Operational Plan 2017/19 December 2016
Section Contents SECTION PAGE NUMBER 1. Supporting the delivery of our Sustainability and Transformation Plan 1 2. How we are supporting the Cheshire and Wirral Local Delivery System 2 3. How we are supporting the Cheshire and Wirral Local Delivery System which in turn supports the STP 3 4. Collaborative working across the Cheshire and Wirral Local Delivery System 4 5. Underpinning successful delivery 17/19 5 6. CCG Key strategic challenges 2017/19 6 7. West Cheshire CCG Footprint 7 8. Local context West Cheshire and Chester 8 9. Working to deliver the LDs and STP priorities utilising RightCare 9 10. Our approach to moving to population health management across West Cheshire and Chester this is supported within the STP and LDS 10 11. Key milestones supporting the delivery of our Accountable Care Organisation (ACO) 11 12. ACO Development Phase 1 to 2 Readiness assessment and strategic alignment 12 13. ACO Development Phase 3 Target operating model, business plan and financial case 13 14. ACO Development phase 4 to 5 Contracting and commercial/build and implementation 14 15. Financial Challenge 17/19 15 16. Financial Projections 2017/18 (underlying position) 16 17. Financial Projections 2018/19 (underlying position) 17 18. 3 year Financial projections 2016 2019 (underlying position) 18 19. Financial Projections 2017/18 (full year position) 19 20. Key Financial Risk to Delivery in 2017/18 20 21. Financial Projections 2018 19 (full year position) 21 22. 3 year financial projections 2016 19 (full year position) 22 23. Integrating health and social care supporting the better care fund and effective continuing care 23 24. Performance Activity 2016/17 (1) 24 25. Performance Activity 2016/17 (2) 25 26. Growth and activity projections aligned to the financial plan 17/19 26 27. Growth and activity projections aligned to the programme delivery and the financial plan 17/19 27 28. Growth and activity projections aligned to programme delivery and the financial plan 17/19 29 29. Growth and activity projections aligned to programme delivery and the financial plan 17/19 30 30. Improving Performance 17/19 (1) 31 31. Improving Performance 17/19 (2) 32
Section Contents SECTION PAGE NUMBER 32. Managing care in the most appropriate setting developing effective planned care (1) 33 33. Managing care in the most appropriate setting developing effective planned care (2) 34 34. Managing care in the most appropriate setting developing self care to support being well 35 35. Managing care in the most appropriate setting developing effective urgent care (1) 36 36. Managing care in the most appropriate setting developing effective urgent Care (2) 37 37. Supporting positive mental health and supporting care for those with a learning disability (1) 38 38. Supporting a positive mental health and supporting care for those with a learning disability (2) 39 39. Supporting a positive mental health and supporting care for those with a learning disability (3) 40 40. Reducing unwarranted variation in medicines management 41 41. Managing care in the most appropriate setting developing care for children and young people (1) 42 42. Managing care in the most appropriate setting developing care for children and young people (2) 43 43. Managing care in the most appropriate setting developing effective primary care services 44 44. Changing how we work together commissioning for quality (1) 45 45. Changing how we work together commissioning for quality (2) 46 46. Changing how we work together commissioning for quality (3) 47 47. Changing how we work together _ commissioning for quality (4) 48 48. Collaboration in the delivery of underpinning strategies developing our workforce. 49 49. Collaboration in the delivery of underpinning strategies embracing digitisation 50 50. Integrating health and social care supporting the better care fund and effective continuing care 51 51. Ensuring delivery of the 17/19 Operation Plan organisational delivery oversight 52 52. NHS West Cheshire CCG Governance Structure 53 53.Communicating with our patients and stakeholders 54 54.Experience and Engagement Framework 57
Supporting the delivery of our Sustainability and Transformation Plan 1
How we are supporting the Cheshire and Wirral Local Delivery System We are working with LDS partners to identify and deliver four priorities to make our health and care system sustainable in the near, medium and long term. To transform our services, we need to reduce demand, reduce unwarranted variation and reduce cost. To comprehensibly address these we must priorities the areas that we will have the greatest impact to our system. Based on our knowledge of our local challenges, and as a result of engagement across the system, we have identified the following four priorities above 2
How we are supporting the Cheshire and Wirral Local Delivery System which in turn supports the STP We are working with our LDS (C&W) CCGs on the following objectives to deliver by 2020/21: Implement Cheshire and Merseyside Wide Prevention strategies in Hypertension, Alcohol, and AMR. Implement Cheshire and Wirral wide prevention strategies for Respiratory conditions and Diabetes. Implement Cheshire and Merseyside Wide Neurology, Cancer and Mental Health Programmes Implement a Gain Share agreement with NHSE for specialised commissioning Embed integrated community teams by 2017/18 that include General Practice, Social Care and Community Services that will manage demand effectively throughout Cheshire and Wirral. Implement high impact demand management initiatives identified by NHSE through our current and ongoing QIPP Programme. Implement measures to reduce CHC expenditure by 8m Encourage and deliver better management of primary care prescribing (through self care, over the counter status, repeat prescriptions) Encourage the extension of use of biosimilar drugs from rheumatology to other specialties with great savings potential Continue to implement and optimise the benefit of sharing clinical information through the Cheshire (and Wirral) Care Record. Establish an approach to deliver Accountable Care Organisations across Cheshire and Wirral. 3
Collaborative working across the Cheshire and Wirral Local Delivery System There is system wide working across Cheshire and Wirral clinical commissioning groups, for examples on the development of procedures of limited clinical value/priority. We are working towards the development of a single programme management office within West Cheshire to support system delivery (including performance targets) and will also support the development of our ACO. We are working across the West Cheshire footprint on the development of an accountable care organisation, oversight of this is via the West Cheshire Strategic Leaders Group. The leaders of health and social care in West Cheshire are creating a single organisation that will take responsibility for the health of local people working to a single set of objectives under a single delegated budget. This will enable us to take responsibility for delivery of all care for our population. We are working across Cheshire and Wirral clinical commissioning groups to develop a joint operational plan. This is to ensure that a consistent message is delivered to all providers and block contract arrangements/repatriation agreements are developed where necessary. We are working with neighbouring CCGs to identify functions that are better delivered across a wider footprint, with the ambition of creating a single strategic commissioning organisation. 4
Underpinning successful delivery 17/19 Underpinning delivery creating firm foundations to support the operational plan delivery: The key improvements from the interventions we have implemented are: Effective programme management infrastructure to deliver the financial recovery plan. Focusing on performance management as well as financial improvement. Being bold in terms of change to realise financial and non financial improvements. Our re emphasis on clinical engagement across primary and secondary care. The health and care system level agreement to focus on delivery of the constitutional targets. Ensuring that all levels of the organisation are focussed on delivery and receive reports on delivery when required. Reviewing of programme and project level resourcing to ensure effort is concentrated on the areas of greatest impact, that will deliver soonest. Our mantra is does it make the boat go faster? 5
CCG Key strategic challenges 2017/19 The challenges nationally have been set out in the Five Year Forward View and recent planning guidance and locally in the West Cheshire Way, Financial Recovery Plan, our Savings Plan and Improvement Plan mean we must radically reshape the future of care delivery across both commissioning and provision. Current provision of secondary care is financially unsustainable in the medium term and we will work with our providers to implement new models of care across potentially two DGH sites building on the work achieved in 16/17 to redesign flow in urgent and planned care. We will focus on reducing variation to increase efficiency (supported by Righcare approach) through greater operational transparency and control. We will continue to work with providers to ensure that the relevant underpinning strategies (including IT and workforce) are fully developed and implemented to ensure that they fully support new models of care delivery during 17/19 and beyond Therefore, the leaders of health and social care in West Cheshire and Chester are committed to creating a single organisation that will take responsibility for the health of local people working to a single set of objectives under a single delegated budget. This will enable us to take responsibility for delivery of all care for our population. We have discussed this approach, which supports the direction of change, as Sustainability and Transformation Plans take greater responsibility for strategic commissioning, planning and assurance. The new Accountable Care Organisation will focus on a range of services for a population of 250,000 people. Delivery of the Accountable Care Organisation will be supported locally and overseen also via the Sustainability and Transformation Plan process. 6
West Cheshire CCG footprint 7
Local context West Cheshire and Chester Finance The CCG s total expenditure between 2013/14 and 2015/16 has risen by over 35 million. This was funded, in part, by allocation growth of approximately 15 million. A proportion of spend has been funded from non recurrent measures which has resulted in the underlying financial deficit of 6 million as at 31 March 2016. Key health challenges The proportion of our population aged 75 and over is predicted to increase significantly over the next 10 years. An increasing number of people with multiple long term condition. An increase in frailty. An increase in the number of older people living alone. Age profile 2015 % of population 2020 % increase 2025 % increase People aged 70 74 3 28 16 People aged 75 79 3 15 44 People aged 80 84 1 19 35 People aged 85 89 2 18 43 People aged 90 and over 6 32 71 8
Working to deliver the LDS and STP priorities utilising RightCare Spend &Outcomes Outcomes Spend Trauma andinjuries Gastro intestinal Respiratory Mental Health Trauma andinjuries Mental Health Maternity Gastro intestinal Circulation Respiratory Gastro intestinal Genito Urinary Cancer Cancer Neurological Supporting the delivery of the West Cheshire Way, LDS and STP we have a programme of work (within planned care) to deliver the benefits in 17/19 identified through RightCare. The above sets out the key outcomes and efficiencies we could deliver across West Cheshire and Cheshire. 9
Our approach to moving to population health management across West Cheshire and Chester this is supported within the STP and LDS 10
Key milestones supporting the delivery of our Accountable Care Organisation We are on plan to deliver the ACO as set out the STP and the local health economy has appointed a full time Programme Director to support and ensure the delivery of key milestones. We are also working with PWC to support us also in the process in achieving the key milestones. This will be a key are of work across the health economy during 17/18. We will deliver a new Accountable Care Organisation delivering both health and social care services for our population by 1 April 2018. Delivery of our Accountable Care Organisation will assist with both the improvement of the care pathway supporting integrated care but also address in part the financial challenges our organisations face in 17/19. A more detailed draft timeline for the delivery of the ACO is set out in the following three slides 11
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Financial Challenge 17/19 The West Cheshire health and care economy continues to face a significant financial challenge. Across Cheshire and Merseyside this challenge is estimated to be 900 million by 2021. To address this challenge, a sustainability and transformation plan (STP) for Cheshire and Merseyside has been submitted to NHS England to address a financial gap. NHS West Cheshire Clinical Commissioning Group will begin 2017/18 with an underlying deficit of 5 million. This results from recurrent pressures during 2016/17 but does not take account of the full year effect of the 2016/17 financial recovery plan and pipeline schemes which is believed to be significant. The planned 2016/17 year end position will only be delivered following 3 million pipeline savings. We are planning to return to financial balance as at 31 March 2018 both in terms of the in year and underlying financial positions. This will require further financial recovery savings of 10.5 million (or 3.1%) which represents a significant challenge. There remains a material level of additional risk for both 17/18 and 18/19 resulting, in the main, from potential delay in delivery of financial recovery plans and continued growth in secondary and continuing healthcare costs. There is a potential risk adjusted deficit of 5.8 million following known mitigations and an assessment of probability. We have agreed a non payments by results contract with our local acute provider which will support the development of a joint recovery plan and, therefore, reduce the level of financial risk. In addition, we are exploring the development of a single delivery team. We have agreed baseline contracts with our local mental health provider and have agreed to prioritise levels of additional investments in mental health services by the end of January 2017. 15
Financial Projections 2017/18 (underlying position) We currently aim to return to 1% recurrent surplus as at 31/03/2018. This assumes a c 7m full year effect of our 2016/17 financial recovery plan. 16
Financial Projections 2018/19 (underlying position) We aim to return to NHS England business rules with a 2% underlying surplus as at 31/03/19. 17
3 Year Financial Projections 2016 2019 (underlying position) The following table shows our trajectory to underlying surplus during the next 2 financial years. Area 2016 17 2017 18 2018 19 2015/16 Underlying Deficit 5,989 5,042 Provider Inflation (+) 11,212 6,734 6,771 Activity Growth (Demog) (+) 8,572 5,799 5,428 Investment (Recurrent) (+) 1,191 1,503 958 Budget Pressures\Reductions 8,051 1,397 Recurrent Allocation Inc. 9,517 6,539 6,619 QIPP Gross Saving ( ) REC 12,336 7,151 2,560 Gross Provider Efficiency ( ) 6,454 5,697 5,718 Other Recurrent Cost Pressures (+) 1,666 1,706 1,740 Total 5,042 0 0 18
Financial Projections 2017/18 (full year position) We plan to return to financial balance as at 31/03/17. 19
Key Financial Risk to Delivery in 2017/18 There is a significant level of risk that is currently not factored into financial forecast. The following table is an extract from the draft 2017/18 financial plan submitted to NHS England. 2017/18 Full Risk Value 15 '000 Probability of risk being realised 15 % Potential Risk Value 15 '000 Proportion of Total 15 % Risks Commentary 15 CCGs Potential growth of hospital activity (2%) above plan. Significant risk associated with Acute SLAs 4,800 50.0% 2,400 22.8% agreement of 17/18 'block' with local acute FT. Current reported shortfall in funding of community services. We are working closely with the community provider to realise efficiencies, in the main, resulting with collaboration with other providers. Planning to agree 'alliance' style contract for Community SLAs 1,800 50.0% 900 8.5% integrated care services. Potential risk from additional investment (in excess of 590k) following 5 year FV for Mental Health SLAs 510 50.0% 255 2.4% mental health. We have levied a significant efficiency target against this programme. There is a risk Continuing Care SLAs 2,000 50.0% 1,000 9.5% that the level of growth will be greater than delivered efficiencies. Half of additional QIPP requirement. Risk that further savings cannot be agreed without QIPP Under Delivery 3,576 50.0% 1,788 17.0% STP/wider hospital reconfiguration programmes. Performance Issues 808 95.0% 768 7.3% Shortfall in HRG4+ funding. This has been modelled and confirmed by the host FT. Primary Care - 0.0% 2% CIP and full year efficiency savings reduction has already levied on prescring budget. Prescribing 800 50.0% 400 3.8% Risk that this cannot be delivered. M6 Forecast non delivery of 16/17 RCA. Potential that this is repeated in 17/18 300k x 33%. Move to Market Rent potential 200k x 100% additional pressure on RC mitigated 100% NHSE Running Costs 500 60.0% 300 2.8% BCF - 0.0% Other Risks 3,299 82.5% 2,721 25.8% We have assumed 1.397m as the full year effect of prescribing and non Countess of Chester hospital efficiencies (and netted this sum off budgets). There is a risk that this is not realsised during quarters 3 and 4 2016/17 1.699 x66% Move to Market Rent potential that funding deemed in Trust baselines not agreed as well as the additional cost of MR 1.6m x 100% to be mitigated ny NHSE TOTAL RISKS 18,092 58% 10,532 100.0% 20
Financial Projections 2018/19 (full year position) We plan to return to NHS England business rules. 21
3 Year Financial Projections 2016 2019 (full year position) The following table highlights our trajectory to delivery of NHS England business rules Area 2016 17 2017 18 2018 19 2015/16 Underlying Deficit 5,897 5,042 Provider Inflation (+) 11,212 6,734 6,771 Activity Growth (Demog) (+) 8,572 5,799 5,428 Investment (Recurrent) (+) 2,666 1,503 958 Budget Pressures\Reductions 8,051 1,397 Recurrent Allocation Inc. 9,517 6,539 6,619 QIPP Gross Saving ( ) REC 15,819 10,495 5,970 Gross Provider Efficiency ( ) 6,454 5,697 5,718 Other Recurrent Cost Pressures (+) 1,706 1,740 Headroom 3,278 3,344 3,410 Total 7,886 0 0 22
Integrating health and social care supporting the better care fund and effective continuing care Better Care Fund 1600 Delayed Transfers of Care TheplanningarrangementsfortheBetterCareFundare aligned to the national planning timescales and reflect the need to develop and agree the Better Care Fund for the next two years. As part of the review of the Better Care Fund, the CCG and LA are working closely to ensure that funding is targeted effectively to the third sector and independent organisations and that Section 256 funding provides value for money with associated outcomes. The CCG has agreed to pool the LD funding within the Section 75 agreement. The LA has also pooled the public health funding in 17/19. The clinical commissioning group will work closely with Vale Royal Clinical Commissioning Group and Local Authority to ensure that the Better Care Fund proposals fully reflect our commitment to deliver the West Cheshire Way and an Accountable Care Organisation. This will require a realignment of priorities whilst ensuring we meet the requirement to deliver a reduction in Delayed Transfers of Care and the priorities set out by the Accident & Emergency Delivery Board. The improvement of the DTOCs (as seen opposite) will be a challenge for the health and social care economy and actions to jointly address this key issue are set out in the revised BCF; we fully recognise the solution is as much about out of hospital care 1400 1200 1000 800 600 400 200 0 200 y = 15.386x + 291.18 y = 12.844x 23.639 y = 2.5415x + 314.82 APRIL JULY OCTOBER JANUARY APRIL JULY OCTOBER JANUARY APRIL JULY OCTOBER JANUARY APRIL JULY OCTOBER JANUARY APRIL JULY OCTOBER JANUARY APRIL JULY OCTOBER JANUARY 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 Sum of NHS Sum of Total Linear (Sum of NHS) Linear (Sum of Total) Sum of SC Sum of Forecast Linear (Sum of SC) 23
Performance and Activity 2016/17 (1) The CCG reviews all constitutional, national and local performance targets at the finance, performance and commissioning committee. As identified in the PricewaterhouseCoopers capacity and capability review we have now made sustained improvement in the delivery of key targets. We now consistently deliver referral to treatment targets (incomplete), improving access to psychological therapies and dementia diagnosis. We have agreed with our provider that all national and constitutional targets will be delivered by 31 st March 2017. All providers have agreed to deliver these within that time frame. Key areas for improvement are accident and emergency 4 hour waiting time (95%), diagnostic tests within 6 weeks (99%) and the 62 day waiting cancer target. Delivery of the March 2017 trajectory has been confirmed with NHS England. Positive Performance In summary, we are aiming to deliver all constitutional and national targets by March 2017 and sustain delivery. In addition the governing body seeks assurance against the NHS England Improvement and Assessment Framework and we also provide assessment of delivery of all our primary care providers. We perform very well on the majority of key measures set out in the framework. We perform in the top quartile for: People with diabetes attending a structured education course Quality of life of carers Definitive treatments of cancer within 62 days of referral One year survival from all cancers People with learning disabilities receiving an annual health check Neonatal mortality and stillbirths Workforce race equality standard We perform in the bottom quartile for 3 indicators and our improvement plan for these areas are included on the next 2 pages. 24
Performance and Activity 2016/17 (2) 25
Growth and activity projections aligned to the financial plan 17/19 Delivery against activity lines for both 17/19 have been calculated and forecast growth expected as below this is assuming the financial recovery plan and pipeline schemes address the growth in 17/19. Forecast Growth 17/18 to 18/19 from CCG 16/17 Forecast Growth Code Activity Line 17/18 Annual Plan 18/19 Annual Plan FOT to 17/18 Plan E.M.7 Total Referrals (General and Acute) 120,984 120,276 2.4% 0.6% E.M.7a Total GP Referrals (General and Acute 59,364 59,016 2.4% 0.6% E.M.7b Total Other Referrals (General and Acute) 61,620 61,260 2.4% 0.6% E.M.8 Consultant Led First Outpatient Attendances 109,692 109,056 2.4% 0.6% E.M.9 Consultant Led Follow Up Outpatient Attendances 226,320 225,936 1.8% 0.2% E.M.10 Total Elective Admissions 35,628 35,004 5.1% 1.8% E.M.11 Total Non Elective Admissions 26,760 26,148 5.1% 2.3% E.M.12 Total A&E Attendances excluding Planned Follow Ups 95,292 93,888 0.3% 1.5% E.M.18 Number of Completed Admitted RTT Pathways 18,623 18,299 5.5% 1.7% E.M.19 Number of Completed Non Admitted RTT Pathways 56,369 56,041 2.5% 0.6% E.M.20 Number of New RTT Pathways (Clockstarts) 69,891 69,488 2.5% 0.6% E.J.3 Number of specific acute bed days relating to hospital provider spells 180,187 183,953 2.3% 2.1% 26
Growth and activity projections aligned to programme delivery and the financial plan 17/19 Activity assumptions have been calculated directly from the QIPP project initiation documents, we have assessed a pipeline failure rate of 50% in 17/19 as given the NHS and wider health and social care provider environment is fluid. Activity assumptions will also need to be reconsidered in 18/19 given the implications of the ACO. Activity reductions aligned to the key programme delivery schemes is as follows: Activity reductions to take place across schemes (17/18) FRP Urgent Care 1,721 Elective Care 11,001 Being Well 10,884 Pipeline Med Mgt 954 Urgent Care 590 Elective Care Pipeline 1,383 27
Growth and activity projections aligned to programme delivery and the financial plan 17/19 Activity reductions aligned to all the key programme delivery schemes is as follows: 28
Growth and activity projections aligned to programme delivery and the financial plan 17/19 Initial demand and capacity predictions across all points of delivery has been undertaken within the CCG through the following process: Activity information was taken dating back to 2013/14 and ran through the operational modelling tool to clearly identify both the natural population changes that are anticipated to take place over the next 5 years and also any pathway activity changes that are forecast within our population based on the current throughput in secondary care. This process then provided us with both linear and logarithmic growth assumptions that needed to be applied to each POD. It was decided that the logarithmic approach would be the foundation for our planning as this method would allow for activity peaks and lessen the rate of increase per year. The whole process identified a significant increase expected over the 5 year period however, a slower rate of growth in 2017/18 when compared to the previous year (outpatients 4%, inpatient admissions 2.34%, A&E 0.31%). The growth assumptions predicted for West Cheshire has cemented the view that local interventions need to be embedded in an aim to mitigate this growth. 29
Growth and activity projections aligned to programme delivery and the financial plan 17/19 The greatest impacts from transformational changes are based around the following changes to service delivery pathways: Referral Management The Accenda system is currently in the process of being rolled out within primary care. This enables all referrals to be reviewed by a consultant prior to them entering the referral pathway to ensure only appropriate referrals are received within secondary care. In addition to Accenda, the CCG is also working with Consultant Connect system whereby the GPs will be able to clinically discuss individual cases prior to making a referral. It is predicted that these referral facilitation methods will have a significant impact on reducing referral rates and elective admissions. Acute to Community Shift An innovative integrated primary secondary care model for diabetes has already enabled people in West Cheshire who would previously have been managed in secondary care to be cared for within their local GP practice. Building on this we will integrate specialist nurse provision with GP clusters and their integrated teams within diabetes and other long term condition specialties, supported by education and expertise of the Long Term Condition Consultants. Outlier Practices A review of referral activity across individual practices has been undertaken and the CCG is working closely with outlier practices to improve activity rates across all PODs. Procedures of Limited Clinical Value/Priority A review of the referral policy to ensure that all procedures being undertaken are of maximum value and effectiveness based on an agreed criteria. 30
Improving Performance 17/19 (1) Injuries from falls in people aged 65 and over West Cheshire CCG is working closely with the locality provider organisations to introduce a comprehensive falls prevention and management programme aimed at both reducing the incidence of falls in the over 65 years population, but also to improve the timeliness of response when fall related injuries occur. In the first instance the CCG is working with Vale Royal CCG and Cheshire West and Chester Council to deliver a prevention model, targeting care home residents and sheltered housing facilities. The programme focuses on balance and movement, along with raising awareness of falls risks. The CCG is also working with Cheshire Fire and Rescue Service to identify patients at risk of falls in their home or place of residence. The Fire and Rescue Service has a team of assessors visiting the homes of elderly patients to assess fire risk. They are using this visit to undertake further risk assessments for falls. This information is passed to the single point of access service for clinical review. The CCG has identified the need to invest in therapy services to improve the responsiveness of the falls management and rehabilitation teams. The therapy investment will be across both acute and community settings to ensure maximum impact on patient care. Population use of hospital beds following emergency admission West Cheshire CCG is working on a number of initiatives on the use of hospital beds following an emergency admission. These include : Increasing capacity for step up beds to allow patients to be better managed in the community. Improved support for care homes, particularly those known to have higher than expected levels of hospital admissions / attendance. Supporting the merger of clinical and social care teams to increase capacity and efficiency, and improve the focus on admission avoidance. Supporting the development of the cluster based community teams, directing their attentions to those patients at highest risk of acute admission using more sophisticated modelling tools going forward. 31
Improving Performance 17/19 (2) People being supported to manage their long term conditions The improvement we have put in place include: Self Management UK courses which provide generic support for those with a long term condition. Peer coaches who provide one to one support for those less activated patients. Puffell, which provides online support for those with a long term condition including peer support forums. Diabetes prevention programme where we recruit to a national evidence based programme which is intensive 9 month course. We are recruiting via diabetes essentials course. Diabetes essentials, which is a specific diabetes course for people post diagnosis (see above) We will be using patient activation measures as a way of tracking the impact of the above. 32
Managing care in the most appropriate setting developing effective planned care (1) Following the successful implementation of consultant connect/virtual basket we intend to ensure that the policies for Procedures of Limited Clinical Value and Priority are adhered to and the use of consultant connect and the virtual basket are fully utilised with all GP practices, our lead provider and with Wirral, Warrington and Mid Cheshire Trusts to support appropriate management of demand. Provision of cataract surgery by Countess of Chester Hospital NHS Foundation Trust is under review and it is our intention to procure these services with a possible alternative provider who can provide improved access and efficiency of services. It is our intention to re procure enteral feed services to an alternative provider who can provide improved access and efficiency of services. We will review and redesign the services we commission for plastic surgery and urology. Trial without catheter will be progressed next year working closely with our providers, which will form part of a redesign of the urology pathway. The musculoskeletal pathway is currently being reviewed and it is our intention to implement a new pathway (including physio first) with our providers in 2017/18 to include orthotics and full integration with orthopaedics. It is our intention to tender the Age related Macular Degeneration services in 2017/18 with a focus on reducing waiting times and improving access. We recognise that access to appropriate diagnostic services will need to improve in 2017/18. We will therefore roll out the virtual basket to diagnostic requests in 2017/18. We will seek to improve access to diagnostics including commissioning alternative provision with Any Qualified Provider if required. The clinical commissioning group will increase the number of specialities that are included on the West Cheshire Way Pathways Portal as it is recognised that agreed pathways will support both primary and secondary care in providing patient care. This action will require input from clinicians in primary, community and secondary care (both physical and mental health). 33
Managing care in the most appropriate setting developing effective planned care (2) All providers will be expected to only accept elective referrals from primary care that have been produced via the West Cheshire Referral Support Hub. All specialties are to assess referrals (our primary provider) via the virtual basket and to use Consultant Connect. Cancer the clinical commissioning group will continue to work closely with secondary care to meet the national targets for the diagnosis and treatment of cancer conditions. During 2016/17 we aim to reduce the proportion of patients diagnosed through the emergency referral route, who will usually have a more advanced cancer, poorer survival chances and higher care costs for the clinical commissioning group. During 2016/17 we will specifically focus on: Lung Cancer implementation of the Cheshire and Merseyside timed pathway for lung cancer diagnosis and treatment. Urology implementation of a haematuria pathway/ implementation of a prostate cancer/ post prostate pathway. Colorectal streamline current pathway. Upper GI streamline current pathway. Dermatology in partnership, we will develop and implement an integrated dermatology service model which includes opportunities for enhanced management of skin conditions in primary care; a rolling programme of joint educational events on dermatological conditions and greater utilisation of tele dermatology. Pain increase the conditions seen by the community pain service to include neuropathic pain Ophthalmology improve access to assessment and treatment services for all eye conditions. Ear, Nose and Throat improve access to assessment and treatment services for hearing tests We intend to deliver most long term condition care outside of the acute hospital setting. In 2017/18 we want to support primary and secondary care clinicians to work together to develop appropriate pathways of care that enable this to be delivered (see also Being Well) 34
Managing care in the most appropriate setting developing self care to support being well It is our intention to commission one well being and self care management service which offers advice, guidance and information along with one to one peer support and self care management for life courses. This is a redesigned service and will replace what was previously three separate commissioned services. This will enhance service delivery and achieve better patient outcomes. Providers are expected to be aware of the self care mechanisms and appropriately signpost patients to these services. Diabetes Essentials a structured education programme that will continue to be commissioned in 2017/18; patients that successfully complete this course will be offered a place on the National Diabetes Prevention Programme. The National Diabetes Prevention Programme has been commissioned by NHS England to reduce the growing numbers of patients develop Type 2 diabetes and we are working to support the delivery of this across Cheshire and Wirral. We recognise that patients would prefer to manage their long term conditions closer to home, therefore work will continue the assess which services can appropriately be delivered in a community setting. The Year of Care holistic approach to Long Term Conditions within primary care has been successfully piloted and delivered against predicted benefits. Therefore, we plan to commission practices to deliver the model during 2017/18. The clinical commissioning group has supported the implementation of a Primary Care early identification programme for domestic abuse. This preventative approach will see suffers of domestic abuse supported earlier to reduce the harm they may receive. Following on from its early success in 2016/17 the clinical commissioning group plan to jointly commission this for 2017/18 with the local authority. Atrial Fibrillation project commence implementation of this project which will be in collaboration between the clinical commissioning group and the NHS Innovation Agency North West Coast. 35
Managing care in the most appropriate setting developing effective urgent care (1) Capacity assessment/modelling to ensure that Chester and West Cheshire patients have access to all the available capacity within Countess of Chester Hospital NHS Foundation Trust (including access capacity when available). This will require utilisation of Consultant Connect and the virtual basket. Improve delivery of value by identifying any additional outlier specialties (using the information contained in Better Care Better Value and Rightcare) and bring these services in line with the best quartile. A key area will be the review of intermediate care (step up and step down) with Countess of Chester Hospital NHS Foundation Trust and other providers. Currently there are 146 intermediate care beds across the health economy and it is our intention to review the utilisation and function of these beds with a focus on step up facility emphasis. The review may lead to potential decommissioning of these beds. How single point of access is being commissioned and utilised will also be reviewed to ensure that there is clarity in terms of who and when services are accessed and ensure they are streamlined to improve the patient journey. This may result in the decommissioning of certain services. The impact of the wider regional Virtual Clinical Hub will need to be assessed as it is rolled out across the wider region, with a view to any potential services which overlap in provision or may need support in response to early disposition allocations during 999/111 triaging. This may impact on the Acute Visiting Service, step up facilities, single point of access, community teams and wider services. There are relatively high levels of over performance of non Countess of Chester Hospital NHS Foundation Trust providers resulting in higher rates of conversion from emergency to acute admission with also relatively longer lengths of stay. We are currently reviewing this and it may be our intention to give notice to repatriate these patients to Countess of Chester Hospital NHS Foundation Trust pending an assessment of capacity with our lead provider. 36
Managing care in the most appropriate setting developing effective urgent care (2) We have successfully completed the GP Out of Hours relocation to acute trust accident and emergency proximity Frailty support with greater input for GP led services including accessing step up facilities and support of the at risk group supporting admission when necessary and then pulling back into the community Greater support of delirium and dementia clients pathways integrated across boundaries Care home support integrated with accident and emergency board initiatives, local authority, community care and metal health support for promotion of model care homes and support of struggling care homes. Focus on timely and appropriate use of Continuing Health Care resources ensuring assessment in suitable step up facilities In 2016/17 we have undertaken a review of our falls service; ongoing discussions will continue to take place with the intention to commission with local authority colleagues and Vale Royal CCG a more effective falls prevention service across the health and care economy. It is our intention to support changes communicated via contracting of services in 2017/18 to ensure that a more effective service is delivered. We have worked jointly with our Local Authority partner and successfully developed an innovative strategy to address falls and the consequence of falls on individuals, their carers and families. 37
Supporting positive mental health and supporting care for those with a learning disability (1) We will continue to build on our success ensuring and build on our partnership arrangements that have ensured the successful development of the Integrated Provider Hub model building for mental health specific and complex care that supports our objective to work in or with the relevant Accountable Care Organisations..Our focus will be to support delivery of the none key projects set out in the Cheshire and Mersey STP. The actions taken locally will deliver better outcomes across our population. We will also continue with the development of prevention strategies, access to services much earlier, improvements in responses to people in crisis, reductions in self harm and suicides, improvements in health inequalities and all of this will be underpinned by ensuring that all services and interventions are of the highest quality. It is likely, following the work of the Sustainability and Transformation Plan and Accountable Care Organisation development, that mental health and learning disabilities will be commissioned on a wider footprint, building on successful regional work including children and young people transformation plans, eating disorder services and developing specialist perinatal Mental Health care. 38
Supporting positive mental health and supporting care for those with a learning disability (2) We would like to work with providers to explore potential commissioning for quality and innovation scheme arrangements to support personalised care /Personal Health Budgets. We will ensure the delivery of Personal Health Budgets (persons with a budget of 84 individuals in 17/18 and work with fellow health and social care partners to increase this number in 18/19. We will work on mental health care pathways with specialised commissioning teams to reduce demand across the system. We will support the closure of learning disability hospital beds and use of out of area beds to support the development of community learning disability intensive support teams. Good quality services should produce good outcomes and ensuring we have an effective way of measuring this is critical to the success of our ambition. Throughout 2017/19 we will continue to develop our quality assurance framework, which is beingdeveloped through our Integrated Provider Hub and draws on the experience of the wider partnership reflected within the hub. A review of home treatment services, ensuring that these services are as responsive as possible, meeting the needs of those in the community and avoiding admission/readmission into acute mental health services and attendance at acute services We will continue to work with the Local Authority on the delivery of the Dementia Strategy which focuses on access, diagnosis and ongoing support and we will review the dementia pathway and service provision to support our Integrated Community Care Teams and clusters, as part of the transformation to the new care model. 39
Supporting positive mental health and supporting care for those with a learning disability (3) Our 2 year operational objectives for delivery with our key partners in health and social care have been agreed as follows: A review of the Acquired Brain Injury pathway to include effective triage of referrals and ensuring that there is a clear pathway for those no longer requiring inpatient services. This may result in the procurement of a new pathway of care. We will continue to improve access to psychological therapies ensuring that our health economy continues to deliver the key targets set out nationally and supporting the delivery of the STP. A review of Autism Spectrum Disorder/ Attention Deficit Hyperactivity Disorder pathway to ensure that services are as effective as possible. This will result in the procurement of a new pathway of care. If it is identified that the Countess of Chester Hospital NHS Foundation Trust is to be one of the 50% Core 24 sites, and we will work jointly with the hospital to implement this. A review (in relation to complex patients) of case management arrangements, ensuring that individuals are appropriately placed and that the necessary clinical reviews are undertaken (and clients remain in inpatient provision for the shortest time possible). Implement the innovative Dementia Strategy developed jointly with the Local Authority, this will require a review of the dementia pathway and may result in the procurement of a new pathway of services. We will build on the work of the Dementia Friendly Communities to raise awareness of the importance of early diagnosis and create communities that support people with dementia to live independently for as long as possible implementing the commitments from the PM s Challenge on Dementia 40
Reducing unwarranted variation in medicines management The clinical commissioning group will roll out the repeat prescribing initiative across all practices. Preliminary model (phase 1) development is being tested in 2016/17 following which a further model will be rolled out across primary care in 2017/18. Adherence to West Cheshire Clinical Commissioning Group Area Prescribing Committee processes for introduction of the new drugs formulary review and development of guidance and pathways, including shared care. Develop formulary for Hospital@Home. Ensure that specials are only prescribed or recommended after due consideration of the risks, benefits and any licenced offlabel product is contra indicated or not tolerated. The provider must fully counsel the patient or carer regarding the unlicensed nature of specials Antibiotic formulary to be in place and reviewed annually with all clinical staff aware of antibiotic formulary and policy and educated regarding antibiotic resistance. Providers to ensure timely clinical input to all drug applications, formulary and guideline development review. There should be no implementation of pathways, guidance or formulary changes until final approval by Area Prescribing Committee with providers ensuring that its employees do not suggest to patients that a non approved drug treatment can be obtained from their GP. We are closing working with secondary care regarding biosimilars, high cost drugs and shared formularies e.g enteral feeds) Ensure no request to primary care or other providers to prescribe non formulary drugs, appliances or dressings and no patient to be treated outside agreed pathways. 41
Managing care in the most appropriate setting developing care for children and young people (1) Implement the outcome of the maternity case mix acuity review, following utilisation of the local maternity dataset, to benchmark against peer and national case mix to reduce variation, release efficiencies, and highlight good practice, whilst maintaining safe and high quality care. Continue to collaborate with key local commissioners and providers to identify and agree shared maternity outcomes during 17/18 and to develop a contracting and finance framework for the commissioning for outcomes approach, to be informed by the NHS England and NHS Improvement reforms in this area, which will be piloted in 2017/18 and implemented in 2018/19. Work in partnership across our local maternity system to implement the recommendations set out in Better Births: The National Maternity Review (February 2016) and support the Cheshire and Merseyside Maternity Pioneer and Early Adopter work. In partnership with primary care and the local authority, to facilitate greater alignment between the multi agency i ART teams and GP clusters enabling those families with complex needs to have holistic health and wellbeing assessment and case management; promoting integrated care, building relationships between professionals and reducing the risk of escalation of need. Implement a revised Children and Young People s Speech and Language Therapy service specification, including care pathways and key local quality requirements, following a jointly led review with the Local Authority. Implement the outcome of the Better Care Fund discussions relating to the exploration of co commissioning opportunities for young carer services across the local authority footprint. Implement the outcome of the joint review of the existing Child Development Service with the local authority, in collaboration with key health providers, and introduce an overarching service specification, or service level agreement amongst health providers, including key local quality requirements. Commission a Children s Hospice@Home service to secure improved access to 24/7 community nursing provision for end of life care, in the location the child/young person and their family prefer. Implement the co designed self care pathways to maximise the ability of children/young people and their parents/carers, where appropriate, to self care, particularly those with a long term condition, such as diabetes, asthma, epilepsy and mental ill health. 42
Managing care in the most appropriate setting developing care for children and young people (2) All providers to continue to meet their statutory duties in relation to SEND and effectively meet the needs of disabled children and young people and those who have special educational needs. Ongoing review and monitoring of the Acute Trust s response to meeting the RCPCH Facing the Future: Standards for Acute General Paediatric Services and the new Facing the Future: Together for Child Health Standards. Review the findings of the North West Paediatric Critical Care Network s benchmarking of Paediatric High Dependency Care services across District General Hospital s and Tertiary Centre s against the Royal College of Paediatrics and Child Health document High Dependency Care for Children Time to Move (October 2014) and agree and monitor the standards required by each provider Trust delivering care. Continue to jointly redesign paediatric services with the Acute Trust to reduce demand and take cost out of the system, whilst retaining quality services and continuing to integrate paediatric expertise within the community and primary care, including extending the scope of the redesign to all hospital services, accessed by children and young people, including the Emergency Department. Maintain You re Welcome quality standard accreditation as a quality requirement of key health providers. Secure care closer to home/in the community, where safe to do so, to improve choice and support independence. All providers to actively promote and provide age appropriate information on how and all providers to review their promotion of local health care services through mobile technology and social media to ensure that the use of such technology is optimised. Increase the number of paediatric specialties included in the West Cheshire Way Pathways Portal to support both primary and secondary care in providing patient care. All providers will be expected to only accept elective referrals from primary care that have been produced via the West Cheshire Referral Support Hub (including the Virtual Basket). Building on the successful partial roll out of Consultant Connect across paediatrics, to secure full roll out in 2017/18 to fully utilise the available resource and maximise its benefits. Continue to collaborate with the Local Authority, primary care and local schools to increase activity levels for primary school children (nursery year 6) within the West Cheshire CCG area to support the prevention of long term conditions, including obesity prevention. 43
Managing care in the most appropriate setting developing effective primary care services A key provider within a newly formed Accountable Care Organisation will be GP practices. The Accountable Care Organisation will work with primary care to involve GP practices, both in the development of the new organisation and the review of service provision, to increase integration with clinicians across pathways of care. As part of the underpinning work, the clinical commissioning group intends to develop, with appropriate fora, a detailed communications strategy identifying the benefits and potential risks of being part of a new Accountable Care Organisation. In addition, in 2017/18 it is our intention to develop and implement a new incentives package for primary care services, aligned closely to the specific needs of the West Cheshire population (as reflected in the West Cheshire Way). This will require close working between our Primary Care Team, clinical commissioning group programme leads and GP practices and will look to replace the individual Local Enhanced Services and Primary care commissioning for quality and innovation scheme with a singleprimary care incentive scheme. This will be fully aligned to the needs of the population and the aspirations set out by the Accountable Care Organisation, particularly focusing on long term condition management (including mental health conditions) and proactive care of the frail elderly. We will look to develop a more integrated infrastructure to support primary care to release time to care. This centralised infrastructure would support delivery of standardised functions such as referral management, offering choice and repeat prescribing. We will continue to work closely with all practices to understand and share the learning from the Princeway cluster on the development of a population health approach to delivery of primary care. This will focus on improving outcomes rather than measuring units of activity. We will adopt the principle of working with practices collectively at scale to ensure sustainability of service delivery and an improved skill mix (including greater autonomy on use of resources for that cluster population). 44
Changing how we work together commissioning for quality (1) We will continue to ensure that the services we commission are high quality by: Identifying measures of improvement in quality that are robust Incorporating these into contracts with providers of health care Reporting on these measures in a way that supports comparative analysis and benchmarking Holding the providers of health care to account for performance Incentivising providers to perform optimally against these standards Publishing this information to empower local people to make choices about the health care they use Our continuous focus on improving patient safety and experience will be highly visible in our contracts with our providers of health care. Local requirements will include: Demonstrating progress in embedding compassion in care Reduce premature mortality by improving access to health services, education and training of staff, and by making necessary reasonable adjustments for people with a learning disability and/or autism Providers to participate in the annual publication of findings from reviews of deaths, to include the annual publication of avoidable death rates, and actions taken to reduce deaths related to problems in healthcare Using audit to evidence changes in practice following Serious Incident Investigations Delivering harm free care through the reduction in occurrences of avoidable harm such as pressure ulcers, absconding incidents and inpatient falls Zero tolerance of health care associated infections Increasing the amount of time staff spend providing direct contact care to patients Improve patient choice, with a focus on maternity, end of life care, and people with long term conditions 45
Changing how we work together commissioning for quality (2) We recognise that as a consequence of this 2 year planning process, CQUIN arrangements have been subject to a number of changes that extend for the forthcoming 2 year period. For the majority of the published national CQUIN goals, there is alignment with our previous year s local CQUIN scheme, and alignment with the programme priorities of the West Cheshire Way. We will apply the same rigour, challenge and robust monitoring of achievement as in previous years, and will encourage partnership working across the health economy where this is beneficial to outcomes for patients. We will hold providers of acute and community and mental health services to account for delivering the Mental Health Five Year Forward View through our regular Quality and Performance meetings with them. In addition we are developing more robust quality monitoring arrangements with our smaller providers, introducing proportionate, but comparable processes to those within our larger contracts. This work will extend to arrangements with our local care homes, with which we have a jointly held contract with our local authority. As we move to full delegated responsibility for primary care commissioning, we will work with our primary care providers to fully implement the General Practice Forward View, and ensure that we hold our secondary care providers to account for the new standards for outpatient appointments and interaction with primary care. We will endeavour to spread quality improvements across all parts of our local health service, as they apply, such as primary care, and local independent hospitals. We will ensure that national imperatives are delivered locally and we will focus on seeking evidence that: All our providers apply reasonable adjustments for all disabilities and impairments and across all functions and that they promote understanding of reasonable adjustment by utilising appropriate guidance and tools Full implementation of the Accessible Information Standard in line with NHS England guidance Patients and staff have access to improved information and there is progress towards achieving fully interoperable digital health records from 2018, and we will continue to build on the advances already made with the implementation of the Cheshire Care Record. Nurses and midwives are prepared for the requirements revalidation brings as they renew their registration every three years. Incidents that cause unintended consequences to patients are disclosedfullytothemandtheirfamilythroughthedutyof candour. Investigation reports must include accounts of an open and honest conversation about what has happened and what has been learnt to prevent future errors. 46
Changing how we work together commissioning for quality (3) Infection Prevention and Control remains a priority for our health and social care economy us and whilst we have seen consistent improvements in MRSA infection rates, the challenge of clostridium difficile in the community remains a risk for our patients. Our local Infection Prevention and Control Network has representation from our partners in health, social care and the independent sector. One of its principle aims is to share best practice and learning from investigations into any incidence of a health care associated infection. In the next 12 months we will work in partnership with public health colleagues in our local authority to take on the challenges of antimicrobial resistance. We have invested in a single repository for patient information, so that themes and trends can be collated and analysed. This insight and intelligence is critical to us as commissioners to inform commissioning and contracting decisions. We have a rich source of patient experience data from our local providers, which we complement with our own proactive engagement. This engagement is linked to patient outcomes, so that we are able to check the success and satisfaction of any service changes with patients/carers. Our Patient Leaders have a vital role in scrutinising our success in delivering changes in response to patient feedback. We are fully committed to the use of the Family and Friends Test as a means of driving improvement and hearing our populations views of the quality of care delivered locally. We will hold providers to account for increasing uptake of the survey recognise and celebrate good results and challenge our providers in hospitals, primary care, mental health and community services to do better when results show dissatisfaction with care. Following publication of the Mazars Independent review of deaths of people in contact with Southern Health NHS Foundation Trust, and requests through NHS England for provider assurances, we will continue to ensure compliance with the recommendations from this inquiry with all relevant providers. 47
Changing how we work together commissioning for quality (4) We continue to play a full and active role in the Cheshire and Merseyside Quality Surveillance Group and take pride in the strength of our relationships with our partners such as Healthwatch. In line with the openness and transparency agenda we will continue to strengthen our public reporting of any measures that could signal any deterioration in the quality of care being delivered to our population. We are committed to playing an active role as statutory partners in the protection of both children and vulnerable adults through the local safeguarding boards. We will continue to develop our strategic leadership role through our designated safeguarding professionals to protect both children and vulnerable adults from abuse. As a CCG we are committed to ensuring that commissioning decisions, business cases and any other business plans are evaluated for their impact on quality. We will fully implement an effective Quality Impact Assessment process to ensure that all commissioning decisions do not negatively impact on quality and where risks to quality are identified that plans to monitor and mitigate risk will be put in place. 48
Collaboration in the delivery of underpinning strategies developing our workforce As part of the development process to develop a new ACO, underpinning strategies are being developed with the support of PWC. Key enablers (specifically, IT and workforce) will be utilised to support more effective delivery of health and social care across primary, intermediate and secondary care services. We will focus on the non medical workforce supporting patient led, preventative care (as set out in the FVFV and West Cheshire Way). We are already focusing changes on non medical roles to ensure that the population suffering with chronic diseases are supported and that the gaps in the primary care workforce likely to materialise in the next 5 years are addressed. We already have physician assistant roles within our provider organisations and advanced practitioner roles will be developed further in primary care. The aim will be to effective support the development of our ACO which will provide integrated care delivery for our population. Consideration of the workforce and the development of our workforce will remain a high priority for consideration by our Governing Body and the ACO Programme. 49