338-346 Goswell Road, London. EC1V 7LQ By Email: paul.bennett8@nhs.net Direct Line: 020 3316 1290 Email: paulsinden@islingtonccg.nhs.uk PA: rachel.russ@islingtonccg.nhs.uk Tel: 020 3316 1007 Fax: 020 7527 1173 Paul Bennett Director of Delivery North, Central and East London NHS England London Region 21 August 2014 Re: Islington System Resilience Plan Please find below a cover note summarising the update to the Islington System Resilience Plan to be submitted on 21 August 2014. In response to feedback from NHS England on the recovery and improvement plan the letter sets out an overview of: How feedback on the Islington plan submitted on 30 July 2014 is reflected in the second version of the plan submitted on 21 August 2014; Current A&E performance against the 95% standard; Current RTT performance against the NHS Constitution standards; A summary of the first meeting of the Islington System Resilience Group held on 14 August 2014; Whole system initiatives to support systems resilience funded from central monies; Mainstream actions in 2014/15 to improve system resilience over and above 2013/14 capacity. The following are appended to this letter in support of the recovery and implementation plan: Updated templates for non-elective and elective pathways; Lessons learned from winter 2013/14; Recovery and improvement plan for Moorfields Eye Hospital referral-to-treatment standards;
Primary Care Foundation report on Primary Care capacity; Islington System Resilience Report; Revised Terms of Reference for Islington System Resilience Group; Notes from the Islington System Resilience Group held on 14 August 2014; Financial summary on the use of central and local monies to support resilience. 1. Development of the Islington Systems Resilience Plan The CCG has received feedback from NHS England and the Trust Development Agency on the plan submitted on 30 July 2014, with an overall medium risk rating. Table 1 below summarises the feedback on the first iteration of the plan submitted on 30 July 2014, and how this is reflected in the second submission made on 21 August 2014: Table 1: Tri-partite feedback Addition to plan for 21 August 2014 Evidence that plan is based on Wash-up from winter 2013/14, appended to this lessons learned from winter cover letter, used to determine capacity for winter 2013/14 2014/15; Implementation of Intensive Support Team recommendations at Whittington Health and Moorfields Eye Hospital for referral-to-treatment pathways. Evidence of capacity planning Medicine and surgery bed analysis from Whittington Health to determine escalation bed requirement; Additional female PICU bed in C&IFT contract to meet placement pressures; Primary Care Foundation work with general practices in Islington to support access; Systems resilience event to be held locally in October 2014 in preparation for winter. Evidence of 7-day working across the system Evidence of mental health engagement Finance summary indicating the use of local and central resilience funds Further development of key performance indicators Terms of Reference for Systems Resilience Group feedback CareLink 7 days per week in community RAID operates 7 days per week 7-day access to hospital pharmacy and diagnostic tests C&IFT are members of the Islington Systems Resilience Group (confirmed in terms of reference); Resilience funds to support mental health hospital liaison and community capacity; RAID model funded in 2014/15 following positive impact in winter 2013/14. A summary setting out the use of local CCG funds and central resilience monies is being submitted on 21 August 2014 First draft of Islington Systems Resilience Report went to SRG on 14 August; Whole system KPIs to be further developed Roles and responsibilities of members added Clarity on mental health engagement
Supporting evidence for the use of prior experience to build the resilience plan and capacity planning is set out in the following appendices: Lessons learned from winter 2013/14; Recovery and improvement plan for Moorfields Eye Hospital referral-to-treatment standards; Primary Care Foundation report on Primary Care capacity that is supported by the Locally Commissioned Service (LCS) for Access. NHSE and TDA will have previously received the recovery and improvement plan for Whittington Health. Whittington Health bed capacity analysis is to follow. 2. A&E Performance Table 2 below compares A&E performance at Whittington Health and Moorfields Eye Hospital in 2014/15 compared to 2013/14. Table 2: Comparative A&E performance 2013/14 Q1 2013/14 Outturn 2014/15 YTD Whittington Health 94.0% 95.1% 95.7% Moorfields 99.5% 99.8% 99.3% The table indicates that performance has improved at Whittington Health in 2014/15 compared to 2013/14, and the strong performance at Moorfields Eye Hospital has been maintained. In Quarter 1 2014/15 Whittington Health saw 95.7% of attendances within 4 hours compared to 94% in Quarter 1 2013/14. A&E attendances in 2014/15 show a 4.1% reduction at The Whittington compared to 2013/14 in Quarter 1. Moorfields A&E Attendances are 6.9% higher in Quarter 1 of 2014/15 compared with the same period last year. Trajectories for the remainder of 2014/5 focus on maintaining Quarter 1 performance (96%) in performance in Quarters 2 and Quarter 3, and meeting the standard (95%) in Quarter 4. 3. Referral-To-Treatment Performance Whittington Health and Moorfields Eye Hospital have submitted plans to reduce waiting times by October 2014, with plans submitted on 18 July 2014 receiving full assurance. Performance against the standards, particularly for admitted care, has fallen from May to June 2014, as both Whittington Health and Moorfields Eye Hospital begin to eat into waiting list backlogs.
Table 3 below sets out current performance and that targeted by October 2014: Table 3: Referral-to-treatment performance 2013/14 Outturn 2014/15 June 2014/15 Target from Oct Whittington Health Admitted pathways (90% standard) 85.3% 87.4% 91% Non-admitted pathways (95% standard) 94.1% 95.1% 96% Incomplete pathways (92% standard) 86.7% 90.2% 93% Moorfields Admitted pathways (90% standard) 89.8% 81.7% 90% Non-admitted pathways (95% standard) 95.3% 95.1% 95% Incomplete pathways (92% standard) 92.1% 91.9% 92% Plans target the following in order to free capacity for winter pressures: Whittington Health will move NHS Constitution targets towards 16 weeks from 18 weeks; Moorfields Eye Hospital will remove the 18-week admitted backlog by October to free capacity for Winter Pressures. 4. Islington System Resilience Group The first meeting of the Islington SRG was held on 14 August 2014, with membership from Primary Care, Social Care, Whittington Health, Moorfields Eye Hospital, Camden and Islington Foundation Trust (C&IFT), NHS 111, Harmoni (GP out-of-hours), London Ambulance Service, a Community Member the CCG, and North Central London Commissioning Support Unit (NELCSU). At the meeting the Islington Systems Resilience Group signed of the first draft of the Resilience Plan submitted on 20 July 2014. The Committee also agreed the following areas of work to further support systems resilience: Consideration of local LAS schemes for addition to the plan, with options including hospital liaison to help reduce ambulance turnaround times at A&E and additional paramedic capacity to reduce conveyance to hospital; Direct referral to mental health services by GP out-of-hours; To undertake an analytical review of the drivers of pressure in 2013-14 to inform plans for 2014/15, with the review covering level and drivers of increased demand, whether activity and complexity actually increased, whether there was any redistribution of demand, changes to the volatility of demand, reduced capacity in trusts to meet demand, and increased resource used in the response to demand; To hold a systems resilience event in October 2014 to agree escalation plans for system pressures and to test system readiness through scenarios including Norovirus outbreaks, shortage of community capacity, and sustained pressure in A&E and assessment beds. Notes from the meeting are appended to this letter.
Updated terms of reference for the group following feedback from NHSE, TDA and the group itself are appended to this letter. The update provides further clarity on the roles and responsibilities of group members, and confirms mental health services as being integral to resilience plans. 5. System Resilience Funding in 2014/15 The Islington Resilience Plan submitted on 30 July and 21 August 2014 aims to show how: Central funds provided for elective and urgent care resilience are to be utilised locally; Resilience is built into mainstream CCG work, over and above the central funds provided, through the CCG s Operating Plan and development of the Better Care Fund. A source and application of funds is appended to the report to demonstrate this; Capacity is being developed across the health and care system to build up resilience, with service developments in primary care, community services, social care, and mental health as well as in hospital capacity. Table 4 below summarises income Islington CCG has received in 2014/15 to support systems resilience: Table 4: Funding Notes Systems resilience funding 000 Non-elective pathways 1,670 Elective pathways Whittington Health 1,432 Islington CCG as lead commissioner receives funds for all other CCGs Elective pathways Moorfields Eye Hospital 1,602 Islington CCG as lead commissioner receives funds for all other CCGs Total 4,704 Note: Elective pathways Islington CCG 1,922 Notional allocation to Islington CCG to be used across all London providers System resilience in Islington in 2014/15 will be supported by both the additional funding received from NHS England set out in Table 4 above and pre-existing plans in the CCG s Operating Plan for 2014/15. Table 5 below summarises how the additional funds for non-elective pathways will be utilised in 2014/15: Table 5: Non-elective systems resilience funding Whittington Health - Escalation beds Funding 000 Notes 977 Staffing (medical, nursing, therapies) and ward consumables to support x escalation beds. The number of escalation beds that will be available for systems resilience is 29, similar to last winter with one escalation ward and flex beds on two other wards.
Whittington Health Emergency Department (ED) capacity 425 Staffing (medical, nursing, admin) to fulfil Tier 3 staffing to meet peak demand. This will cover ED consultant sessions, evening senior ED sessions (middle grade/gp), Band 6 cover, and night time administration. C&I FT Rapid Response 48 Additional Community Psychiatric Nurse C&I FT Crisis Interventions 96 Bridging support and reablement service between GP, A&E and Primary Care Mental Health. Supports delivery of Crisis Concordat. Whittington Health / Islington Council Domiciliary Care capacity Total 1,670 124 Additional support for 7-day working Referral-to-treatment submissions for Whittington Health and Moorfields Eye Hospital made on 18 July 2014 are appended to this letter. Submissions are in line with the financial values for Whittington Health and Moorfields set out in table 2. 6. Mainstream Service Improvements in 2014/15 System resilience in Islington in 2014/15 will be supported by both the additional funding received from NHS England set out in Table 3 above and pre-existing plans in the CCG s Operating Plan for 2014/15. 6.1 Contracts for 2014/15 In 2014/15 contract baselines with local providers include the following: C&I FT - 350k investment funds for primary care mental health and locality teams linked to GP practices; RAID model to provide 24/7 cover funded throughout 2014/15 to maintain psychiatric liaison cover; Whittington Health 5% non-demographic growth to community services ( 1.5m) to support Integrated Care Organisation (ICO) service models and community capacity; Comprehensive geriatric assessment in ambulatory care in Whittington Health CQUIN; Ambulatory Care service funded in Whittington Health contract baseline ( 0.5m); Establishment of adult hospital at home services at Whittington Health and UCLH; Establishment of integrated hospital at home service for children across Whittington Health and UCLH. 6.2 Better Care Fund In 2014/15 the CCG has identified 1.1m from QIPP plans to support the introduction of the Better Care Fund (BCF), with funds identified to support: Developing the Locality Offer ( 902k); Support interoperability of IT systems across organisations ( 170k). This focuses on preparatory work for an integration engine, to work across IT systems in different organisations, and will support systems resilience in future years.
In 2014/15 the BCF also includes Section 256 monies ( 4.8m) for Social Care services that benefits health. This is existing funding historically transferred to Social Care including reablement monies. Table 6 sets out how service developments, as part of the Better Care Fund, will support systems resilience in 2014/15: Table 6: BCF contribution to systems resilience Primary Care Discharge Nurses Funding 000 Notes 80 Addition to Early Supported Discharge Team. 2 nurses aligned to Whittington and UCLH Rapid Response Teams 160 Salaried GPs to support 4 Localities including Pilot of Primary Health and Care (Locality) Team Realignment of REACH and reablement services across Social Care and Whittington Health Home Visits 250 Nursing, Community Matron, Social Care, and Mental Health practitioner. Development informed by primary care 2% case finding. 150 Alignment to support reduction in use of residential and nursing care placements GP practice interoperability 100 To enable practice systems to communicate with each other in support of Locality development Whittington Health Intermediate Care Beds pilot Total 790 50 Trial 2 beds at Whittington Hospital as part of Islington intermediate care review The initiatives funded through the BCF in 2014/15 are pilots and mainstreaming in 2015/16 will be determined by evaluation. 6.3 Operating Plan for 2014/15 In 2014/15 the CCG has mainstreamed the following in support of systems resilience, with support summarised according to the CCG s delivery strategies for primary care, integrated care, urgent care and planned care: 6.3.1 Service developments in primary care Islington CCG has a wide range of service developments in place to reduce the need for A&E attendances and admission to hospital and move care nearer to the patient s home, thereby supporting A&E throughput. Primary Care access, to support this, is addressed through: Locally Commissioned Service for improving Primary Care Access embedding service developments developed with the Primary Care Foundation; Introducing a primary care service for patients affected by personality disorders, a cohort known to be frequent users of primary and unscheduled care;
Implementation of Year of Care Planning Tool across primary care workforce including training for HCA and practice staff; Collaboration initiatives across practices in each of the 4 Localities including access, sharing of staff through bank arrangements, and cross-referring for services (warfarin, minor surgery, glucose tolerance testing). Collaboration initiatives funded through the BCF as set out in Table 6 above: o Primary Care Discharge Nurses; o Rapid response team locality GPs; o Development of primary care health can care core teams; o Alignment of REACH and reablement services; o GP practice interoperability. 6.3.2 Service development in integrated care The following services are in place in 2014/15 to support system resilience: Locally Commissioned Service in primary care for long-term conditions encompassing COPD (practice based spirometry and the use of prophylactic exacerbation packs), and diabetes (Year of Care planning); Identifying the at-risk population via the Close the Prevalence Gap Local Enhanced Service and NHS Health Checks (Over 75s) Local Enhanced Service; Development of a multidisciplinary team in all four localities to support monthly case conferencing for complex patients. Formal evaluation of the case conferencing will be available in August 2014. The Better Care Fund will be used to fund the development of the Locality teams (see Section 5.2); The development of IT links across providers, including between primary and secondary care providers. Service developments in place include DOCMAN for electronic transfer of referrals and discharge letters, GP portals at UCLH and Whittington Health to allow GPs to view test results, Adaptor pilot at Islington Council to allow referrals to be sent between social care and health (Whittington and UCLH), and Medically Interoperable Gateways to allow UCLH and Whittington Health to view primary care records; Continuation of the community COPD service that has delivered a 14% reduction in non-elective admissions over the last 3 years. 6.3.3 Service developments in urgent care The following services are in place in 2014/15 to support system resilience: Development of the community geriatrician service to support admissions avoidance as part of a rapid response offer; Contract monitoring of NHS 111 number and GP Out-of-Hours contracts, with contracts for both services extended for one year to March 2016 to allow an integrated service to be commissioned from April 2016; Implementation of the Direct Enhanced Service for admissions avoidance. 6.3.4 Service developments in planned care The following services are in place in 2014/15 to support system resilience: Introduction of ambulatory care assessment unit as an alternative to admission, with ambulatory care the default option rather than admission for relevant
conditions. This has reduced the A&E to admission conversion rate from 21.4% in 2011/12 to 19.1% in 2013/14. The scope of ambulatory care will increase further in 2014/15 from 620 patients per month in February 2014 to 1,650 patients per month; Referral management will be supported by peer review of GP referrals in Clinical Commissioning Locally Commissioned Service, and extension of pathways covered by Map of Medicine, with eighty pathways uploaded in support of referral management (the third highest total nationally); The introduction of enhanced recovery models to reduce length of stay for surgery and medicine patients and release excess bed day charges for reinvestment. Length of stay. Related outcomes are: o Length of stay for older people has fallen from an average of 11 days in 2011/12 to 9 days in 2013/14; o 95 th percentile length of stay has fallen from 2011/12 to 2013/14 by 5 days; o Medicine emergency excess bed days have fallen by 50% from 2011/12 to 2013/14; Productivity gains in line with contract metrics; Improvements to theatre utilisation; Shifting of elective care from inpatient to daycase releasing 12 surgery beds (primarily gynaecology) to provide 12 medicine beds to support winter pressures; Qualitative reductions supported through transformation funds include: E-rostering incorporating Safer care, reduced lengths of stay and patient flow; Improved pre-admission and theatre utilisation Transformation capacity building; Elderly day hospital incorporated into ambulatory care; Heart failure services redesign with a new clinical model being rolled out in 2014/15; DNA and cancellations policy to improve patient experience 7. Financial Summary Table 7 below provides a summary of the financial support for systems resilience coming from central funds and the CCG s Operating Plan. Supporting financial information is set out in greater detail in an appendix to the letter. Table 7: Supporting 000 Notes Financial Information Resilience Funding 1,670 See Table 5 Better Care Fund 790 See Table 6 Contract Baselines 850 Ambulatory Care at Whittington Health and primary care mental health capacity at C&IFT Primary Care 844 LSC for Access and Care Homes, NHS 111 pilot Sub-total Operating Plan 2,484 Total Resilience Support 4,154
8. Learning from 2013/14 Schemes established through both the systems resilience funds and the CCG s Operating Plan have been developed from the learning from winter 2013/14. A summary of winter 2013/14 is appended to this letter for evidence, with examples of the continuation of successful schemes from winter 2014/15 being: Additional capacity in the Emergency Department at Whittington Health; Flexible bed capacity (up to 29 beds) with enhanced discharge and site team support at Whittington Health; 7-day working in hospital and community services Mainstreaming of mental health liaison in A&E (RAID) Building on the experience of winter 2013/14 additional capacity for winter 2014/15 (compared to last year will be): The expansion of ambulatory care capacity at Whittington Health, and corresponding support for reducing non-elective admissions General practice capacity through the Access Locally Commissioned Service accruing from work with the Primary Care Foundation; Rapid response in the community including community geriatrician support; Mental health crisis capacity in the community; Direct Enhanced Service for admission avoidance in primary care; Intermediate Care bed capacity pilot at Whittington Health (2 beds). The two largest schemes to support resilience in non-elective care pathways relate to Whittington Health escalation beds and Emergency Department capacity, and have been developed directly from the experience of winter 2013/14. Summary project scopes for each of these schemes are appended to the letter. 9. Systems Resilience Report The updated system resilience report is appended to this letter, and was used at the initial Systems Resilience Group meeting on 14 August 2014. The report provides an overview of performance along non-elective pathways and elective pathways. Indicators for non-elective pathways encompass services for GP out-of-hours, NHS 111, London Ambulance Service, Acute (A&E, bed occupancy), and system indicators (Delayed Transfers of Care and community services). The next iteration of the plan will incorporate more indicators that focus on the overall system and targeted to the funded initiatives in the resilience plan. The supporting templates for electives and non-electives contain some of these indicators including targets for: Weekend discharges compared to weekday charges to help maintain bed throughput; Additional primary care consultations accruing from the work in the Access Locally Commissioned Service with general practices supported by the Primary Care Foundation; A stretch target to reduce Delayed Transfers of Care in line with the metric in the Better Care Fund.
10. Summary The systems resilience plan for Islington is supported by: Central systems resilience monies for elective and non-elective pathways; Service developments built into provider contracts for 2014/15 Better Care Fund priorities for 2014/15 building primary and community care capacity primarily through development of locality teams; Mainstreamed service developments for 2014/15 across primary, integrated, urgent and planned care providing capacity over and above that in 2013/14. 11. Next Steps The Islington Systems Resilience Plan will be further developed through: Further development of the Systems Plan for the next Resilience Group meeting on 18 September 2014 linked to actions agreed at the initial meeting in August; Further development of Better Care Fund plans for 2014/15 and 2015/16 in line with the latest guidance; Further development of targeted outcomes through the Systems Resilience Group; Further refinement of plans where required. I hope that this submission of the Islington Systems Resilience Plan, and supporting information, provides assurance on delivery of NHS Constitution standards for both elective and non-elective pathways. Please contact me if you require any further information on our plans. Yours Sincerely Paul Sinden Director of Commissioning Islington CCG