Jun 26, 2012 - optimise the prescribing of medication and reduce adverse patient outcomes. 3.5 Leicester, Leicestershire
NHS East Leicestershire and Rutland Clinical Commissioning Group
Integrated Plan 2012-2015
Listening. Responding. Delivering.
Integrated Plan 2012-2015 Listening. Responding. Delivering.
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Introduction
I am delighted to present East Leicestershire and Rutland Clinical Commissioning Group’s first Integrated Plan. Since we were established in shadow form last year, we have worked hard to ensure that we understand the needs of the local population and respond appropriately. We have involved patients and carers, member practices, clinicians, local authorities, partners, and others to ensure that our strategy and plans directly meet the needs of local people. Throughout our plans, we remain focused on ensuring high quality outcomes and positive experiences for patients and their carers. We want to encourage better choice of, and access to services closer to home. We are committed to improving the quality of care provided within primary and community care, and to taking proactive measures to prevent ill health and to detect health conditions earlier. This will help to ensure that people stay healthier for longer, and it will also reduce the burden on local emergency care services. Over the past year, we have forged new relationships or built on those in existence with our predecessors, to ensure that we are well placed to undertake joint commissioning and partnership arrangements. We believe that this will enable more integrated and seamless services for our patients and carers. Furthermore, working with partners is an important factor in delivering high quality services for the future, which are both sustainable and affordable within the current economic climate. Now that we have established robust arrangements to operate effectively and efficiently as an organisation, we want to make sure that patient and carer voices are at the centre of all our decision-making processes. We are committed to involving people both directly, and through their feedback as standard in all our activities.
Equally, we will ensure the involvement of clinicians, with programmes and activities both led and informed by our local clinical experts. During the course of our first year we have learnt a lot about how to do this, but we are always keen to improve. Our new organisation benefits from staff with high levels of expertise and experience, both clinical and managerial. But we recognise that under the new NHS arrangements we are all on a new learning curve to ensure that we become highly effective commissioners in readiness for our formal establishment on 1st April 2013. We have focused on developing clinical and other leaders, to ensure that we have the collective expertise and know-how that we need, both for now, and for the future. We are very excited about the opportunity to work differently with local people, local authorities, and partners to make a real difference to local health and wellbeing services. As always, we welcome comments and suggestions on our plans, and encourage you to get in touch with us if you would like to become more involved in shaping the future of healthcare services for East Leicestershire and Rutland.
Dr David Briggs Chief Clinical Officer/Accountable Officer East Leicestershire and Rutland CCG
Integrated Plan 2012-2015
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Content
4
1
Introduction
8
2
Context
12
2.1
Population Health Overview
12
2.1.1 2.1.2 2.1.3 2.1.4 2.1.5 2.1.6 2.1.7 2.1.8 2.1.9
Demographics Health Inequalities Diabetes COPD Coronary Heart Disease Cancer Older People Dementia End of Life Care
12 13 14 14 14 14 14 15 15
2.2
Provider Landscape
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2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6
General Practice Leicestershire Partnership Trust University Hospitals of Leicester Other Acute Care Providers East Midlands Ambulance Service Voluntary Sector
16 16 17 17 17 17
2.3
Partner Landscape
17
2.4
Financial and Economical/Environmental Context
18
2.5
Commissioning Services Based on Health Profiles
18
3
Review of Delivery 2011/12
20
3.1
Transformational Funding
20
3.2
Community Hospital Developments
21
3.3
Cancer
21
3.4
Prescribing
22
3.5
Leicester, Leicestershire and Rutland Programmes
22
3.5.1 3.5.2 3.5.3 3.5.4 3.5.5
Urgent Care – LLR Emergency Care Network Frail Older People’s Pathway Right Care Programme Primary Care Key Performance Indicators National Key Performance Indicators
22 23 23 23 24
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Vision, Values and Strategic Aims
25
4.1
ELR CCG Vision and Values
25
4.2
Strategic Aims
26
4.3
Communication of Vision, Values and Strategic Aims
26
5
Delivering our Strategic Aims
28
5.1
Deliverables
28
5.1.1 5.1.2 5.1.3 5.1.4 5.1.5 5.1.6
Transform Services and Enhance Quality of Life for People with Long-Term Conditions Improve the Quality of Care Reduce Inequalities in Access to Healthcare Improve Integration of Local Services Listening to our Patients and Public Living within our Means
28 28 28 29 29 29 29
5.2
Three Year Delivery Plan
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6
Transformational Programmes for 2012/13
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6.1
NHS Operating Framework Guidance
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6.2
LLR Transformation Fund – 2012/13 Approach
32
6.3
Allocation of Funds
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6.3.1 6.3.2 6.3.3 6.3.4 6.3.5 6.3.6 6.3.7
Long-Term Conditions Diabetes COPD Frail Older People Emergency Care Information Management and Technology East Leicestershire and Rutland Integrated Care Model
34 34 35 35 36 36 37
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Operational Priorities and Plans
38
7.1
Local Priorities
38
7.1.1 7.1.2 7.1.3 7.1.4 7.1.5 7.1.6 7.1.7 7.1.8
Pathway Re-design Reduce Health Inequalities Mental Health Cancer CVD Delivery of ELR Key Performance Indicators Research and Development Other Enablers
38 39 40 41 41 42 42 42
7.2
NHS Operating Framework
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7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 7.2.6 7.2.7 7.2.8 7.2.9 7.2.10 7.2.11
Dementia Care of Older People Carers Military and Veterans Health Visitors and Family Nurse Partnerships Use of Telehealth and Telecare Mental Health Patient Experience and Feedback NHS111 Travellers Compliance with the Equality Act
43 43 44 44 44 44 45 45 46 46 46
Integrated Plan 2012-2015
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7.3
Delivery of LLR QIPP Programmes
47
7.4
SHA Ambitions
48
7.4.1 7.4.2 7.4.3 7.4.4 7.4.5 7.4.6
Pressure Ulcers Making Every Contact Count Quality and Safety in Primary Care Quality Governance Local Government Partnerships Create a Revolution in Patient Experience
48 48 49 49 50 50
7.5
Children, Young People and Families
51
7.5.1 7.5.2 7.5.3 7.5.4 7.5.5 7.5.6 7.5.7
Partnership Working Maternity – Improve 12 Week Access and Pathways Healthy Child Programme Mental Health Services for Children and Young People Children and Young People with Disability and Long-Term Conditions Non-Elective Care Complex Care
51 51 51 52 52 52 53
7.6
Authorisation
53
8
Provider Development
55
8.1
Community Hospitals Developments
55
8.2
Review of Minor Injury Units
55
8.3
Extension of Patient Choice of Community Provider (Any Qualified Provider Approach)
56
8.4
Leicestershire Partnership Trust (LPT)
56
8.5
University Hospitals of Leicester NHS Trust (UHL)
57
8.6
Best Use of Local Healthcare Estate
57
9
Draft Commissioning Intentions for 2013/14
58
9.1
Developing Commissioning Intentions
58
9.2
Timetable for the 2013/14 Planning Cycle
58
9.3
ELR CCG Commissioning Principles
59
9.4
Draft Commissioning Intentions 2013/14
59
9.4.1 9.4.2
Shared Commissioning Intentions LLR East Leicestershire and Rutland-specific Commissioning Intentions
60 61
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Partnership and Collaboration
63
10.1
Health and Wellbeing Boards
63
10.1.1 10.1.2
Leicestershire Shadow Health and Wellbeing Board Rutland Shadow Health and Wellbeing Board
63 63
10.2
Local Authorities and Social Care
64
10.3
LLR CCGs
64
10.4
Out of Area Commissioners
64
10.5
GEM CSO
64
10.6
Voluntary Sector Providers
64
10.7
Universities and Education
64
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Communication and Involvement
66
11.1
East Leicestershire and Rutland Patients and Carers
67
11.2
East Leicestershire and Rutland Constituent GPs and CCG Staff
68
11.3
Partners
68
11.4
Local Involvement Network (LINks) and Healthwatch
68
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Implementation
70
12.1
Financial Plans
70
12.2
Governance Framework
70
12.3
Framework for Delivery of Programmes
70
12.4
Contracts and CQUINs
72
12.5
Management of Risk
72
12.6
Organisational Development
72
12.7
Communications and Engagement
72
Appendix 1: Appendix 2: Appendix 3: Appendix 4: Appendix 5: Appendix 6: Appendix 7: Appendix 8: Appendix 9: Appendix 10: Appendix 11:
Leicestershire Joint Strategic Needs Assessment Rutland Joint Strategic Needs Assessment National and Local Target Priorities – Delivery for 2011/12 and Targets for 2012/13 Stakeholder Engagement to Develop our Strategic Aims Together Health Inequalities Action Plan 2012 - 2015 ELR CCG Primary Care Quality Indicators East Leicestershire and Rutland Financial Strategy and Plan QIPP Savings – 2011/12 and Projected for 2012/13 East Leicestershire and Rutland Future Years Financial Plan 2013- 2015 ELR CCG Board Assurance Framework Development of Joint Health and Wellbeing Strategies for Leicestershire and Rutland For access to these appendices, please visit our website
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Integrated Plan 2012-2015
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1
Introduction
In July 2010, the Department of Health (DH) published the White Paper Equity and Excellence: Liberating the NHS. In January 2011, the Coalition Government placed before Parliament the Health and Social Care Bill, which outlined the measures they wished to put in place in order to achieve their overall vision. The Bill proposed the creation of a new network of organisations: Clinical Commissioning Groups (CCGs) for the governance, strategic planning, and commissioning of health and social care services in England; as well as official bodies (NHS Commissioning Board and regional offices, and Healthwatch) to scrutinise the delivery of CCGs on behalf of patients.
Whilst the reforms underway have led to the creation of some new organisations, they have also both phased out others, and changed the roles of some existing bodies, such as local authorities and NHS healthcare providers. To facilitate the transition, arrangements were put in place that would support the NHS in moving from its current state to the proposed new structure, with the intention of being fully operational by 2013/14.
Figure 1: The Emerging NHS Landscape in Leicester, Leicestershire and Rutland
NHS Commissioning Board: Primary Care (Including GPs, Dentists, Chemists, Opticians); Specialised Commissioning, Offender Health, Military/Veteran’s Health; Secondary Dental Services
Clinical Commissioning Groups: East Leicestershire and Rutland CCG; West Leicestershire CCG; Leicester City CCG
Commissioning Support Organisations: Greater East Midlands CSO
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NHS Commissioning Board Local Office
Leicester, Leicestershire & Rutland PCT Cluster: (NHS Leicester City and NHS Leicestershire County and Rutland)
Local Authorities: Leicester City Council Leicestershire County Council Rutland County Council
Providers: NHS Trusts and Foundation Trusts; Acute and Community; Community Health Services; Voluntary and 3rd sector; Independent Sector Emerging provider market
East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) was established in March 2011 in ‘shadow’ form. The CCG comprises General Practitioners from 34 practices in the South and East of Leicestershire and Rutland, working across the areas of Melton, Rutland, Market Harborough, Blaby District, Lutterworth, and Oadby and Wigston. We serve a registered population of around 315,000 patients, over 35,000 of whom live in neighbouring areas. As a group we decided to focus on improving the quality and delivery of services for our patients, and on reducing health inequalities across the area. We are part of the national pathfinder programme, testing concepts for clinical commissioning and exploring how emerging CCGs will best be able to undertake their future functions. We have a firmly established Board, which is responsible for managing the transition period until March 2013, while overseeing the implementation of the CCG’s plans for the future. Board members include GP clinical leads,a nurse, and independent lay members, with members of LINks in attendance. The first six months of ELR CCG’s existence focused on developing strong clinical leadership and engaging local GP practices, both through effective localities, and at a CCG level. This approach was supported through discussions at practice level, via a series of practice visits and meetings conducted by ELR CCG’s Clinical Chair, Chief Operating Officer and other GP Locality Board Members. The meetings provided an opportunity for the CCG governing body and leadership team to listen to our constituent GPs and to gain a greater understanding of the services, pathways and processes they wanted to change and/or commission differently in the future.
ELR CCG is committed to involving patients and carers, partner organisations and the general public in our work. To ensure that our commissioning priorities meet the needs of local people, we have undertaken a period of engagement with a wide range of stakeholders. This engagement will be on-going as we continue to evolve and develop as a commissioning organisation. Feedback from all of our stakeholders – patients and carers, member practices, clinicians, staff and partners - has informed the development of our vision, values and strategic aims. These include the elements of local healthcare that we wish to transform most significantly in the longer-term, and are as follows: • Transform services and enhance quality of life for people with long-term Conditions With a particular focus on COPD, diabetes, dementia and mental health • Improve the quality of care Focusing on clinical effectiveness, safety and patient experience, with specific goals to deliver excellent community health services and improve the quality of primary care • Reduce inequalities in access to healthcare Targeting areas and population groups in greatest need • Improve integration of local services Between Health and Social Care, and between Acute and Primary/Community Care • Listening to our patients and public Commitment to listen, and to act on, what our patients and public tell us • Living within our means Effective and efficient use of public money
ELR CCG recognises the interdependencies across the healthcare system. We have focused on building strong foundations for collaboration with other local commissioners, including the other two CCGs within Leicester, Leicestershire and Rutland: West Leicestershire, and Leicester City; social care and our two regional local authorities, Leicestershire County Council and Rutland County Council; and other partners. We have been an active participant in the development of the Leicestershire and Rutland Health and Wellbeing Boards and the setting of our shared strategies and priorities (see Appendix 11).
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Alongside our own strategic aims, we also recognise that there are a number of other strategic developments and priorities, both regionally and nationally, to which we remain committed. Furthermore, there are a number of more operational areas where we know we need to make improvements to ensure better local healthcare in line with England and ONS Cluster averages. These additional priorities are in the context of the overarching NHS Planning Framework and other relevant guidance, including, but not limited to: • NHS Operating Framework (2012/13) • NHS Outcomes Framework (2012/13) • NHS Midlands and East Regional Commissioning Framework (2012/13) • SHA Ambitions (2012/13) • LLR Integrated Plan (2012/13) • Joint Strategic Needs Assessment • Shadow Health and Wellbeing arrangements • Transforming our health care system – Ten priorities for commissioners (The Kings Fund 2011) • NHS Constitution
In order to deliver our strategic and operational priorities, we know that there are a number of key enabling programmes that we need to deliver. Examples of these include ensuring the best use of local healthcare estate, the development of our CCG and its people, and developing collaborative arrangements with partners. Our strategic approach is shown pictorially in Figure 2 overleaf. This strategy pyramid outlines our vision, values and strategic aims, together with our key operating priorities and supporting strategies and plans. Key to our achievement of these are the development of clinical leaders, and engagement and involvement with key stakeholders, in particular, patients, carers and local people, member practices, clinicians, staff and partners. Our Integrated Plan has both informed, and reflects the Leicester, Leicestershire and Rutland (LLR) Integrated Plan, demonstrating our commitment to the LLR vision to ensure that services are ‘right-sized’ and delivered in more cost effective settings, where it is safe and appropriate to do so. ELR CCG is also committed to contributing to the LLR health and social care economy both through collaboration, and by delivering high quality, integrated and consistent results. Our strategy reflects local emerging health and wellbeing priorities for Leicestershire and Rutland, and we remain focused on delivering Leicester, Leicestershire and Rutland QIPP (Quality, Improvement, Productivity and Prevention) programmes. This Integrated Plan describes the current context within which the CCG operates, and details our commissioning strategy, encompassing strategic and operational priorities for 2012/13 and beyond. It will be updated annually to reflect the yearly NHS Planning Framework, emerging local health trends, partner strategic priorities, and the needs of local people.
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Figure 2: East Leicestershire and Rutland CCG Vision and Strategy
Achieving excellent patient and carer experience and outcomes
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• Annual plans • Quality, Innovation, Productivity, Prevention (QIPP) plans
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Getting the basics right • Integrated plan 2012-15 • NHS Operating Framework • NHS Outcomes Framework
6. Living within our means
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5. Listening to our patients and public
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4. Improve integration of local services
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1. Transform 2. Improve 3. Reduce the quality inequalities services and enhance quality of care in access to healthcare of life for people with Long-Term Conditions
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Our strategic aims
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• Involvement • Progression • People • Innovation • Education • Quality • Economy • Respect (dignity) • Inspiration
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Our values
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To improve health by meeting our patients’ needs with high quality and efficient services, led by clinicians and delivered closer to home
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Our vision
• SHA Ambitions, e.g. pressure ulcers • Children, Young People & Families
Making it happen (Enablers) • Best use of local healthcare estate • Developing our organisation, members and people • Involving local doctors, nurses, AHPs and other clinicians
• Communications and Involvement Strategy • Joint Health and Wellbeing Strategy • Collaborative arrangements with partners
Clinical Leadership
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2
Context
This section provides an overview of the key health and population demographics of East Leicestershire and Rutland, the area served by our CCG. It also describes the key providers from whom we commission services. 2.1 Population Health Overview ELR CCG has been actively involved in developing a joint understanding of local needs and priorities across health and social care. This involvement has been through membership of the Joint Strategic Needs Assessment (JSNA) steering group; Health and Wellbeing Boards, and their Staying Healthy sub-groups; participation in stakeholder events for JSNA Health and Wellbeing Boards; and a CCG Board review of strategic priorities emerging from the 2012 JSNA refresh. Various JSNA stakeholder engagement events have been held to inform the development of the local JSNA for Leicestershire and Rutland. Key findings from both JSNAs are summarised within this section.
Copies of the JSNA summaries for Leicestershire and for Rutland can be found in Appendix 1 and 2 respectively. 2.1.1
Demographics
ELR CCG has an estimated population of approximately 315,000 based on the number of patients registered with GP practices in 2011/12. Just over 35,000 of these patients live in neighbouring areas; whereas around 46,500 people live within East Leicestershire and Rutland but are registered with neighbouring CCGs.
Figure 3: East Leicestershire and Rutland by Registered Population, and Location of GP Practices
Proportion of residents who are registered with the CCG’s practices > 75% 50 to 75% 25 to 50% 1 to 25% The map shows practices with different symbols/colours according to the CCG area. ELR CCG’s GP practices are shown as bright red crosses. Practices are located according to the centroid of their postcode recorded by the Organisation Data Service (branch practices are not shown). Local Authority boundaries are shown as yellow lines and ELR CCG’s geographical boundaries as thick red lines. Mixed red/yellow lines indicate shared LA/CCG boundaries.
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50.6% of our population is female, which is similar to the England average of 50.2%. The average life expectancy within East Leicestershire and Rutland is 80 years for men, and 83.9 years for women, both of which are higher than the England average. In 2009 there were 2,701 deaths of people resident in East Leicestershire and Rutland; 851 of these were premature (i.e. before the age of 75). Among the premature deaths, the highest percentage was from cancer (34%), followed by cardiovascular diseases (22%), and respiratory disease (16%). Figure 4: Population of East Leicestershire and Rutland by Age
Accounting for 72% of all deaths, the major killers for East Leicestershire and Rutland CCG are: • Cancer • Cardiovascular disease • Respiratory disease High numbers of people are affected by the major risk factors for ill health. Around 1 in 6 adults (over 50,000) in East Leicestershire and Rutland smoke, and 1 in 5 (around 53,000) drink alcohol above safe levels (increased or high risk). The CCG currently has high levels of non-elective activity when benchmarked against similar health economies. Without a focused approach and active intervention, the ageing population will increase the gap between expected and actual activity. Elective activity is consistent with the national average. In terms of prescribing activity, ELR CCG spends £75,338 per 1,000 population compared to £79,662 nationally. However, the rate of growth in spending over the last three years has increased by 6% against a national average growth of 3%. 2.1.2
Health Inequalities
Health inequalities can be defined as the differences either in health status, or in the distribution of health determinants between different population groups. A quarter of the population of East Leicestershire and Rutland is under the age of 20, and around 25% are aged 60 and over. The number of people aged 60 and over is higher than the England average, and our older population is predicted to increase over the next 10 years, with an estimated 31,500 additional people aged 60 years and over; 7,500 of this population will be aged over 85 years. This, coupled with a lower than England average birth rate, would indicate that we have an ageing population. The health of our local population is generally better than the overall population of England. However, there is a significant number of people affected by ill health, including GP-diagnosed coronary heart disease (10,800 people), hypertension (44,010 people), and diabetes (12,960 people).
The population of ELR CCG as a whole has relatively low levels of material deprivation, compared to other parts of England. In comparing the various areas where our population live against the rest of England, we rank overall as 200 out of 212 CCGs for deprivation (where 1 is the most deprived). Nevertheless, there are significant pockets of disadvantage in areas on the edges of Leicester City and within the market towns. Within East Leicestershire and Rutland CCG, there are areas that have poorer health outcomes. The main areas affected are in Oadby and Wigston. These inequalities in health need to be addressed. Significant health inequalities exist for other minority and hard to reach groups, e.g. Black and Minority Ethnic (BME), and travellers.
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Around 14% of school children are from black or minority ethnic groups and 11% of children are living in poverty. This is similar to, or better than the England average. Infant and child mortality rates are similar to the average, as are breastfeeding initiation levels. Although the health of children in East Leicestershire and Rutland is generally similar to or better than England’s average, we recognise that there are key pockets of socio-economic deprivation, particularly in Melton, Rutland and Wigston. Men and women in one area of Wigston have a significantly lower life expectancy than the England average. The same area of Wigston has a significantly higher rate of respiratory disease mortality than the England average, and higher (although not significantly so) rates of CVD, cancer mortality and adult smoking. Although not as significant as in Wigston, other pockets of greater need exist in other parts of East Leicestershire and Rutland, including Melton, Harborough and Blaby. Evidence suggests that the most effective way to reduce the gap in life expectancy in the short-term is to improve the management of diseases (including CVD and COPD) and their risk factors (including smoking, alcohol, hypertension and diabetes) that predominately affect the socially excluded. 2.1.3
Diabetes
In 2010/11, 13,177 patients in East Leicestershire and Rutland were registered with their GP as having diabetes. This is an estimated diabetes age-specific prevalence rate of 5.3%, which is similar to the England average (5.5%). In 2005, there were approximately 290 deaths from diabetes in people aged between 20 and 79 years in Leicestershire County and Rutland. This represented around 11% of all deaths in that year. 2.1.4
COPD
In 2008/9, there were 106 deaths from chronic obstructive pulmonary disease (COPD) in East Leicestershire and Rutland. This is a rate of 8.5 per 100,000 population, which is lower than the England average (11.8 per 100,000 population). Overall, there has been little change in the trend of COPD across Leicestershire County and Rutland over recent years.
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2.1.5
Coronary Heart Disease
In 2010/11 there were 10,544 patients registered with coronary heart disease (CHD) in East Leicestershire and Rutland. This GP recorded prevalence of 3.4% compares to a model based estimate of actual prevalence of 5.1%. The difference would indicate that there are approximately 3,000 patients with undiagnosed CHD in East Leicestershire and Rutland. For premature mortality, there were no areas of East Leicestershire and Rutland with CVD mortality rates significantly higher than the England average. However, there was clear variation between areas with above average rates (including parts of Oadby and Wigston and Melton), and areas where rates were significantly better than the England average (including parts of Harborough and Rutland). 2.1.6
Cancer
Although there is some variation across East Leicestershire and Rutland, rates of premature mortality from cancer are either significantly lower than, or similar to the national average. Based on Quality and Outcomes Framework data, the GP recorded prevalence of cancer is higher than the England average (1.9% of the registered population). However, higher prevalence of cancer may be indicative of better diagnosis rates, which is probable given the higher survival rates within the local area. 2.1.7
Older People
In 2010, there were approximately 80,100 people aged over 60 in East Leicestershire and Rutland, and 16,000 aged over 80. The population of East Leicestershire and Rutland aged over 60 is estimated to increase by around 60% by 2030. Around 14,000 of the population aged over 75 in East Leicestershire and Rutland lived alone in 2010. This number is predicted to rise to 26,200 by 2030, an increase of 87%. In 2010 there was an estimated 25,400 people in East Leicestershire and Rutland over the age of 65 with a long-term illness. By 2030, this is predicted to increase to around 42,900, an increase of 69%. The 2009 JSNA noted particular increases in dementia (63% by 2025), and hypertension (17% by 2020).
This increased burden of disease could lead to increased hospital activity linked to age, unless there is a change in the way care is delivered. Between 2008 and 2018, non-elective inpatients are estimated to increase by 18% across Leicestershire County and Rutland, bed days by 26%, and elective inpatients by 15%. 2.1.8
2.1.9
End of Life Care
National studies report that over half of people would prefer to die at home. In 2010, half of deaths in East Leicestershire and Rutland took place in hospital, and around one quarter took place at home.
2.2 Provider Landscape
Dementia
In 2010 there were around 900 people in East Leicestershire and Rutland with diagnosed dementia. By 2030, the number is estimated to double to around 1,800 people. As advocated by the National Audit Office in their value for money report 2007, investment in improved and expanded Dementia care management, incorporating earlier diagnosis, is essential to increase the quality of lives for patient and carers; the quality, effectiveness and experience of care; and to reduce both healthcare, and societal costs.
ELR CCG commissions services for the population of East Leicestershire and Rutland to the value of approximately £315million. We hold contracts ranging from small grants to the voluntary sector, to £116million with our main acute provider, University Hospitals of Leicester (UHL). A breakdown of the CCG’s 2012/13 budget by provider is shown below in Figure 5.
Figure 5: ELR CCG 2012/13 Budget by Provider
£5,853,384 £879,351 £2,681,339 £5,410,167 £3,160,863 £7,167,941
£24,956,764
£24,753,915
LPT - Mental Health & LD
£29,425,952
LPT - Community Services EMAS Derbyshire Community Health Services
£8,325,985
£8,758,289
Voluntary Sector University Hospitals of Leicester Independent Sector
£4,220,808
£6,791,920
LD Pooled Budget (Local Authority) ECRs
£3,649,920
Kettering General Hospital NHS FT Nottingham University Hospitals NHS Trust Peterborough & Stamford Hospitals NHS FT University Hospitals Coventry & Warwickshire NHS Trust
£116,220,528
Other Out Of County Providers Other
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2.2.1
General Practice
ELR CCG comprises General Practitioners from 34 practices in the South and East of Leicestershire and Rutland, serving patients in the three locality areas of Melton, Rutland, Market Harborough; Blaby District and Lutterworth; and Oadby and Wigston; together with surrounding areas. (See Figure 3 above for specific GP practice locations and registered populations). 2.2.2
Leicestershire Partnership Trust
Employing almost 7,300 staff, Leicestershire Partnership NHS Trust (LPT) provides a range of mental health, community health, and health and wellbeing services for patients living within East Leicestershire and Rutland CCG. Community health services transferred to the Trust in early 2011 as part of the national Transforming Community Services programme. The community health services element of LPT incorporates 1,900 staff, such as district nurses and health visitors, working within community teams across LLR in ten community hospitals,
various health centres, minor injury units, a walk-in centre, schools, residential homes and in patients' own homes. It also provides physiotherapy, occupational therapy, podiatry, speech and language therapy, nutrition and dietetics services, and community dentistry. Shown in Figure 6, the community hospitals located within East Leicestershire and Rutland are as follows: • • • • • •
Market Harborough District Hospital St Luke’s Hospital, Market Harborough Rutland Memorial Hospital Feilding Palmer Hospital, Lutterworth Melton Mowbray Hospital St Mary’s Maternity Hospital
The overall budget for LPT from LLR commissioners is £250million. ELR CCG’s budgetary contribution for mental health and learning disabilities services is in excess of £24million; and for community health services, £29.5million. Figure 6 below shows the various acute and community hospital providers from whom we commission services.
Figure 6: Map of Acute and Community Hospitals Across Leicestershire, Leicestershire and Rutland and Neighbouring Areas
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2.2.3
University Hospitals of Leicester
Our principal acute provider, UHL, is one of the biggest and busiest NHS trusts in the country, incorporating the Leicester General, Glenfield and Royal Infirmary hospitals. UHL has more than 10,000 staff providing a range of services primarily for the one million residents of Leicester, Leicestershire and Rutland. UHL offers a number of specialist treatment centres and services in cardio-respiratory diseases, cancer and renal disorders, which means that the Trust provides care for up to a further three million patients from across the rest of the country. 2.2.4
Other Acute Care Providers
We also commission acute care from other providers, including out of county NHS Trusts, and a range of Independent Sector Providers such as Spire Leicestershire, Nuffield Leicestershire, and Nations Treatment Centres at Nottingham. 2.2.5
East Midlands Ambulance Service
East Midlands Ambulance Service NHS Trust (EMAS) provides emergency 999, urgent care and patient transport services for the 4.8 million people within Derbyshire, Leicestershire, Rutland, Lincolnshire (including North and North East Lincolnshire), Northamptonshire and Nottinghamshire. They employ over 3,200 staff at more than 70 locations, including two control rooms at Nottingham and Lincoln, with the largest staff group being accident and emergency personnel. ELR CCG’s annual budget for EMAS is £8.3million. 2.2.6
2.3 Partner Landscape ELR CCG works closely with all our partners to transform and improve healthcare within our local communities. Over the last 12 months, we have actively engaged with partner organisations to forge vital links, to build on existing relationships, and to develop new and improved relationships with clinicians, patients and carers, public members, staff, partner organisations including local authorities, and other commissioning agencies. We have many partners, and have key working relationships with the following: • • • • • • • • • • • •
Leicester City CCG West Leicestershire CCG Out of area CCGs Leicestershire County Council (including social care services) Rutland County Council (including social care services) Voluntary sector providers and charities Emergency services, i.e. police and fire Leicestershire and Rutland LINks, and other patient and carer representative bodies De Montfort University Leicester University Health and Wellbeing Boards Greater East Midlands Commissioning Support Organisation (GEM CSO)
More information on how we collaborate with key partners can be found in section 10.
Voluntary Sector
We fund a number of voluntary sector organisations through grant agreements. These grants enable a contribution towards the funding of voluntary sector or charity organisations who deliver local services with a healthcare element. Services range from mental health services and palliative care, to children’s services and support for carers. Providers include Alzheimers Society (carer’s support service); Carer’s Action (carer’s support); LOROS hospice (end-of-life care); and The Laura Centre (support for adults and children affected by the death of a child).
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2.4 Financial and Economic/Environmental Context
2.5 Commissioning Services Based on Health Profiles
The economic climate in which we operate remains a challenge for all NHS organisations. We have assumed zero growth for the foreseeable future, and our commissioning intentions are modelled primarily on this basis. We recognise the need for service improvements to deliver better quality of patient care and experience in the long-term, whilst reducing clinical variation, eliminating waste and delivering better value for money. This we will achieve through on-going recurrent investment; investment of our transformational fund into the delivery of longerterm strategic priorities; and through delivery of our QIPP (Quality, Innovation, Productivity and Prevention) programmes.
The demographics of the population, along with existing health equalities, are a key consideration when developing our annual commissioning intentions. The commissioning of local NHS services involves the CCG working with public health, providers, partners and local communities, to identify and understand patients’ needs and to design services to meet those needs. This is done by working within a structured and planned process called the ‘commissioning cycle’, demonstrated in Figure 7 below. This process is continuous to ensure that services are developed and improved based on provider performance, patient experience and outcomes, and emerging health trends. The commissioners of services lead the process for deciding how best to provide services and for making this happen.
Figure 7: The Commissioning Cycle
Assess Needs Manage Performance (Quality, Performance and Outcomes)
Clinical Decision Making
Review Current Service Provision
Clinical and Patient and Public Involvement
Manage Demand and Ensure Appropriate Access to Care
Design Service
Shape Structure of Supply
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Decide Priorities
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3
Review of Delivery 2011/12
During 2011/12 ELR CCG has focused on delivering or preparing to deliver a number of strategic and transformational priorities for the CCG. The identification of these was clinically led, following extensive consultation with member practices, including discussions at locality meetings and visits to every practice by the Accountable Officer and members of the senior management team. We have also worked collaboratively with other CCGs and strategic partners to identify and deliver system-wide priorities. This section outlines the key activities undertaken, together with highlights of progress during our first year of operating in shadow form.
3.1 Transformational Funding In order to prioritise investment of transformational funding for 2011/12, ELR CCG considered the health needs assessments of our area. Led by clinicians and supported by feedback from member practices, this showed that: • Long-Term Conditions are very common in the East Midlands with over 590,000 households reported as having at least 1 person with a Long-Term Condition • Patients with Long-Term Conditions account for almost 80% of GP consultations • Patients with Long-Term Conditions utilise around 40% of hospital/urgent care bed days • Care between primary, secondary and community services in general is very fragmented and more integration is needed • More prevention and earlier detection is essential to improving outcomes • Better care planning with greater patient involvement is required to empower patients towards more self-care. Taking these findings into consideration in 2011/12, we established a Long-Term Conditions programme utilising transformational funds. This placed an emphasis on COPD, Diabetes and End of Life Care. Each practice within ELR CCG was asked to subscribe to the “Achieving Excellence in Long-Term Conditions Programme”, which focused on achieving a co-ordinated approach to Diabetes, COPD and End of Life.
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The programme looked to undertake clinically-led commissioning with the objective of improving health outcomes, as well as reducing the variation in clinical quality. It focused on the training and development of practice clinicians; screening support to improve prevalence and early diagnosis; and the provision of structured clinical care as per a defined pathway. It aimed to improve capabilities and efficiencies in primary care, reduce emergency admissions, and facilitate an improvement in the integration of care between primary, secondary and community services. As a result: • 31 out of 34 GP practices signed up to the Long-Term Conditions programme • A nominated GP and practice nurse from every practice undertook diabetes training modules at University of Leicester to improve the management of type 2 diabetics within primary care (this training will be continued in 2012/13) • 27 practices have undertaken spirometry accreditation/reaccreditation • 22 practices attended educational sessions provided by LOROS that focused on end of life care • We delivered a 5.7% reduction in outpatient attendances • There was a 3.6% reduction in emergency spells (by month 8 of 2011/12) • There has been an increase in the numbers of diabetes patients with more complex needs who are now cared for within primary care • Patients with indicators of COPD then received either pulse oximetry, or an onward referral to pulmonary rehabilitation. Many practices have purchased the necessary supporting equipment. In 2012/13 these practices will be undertaking a clinical review of patient records to determine the accuracy of their current COPD patient list.
3.2 Community Hospital Developments ELR CCG has confirmed our commitment to developing community hospital services by approving the next phase of development at the St Luke’s Hospital site in Market Harborough. ELR CCG carefully considered the options for developing hospital services in Market Harborough, under delegation from the NHS Leicestershire County and Rutland Trust Board in March 2011. The CCG decided to push forward with plans to see the new hospital development, which has received widespread support from clinicians, patients and local people following extensive consultation and engagement. However, the CCG has secured £4million NHS capital funding and a further £250k of transformational funding, rather than through the originally proposed private finance initiative arrangements. This ensures that the CCG avoids a more expensive, long-term ‘mortgage’ commitment. In September 2011, ELR CCG announced its plans, which should see the long-awaited new hospital development open by 2014. The new development will see improved services for patients and significant benefits to local healthcare, with the provision of a variety of services on one site in the town. The plans will include increased diagnostic and treatment facilities, leading to more patients being seen and treated more quickly, and closer to home. This will in turn assist ELR CCG in decommissioning activity in acute hospital settings. Services to be provided by the new hospital development include: • • • • • • • • • • • •
Cardiology Dermatology Diabetic medicine Endocrinology ENT Gastroenterology General medicine General surgery Gynaecology Maxillofacial Minor plastic surgery Neurology
• • • • • •
Ophthalmology Paediatrics Respiratory medicine Rheumatology Trauma and Orthopaedics Urology
ELR CCG will continue to involve the local public in plans for the new development, particularly in the search for a new name, and in determining a new home for Market Harborough War Memorial on the existing Market Harborough District Hospital site.
3.3 Cancer As part of the Long-Term Conditions work (see section 3.1) we have encouraged primary care to adopt best practice in terms of early diagnosis and treatment of Long-Term Conditions. This assessment also helps to pick up early cancers as part of the diagnosis of the condition, particularly where a patient’s condition has worsened e.g. prolonged cough for COPD sufferers may lead to a chest x-ray and spirometry; or prolonged weight loss and confusion for patients with dementia may lead to further tests. This process has helped us to improve the number of patients diagnosed with cancer. In Leicestershire and Rutland the number of patients referred has increased from 11,280 (2010/11) to 12,577 (2011/12, indicating an increase of 10% in referral by GPs. As part of our prevention agenda we have also commissioned alcohol liaison workers and further interventions in general practice to provide lifestyle advice, e.g. in terms of smoking cessation or misuse of substances. These will also help to reduce the incidence of cancer in the longer-term. We have also worked in partnership with LOROS (the Leicestershire and Rutland Organisation for the Relief of Suffering) to deliver workshops to 28 member practices. These focused on both improving the adherence to pathways for patients at the end of their lives, symptom management and maintaining comfort and wellbeing, advance care planning, and how to approach the topic of End of Life treatment with patients and carers.
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3.4 Prescribing We believe that efficient prescribing results in better outcomes for patients. We have therefore focused on normalising prescribing across East Leicestershire and Rutland to reduce variation between GP practices. We have applied QIPP targets to GP practices where spending is higher than expected for their registered population, and have worked with those where it is lower to help improve patient outcomes. In some cases this has resulted in an intended increase in prescribing costs. Whilst there has been a related increase in prescribing costs over recent years to bring us more in line with the England average, spending has now levelled off and we remain focused on our QIPP prescribing target to improve the quality of patient outcomes whilst eliminating unnecessary cost and variation. Our focus on prescribing cost-effective statins as part of our QIPP priorities in 2010/11 has resulted in £21,291 annualised savings in 2011/12, with further savings planned for 2012/13. Our prescribing targets in relation to QIPP 2012/13 will be achieved through a combination of targeted medicines management input at practice level; and strategic input via regular QIPP performance reports to all practices. Transformation funding has been approved for a Care Homes Medication Review project which will optimise the prescribing of medication and reduce adverse patient outcomes.
3.5 Leicester, Leicestershire and Rutland Programmes ELR CCG remains committed to on-going collaboration with other commissioning partners across Leicester, Leicestershire and Rutland (LLR) to achieve system-wide change throughout health and social care. As such, the CCG is an active participant in a number of LLR-wide programmes, with clinical and other leads playing a key role in programme boards and teams, and in advocating and enabling change within the East Leicestershire and Rutland area. Key on-going developments in 2011/12 have already led to success in terms of Quality, Innovation, Productivity, Prevention (QIPP) programmes in the areas described in the following sub-sections.
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3.5.1
Urgent Care – LLR Emergency Care Network
In March 2011, the LLR Emergency Care Network agreed a set of outcome success measures across the LLR healthcare system. Despite surges in emergency department attendance, the year-end performance against planned activity for LLR commissioned patients stood at 0.2%. The emergency admission trend shows a similar decrease. Although the system did not achieve the 4-hour performance target in 11/12, key improvements across the urgent care system have enabled patients to be assessed, treated and discharged in a more efficient manner. In order to ensure that these developments continue to deliver sustainable improvement and consistent delivery of standards, the Emergency Care Network will continue to oversee progress in 2012/13. System-wide projects include: • Mental Health Liaison in the Emergency Department: The introduction of a psychiatric liaison service within the Emergency Department from 9am to midnight, 7 days a week. • Early discharge: Discharge by 1pm at UHL with a revised discharge process designed and embedded in 20 acute wards with planned rollout across UHL in 2012-13; Discharge by noon in Community hospitals, with a revised discharge process designed and embedded. Discharge to assess - The LLR PCT Cluster in partnership with University Hospitals of Leicester NHS Trust have worked together to provide patients with temporary two-week placements in local nursing homes, where they can be assessed and re-located to a permanent residence equipped with an individually tailored package of healthcare. BEDs – the UHL BED Before 11:00 Project is focused on improving both the quality and timeliness of patients’ discharge or transfer of care. • East Midlands Ambulance Service Improvement Improve EMAS GP urgent conveyance rate (8am-8pm) and alternative pathway for conveyance to Urgent Care Centre/8am to 8pm centres/and Walk in Centres for category ‘c’ minor calls.
3.5.2
Frail Older People’s Pathway
Significant progress has been made across LLR in the design and implementation of services to reduce emergency care for frail older people, and to bring services closer to home. In November 2011, the non-weight bearing pathway was introduced. From this time until the end of March, 340 acute bed days were saved. This was as a result of UHL working with the local authority to spot-purchase beds to move stable non-weight bearers (overwhelmingly older people) out of acute beds and closer to home, or in some cases actually back to home with enhanced support. The Frail Older People’s Advice and Liaison Service (FOPALS) has resulted in weekly clinics in most of the county hospitals, in addition to a weekly ward round to review frail older in-patients. This year they will also be delivering some care home and domiciliary visits to support GPs and community nursing. The FOPALs service has resulted in a reduction in referral to transfer time for older patients needing therapy, from 2.8 days to 1.8 days for county patients and from 4.7 days to 1.78 days for city patients. This is as a result of extensive partnership working between all stakeholders across LLR. There was also an increase in discharge before midday across county hospitals from an average of 26% in 2010/11, to 40%. Discharge from UHL by 1pm increased from 13% to 17.5%. 3.5.3
Right Care Programme
The LLR Right Care Programme was established to improve the use of evidence-based medicine, and to reduce clinical variation in line with the recommendations made in the Innovation, Health and Wealth (2011) paper and the Right Care 2nd Atlas of Variation (2011). The programme has initially focused on eight clinical procedures with the aim of ensuring high quality, clinically appropriate care, whilst releasing funds to be re-invested or saved. Procedures include: • • • • •
Hip replacement surgery Knee replacement surgery Carpal Tunnel surgery Cataracts Tonsillectomy
Clinical thresholds for the identified procedures were implemented from June 2011 with full year savings in 2011/12 for ELR CCG projected to be £700,000. 3.5.4
Primary Care Key Performance Indicators
The focus on practice engagement has delivered performance improvements in five primary care priority target areas in 2011/12. Linked to our primary care QIPP programme, these areas will continue to be a priority in 2012/13, and are as follows: • Increasing the number of NHS Health Checks being carried out: 65.5% of people were offered NHS Health Checks in 2011/12. In 12/13 we expect this number to increase as we are offering financial incentives to practices that achieve the 65% target set by the SHA. We are also asking practices to submit monthly performance data as opposed to quarterly. • Increasing the number of GPs with extended opening hours: 24 out of 34 practices provided extended hours in 2011/12. We are introducing a new Extended Opening Hours Local Enhanced Service (LES) for 2012/13 to make it more flexible. We expect the majority of practices to sign up to this. • Increasing the use of Choose and Book (CAB) within general practice: 67% of referrals were booked through CAB. We have applied an incentive of £1 upfront payment for practices signing up to the GP Support Framework. This requires practices to use CAB and we expect this to continue to improve in 12/13. • Increasing the number of Learning Disability (LD) Health Checks being carried out: 77.56% of LD clients had a health check in the last 12 months. We are working collaboratively with the LD facilitators to continue to improve uptake and have amended the LD LES to require practices to provide monthly performance data as opposed to quarterly. • Improvement in the reported patient experience in relation to Long-Term Conditions in the GP survey
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3.5.5
National Key Performance Indicators
The performance of health services that we commission is measured against a number of national key performance indicators. At the beginning of the year 2011/12 we agreed to focus on improving a number of areas as follows: • Percentage of people seen within 4 hours in A&E • Percentage of people who spend at least 90% of their time on a stroke unit • Percentage of people who have a TIA who are scanned and treated within 24 hours. • Percentage of people offered a health check, and percentage of people who have received one • Percentage of women who have seen a midwife for a full health and social care assessment by 12 week and 6 days of completed pregnancy • Percentage of people who commence treatment within 18 weeks from GP referral to the start of hospital treatment Action plans were developed to address each area and we have made good progress over the last year on setting the foundations for future improvement of these targets; we have already seen a positive change in a number of them, for example, NHS health checks. At the beginning of the year the number of NHS health checks carried out was below the planned target.
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Over the year we ran a campaign across all practices and localities, and redeveloped the pathway. This resulted in a significant improvement in performance, from 453 health checks offered and 81 received in quarter one, to 7,382 offered and 4,837 received by the end of the year. Over the past year we have set in place a number of actions required to deliver a stepped improvement in performance in the stroke pathway. This will enable us to improve performance against both stroke-related targets. We have worked with our main acute provider, UHL, to deliver plans for 2012/13, including direct booking to the TIA clinic and on-going commissioning of the early supported discharge team. With regard to the delivery of the 18-week target, significant work has been undertaken with acute providers and the total number of incomplete pathways has decreased over the past year as a result. This on-going programme will continue and will help to improve future performance. In the meantime, this target remains somewhat problematic. Further information on our work to improve emergency care performance and improving the 12 week access to maternity assessment can be found in sections 6.3.5 and 7.5.2 respectively. A copy of our National and Local Target Priorities: Delivery for 2011/12 and Targets for 2012/13 can be found in Appendix 3.
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Vision, Values and Strategic Aims
This section outlines ELR CCG’s vision, values and strategic aims. These were developed following significant engagement with member practices, patients, carers and members of the public, staff, clinicians and partners. A more detailed account of some of the discussions and events that took place can be found in the Appendix 3. It should be noted that our local values underpin those set out within the NHS Constitution, and as such should be taken together with these. Resulting from a nationwide engagement programme led by Lord Darzi in 2008, these values are: • • • • • •
Respect and dignity Commitment to quality of care Compassion Improving lives Working together for patients Everyone counts
4.1 ELR CCG Vision and Values ELR CCG developed our Vision and Values during a series of Board Development sessions in 2011, incorporating suggestions and feedback from a variety of stakeholders, including ELR CCG staff, GP practices, patients and carers, representatives from LINks, partner organisations and local community groups, including learning disability support groups and the traveller community. The results can be seen at Figure 8, with the vision central to our values:
Figure 8: ELR CCG Vision and Values
Quality People
Economy
Involvement
To improve health by meeting our patients’ needs with high quality and efficient services, led by clinicians and delivered closer to home
Education
Innovation
Progression
Respect
Inspiration
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4.2 Strategic Aims The CCG has undertaken extensive engagement to ensure the involvement of key stakeholders in the setting of our key strategic aims. Various meetings and other activities, such as locality GP meetings, Patient Participation Groups, engagement events and surveys took place over a period of nine weeks with member practices, community and secondary care clinicians, Leicestershire and Rutland LINks, patients, carers and the public, and partners, including local authorities and members of the Health and Wellbeing Board. We discussed the findings of the Joint Strategic Needs Assessment in conjunction with local knowledge of healthcare services, and developed our strategic aims for the following three years. We also discussed our emerging priorities with partners at the Health and Wellbeing Board meetings of both Leicestershire County, and Rutland County. This was to ensure both support from partners, and alignment with Health and Wellbeing interim priorities as follows: Leicestershire Health and Wellbeing Board Interim Priorities: i. Improving health and wellbeing and reducing inequalities ii. Improving service integration iii. Improving efficiency and balancing the economy Rutland Health and Wellbeing Board Interim Priorities: i. Staying Healthy: Improving health and wellbeing and reducing inequalities ii. Complex Needs: Improving outcomes for people with complex needs iii. Children, Young People and Families: Improving care and support iv. Sustainability: Improving efficiency and balancing the economy v. Cross-cutting themes Further details relating to the development of Health and Wellbeing priorities and strategies can be found in Appendix 11.
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We asked for input and feedback, and the views of all members were taken into consideration. Emerging themes were formally reviewed by the public health team with respect to both alignment with population health needs and Health and Wellbeing Board priorities, and the potential to tackle health inequalities. The resultant report was discussed by partners at a later Board meeting, helping us to ensure that our strategic aims and the priorities of both Health and Wellbeing Boards were mutually supportive. This work was then shared with a wider audience through a series of open engagement events across East Leicestershire and Rutland. Our strategic aims also align closely with the areas of focus identified by the Leicestershire LINk. These are mental health and social care. We are confident that as a result of this robust programme of engagement, our commissioning priorities directly respond to the needs of local people, and also reflect wider partnership aims. A more detailed account of this work can be found in Appendix 4. Our strategic aims: • Transform services and enhance quality of life for people with Long-Term Conditions With a particular focus on COPD, diabetes, dementia and mental health • Improve the quality of care Focusing on clinical effectiveness, safety and patient experience, with specific goals to deliver excellent community health services and improve the quality of primary care • Reduce inequalities in access to healthcare Targeting areas and population groups in greatest need • Improve integration of local services Between Health and Social Care, and between Acute and Primary/Community Care • Listening to our patients and public Commitment to listen, and to act on, what our patients and public tell us • Living within our means Effective use of public money
In addition to the strategic priority areas identified above, ELR CCG recognises that the maternity and child health agenda is vast and complex. It is clear that the Government sees ‘Getting it right for children and young people’ (Sir Ian Kennedy: September 2010) as a key priority for commissioners and this is clearly reflected in the challenges relating to maternity care, health visiting, non-elective care, Long-Term Conditions, safeguarding, complex families and their care, and Child and Adolescent Mental Health Services (CAMHS). ELR CCG is committed to working in partnership with a range of organisations to improve quality and productivity across universal, targeted and specialist services to improve outcomes for infants, children, young people and their families. Further detail on how we plan to deliver these areas of care can be found within section 7.5.
4.3 Communication of Vision, Values and Strategic Aims We recognise that communicating our vision, values and strategic aims is key to our success in realising them. We have communicated and engaged with member practices, key clinicians, staff, partners, patients, carers, members, and others to ensure that they are aware of them, that they subscribe to and support them, and that everyone is committed to delivering them in collaboration together. We have delivered presentations at locality meetings and key partner meetings, for example the Health and Wellbeing Board and District Council health forums; spent time talking directly with practices during face-to-face visits; held staff briefings; and shared information in our staff and public member newsletters. More work to involve stakeholders and to communicate our vision, values and strategic aims will take place over the summer of 2012 with open engagement events, media releases, the launch of our website and further meetings with key partners and stakeholders. This will raise awareness further and encourage subscription and collaboration. We recognise that this is an on-going process and, therefore, sharing our vision, values and strategic aims will remain a fundamental part of all future communications activity. Central to our communications approach is the development of our ‘strategy on a page’ which outlines our vision, values and strategic aims and how they link to other priorities and plans, including the NHS Framework and collaborative working with partners. This strategy ‘pyramid’ (see Figure 2 in section 1) also depicts the central importance of clinical leadership, and of involvement of clinicians, staff, partners and member practices in delivering our vision. In terms of more specific engagement and communications arrangements, our Involving and Informing Strategy sets out our key stakeholders and how we will engage with them on an on-going basis.
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5
Delivering our Strategic Aims
This section sets out our plans for delivering our six strategic aims as identified within section 4.2 above. 5.1 Deliverables We have developed a number of deliverables against each of these areas as shown in the table below. These have been developed following stakeholder involvement and feedback as described within section 4 above. Aligned with the local JSNA, specific areas of focus have been influenced strongly by the views of patients and clinicians; the priorities agreed by our Health and Wellbeing Boards; and the focus areas identified by LINks. For example, following a public meeting in Oadby and a strong consensus of opinion from patients, carers and local clinicians, we have strengthened our plans to improve mental health services (see 7.1.3 and 7.5.4).
• Equitable access to health checks for all patients including hard to reach groups • Continuous improvement and learning through clinical peer review Delivering excellent community health services, for example • Extending patient choice of provider for a range of community and mental health services through use of local and national Any Qualified Provider (AQP) processes • Redesign and procure elective care services including out patients • Diagnostics and day surgery to bring care closer to home and improve patient choice and experience
Deliverables are set out within the following sub-sections:
• Deliver efficiency by maximising use of community services
5.1.1
Transform Services and Enhance Quality of Life for People with Long-Term Conditions
• Assure delivery through collaboration with main providers ensuring ‘value for money’ for all partners.
• Further develop training and education in primary care thus reducing patients' reliance on secondary care services including end of life care
Improving the quality of patient services and experience
• Expand current COPD scheme to provide better condition management and improve prevention • Develop community based diabetes service • Investment in improved and expanded Dementia care management • Optimise use of Telehealth and assistive technology to improve patient self management and treatment within primary care
• Continuously improve the quality of care within our providers, including acute, mental health and community services using contractual processes as a lever • Triangulate commissioning and provider data with patient safety data and patient and carer feedback, including from complaints, reference groups and engagement events, to inform areas requiring improvement and attention and to ensure on-going improvement
• Equitable access to primary care services
• Build on governance processes already in place to share patient feedback and experience information with Board, committees, staff, member practices and partners to inform decision-making and raise the quality of services
• Improve appropriateness of referral to other services
• Ensure the continuous improvement of quality and patient and carer
• Appropriate prescribing
• Experience through the routine contractual performance management process
5.1.2
Improve the Quality of Care
Reduce variation in primary care, for example:
• Improve disease prevalence rates and earlier diagnosis
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5.1.3
Reduce Inequalities in Access to Healthcare
• In partnership with social care, deliver the Together Health Inequalities Action Plan 2012-2015, covering supporting families, mothers and children; engaging communities and individuals; preventing illness and providing effective treatment and care; and addressing the underlying (wider) determinants of health. • Increase access to smoking cessation services • Work with providers to achieve the standards of care as set out within the UNICEF/WHO Baby Friendly Initiative • Identify shared budgets and plans with Local Authority partners and the Health and Wellbeing Boards to target geographical areas and groups with health inequalities • Continue to support nutrition and lifestyle services in targeted neighbourhoods as part of local obesity care pathways • Continue to support targeted services in children’s centres for referral of vulnerable parents or families, e.g. through increasing health visitors and providing outreach workers for families • Develop healthcare services tailored to the needs of specific priority groups, e.g. military, and travellers. 5.1.4
Improve Integration of Local Services
• Extend integrated working across health, social care and all third sector organisations e.g. voluntary services to enable delivery of seamless end to end care pathways • Work with local authorities to address the health and social care needs of specific groups e.g. military families; travellers • Deliver value for money for all partners whilst improving overall health outcomes by maximising benefit realised by appropriate use of social care funding • Improve the quality of care in Care and Nursing Homes and those who are housebound
5.1.5
Listening To our Patients and Public
• Embed effective public engagement and consultation processes within the organisation to ensure patients are involved fully and appropriately in decisions about their own care and local health services • Integrate patient experience, complaints and quality data with feedback from public engagement and consultation activity to provide patient-centred insights to our commissioning decisions • Build strong relationships with key stakeholders and partner organisations, ensuring effective partnership and collaboration to deliver integrated care and the best possible services for our patients Develop a wide range of ways for local people to access reliable information about health and local health services, ensuring information is available in a variety of formats tailored to people’s needs, and making the best use of technology 5.1.6
Living Within our Means
• Work collaboratively with public health and other partners to ensure that financial resources are targeted towards delivering priority local needs • Ensure that collaborative arrangements for contract management secure the financial needs of ELR CCG • Deliver QIPP targets for LLR and ELR CCG • Ensure good financial management from Board to budget holder, including the investigation any variances from plan • Deliver training to ensure that budget holders have the appropriate capability • Ensuring that financial implications of pathway changes and other programmes are understood and planned for • Ensuring flexibility in financial planning to adapt to changing needs and circumstances • Adherence to financial governance framework
• Ensure more seamless, joined up care between primary and secondary care through clinicians from these areas working collaboratively to improve a number of pathways, including diabetes, frail older people, COPD and integrated care. This will also facilitate better working relationships.
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5.2
Three Year Delivery Plan
Early in 2011/12, we agreed a three-year approach to delivering our strategic aims. In our first year we are paving the way to ensure that we have the appropriate foundations for future success, e.g. through developing robust collaborative arrangements and relationships with partners, engagement and involvement of stakeholders, training and development of primary care clinicians, and the development of a comprehensive governance framework which will also ensure the successful delivery of programmes In our second year we will implement our programmes and plans if we have not done so already, ensuring that we continue to involve stakeholders and learn from the changes we are making. We will also ensure that service developments and future plans are reflected in contract arrangements for following years. We will continually monitor the changes we are making to ensure that they are having the intended impact on improving patient outcomes and experience. In our third year we will review and evaluate the changes we have made. We will secure funding for on-going investment where programmes have been implemented successfully, and revise our plans for areas that may not have had the expected outcomes.
By the end of the third year we expect to see a successful step change in all our strategic aim areas. We will share learning and will celebrate the positive changes made. However, we will also recognise that there is much more to be done, and we will be clear on both how we plan to sustain the changes made, and how we plan to continue to improve for the future. We will formally revise our strategic aims at this time to ensure alignment with emerging health trends, the strategic aspirations of partners such as the Health and Wellbeing Board, and the opinions of local people and clinicians. We are committed to ensuring clinical leadership and clinical involvement in all of our programmes. For this reason our GP Board members have clinical portfolios supported by senior responsible officers to oversee and ensure the delivery of each of our clinical programmes. Each work stream includes strong representation from various clinical professions, social care, and management as appropriate to the programme. Where common areas of interest exist, e.g. COPD and Frail Older People, our ELR CCG programmes and clinical leads link into those of the LLR collaborative (see section 12.2).
Year 1: Paving the Way • Finalising and ensuring robust governance arrangements • Getting the basics right • Understanding the needs of our local population through local JSNAs and stakeholder engagement, and involving stakeholders to agree priorities • Developing our vision, values and strategic aims to inform the overall direction of ELR CCG • Involving and engaging with patients, public, member practices, clinicians, staff, partners and others • Bringing primary care clinicians up to a common level of understanding and competence in the
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detection and management of conditions such as cancer, diabetes, dementia and COPD, and improved referral • Increasing the number of patients with conditions detected earlier on • Reviewing our local healthcare estate to ensure we can use it in the best way possible in the future • Developing good relationships with partners and building strong foundations for collaborative working • Establishing work streams and programmes, ensuring both excellent clinical leadership and involvement throughout, and joint working with partners wherever possible and appropriate.
Year 2: Launching our Plans • Use the findings from reviews, research and best practice to inform the direction of travel for this year and beyond, e.g. integrated care, best use of local healthcare estate • Roll out the plans, either as pilots or in full. These will include new and revised care pathways, and transformational work such as Diabetes, COPD, Frail Older People and End of Life. It will also include initiation of the Integrated Care Team programme to implement an integrated approach to community care of patients with chronic co-morbidities • Implement the recommendations from the local healthcare estate review • Continue to deliver training and development within primary care to improve earlier identification, prevention, and on-going management of conditions
• Deliver training and education for patients to facilitate self-care and enable them to make more informed choices about accessing services • Assess how risk stratification tools and techniques investigated and piloted might support the ELR CCG Long Term-Conditions programme • Ensure good performance management and progress against plan. Review where progress has not been as expected and revise proposals accordingly • Continue to strengthen partnership and collaborative arrangements • Build service changes into the contracting round for the following year • Continue to involve stakeholders on an on-going basis.
Year 3: Seeing Results • Consolidation of learning from the Long-Term Conditions pilots to inform the commissioning of robust integrated pathways, which deliver care in appropriate settings in a way that is sustainable and meets the needs of the local people • Continued implementation of the integrated care pathway • Build changes into future contracts to ensure the appropriate levers for sustainable, affordable change • Secure funding to ensure the on-going delivery of successful programmes
• Develop and apply learning from pilots and programmes undertaken and revise commissioning intentions and approaches accordingly • Involve all key stakeholders in evaluating the impact made on patient and carer experience and outcomes • Share learning and celebrate success, whilst recognising the areas where more work is needed • Continue to commission services based on emerging themes from national frameworks • Revise strategic aims for following years to align with joint health and wellbeing strategy and local health trends and priorities.
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6
Transformational Programmes for 2012/13
This section outlines the transformational programmes agreed by the LLR Commissioning Collaborative Board (see section 12.2) for investment during 2012/13 in both local East Leicestershire and Rutland schemes, and in LLR schemes to be delivered jointly by commissioning partners. ELR CCG has ensured that all programmes will contribute directly to the delivery of our six strategic aims (see section 4.2). 6.1 NHS Operating Framework Guidance The NHS Operating Framework sets out a requirement for all PCTs to set aside 2% of their income to invest non-recurrently in supporting service transformation. The purpose of the Fund is to reinforce delivery of existing priorities by accelerating the pace of service transformation. All schemes must therefore be able to demonstrate that they will make a direct and significant contribution to at least one of the following categories: • National priorities and commitments as set out in the NHS Operating Framework • Regional priorities and commitments (ambitions) as set out in the SHA Plan • Local priorities and commitments as set out in the PCT Cluster Integrated Plan and the three CCG commissioning priorities • The LLR QIPP work streams • Provider-specific CCG commissioning intentions • Internal provider efficiency and cost base reduction
6.2 LLR Transformation Fund - 2012/13 Approach Following the allocation of transformational funds to support pre-committed contract arrangements with providers, the NHS 111 service (see section 7.2.9), and the restructuring of commissioner and provider organisations across LLR, a total of £9.3million remained for investment by the three CCGs and the LLR PCT cluster in key transformational programmes.
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For this year, it was agreed that resources will be allocated at commissioner level, rather than by provider. This means that the relevant ‘stake’ of the overall transformational fund will be clearly visible in terms of each of the three CCGs operating in Leicester, Leicestershire and Rutland, and the LLR PCT Cluster. The fund will be managed jointly by the three local CCGs and the Cluster, with investment decisions taken through the LLR Commissioning Collaborative Board (which incorporates representatives from ELR CCG). This process will enable the four bodies to invest jointly in LLR-wide priorities whilst also retaining the ability to tailor funds to local need where this is appropriate. Most importantly, in terms of preserving autonomy, final sign-off for using each commissioner’s respective ‘stake’ will rest with their appropriate governing body. Governance oversight will remain with the LLR PCT Board as the statutory body. ELR CCG has assessed and, where necessary, prioritised each proposed scheme against the following criteria agreed by the three LLR CCGs: • Extent of contribution to strategic priorities/aims (see section 4.2) • Potential to reduce running costs of the NHS • Evidence base to support proposed service change/intervention • Level of clinical support • Ability to measure and monitor impact • Overall value for money
All bids were required to provide contingency arrangements which detailed what might happen in the event of slippage in spending, or different outcomes to those expected. Each project is formally measured against a number of locallyagreed performance indicators, which are reviewed via the Transformation Steering Group (ELR) and by the Commissioning Collaborative (LLR).
Five work stream groups have been identified to take this work forward. They will adopt a LLR integrated pathway approach and involve representation from each CCG. The agenda for each work stream reflects both the overarching LLR aims, and the individual priorities of each CCG as outlined in their transformation funding bids.
These contingency plans provide appropriate measures to take in the event that plans are not on track.
Specific work stream aims and activities are outlined within the following sections. Five work stream groups have been identified to take this work forward. They will adopt a LLR integrated pathway approach and involve representation from each CCG. The agenda for each work stream reflects both the overarching LLR aims, and the individual priorities of each CCG as outlined in their transformation funding bids.
ELR CCG’s priority bids were then submitted for consideration by the LLR Commissioning Collaborative Board in conjunction with bids from the other two LLR CCGs.
6.3 The Commissioning Collaborative Board
Specific work stream aims and activities are outlined within the following sections.
As many of the priorities were common to all three CCGs across LLR, the Commissioning Collaborative Board agreed on a collective approach across five areas. Following the initial approvals stage, £2.3million of the transformational fund remains unallocated. Total allocated funding for each LLR work stream is detailed below in Figure 9.
Figure 9: LLR Transformation Funding Allocation 2012/13
Diabetes
LLR Diabetes Group
£1,000,000
COPD
COPD Working Group
£1,000,000
FOP / Dementia / Care Homes
LLR FOP Group
£2,000,000
Emergency Care
Emergency Care Network
£2,000,000
IM&T
IM&T Working Group
£1,000,000
Total Priority Investment Budget
£7,000,000
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6.3.1 Long-Term Conditions
6.3.2
The Department of Health defines Long-Term Conditions as a condition that cannot at present be cured, but can be controlled by medication and other therapies. Examples of Long-Term Conditions are diabetes, dementia, heart disease and chronic obstructive pulmonary disease.
In 2011/12, we focused on training and education to improve skills within primary care. This enabled GPs to treat more patients within a community setting, allowing us to shift more activity from secondary care into primary care.
East Leicestershire and Rutland CCG recognises that patients with Long-Term Conditions require a better quality of care that is more evidencebased and structured. With our increasing older population, there will be an associated increase in burden of disease with ever more people living with Long-Term Conditions. As part of our key role to deliver sustainable improvement in the quality of Primary Care and with this health need identified, the CCG will focus on the transformation of care for patients with Long-Term Conditions. This will mean more co-ordinated, integrated management of care, which is proactive and consistent across the health and social care economy, and which results in improved outcomes. To support the transformation from non-planned to planned care we will improve health outcomes by investing in innovation in Long-Term Conditions and Telehealth. Patients, GPs, Public Health and CCG clinicians have helped us to identify the need for the development of a high quality, clinically-led and accessible service to improve care in diabetes, COPD and other Long-Term Conditions. All of our Long-term Conditions work streams (detailed in 6.3.2 to 6.3.4) are underpinned by interactive, locally delivered educational events.
Diabetes
In 2012/13, further training is being scheduled to strengthen existing primary care services, which support patients with diabetes. These courses will aim to achieve both better clinical outcomes, and a reduction in multiple outpatient attendances. They will also facilitate the offer of care closer to home for the patient. Additionally, ELR CCG is planning to pilot the greater use of Diabetic Specialist Nurses. Current provision is fragmented across the county and recruitment of additional nurses will ensure a more equitable level of service provision, allowing for existing gaps to be addressed. A team of diabetes specialist nurses will work within a community setting, liaising with primary care and holding clinics within GP practices. They will help to improve skill levels in practices and support the Long-Term Conditions education programme being rolled out across ELR CCG. Key benefits from implementing this project will be: • Reduction in health inequalities • Increased levels of patient satisfaction • Creation of a ‘left shift’ in activity (the movement of care to a lower cost setting closer to home where it is safe and appropriate to do so) • Improved levels of control and outcomes with no reduction in quality of service • Reduction in new referrals • Reduction in the number of patients under active follow up within secondary care The wider health economy is looking at the development of an integrated Diabetes pathway across Leicester, Leicestershire and Rutland, which is outlined below at Figure 10. The work planned within ELR CCG complements and supports this model. There is a clear focus on shifting care into the community, increasing skilled capacity in primary care, and empowering patients to manage their condition. A project group with strong representation from ELR CCG will take this piece of work forward.
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6.3.3
COPD
6.3.4
In 2012/13 ELR CCG aims to improve the quality of care received by patients with COPD. We also aim to increase the level of support to GP practices so that more screening can be undertaken to improve and increase the identification of patients who are at risk. This will be achieved by further education in primary care, improved screening resources and improved access to relevant equipment and hand-held records. This project will improve overall consistency and reliability of patient care, and enable earlier clinical interventions, which can improve long-term outcomes and will support patients in managing their conditions better.
Frail Older People
Funded by transformational funding, a number of initiatives are planned for 2012/13 to improve the care of frail older people. The aims of these projects are to: • Promote the health, wellbeing (including mental health) and continued independence of older people through early intervention and prevention of chronic illness, and by developing reablement and rehabilitation services to improve and maintain older people’s functional abilities. • Promote the dignity and respect of older people by ensuring that staff across health, social care and residential settings are appropriately trained to assess and meet the needs of older people
Figure 10: Integrated Diabetes Care Pathway for LLR
Primary care ‘The Necessary Nine’ 1. Screening 2. Prevention 3. Regular review / surveillance 4. Prescribing 5. Insulin 6. Patient education 7. Cardiovascular 8. Housebound/care homes 9. Outcomes/audit
Primary care (core) Primary care (enhanced)
Specialist support for primary care
Secondary and Tertiary care Complex care
‘The Super Six’ 1. Inpatient care 2. Insulin pumps 3. Renal 4. Foot 5. Children/adolescents 6. Pregnancy
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• Reduce the number of unnecessary admissions to hospital and excessive lengths of stay by supporting pathway redesign. This will enable the “left shift” of resources in areas such as end of life care, support of carers, risk predictive modelling, and falls. These pathways will require the creation of integrated health and social care teams working with primary care to provide more holistic care to avoid some of the current patterns of over use of acute care services.
6.3.5 Emergency Care
• Support the specialist assessment, treatment and care of frail older people in crisis across community, primary and secondary care by developing greater integration between specialist geriatric medical services both within emergency care settings and outside of hospital
• The development of a community IV antibiotics service to prevent stays in the acute setting and bring care closer to home
• Work with other bodies such as the Emergency Care Network to ensure that discharge processes for older people are as efficient and robust as possible so as to avoid extended lengths of stay, delays in transfer and readmissions. ELR CCG is also piloting the use of Risk Predictive Modelling and a case mix tool, initially in five GP practices. This software will enable identification of patients who are at most risk of hospital admission due to their current health status. Patients with Long-Term Conditions will be treated on the basis of the totality of their health needs, and those identified as high risk will be given a care and self-management plan. Projects are planned that will aim to realise the potential of care homes to reduce emergency hospital admissions. GPs will have the option of admitting their patients to a local care home with whom they have a good working relationship, instead of to hospital. The benefits of delivering this programme include less risk of hospital acquired infections, a reduction in hospital emergency admissions, greater continuity of care, reduced loss of independence and reliance on care homes, and care closer to home. Additionally, an amount of £349k from social care transfer monies has been allocated to improve the safeguarding of vulnerable older people in care homes.
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Monitored on a monthly basis through the Emergency Care Network governance structure, partners from across health and social care focus on a number of initiatives to improve emergency care across Leicester, Leicestershire and Rutland. These include: • Improving discharge from acute hospitals by 1pm, and from community hospitals by midday
• Access to care home beds to support acute discharge for patients awaiting care packages • Earlier conveyance of patients referred by GPs to the acute hospital, to reduce unnecessary admissions • ‘Choose better’ campaign to provide patients with appropriate information to make informed and responsible decisions about accessing care • A GP/consultant hotline for urgent review of patient cases to increase communication between primary and secondary care and enable more timely, better clinical decision-making • Implementing the Hospital at Night scheme to enable fuller medical cover and access to services around the clock, whilst preserving time for doctors’ training 6.3.6 Information Management and Technology This work stream focuses on the delivery of a number of IM&T (Information Management and Technology) initiatives, including electronic outpatient letters and electronic prescribing to be implemented within our main acute provider, the University Hospitals of Leicester (UHL); GP system migrations and upgrades; online access to patient records; systems training; and Telehealth. A joint clinical lead has been appointed by West Leicestershire, and East Leicestershire and Rutland CCGs to champion IM&T developments across the two CCGs.
6.3.7 East Leicestershire and Rutland Integrated Care Model In addition to developments through Transformation Funding, ELR CCG has prioritised £400k investment in the development of an Integrated Care Model for implementation across East Leicestershire and Rutland. This has been matched by a £500k contribution from Leicestershire County Council. Research tells us that improved care co-ordination can have a significant effect on the quality of life of frail older people, and people with multiple Long-Term Conditions (Hofmarcher et al, 2007). As part of a three-year strategy, we aim to build fully integrated health and social care teams, based around local populations. This model will see improved integration of local services across health and social care, and will involve care providers from: • • • • •
the acute sector community health GP practices social care voluntary and private sectors
The care teams will focus on providing better, local and faster access to care, and improved services for patients with chronic complex conditions. They will provide patient-centred care, supporting self-management and reducing unnecessary admissions to hospital. This will be facilitated by empowering patients to maximise self-care, risk profiling patients, and enabling joined-up working between the various and previously diverse care providers.
The first stage of implementation in 2012/13 will see ELR CCG embark on a wider engagement process, where we will bring together members of the stakeholder teams in addition to utilising current stakeholder forums. This will involve a series of meetings and workshops with individuals and groups including patients, carers and staff from the various providers. We will use patient experience narratives to highlight our vision. Those involved will be asked if we can improve integrated care, and what an integrated approach might look like for local teams. This approach will elicit ‘best practice’ models for the local population, ensuring that organisations and individuals are signed up and willing to work in new ways to improve outcomes for their patients. This three-year programme is a key enabler to the delivery of our strategic aims as follows: • Delivering care closer to home • Use of care homes for “step up”/“step down” beds • Improved care and outcomes for frail older people and patients with dementia • Shift of activity away from the acute sector to the community. • Care for Long-Term Conditions being mainly community based By the end of 2012/13 we will have an agreed new model of care that informs contracting rounds so that a move towards the integration of care pathways can commence in 2013/14.
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7
Transformational Programmes for 2012/13
This section outlines the key operational priorities for ELR CCG in 2012/13. These have been identified as a result of triangulating findings from the JSNA, with feedback resulting from engagement with constituent GP practices and other local clinicians, experts and partners; and with data comparisons between local outcomes and ONS cluster/England performance. We have also undertaken extensive consultation with patients, carers and members of the public to determine priorities and areas for improvement. Our operational priorities link directly to the following:
7.1
Local Priorities
• LLR Integrated Plan (2012/13)
Following engagement with our various stakeholders, including member practices, clinicians and local providers, and patients and carers, a number of local commissioning themes have been identified to inform our operational priorities for 2012/13. ELR CCG has ensured that these priorities link with local Health and WellBeing Board priorities and the five pillars of the NHS Outcomes Framework, which are as follows:
• Joint Strategic Needs Assessment
• reduce the number of people dying prematurely;
• Shadow Health and Wellbeing interim strategic priorities
• enhance the quality of life for people with Long-Term Conditions
• Transforming our health care system – Ten priorities for commissioners (The Kings Fund 2011)
• help people to recover from episodes of ill health or following injury
• NHS Constitution
• ensure that people have a positive experience of care
• NHS Operating Framework (2012/13) • NHS Outcomes Framework (2012/13) • NHS Midlands and East Regional Commissioning Framework (2012/13) • SHA Ambitions (2012/13)
Achieving improvements in these areas will ensure that we are getting the basics right for our patients and carers. Addressing requirements as set out by the NHS Operating and Outcomes Frameworks is essentially a ‘must do’, and might be considered as the CCG’s ‘licence to operate’.
• ensure that patients are treated and cared for in a safe environment and that they are protected from avoidable harm Our priorities also link with the two high level outcomes detailed within the social and public health outcomes framework, which are: to increase healthy life expectancy; and to reduce differences in life expectancy and healthy life expectancy between communities. 7.1.1 Pathway Redesign We have a number of areas where we wish to improve patient and carer services over the coming year. These are presented below by organisation/ contract. Work involves the review of pathways, development of service specifications, and implementation of recommendations and best practice.
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• University Hospitals of Leicester NHS Trust -
Diabetes community-based model COPD community-based model DVT Service Early Pregnancy Assessment Service (EPAU) Elective activity shift into the community (safe and cost-effective)
• Leicestershire Partnership Trust (Mental Health) - Crisis Resolution Health Team - Improved choice in mental health - Adherence to formulary and 28 day prescribing - Single point of access (SPoA) - Personality disorder pathway • Leicestershire Partnership Trust (Community Services) - Adult Community Nursing - Adult Physiotherapy - Intermediate Care • Primary Care - Glaucoma pathway (Optometry) - Enhanced Services (outcome of current commissioning review) - Clinical peer review (continual learning and improvement)
Both Health and Wellbeing Boards share our strategic aim of reducing health inequalities and we will work collaboratively with our partners to develop and implement plans to improve health and wellbeing in key areas. Discussions have already commenced with Leicestershire County Council to consider the possibility of joint investment to target certain localities. Key areas of focus to improve health in the longer-term include: • Increasing access to smoking cessation services • Promoting breastfeeding and the achievement of the UNICEF/WHO Baby Friendly Initiative • Tackling obesity and physical activity, e.g. through nutrition and lifestyle services • Delivering targeted healthcare services and support for families and vulnerable parents through local children centres, e.g. Surestart • Reducing alcohol-related harm through identification and brief intervention In collaboration with partners, we are committed to delivering the Together Health Inequalities Action Plan (2012-2015), a copy of which can be found in Appendix 5. This action plan covers the following areas: • Supporting families, mothers and children
• Out-of-County (increasing influence sought e.g. Right Care)
• Engaging communities and individuals
• East Midlands Ambulance Service
• Preventing illness and providing effective treatment and care
- Admission protocols • Derbyshire Community Foundation Trust (Access to diagnostics at Community Hospitals) 7.1.2
Reduce Health Inequalities
We recognise from the JSNA that, alongside specific groups, such as travellers and military families, there are a number of geographical areas with inequalities in health, such as life expectancy and prevalence of cancer, cardiovascular disease (CVD), respiratory diseases (in particular COPD), and other long-term conditions including diabetes. These areas have higher levels of deprivation, and include neighbourhoods within Oadby and Wigston, Blaby, Harborough, Melton, and Rutland.
• Addressing the underlying (wider) determinants of health Furthermore, we are ensuring that all of our programmes of work consider the opportunity to reduce health inequalities as part of their key objectives. For example, with Long-Term Conditions we have expanded community-based services which will help to improve access and which, we believe, will benefit disproportionately those with the greatest of health needs. These programmes include the initiative to reduce emergency admissions through better management of CVD risk factors within primary care, such as the monitoring of cholesterol, blood pressure and DM (Diabetes Mellitus), and the more appropriate use of aspirin.
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We have also increased opportunities for patients to access lifestyle risk management services, including stopping smoking, exercise referral and alcohol brief intervention services. ELR CCG has recently reviewed its local enhanced services, including alcohol brief intervention and long-acting reversible contraception, with the specific objective of increasing equity of access. 7.1.3
Mental Health
Improving the quality of mental health services is one of the key areas of focus for ELR CCG and for the Health and Wellbeing Boards. NHS Operating Framework requirements for mental health services will be delivered collaboratively across the LLR PCT Cluster during 2012/13 and will include: • Improved access to psychological therapies as part of the commitment to roll-out fully by 2014/15 so that services remain on track to meet at least 15% of disorder prevalence • Improved physical healthcare of those with mental illness to reduce their excess mortality • Improvements in offender health • Improvements in targeted support for children and young people at risk of developing mental health problems such as ‘looked after’ children. We are also undertaking work across a number of mental health-related pathways. These are detailed below. Dementia Pathway Working jointly with partners, ELR CCG is the appointed lead for the implementation of a joint health and social care commissioning strategy for dementia. Led by a Board GP, the aim is to integrate health and social care commissioning to result in a co-ordinated dementia pathway. This will include a new memory assessment pathway, where GPs will receive specialist dementia training and work more closely with specialist psycho-geriatricians and specialist memory assessment nurses. There is also a focus on ensuring greater support for carers. For those people living with dementia and their carers, GPs will promote referrals to dementia advisors (commissioned by the local authority), who will provide support and advice following their diagnosis. The three LLR CCG GP leads for dementia will continue to engage with all stakeholders, in particular the three Local Authorities and our main acute care provider, UHL,
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to improve the detection of dementia and to offer support to people with dementia in the general hospital setting. Funding has been allocated to develop elements of this pathway and to expand specialist in-reach dementia care for patients living in care homes. It is envisaged that this pathway redesign will enable GPs to support more people with dementia and to improve dementia diagnosis rates. A Local Enhanced Service, funded by £200k of recurrent funds, will deliver an agreed Shared Care Scheme to facilitate the use of new pathways, and so lead to better and earlier identification of patients with dementia. Improving Access to Psychological Therapies We are part of an LLR-wide programme, led by West Leicestershire CCG, to review the provision of IAPT services in Leicestershire. This review will ensure that all aspects of mental health care continue to be provided at a primary care level using a stepped-care approach. Mental Health Facilitators, who support people with Severe Mental Illness, are working alongside IAPT therapy workers in primary care to provide an innovative, comprehensive primary care mental health service. This is assisting GPs both in preventing the need for onward referral, and in supporting people following discharge from secondary care services. Acute Care Pathway Through our contracted service development with our local mental health provider, LPT, plans are under way to implement a new acute care pathway. This will replace the many and varied access routes to secondary care mental health services, to provide one single point of access. This will enable a timely response for all users and eliminate the confusion between “emergency”, “crisis”, and “urgent” response services. This follows both user and GP feedback about the requirement for more timely access to services at times of greatest need. Mental Health Care Cluster Pathways We will deliver local plans to implement the national mental health Payment by Results (PbR) care cluster. This will enable better planning of services, including staff capacity and capability, and will ensure that providers are paid specifically on the basis of the services provided in terms of quality and activity.
This will move us away from the traditional block contract arrangements in place. Each of the 21 care pathways identified within the cluster will aim to improve patient care and experience; for example, patients will be informed at the outset about what to expect in terms of services they will receive and related waiting times. Increasing mental health professionals A total of £302k has been allocated to facilitate early discharge and increase the adult mental health work force to improve the quality of patient care and outcomes. This includes professional posts to support crisis resolution, and home treatment and in-patient services. 7.1.4 Cancer Overall, excellent progress has been made over recent years with respect to the target to reduce premature mortality from cancer, with the rate having dropped by almost 20% in Leicestershire County and Rutland PCT between 1993 and 2010. We have implemented a number of measures over the past year, linked to our Long-Term Conditions programme, which will help to improve diagnosis and to prevent cancer (see sections 3.1 and 3.3) on an on-going basis. In primary care we will continue to focus on the early diagnosis of cancer, and on programmes of prevention to ensure increased survival rates and better health for our local population. ELR CCG is committed to expanding breast, bowel and lower GI screening as well as to increasing access to healthy lifestyle and prevention programmes, such as smoking cessation, obesity and substance misuse. We will work with Public Health England and Local Authorities to optimise benefits for patients. We will re-run a cancer audit, where member practices will look at the pathways of patients recently diagnosed with cancer to identify delays to diagnosis or treatment. We will use this information to focus on the key issues identified to improve the quality of services for patients, to result in more efficient pathways and better patient outcomes and experience.
ELR CCG plans to raise awareness of the ‘Direct access to diagnostic tests for cancer best practice referral pathways for General Practitioners’. We have worked with our providers to enable increased access to a diagnostic test undertaken within a community setting. We are procuring via the AQP (Any Qualified Provider) route to increase the local availability of ultrasound, and so increasing patient choice and access. 7.1.5
CVD
Cardio Vascular Disease (CVD) is one of East Leicestershire and Rutland’s areas of greatest inequality and therefore remains a priority. ELR CCG believes that better improvements in health outcomes per pound invested will be achieved by investing “upstream” in the care pathway. Early detection and treatment through improving GP awareness of TIA and stroke referral processes is one such example of this. Our prevention programmes in smoking cessation, obesity and lifestyle, and alcohol misuse, as described elsewhere within this plan, form part of our strategy to improve the health of our local population in the longer-term. Over the last year we have also increased access to health checks. These have increased the early detection and prevention rates across East Leicestershire and Rutland by detecting those most at risk of developing CVD over the next 5 years. This follows on from earlier programmes to enable early detection of conditions, leading to a significant increase in the number of patients recorded with prevalence of disease, for example atrial fibrillation and heart failure. These patients are subsequently offered lifestyle advice and access to a range of programmes to help them to reduce their overall level of risk in the longer term. This programme remains a priority for ELR CCG in 2012/13 and significant investment has been made to support this.
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Since the publication of the National Stroke Strategy in 2007, there has been significant progress in a number of key areas on the hyper acute and acute stroke pathway, as well as inpatient rehabilitation and primary prevention. Going forward, ELR CCG will ensure that this momentum is upheld, and we will remain actively involved in the development of the stroke pathway whilst continuing to progress these areas. We will continue to work collaboratively with partners such as service providers, primary care, the East Midlands Cardiovascular Network and the SHA Cluster to maintain a focus on these key areas. The development of plans for stroke, atrial fibrillation and heart failure will feed in to our wider Long-Term Conditions programme. 7.1.6
Delivery of LLR Key Performance Indicators
We will continue to focus on improving performance against national targets where we remain outliers against CCGs with similar population profiles. Action plans are in place for these, both at ELR CCG and at LLR level where appropriate, and work is already under way (see section 3.5.5). Key areas of focus for 2012/13 remain as follows: • Percentage of people who spend at least 90% of their time on a stroke unit • Percentage of people who have a TIA who are scanned and treated within 24 hours. • Percentage of people offered a health check and percentage of people who have received one • Percentage of women who have seen a midwife for a full health and social care assessment by 12 week and 6 days of completed pregnancy. (See section 7.5.2) • Percentage of people seen within 4 hours in A&E (see 6.3.5) • Percentage of people who commence treatment within 18 weeks from GP referral to the start of hospital treatment See Appendix 3 for our National and Local Target Priorities – Delivery for 2011/12 and Targets for 2012/13.
7.1.7
Research and Development
ELR CCG understands the requirement to comply with our statutory responsibilities regarding promoting research and development (R&D). Through the LLR Cluster arrangements we are members of the LNR (Leicestershire, Northamptonshire, Rutland) Comprehensive Local Research Network (CLRN) and have included the formal governance arrangements for research within the terms of reference of our Quality and Clinical Governance Committee. We are committed to the policy of ensuring that the NHS meets the treatment costs for patients who are taking part in research funded by Government and by research charity partner organisations. We do this through the hosting arrangement we have in place within Leicester City CCG. This includes: • A LNR Comprehensive Local Research Network (CLRN) funded research facilitator based within the R&D team • Agreements with LNR CLRN for the provision of research management and governance services for portfolio and non-portfolio research services - Receipt of Research Capability Funding 2012-13 as research active organisations - Bi monthly R&D group meetings and research governance reporting to Cluster 7.1.8 Other Local Enablers There are a number of enabling programmes and activities which are critical to the successful delivery of our strategic aims. These include: • The development of our organisation and its people, as outlined within our Organisational Development Plan. This includes developing clinical leaders, both for now and for the future, and ensuring the capacity and capability to deliver our integrated plan (see section 12.6) • The finalising of service level agreements and contracts between ELR CCG and our Commissioning Support Service, GEM CSO (Greater East Midlands Commissioning Support Organisation) (see section 10.5) • Ensuring the best use of healthcare estate (see section 8.6)
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• The development of joint health and well-being strategies for Leicestershire and Rutland (see section 10.1) • The agreement of collaborative commissioning arrangements with partners (see section 12.2) • The finalising of robust programme management arrangements to deliver key strategic and operational priorities, as outlined within section 12.2.
7.2.2
Care of Older People
The care of older people is a strategic priority and ELR CCG has both identified a clinical lead for Frail Older People, and signed up to an older person’s pathway (see section 6.3.4). The pathway incorporates: • Risk-predictive modelling • Reablement • Enhanced multi-disciplinary geriatric care for patients in the acute sector
7.2 NHS Operating Framework The Operating Framework for the NHS in England 2012/13 was published in November 2011 and sets out the planning, performance and financial requirements for the NHS in 2012/13, together with the basis for which the NHS will be held to account. The Operating Framework sets out four key themes for 2012/13: • Putting patients at the centre of decision making • Development of the new system for delivery • Quality, Innovation, Productivity and Prevention (QIPP) • Managing and Improving Performance It is acknowledged that 2012/13 is the final year of transition to the new commissioning management system for the NHS.
• Work to support patients in care homes as part of locality-integrated teams in the community • Greater identification and support of dementia patients (and their carers) Delivery will be largely through integrated health and social care locality teams and improved access to specialist geriatric care in the acute sector. This large patient group has high levels of need, risk and cost, and offers significant opportunities to improve the quality of care and patient experience. ELR CCG will: • Improve clinical outcomes – especially in dementia, diabetes, COPD, CHD and end-of-life care • Move care closer to the patient
The Operating Framework identifies a number of key areas that require specific attention during 2012/13. We have set these out below along with our approach:
• Reduce expenditure on unnecessary, non-elective hospital admissions
7.2.1
• Successfully deliver National Framework and LLR priority outcomes
Dementia
ELR is fully engaged with developing the National Dementia Strategy across East Leicestershire and Rutland. Please see 7.2.1 for more details.
• Continue the shift towards prevention, self-care and maintaining the independence of older people
Further details on ELR CCG’s plans for developing integrated working across health and social care are included in section 6.3.7.
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7.2.3
Carers
Through our clinical lead for Frail Older People, ELR CCG is the appointed lead to implement the refreshed Carers Strategy – Supporting the Health and Wellbeing of Carers, which relates to all carers regardless of age. This was formally signed off by the local authority cabinets and the LLR Commissioning Collaborative Board in May 2012. New funding has been identified from the Health and Social Care Fund to support implementation of the strategy, and Section 256 Carer contracts (formal funding arrangements between the CCG and the local authority) are currently being reviewed. A strategy implementation plan has been developed in order to meet national timescale requirements. 7.2.4
Military and Veterans
An Armed Forces Champion has been identified to represent the LLR PCT Cluster and its constituent CCGs at the East Midlands Regional Armed Forces Forum. This forum oversees the implementation of the Ministry of Defence / NHS Transition protocol for those seriously injured in the course of their duty.
Health Visitors and Family Nurse Partnership
It is clear that health visiting numbers are a top priority for the Department of Health (DH) as set out in the document: “Health Visitor Implementation Plan 2011-2015 – A Call to Action”. The key aim of the Programme is to improve services and health outcomes in the early years for children, families and local communities, through expanding and strengthening the health visiting workforce, with an extra 4,200 Health Visitors in post nationally by April 2015. This will be achieved through: • Implementation of local Health Visitor Implementation Plan 2011/2015 – A Call to Action • Increase in the number of Health Visitor training places • Increase in the number of Health Visitors • Review of local current service structure • Becoming a national early implementer site - wave two
The Leicester Disablement Service Centre has an excellent understanding of veterans’ prosthetic needs and includes a consultant-led amputee prosthetics and rehabilitation service. They are also the prosthetics provider to the Defence Medical Service at Headley Court and are fully conversant with the Murrison report (‘Fighting Fit’ - a mental health plan for servicemen and veterans 2010) and the Military Covenant (2000).
ELR CCG is working with NHS Midlands and East to deliver the Government’s commitment to increase the number of health visitors to required levels by April 2015, and to maintain existing delivery and continue expansion of the Family Nurse Partnership Programme. A total of £210k development funding has been allocated to LPT for this purpose.
The Army is repatriating two regiments from Cyprus in 2012 and Germany in 2013 to the former RAF Cottesmore base in Rutland. This new Ministry of Defence base will become the home of up to three further regiments as part of the Army 2020 review and will bring significant potential health care needs, especially in maternity and child health care. ELR CCG has led a cross-party health committee with the army and Rutland County Council alongside all key stakeholders to make sure that the local healthcare system is prepared for and tailored to the arrival of the initial 2,000 soldiers and their dependents.
7.2.6
This review of the health needs of the incoming army population and the subsequent planning of service delivery will also help ELR CCG to plan services for the wider Rutland health community.
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7.2.5
Use of Telehealth and Telecare
ELR CCG and our partners are keen to explore the benefits of Telehealth and Telecare as part of the on-going transformation of local services. Both have been identified as high impact innovations in Innovation Health and Wealth (Department of Health 2011). The LLR PCT Cluster undertook a successful Telehealth respiratory care pilot at Glenfield Hospital. Through this we are working collaboratively with local authority partners in the city and counties to embed Telehealth and Telecare into joint work supporting independence, and avoiding or delaying hospital and institutional admissions.
Headline findings of the Department of Health’s Whole System Demonstrator Programme (2011) are now available and show that Telehealth can substantially reduce mortality, the need for admissions, the number of bed days and time spent in A&E. It also highlights that the key to success is to integrate these technologies into care and services. As further programme evidence becomes available it will be considered by the LLR Commissioning Collaborative Board to ensure integration into key service redesign work streams including diabetes, COPD, dementia, frail older people and integrated community teams. Taking this work forward, ELR CCG is keen to contribute to the Three Million Lives campaign (2011)1 , and will work closely with local authorities to maximise benefits for patients across health and social care. ELR CCG will be working with the Leicester, Leicestershire and Rutland (LLR) IM&T Delivery Board in reviewing progress with Telehealth across the LLR health community. Together, we will consider a wider and more strategic and co-ordinated approach to gain the maximum benefits possible from Telehealth and Assistive Technology initiatives. Just over £1m of social care transfer funds has been assigned to this programme. 7.2.7
Mental Health
See section 7.1.3 above 7.2.8
Patient Experience and Feedback
Improving patient experience and using patient feedback is a theme that runs throughout the NHS Operating Framework. It is also a SHA ambition and is supported by the NHS Constitution. ELR CCG will maintain a focus on improving patient experience and collating evidence and feedback to influence the commissioning and contractual process. The LLR PCT Cluster will also develop a Patient Revolution Action Plan for 2012/13, along with a timetable of system activities and milestones for implementation.
The LLR PCT Cluster Director of Nursing is the lead working with colleagues to produce and implement an agreed action plan. As part of the implementation plan all providers will be required to ask the ‘net promoter’2 question in all patient surveys from April 2012/13, with subsequent scores in patient survey reports expected to demonstrate a continuous improvement. ELR CCG, initially through the LLR PCT Cluster, will work with provider colleagues to ensure the realisation of the SHA Cluster ambition for all acute organisations to demonstrate more than 10% improvement on scores by March 2013 (or top quartile improvement). ELR CCG will not only promote innovative ways to undertake real-time patient surveys, including the use of web based tools, but will also build on existing good practice by utilising evidence from national patient surveys. As of 1 April 2012 all acute hospitals now have mechanisms in place for obtaining real-time patient feedback, and demonstrate commitment to improving patient experience during 2012/13. The information provided from real time data capture will be the subject of discussion within the contract monitoring process to ensure that sufficient emphasis is given to rectify any negative feedback, but also to promote good practice and share positive feedback directly to staff at a clinical and departmental level. The CCG has set up processes as part of our governance arrangements to ensure that the patient’s voice is central to the activities of the CCG. Monthly reports providing a high-level summary of engagement activity, patient experience, practice and stakeholder feedback are presented to the Quality and Governance Sub-group of the ELR CCG Board. These reports are in turn reflected in the monthly minutes submitted to the Governing Body.
1
At least three million people with Long-Term Conditions and/or social care needs could benefit from using Telehealth and Telecare. To achieve this level of change the Department of Health is planning to work with industry, the NHS, social care and professional partners in collaboration with a difference, the “Three Million Lives” campaign.
2 The Net Promoter Score (NPS) - A standard net promoter question is 'How likely it is that you would recommend our company to a friend or colleague?' and respondents indicate this likelihood on a 10-point rating scale. Those scoring services with a 9 or 10 are promoters, those scoring 0-6 are detractors and those between 7-8 are passively satisfied or neutral. The NPS is the difference between the percentages of users who would recommend your services minus the percentage of those who would not. A score of 75% or above is considered quite high.
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Quarterly reports on patient experience, engagement and feedback are received by the ELR CCG Board for information and action as appropriate. Patient experience and feedback reports and/or summaries will also be circulated to relevant CCG staff to ensure that intelligence and insight about patient experience is incorporated in the everyday business of the CCG. 7.2.9
NHS 111
The NHS 111 initiative will result in a freephone number for patients to call 24 hours a day, 7 days a week, 365 days of the year to respond to their non-emergency healthcare needs. It will be operated by highly trained advisers and supported by experienced clinicians, who will assess the caller’s needs and determine the most appropriate course of action. The service will be supported by an electronic Directory of Services (eDoS), NHS pathways triage system and a capacity management system. The project is being designed in conjunction with all LLR CCGs to take into account local pathway developments, clinically-led initiatives and desired end points that include ensuring patients are seen in the right place, first time across the LLR urgent care system ELR CCG, in collaboration with the LLR PCT Cluster, has opted to undertake a local 111 procurement parallel to (but independent of) the regional procurement process. This will ensure a robust and locally driven service, tailored to the needs of the LLR population. A locally-led pilot will commence in August 2012 and last until March 2014, at which point the chosen provider will take over. 7.2.10 Travellers Historically, there have been inequalities in targeted health care service for the 1,400 members of the travelling community within the East Leicestershire and Rutland area. There has been a successful service operating in South Leicestershire, which covers approximately 400 travellers. The learning from this is being used as the basis for a wider service, to be rolled out in 2012 in conjunction with the county and district councils. ELR CCG has prioritised significant investment to tailor a service to help reduce health inequalities amongst this section of the population. We are currently working with public health to assess health needs and current provision.
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A Local Enhanced Service will be introduced to underpin improvements in access. This year we have added a recurrent £100k to the existing £50k fund to address health inequalities within the travelling community. 7.2.11 Compliance with the Equality Act (Equality Delivery System) Delivering Equality and Diversity for the CCG has been set out in our comprehensive Equality and Diversity Strategy (2012-15) and its supporting delivery plan. We have agreed our equality objectives in line with the Equalities Act (2010) and the LLR PCT Cluster. We have made a commitment to use the Equality Delivery System as the audit/performance tool of choice to ascertain robust and meaningful knowledge that will support our ambitions for effective equality and diversity practice throughout the CCG. This will provide us with real-time data to deliver effective commissioning to our patients, working in collaboration with our partners. We have also set aside a statement of intent in relation to our Equality and Diversity ambitions, and these have been incorporated into our Equality and Diversity Strategy. A key focus of our strategy is that our Accountable Officer is the equalities champion for the promotion of equality and diversity within the organisation. We have agreed that our providers and our policies are bound by the duties placed upon us as a public sector organisation with due regard to the protected characteristics as set out in the Equality Act (2010). This means that our community engagement plan; OD plan; and commissioning plan conjoin to deliver and determine best equality and diversity practice. There are a number of examples which demonstrate how, based on the JSNA and specific needs assessments, we are commissioning and targeting activity at CCG level that will deliver against our equality objectives. These include Long-Term Conditions programmes for diabetes, COPD, and end of life care;work streams linked to frail older people and maternity service redesign; and initiatives targeted at specific communities such as travellers, and geographical areas with higher levels of deprivation. All proposals for service developments are subject to comprehensive Equality Impact Assessments which include ‘due regard’.
7.3 Delivery of LLR QIPP Programmes The LLR health system has a track record of working collectively within an agreed financial envelope. The two PCTs forming the LLR Cluster are going into 2012/13 with healthy underlying surpluses. In addition, the 2% transformation funding and local authority reablement funding will further pump prime system change. ELR CCG QIPP (Quality, Innovation, Productivity and Prevention) programmes are forecast to deliver a total of just under £5.8 million in 2012/13 in the following areas: Our approach to delivering our QIPP target is to integrate the delivery of QIPP outcomes into relevant work stream areas. In this way, the focus on reducing costs sits directly alongside delivering improvements in quality. QIPP targets are an integral part of every programme’s key performance indicators, against which the programme team is held to account. For example, the QIPP deliverable for Right Care sits within the programme for Right Care (see section 3.5.3); for Prescribing, see section 3.4; and for mental health, see section 7.2.7.
A more detailed table outlining QIPP programmes and their respective savings can be found in Appendix 8. Achieving these savings is critical to the balancing of our financial plan for 2012/13, which is attached in Appendix 7. Appendix 9 outlines the forecast QIPP savings plan from 2013/14 to 2015/16 based on current financial planning assumptions. The LLR approach to QIPP is to be clear about pathway and service transformation, then to reflect this in contracts with, and targets for individual provider organisations. Opportunities for whole-system pieces of work are then assessed. All QIPP priorities are subject to a quality impact assessment to identify both benefits and risks to the quality of patient care. Quality indicators are in place to enable the monitoring of provider performance against QIPP plans. This ensures early signals of deterioration in the quality of care as a result of provider cost improvement plans (CIPs).
QIPP Description Urgent Care - LLR Work Stream and Clinical Variation Right Care - LLR Work Stream Out-patients attendance - Clinical Variation Peer Review IT Solution to Care Pathway OOC Urgent Care Reductions Integrated Care Prescribing Prescribing - Cat M Drugs Capacity & Assets Facilities Management Continuing Healthcare Joint Commissioning Mental Health Total QIPP
£'s 776,000 731,562 221,000 200,000 100,000 975,000 1,000,000 700,000 184,480 184,480 235,440 461,200 £5,769,162
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7.4 SHA Ambitions The majority of patient contacts, access, co-ordination and continuity of care is provided within primary care. However, quality and safety can be variable and there is currently no single defining set of measures for quality in primary care. In order to address this, the SHA has agreed a number of priority areas in which to deliver significant improvements in quality and safety in primary care within 2012/13. • The elimination of avoidable grade 2, 3 and 4 pressure ulcers by December 2012 • ‘Making Every Contact Count’ • Quality and safety in Primary Care • Ensuring radically strengthened local government partnerships • Creating a revolution in patients and customer experience 7.4.1
Pressure Ulcers – The Elimination of Avoidable Grade 2, 3 And 4 Pressure Ulcers by December 2012
A pressure ulcer can often be a reflection of the quality of overall nursing care. Therefore, realising the ambition of eliminating avoidable pressure ulcers will be an indicator of the level of nursing care across a range of areas, such as hydration and nutrition. The LLR PCT Cluster Director of Quality has been charged with leading the realisation of this ambition. Led for CCGs by the ELR CCG Chief Nurse and Quality Officer, we will ensure the elimination of avoidable pressure ulcers grade 2, 3 and 4 by the end of December 2012. We are adopting a task force approach to this programme, with sign up from all CCGs and major providers. The aim will be achieved aided by regular monitoring information, embedded in the contractual process to emphasise its importance. The contractual process will also include the treatment and prevention strategies adopted by provider organisations. For some providers the increase in data recording systems will be significant and will require additional resources to achieve the baseline target of 100% of patients assessed in all areas, followed by a continuous improvement in the reduction of recorded avoidable pressure ulcers.
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This data will be provided via the SHA’s NHS Safety Thermometer harm measurement instrument, which has now been implemented in all provider contracts for 2012/13. The LLR PCT Cluster will launch supporting documentation, such as ‘Pressure Ulcer Assessment and Treatment’ bundles and ‘Good Practice for Nutrition and Hydration’. The Cluster will also seek assurance from all providers, via evidence within the contractual process, that they have an identified Board Champion and a Clinical Lead, and that regular reports are received at their public Boards, outlining implementation and remedial actions, as necessary. The LLR PCT Cluster will ensure that best practice and ‘lessons learnt’ are shared effectively via the established regular formal and informal communication systems between providers and commissioners. This will include regular reporting on achievement of this ambition in LLR PCT Cluster public Board reports. 7.4.2
Making Every Contact Count
Public health teams from Leicester, Leicestershire and Rutland are working together to support the implementation of the SHA ambition of Making Every Contact Count (MECC). MECC is a long-term strategy that aims to help us create a healthier population and reduce NHS costs. MECC puts the prevention of health problems and disease at the heart of every NHS contact. The aim is to use each contact with a patient to offer appropriate brief advice on staying healthy. The LLR PCT Cluster has undertaken local initiatives to provide healthy lifestyle advice via frontline NHS staff. This includes enabling GP brief interventions for alcohol, alcohol liaison workers within the acute trust and brief interventions to provide smoking cessation advice. This is underpinned by guidance such as alcohol identification and brief advice, and NICE Guidance on smoking cessation. Recent local experience of regional QIPP and CQUIN schemes for stop smoking through acute trusts has demonstrated that a higher-level approach is the most effective way of achieving large scale and coherent system change. The important role for the CCGs is to ensure coordinated local movement on the MECC agenda that anticipates the higher-level developments through Health Education England. The NHS Midlands and East draft MECC CQUIN3 (whether for local or regional implementation) provides a
Supporting the SHA Making Every Contact Count Ambition - DRAFT CQUIN. February 2012
basis for embedding MECC in contracts and it is ELR CCG’s intention that MECC will be part of contractual arrangements with current providers. As part of its commitment to MECC, ELR CCG will: • Work with the LLR PCT Cluster, secure engagement and a commitment from all NHS organisations commissioned by them to the ambition and achievement of agreed metrics • Agree a work programme devised by the LLR PCT Cluster to develop and implement health improvement training for staff, data collection and reporting mechanisms across NHS organisations, with a potential initial focus on smoking and alcohol • Approve a scheme of formative and summative evaluation and agree plans for further roll-out, including other non-NHS organisations in conjunction with the LLR PCT Cluster • As commissioners of NHS Stop Smoking Services, co-ordinate data collection on sources of referral and ensure that NHS organisations develop internal data collection mechanisms. Timetable for implementation: • local model developed by July 2012 • training programme implemented from August 2012 • recording mechanisms in place by September 2012 • monitoring and evaluation in place and undertaken from September 2012 • review and plans for further roll-out by January 2013. 7.4.3
Quality and Safety In Primary Care
This ambition aims to ensure that each CCG works with member practices to create a definitive set of measures to improve the standard of primary care and prescribing practice.
successful in improving quality through alignment to CCG priorities such as diabetes, COPD, dementia and mental health and the retention of a strong evidence base. This will ensure validity and ownership by our clinicians. The Quality Indicators are being shared with member practices to inform the final framework. • A work programme has been established associated with reduction in cephalosporin and quinolone prescribing through our targeted approach contained within QOF indicators for Medicines Management 6 and 10 • Safety of care for patients receiving warfarin is being improved through a Local Enhanced Service for INR monitoring. • We are committed to the delivery of a new local pathway for diabetes (see section 6.3.2) which will improve the quality of care for those managing diabetes 7.4.4
Quality Governance
ELR CCG has developed a GP Performance Framework based on peer review. The resulting Primary Care Quality Indicators (see Appendix 6) reflect SHA ambitions for primary care alongside other local priorities such as Long-Term Conditions In terms of monitoring and assuring quality for all SHA Ambitions, ELR CCG has established a Quality and Governance Committee, which is a sub-committee of the Board. Key elements within the regional framework include: • an established practice of peer review within primary care which allows for clinical debate and challenge (ambition 5) • existing transformation schemes should target education and improved management of patients with diabetes (ambition 4)
ELR CCG has a number of work programmes in primary care, many of which link to our QIPP programmes, and reflect the Midlands and East SHA Ambitions.
• oversight of the prescribing of quinolones and cephalosporin’s through the Quality and Governance sub-group (ambition 2)
• We are currently developing Primary Care Quality Indicators for consultation with localities and member practices; this includes quantitative and qualitative measures associated with patient safety and experience which will contribute to ensuring that we are
• clear detailed plans to support the reduction of Clostridium Difficile (ambition 2)
• established high quality INR monitoring services (ambition 3)
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7.4.5
Local Government Partnerships
The SHA ambitions set out the aim of ensuring radically strengthened partnerships between the NHS and local government. ELR CCG is committed to on-going partnerships and collaboration with local authorities. In our first year of operation we have focused on ensuring a firm foundation for the future with our partners at Leicestershire County Council and Rutland County Council. We will continue to develop and strengthen our relationships with Local Authorities, and plans include: • The Integrated Commissioning Board comprises members from across the County Councils and local NHS, and is chaired by a CCG Managing director. This Board has been established to oversee the delivery of areas of joint commissioning, such as mental health and learning disabilities, and areas of Section 256 transfers. It ensures alignment of social care and reablement investment to support the avoidance of inappropriate admissions and to reduce readmissions. ELR CCG leads a number of priority areas on behalf of partners, such as the implementation of the carers’ strategy, which is supported by £500k from social care transfer funding. • The development of joint commissioning arrangements and pooled budgets, for example, Learning Disabilities, and shared targeted initiatives to improve the quality of health and wellbeing for disadvantaged communities and groups. • Partnership working to address common areas of concern, including safeguarding and the development of children, young people and families services (see sections 7.5.1 and 7.5.5) • Continued collaboration at priority workstream level e.g. emergency care projects within the ECN portfolio, where clinical leads will continue to represent ELR CCG and, through clinical leadership, ensure the delivery of plans within both East Leicestershire and Rutland, and more widely across LLR. • Joint recurrent investment of £900k into a three-year programme to deliver integrated models of care within the community, with the aim of reducing acute admissions through improved self-care management and preventative care. Led by ELR CCG,
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the programme involves clinicians and professionals from across social care, general practice, community care, and mental health. • Continued involvement through leadership representation on the two Health and Wellbeing Boards that have been established across for Leicestershire, and Rutland • Local government membership on the ELR CCG Transformational Steering Group. In addition, an on-going programme of quarterly meetings is being established to ensure opportunities for two-way dialogue between the CCG and our local MPs. This will be supported by regular communication and engagement with MPs and local councillors through stakeholder bulletins and key project updates. More information on partnership working is detailed in Section 10. 7.4.6
Create a Revolution in Patient and Customer Experience
This SHA aim considers the innovative use of information and other feedback to improve the experience of patients, carers and others. Aligned to this, ELR CCG has an ambition to achieve top quartile national performance in patient experience and outcomes. Together with colleagues in the PCT Cluster and other LLR CCGs, we will actively promote innovative ways to undertake real-time patient surveys, including the use of web-based tools. We will also build on existing good practice by utilising the evidence within the national patient surveys. Lead nurses from across the PCT Cluster, CCGs, UHL and LPT have agreed an action plan, which has since been approved by the ELR CCG Board. A key area of focus has been agreed across all CCGs in relation to obtaining patient feedback. This involves to the roll out of the ‘In Your Shoes’ project in place in LPT to a specific patient group. This will enable clinicians, staff and others to understand patient and carer experience from their perspective, and to highlight key areas for improvement and development. This will greatly inform and enhance clinical and Board decision-making. See also section 7.2.8.
7.5 Children, Young People and Families With a quarter of ELR CCG’s population comprising children and young people, it is essential that the CCG addresses the issues outlined in the following sub-sections that are facing children’s services over the next 12 months and beyond. 7.5.1
Partnership Working
The CCG has an active role on the Children’s Trust Boards in both Leicestershire County, and in Rutland. Both Boards have produced Joint Children and Young Peoples Strategic Needs Assessments, which identify key areas where partnership working is essential. All agencies work together to address these areas, which are namely the troubled families’ agenda, safeguarding, and carers. Troubled families Troubled families have multiple and complex needs and therefore require significant support from the public and voluntary sectors. Partners have agreed the twin aims of improving outcomes for these families and their children, and of reducing the associated cost to the public sector. Safeguarding We will work in partnership with Local Authorities to address issues identified through recent safeguarding and Looked after Children and Young Peoples inspections. These include the need to provide training for GPs and ensure access to Child and Adolescent Mental Health Services (CAMHS). ELR CCG’s Chief Nurse and Quality Officer is the designated Board lead for Adult and Children’s Safeguarding and as such represents ELR CCG at the Leicestershire County and Rutland Local Safeguarding Children’s Board, and the Safeguarding Adult Board. Carers There is a growing number of carers, both adults and children, for whom we need to develop services and provide support. We will continue to collaborate with local authorities and the voluntary sector to deliver a joint carers strategy. 7.5.2
Maternity - Improve 12 Week Access and Pathways within Maternity Services
All women should have access to maternity services for a full health and social care assessment of needs, risks and choices by 12 weeks and 6 days of their pregnancy.
Accessing these services during this time ensures that they are able to experience the full benefit of personalised maternity care, improve their outcomes, and enjoy a better experience for both mother and baby. Across ELR CCG, achievement of the ‘12 week access to maternity services’ has been an on-going challenge. Nationally it is acknowledged that pockets of demographic and socio-economic complexity impact on early access. This remains an important priority in East Leicestershire and Rutland, and the CCG is committed to improving performance. Led by West Leicestershire CCG on behalf of all three LLR CCGs, an action plan has been agreed to cover the following: • Delivering services differently in a more targeted way to specific groups, for example, through the involvement of local religious leaders • Undertaking a focused piece of work looking at providing intensive input to specific areas that were highlighted as particular reasons for pregnant women not booking before 12 weeks and 6 days of their pregnancy • Developing a local maternity focused website which will support a single point of access. • Promotion of the wide range of maternity services available to women in ELR CCG and the benefits of early access using various methods of communication that are tailored to individual groups Over the last three years, significant work has been carried out to modernise and ensure safe and sustainable maternity and neonatal services. This has resulted in significant investment for midwifery, neonatal and other obstetric services, and the launch of a one-stop-shop for early pregnancy assessment (EPAU). Over the next 12 months the CCG will continue to monitor the success of the EPAU and will seek to improve 12 week access 7.5.3
Healthy Child Programme
The Government recognises that children and young people’s public health nurses (health visitor and school nurses) are fundamental to ensuring better health and wellbeing.
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Their unique skills in assessing health needs at both population and community level, and family and individual child level, make them central players in ensuring that children develop well and that parents, carers, families and communities achieve optimum health outcomes. Plans for health visiting and family nurse partnerships are detailed in section 7.2.5. 7.5.4
Mental Health Services for Children and Young People
Child and Adolescent Mental Health Services (CAMHS) continue to be a high priority locally, as mental health problems in children are associated with educational failure, family disruption, disability, offending and antisocial behaviour, placing demands on health, social services, schools and the youth justice system. In order to improve children’s mental health services ELR CCG will: • Implement a pilot for Improving Access to Psychological Therapies (IAPT) for children and adolescents. This aims to increase access to, and use of, evidence-based therapeutic interventions to tackle problems of depression, anxiety and conduct disorder • Measure and tackle waiting times for assessment and treatment for services, including a review of pathways • Support the development of a cost-effective model for paediatric psychology and liaison across Leicester, Leicestershire and Rutland • Explore the options around pathways for children and young people with autism, including issues relating to sensory integration Following the evaluation of the IAPT pilot and the outcomes from the work highlighted above, any additional investment required will form part of the 2012/13 investment process. As such it will be subject to a prioritisation process along with all other proposed investments. 7.5.5
Children and Young People with Disability and Long-Term Conditions
Due to the changing demographics of children and young people with complex health needs, there is an increased demand for health service provision. These children are often young in age and require a continuing service for a number of years. The related pressure on these families can result in inappropriate admissions to hospital, or a breakdown in family circumstances.
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ELR CCG plans to review the following pathways to ensure that they are meeting the growing needs of the population. This will require joint work with the local authority. Short Breaks It is acknowledged that the population of children and young people with life limiting / life threatening conditions is increasing continually owing to advances in medical technology. This factor has an on-going impact on the capacity required from a sustainable short break service. The CCG will prioritise a review of the current service to determine future capacity requirements, and this will be looked at in conjunction with the personalisation agenda. Neurology The paediatric neurology service has been under significant pressure since early 2011. Commissioners have agreed that work will be progressed to develop multi-agency pathways across primary, community and acute care to avoid further recurrence of these issues. This work will identify new commissioning pathways, and will potentially have an impact on contracting and current investment arrangements. Equipment There are significant issues with the current processes in relation to supply of equipment for children and young people requiring advanced medical technology, such as ventilators, cough assist machines, humidifiers and saturation monitors. The CCG will review the current process to develop an options appraisal, which will determine how children’s medical equipment will be commissioned in future years. 7.5.6
Non Elective Care
As already identified in section 6.3.5, work is underway to look at urgent care pathways. As part of this there are specific pieces of work in relation to the children and young people’s pathway. Children’s non-elective hospital admissions have increased steadily over the last 10 years, both locally and nationally. Managing the increase in demand has required different approaches, including the introduction of a Children’s Admission Unit (CAU) as well as a dedicated Children’s Accident and Emergency Department (CED). This in turn has caused some duplication in clinical and other resources and, as such, a related increase in commissioning spend.
To reduce the numbers of attendances/admissions, and ensure effective delivery of children’s acute care and best use of clinical resources, a wholesystem change has been agreed. This involves a single front door with senior decision makers and a short-stay assessment area. This change is scheduled to be implemented during 2012/13.
• Establishment of Quality and Governance, and Finance and Performance sub-committees, both chaired by an independent lay member
7.5.7
• CCG Board meetings held in public from April 2012
Complex Care
Some children and young people require services above and beyond those currently commissioned within the core service provision. This is owing to the nature of their complex needs. Packages of care for these individuals are jointly financed through health, social care and education, and are known to be costly. The Complex Care Panel will focus on reviewing the current funding pathways in line with the Responsible Commissioner and Personalisation agendas.
7.6 Authorisation The next stage of development for ELR CCG is the move towards full accountability and responsibility across the broader commissioning agenda through the authorisation process. We have opted to participate in the first wave of applicants for authorisation. Our review will commence on 2nd July 2012 with the submission of key documents, followed by a site visit in September 2012, with the final decision on authorisation made thereafter. In readiness for authorisation, we have established an Integrated Governance Framework, which includes our Board Assurance Framework, to provide assurance that decisions about patient services and use of public money are made in an open and transparent manner. The integrated governance framework includes: • Our Constitution • Involvement of independent lay members through our Board membership • Our Risk Management Strategy and Policy • Our Equality and Diversity Strategy and Delivery Plan • Our Communication and Involvement Strategy • Our Scheme of Delegation and Memorandum of Understanding • Our Standing Financial Instructions • Our Joint Commissioning Strategy
• Establishment of the Audit Committee in April 2012 • Establishment of the Contracting and Procurement Committee in April 2012
• On-going recruitment of the senior management team to maintain strong and effective commissioning whilst working towards accreditation; these include our Chief Operating Officer; Chief Finance Officer; Chief Nurse and Quality Officer; Chief Strategy and Planning Officer and Chief Corporate Affairs Officer. • The appointment of our Accountable Officer, who is also our equality champion. Following authorisation the CCG will discharge all of its functions through the above processes and systems. These arrangements will also be reflected in all future policy design to ensure transparency, probity and assurance. Other elements either in place or underway include the following: • Development of a shared approach to the main LLR provider contracts through a tripartite agreement with the other two CCGs within LLR • Creation of an organisational form that identifies: - What will be delivered by ELR CCG - What will be delivered collaboratively across the LLR PCT Cluster - The process in place to finalise outsourcing requirements, pending market developments • Shadow Board members in place, with the recruitment of the secondary care clinician in progress • Running cost of CCG identified and agreed • Structure in place to manage delegated commissioning budgets from April 2013 with the expectation that all relevant budgets will be delegated to CCGs from 1 April 2012 • Active participant in the shadow Health and Wellbeing Board within both Leicestershire County, and Rutland County • Working towards the finalising of commissioning support contracts
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8
Provider Development
We recognise that to enable excellent healthcare services for local people in the long-term, developing the local provider market and the providers within it is essential. This section considers the specific development requirements of our local provider landscape, and outlines our plans to meet them. 8.1 Community Hospital Developments ELR CCG is committed to making effective use of health economy assets and to developing end-toend services in the community. This will enable more patients to be treated closer to home where it is safe and appropriate to do so. Development of services provided in community hospitals is a major factor in delivering this commitment. ELR CCG will build on the community hospital developments in 2012/13 outlined in Section 3.2. A key priority for 2012/13 is the redesign and procurement of elective care services to include out-patients, diagnostics and day case surgery with the aim of providing care closer to home, and improving patient choice and experience. The current contract for elective care services is with Derbyshire Community Health Services and runs until 31 March 2013. ELR CCG plans to proceed to procurement for the East Leicestershire and Rutland elective care service bundle with the aim of mobilising service delivery from 1 April 2013. The strategic objectives of the project, reflecting the overall objectives of ELR CCG, are to: • Improve health outcomes in Long-Term Conditions through use of innovation and technology (including Telehealth) • Make productive use of health economy assets • ‘Make every contact count’ • Develop end-to-end services in the community • Address the health needs of the population • Develop services to deal with the increasing older population in ELR CCG • Transformation from non-planned to planned care
• Moving activity to a lower cost setting where it is appropriate and clinically safe to do so • Promote compliance with LLR agreed care pathways • Improve access for patients e.g. elderly patients • Reduce inequalities ELR CCG is also working collaboratively with West Leicestershire CCG to model the use of inpatient beds across Leicestershire and Rutland. This is with a view to optimising the use of resources whilst maintaining a focus on the quality of patient care. This includes working with Leicestershire Partnership Trust to facilitate earlier discharge to care at home, to be enabled through enhanced community care. ELR CCG’s approach of integrating community care through wide stakeholder involvement and clinical ‘buy-in’ will improve clinical outcomes and patient experience.
8.2 Review of Minor Injury Units ELR CCG has a small unplanned care provision in our area, delivered through Minor Injury Units (MIUs). Currently provided by both GPs, and Leicestershire Partnership Trust, these are: • Oakham Medical Practice for Oakham • Latham House MP for Melton • Market Harborough Medical Centre for Market Harborough • Fielding Palmer Hospital for Lutterworth The contracts are due for renewal in March 2013. In order to commission future services that meet local needs, ELR CCG is undertaking a review of MIUs.
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The purpose of the review is to determine the most effective and efficient minor injuries service to meet the needs of the population of East Leicestershire and Rutland. The review will be led by a clinician who is not responsible for delivering the MIU services currently available, thus avoiding any issues of conflict of interest. The MIU project team is responsible for the review of the current service, and for design and delivery of a new model of care that is fit for an integrated health care system. The future service will be fully integrated with other elements of the Urgent Care System across Leicester, Leicestershire and Rutland. The review process will be supported by a robust communications and engagement process.
8.3 Extension of Patient Choice of Community Provider (Any Qualified Provider Approach) From 2013/14 onwards it will be for commissioners to decide those service areas for which patient choice of provider should be extended locally. ELR CCG fully supports the Government’s commitment to offering increased choice and control to patients and to extending patient choice of provider in community services. Eight services were identified nationally for consideration. The three CCG’s within LLR, together with other partner organisations, identified three service areas where choice needed to be extended across LLR: • Musculo-skeletal services for back and neck pain • Community based Diagnostics • Continence Services (adults only) These areas were chosen to reflect the greatest gaps in local health provision, the greatest opportunity for increasing competition to drive up quality and access, and the greatest local health needs, based on JSNA findings, local knowledge of member practices and clinicians, and feedback from patients and carers.
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ELR CCG is leading the implementation of Any Qualified Provider on behalf of the LLR PCT Cluster with input from all three CCGs. There has been good engagement with clinical CCG leads on the agreed service areas. As a result, the national service specifications have been amended to reflect local need, and have been approved by the LLR Commissioning Collaborative Board. Patients will be offered a choice of provider in all three of the locally selected service areas from September 2012.
8.4 Leicestershire Partnership Trust (LPT) Over the past year LPT has worked with local CCGs on developing new relationships to enhance relationships and commissioning arrangements, to ensure opportunities for strong clinical engagement, and to ensure broad alignment between local commissioning intentions. LPT’s integrated business plan reflects key service development initiatives, such as dementia, frail older people and the redesign of the acute mental health care pathway (see section 7.1.3). Early in 2011, LPT decided to postpone their foundation trust authorisation process to concentrate on the full integration and transformation of their mental health and learning disability services (annual income of around £140m), together with community health services (annual income £120m) which were transferred to them on 1 April 2011 as part of the Transforming Community Services programme. They have agreed with Monitor that they will operate for a full year as an integrated organisation and then reapply at the end of June 2012, aiming for authorisation by the end of 2012. Securing their application is key to organisational reputation, market share, and the achievement of greater financial flexibilities for both the organisation and the wider health economy in terms of access to funds for capital investment. ELR CCG recognises the importance of the achievement of NHS Foundation Trust status for LPT and the wider health economy, and will actively support the Trust in its application.
8.5 University Hospitals of Leicester NHS Trust (UHL) Financial challenges and difficulties with Accident and Emergency (A&E) performance have resulted in UHL deferring their initial foundation trust application. The original risks stated in the tripartite formal agreement between LLR commissioners, UHL and the SHA are A&E performance, the nature of the contract with commissioners, and liquidity. ELR CCG is currently working collaboratively with UHL to improve quality and patient experience, whilst continuing to focus on overcoming the recognised challenges. Recent intervention by the SHA resulted in additional goals for the Trust to achieve financial balance both in 2011/12, and recurrently. In addition it was to develop a clear service strategy to demonstrate long-term clinical and financial sustainability, the latter being part of the LLR collaborative agreement to work together to secure service redesign and reconfiguration. The Trust was involved in a meeting with Monitor and the SHA on 28 January 2012, and discussions took place with regard to a revised application and timelines. ELR CCG is working closely with UHL to develop pathways that will deliver the CCG priorities whilst ensuring ‘value for money’ for all partners and improved outcomes for patients.
8.6 Best Use of Local Healthcare Estate Together with Leicester City and West Leicestershire CCGs, we collectively recognise that the cornerstone of a sustainable LLR system will be reconfigured services and sites operating at a lower cost base, without detriment to quality of care. We are also committed to enabling care closer to home, where it is safe and practicable to do so, through the development of community and primary care services. We are therefore participating in a review of local NHS estate to ensure that it is being used in the best way possible. The LLR reconfiguration programme focuses on delivery of the following activities: • Integrated care through the establishment of community hubs Rationalisation of the community estate informed by demographic need. Better utilisation of the remaining community hubs to improve key patient pathways including frail older people, outpatient and day case • Outpatients and homecare Significant shifts in outpatient attendances out of acute and into community settings where it is feasible and safe to do so thereby delivering more care closer to home whilst improving occupancy of fixed community assets • Integrated community, health and social care Developing and implementing integrated care pathways particularly with particular focus on care of older people, intermediate care and re-ablement • Acute care consolidation As a consequence of the above, consolidation of complex care onto two acute sites and fundamentally redesign the third site to provide a City centre of excellence for planned and intermediate care, focusing on services that cannot be provided from within City-based community facilities • Knowledge transfer and self-care Critical to all of the above is the need for knowledge transfer between clinicians, doctor and patient and local people
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9
Draft Commissioning Intentions for 2013/14
This section outlines our plan to develop and finalise ELR CCG’s commissioning intentions for 2013/14. ELR CCG’s commissioning intentions will inform both current and new providers, and other stakeholders of: • Changes in services or pathways that we wish to commission for 2013/14 • Work that we will undertake during the remainder of 2012/13 and 2013/14 to underpin negotiated changes to services in subsequent years • Any services within existing contracts for which we intend to give notice. This is in accordance with contract terms, and in advance of undertaking a competitive procurement process or disinvesting in the service Commissioning intentions are usually developed as part of the NHS Planning Cycle which will take place in the Autumn/Winter of 2012 following central publication of guidance for 2013/14. However, we are required to demonstrate development of draft commissioning intentions to support our application for authorisation as a statutory body from April 2013. The commissioning intentions set out within this section should therefore be considered an early draft. Whilst these are based on previous engagement and consultation, further engagement with clinicians, patients and carers, partners and others will be required to develop them further. A timetable for this process is set out below.
9.1 Developing Commissioning Intentions Commissioning intentions are informed by and take account of any guidance published by the Department of Health in the Annual Planning Framework. Until such time as this is published for 2013/14, draft commissioning intentions cannot reflect such guidance. Nevertheless, some assumptions with regard to existing priorities and guidance can be made at this time. These are subject to any changes mandated by the NHS Commissioning Board on publication of the 2013/14 Planning Framework in the Autumn of 2012.
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Our commissioning intentions reflect ELR CCG’s vision and strategic priorities as identified in section 4.2. They will also reflect the various national and regional guidance and ambitions as set out within section 7.
9.2 Timetable for 2013/14 Planning Cycle The timetable below provides an indicative timescale for the development of finalised commissioning intentions. This is subject to publication of the NHS Planning Framework for 2013/14.
June 2012
Development of ELR CCG Draft Commissioning Intentions for 2013/14
July to December 2012
Consultation with member practices and stakeholders on Draft Commissioning Intentions
November to December 2012
Publication of 2013/14 Planning Framework
November to December 2012 November to December 2012 January 2012 to March 2013
Update / refresh ELR CCG Commissioning Intentions further to publication of 2013/14 Planning Framework Finalised Commissioning Intentions to Providers Agree contracts with providers in line with Commissioning Intentions
9.3 ELR CCG Commissioning Principles Commissioning and contracting discussions with all providers will be underpinned by ELR CCG’s commissioning principles: (i) The shared objective of the health and social
care economy in facing the current financial challenge is to transform the services we offer patients, to improve the quality and clinical effectiveness of services, delivering services in a lower cost setting where it is safe and appropriate to do so (ii) In order to achieve whole system financial
viability, LLR organisations will be required to collaborate to deliver their agreed service change responsibilities, including both disinvestments, and new investment to improve quality and effectiveness
c) Work in partnership with providers to identify new opportunities for delivery of QIPP (Quality, Innovation, Productivity and Prevention) objectives, where health outcomes can be improved whilst reducing costs for both commissioner and provider. d) Support providers to work collaboratively across health and social care to improve patient experience of seamless service delivery. e) Ensure all commissioned services will have agreed service specifications and outcome measures f) Work with all providers to ensure delivery against service specifications, indicative activity levels, quality standards, performance targets, standards and budgets.
(iii) All investment, disinvestment or change
proposals will be preceded by appropriate clinical engagement within and across the health community (iv) Added value must be demonstrated in all
current and prospective services within existing resource constraints. Existing services must demonstrate value for money and price must be aligned to cost of delivery (v) Only activity that has been authorised by
commissioners will be paid for; commissioners will not fund the consequences of changes that have not been formally agreed In undertaking its commissioning functions, ELR CCG will: a) Work with our population to identify health need and commission services from providers best placed to meet the needs of our patients and population. b) Commission services from providers who offer a safe and effective service; best value for money; and timely access to appropriate, quality services.
9.4 Draft Commissioning Intentions 2013/14 This Plan has articulated our strategic and operational aims for delivering better patient outcomes and experience, both within East Leicestershire and Rutland, and across the wider Leicester, Leicestershire and Rutland health and social care economy. Our draft commissioning intentions for 2013/14 reflect this, where some activities of work will be delivered specifically by ELR CCG, and others will be delivered collaboratively with commissioning partners across LLR and sometimes more widely. In terms of operational commissioning priorities, as defined by national and regional frameworks and ambitions, we have assumed that these will be largely similar to previous years. However, these are subject to change following publication of the NHS Operating Framework in Autumn 2012. Our commissioning intentions may also be revised to ensure closer alignment with the final Health and Wellbeing Strategies for both Leicestershire and Rutland, once these have been finalised later in the year.
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9.4.1
Shared Commissioning Intentions, LLR Section Reference
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Continue to deliver new/improved pathways of care for frail older people, including initiatives relating to end-of-life and care homes
6.3.4
The delivery of a new shared pathway for diabetes
6.3.2
The delivery of new dementia pathway and related initiatives
7.1.3
The delivery of the Right Care programme to reduce new to follow-up ratios, care closer to home, better use of clinical resource and estate, and encourage left shift of patient activity where appropriate
3.5.3
Improving emergency care, including reducing avoidable admissions to acute care, achievement of the 4-hour wait, and better detection and management of conditions in primary and community care
6.3.5
The introduction of a psychiatric liaison service within the Emergency Department from 9am to midnight, 7 days a week.
3.5.1
Implement pathway change initiatives to reduce the number of attendances and admissions and ensure the best use of clinical resources for children and young people
7.5.6
Implementation of the carers’ strategy (led by ELR CCG)
7.2.3
The reconfiguration of LLR healthcare estate as informed by the review to be completed in 2012/13
8.6
The implementation of new pathway for COPD
6.3.3
Redesign of the DVT service
5.1.1
Implementation of 2012/13 redesign of mental health pathways, including crisis resolution, improved choice, formulary and 28 day prescribing, single point of access, and personality disorder
5.1.1 & 7.1.3
Implementation of 2012/13 review recommendations re: adult community nursing, physiotherapy and intermediate care services and pathways (LPT)
5.1.1
Implementation of 2012/13 review of glaucoma, enhanced services and clinical peer review
5.1.1
Delivery of IM&T initiatives including electronic prescribing in UHL
6.3.6
Implementation of new care pathways (provider-specific)
5.1.1
Implementation of initiatives to secure the 18 week wait target
7.1.6
Increase of health visitors and implementation of family nurse partnership programme
7.2.5
Implementation of NHS 111
7.2.9
Quality initiatives to reduce pressure ulcers (led by ELR CCG)
7.4.1
Improvements in offender health
7.1.3
9.4.2
East Leicestershire and Rutland-specific Commissioning Intentions
Community and Primary Care
Section Reference
Full implementation of GP performance framework, including the primary care quality indicators
7.4.3
The delivery of training and education to GP practices in relation to Long-Term Conditions, including diabetes, cardiovascular disease, COPD and dementia
3.1, 3.3 & 6.3.1
Improve support for GPs to screen for and manage COPD and other respiratory conditions
6.3.3
Continue with LES for dementia to improve early diagnosis and on-going management
7.1.3
Increase of health checks to enable the early diagnosis and referral for Long-Term and other conditions, including cancer, dementia and CVD
3.5.5 & 7.1.6
The implementation of risk-profiling tools (subject to clinical recommendations following research and benchmarking)
5.2, 6.3.4, 6.3.7, 7.2.2
More efficient prescribing and the prescribing of cost-effective statins and other medicines to improve the management of Long-Term Conditions
3.4
Re-run cancer diagnosis audit to improve patient outcomes following more efficient pathways, from diagnosis to treatment
7.1.4
The implementation of the ELR integrated care pathway model
6.3.7
Targeted interventions in geographical areas with high levels of deprivation, and certain groups with known health inequalities, such as travellers and military families
7.1.2, 7.2.4, & 7.2.10
The implementation of any ELR recommendations following review of local healthcare estate
8.6
Implement a revised Local Enhanced Service (LES) for GP extended hours
3.5.4
Increase access to choose and book within general practice as part of the GP Performance Framework
3.5.4
Ensure the delivery of services procured via AQP, e.g. musculo-skeletal, continence and diagnostics
8.3
The implementation of recommendations resulting from the review of Minor Injury Units and the procurement of elective care services
8.1 & 8.2
The implementation of recommendations following the 2012/13 review of pathway to access diagnostics at community hospitals (Derbyshire Community Foundation Trust) – with West CCG
5.1.1 & 8.1
Investment into Telehealth and other assistive technologies
7.2.6
Delivery of ELR IM&T initiatives including GP system migrations and upgrades and on-line access to patient records
6.3.6
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Mental Health • Improve access to psychological therapies
7.1.3
• Improve physical healthcare of those with mental health to reduce excess mortality
7.1.3
• Improvements in services for children and young people at risk of developing mental health problems, CAMHS services, and IAPT for children and young people
7.1.3 & 7.5.4
Acute
Section Reference
• Implementation of age extension screening for bowel, lower GI and breast cancers
7.1.4
• The majority of work is being undertaken collaboratively within acute, but there will be implementation of local initiatives to support LLR-wide programmes. These are to be determined in 2012/13
5.1.1
Cross Cutting
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Section Reference
Section Reference
• Implement the patient revolution action plan
7.4.6
• Implement initiatives to ensure compliance with the Equality Delivery System in line with our E&D Strategy and Plan
7.2.11
• Implementation of child, young people and families initiatives to ensure safeguarding and appropriate levels of support
7.5
• Implement pathway improvements across paediatric neurology within primary care, community and acute
7.5.5
10 Partnership and Collaboration ELR CCG recognises the importance of collaborating with partners to deliver our strategic priorities and ultimately to improve experience and outcomes for patients and carers. We also recognise the important, wider role that we play in socio-economic terms, working with local authorities and councils, police and other emergency services, schools and universities, local people and other partners, to improve the quality of life for the local population. We are committed to working collaboratively with partners, in terms of both health and social care, and the wider socio-economic agenda. We have already established good working relationships with key partners, building on those already in place with our predecessors. This focus will continue with the development of collaborative agreements and working arrangements with other CCGs, local authorities and health and well-being boards, and others. This section sets out some of our key partners and our plans for strengthening links with them.
10.1
Health and Wellbeing Boards
ELR CCG is an active participant in the Health and Wellbeing Boards in Leicestershire and Rutland, with the Accountable Officer and Chief Operating Officer attending meetings bi-monthly (Leicestershire) and quarterly (Rutland). Through our involvement with the Boards, we have refined our own vision and priorities in order to align with, and complement the strategic intentions of other Health and Wellbeing members where appropriate. Closer working has also strengthened relationships between health and social care, and has facilitated integrated commissioning. 10.1.1 Leicestershire Shadow Health and Wellbeing Board Leicestershire’s Health and Wellbeing Board has been established with a commissioning-focused membership. This includes three county councillors; two district councillors; four CCG representatives; two LINks representatives; one LLR PCT Cluster representative and the Directors of Public Health, Adults and Communities and Children’s and Young People’s services.
It is a formal ‘early implementer’ and is actively engaged with the Department of Health’s programme of HWBB Accelerated Learning Sets, with the Director of Public Health leading one national learning set on improving the health of the population. A substructure has been established including the Staying Healthy Board, JSNA and Joint Health and Wellbeing Strategy Steering Board, Substance Misuse Board and Integrated Commissioning Board. Members of ELR CCG have been actively involved in each of these groups. Development sessions have been undertaken and a number of business meetings held. Interim priorities for 2011/12 have been established from existing strategies, commissioning intentions have been agreed and an Outcome Framework for these priorities is in development. The JSNA refresh is in progress, as previously planned, with the production of a Joint Health and Wellbeing Strategy due for completion in Autumn 2012. 10.1.2 Rutland Shadow Health and Wellbeing Board Although not an official ‘early implementer’, Rutland has made good progress in establishing and developing its shadow Board. Formal membership of the Board includes the Director of Public Health and both GP and managerial representation from ELR CCG. Broader PCT representation has been provided by the LLR PCT Cluster Chair, a consultant in public health and a partner NHS Trust director supporting Leicestershire County Council (LCC). ELR CCG’s chief operating officer and public health consultant programme director have played a key role in the Board development group, with public health leading specific work to agree the strategic priorities and supporting structure for the Board, and to develop action plans and an overarching outcomes framework.
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As part of the supporting structure, the public health consultant chairs the Staying Healthy Rutland sub-group that will deliver the Board priority to improve health and reduce health inequalities in Rutland. This group includes members of ELR CCG.
10.2
Local Authorities and Social Care
See section 7.4.5
10.3
LLR CCGs
It is vital that we collaborate with other CCGs across Leicester, Leicestershire and Rutland to commission services and to develop new and improved pathways which span across the local health and social care community. Working together will also enable economies of scale in terms of procurement, as well as efficiencies in terms of pooling resources. We have agreed a number of areas where between us we share or host resources on behalf of other CCGs, and we have established joint committees to oversee common areas of healthcare, such as the management of LPT and UHL contracts, or LLR QIPP programmes. We have agreed a Memorandum of Understanding for how we will operate together through the Commissioning Collaborative Boards, and the Performance Collaborative.
10.4 Out of Area Commissioners A significant number of our registered patient population lives outside East Leicestershire and Rutland, and/or access services out of the area. ELR CCG will work closely with commissioners neighbouring Leicester, Leicestershire and Rutland, and will develop more formal collaborative arrangements for the future. We are already actively involved in out-of-area monthly performance management meetings and feed in to the associate governance framework for associate CCGs.
10.5 GEM CSO Greater East Midlands Commissioning Support Organisation is our chosen provider of support services, which will include: • Business intelligence • Human resource management, legal support and some financial management • Procurement and market management • Provider management • Communications and engagement Greater East Midlands Commissioning Support Organisation (GEM CSO) is one of the largest CSOs in the country with 22 CCG customers (including West Leicestershire, East Leicestershire and Rutland and Leicester City CCGs). It covers a total population of around 5.4 million and brings commissioning support staff together from across 6 PCT Clusters (Leicester, Lincoln, Northampton, Derby, Nottingham, Luton and Bedford). The fostering of a strong working relationship with GEM CSO is integral to the building of a strong, sustainable clinical commissioning group moving forward, as they will be responsible for delivering key essential support services on our behalf to assist the day to day operation of our CCG. ELR CCG is currently in the process of agreeing a service level agreement to define the service specification and contract terms. In the meantime we have agreed a memorandum of understanding which extends to the other two LLR CCGs.
10.6
Voluntary Sector Providers
We recognise the importance of involving voluntary sector providers in our activities, particularly if we are to innovate new ways of working in a more integrated way and extend patient choice closer to home. We engage with a number of organisations as part of our programmes, with active representation at a number of forums including the Voluntary Care Sector Governance Group.
10.7
Universities and Education
In 2011/12 ELR CCG worked collaboratively with local universities and other local higher education establishments. For example, the University of Leicester supported the delivery of our Long-Term Conditions’ training and development programme. We will continue to work in partnership as we develop training and education programmes for general practice.
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11 Communication and Involvement Although this section features towards the end of our integrated plan, involving patients and the public, member practices, clinicians, staff, partners and other stakeholders remains one of our key priorities. In addition to fulfilling our legal duties and responsibilities to engage and consult patients, the public and partners in decisions around service change, ELR CCG is committed to becoming an organisation where involvement is embedded in everything we do. This means regular, open dialogue with all of our stakeholder groups, maximising opportunities for collaborative working and joint-solutions, and ensuring that ELR CCG is represented at the various health-related forums throughout East Leicestershire and Rutland.
We believe that effective communications and involvement can help us to bring about this necessary change in relationships and behaviour. In addition, there are a number of other benefits, including:
Involving people in developing and evaluating health services is an integral part of ensuring that local healthcare is patient focused, of high quality, and meets the needs of our local communities.
• Better relationships between health services and the public
The ambition and challenge for ELR CCG over the next few years is to deliver services that give patients more choice, more personalised care, and which empower people to improve their own health. This requires a fundamental change in the relationships between health services and the patients and public we serve.
• Shared responsibilities for healthcare between NHS services, local authorities and the public
We need to move from a service that does things to and for patients, to a service that is truly patient-led, where the service works with patients to support them with their health needs.
• Increased patient satisfaction • More accessible, sensitive and responsive health services • Better understanding by the public of how the NHS operates, and therefore more appropriate use of services
• Greater sense of ownership of the NHS
• A health service that is based on the needs of patients and carers, and not the needs of the health service ELR CCG has developed an approach and model for involvement (Figure 11) which establishes mechanisms and forums at all levels of our organisation for engaging with, listening to, and acting on the experience and views of our patients and carers, clinicians, staff, our partners and the public.
Figure 11: Involvement Model LINk / HealthWatch
Constituent GPs / CCG Staff LLR Commissioning Collaborative
LINk / HealthWatch
ELR CCG Board
Operational
Patient Board Member / LINK Reps PPG Chairs Network; Locality PPG meetings; LINk Boards; CCG level complaints
All patients; PPG members; CCG membership (>4,300 members); LINk members; Patient Experience Surveys; CQINS, complaints to practices, provider quality data
Front-line
66
Quarterly reports to CCG Boards
Monthly summary to Q&C Sub Group
Stakeholders / Partners
Elected Locality GPs & CCG SMT reps Locality Groups; Practice Manager Forum; Practice Nurse Forum; LES / DES; practice visits; CCG SMT; CCG team meetings All constituent GPs; Practice Managers; Practice Nurses; Health Visitors; Practice staff; ELR CCG team members
Quarterly reports to CCG Boards
Monthly summary to Q&C Sub Group
OSCs / Health & Wellbeing Boards
Lay Board Members (x2)
District / Borough Council Health Groups; regular meetings withkey stakeholders; CCG Project Boards All stakeholders and partners geographical and interested (including MPs, Councillors, voluntary organisations, local authorities, local NHS Trusts, seldom heard groups, local media etc)
11.1 Group A
Patients, service-users and carers accessing NHS services, PPGs, PPG Chairs Network
Group B
Community organisations - includes condition specific, religious/faith groups, elderly and young people, voluntary organisations
Group C
ELR CCG practices – our constituent GPs, Practice Managers and Practice Nurses
Group D
Clinicians - NHS partner organisations including UHL, LPT, DCHS and EMAS, independent primary care contractors (dentists, optometrists, pharmacists)
Group E
ELR CCG staff – includes all staff and Board Members
Group G
General public and local opinion formers - includes special interest groups, patient representative bodies such as Leicestershire LINk, HealthWatch, MPs and the media
ELR CCG has undertaken a detailed stakeholder mapping exercise to ensure that we understand who our key stakeholders are, together with their needs, preferences and influences, and how we intend to involve them. This is set out in detail within our Communications and Engagement Strategy. Naturally the stakeholder list will be used and adapted to reflect the needs of individual CCG projects, and to ensure that our stakeholders have a say on the things that matter most to them. The overarching stakeholder groups are as follows: We have already built strong links with various stakeholder groups, and the coming years will see us strengthening those links and building new relationships with other organisations, groups and individuals. To ensure that involvement happens at all levels, we have invited stakeholder membership on our Board, and in a number of our Project Boards. We actively encourage our staff and Board Members to be proactive in working with stakeholders in all aspects of our work. Some of the key relationships that we have established with our stakeholders are described in the following sections.
East Leicestershire and Rutland Patients and Carers
ELR CCG is keen to maintain a focus on improving the patient and carer experience. We will listen to patients and carers, and will collate feedback and other evidence to influence the commissioning and contractual process In addition to the work on capturing patient feedback outlined in sections 7.2.8 and 7.4.6, ELR CCG is planning to develop existing Patient Participation Groups (PPGs) across the patch and establish new groups for practices who currently do not have them. Working with Leicestershire LINk, ELR CCG has already established a PPG Chairs’ Network which is a new forum designed to bring PPG Chairs together to share best practice and co-ordinate the work of the PPGs across East Leicestershire and Rutland. ELR CCG will use this forum to capture feedback from patients, producing ‘intelligence reports’ to identify areas and practices needing development to improve patient experience. The reports will also highlight areas of best practice. ELR CCG has taken ownership of its segmented share of NHS Leicestershire County and Rutland’s membership. These are patients, carers and members of the public who have signed up to become members of the organisation. Many of them have a particular interest in helping to shape health services and to learning more about the local NHS and about healthy living. ELR CCG will communicate regularly with our members, who currently total more than 4,300, and will use their views to help inform decisions on local healthcare. Monthly summary reports giving high-level detail of patient experience issues, including complaints information, will be received by the Quality and Clinical Governance Committee. Reporting to the Board, the scrutiny and oversight of this group will help keep a regular check on performance and ensure that the patient’s voice is central to the activities of the Board. In turn, minutes from the Quality and Governance Sub-committee are presented to the monthly ELR CCG Board meeting, which also receives a quarterly report on patient experience and feedback. This ensures that key decision makers within the CCG are privy to regular feedback from patients, carers and our public members to help inform commissioning decision and approaches.
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11.2
East Leicestershire and Rutland Constituent GPs and CCG staff
Ensuring that our constituent GPs, practice staff and CCG staff are fully involved in all aspects of our work and decision making is vitally important to us. Some of the key methods we are employing include: • Regular practice visits by members of our CCG Board to discuss and share the issues which are at the top of our agenda, and to capture views and feedback direct from GPs, nurses, other clinicians and staff • Monthly locality meetings to share and gather information with and from constituent GPs in each of our three localities • Regular meetings and use of the Practice Manager’s Forum • Monthly CCG team meetings and ad hoc focus groups • Regular staff briefings • Regular feedback obtained via staff surveys, forums and one to ones, with a focus on sharing and gathering feedback on key CCG issues • Monthly newsletter to staff and constituent GPs • Shared intranet for CCG staff and constituent GPs Additionally, ELR CCG is planning to establish a Practice Nurse Forum to ensure there is an appropriate forum for nursing staff to share best practice, identify areas for development and feed back their views to the CCG. It is anticipated that the stakeholder engagement to be undertaken as a part of the development of the integrated care team approach will also inform the establishment of additional groups which include other clinical professions such as Allied Health Professionals.
11.3
Partners
We recognise the importance of involving and collaborating with partners. We have focused heavily in our first year as a shadow organisation on developing robust relationships with them. This will enable us to collaborate to deliver the optimum services for local people across East Leicestershire and Rutland, and to contribute to the wider agenda within LLR. More information on how we involve and collaborate with our partners can be found in section 10.
11.4
Local Involvement Network (LINks) and Healthwatch
ELR CCG has built strong relationships with our two local LINk organisations in Leicestershire and Rutland. Two representatives from LINks sit ‘in attendance’ at our Board Meetings, giving them the opportunity to scrutinise and challenge our work from a patient perspective, as well to ensure patient voices on our Board. Additionally, LINks representatives sit on several of our key work stream project boards and steering groups. We are drawing up a protocol, which sets out more formally our commitment to working with our two local LINk organisations, and which clearly reflects the value we place on their involvement in our work. This will be adapted to incorporate HealthWatch as it forms. There will be two HealthWatch organisations in our area – one in Leicestershire and one in Rutland. From October 2012, each HealthWatch will signpost people to information and advice about health and social care services; and from April 2013, they will be required to play an advocacy role for patients and carers with complaints. In Leicestershire, Healthwatch also has pathfinder status and is currently developing three work streams: • Hard to reach/seldom heard groups • Signposting • Delivery of the new Healthwatch organisation. ELR CCG will continue to support LINks and HealthWatch and will seek ways to increase their involvement in the commissioning and delivery of local healthcare.
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12 Implementation This chapter describes the arrangements in place to ensure delivery of this Strategy, including financial plans, governance, organisational development and communications and engagement. 12.1
Financial Plans
The primary financial strategic objective is to enable and support the CCG in achieving our vision. The financial plan focuses on using our resources to meet the health needs of East Leicestershire and Rutland, ensuring value for money, and fair and efficient use of funding to improve the health and wellbeing of the population. In order to achieve these objectives we have developed a long-term financial plan that delivers an underlying surplus, which will enable funding to be spent non-recurrently each year, thus facilitating transformation on an on-going basis. Appendix 7 provides details of our financial strategy and plan for 2012/13 – 2015/16. It should be noted that details of the allocation have been confirmed for 2012/13 only, and therefore subsequent years may be subject to change. Other influencing factors include the publishing of next year’s NHS Outcomes Framework in Autumn 2012.Our internal governance structures and processes will ensure accurate monitoring and reporting of the financial position. This will be assured by both the ELR CCG Board and, during 2012/13, the LLR PCT Cluster. Our QIPP savings plan for 2012/13 is given in Appendix 8, and our savings plans for 2013/14 -2015/16 are in Appendix 9. Along with the financial plan, these will be monitored via the Finance and Performance Committee.
12.2
Governance Framework
ELR CCG has developed a comprehensive governance framework which will ensure the delivery of this Strategy. This includes clear lines of accountability for delivery of the various elements described within, and performance management arrangements to ensure that progress is made against plan. In terms of individual responsibility, key deliverables are written into personal objectives, which are reviewed regularly by line managers and the committees to which they report; and on which they will be formally appraised annually.
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Where common areas of commissioning exist between the three LLR CCGs, collaborative governance structures have been put in place. The Commissioning Collaborative Board (incorporating the Performance Collaborative) oversees a number of shared areas including performance management and delivery of QIPP and transformational programmes in addition to shared contracts with providers and other initiatives. Reports from this committee are received at each of the three CCG Boards. An illustration of the Board and its committees is shown in Figure 12.
12.3 Framework for Delivery of Programmes A programme framework is being developed to ensure the delivery of key work streams, including those relating to our strategic aims and transformational funding. This is shown below in Figure 13. Each work stream has agreed terms of reference and specific deliverables. These ensure that members are united in their focus on the work that needs to be undertaken, and what it is expected to achieve. Whilst the programme team will be responsible for undertaking monitoring and evaluation of progress against plan, this will be reported into one of the Board’s delegated committees. With respect to the delivery of QIPP, the Commissioning Collaborative Board is accountable for monitoring the delivery of LLR-wide QIPP schemes. In turn, reports from this group are reported into the three CCG Boards. The delivery of local QIPP schemes is monitored and reported through the ELR CCG Finance and Performance Committee, and in turn through to the ELR CCG Board.
Figure 12: ELR CCG Governing Body and Delegated Committees
Board
Audit Committee
Quality and Clinical Governance Committee
Finance and Performance Committee
Ratification
Competition and Procurement Committee
Remuneration Committee Finance and Performance Committee
Assurance
Figure 13: Programme Governance Framework
3 CCG Boards
LLR Commissioning Collaborative
Diabetes Pathway Transformation Group
EOL Programme Board
Frail Older People
COPD Pathway Transformation Group
LLR Reconfiguration Board
IM&T Transformation Group
Urgent Care
ELR CCG Priorities 2012/13
Quality and Governance Group
ELR CCG Transformation Steering Group
Diabetes Development
COPD
Integrated Care
LLR Priorities 2012/13
End of Life
Medicines Management
Re-ablement
Frail Older People
Dementia
Nursing Homes
Risk Stratification
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12.4
Contracts and CQUINs
We will use contracts as our key lever to drive improvements in quality and performance. ELR CCG has developed local CQUIN indicators for 2013/14, linked to ELR CCG clinical priorities, including QIPP targets. These were developed during quality workshops which involved clinical leaders. Financial values have been agreed for each CQUIN indicator, which will be monitored in partnership with our Clinical Quality Review Group. ELR CCG has played an active role in the 2012/13 contracting round, with members of our Board assigned to the major contracts, i.e. UHL, LPT (mental health and community health services), and Derbyshire Community Health Services. Additionally, clinical leads have been assigned to out-of-county acute contracts to ensure that ELR CCG interests are appropriately represented.
12.5
Management of Risk
ELR CCG has developed a comprehensive Board Assurance Framework (see Appendix 10) to ensure the appropriate identification and management of risks relating to our activities. Aligned to our Risk Management Strategy and Policy (2012-14), this includes the mitigation of risks relating to the delivery of our Strategy, including strategic and operational priorities. It covers all types of risk - governance, management, quality, legal, reputational, clinical and financial. Responsibility for updating and monitoring risks rests with the Board and its delegated committees, and accountability at an individual level is clearly identified against each risk. The Strategic Risk Register is reviewed by the Quality and Governance Committee on a monthly basis, and reports are made to the Board every quarter. Our internal audit process is another mechanism for gaining assurance on the management and mitigation of risk in terms of delivering this Strategy. With accountability falling to the Accountable Officer and Board, the role of internal audit is to provide an opinion on the effectiveness of corporate governance, risk management and internal control.
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12.6
Organisational Development Plan
Critical to the successful delivery of our Strategy, is the implementation of our Organisational Development (OD) plan. We recognise the need to develop our organisation and its people to enable the delivery of our strategic aims and operational priorities. In our OD plan, we have clearly set out the gaps between where we are now, and where we need to be, together with a plan on how we intend to achieve this. This includes the development of current and future clinical leaders, both at Board level and in localities; the training and development of our staff in terms of basic and mandatory skills, and in terms of skills development, career progression and succession planning to ensure the appropriate capacity and capability; and the development of partnership and collaborative commissioning arrangements.
12.7
Communications and Engagement
Communicating and engaging with our patients, carers, member practices, staff, clinicians, partners, local citizens and other stakeholders is crucial to the effective delivery of our strategy. We recognise that our strategy will need to remain fluid and therefore responsive to the changing needs of our local population. Involvement our stakeholders is therefore essential to ensure that this the case. We encourage our local population and member practices to hold ELR CCG to account with regard to the delivery of our Strategy. We will therefore ensure appropriate opportunities to share and involve people in the development of our organisation and our activities. This will range from hosting events such as the annual general meeting, stakeholder discussion sessions, and Board meetings held in public, to the appointment of lay members on our Board and key programme groups. We have developed a comprehensive Communications and Engagement Strategy, which identifies our key stakeholders and how we will involve them on an on-going basis.
Glossary A&E AQP BME CAB CAMHS CAU CCG CED CHD CHS CLRN COPD CQUIN CVD CYP DH DVT ECN eDoS ELR CCG EMAS EPAU FOP FOPALS GEM CSO GP IAPT IM&T INR JHWBs
Accident & Emergency Any Qualified Provider Black Minority Ethic Choose and Book Child and Adolescent Mental Health Services Children's Admission Unit Clinical Commissioning Group Children's Accident and Emergency Department Coronary Heart Disease Community Health Services Comprehensive Local Research Network Chronic Obstructive Pulmonary Disease Commissioning for Quality Innovation Cardiovascular Disease Children and Young People Department of Health Deep Vein Thrombosis Emergency Care Network Electronic Directory of Services East Leicestershire & Rutland Clinical Commissioning Group East Midlands Ambulance Service Early Pregnancy Assessment Unit Frail Older People Frail Older People’s Advice and Liaison Service Greater East Midlands Commissioning Support Organisation General Practitioner Improve Access to Psychological Therapies Information Management & Technology International Normalised Ratio Joint Health and Well-being Boards
JSNA KPI LD LEFT SHIFT
LES LINKS LLR LOROS LPT LTC MDT MECC MIU NHS NHSCB NICE ONS PCT PRG Q&C QIPP QOF R&D RAG RTT SHA SPoA TIA UHL UNICEF VCS VTE WHO
Joint Strategic Needs Assessment Key Performance Indicators Learning Disabilities The programmed movement of care from acute settings to less urgent and community settings Local Enhanced Services Local Improvement Networks Leicester, Leicestershire and Rutland Leicestershire’s Organisation for the Relief of Suffering Leicestershire Partnership Trust Long Term Conditions Multi-Disciplinary Team Making Every Contact Count Minor Injury Unit National Health Service NHS Commissioning Board National Institute of Clinical Excellence Office of National Statistics Primary Care Trust Patient Representation Groups Quality and Contracting Quality Innovation Productivity Prevention Quality Outcomes Framework Research and Development Red Amber Green Referral To Treatment Strategic Health Authority Single Point of Access Transient Ischemic Attack (mini stroke) University Hospitals Of Leicester United Nations Children’s Fund Voluntary & Community Sector Venous Thromboembolism World Health Organisation
Integrated Plan 2012-2015
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Version Control for Integrated Plan Version
Description
Date
1.0
Draft version 1.0 outline of the plan submitted to the Board that includes Inclusion of vision, values and strategic priorities, local background, engagement, key priorities 2012/13, QIPP, Operating Framework 2012/13, SHA Ambitions, Equality and Diversity and Transition and Reform
10/04/2012
2.0
Draft version 2.0 submitted to the Board following feedback which includes:
12/06/2012
3.0
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•
Restructuring of sections in line with priorities.
•
Re-ordering of populations health overview and incorporation of/reference to relevant elements from CCG population and performance profile
•
Addition of provider and partner landscape sections
•
Introduction added to sections to frame the narrative
•
General simplification of jargon
•
Expansion of transformational funds section to include more details of plan for 2012/13.
•
Incorporation and cross reference of emerging Health and Well-being priorities and JSNA data
•
Expansion of provider landscape including map.
•
Inclusion of breakdown of budgets for 2013/13 including graph
•
Strengthening of key sections, including cancer and mental health
•
Revision of local priorities section
•
Strengthen targeting of areas with health inequalities
Draft version 3.0 submitted to the Board following feedback which includes: •
Comparison and incorporation of published health profiles data from NHS Commissioning Board.
•
Inclusion of section on research and development.
•
Cross-reference against authorisation criteria.
26/06/2012
Integrated Plan 2012-2015
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