Operational Plan

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1 Introduction This two year operating plan is written to provide NHS England with assurance that Sandwell and West Birmingham CCG has plans in place aligned to the Black Country Sustainability and Transformation Plan (STP), that will deliver the nine must dos, the NHS Constitution and the CCG Improvement and Assessment Framework. We are working with partners across the Black Country STP and the Birmingham STP (as an associate commissioner) with the explicit purpose of delivering sustainable health and social care now and in the future. As part of the STP we will focus on designing services that manage demand effectively in the community and provide modern specialist interventions in the right place and at the right time with less variation in the care that patients receive. There are many similarities between the registered populations of the STP partners but also some differences which will need to be taken into account when redesign and commissioning services. The Sandwell and west Birmingham population is relatively young compared to England and we have a higher proportion of women of child bearing age. The rate of live births in our population has consistently been higher than England and has been steadily increasing with a slight plateauing in the last couple of years. In addition to this a significant proportion of births are to first generation migrant mothers. Consequentially we have a higher proportion of children in our population and there is increasing diversity in terms of ethnicity and culture. Conversely, the proportion of people aged 65 years and over is lower than England average (12.5% versus 17.1%). Life expectancy is improving in our population; however the inequality gap with other areas persists (2.4 years for men and 1.3 years for women). Additionally, not only do our population experience ill health and death earlier than most areas, they live in poor health for longer. We know that cardiovascular disease, cancers and respiratory disease are the top three health factors impacting on the inequality in our population. Our Right Care programme is focusing on how we maximise patient outcomes on all three of these areas. Whilst public health may commission and ultimately be held to account for delivering some prevention outcomes, it requires the collective efforts of health and social care if we are going to achieve any meaningful impact moving forward. Preventing ill-health and onward progression of disease is vital if we are to achieve a sustainable health and social care economy. As a core component of our Right Care programme and an integral part of delivering QIPP we will ensure that at each stage of prevention we consider the appropriate interventions required. We liaise with public health colleagues to understand primary prevention services and pathways that they commission, to try and ensure that they align with our commissioned services. There is an identified risk to the CCG relating to public health commissioned services, with a number of services already being reduced or decommissioned and potential further reductions in funding being available from 2019-20 onwards. Reducing primary prevention interventions will inevitably have an impact on CCG commissioned services and resources. As previous stated our population experience poor health at an earlier age, with worse outcomes and a significant contributor is lifestyle factors. A number of examples of lifestyle factors that adversely affect morbidity and mortality for our CCG are outlined below. 2

Fewer adults are reporting that they smoke tobacco, currently 19.6% people but this still remains higher than England average 16.4%. Recorded prevalence of Obesity in adults is 10%, much lower than the estimated prevalence of 27%. 40% of children in year 6 are classed as overweight or obese, significantly higher than both West Midlands and England average of 33%. Our population, in particular Sandwell undertake significantly less physical activity (children and adults) than England average and typically our population eats a less healthy diet. Alcohol specific hospital admissions and under 75 years mortality rate from alcoholic liver disease (particularly in men) are both significantly worse than England average in our population. CCG QOF performance is comparable to national performance, however we know the rate of emergency admissions and mortality are often above comparator CCGs and England average. The Infant Mortality rate is much higher in the Black Country and West Birmingham compared to England rate of 4.0 deaths per 1000 - Sandwell & West Birmingham 6.9. The Premature Mortality rate for Respiratory Disease in the Black Country and West Birmingham is higher than the England average rate of 28.1 per 100,000 - Sandwell & West Birmingham has a rate of 38.1. The plan is written within the context of the wider Black Country Sustainability and Transformation Plan, the CCG Transformation Area Plan, the recently submitted Strategic Demand Management Plan, the CCG General Practice Strategy, CAMHS Local Transformation Plan and the Better Care Plans. 2 Relationship to the STP In Sandwell and West Birmingham, like the rest of the Black Country, people are living longer with ever more complex conditions; progress in treatments and medical techniques comes with new costs and expectations, and modern lifestyle issues such as obesity are causing an increase in long term conditions. To be able to provide a sustainable health and care system, we must transform services to adapt to these challenges. Working with partners across the Black Country STP and the Birmingham STP (where we are an associate commissioner), to change the way we spend money and use our limited resources, we must make the most of modern healthcare through innovation and best practice. We must also focus on shifting demand away from our hospitals and to a more community centred approach. When patients need hospital care, however, it should be of the highest quality, providing specialist interventions in the right place and at the right time with less variation in the care that patients receive. Our aim is to materially improve the health, wellbeing and prosperity of the population of Sandwell and West Birmingham through providing standardised, streamlined and more efficient services. At the heart of our plan is a focus on standardising service delivery and outcomes, reducing variation through place-based models of care provided closer to home and through extended collaboration between hospitals and other organisations. 3

3 2017/18 and 2018/19 nine must dos 3.1 Develop/deliver Sustainability and Transformation Plans The recently published Black Country Sustainability and Transformation Plan (STP) sets out a strategic plan for the transformation of health and care across the Black Country and west Birmingham footprint. The STP has no statutory powers; it is a collaboration of 18 organisations across primary care, community services, social care, mental health and acute and specialised services across the Black Country and the west of Birmingham. As a key delivery partner, Sandwell and West Birmingham CCG has aligned its operational plan priorities with the delivery of the STP. Drawing on the collective efforts of partners across the Black Country and west Birmingham, we aim to realise a range of opportunities and benefits for people who use our health and care services. 3.2 Financial sustainability To achieve sustainability in local health and care services, the Black Country STP partners need to take significant action to reduce both the projected growth in demand and the costs of the services provided. The challenge equates to avoiding spending of 512m by 2020/21 across the Black Country and west Birmingham. With an indicative national Sustainability and Transformation Fund allocation of 99m in 2020/21, the STP challenge equates to 413m. Sandwell and West Birmingham CCG retains responsibility for delivering annual savings, efficiency targets and compliance with business rules: Maintaining a minimum of 0.5% contingency The non-recurrent utilisation of 0.5% (clear non-recurrent utilisation of full 1% of nonrecurrent resources from delegated GP Services) No benefit to the bottom line from the business rule regarding the 0.5% CQUIN Strict adherence to the CCG 2 Year allocations that have been issued Robust inflation and growth assumptions based on historic and future plans. National parity requirements around Mental Health and Child and Adolescent Mental Health Services. Demonstrate the use of the 3 per head for GP Forward View A requirement to confirm adherence to the national must dos (0.56% within each CCG growth uplift) Income In 2017/18, the CCG will receive an allocation of 779.048 m (including the brought forward surplus and an in-year drawdown of 2.5m). This represents a growth increase of 2.3% when compared with recurrent allocation in 2016/17. In the following year the CCG will receive 796.146 m, which represents growth of 2.2% and includes an in-year drawdown of 2.4m against the planned surplus carry forward. Further non-recurrent allocations may become available in future years. However, at present these amounts are unknown and it would be imprudent to rely upon their receipt. 4

Expenditure A full analysis of the cost pressures facing the CCG in 2017/19 has been undertaken. The assessment has included: Expected growth in healthcare contracts; Pressures from National Policies Pay and Price inflationary pressures Planning Guidance requirements. The main assumptions used in formulating the CCG s financial plan are summarised as follows:- Table 1 Key Planning Assumptions The CCGs expenditure is estimated to be 779m in 2017/18, which is summarised below. Table 2 CCG Expenditure Summary Overview of Expenditure by Programme Area 5

The acute commissioning portfolio continues to be our biggest area of spend accounting for nearly half the CCG s annual spend. Acute commissioning combined with prescribing, mental health, community services and primary care co-commissioning equate to over 90% of our total spend. Graph 1 Planned Expenditure 2017/18 Planned Surplus The planned surplus is 9.506m for 2017/18 and 7.106m for 2018/19 and represents the approved drawdown of historical surplus amounting to 2.5m and 2.4m respectively. This equates to 1.4% of the CCG s (qualifying) Revenue Resource Limit in 17/18 and reduces to the nationally required level of 1.0% in 2018/19 and is therefore RAG rated Green by NHS England. Underlying Position The underlying financial position is a key metric when considering the long-term financial sustainability of an organisation. The underlying surplus is calculated by taking the planned financial position, adjusting for the full year effect of expenditure commitments/savings and removing non-recurrent items. The underlying surplus (as submitted in our plan to NHSE in November 2016) is 2.3% of total expenditure in 2017/18 and 2.26% in 2018/19. Table 3 CCG Underlying Position Contract Position The CCG has used the planning assumptions contained within this paper to estimate the contract values for 2017/19. The assumptions include adjustment for demand growth, demographic growth, patient flows, national tariff, the new Midland Metropolitan Hospital trajectory and new investment. It also includes estimations for efficiencies and demand management. The CCG s is currently 6

negotiating its contracts for 2017/19 2 year period. The progress will be updated in plans as appropriate. Primary Care Co-commissioning The budget in respect of primary care co-commissioning is included within our financial plans and the attached GP Forward View Plan. The allocation received in respect of primary care cocommissioning is 79m in 2017/18 and 80.8m in 2018/19 ( 77m in 2016/17). Activity Growth Growth on activity has been determined by taking into account underlying historical growth trends, future demand and capacity, consideration of demand management initiatives and QIPP alongside the required delivery of the national RTT target. QIPP The financial plan has identified the gap between available resources and predicted levels of expenditure for 2017/18 and 2018/19. The annual challenges are set out in the table below:- Table 4 In order to tackle the growing financial challenge in future years it is proposed to establish a work programme focused on the Right Care opportunities that have been developed and recently published by NHSE. This tool again identifies where the CCG is an outlier in terms of expenditure, but also attempts to indicate the health benefit to patients. 7

The above QIPP values exclude health economy wide price efficiency savings that are a further 20m. Running Cost Allowance In 2016/17, the CCG has a Running Cost Allowance of 11.5m. However, the CCG is forecasting to only spend 11m in the current year. In 2017/18 and 2018/19, the CCG s Running Cost Allowance will remain at 11.5m. Whilst the running costs of the CCG are still predicted to be affordable and within the Running Cost Allowance, the level of underspend will reduce. This expected increase in cost is caused by inflation (pay and non-pay) and incremental drift. Despite the additional growth in the CCGs allocation, the CCG faces some significant challenges during 2017/19 and there are some significant risks that need to be managed diligently in order that the statutory break even duty can be achieved in future years. The CCG takes these challenges seriously and has robust systems in place to address the situation. 3.3 Primary care The CCG is committed to delivering the GP Forward View and addressing the significant challenges faced by primary care such as, increased demand, insufficient funding, workforce shortages and the ambitious modernisation agenda set out in the Five Year Forward View new models of care. What we know: Our members provide a higher than expected consultation rate (5.79 compared to the national average of 5.24) Our members provide 1,773,512 GP consultations per annum Our GP surgeries provide 824,408 pre bookable consultations per annum 53.5 % of appointments are bookable on the same day 46.5% of appointments are bookable in advance 50% of our practices use telephone consultations, 2% use video consultations, 1% currently use mobile apps and another 15% are considering which methods they might utilise. The primary care vacancy rate is 4.9% across all clinical and non-clinical groups 19% of our GP s are aged 60 or over and 13% are considering retirement within the next 5 years 51% of practice nurses (including ANP s and nurse prescribers) are aged 50 or over, with 12% aged 60 or over Our GP registered population has increased by 8% to 571,459 patients. Our GP practice registers show a great variation in proportion of Black and Minority Ethnic (BME) patients (from less than 10% to greater 90% of practice populations). GP interpreting requests reveal the true extent of our multi-ethnic and multi-cultural diversity of our population, with 46 languages and dialects being accessed. We are one of six national Excellence Centres with the National Skills for Health and the lead for local Community Education Provider Network (CEPN), as such we have strategies in place to recruit new entry level recruits, strengthen the skills of the current primary care workforce and attract an experienced workforce. We have been investing in primary care services, above and beyond the core General Medical Contract for the past two years and we will continue to increase the investment during 2017/19. At 8

the heart of our plans to improve primary care is our Primary Care Commissioning Framework (PCCF), which will be our main vehicle for incentivising and supporting general practice until they are ready to deliver the New Model of Care set out in the Five Year Forward View. The PCCF encourages practices to develop at scale solutions, to deliver improved clinical outcomes for patients, provide targeted interventions, improve access, and improve the early detection of long term conditions and screening for priority cancers. The framework already contains many of the 10 High Impact Actions and we intend to expand the breadth of the framework by April 2017. We are supporting our practices to adopt innovation designed to support the management of demand including online access and digital signage tools, national programmes such as the Releasing Time for Patients development programme, resilience funding, maximise local pathways to help patients with self-care and minor ailments. We are also using the NHS Standard Contract and its new legal requirements for acute hospitals and community providers to relieve some of the administrative burden on practices by not automatically discharging patients back to their GP for re-referral if they miss an outpatient appointment; by taking account of GP feedback when considering service redesign, by providing electronic discharge summaries and clear clinic letters. These changes should impact positively in primary care. In order to achieve sustainable transformation the CCG needs to make some targeted capital investments, these are outlined in the attached GP Forward View Plan. 3.4 Urgent and emergency care During 2016 the CCG has both been part of and led a regional procurement for Integrated Urgent Care Services, which is one of the first services in the country to go live. Whilst the service will mobilise in November 2016 and will initially incorporate NHS 111 and OOH services, we will aspire to introduce wider functional integration across the remainder of the urgent care system in 2017/18. NHS111 is now the single point of entry into urgent care services and calls from patients will be taken by doctors and other health professionals including pharmacy, dentist and mental health services. We have focused upon improving access to patient s records so that clinicians can be better informed when making decisions about treatment. We will also work to support the introduction of NHS 111 online in order to improve accessibility to patients through the use of technology. To make it as simple as possible for patients to find and get treatment from the service that they need 24 hours per day, 7 days per week, we want to clearly identify which services are available. The Directory of Services which will underpin this work will be expanded to include a wider range of services and will be accessible by more care providers ensuring that patient s benefit from improved information flows and technical interoperability. We are aiming to reduce the need for patients to be transported to hospital by ambulance and we are doing this by making more advice and treatment available at the scene including in patients homes and will be developing opportunities for supporting patients to self-care. Calls to the integrated 111 and urgent care service will, over time, channel patients to a range of other services such as pre-booked appointments in primary care or urgent care settings, community nursing, voluntary and community sector and adult social care. 9

Providers are currently struggling to achieve the 95% 4 hour target. The reasons for the dip in A & E performance are multifactorial but include; changing patient behaviours, a rising number of unfilled shifts at a trust level, reliance on bank and agency staff in ED, delays in clinical decision making, above predicted ambulance conveyances, higher than predicted attendances at A & E, internal patient flow delays and wider system issues such as, the pace of establishing community care packages and placements. Building upon progress made in 2016/17, the CCG will continue to work with providers to ensure that the 4 priority clinical standards for seven day services and the five elements of the A&E Improvement Plan are achieved. We will also: 1. Refine specifications for ambulatory care units at City/Sandwell in line with national best practice and local need. Also to ensure an interface with the NMC programme to support a stronger primary/community offer for urgent care sensitive conditions. 2. Build on the mobilisation of the new Integrated Urgent Care service to ensure patients can access clinical advice and support and can be provided with certainty and choice through pre-booked appointments at appropriate services. Ensure compliance with NHS 111 CQUIN which calls for a 10% reduction in the number of calls that end in an A&E disposition. 3. Work with system partners to refine plans for the new emergency and urgent care services and ensure a robust communications plan is in place supporting patients to choose the rights points of access. 4. Self-care - development of a proposal via WMUECN to deliver a more tailored approach to self-care via Integrated urgent care and local adoption and implementation of these plans. 5. Implementation of urgent care demand management project with CCG membership. The pilot scheme already completed will be introduced across the CCG to proactively develop care plans for patients. 6. Improve mental health services to better meet the needs of people accessing emergency services with a mental health illness. 7. Through the Sandwell and Birmingham Better Care programmes we will continue to develop plans for the implementation of the joint Sandwell and West Birmingham Strategy for Intermediate Care which aims to address timely planning for discharge, supporting patients in their own home and promoting Independence. 10

3.5 Referral to treatment times and elective care Over the last three years we have initiated a range of programmes to support effective demand management of planned care: 2013/15 General practice peer reviews 2013/15 Referral management services (for groups of practices and specific long term conditions) 2013/16 Commissioned a range of primary care led speciality services (i.e. cardiology, dermatology, gynaecology) 2014/15 Audited every practice access and productivity flows and initiated individual project plans 2014/16 The establishment of 10 Population Management Pilots sites covering a total population of 210,000 (pre the initiation of the West Birmingham Vanguard) 2015/16 Developed and expanded the West Birmingham New Model of Care Vanguard Connected Care Partnership) 2015/16 The development of an acute led Consultant Advice and Triage Service. 2016/17 Initiated a new Primary Care Commissioning Framework to improve horizontal integration between practices, reduce variation in access, increase community diagnostic provision and proactively target the health and wellbeing of carers, people with enduring mental health illness and people at risk of coronary heart disease, stroke and diabetes. With the exception of the Primary Care Commissioning Framework which is a long term strategy designed to support General Practice work towards delivering new integrated models of care (MCP/PACs); all the above initiatives have had a marginal positive impact and/or increased costs. Lessons learnt from our attempts to manage demand clearly show that in order to manage demand effectively we need to balance the aspirations of providers, with an incentive structure that supports transformation, aligns to quantifiable patient outcomes and is supported by a workforce with the required capacity and capability. The emerging new models of care and new contractual mechanisms provide an opportunity to incentivise a step change over the next two years which will redesign care pathways around the needs of the local population. Over the next two years we will transform community and primary care services to enable providers to adopt a population health approach through integrated, standardised, place-based services built around the registered list. Providers (integrated) will be responsible for managing demand for planned and unplanned care. Escalating the delivery of integrated population based management approaches is key component of the CCGs Operational Plan. In the autumn of 2018 the new Midland Metropolitan Hospital will open and its business case is predicated on delivering new ways of working and managing planned care. The future hospital model relies on a higher proportion of day case activity, shorter inpatient length of stays, a reduction in the new to review outpatient ratios and an increase in shared care with general practice. The delivery of the new models of care and the redesign of care pathways is an essential component of this transformation. 11

Key actions planned include: Accelerating the learning from our vanguard sites across the whole of our footprint Developing and implementing new incentive and risk management models Developing transformation plans for defined populations (covering the whole of our footprint), maximising the new primary care funding as outlined in the GPFV and the transfer of services to the community (the plans will include lessons learnt from the Demand Management good Practice Guide) Focused pathway transformation in the key areas (identified in the RightCare analysis) - Diabetes, Coronary Heart Disease, Respiratory, Cancers and Maternity Monitoring performance and proactively address areas of increasing demand, including commissioning alternative providers if required. Adopting a STP developmental evaluation framework that will enable accelerated implementation across the Black Country Increasing primary care activity through the Primary Care Commissioning Framework Developing standardised access to services utilising the full benefits new digital technologies across the STP. Supporting STP provider network collaboration that improves diagnostic and care pathways for key improve long-term conditions. The STP provider efficiency programme will: Develop share/single service plans for acute specialities with particular opportunities or challenges Develop new models of care to support specialised services including cancer and vascular Develop options for the delivery of efficient pathology services Reduce variation in care and improve outcomes across the Black Country footprint The CCG 2016/17 Right Care review identified cardiovascular, respiratory and diabetes as areas that would present achievable QIPP contribution. Our approach to realising these potential savings is outlined in the RTT and Elective Care Template in Appendix 1. Through the STP care networks and specialist services work streams we will support the delivery of the care networks for the treatment of radiology; ear, nose and throat; rheumatology; vascular surgery, stroke and pathology. We will maximise the benefits of these networks and develop new joint working arrangements for children s services and orthopaedics. 3.6 Cancer Overall incidence of cancers for Sandwell and West Birmingham CCG is similar to the national average. However, focusing on this figure alone is misleading. The incidence of lung and stomach cancer is significantly higher than the national average whereas breast cancer is significantly lower. Since 2001 the cancer incidence rate in England has increased by 0.7% per year whereas for the CCG the increase has been 1.5% per year. Lifestyle factors associated with increasing risk of cancer are all worse than the national average including smoking, increased alcohol consumption, reduced physical activity and being overweight. Addressing the causes of cancer requires wider partnership effort, effective Public Health initiatives play a key role, including: - Uptake of health checks 12

- Physical health initiatives - Smoking cessation services - Tobacco control strategies - Addressing obesity - Monitoring and addressing early screening services via the Strategic Cancer Network - Exploring patient education and on-going support programmes - Working with Public Health we aim to reduce adult smoking prevalence to less than 13% by 2020 and less than 5% by 2035. The CCG has a higher than average diagnosis via emergency presentation for cancers (22%) and the percentage of lung cancers diagnosed at an early stage (1 or 2) is lower than the national average at 18.7%, which indicates we are not detecting early signs and symptoms as effectively as we could. The number of eligible people screened for breast, cervical and bowel cancer is lower in the CCG than the national average for these 3 cancers. There is a particular low uptake for bowel screening across the CCG footprint. Cancer Research UK is working with the CCG through the Facilitator Programme to support GP practices on cancer prevention and improving screening uptake with a Cancer Research UK Health Professional Engagement Facilitator working on a one to one basis with our GP practices. Through this programme we hope to see an increase in the number of people attending screening for breast, cervical and particularly bowel cancer. We also hope to see an increase in cancers diagnosed at an early stage and improved prognosis. One year cancer survival in the CCG is lower than the national average. Bowel cancer survival is of particular concern, linked with the low uptake of bowel screening; more patients are diagnosed at a later stage with lower survival rates. We plan to work with MacMillan Cancer Support, the MacMillan Primary Care Nurse Facilitator and Sandwell and West Birmingham NHS Trust, to implement all elements of the Recovery Package and ensuring that: - All patients have a holistic needs assessment and care plan at the point of diagnosis. - A treatment summary is sent to the patient s GP at the end of treatment. - A Cancer Care Review is completed by the GP within six months of a patient s cancer diagnosis The MacMillian Nurse Facilitator will support workforce development within our practices to improve patient, carer experience and patient outcomes. We will raise patient awareness through a structured communications and engagement plan for all 3 strategic priorities early diagnosis, living with and beyond cancer and breaches. We are reviewing activity for urgent referrals and day case admissions to better understand patient pathways and identify unnecessary variation, including monitoring the achievement of the 2 week wait, 31 day and 62 day standards. We will work with Sandwell and West Birmingham NHS Trust to implement ERS usage for urgent 2 week wait referrals, to reduce the time patients wait for a diagnosis and support the achievement of the 2 week wait, 31 day and 62 day standards. Working with Sandwell and West Birmingham NHS Trust, we plan to undertake a review of diagnostic services, to review direct access, monitor turnaround of results and apply the learning from diagnostic pilot sites. We will work with the Strategic Cancer Network to model implications for demand on diagnostics as a result of the revised NICE guidance for suspected cancer. 13

During 2017/18 Sandwell and West Birmingham NHS Trust will embed the West Midlands Inter Trust Breach Allocation Policy for referral transfers and explore initiatives for breast and prostate follow up pathways. The combination of our actions will improve detection of early indicators, ensure timely referral, increase patient survival rates and address the inequity of access to a comprehensive recovery package across the CCG. 3.7 Mental health In the Black Country and West Birmingham men and women with severe and enduring mental health problems in contact with mental health services have a lower life expectancy than the rest of the population. The life expectancy gap, is 17 years for men and 14 years for women. Much of this discrepancy is due to physical ill Heath; addressing parity of esteem will ensure people with mental health problems have the same opportunity for healthcare as the general population. Mental health service users experience higher mortality rates across all major disease groups. Whereas cancer is the leading cause of death for the population as a whole, circulatory disease is the most common cause of death for mental health service users. Approximately 1 in 5 of all A&E attendances and emergency admissions relate to mental health service users. Mental health service user s outpatient DNA s run at almost 15%; it is considerably higher than other patient groups. Rates of diagnostic imaging are almost twice as high among mental health service users than the rest of the population. We have good local IAPT services that provide low and high intensity talking therapies and we aim is to increase the level of provision year on year to provide additional support services to people with long term conditions. We have also invested in support services for people with mental health issues who enter A&E with a physical health need (via Psychiatric Liaison Oak Unit). Tackling inequalities for people with mental health illness requires concerted effort it is therefore, our intention to commission mental health services in collaboration with other Black Country STP commissioning partners. As one commissioner we will substantially reduce the current unwarranted variations in the quality of care, we will standardise services, and create an environment in which our providers can maximise resources and workforce through better skill mix utilisation. Collectively we will realise the following STP opportunities to improve the care for mental health service users: up to 1.9m in A&E attendances e.g. reducing admissions for mental health issues, self-harm and medicines adherence. up to 17.7m in inpatient care in subgroups which may be amenable to commissioner based QIPP schemes. Targeted investment in evidence-based interventions to release acute hospital costs whilst improving the physical health of mental health service users. Enhance annual health checks, making them effective as part of the individuals overall health care plan, review all prescribed medication for toxicity and side effects, work with partners to very significantly increase health improvement /risk reduction interventions (e.g. exercise on prescription, use of third sector community building opportunities) and staff in mental health services could develop a better understanding of physical health needs. 14

Develop local arrangements for integrating primary and community services on a place basis should always include mental health, social care and voluntary services. This represents the ideal opportunity to consider how this integrated team can develop innovative, locally sensitive options to address the physical health needs of their population in receipt of mental health services. This approach will build on the Transforming Care Together (TCT) partnership vision to create synergies and improve the experience of Black Country and West Birmingham residents affected by Mental Health and Learning Disabilities (MHLD). By sharing best practice and aligning to the work of other agencies we will reduce variation; improve access, choice, quality and efficiency; and collaborate to develop new highly specialised services in the Black Country and West Birmingham (e.g. Children s Tier 4, secure services and personality disorder services). Inpatient episodes of care are resource heavy and are only appropriate for a minority of people in contact with mental health services. Our ambition is to ensure that patients receive hospital care only when their health needs require it by commissioning appropriate consistent crisis services across the Black Country and West Birmingham. When an admission is required it is (where possible) within the Black Country and West Birmingham ensuring that links are maintained with local support networks. We will determine the optimum bed requirement for existing services provided by NHS providers, which should support development of new highly specialised services. By agreeing common specifications and models we will develop standardised and effective solutions to minimise service variation. This will include a recovery model that supports people to avoid crisis, to manage their own care as much as possible and access timely support at times of need. We will ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals. This crisis work includes the partnership of the triage car where a paramedic a police officer and a community psychiatric nurse provides emergency care in the community with an aim of attending in under one hour. Overall, our approach to harmonize and standardise will: Simplify access to services improving health and wellbeing for users, families, staff and communities; Put in place common, responsive and standardised all age Early Intervention services; Combat variation in care and service delivery across the Black Country and West Birmingham; Ensure clear, simplified pathways for users, ensuring most effective use of resources; Achieve economies of scale for providers and reduction of duplication; and Improve utilisation in front line services through better skill mix usage and reduction in temporary and locum costs. Our plans over the next two years will be to deliver the Mental Health Forward View which identifies three key priorities; A 7 day NHS right care, right time, right quality An integrated mental health and physical health approach Promoting good mental health and preventing poor mental health Our plans to deliver the above priorities include; commissioning additional psychological therapies integrated with primary care, increasing crisis support, supporting people in acute services, reducing out of area placements for non-specialist acute care and improving mental health services for children and young people. 15

We are actively working to improve the dementia diagnosis rate in line with the national diagnosis rate of at least two thirds of estimated local prevalence, and have due regard to the forthcoming NHS implementation guidance on dementia focusing on post-diagnostic care and support. We are working in partnership with voluntary organisations to develop community support post diagnosis for patients and carers. We are commissioning community eating disorder teams so that 95% of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases and our CAMHS Local Transformation Plan sets out the following priorities for 2017/18: Increased early intervention and prevention, co-produced with people with lived experience of services, their families and carers; Post diagnostic interventions for children with global developmental delay and autism Timely specialist psychological assessment Input into feeding, sleeping and behaviour interventions offered by the Early Years team Training, consultation and supervision to appropriate other professionals within the Early years team Support for parents and carers post diagnosis Support and input into the Attention Deficit Hyperactivity interventions 3.8 People with learning disabilities Similar to mental health, we intent to establish a one commissioner approach across the Black Country STP to commissioning services for people with learning disabilities. Working across the Transforming Care Partnership (TCP) with local authorities, CCGs and NHSE (Specialised Commissioning) we will deliver the vision set out in Building the Right Support and the National Service Model. The TCP partnership will enable us to build on existing collaborative commissioning arrangements, facilitate improved local health services for people with a learning disability and/or autism, to commission at sufficient scale to manage risk, develop commissioning expertise and commission strategically for relatively small numbers of people whose packages of care can be very expensive and difficult to procure. We aim to deliver Building the Right Support (the National Plan) across the STP footprint, to reduce reliance on inpatient care by 62% within 3 years, to improve quality of outcomes for people with learning disabilities and/or autism through the development of standardised outcome measures, care pathways and clinical services. Ten inpatient assessment and treatment beds have already been decommissioned (2 in Sandwell) and consultation is currently underway regarding the proposed closure of one Assessment and Treatment hospital. Dependence on inpatient services has reduced by 12% across CCG and NHSE commissioned beds over the last six months; an Intensive Support Service is being piloted in Wolverhampton with a view to sharing learning across the STP footprint early in 2017. We aim to retain Black Country and West Birmingham funding in the STP to deliver the right care in the right place for service users, working across current NHS providers, ensuring the right capacity of beds to meet the demand (numbers and service type). Although bed day costs are unlikely to deliver savings, efficiency should be delivered through reduced length of stay from strong local 16

partnerships with social care, housing and family. This should reduce cost for Commissioners through existing out of area placements (savings only for services that can be provided from existing skilled staff). It will improve sustainability to existing providers by improved utilisation and profitability of inpatient units. We will be working towards improving health care for people with a learning disability so that by 2020, 75% of people on a GP register are receiving an annual health check. We will do this by ensuring GP learning disability registers are up to date, and that health facilitation nurses support practices to carry out the health checks. This will include supporting people with learning disabilities to understand the importance of health checks. Access to GP practices will be easier due to practices making reasonable adjustments, such as longer appointments as more time is needed or evening appointments so that a person with learning disabilities does not have to miss work or their day service. The Health Facilitation Nursing team and Learning Disabilities GP clinical lead will provide education to GP s and primary care staff. PAMHS nurses will continue to work directly with patients and carers for them to understand appointments and procedures that may be carried out using accessible methods, eg models of the body, drawings etc. The Health Facilitation Nursing team will also support people with learning disabilities to access health screening. We will implement findings and recommendations from the Bristol University Learning Disability Mortality Review Programme (LeDeR) in relation to reducing premature mortality rates. A local priority is to annually review all inpatients, to plan their stepped down needs. Pathways are yet to be developed for people being stepped down from specialised commissioned beds. This work is presently being scoped with NHSE with the TCP and will be completed by December 2016. 3.9 Improving Maternal and infant Health Review of our maternity Right Care programme highlights Sandwell and West Birmingham have; overall outcomes worse than comparator areas, resulting in more local demand for services. higher levels of low birth weight babies, this typically results in longer hospital stays and increased likelihood of neonatal intensive care use. higher rates of low birth weight babies, which increases the likelihood of emergency admissions for lower respiratory tract infections and gastroenteritis in the first 12-24 months Obesity, diabetes, the age at which women give birth, and the use of fertility are all increasing. These factors increase the risk of a safe birth for both mother and baby. The infant mortality rate in the Black Country and West Birmingham is much higher than the national average. Other than Dudley, all local authorities in the Black Country and West Birmingham have a higher rate of infant mortality than the national average. High levels of deprivation, teenage conceptions and smoking at the time of delivery contribute towards the poor maternal, infant and child outcomes. We are currently developing solutions with our main maternity provider and Public Health teams to improve the quality of maternity services, increase patient engagement and understand how we better meet needs in order to improve outcomes. Addressing our challenges around maternal 17

health (in particular, maternal smoking) and its impact on neonatal death rates and other infant is a priority. A coordinated maternity pathway alongside the provision of universal and targeted support will improve the quality of maternity care and prevent lifelong disability arising from poor outcomes at birth. Across the Black Country and West Birmingham, if we reduce the current high level of infant mortality to the national average, we would avoid the death of 34 babies a year - the equivalent of one child every 11 days. We will work across boundaries to provide and commission maternity services that support personalisation, safety and choice, with access to specialist care whenever needed. This will include undertaking a single review of maternity and neonatal service capacity, including and implement recommendations from the national Better Birth agenda to improve the quality of care, make care safe, as well as giving women greater control and more choices. Together we will engage with the people who use these services and create a more person-centred and sustainable model of care for maternity and neonatal services. 4 Complex care and personal health budgets Personal Health Budgets The CCG begins from a low baseline position for PHB cases, with a cohort comprising individuals in the pilot group and a small number of cases approved since implementation. To address this and achieve the outlined trajectory towards the Mandate targets, a multifactorial approach will be necessary. Existing CHC patients likely to benefit from PHB based on care package characteristics will be identified via the CONI QA patient management system, to facilitate a targeted approach; these individuals will be identified to case managers to ensure the option of PHB is discussed during care reviews. This approach will be supported by training and supervision at group and individual clinician level to ensure consistent capability and confidence across the clinical team, to maximise likelihood of successful conversion through robust care planning and mitigation of clinical and financial risk. These activities will be supported through development and distribution of accessible information to promote uptake. This will be achieved through engagement with patient interest groups to ensure materials meet the specific needs of identified patients and their carers. This will be coupled with monitoring of assessment data to identify offer and progression rates at individual assessor and team level, along with on-going monitoring of clinical and financial review to ensure consistent performance as activity volumes increase. Further increases in activity volumes will be achieved through expansion of PHB into patient groups not eligible for CHC, by identification of target groups and engagement with lead commissioners for these areas. As funding of care for individuals will fall outside existing CHC provision, analysis of existing block contract arrangements will be required to determine potential funding mechanisms; this is likely to delay full implementation until 2018/19. Actions to achieve required governance improvements for the larger cohort resulting from these interventions will include the ratification of a revised PHB policy to provide a governance framework that encompasses all patient groups, and the procurement of an expanded brokerage provision, completed via a procurement exercise or framework mechanism. In addition, revised KPI for CCG 18

and external functions will be implemented to enable effective performance management of all aspects of service delivery, with data reported via the CCG s Quality and Safety Committee. Continuing Healthcare The actions identified will improve performance and responsiveness of the Continuing Healthcare function, through optimised use of capacity and improved engagement with the wider health and social care economy to support identification of eligible individuals. Measures will also be introduced to increase the number of assessments completed outside of the acute setting. The actions to increase available capacity in the clinical and administrative team include the implementation of enhanced IT functionality to support paperless working. The tablet technology to support this is currently being piloted by a small cohort of assessors and will be extended to all assessors once full functionality is achieved. It is envisaged that the will be completed by the end of Q2 of 2017/18. This technology will increase efficiency within the assessment process by utilising handwriting recognition software to enable electronic completion of the Decision Support Tool in the field reducing administration time away from the patient, and will enable remote transmission of information directly into the CONI QA system, reducing delays from assessment to decision and commissioning. The introduction of a flexi pool staffing model to support demand management will enable a more responsive service and this will be extended during 2017/18, subject to successful evaluation of the Q4 pilot in 2016/17. These changes will increase resilience and enable escalations in assessment demand in the community and within partner organisation to be managed more effectively. Measures to increase responsiveness will be balanced against the need to reduce the percentage of assessments completed in acute settings toward the national target of 15%. The CCG currently completes a high percentage of assessments within acute trusts (above 60% in 2016/17 benchmarking figures), linked to standing commitments to providers as part of Delayed Transfer of Care arrangements. Scoping activity will be completed in 2017/18 to identify availability of any suitable capacity in the existing intermediate care bed base and in wider community care settings within the CCG footprint to support discharge to assess. This will be balanced against the existing commitments to response times in place with acute partners. Subject to viability and affordability, a pilot cohort of discharge to assess beds will be established and evaluated to inform activity in 2018/19; the high baseline figure and uncertainty over the capacity and utilisation of this model have contributed to the trajectory target remaining above 15%. To further support the optimal deployment of assessment resources to meet the needs of those individuals most likely to be eligible from CHC funding, the development of robust integrated care pathways between health and social care partners will contribute to a reduction in the use of CHC assessment as a gateway mechanism for non-chc health funding. This approach will support provision of care to those with needs below the CHC threshold at an earlier stage, potentially reducing the reliance on other services, while increasing responsiveness and capacity for assessment and case management for those individuals whose needs are of a nature, complexity, intensity, and unpredictability that would confer eligibility for CHC. The other actions to support the increased identification of eligible individuals are focussed on education of health and social care professionals, potential service users and carers. Training to primary care professionals will be delivered via established protected learning time mechanisms, 19