service Re-design and Pathway Changes (42) (13) (193) (265) (385) (49) (5) (543) (65) (651) (675) (682) (5,161) Unidentified QIPP Other Programme Services (257) (257) (257) (257) (257) (257) (1,539) - Total Unidentified QIPP - - - - - - (257) (257) (257) (257) (257) (257) (1,539) Total QIPP Schemes (352) (44) (53) (575) (694) (799) (1,7) (1,113) (1,175) (1,22) (1,245) (1,253) (1,437) QIPP Profile % 3.4% 4.2% 4.8% 5.5% 6.7% 7.7% 1.2% 1.7% 11.3% 11.7% 11.9% 12.% Total Expenditure Profile % 8.% 8.5% 8.2% 8.4% 8.% 8.2% 8.2% 7.9% 7.9% 8.% 7.8% 11.% 71
Appendix E 5 Year Better Care Fund Financial Plan 72
Appendix F Better Care Fund Detailed Schemes (Final@4/4/14) 73
Appendix G 74