Worcestershire CCGs Commissioning Intentions 2012-14
1. INTRODUCTION This collaborative document details the commissioning intentions of Worcestershire s three Clinical Commissioning Groups (CCGs) covering a population of 576,538 (South Worcestershire 292,747 Redditch and Bromsgrove 171,736 and Wyre Forest CCG 112,005; serving 67 practices across the county of Worcestershire. With a commissioning portfolio worth in the region of 293m the activity commissioned from the acute sector is around 750,000 outpatient attendances, 85,000 planned admissions, 135,000 A&E attendances and 45,000 emergency admissions each year. CCGs commissioning portfolio is diverse due to the large geographical footprint of Worcestershire. Contracts are held with healthcare providers in Oxford up to Birmingham and Shropshire although predominately services are secured from Worcestershire Acute Hospitals NHS Trust and Worcestershire Health and Care Trust (Evesham, Malvern, Tenbury and Bromsgrove Community Hospitals). Worcestershire commissioners also have strong links with a number of providers in close proximity to CCGs. For South Worcestershire with Gloucestershire Hospital s NHSF Trust, Dudley Hospitals NHSF Trust in Wyre Forest and University Hospitals NHSF Trust R&BCCG. Additionally, strong links have been forged with the two independent sector providers in Worcestershire and third sector organizations. In order to improve patient outcomes CCGs in Worcestershire place high importance on integrated care with seamless pathways that should transcend organizational boundaries. This document, whilst building on the existing 2012/13 Commissioning Intentions brings acute services and community services commissioning intentions together into one combined document. This document will inform the contract negotiations and plans for each of the three CCGs in Worcestershire in 2013/14 and beyond. This document is work in progress and whilst concentrating, at this time, on short term ambitions will be further developed to include longer term strategic direction. 2. COLLABORATIVE ARRANGEMENTS In order to reduce transactional costs yet optimising the existing expert commissioning skills available locally, the three CCGs in Worcestershire have agreed to work collaboratively in the commissioning of healthcare services. To this end, there is a small CCG Commissioning Team who will lead the commissioning of contracts for the three CCGs with the support of The Arden Commissioning Support. Working within this framework will ensure consistency in quality of services for all patients in Worcestershire and avoid unnecessary duplication of effort and resource from both a provider and commissioner perspective. Furthermore collegiate working will make best use of clinical time ensuring that where service an performance reviews are conducted one CCG clinical lead may represent their partner organizations. It is important to Page 2 of 35
remember that each CCG is still responsible for retaining accountability for the commissioning of services therefore robust governance arrangements are in place for collaborative commissioning. A range of stakeholders have been involved in shaping this document through ongoing work to develop and redesign services, including acute and community service providers, Local Authority and voluntary sector organisations. Practice locality group and their Patient Representative Groups have all had an opportunity to influence and shape these Commissioning Intentions in addition to the contributions from the various service redesign workstreams and QIPP projects. 3. CONTEXT It is widely accepted that existing patterns of care and demand within systems cannot be simply replicated into the future and that local system change is critical to deliver improved patient outcomes and productivity throughout the system. Commissioners require the provider to collaborate in the development and delivery of the system plan; demonstrating commitment to change even in the absence of business benefit. Signing up to joint working to achieve responsive, proactive care which systematically meets the needs of individuals regardless of organizational boundaries will ultimately achieve improved patient outcomes. Acknowledging that each CCG has its own priorities and local plans to develop services, appendices 1, 2 and 3 detail these for each respective CCG. To inform individual CCG plans activity adjustments resulting from such schemes will be included within activity modeling; clearly identified through the production of an activity assumptions audit trail. As per the Contract Clause 38 in year service change will be appropriately notified through the serving of formal notice of such activity and financial variations. Unless the service change is material requiring a longer timescale to adjust capacity commissioners expect providers to be proactive in agreeing to service variations. Faced with the challenge of rising healthcare inflation, demographic growth and new expensive technologies and drugs, Worcestershire s CCGs are working collaboratively with local healthcare providers in consideration of the case for change. The extent of the financial change in Worcestershire, which is similar across the rest of the country, is such that clinicians are of the view that radical service transformation and centralisation, where clinically beneficial, is required in order to continue to deliver safe, high quality care. Over the coming months CCGs will continue to work with the Worcestershire Acute Hospitals NHS Trust and other stakeholders in the review of the way hospital services are delivered, making best use of capacity and resources. Whilst this work is in its infancy it will form a major area of priority for the CCG over the coming months requiring detailed financial appraisal and activity modelling. As the work progresses and plans are firmed up this iterative document will be further developed and refined. A range of documents will inform the further development of this document including, but not mutually exclusive, The Worcestershire Joint Health and Well-being Strategy 2012-15, the 2013/14 Operating Framework and CCG s Integrated Plans. Page 3 of 35
4. KEY PRINCIPLES Driving an improvement in quality, innovation, productivity and maintaining financial balance, the CCGs will continue to monitor their existing QIPP schemes and explore further opportunities with partner organizations. CCGs will endeavour to explicitly detail the schemes and planned outcomes to ensure that the commissioning plans are robust and that providers have confidence in deliverability. Provider Service Improvement Plans (SIP) should be explicit, transparent and available to commissioners to give CCGs the necessary assurance that the quality of service will not deteriorate and staffing levels are maintained to such a level that patient safety and the quality of service is not compromised. Achieving truly integrated care pathways will require joined up health and social care services that revolve around the patient, improving patient outcomes and experience. The production of robust data which provides CCGs and their consistent practices with confidence that data is accurate. This is particularly important when GP referral data is used to challenge referral trends. Moreover that the clinical coding of data is appropriate to the intervention and financial cost attributed. CCGs wish to work with providers who share their vision, who wish to work in partnership with other providers to achieve the best outcomes for patients irrespective of organizational boundaries and financial interests. To this end, providers will work to move provision of care into the community or use ambulatory care models to replace traditional inpatient care. This will require providers to work in partnership, exploring different funding mechanisms such as sharing tariff. Through these Commissioning Intentions and associated contractual documents: activity / financial plans, quality schedules, CQINN plans and service specifications with defined KPIs, Providers should be clear about expectations and service quality. These will be robustly performance managed through the collaborative arrangements in place. Deviances from plans including failure to meet required standards will require prompt action from parties and remedial actions agreed in a timely manner. 5. ACTIVITY MODELLING The activity model, based on a 12 month rolling average, will be developed in partnership with commissioners and the respective provider. Individual CCG level plans will incorporate individual planning assumptions and demographic changes and growth assumptions. The agreed baseline will be adjusted, at full cost to reflect expected demand and service repatriation. The national efficiency requirement will be factored into non PbR tariffs (may be offset by pay and price inflation). CQUIN schemes to be determined by the Commissioners and agreed with providers will be set as per the national level (currently payable at 1.5%). This rate will not be payable on PBR Page 4 of 35
excluded drugs and devices as these are pass-through costs. Market Forces Factor (MFF) will be payable as per the nationally calculated percentage. 6. PATIENT QUALITY & SAFETY This Commissioning Quality and Patient Safety Strategy is a short-term strategy developed in partnership by the three Clinical Commissioning Groups (CCGs) in Worcestershire. The strategy sets out the CCGs respective ambitions for their patients, together with their commitment to work together and in their individual CCGs to commission high quality health care for the patients of Wyre Forest, Redditch and Bromsgrove and South Worcestershire. The strategy focuses on the three domains of quality defined in High Quality Care for All (2008): Safety: do no harm keep patients as safe as possible; Effectiveness: success clinically effective and cost effective treatments; and Patient experience: quality of caring understanding patient satisfaction through their experiences. The strategy also reflects the five domains of the NHS Outcomes Framework (2011): Preventing people from dying prematurely; Enhancing quality of life for people with long-term conditions; Helping people recover from periods of ill health or following injury; Ensuring people have a positive experience of care; and Treating and caring for people in a safe environment; and protecting them from avoidable harm. Quality will be the key consideration in the commissioning of services and the strategy will both support the implementation of Quality, Innovation, Productivity and Prevention (QIPP) and quality assurance of services. Implementation of the strategy will also address the quality priorities outlined in The Operating Framework for the NHS in England 2012/13. 7. SERVICE SPECIFIC DETAILS The table below provides details behind some of the service areas and major reviews, projects which will influence provider plans. The activity behind these will be quantified within the activity modelling: 1. Joint Service Review 2. Worcestershire s Joint Health and Well-being Strategy 3. QIPP Plans 4. Stroke Services 5. Unscheduled Care 6. Long Term Conditions 7. Planned Care 8. Dementia 9. Self-Care Page 5 of 35
10. Carer s Strategy 11. Medicine s Management 12. Providers Role in Health Protection and Major Incident Response 13. Cancer Services 14. Clinical Pathways 15. End of Life 16. 18 Week Referral to Treatment Times (RTT) 17. Individual Funding Requests and Prior Approval Page 6 of 35
Worcestershire s Joint Health and Well-being Strategy Joint Service Review SERVICE AREA INTENTIONS CCG Clinical leads are working with Worcestershire Acute Hospitals clinicians and managers in the review of the way hospital services are delivered, making best use of capacity and resources available.. The four clinical areas are: Elderly Care, Women s and children s services, planned care and emergency care. However services are reconfigured in the future community service provision will be key in ensuring, where appropriate, patient care is as close to home as is possible. Following public consultation on the potential reconfigurations of acute services in Worcestershire the selected option will determine the timescale for service change therefore the Commissioning Intentions will be adjusted over time in agreement with partners. ACUTE To be identified in due course COMMUNITY The reconfiguration of acute services may provide community services with an opportunity to expand service provision whilst enhancing care pathways. Worcestershire s Joint Health and Well-being Strategy Worcestershire s Joint Health and Well-being Strategy, currently out for consultation, sets out the priorities and goals for 2012-15, based on the Joint Strategic Needs Assessment. Of the five priorities outlined below, some of them will require long term action to improve education, employment, housing, transport and the environment. Others need to be addressed in the short term, with action to improve and integrate health and social care services. The priorities are: Older people and management of long term conditions Mental health Obesity Alcohol Acute hospital services For each of the priorities the Health and Well-being Board will set a series of outcomes, with associated indicators to allow progress to be measured and action plans to be monitored. Once the work-streams are set up and action plans developed these will be considered in light of these commissioning intentions. Page 7 of 35
QIPP SERVICE AREA QIPP Plans ACUTE INTENTIONS Providers will work jointly with commissioners to deliver the CCG s QIPP schemes. Where concerns are raised regarding delivery of a project s aims and object, a review will be undertaken to agree the mitigating actions required. Additionally CCGs will refresh the QIPP activity assumptions on an annual basis whilst exploring other initiatives and opportunities for improving quality and productivity. Providers are expected to be responsive to commissioners needs in this respect. COMMUNITY Page 8 of 35
Stroke Services SERVICE AREA INTENTIONS NHS Midlands and East Cluster Strategic Health Authority is undertaking a review of stroke and TIA services to identify how it can improve the quality of patient care including clinical outcomes and patient experience. Currently the quality of patient care varies considerably across the whole stroke patient s care pathway. This is illustrated by achievement against a number of quality care standards including NICE, the Care Quality Commission s Review of stroke services and performance against the NHS Accelerating Stroke Improvement. The review aims to set a performance baseline across the whole pathway that will enable robust evaluation of the outcomes from the review and that will also see support services further refined where necessary to achieve the required improvements. By working together the CCG and its partners aim to improve stroke services to bring significant benefits to patients by increasing survival rates; improving quality (e.g. reducing disability; shortening recovery times); and improving patient experience. The work will be undertaken with full engagement with service users and carers. The work will reflect the whole pathway of care; ensuring that patients suffering a stroke receive the best care possible at all stages of their stroke journey; giving them the best chances of survival and the fullest recovery possible. A service specification has been produced that spans the whole pathway of care from primary prevention to life after stroke, and ultimately, end of life. This has been produced with the expertise of an External Expert Advisory Group (EEAG). Running in parallel to this work Commissioners have agreed that acute stroke services for Worcestershire should be centralised as soon as possible so that the service can achieve the infrastructure and processes recommended by the National Stroke Strategy and NICE guidance. This change should lead to improvements in mortality, reductions in length of stay for people with stroke and reduced long-term disability and enable best practice tariffs to be achieved. The implementation plan is currently being drafted which will see services for Worcestershire s population being delivered from a dedicated stroke ward on the Worcestershire Royal Hospital site from November 2012. ACUTE COMMUNITY The implementation team will be working with community services to ensure that where possible rehabilitation post acute phase can be delivered in appropriate facilities closer to patients homes. Commissioners require assurance that community services have appropriately trained staff in order that nasal gastric feeds can be managed outside an acute setting Commissioners require assurance that community services have appropriately trained staff in order that nasal gastric feeds can be managed outside an acute setting Page 9 of 35
Unscheduled Care SERVICE AREA A&E Services INTENTIONS CCGs expect providers to achieve and sustain the A&E standard 95% patients treated within four hours. South Worcestershire CCG clinical leaders, on behalf of Wyre Forest CCG and Bromsgrove and Redditch CCG will continue to work in partnership with the Trust in the delivery of the joint action plan to ensure there are no system blockages and that primary care services are being fully utilize. Given Worcestershire s poor performance during 2011/12 and the first half of 2012/13 CCGs place great importance on the delivery of this key standard. Failure to achieve and sustain this standard is not acceptable such that commissioners will not hasten to issue a performance notice or impose a financial penalty. Ambulance Turnaround Times Emergency Re-admissions within 30 Days The Midlands and East SHA require providers to achieve a 15 minute clinical handover period (from recorded time of arrival at A&E to trolley clear ). Where the Provider fails to achieve the 80% threshold in any month a contractual financial penalty will be applied. Details of the financial calculation will be included in the revised quality schedule. The work of the clinical audit task and finish group will inform the threshold above which there will be no provider reimbursement for emergency readmissions within 30 days following an emergency or elective episode. ACUTE COMMUNITY Page 10 of 35
Long Term Conditions SERVICE AREA INTENTIONS The emphasis on managing long term conditions in line with the principles of the Health and Social Care risk stratification model continues. Public Health in partnership with the Jointly Commissioned Health and Well-being Service will continue to invest in low level prevention services such as foot care, the OT mobile assessment vehicle, Life Style Matters courses. The use of the risk stratification tool will continue to be used across the three CCGs to identify patients at high risk of admission to hospital in order to reduce the number of emergency admission to hospital. The focus will be to manage patients within the community, thereby reducing the likelihood of the patient requiring crisis intervention. Staff with responsibility for managing the needs of patients with long term conditions in both acute and community settings will be expected to continue to contribute to this work through the identification of patients at high risk of admission, ensuring risk reduction plans are in place and supporting patient s to reduce emergency admissions and facilitate early supported discharge. The focus on ensuring services are in place to support admission prevention and early supported discharges will remain a priority for Commissioners in 2013/14. During 2013/14, Commissioners will continue to optimize the potential for use of telehealth and telecare to help people stay in their own homes. The Adult Joint Commissioning Unit has established an active Telehealth Care Commissioning Group. Current projects include falls, dementia/mental health, end of life, intermediate care, care homes, carers, call alarms, learning disabilities and assistive technology. The aim is to enable patients to manage their own conditions and improve the efficient use of healthcare resources. This will require different ways of working and will continue to be rolled out during 2013/14. This should also be identified as a key area for development in the Providers Clinical Strategy. As part of the Commissioners commitment to ensuring successful implementation and roll-out of telehealth care, clinical champions will be identified to lead on the implementation within the various professional groups. Hospital at Home Review the opportunities for expanding H@H into other areas of South Worcestershire. Embedding the admission avoidance element of the service into the existing core service. ACUTE COMMUNITY Page 11 of 35
Planned Care SERVICE AREA Reducing Unnecessary OP Appointments INTENTIONS To reduce unnecessary out-patient appointments patients the Provider is expected to comply with the Commissioning Policy for Reducing Unnecessary OP Appointments. Patients are to be discharged to their GP where: The treatment regime is stable; The condition/problem is one that can be reasonably managed in primary care. Routine surgery, unless clinically appropriate. First OutPatient Attendances In developing provider activity plans latest NHS Comparators data will be used to influence commissioning activity plans. Where there are variances from national averages for Worcestershire s population commissioners will work with the provider to review pathways, consider different models of care, where appropriate, outside an acute setting New to Follow Up Ratios The Provider is expected to operate within the new to follow up OP ratios set by commissioners based on the NHS Comparators national averages as a minimum. A table outlining these will feature in the contract and will outline the maximum ratios expected during 2012/13. No payment will be made to the Provider for activity over the stipulated ratios without discussion with the Commissioner. The ratios will take into account follow up attendances which are consultant led and non consultant led (both within and outside tariff). Ophthalmology Services Stable Glaucoma Pathway (Level 2) Commissioners are committed to achieving the best practice guidelines within the National Institute for Health and Clinical Excellence (NICE) Clinical Guideline on Glaucoma: Diagnosis and Management of Chronic Open Angle Glaucoma and Ocular Hypertension (CG85 April 2009). During 2012/13 commissioners will scope the potential for a community optometric service to monitor patients with stable chronic open angle glaucoma (COAG) and ocular hypertension (OH) outside of secondary care based ophthalmic services. Provision will be within the current NICE guidelines and will ensure stable glaucoma patients are managed within an appropriate clinical setting with access to all relevant assessments including Goldmann applanation tonometry and gonioscopy when clinically indicated. The scheme is being refreshed 2012/13 and any activity adjustments required will be reflected in the activity modeling assumptions. Pears Service/R&B Community Eye Service Building on the successful development of a community based Primary eye care acute referral scheme (PEARS), operating in South Worcestershire and Wyre Forest, and the R&B Community Eye Service set up to manage and treat patients with common ophthalmic conditions in the community, the provider will agree and implement the ophthalmology service specification. Page 12 of 35
Neurology Commissioners in collaboration with relevant stakeholders have conducted a review of neurology services in Worcestershire. A service specification for Neurology out-patient services has been developed as a result of that review and the expectation is that, subject to CCG approval, it will be implemented in 2012/13. The review also outlines a service model that will support an enhancement of multi-disciplinary working and, where appropriate, the development of Consultant Outreach clinics. The aim of the service model is to improve the levels of integrated care between acute and community services, enhancing the quality of service provision. The Provider and its subcontracted Neurology Consultants will be expected to work collaboratively with all appropriate organisations to deliver the requirements of the acute service specification and the wider service model of integrated working. To improve patient experience the provider will reduce the number of patients booked into clinics, providing appointment slots in accordance with the timings outlined in the jointly agreed service specification. Commissioners are currently considering a proposal to develop an adult epilepsy nursing service for implementation in 2012/13. A reduction in admissions to A&E is expected and will be quantified in preparation for a contract variation to be agreed in-year. Orthopaedic Services Evaluation of the three Musculoskeletal Integrated Clinical Assessment and Treatment services (ICATs) will be undertaken in November 2012 to inform the commissioning plans for 2013 and beyond. ICAT services will be competitively tendered during 2012/13 in preparation for contract award by the end of March 2013. Analysis of OP orthopaedic referrals to secondary care services, illustrate a trend increase in recent months. The orthopaedic group will review further opportunities to utilize ICAT services to possibly include rheumatology and pain management referrals. Community Dietetics Adult Community Services: Subject to successful evaluation of the pilot community dietetic service, and support of the CCGs, Commissioners will be considering procurement options for a substantive community dietetic service. Continuing to support the full integration of the community nursing, therapy and social care teams to deliver the requirements of the service specification. Page 13 of 35
Any Qualified Provider During 2012/13, Any Qualified Provider (AQP) was applied to Adult Hearing Services (for adults over the age of 55 years with age related hearing loss) and Podiatry (nail surgery only). Following evaluation of potential bidders undertaken during the summer of 2012, approved providers of these services were authorised to deliver the services as per the respective AQP service specifications under a 12-month standard NHS contract. Contracts are zero-based with no indicative levels of activity or income for the period of the contract. The contracts of existing providers of these services prior to 1 st October 2012 were reduced by the value of the activity historically undertaken. For 2012/13, the part year reductions were applied. Therefore, for 2013/14, the remaining part year effect will be applied. With regard to further application of AQP, the CCGs will determine whether they wish to use AQP as a procurement tool in other services during 2013/14 and thereafter. An assessment of the opportunities for use of AQP will be undertaken during 2013/14. Any decision to use AQP to procure further services will be undertaken in line with procurement rules and timeframes ACUTE COMMUNITY Page 14 of 35
Dementia SERVICE AREA General Principles: INTENTIONS Continuing to re-emphasise the overarching principles around management of long term conditions, Living Well with Dementia (over-arching Dementia Strategy) and promoting self-care The 2012/13 National Operating Framework has prioritised dementia care and the areas for development are already central to Worcestershire's countywide Dementia Strategy which aims to improve outcomes for people with dementia and their carers are to help them to live well with dementia, no matter what the stage of their illness or where they are in the health and social care system. Commissioners have invested considerably in the commissioning of specialist dementia provision including the Early Intervention and Diagnosis in Dementia Service, RMN's in Intermediate Care and the psychiatric liaison pilot. These developments in dementia are aligned to the reconfiguration of Older Adults Acute/Older Adults community pathway as part of the Worcestershire Health & Care NHS Trust s Strategic Modernisation Programme. Providers will be expected to continue to monitor progress made on delivering the elements of the National Dementia Strategy where pertinent to their services. Providers will be expected to continue to fully participate in the Health and Social Care Dementia Programme, including the integration of the Acute Dementia / Delirium pathway into other pathways across the system including the ongoing work around supporting dementia in intermediate care. Commissioners would also expect ongoing clinical input into modeling initiatives around dementia including those care needs linked to comorbidity and ensuring attendance on the Dementia training programme across all staff levels. ACUTE COMMUNITY Page 15 of 35
Self Care SERVICE AREA INTENTIONS As a cornerstone of the national QIPP long term conditions workstream, the Commissioners expect all providers to support the Department of Health (DH) generic model for long term conditions, that emphasises patients with a long term condition (LTC) should be empowered to maximise their self management, including ensuring they have a personalised care/health plan and appropriate information and knowledge about how to manage their condition. All staff are required to support the principles of self management and encourage patients where appropriate to attend condition specific training courses to enable them to do this. Training to facilitate the development of Personalised Care Plans will continue to be cascaded through Train the Trainer process during 2012/13 to ensure all staff who are responsible for assessing and care planning for people with long term conditions are able to work in partnership with patients and their carers in the planning of future care. ACUTE COMMUNITY Page 16 of 35
Carer s Strategy SERVICE AREA INTENTIONS The Commissioners and Worcestershire County Council Adult Joint Commissioning Unit have developed a Carer s Strategy 2009-14. Staff are expected to continue to support this strategy and vision, which recognises the value of carers and assists in identifying carers earlier. The strategy includes investment in pathways for carer support, which all staff should be aware of in order to signpost and support carers appropriately. ACUTE COMMUNITY Page 17 of 35
Medicines Management SERVICE AREA INTENTIONS It is the expectation that all providers will work collaboratively with the Commissioners Medicines Management Team and Area Prescribing Committee to review prescribing in order to optimise drug expenditure. The Provider will ensure a copy of their Medicines Management Audit programme and copies of action plans for completed audits are made available to the Commissioners. The Commissioners expect quarterly reports to the relevant Clinical Quality Review Group to demonstrate safe medicines handling and compliance with the agreed medicines schedule. All prescribing should be in line with the Commissioners agreed Joint Formulary and local or national guidelines and policies; The Commissioners wish to work in partnership with Providers to explore opportunities e.g. healthcare at home, hospital FP10 prescribing, use of biosimilar and generic alternatives to ensure best value for money is delivered. It is the Commissioners expectation that the Provider will realise the savings, when available, through Patient Access Schemes. The Commissioning for Quality in medicines Management agreed with the Provider during 2011/12 will be updated where appropriate and included within the contract documentation for 2013/14. ACUTE COMMUNITY Page 18 of 35
Providers Role in Health Protection and Major Incident Response SERVICE AREA ACUTE COMMUNITY INTENTIONS Many organisations including the Health Protection Agency, local authorities and healthcare providers may have responsibilities and be involved in responding to a health protection incident, depending on the circumstances and scale of the incident. This may require the delivery of health protection measures to prevent the further spread or transmission of infection or contamination or to reduce the public health impact. These interventions might include immunisation, prophylactic treatment, disinfection or isolation. If it is decided that action is required, the Commissioners may expect Providers to ensure adequate staff and resources are available to allow the investigation and control of the outbreak to proceed without hindrance. Providers may be expected to release appropriately qualified staff to provide clinical support in the delivery of the intervention(s) required. Due consideration will however be given to the impact on the delivery of routine services ie. In-patient and out-patient care, and the provider must ensure that in the event of services being reduced to accommodate the health protection/major incident response, the risk to patients is minimized. This would be formerly discussed by the commissioners and the provider to ensure the impact on patient critical services is minimized and to agree those services that could be temporarily suspended to allow staff to respond to a health protection/major incident. In addition to the statutory responsibilities contained in the Civil Contingencies Act 2004, the DH Emergency Planning Guidance 2005 and associated guidance outline the key roles and responsibilities placed on the NHS during the response to, and the recovery from a major incident. Providers must ensure they meet their responsibilities, and have plans in place to mobilise their workforce when requested to do so by the Commissioners and to ensure the continuation of essential services. The Commissioners will support Providers to prioritise workload if the response to a health protection incident or major incident cannot be met from within existing resources. Page 19 of 35
Cancer Services SERVICE AREA Non Surgical Oncology INTENTIONS Commissioners will continue to support WAHT in its work to develop nonsurgical services in Worcestershire, through the work of the Worcestershire Oncology Project, specifically NHSW supports: The development of a radiotherapy facility at Worcester Royal Hospital, financial commitments with regard to transitional funding of the radiotherapy facility is outlined in the LTMP. Implementing improvements with regard to chemotherapy services o Developing options for care to closer home o Improve Pharmacy capacity within the acute trust with regard to preparing and delivering chemotherapy drugs o Improve operational processes at all chemotherapy suites. o Reduce waiting times for patients to receive chemotherapy Reduced follow activity It is recognised that the traditional, outpatient-based, model for follow up for cancer patients is not seen as representing an effective model of care. Alternative models for follow have been developed by Commissioners with regard to prostate cancer and Commissioners will look to develop similar models for other tumour sites. Commissioners will expect that WAHT works collaboratively with primary care colleagues to develop new models. Early Diagnosis and Detection Increasing emphasis is being placed nationally, on early diagnosis and detection of cancers, Commissioners expects that WAHT will work collaboratively with CCGs and Cancer Networks to fully support initiatives that will improve early diagnosis and detection. Endoscopy capacity The provider must develop an action plan, for consideration by Commissioners, to show how endoscopy capacity will be increased to meet the expected increase in demand for endoscopy to support both the bowel cancer screening service and the expected increase in cancer that will require more capacity for symptomatic services. Psychological Support Commissioners will work with the provider to develop the most effective model for providing psychological support to cancer patients. Commissioners acknowledge that this service is outside of the tariff and that any new service would need to be funded by Commissioners and procured through competitive tender. Cancer Service Delivery The provider will: Ensure all patients are placed on a defined inpatient pathway based on their tumour type and reason for admission, including carcinoma of unknown primary; Continue with the work to reduce lengths of stay e.g. enhanced recovery pathway for colorectal patients; Continue to deliver performance above the required waiting time standards for all cancer patients. Page 20 of 35
Respond appropriately and promptly to any issues identified as a consequence of Peer Review, be that an Immediate Risk, a Serious Concern, or a Concern Commissioners will seek to progress with the recommendations contained within the National Audit Office report Delivering the Cancer Reform Strategy and will work with the provider to agree an efficient and effective ways to implement the recommendations contained in this report. This approach will include, improving the level of data collection for patients with cancer, e.g. recording staging data of patient s cancers at time of diagnosis. Commissioners will seek to progress with the recommendations contained within Improving Outcomes: A Strategy for Cancer, DOH 2011; working with the provider to agree efficient and effective ways to implement the recommendations contained in this report. ACUTE COMMUNITY Page 21 of 35
Clinical Pathways SERVICE AREA Community Hospital Services INTENTIONS Reducing the length of stay in community hospitals and therefore patient flow through the community hospitals by improved medical management of patients, ensuring regular review of in-patients. Commissioners are keen to review the potential for implementation of medical models of care in community hospital settings. Improving access to acute medical beds in community hospitals for those patients who are acutely unwell but who do not require access to an acute hospital bed. Continuing to ensure compliance with ESMA (sleeping and walk-through) Improving the quality of care in general hospitals for patients with dementia (part of the Dementia Strategy) Malvern Community Hospital: Recurrent and non-recurrent support has been provided to the Trust to support the new MCH. The provider is expected to work with the commissioner to reduce the amount of empty clinic capacity within the hospital thereby converting current expenditure into outputs. Minor Injury Units: Consideration will be given to promoting access to MIUs and improving diagnostic support to the MIUs to enable more patients to be managed through non-a&e based services. ACUTE COMMUNITY Page 22 of 35
End of Life SERVICE AREA End of Life and Palliative Care INTENTIONS End of Life and Palliative care remains a priority for development in 2013/14. The pathway is still linked to QIPP and we expect the redesign to realize savings of 681,000 in 13/14 as well as enable an additional 227 patients to die in their preferred place of care (which for the majority is at home). In order to realize these savings it will be vital for providers to work together to deliver a seamless pathway to patients and engage in improving communication across the pathway. We will be investing in an I.t system that will enable communication between providers regarding care planning and advance care plans. To enable more patients to be supported in the community the integrated community teams (extended primary care teams) will be expected to have the capacity and capability to meet patients end of life and palliative care needs. Providers will be expected to participate in a workforce planning exercise based on the National Occupational Standards for end of life care, which will be facilitated using Skills for health. The results of this exercise will inform the gaps in skills that exist in the teams and will help shape new ways of working. An advance care plan and an advance decision to refuse treatment document have been produced which have been approved by the Worcestershire Clinical Senate. It is the expectation that all organizations across Worcestershire will adopt this documentation and enable the appropriate workforce to access training to support the use of the document. It is important to us as commissioners that patient experience is monitored to ensure that new ways of working have a positive effect on the experience of patients. This is a challenge in end of life care so we would expect the continued use of the VOICES questionnaire to support this. We expect organizations to continue the use of the Liverpool care pathways and maintain the level of use that was achieved in 2012/13. We would like all organizations to be using Version 12 of the LCP by mid 2013/14 and support their primary care partners to make the transition to the updated documentation. Commissioners will be investing in extra capacity to support the rapid discharge of patients from the Acute Trust at the end of life and have the expectation that providers will work together to ensure seamless rapid discharge is possible. Commissioners will be commissioning joint palliative care clinic pilots for Respiratory, Cardiology, parkinsons, frail elderly and respiratory patients. This will require input from Hospice, Health and care trust and Acute trust staff and all clinics will be funded appropriately. The pilot period will be for 18 months and most will start in financial year 2012/13 but run through 2013/14. Page 23 of 35
ACUTE COMMUNITY With changes in the configuration of specialist palliative care across the county we will be revising the service specifications for the provision of specialist palliative care for all providers to become operational for the start of 2013/14. It is not anticipated that any of these changes will result in radical changes but will add further clarity on the changes that have been made so far. Page 24 of 35
18 Week Referral to Treatment Times (RTT) SERVICE AREA INTENTIONS Patients will receive treatment within 18 weeks of referral unless there is a valid reason for waits beyond this performance standard. Monitoring will also focus on waits for first OP appointment, diagnostics and waits in excess of 26 weeks and 52 weeks. The expectation is that there will be no waits in excess of 52 weeks for treatment. The number of Worcestershire patients (all providers) on a waiting list for treatment, April 2011 to June 2012, has increased slightly by 2% from 25,676 to 26,162.. There has been a focused effort to reduce the >18 weeks incomplete waiting list which rose to 2296 in October 2011 that included 589 > 26 weeks and 48 > 52 weeks. This has reduced to 823, a 63% reduction with 88 > 26 weeks and 6 > 52 weeks. (No waits > 52 week waiter at WAHT). Whilst maintaining financial balance and the delivery of contracted activity levels providers are expected to maintain the waiting time standard of treatment within 18 weeks ensuring that patients are TCI d by 16 weeks. When undertaking activity modeling to set annual activity and financial plans consideration will be given to waiting list movement, numbers waiting and median waiting times. ACUTE COMMUNITY Page 25 of 35
Individual Funding Requests and Prior Approval: SERVICE AREA INTENTIONS The Commissioner will also continue to consider Individual Funding Requests (IFR) via their locally agreed process. The IFR process will be undertaken at a county wide level to ensure the fair and equitable consideration of all cases. The Commissioner will continue to expect ALL service providers to adhere to their published commissioning policies. The Commissioner will notify service providers if a new or updated policy is endorsed and will seek to involve service providers and the public in the commissioning decisions that are documented in said policies. Service providers continue to be expected to seek prior approval for those treatments identified as requiring such an application. The Commissioner reserves the right to review and challenge the NHS funding of any treatments/interventions undertaken which are later identified as not having said prior approval. ACUTE COMMUNITY Page 26 of 35
Document Control Version Date Author Changes Authorisation Distribution 1.5 09/08/12 Chris Emerson Additions Via email Page 27 of 35
South Worcestershire Clinical Commissioning Group Commissioning Intentions 2013-2014 A New Approach to Commissioning South Worcestershire Clinical Commissioning Group is a new organisation whose commissioning responsibilities are led by our clinical Board members and shaped by our 32 member practices and the local community. We have an opportunity to work differently, to demonstrate the link to our organisation s overall vision and purpose and to set out our intentions in a form which is accessible as possible to member practices and the wider community. We are working in partnership with Wyre Forest and Redditch and Bromsgrove CCGs to set out a coherent set of intentions for Worcestershire as a whole. The SWCCG commissioning intentions should be read in conjunction with the Worcestershire wide documentation. Our Vision and Purpose Improve the health of our patients by commissioning high quality, value for money healthcare services Listen to and gain respect of the community, as well as being trusted and respected by the community Work in partnership with statutory, voluntary and private sector organisations for the betterment of the population we serve Invigorate healthcare delivery by creating value-based competition founded on improved patient outcomes Pioneer new and innovative ways to provide healthcare Our Vision of Integration To serve the people of south Worcestershire, we firmly believe that health care organisations across Worcestershire need to find ways of ensuring that the needs of patients transcend the pressures on individual organisations. Integration is often portrayed as a panacea for achieving better outcomes. We believe that it is the way forward but will not be achieved without very practical commitment and focus. The statements below capture our vision for integration: South Worcestershire Integrated Services for Health - SWISH We commit to a radically different model of care where everyone signs up to joint working to achieve responsive, proactive care which systematically meets the needs of individuals regardless of organisational boundaries and delivers measurably improved outcomes Joined up health and social care services that revolve around the patient and which provide high quality, efficient and effective care. People are supported to manage their health and when services are needed they are available in the right place at the right time. Building Blocks of Integration Page 28 of 35
However good our intentions, the evidence suggests that the building blocks outlined below need to be in place to achieve integrated services. Our interest is in commissioning services from providers who share our vision of integration and are willing to work with other providers to achieve the best outcomes for patients even if this challenges the configuration of organisations. Robust Governance including Dedicated Project Team Dedicated resources are committed to developing integration with clear markers for success Aligned Incentives Funding and risk sharing across organisations are agreed, with savings supporting patients rather than organisations Strong leadership and Patient Focused Culture Strong leaders work together across organisations to deliver the best care for patients irrespective of the needs of their organisation and ensure that this culture pervades throughout each organisation Information Technology Information systems are in place to enable real time patient records to be accessible to patients and all health and social care providers. The systems enable patients to be risk stratified and provide accurate and timely data for performance management Patient Engagement Patients are routinely involved in developing their own care plans and are well supported to self manage as appropriate. Patient and community forums, especially the Patient Representative Groups in each practice are involved in shaping commissioning priorities and redesign projects Page 29 of 35
Commissioning Principles Our experience is that commissioning is most effective when it is a partnership between commissioner and provider with clear roles and responsibilities. We seek to commission services from providers who share our focus on partnership working and are willing to endorse the following principles: Provider Responsibilities Commissioner Responsibilities Aim to move provision of care into the community or use ambulatory care models to replace traditional in-patient care Work in partnership with other providers, finding creative ways of sharing tariff Deliver care closer to home where clinically appropriate, using the tariff to fund venues and support if necessary Work with the local population to effectively identify local health needs and commission services from the providers best placed to meet the needs Facilitate a clinical dialogue between clinical commissioners and providers Ensure a realistic match between QIPP plans, activity modelling and contract values Use latest evidence to ensure interventions are clinically effective and financially efficient and can demonstrate improvements in health outcome Adhere to national and local commissioning guidance Adhere to service specifications, particularly noting the importance of timely and accurate communication and the provision of information Develop clear service specifications with defined KPIs and outcome measures Robustly manage contracts and be clear about expectations Implement penalty clauses when necessary within the terms of the contract Support patient choice and treat patients as partners in their care ( No decision about me, without me ) Ensure prevention opportunities are maximised ( Every contact counts ) Page 30 of 35