City and Hackney Clinical Commissioning Group Prospectus May 2013
Foreword We are excited to be finally live as a CCG, picking up our responsibilities as commissioners for the bulk of the NHS. The changeover time has inevitably been difficult, but we are ensuring we talk to our partner commissioners, NHS England, the Corporation of London and Hackney Borough to try to coordinate plans for the NHS. There are tensions to be managed between centralism and localism, steadily rising demand and decreasing resources, specialist, hospital care and primary care with prevention. The NHS is under pressure because people have been encouraged to expect easy access and excellent services with little rationing, and services have improved dramatically with the increase in resources over the last 10 years. It is less clear how we can manage with far less growth but continued and welcome improvements in treatments and people living longer, as well as more ill health because of poverty and austerity measures. Contents Foreword introduction from the Chair, City and Hackney CCG 1. Our CCG 2. Our vision 3. Our population 4. What we want to achieve and improve 5. Our plan 2013-16 6. What our plan means 7. Our partners 8. Financial plan 9. Our contact details We are lucky to have very good services locally, and we will carefully monitor the quality of services to ensure they stay that way and we do not fall into the trap of relying on processes rather than listening to what patients and clinicians tell us about how good services are or aren t. Staff work well when they feel they are providing a service they can feel proud of that is really helping their patients, and we want to be able to support and resource local services to maintain this ethos and morale. As clinicians, we have and will continue to have plenty of good ideas about how to make services work better. We have laid these out in our prospectus. We are really keen to get our public and patients to contribute their ideas too, and have set up practice participation groups in every practice, as well as public input into our Board meetings and clinical Boards. We would love to have your comments and feedback, and especially any ideas for improving services. Please do get in touch about this prospectus or about NHS Services. Our contact details are at the back of this document. Dr Clare Highton Chair, NHS City and Hackney Clinical Commissioning Group 2 3
01 Our CCG The NHS is changing. The Health and Social Care Act brings in the most wide-ranging reforms of the NHS since it was founded in 1948. On 1 April 2013 the main changes set out in the Act came into force, and most parts of the NHS will be affected in some way. Every GP practice in England is now part of a Clinical Commissioning Group (CCG), with responsibility for the local NHS budget. There are 44 GP practices in City and Hackney looking after 293,000 registered patients. Our CCG is responsible for designing local health services in City and Hackney. We will continue to do this by planning and commissioning hospital, community health and mental health services on behalf of local people. We work with patients and healthcare professionals and in partnership with local communities and local authorities. We have a governing body that includes GPs, a registered nurse and a member of the public. We are responsible for arranging emergency and urgent care services and for commissioning services for any unregistered patients who live in our area. Our CCG has wide-ranging responsibilities and we manage a very large budget, so it is important there are checks in place to make sure we are meeting our responsibilities. We are overseen by NHS England (NHS Commissioning Board) which ensures that we have the capacity and capability to commission services successfully and to meet our financial responsibilities. There are also Health and Wellbeing Boards in City and in Hackney to ensure we are meeting the needs of our local population. We work closely with NHSE who commission GP, dental, pharmacy and optometry services, specialist services and with the two local authorities who are now responsible for commissioning health and wellbeing and prevention services through their public health departments. What we have achieved so far Our CCG has grown from two highly successful clinical commissioning consortia, who have been working together with our 44 practices since 2005, to six consortia in 2013. We have so far been successful in improving services for local people and containing rising costs. We think this is the result of some excellent joint work with our provider clinicians, our joint commitment to improving the quality and productivity of services, and to doing what s best for patients. Our challenge The next three years will be challenging for health services in City and Hackney because there is no longer growth money to cover increased costs, while our population faces an increase in poverty and chronic long term conditions, with rising unemployment and loss of welfare benefits. We expect increased ill health and higher demand, including for mental health services. Our Joint Strategic Needs Assessment details the local health challenges and we look forward to working with our constituents and partners to address these, building on all our work to date. 4 5
02 Our vision The vision across England is that CCGs are a vital foundation of a new, clinically-led NHS that is focused on delivering improved health outcomes, quality, patient safety, innovation and public participation. In City and Hackney we have five clear aims to improve the health and wellbeing of local people: 1. improve the equality of health care for Hackney and City of London residents; 2. ensure our health care system is affordable and of high quality and improves patient experience; And we will deliver: 1. fewer emergency admissions; 2. more community services to reduce our hospital spend; 3. more community based mental health services; 4. better control of long term conditions; 3. work with our partner commissioners and our Health and Wellbeing Boards to reduce health inequalities and improve outcomes for local people; 4. develop integrated out of hospital services to mitigate the increasing cost of hospital based unscheduled care; 5. increased patient satisfaction as measured by national surveys; 6. maintained good performance on the rights in the NHS Constitution; 7. a financially stable health economy. 5. reduce the early death rates from cardiovascular and respiratory diseases. 6 7
03 Our population Hackney s population is estimated at 246,300, with almost a quarter of residents aged under 20. The under fives are particularly well represented, with 19,200 currently living in the borough. The population is growing with a large turnover each year. The official estimate of the City s population is 11,700 people, most of whom are of working age. The population is ageing but is also characterised by the significant number of commuters travelling into the City each working day, estimated at 360,000 workers. The City of London and Hackney face a significant health and wellbeing challenge. Hackney is the second most deprived borough in England and although the City of London has low levels of deprivation overall, there is considerable variation between wards, with Portsoken classified within the most deprived 20 per cent of wards in the UK. In Hackney, male life expectancy is lower than the national average and female life expectancy varies by 4.6 years when comparing the most and least deprived wards. In addition, there are a number of pressing health needs in the area, including high levels of childhood obesity, prevalence of severe mental health conditions, late presentation for cancer and deaths from heart disease and stroke. 8 9
04 What we want to achieve and improve The CCG is committed to improving health outcomes and reducing health inequalities for the people of Hackney and the City of London. We have worked with partners and other commissioners to identify areas where we perform poorly or could improve and therefore will focus on these areas over the coming year: reducing the number of people who die prematurely in our population, with a key focus on reducing the number of people that die from cardiovascular and respiratory diseases; reducing the number of people who get admitted to hospital as an emergency, by improving the care they get from their GP and in the community; improving patient experience of their healthcare; reducing the number of people who get infections during their stay in hospital (such as MRSA and C difficile); improving rate of diagnosis of dementia as early identification leads to earlier treatment when it is more effective and can slow the progress of the disease; improving the satisfaction of people who undergo knee replacement surgery; improving the support for people who have a long term condition, so they feel they can manage their condition better. We are also committed to making sure that standards in our local hospital, the Homerton, are maintained, including: that urgent calls to 999 for ambulances result in an ambulance arriving within 8 minutes (and over 9 out of 10 arrive within 19 minutes); that people who come to Accident & Emergency will wait for a maximum of 4 hours to be seen, treated, admitted or discharged; that all patients will wait a maximum of 4 and a half months (18 weeks) from their GP referral to the start of their treatment; that patients with cancer should wait a maximum of 2 months from their GP referral to the start of their treatment; to increase access to psychological therapies and to increase the amount of people who recover as a result of their therapy. 10 11
05 Our plan 2013-16 Here we set out how we plan to make services better for our patients. Urgent care We are seeing an increase in the number of visits to Accident and Emergency (A&E). The rate of A&E attendance is high with 413 attendances for every 1,000 residents each year, compared to a London average of 335. However, the rate of emergency hospital admissions is average for London. This suggests that there are too many people in Hackney and the City attending A&E departments for problems that could potentially be addressed elsewhere. To tackle this issue, we will: Cardiovascular and respiratory diseases Every year in Hackney and the City, diseases of the heart and blood vessels lead to many deaths and much disability, though rates are declining. Respiratory diseases such as Chronic Obstructive Pulmonary Disease which kills over 60 people in Hackney every year are also a major concern. We aim to reduce early deaths from cardiovascular and respiratory diseases and to help us achieve this we will commission community awareness, screening and control programmes. recommission the GP out of hours service to improve the quality of out of hours care; continue to work with the Homerton Hospital to audit the decision to admit from A&E and develop care pathways for those with asthma, paediatric problems, lower intestinal pain, chest pain and incontinence; Long term conditions We want to improve quality of life for those living with long term conditions and help them to better manage their health. The steps we will take to do this include: developing a social prescribing scheme that sees patients referred to health promotion programmes; commission an alternative service for people who fall at home to avoid a transfer to A&E unless clinically needed; support Tower Hamlets CCG (as the lead) to implement the 111 NHS non-emergency telephone helpline locally; commission duty doctor arrangements and ensure our practices are able to respond to urgent problems; see how we can best work with the London Ambulance Service to care for more people in the community and decrease hospital journeys. working with the Homerton Hospital to improve the sharing of care plans for people with long term conditions on admission and discharge; commissioning extended integrated community teams across health and social care managing patients safely in the community; supporting clinicians to case plan with patients, relative and carers, ensuring more choice for care in the last years of life; refocus case finding and case review programme so risk stratification of our population is embedded across teams. 12 13
Mental health Good mental health underpins wellbeing and quality of life. It encompasses everything from an individual s ability to cope with stress to more severe clinical conditions such as depression and schizophrenia. The prevalence of these severe conditions is high locally with one in ten adults in Hackney experiencing depression. Although the prevalence of these conditions is relatively stable, other indicators suggest that mental health needs may be increasing, with mental health admissions in Hackney and the City increasing to 936 in 2010/11 the highest rate in London. To address this, we will: develop a new mental health liaison service for the acute sector, reducing admissions and length of stay; transfer mental health care to GPs and ensure good mental health support in the community leading to a reduction in bed capacity; improve mental health prescribing practice; commission improved pathways for dementia and psychological therapies; develop better training in dealing with mental health problems and addressing physical health issues of people. Children We have a young population and we appear to perform well on emergency paediatric admissions. However, our local analysis shows an increasing referral rate to some paediatric specialities and increasing A&E attendance of children with problems related to asthma. We will: develop integrated referral pathways for common conditions such as asthma, ear nose and throat, and dermatology; introduce consistent proactive reviews by GPs and identification of vulnerable and at risk families; improve working arrangements between practices and health visitors and more integrated early years care across NHS and social services; implement clinical pathways with more non-hospital based provision, reducing referrals and emergency admissions. Maternity Our GPs have always taken a very active role in the care of our pregnant women and through close working with our community midwives they provide some antenatal appointments which elsewhere would be undertaken in hospital. They are active in booking to ensure that we can support women to book early to benefit from the diagnostic and review services we commission and to help identify socially and medically at risk and vulnerable women and families. We will: use feedback from pregnant women to improve the service model and quality of service; increase early booking; improve early identification and increase co-ordinated GP-led care for vulnerable and at risk women, as well as improving preconception and postnatal care. Planned care We have successfully worked with our GP practices to maintain a referral rate of 173 patients out of 1,000 each year, compared to the England average of 188 out of 1,000, and an annualised growth rate of 1.5 per cent, compared to a national average of 4.6 per cent. We have achieved this through a joint clinical leadership programme with consultants at Homerton Hospital focusing on referral pathways, clinical audit and clinical education. We will: develop alternative models to traditional hospital outpatient follow-up and ensure follow-up rates are at national best practice; stop consultant to consultant referrals where there is no clinical benefit; improve access to diagnostic tests and support early cancer diagnosis initiatives; maintain GP referral rate growth at 1.4 per cent make savings in prescribing whilst maintaining high quality GP prescribing; ensure our community services meet clinical quality standards, are at national benchmarks for efficiency and value for money, and are leading the way in keeping people out of hospital and reducing our hospital spend; ensure choice of community health services for City of London residents. 14 15
06 What our plan means For practices: sharing good practice; decreasing variations in care; primary care teams with wider sets of skills; proactive case finding and care management. For providers: more integrated health and social care teams; outreach and education programmes to support community based care; For our CCG: patients and public have a voice and demonstrable influence and impact; strong clinical leadership driving change on the ground; effective board and governance; financial headroom through Quality, Innovation, Productivity and Prevention (QIPP) programme to achieve savings without hurting patient care ; we are acting on what people are telling us. community services which are best in class for efficiency, value for money and safely reducing hospital spend; services measure their impact on the wider health economy and support delivery of outcomes. For quality and patient safety: commission evidence based pathways and services; benchmark provider performance and scrutinise any outside a reasonable range. compare evidence from patients, GPs, clinicians and hard data; ensure providers can demonstrate how they have addressed patient views; robust adults and children s safeguarding systems and processes; clinical audit and feedback to measure quality between primary and secondary care and audit findings implemented. 16 17
07 Our partners We work closely with the following organisations, as well as many other partners, to ensure we have a joined up approach to meeting local residents health needs. City of London Corporation The City of London provides local government and policing services for the financial and commercial heart of Britain, the Square Mile. London Borough of Hackney The local Council in Hackney provides services and support to 250,000 residents, as well as local businesses. Healthwatch City & London Offers citizens and communities a voice to influence and challenge how health and social care services are provided and designed locally. Healthwatch Hackney Gives people a voice locally and nationally to help them get the best out of their local health and social care services. East London and City Commissioning Support unit The NHS organisation provides expert support and advice to help clinical commissioners to deliver improved health services to local populations. Homerton university Hospital Provides general hospital and community services to Hackney and the City of London, and specialist care in obstetrics, neonatology, fetal medicine, fertility, bariatric surgery and neurorehabilitation across east London and beyond. Hackney Council for Voluntary Services Hackney s leading voluntary and community sector support agency and the local Council for Voluntary Services. Health and Wellbeing Boards Health and Wellbeing Boards are new bodies set up in each local area that bring together leaders from across public services and the community to improve health and wellbeing outcomes and reduce health inequalities by identifying and addressing complex health and wellbeing issues which cannot be tackled by a single organisation. East London Foundation Trust Provides mental health and community health care. The trust has university status and provides services to the City of London and the London Boroughs of Hackney, Tower Hamlets, Newham, Richmond and specialist services to a wider population. Bartshealth The largest NHS Trust in the UK serves a population of over one million in east London and beyond. The CCG is represented on both the City s and Hackney s Health and Wellbeing Boards and has a joint duty with each local authority to produce a Joint Strategic Needs Assessment and a Health and Wellbeing Strategy through the Board. A key focus of our joint work is the drive towards person-centred integrated care and support and the development of a new, jointly commissioned Intermediate Care Service provides a building block for the further development of integrated care across all our providers. 18 19
08 Financial plan 2013-14 City and Hackney CCG receives an annual allocation of funds to commission services predominantly for patients registered with GPs in the City of London and the London Borough of Hackney. The allocation for the year ending 31 March 2014 is 341million. The CCG s financial plan sets out how this allocation will be used and the chart below provides an indicative breakdown of the investment in services commissioned. The CCG is required by NHS England to end the year with a 1 per cent surplus, equal to 3.5m; to start the year with a planned contingency of 1.8m; and for 2 per cent of the allocation to ensure it is only committed non-recurrently. In 2013/14 the CCG s allocation was increased by 2.3 per cent from the equivalent PCT baseline. However assumptions for inflation and demographic and non-demographic growth result in pressures which significantly exceed that increase. To offset this funding gap, the NHS requires its providers to deliver 4 per cent efficiency savings. As a commissioner, the CCG has a Quality, Innovation, Productivity and Prevention (QIPP) programme in place to deliver savings of 5.5m (1.6 per cent) for 2013/14. Demand for health services continues to grow and the CCG will have a similar QIPP challenge for each of the years 2014/15 and 2015/16 in addition to that delivered in 2013/14. Acute Hospital Services Mental Health Continuing Care Community Services GP Prescribing Learning Difficulties GP Based Services Other Surplus The CCG also receives an annual running cost allowance (RCA) of 25 per head for City and Hackney patients to cover the operating costs of the CCG which, for the year ended 31 March 2014, is 6.5million. Running costs include board costs, premises, audit, clinical leadership and commissioning support services. The CCG has a contract with the North East London Commissioning Support Unit, which provides support services to 12 CCGs across North and East London. 20 21
Our contact details Our registered address is: NHS City and Hackney Clinical Commissioning Group Second Floor Lawson Practice Nuttall Street London N1 5HZ Email: cahccg.cityandhackneyccg@nhs.net To find out more about our vision, values, constitution and policies, visit our website: www.cityandhackneyccg.nhs.uk To find out more about our population and the health challenges faced by people living in City and Hackney, you can read the local Joint Strategic Needs Assessment (JSNA): www.hackney.gov.uk/health-and-wellbeing-board
Produced & Designed by Communications Hackney Council June 2013 PJ51561