NHS Cumbria Clinical Commissioning Group. Strategic & Operational Commissioning Plan

NHS Cumbria Clinical Commissioning Group Strategic & Operational Commissioning Plan 2012 2015

Document History Document Ref: Cumbria CCG Strategic Commissioning Plan 2012-2017 Version: Discussion draft Date: January 2012 Classification: Internal draft for CCG Change Control Version: Date: Author(s): Summary of Changes: Draft 1 12 th January 2012 A. Gardner Outline framework Draft 2 18 th January 2012 A. Gardner Sections on engagement, OD and amendments to vision by Dr Hugh Reeve Draft 3 3 rd February 2012 A. Gardner Deletion of OD, Finance sections etc to focus on agreement of narrative & strategy Draft 4.1 27 th March 2012 A. Gardner Addition of quality, engagement, OD & Finance sections following ISOP submission Draft 4.2 5 th May 2012 A Gardner Minor correction on vision and addition of safeguarding reference to Children s section Draft 5.1 27 June 2012 A Gardner Updating of financial Plan to include CCG plan Note on Scope of the Plan: For 2012/13 the CCG have supported the NHS Cumbria Cluster in planning for those areas for which the CCG will have responsibility for commissioning services. This has led to the development of the Integrated Strategic Commissioning Plan. The ISOP also includes plans for the other elements of the NHS commissioning architecture such as Public Health and Specialised Commissioning. This CCG Strategic Commissioning Plan contains the CCG elements of the ISOP together with further detail in specific areas (eg the vision and organisational development plan). Cumbria CCG Strategic Commissioning Plan April 2012 v4.3

Contents Page Section 1 CCG Integrated Strategic and Operational Plan: Summary Plan 1 Section 2 Our vision, value and commitments 2 Section 3 Our local needs assessment and priorities 4 Section 4 Our key goals and initiatives 9 Section 5 Our approach to quality and engagement 11 Section 6 Our resources: finance, people & ICT and our approach to QIPP 14 Section 7 Our key organisational development priorities 22 Appendix 1 Plan on a page: 1.1 Planned care 1.2 Unplanned care 1.3 Children and Young People 1.4 Long Term Condition Management 1.5 Primary care 1.6 Delivery of Clinical Strategy & Acquisition in North Cumbria 1.7 Development of a Clinical Strategy in Morecambe Bay 23 24 25 26 27 28 29 Appendix 2 Key Performance Measures 30 Appendix 3 Clear & Credible Activity Plans 33 Appendix 4 Medium Term Resource Plans 39 Cumbria CCG Strategic Commissioning Plan April 2012 v5.1

Engagement Improve patient and community engagement arrangements and arrangements for assessing patient experience Quality Commission for quality and improve quality management information Section 1: CCG ISOP: Summary Plan Context Priorities Outcomes/outputs QIPP Programmes & Cross Cutting Initiatives Long term conditions management Improve care to Deliver new pathways for diabetes, respiratory, heart failure, and service models for older people respond to the with frailty challenges of an Develop a holistic strategy for long term conditions ageing population and integrated primary and community delivery models Excess cancer & CVD deaths Health inequalities Premature mortality Ageing population Limited resources Improve the health of children and young people and the quality and integration of care services Improve mental wellbeing and reduce alcohol misuse Reduce health inequalities and premature mortality, focussed on cancer and cardiovascular disease Reconfigure and modernising health services to provide more sustainable and higher quality care Increase in the percentage of people with a long term condition to feel independent and in control of their own condition Reduction in the rise of unplanned hospitalisation for adults with chronic ambulatory care sensitive conditions Reduction in patients prescribed anti-psychotics (on primary care dementia registers) Reduction in unscheduled admissions from residential care homes to acute trusts Reduced increase in adult non elective admissions Reduction in the overall number of paediatric non elective admissions 5% reduction in unplanned hospitalisation for under 19s for lower respiratory tract infections Increase in the number of people with depression receiving psychological therapy (IAPT) Increase in the number of people who complete psychological therapy moving to recovery 95% of people under adult mental illness specialties on CPA followed up within 7 days of discharge from psychiatric inpatient care Work with Public Health to reduce the number Reduction under 75 mortality rate from cancer Reduction under 75 mortality rate from CVD Reduction in mortality within 30 days of hospital admission for stroke 80.05% of people with a stroke receive 90% of their care on a specialist stroke unit Increase in patients receiving first treatment for cancer within 62 days of an urgent GP referral Increase in patients who receive subsequent treatment for cancer within 31 days for surgery, anti-cancer drug regime or radiotherapy 95% of patients seen in A&E in 4 hours or less 90% of patients referred for treatment admitted within 18 weeks 95% ambulances respond to category A calls within 19 minutes Reduction in hospital acquired infections, specifically C difficile and MRSA 0% of people wait over 52 weeks for consultant led treatment, or over 12 hour A&E waits Children and young people Implement short stay paediatric assessment services integrated with Emergency Floor model Improve access to and quality of CAMHS Improve quality of maternity and paediatrics Significantly strengthen safeguarding arrangements and service delivery for looked after children Working with partners deliver the CQC/Ofsted improvement plan Unplanned care Implement integrated emergency floor Optimise the single point of access for urgent care Optimise the use of community hospitals as part of whole system care pathways Planned care Reduction in procedures with limited clinical value through a revised approach to evidence based referrals Transfer ophthalmology & MSK into community Primary Care Reduce unwarranted clinical variation Implement long term conditions strategy Deliver more focused health improvement work such as health checks and smoking cessation Increase primary care capacity in Barrow, and Workington, and reconfigure urgent day time primary care Provide more straight forward planned care Develop a strategy for managing the changing age Secondary care transformation & reconfiguration Deliver the North Cumbria Clinical Strategy and support the acquisition of NCUHT by Northumbria Healthcare Ensure system wide approaches to support the West Cumberland Hospital reconfiguration Working with Lancashire North CCG and stakeholders, develop and begin to deliver a clinical strategy for the Morecambe Bay area. Ensure rapid improvement in the quality of Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 1

Section 2: Our vision, values and commitments Vision: We are here to make a real difference to people s lives. Firstly this is about making a difference by improving the health and wellbeing of individuals and their families. In particular it is about taking serious action to reduce the inequalities in health that exist between different communities across Cumbria. We want to add years to peoples lives, and quality life to these extra years. Making a difference to people s lives also includes improving the day to day experience of patients and those working to deliver better healthcare. Working for the health service in Cumbria should be a privilege and a source of pride. We want this to be true for all our colleagues, as we recognise that quite simply people who are happy in their jobs provide better care. We have been given stewardship of the significant resources that are spent on the provision of healthcare in Cumbria. We believe that with clinicians leading the planning and delivery of healthcare we are more likely to make a real difference to people s lives. Doing the right thing for our patients. We will strive to commission services that are safe and are based on the best research evidence available. We will be transparent in our actions and will not allow any conflicts of interest to influence our decisions. Trust is important and has to be earned. As clinicians we believe our patients trust and support us in our role as providers. We want people to feel the same about us as commissioners. Putting ourselves in your shoes is this the care we would want for ourselves or our families? We will expect those providing healthcare to deliver services of the standard we ourselves would be happy to receive. Clinicians have local knowledge of health needs and we receive daily feedback on our patients experiences. If a service is not of the standard we would expect we will not rest until we see significant measurable improvements, using our patients experiences to help put things right. Access to the right healthcare, in the right place, right when you need it. When we need urgent help it is vital we can access this quickly and any initial treatment is safe and of a high quality. At other times we may have to travel to see the right specialist. We want services to be as close to patients homes as possible, but there is a balance needed between localness, quality and cost, and this is a particular challenge in rural areas like Cumbria. The Cumbrian health pound is finite and can only be spent once. We must be responsible stewards of the financial resources entrusted to us on behalf of the local population. This will involve us, at times, in taking difficult decisions. We will engage our local population in discussions concerning those decisions and we will be honest and open about the difficult choices that have to be made. As we seek to live up to these values we are setting out a number of commitments. These involve three groups of people: our local population to individuals and communities our partners those we work with to commission services and those we contract with our members the practices who constitute the CCG. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 2

Section 2: Our vision, values and commitments Our commitment to you our local population: individuals and communities To commission care that is safe, of the quality we ourselves would expect, and as close to you as possible but safety and the availability of the right clinical expertise may require trade offs We will improve the health and wellbeing of our communities and we will work with our partners to address the main causes of illness and death across Cumbria We will put patients at the heart of everything we do by always putting ourselves in your shoes and by using your experiences to shape care pathways and service delivery Our commitment to you our partners: those we work with to commission services and those who provide the services we commission We will build relationships based on openness, honesty and trust this is a two way process As clinical commissioners we will work with you to ensure local health care is led by clinicians We want to develop partnerships that reward real improvements in quality and outcomes and where we share both risks and gains However, we will not accept behaviours that put at risk the wider commitment we have made to individual patients and our local communities. Our commitment to each other the member practices who constitute the CCG We are a member organisation that will thrive if together we deliver on the promises we make to our patients and communities We will use your knowledge and experience to tackle the major health challenges that face you in your local communities and tackle the infrastructure barriers (such as poor IT and information sharing) that will allow you to provide a higher quality of care Together we will: - Develop local healthcare services by pursuing innovative, high value solutions - Develop relationships built on openness and honesty, with transparency in our decision making - Support and develop all clinicians, managers and teams across the organisation they represent our greatest resource - Make best use of the resources entrusted to us and hold each other to account for the way we use public funds, ensuring we live within our means and commission or deliver safe and high quality services. Engagement on Vision and Priorities We have engaged with our main stakeholders and the public in developing this vision. This builds on what the public told us through the Closer to Home Consultation and delivery. The vision was built with our practices (eg at an elected GP forum in January) and the priorities reflect engagement with the County Council (eg on Safeguarding and Care for Older People). It has also been shared with the Health and Wellbeing Board (eg at the HWB Workshop in February) and events with the 3 rd Sector (eg with Cumbria Third Sector Network. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 3

Section 3: Our local needs assessment and priorities In line with the CCG s strategic needs assessment, our key priorities for improved outcomes are: Improving care to respond to the challenges of an aging population Improving the health of children and young people and the quality and integration of care services Improving mental wellbeing and reducing alcohol misuse Reducing health inequalities and premature mortality from cancer and cardiovascular disease Reconfiguring and modernising health services to provide more sustainable and higher quality care Introduction The CCG is determined to ensure it has a clear evidence base behind its decision making. Critical to this is the Joint Strategic Needs Assessment which is being developed with Cumbria County Council and input from colleagues in District Councils (eg on housing). We have considered the available needs evidence from the JSNA and also across a number of other themes (in particular: a review of the key priorities in locality Plans; quality and performance issues in current service delivery; and the Department of Health Operating Framework must dos ). A full report is available at on the CCG web site. This section summarises the key findings and conclusions to show how we have arrived at our priorities. Key Findings and Conclusions Cumbria has a higher than national average proportion of older residents and the population is aging faster than national rates; this will affect all localities with a particular impact in South Lakes and Eden. Given that two thirds of inpatient beds are used by patients over 65 this will place increasing pressure on acute health services. The increase will also lead to more people living with a long term condition such as diabetes and dementia. There is currently a performance issue in relation to meeting the 80% stroke target and the operating framework places heavy emphasis on the need for local responses and close partnership with the local authority to the national dementia strategy. Finally, all localities have set as a priority the need for better long term condition management and the need to develop a comprehensive service model for frail older people. The number of children is reducing in all localities except Carlisle. But health outcomes are not always good, with particularly high levels of childhood obesity. The organisation of child health services has historically been poor with the Dr Andy Mitchell review highlighting the need for better coordination and integration of pathways with a clearer focus on outcomes. All localities have higher than national average rates of paediatric non elective admissions and all localities have prioritised the need to improve the hospital paediatric assessment service. There have been a number of quality concerns relating to maternity, paediatrics in south Cumbria and CAMHS in all localities. All localities have prioritised the implementation of improved pathways such as the acutely ill child. The level of suicides in Cumbria is higher than national averages, particularly in Copeland and Allerdale and admissions to hospital for deliberate self harm are high in Barrow, Copeland and Carlisle. There are significant concerns about the quality of and access to CAMHS services for children in all localities. There are high levels of alcohol-related admissions to hospital, especially in Carlisle and Copeland. All localities have set a priority to develop more community mental health services, but the need for more effective intelligence and benchmarking information means the strategy for this has not yet crystallised. The main causes of premature mortality in Cumbria are cancer (particularly lung cancer) and circulatory disease: whilst rates for Cumbria are in line with national averages, low levels in Eden and South Lakes mask significantly high Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 4

Section 3: Our local needs assessment and priorities rates in Barrow, Copeland and Carlisle. Cumbria is only just achieving the 62 day cancer target. There are significant levels of deprivation and health inequalities, particularly in Barrow, Carlisle and areas of the west coast: male life expectancy varies by up to two and a half years between Furness and Eden, with a 20-year gap in life expectancy between people living in Moss Bay in Workington and Greystoke in Eden. There is also significant deprivation in rural areas, which is often unrecognised due to the small numbers. Sparsity levels in Eden and parts of South Lakes make access to services difficult and Eden is the most deprived district in terms of geographical barriers in the whole of mainland England. Like most deprived areas, there are particular problems with lifestyle issues such as high levels of smoking, obesity and alcohol-related illness. The Cumbrian health economy has long suffered from the twin challenges of clinical and financial sustainability, caused in part by the need to provide services in a large, sparse county whose topography (with lakes and mountains in the middle) makes travel difficult and journey times long. The Closer to Home Strategy anticipated national policy in seeking to shift care, particularly for long term conditions, from an acute to community setting, with a reconfiguration of the bed base and improved emergency care model. Implementation of the Strategy has proved problematic with a continued need to improve the emergency flow, paediatric assessment unit and reduce procedures of limited clinical benefit. Although rates of elective and non elective admissions are around national averages for Cumbria as a whole, they are significantly above average for both elective and non elective admissions in Furness and for elective admissions in Copeland and above average for paediatric non elective admissions in all localities. The cost of acute care is also higher than benchmark activity levels would suggest should be the case. There are significant quality concerns for some aspects of service: particularly A&E, outpatients, maternity and paediatrics in UHMBFT. There are also concerns that patient numbers in some areas may be too low to ensure safe clinical services unless models of care are reconfigured to ensure greater integration with primary care and better networking both across sites within Cumbria and with tertiary networks outside of Cumbria: the acquisition process in North Cumbria and the development of a clinical strategy for Morecambe Bay will both support this. The standardised mortality figures demonstrate high mortality rates in both UHMBFT and NCUHT. The areas of concern reside in the high prevalence conditions including stroke, ischaemic heart disease, upper gastrointestinal bleed, and respiratory conditions. Cancer survivals are also poor, especially for respiratory and colorectal tumours. The CCG and Cluster is actively working with both Trusts to improve performance. Examples are enabling service redesign to ensure consultant led acute services 7 days a week to counter the increased risk at weekends and overnight. Improved clinical pathways will ensure prompt assessment of acute illness within Trusts and the community We have good primary care in Cumbria but more can be done to reduce unacceptable variation (eg on the level of exceptions) and further up-skill all clinicians to better deliver long term condition management (through the year of care approach) day time urgent care, upstream health improvement (eg CVD checks; earlier diagnosis of cancer); there is also a need to improve primary care capacity in Barrow. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 5

Section 3: Our local needs assessment and priorities This needs assessment evidence would suggest five high level challenges for the CCG with a number of attendant issues to resolve: Challenges Key Issues The aging population The development of a comprehensive service model for frail older people Further Integration of Care with Adult Social Care The need to continue to improve long term condition management through the year of care model, with better patient education and self management Delivery of the national and local dementia strategies in partnership with the local authority. Improve the quality of and access to stroke care The health of children and young Continue to improve the integration of children s health care across the Health System and with the local authority. people and the need to improve the Implement the revised paediatric assessment model in secondary care quality and integration of care services Implement the 6 key priority pathways for children and young people Improving mental wellbeing and reducing alcohol misuse Reducing health inequalities and premature mortality from cancer and CVD Reconfiguring and modernising health services to provide more sustainable and higher quality care Work with public health commissioners to support lifestyle improvement for children, particularly on obesity Improved benchmarking and intelligence as part of the transition to PbR for mental health services Improve access and quality of primary and community mental health services, particularly: learning from the IAPT programme; expansion of Psychiatric Liaison Services; and development of Psychological Therapies Improved access, capacity and quality in the Child and Adolescent Mental Health Service Continued focus on supporting the repatriation of service users receiving out of county care packages Develop a CCG strategy for cancer, including continued delivery of the national 62 days cancer target Support public health commissioning for health improvement, particularly through primary care delivery of CVD, smoking cessation and brief interventions on alcohol. Support the continued reconfiguration of the acute sector in Cumbria through the acquisition process in north Cumbria and the development of a clinical strategy for Morecambe Bay Transform the unscheduled care system through delivery of emergency floor, single point of access as part of a modernised emergency care model Improve elective care pathways Develop and deliver a strategy for transforming primary care, with particular emphasis on capacity Ensuring accessibility to services in rural parts of the County through effective primary and community services as part of the getting closer to patients improvement in Barrow Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 6

Section 3: Our local needs assessment and priorities What will the health economy look like in 5 years time? In line with the strategic vision and the priorities arising from the needs assessment, the Cumbria health and social care economy in 5 years time will have the following characteristics: Improved outcomes and performance Improved safety and quality Greater integration of care across pathways which break down traditional barriers in primary, community, secondary and social care Clinical leadership at all levels Financial stability for all organisations Individuals supported to take responsibility for their own health care Meaningful engagement of patients and communities in decision making and active use of patient experience to improve care Greater innovation and use of technology to drive improved outcomes and transformation Earlier intervention through better identification of patients at risk and targeted support Innovative forms of contracting which incentivise integration and joint delivery of better outcomes and quality Given the context we are operating within in Cumbria, we believe that it makes sense to provide care as close to our patients as possible, although safety and the availability of the right clinical expertise may inevitably require trade offs. Our communities In 5 years time we will have seen a measurable improvement in health outcomes, particularly in relation to cancer, CVD and long term condition management and a reduction in health inequalities across our communities. We will have a higher level of engaged patients and engaged communities, with more patients taking responsibility for their own health and wellbeing. In particular, there will be better education for patients to help them coproduce their care plan and manage their long term conditions; there will also be greater support through decision aid tools to allow patients to take informed decisions on secondary care procedures, such as orthopaedic operations. Patients will have access to their care records and summary information will be available to all clinicians to provide better care. There will be integrated work with local authority public health team to help improve lifestyles and stay healthier for longer, actively mobilising our many community assets. Primary Care Primary care will continue to be the gatekeeper for patients care. There will be a higher level of quality and consistency of delivery. There will also be an expansion of capacity in Barrow and changes in workforce skill mix and deployment across Cumbria, to attract, retain and upskill primary care, and to support the integration and sustainability of pathway models (particularly around emergency flow). There will be greater management of long term conditions and frail older people to improve quality of life, keep people healthier for longer and reduce unnecessary admissions. More straightforward elective procedures will be undertaken in primary settings closer to patients, freeing up acute capacity for more specialist work. Practices will collaborate more effectively together in a more federated way, with ICT (such as Emis Web) leading to greater integration and efficiency. Significant improvements in GP estate, particularly in Barrow, will help drive reconfiguration of primary care and improve patient satisfaction and access. Community and mental Health The Partnership Trust will be a key player in delivering community services to support long terms conditions management and providing more community alternatives to acute secondary care, closer to patients. They will also provide an improved interface with the two local acute trusts to speed up and ensure appropriate admissions and discharge, co-ordinated through single point of access and supported by integrated health and social care teams. There will be enhanced integration between community and mental health services, particularly for dementia (which will also be integrated with Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 7

Section 3: Our local needs assessment and priorities social care). There will be an increased move to more community mental health services rather than inpatient care to promote and sustain mental wellbeing (the new approach to PbR domains and the linked development of care pathways will support this approach) and more effective drug and alcohol services. Secondary care Over the next 5 years we see a continued move to higher quality acute units, with outcomes, particularly mortality rates, in line with national averages. Reconfiguration work in Morecambe Bay will have led to the provision of safe, sustainable obstetrics, paediatrics and A&E services. Confidence from the local population in safe and effective care delivery will have been fully restored. In-County provision will be from larger, more sustainable Foundation Trusts, following the successful acquisition of NCUHT, which will ensure financial stability and provision within tariff, as well as implementation of new models of care based on best practice in the North East and improved clinical networking and education/skills opportunities over the new Trust. Reconfiguration work through the System Board focussing on implementation of the emergency floor, single point of access, paediatric assessment unit and repatriation of out of county work will have been fully implemented. There will be full integration of services across north Cumbria and between the Whitehaven Carlisle hospitals and the opening of the new West Cumberland Hospital will see safe sustainable obstetric and emergency care models. The general focus on acute delivery within the County will be on services which cannot be provided at a local level within primary/community settings, with more effective networking with other out of county hospitals and tertiary centres to improve skills and improve the patient flow to and from specialist services in areas where clinical skills cannot be sustained within the County. There will be improved integration with primary care to ensure clinical sustainability, especially around the emergency floor model and for consultant support for better long term condition management and care for frail older people in community settings. Non elective admission rates per 1,000 population, already good in most localities, will be maintained, despite demographic change, through the implementation of the integrated emergency floor model and long term condition pathways; however, there will be a particular focus on reducing the high levels of unnecessary emergency admissions in Barrow. We will also have reduced the relatively high rates of paediatric emergency admissions throughout the County through implementation of the new paediatric assessment service in each hospital, linked to the emergency floors and supported by implementation of integrated pathways for children (such as the acutely ill child). Steady improvements against the already good elective admission rates will have been made through reductions in elective procedures of limited clinical value and greater support for patient decision making (eg on orthopaedics). This will have also freed-up capacity to deliver the repatriation of significant levels of out of county elective activity alongside the development of new services (such as PCI) not previously available in Cumbria, but now achievable as a result of the acquisition and better hospital networking. Social Care Finally, we will continue to ensure integration with social care, both for children and older people. This will clearly focus on priority areas associated with the aging population (such as dementia and frail older people) and children and young people. There will be more integrated nursing and social care (eg short term intervention services and general domiciliary care) to support discharge from hospital and we will have drastically reduced delayed transfers of care. We will be jointly commissioning more services together (eg nursing and residential homes) for better value for money and market management and there will be more joint deployment of technology (eg for telehealth/telecare) and innovation. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 8

Section 4: Our transformation programmes and outcome goals The previous section set out the context of health and needs in Cumbria which gives rise to our key priorities: Improving care to respond to the challenges of an aging population Improving the health of children and young people and the quality and integration of care services Improving mental wellbeing and reducing alcohol misuse Reducing health inequalities and premature mortality from cancer and cardiovascular disease Reconfiguring and modernising health services to provide more sustainable and higher quality care In order to deliver these priorities we have established 6 transformational programmes: Planned care Unplanned care Children and Young People Long Term Condition Management Primary care Reconfiguring Secondary Care in North Cumbria and South Cumbria We recognise that in view of the needs context, transformation is required in other areas (particularly mental health). However, we also recognise that given the significant challenges we face, we must prioritise if we are to deliver. This will allow us to deliver and move on to further challenges through the lifetime of this planning timeframe. A summary of the key deliverables from these programmes is set out to the right; more detailed plans on a page are set out for each area in Appendix 1. Long term conditions management Children and young people Unplanned care Deliver C2H Pathways for diabetes, respiratory, heart failure and service models for older people in care homes and end of life care Develop a holistic strategy for long term conditions and integrated primary and community delivery models Implement short stay paediatric assessment services integrated with Emergency Floor model Improve outcomes across 6 key pathways Improve access to and quality of CAMHS Improve quality of maternity and paediatrics (see Morecambe Bay programme) Implement integrated emergency floor Implement single point of access for urgent care Implement new care pathways Planned care Implement referral protocols and guidelines for clinically agreed EBR procedures and increase repatriation of out of county activity Transfer ophthalmology & MSK into community setting Repatriate out of county activity Primary Care Reduce unacceptable variation Implement long term conditions strategy Deliver more focused health improvement work such as health checks and smoking cessation Increase primary care capacity in Barrow, and reconfigure urgent day time primary care Provide more straight forward planned care Develop a strategy for managing the changing age and skill profile of the general practice workforce Secondary care transformation & reconfiguration Deliver the North Cumbria Clinical Strategy in line with the recent NCAT review and support the acquisition of NCUHT by Northumbria Healthcare Develop and deliver a clinical strategy for the Morecambe Bay area and ensure rapid improvement in the quality of services for: maternity; paediatrics; A&E; stroke; and outpatients Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 9

Section 4: Our transformation programmes and outcome goals Each of the transformational plans sets out the expectations in terms of improved outcomes. However, as a number of these programmes are still being fully developed (eg development of the clinical strategy for Morecambe Bay) not all have specific targets. Our outcomes goals are set out in the box below. In addition to local outcomes improvement, the NHS Operating Framework sets out the national expectations for quality and performance improvement against which CCGs are expected to deliver. Within this context, NHS North of England have set out a small number of key performance indicators. Whilst these may change in future as national priorities are met, for 2011/12 they were: Referral to Treatment A&E 4 hour wait Cancer - 62 day waits Stroke Mixed Sex Accommodation HCAI Ambulance Cat A. Key measures are included alongside local outcomes in the box below; detailed targets for all required Operating Framework targets for 2012/13 are set out in Appendix 2. The CCG will continue to ensure achievement of national standards through the contractual process, supported by CQUIN and other improvement initiatives as well as the transformation programmes for north and south Cumbria. Priority Improve care to respond to the challenges of an ageing population Improve the health of children and young people and the quality and integration of care Improve mental wellbeing and reduce alcohol misuse Reduce health inequalities and premature mortality from cancer and cardiovascular disease Reconfigure and modernising health services to provide more sustainable and higher quality care Outcomes 83% of people with a long term condition to feel independent and in control of their own condition Reduction in unplanned hospitalisation for adults with chronic ambulatory care sensitive conditions* 15% reduction in patients using anti-psychotics (on primary care dementia registers) 10% reduction in unscheduled admissions from residential care homes to acute trusts Net 2.3% reduction in adult non elective admissions Net 5% reduction in number of elective admissions 35% reduction in the overall number of paediatric non elective admissions across three years Reduction in unplanned hospitalisation for under 19s for asthma, diabetes, and epilepsy* 13.5% of people with depression receiving psychological therapy 48.5% of people who complete psychological therapy moving to recovery 95% of people under adult mental illness specialties on CPA followed up within 7 days of discharge from psychiatric inpatient care Reduction in number of alcohol related hospital admissions** Reduction under 75 mortality rate from cancer** Reduction under 75 mortality rate from CVD** Reduction in mortality within 30 days of hospital admission for stroke** 85% of patients receive first treatment for cancer within 62 days of an urgent GP referral 98% of patients receive subsequent treatment for cancer within 31 days for surgery, anti-cancer drug regime or radiotherapy treatment course (94%) 3,807 four week smoking quitters 20% of people aged 40-74 have been offered an NHS health check 95% of patients seen in A&E in 4 hours or less 90% of patients referred for treatment admitted within 18 weeks 95% ambulances respond to category A calls within 19 minutes Reduce hospital acquired infections Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 10

Section 5: Our approach to quality and engagement The CCG approach to quality The CCG recognises the importance of ensuring quality and is developing its approach to quality, with a focus on clinical leadership and embedding quality in the commissioning and contracting process. The CCG wishes to ensure that its approach to contracting and quality concentrates on the following major areas: Patient experience both more effectively acting upon what patients tell us and strengthening their voice in service improvement and in targeting specific aspects of patients experience, such as personal dignity and communication Safety of clinical services: targeting areas of concern raised by external or local intelligence including proactive assurance of performance against national standards and ensuring that action from lessons learnt is taken effectively Good clinical practice. Ensuring that clinicians and services are systematically working to accepted good practice guidelines, and that there are good systems of clinical communication that are timely, accurate, relevant and systematic Agreed pathways of care, ensuring the effective adoption by primary, community and secondary care services of agreed care pathways in Cumbria, with care indicators that measure the quality of a whole pathway of care Commissioning intentions and implementing new models of service delivery In each area there will be a strong emphasis on patient choice, integration of care between providers, primary, community and secondary, with the CCG recognising its responsibility as a partner to ensure that primary care works effectively as part of the health system. The CCG understands integration to mean the effective management of care for a patient between providers, requiring collaboration and communication. From the patients perspective we need to ensure that the service they receive is coherent and of high quality from the health system. That requires individual NHS providers to provide good quality care, but it also requires collaboration between organisations and clinicians to make sure that the patient is the focus of how care is provided. Promoting and supporting that collaboration will be a key feature of the contracts with providers. This will centre on an approach that: Incorporates common indicators across individual Trusts, to support integrated working and improved communication Is actively led by clinicians Motivates staff and focuses on direct patient care, at team or ward level Includes specific quality measures for children s services in all contracts. During the next few years the CCG wishes to develop alternative approaches to contracting that better support integrated working between primary, community and secondary care and place quality at the heart of the contracting process. In agreeing contracts for 2012/13 the CCG wishes to anticipate those developments by laying foundations for this changed approach, by maximising the potential in existing contracting arrangements towards supporting its aims for quality. The CCG regards contracting as a major lever, for both commissioners and providers, in driving attention to and improved performance in the quality of health and health care in Cumbria. It wishes to see contracting used as an integrated part of its commissioning processes to support the focus on quality. CQUIN will be agreed in 2012/13 and beyond as an incentive to improved performance. This may be performance beyond that nationally mandated or in areas of specific local concern. CQUIN will not be used to incentivise practice or performance which would normally be expected to be delivered as part of the national NHS contract. In line with national guidance, targets previously incorporated within local CQUIN schemes will be incorporated within the main contract, with CQUIN focussing on new areas of improvement or higher levels of performance in areas that remain a priority. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 11

Section 5: Our approach to quality and engagement The CCG wishes to work supportively with its NHS Provider partners to ensure that we have a small number of highest priority areas that remain at the top of our agenda, and drive our overall approach to quality care. These will be: 1. Service Reviews. Each Trust will be required to undertake two service reviews per year. These reviews will be in areas highlighted through our shared understanding of Hospital Mortality data (SHMI) and the NHS Atlas of Variation. The reviews will be against NICE or best practice guidelines with the review scope jointly agreed with Commissioners. Improvement plans, where required, will be jointly agreed between commissioners and providers and progress monitored through the Quality- Contract Meetings 2. Lessons Learnt. Each Trust will be required to report regularly on the outcome of lessons learnt from complaints, serious incidents and external service reviews, providing evidence of the effective implementation of lessons learnt or agreed action plans 3. Each Trust will participate, with primary care, in a shared clinical audits, two per annum, across jointly agreed patient pathways, with jointly agreed development plans monitored for implementation 4. Each Trust will demonstrate effective collaboration across provider Trusts for the implementation of agreed models of Care for Children s services 5. Collaborative working. Each Trust will be invited to include within its contract a shared incentive approach to two designated clinical areas, that through collaborative working across all providers will improve the quality of care for patients. Targets will be agreed that share the commissioning expenditure saved in each area across the commissioner and participating providers. The initial areas identified are: Dementia care: reduction is hospital admissions and the length of time a patient who has dementia spends in an acute hospital Alcohol Misuse: reduction in admission to acute hospital for alcohol related illnesses The CCG will ensure that the care that it pays for through its contracts is of good quality. Therefore the CCG will: Not pay a Trust for care carried out that is a agreed locally or nationally as a never event Reduce the total contract payment to a Trust should the Trust be in receipt of an improvement notice from the CQC. Clear expectations for performance and quality are embedded in the CCG s relationship with its providers, with all quality and performance standards mapped against the NHS Outcome Framework, developed in collaboration wit the Cluster. The CCG is developing its governance arrangements and its intelligence systems with clinical leadership, through forums such as Clinical Advisory Groups where clinical leaders from all Trusts address outcome, service quality and development issues in open discussion and work projects across Trusts. The CCG s six localities ensure clinician and patient feedback are as close to the patient as possible, with delegated authority to address local issues. This local intelligence, is brought together with information from a broad range of data sources ( lessons learnt, public health mortality and trend data, etc) to proactively identify quality issues for action at local, or countywide level. Quality contracting meetings will be appropriately supported at Director level with clear communication between and within organisations. Each quality component of the contract, individual targets and major areas of focus, will have a named clinical lead from the CCG and from the NHS Provider Trust. It is expected that this lead will be a Consultant, GP or Senior Clinical Professional at an equivalent level Engagement: Clinicians in Cumbria have always set great store on engagement of patients in decision making and service re-design. For example, engagement of patients is at the heart of the diabetes pathway re-design, with a focus on patient education and co-production of the care plan. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 12

Section 5: Our approach to quality and engagement In line with the promise to patients and communities outlined above, the CCG are keen to make a quantum leap in the development of its engagement arrangements, and like quality, embed them at the heart of all the commissioning arrangements. An early priority for the CCG will be to carry out an extensive Listening to Cumbria campaign throughout the spring of 2012. This will involve health roadshows, meet your GP surgeries and other public facing events in every locality in the county. It will be led by the elected GPs from each locality and seek the views, aspirations and needs of patients. It will also be an introduction to the new world of GP commissioning. There will also be programmed meetings with key stakeholders such as the Overview and Scrutiny Committee, emergent Health and Wellbeing Board, MPs, League of Friends, LMC and social care and local authority representatives. We will also actively seek patient views about how they can be more closely involved with decision-making on both individual and collective levels. The outcome of the listening campaign will be an evaluation which will lead to a new and dynamic multi-channel methodology for capturing and acting upon patient experience on an industrial scale.this multi-channel methodology will focus include: 1. Near time, post treatment, out-bound telephone follow-up interviews. 2. On-line opportunities to comment on-line with moderated feedback and publication. 3. Structured attitudinal surveys. 4. Patient experience sampling across service lines and provider geography. 5. Proactive mobilisation of community and voluntary groups to monitor. 6. Primary care satisfaction surveys. 7. Comments and notes boxes in every GP surgery. 8. Requirements of providers to carry out satisfaction surveys in situ. 9. Deliberative patient groups in every locality. 10. Feedback loops to patients to demonstrate how their experience has been taken into organisational and contractual learning to make service changes. It is expected that the CCG will commission these services from an external agency to provide a regular and systematic monitoring of patient experience. This data will be reviewed by clinicians at monthly locality and CCG executive boards as a core metric in the quality dashboard and for contract monitoring and service development. Equality & Inequality The PCT Cluster met the 1st part of the PSED by publishing information of the effects of policies on people protected by the Act on 31st Jan 2012. In addition the Cluster is reviewing EDS evidence with self assessment alongside providing training to enable grading of self assessment by wider Stakeholders. A Joint accreditation event where wider stakeholders will verify self assessments leading to a Cumbria wide assessment proving a baseline for EDS will be held in early 2012/13. From the event Equality Objectives will be drafted for verification by the Board leading to development of an Equality Strategy later in 2012/13. The Cluster and CCG will work together to develop performance measures to show how Equality Objectives will be met over the next 4 years. There are a number of areas in this plan which will have a direct impact on reducing health inequalities, such as: Delivery of health checks and smoking cessation targets Delivery of the Cumbria Cancer Strategy and the cancer access to treatment targets Action in response to SHMI/HSMR data The new approach to long term conditions management The transformation of primary care programme Delivery of the Cumbria Suicide Prevention Strategy Improvements in the quality of Stroke services Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 13

Section 6: Our Resources: Finance, QIPP & ICT Financial Plan 2012/13 to 2014/15 NHS Cumbria has agreed a high level of delegation to CCCG, with 100% of the relevant CCG budget delegated. For 2012/13 this amounts to 676m or 76% of the 893m NHS Cumbria budget. The CCG financial plan for the three years 2012/13 to 2014/15 is set out in the table opposite. The financial plans for each locality are set out in Appendix 4. The medium term financial strategy has been structured in line with best practice, as set out by the Audit Commission report on PCT medium term financial planning and addresses the following: 1. Demonstrating strong leadership of finances and strategic direction 2. Using the medium term financial plan to support the achievement of strategic objectives 3. Establishing lines of accountability for producing and adhering to the medium term financial plan 4. Producing a medium term financial plan that identifies and manages the financial implications of risk 5. Understanding fully the CCG s cost drivers, through the collection and analysis of a wide range of data and planning over the medium term to improve value for money 6. Recognising the importance of good quality data 7. Producing a medium term financial plan that is comprehensive, accurate and has content that is relevant and useful 8. Providing internal and external stakeholders with an opportunity to scrutinise and challenge the medium term financial plan 9. Ensuring Governing Body / CCG Executive approval of the medium term financial plan and that the medium term financial plan is communicated to the right people 10. Using the Medium term financial plan as the key financial document from which the annual budget is developed and puts in place the systems for achieving, monitoring and continually refreshing the MTFP. Cumbria CCG Strategic Commissioning Plan April 2012 v5.1 14