2 August 2016 Prioritising the Use of Resources Background Governing Body members are aware of the huge growing pressures on NHS finances nationally and locally. This is primarily due to the slowing down of growth in allocations to the NHS (along with other parts of the public sector, e.g. councils) and a rising demand for services. This has made it increasingly difficult for the NHS, providers and commissioners, to live within its means. The work for the Sustainability and Transformation Plan for Lancashire and South Cumbria, identified a financial gap of 58.4 million in 2016/17, rising to 419 million by 2020/21, if nothing is done differently. NHS Blackpool CCG has a challenge this year in that we need to reduce our expenditure during 2016/17 in order to ensure adequate resources are available to fund the services we commission for the people of Blackpool. Our plans rely on us reducing our spending by 6.4 million (net) and even this does not achieve the business rules set by NHS England. The main factors driving the challenges for Blackpool are the underlying shortfall in our allocation (we remain 2.9%, 11.5 million, under our place based target), and an increasing demand for services, particularly elective care (operations and procedures) which grew by 3.5 million in 2015/16 compared with 2014/15. This growth has therefore driven our increase in costs predicted for 2015/16, which are unaffordable for the CCG. Financial Recovery Plan As Blackpool CCG is not planning to meet the NHS England Business Rules to deliver a 1% surplus (our plans deliver a 0.5% surplus), we are required to produce a recovery plan. The CCG has a QIPP (Quality, Innovation, Productivity and Prevention) Plan, which is being revised and strengthened to maximise delivery of savings during 2016/17 and into future years. As part of this process, it is clear that there are further actions required to help to manage the demand for services to reduce our costs. Healthcare systems around the world have to take difficult decisions about which services and treatments to provide and for whom. These decisions are taken at many levels, by national bodies, by local commissioners and providers, and by individual clinicians. These decisions are based on a number of factors including national policy, clinical guidelines, historical local provision, local priorities and needs and individual clinical judgements and conversations with patients. Given the financial position of Blackpool CCG and the NHS as a whole, it is more important than ever that we make the best use of the resources available and ensure that taxpayer s money is spent wisely, enabling the local population to access safe, high quality and efficient healthcare services. To ensure that we are able to maintain clinically sustainable, safe and effective services which can deliver the best possible outcomes within the resources available to us we will have to make difficult decisions about which services offer the best clinical outcomes, and whether there are more cost effective ways of delivering these outcomes. We will also need to consider thresholds for intervention. 1
Proposals for Discussion 1. Managing Referrals During 2015/16 there was a large increase in GP referrals to acute services which drove an overall increase in cost of 3.5 million which has therefore been built into our contracts and predicted costs for the current year. The growth in GP referrals was higher than previous years and the CCG is an outlier, when compared to others It is important that practices are supported in a number of ways to help patients access effective treatment appropriately and in a timely way. The CCG is proposing to achieve this in a number of ways: a) Implementation of the new GP plus contract Reduce variation in the referral rates for procedures of limited clinical value (POLCV) and total referrals through practice triage, clinical discussions with outlying practices, communication aids to practices and patients and access to timely information at practice level. b) Implementation of referral management systems The CCG will establish a referral management system. This will involve a review of all referrals for procedures, which are subject to a CCG policy for approval of funding. c) Developing further policies for procedures of limited clinical value - The CCG has a range of clinically approved policies for procedures which are deemed to be of limited clinical value which cover: Apronectomy/Abdominoplasty Assisted Conception Policy Blepharoplasty (eyelid and lower lid surgery) Body Contouring (surgery following significant weight loss) Breast Augmentation Breast Mastopexy Breast Reduction Carpal Tunnel Syndrome Circumcision (Male) Complementary and Alternative Therapies Dilatation and Curettage (D& C)/Hysteroscopy 2
Face and Brow Lift Grommets in Children (under 12 years) Hair Depilation Hair Loss (Correction) Hysterectomy (Excision of Uterus) Knee Joint (endoscopic procedures) Laser Eye Surgery (to correct refractive error) Pinnaplasty (Ear Correction) Reversal of Sterilisation in Males and Females Rhinoplasty (Nose Re-shaping) Skin Lesions Spinal Cord Stimulation Tattoo Removal Tonsillectomy Trigger Finger (surgical release) These policies have been developed and agreed across Lancashire, To make sure that Blackpool Clinical Commissioning Group (CCG) is able to make the best care available for most people, it s vital we make every penny count. We must support and pay for treatments that have the greatest benefit not only for individuals but also for our community as whole. Some treatments cannot be justified as there is little evidence to say they improve health. There is a limited pot of money and some hard choices have to be made. Local doctors and other health professionals have been working hard to produce a list of treatments that have little or no health benefit. For example, NHS funding is not usually made available for treatments to correct hair loss. It is also unusual for the NHS to carry out cosmetic procedures or to fund alternative therapies such as homeopathy. For some procedures, there are criteria in place which need to be met before the NHS will consider making funding available e.g. removal of tonsils. 3
It is important, however, to remember that while the NHS is not likely to provide treatment that has little health benefit, there are sometimes exceptional circumstances in which there may be overwhelming health benefits for an individual patient From Blackpool CCG s website. A set of principles underlying the commissioning decisions and policies have been developed and agreed by all the Lancashire CCG s (see appendix 1). During 2015/16 a total of 3788 POLCV were undertaken at a cost of 2,940,434. Not all of these would be inappropriate but a proportion would. The introduction of clinical triage process outlined previously will help to ensure that the policies are applied appropriately and consistently for all patients. A further range of POLCV are being developed on a Lancashire wide basis which will be released in September covering: Stage 2 POLCV/ Additional procedures- subject to CCG agreement Lumbar Spine Procedures Other Stomach Operations Bariatric Surgery Insulin Pumps Caesarean Section Hip Arthroscopy Treatment of Varicose Veins Functional Electrical Stimulation (FES) for the Treatment of Drop Foot Neurological Origin It is proposed that these are adopted as soon as possible by Blackpool CCG. The CCG also propose to review policies which have been adopted by other CCGs nationally and will adopt where appropriate. All of these policies, once approved, will be available to the public, GPs and providers who will need to follow the agreed process before a procedure can be undertaken. This will involve the referring GP ensuring that the patient meets the criteria in the policy, the CCG reviewing referrals and ensuring that the policies are being consistently followed, obtaining additional clinical opinion where necessary and deciding if exceptional circumstances apply. d) Prior Approval The CCG also plan to introduce a prior approval scheme which requires all providers to seek approval from the CCG before undertaking any POLCV. 4
2. Low Priority Prescribing The CCG has already introduced a number of initiatives to reduce expenditure in GP prescribing which have been discussed widely with the public. A further list of low priority prescription items has been considered by Clinical Leadership Team which are recommended for adoption by the CCG. The total savings from these items is over 800,000 per year and include items which are readily available over the counter from community pharmacies or supermarkets e.g. paracetamol, cough and cold remedies, sunscreens, haemorrhoid preparations, etc. Many other CCGs have already agreed similar polices or are planning to do so both locally and nationally for example NHS Warrington CCG, NHS Heywood, Middleton and Rochdale CCG and NHS Eastern Cheshire CCG have introduced similar polices and many others are considering doing so. Recommendation The Governing Body is asked to consider the issues raised in the paper and to agree to a process of engagement with the public and other key stakeholders David Bonson Chief Operating Officer 5