luton ccg operational plan - draft

Luton CCG Operational Plan - Draft

2014-15 to 2015-16

1 V1.2 March 14th 2014 DRAFT

Appendix 1

Contents

1. Context of Plan

2. Our Vision, Mission and Values

3. Outcome Goals

4. Ensuring High Quality and Safe Outcomes

5. Our Commitment to patients

6. Key Programmes 2014/15 – 2015/16

7. Enabling Programmes

8. Financial Plan

9. Governance

10. Activity Plan

2 DRAFT

1. Context of Plan

3 DRAFT

National Context National Planning Guidance requires that individual units of planning develop a five year system strategy 2014/15 to 2018/19 with key deliverables for the first two of those years articulated via:

A CCG Operating Plan

A CCG Financial Plan

A Better Care Fund Plan

Individual Provider Plans

An NHS England Area Team Direct Commissioning Plan

This Operational Plan represents Luton CCG’s two year contribution to the delivery of the Five year strategy, which itself is a key component in the delivery of the Luton Health and Wellbeing Strategy.

The need for a cohesive system planning programme is essential to meet the sustainability issues posed by the imbalance between rising demand and supply pressures and our unit of planning (Luton CCG, Luton Borough Council, Luton and Dunstable Hospital, Cambridgeshire Community Services, South Essex Partnership Trust and the Luton Health and Wellbeing Board) will publish its draft five year strategy to deliver a Healthier Luton through a sustainable health and social care system in early April 2014.

1. Context of Plan

4 DRAFT

Local Planning Context The diagram on the next page shows how local plans fit together to support the Luton Health and Wellbeing Strategy.

The Health and Wellbeing Strategy makes a number of commissioning recommendations based on a in depth analysis of local needs and highlights three major outcome goals:

The Children and Young People’s Plan articulates how Goal 1 and elements of Goal 2 are being addressed. The System Five Year Strategy with its focus on adults will articulate plans to address Goal 3 and elements of Goal 2.

Operational Plan 2014/15 to 2015/16

This LCCG Operational Plan describes CCG responsibilities for 2014/15-2015/16 to deliver the first two years of the System Five Strategy and elements of the Children and Young People’s Plan.

1. Context of Plan

5

Health and Wellbeing Goal 1. EVERY CHILD AND

YOUNG PERSON HAS A HEALTHY START IN LIFE

Health and Wellbeing Goal 2. REDUCED

HEALTH INEQUALITIES IN LUTON

Health and Wellbeing Goal 3. HEALTHIER AND

MORE INDEPENDENT ADULTS AND OLDER

PEOPLE

DRAFT

Health and Wellbeing Strategy 2012-2019

EVERY CHILD AND YOUNG PERSON HAS A HEALTHY

START IN LIFE

REDUCED HEALTH INEQUALITIES IN LUTON

HEALTHIER AND MORE INDEPENDENT ADULTS

AND OLDER PEOPLE

Children and Young People’s Plan 2012-13 (to be updated

2014/15 – 2018/19)

Five Year System Strategy 2014/15-2018/19

CCG Two Year Operating Plan 2014/15 – 2015/16

CCG Two and Five Year Financial Plans

Area Team Two Year Direct Commissioning Plan 2014/15 – 2015/16

Better Care Fund Two Year Plan 2014/15 – 2015/16

Provider Two Year Plans 2014/15 – 2015/16

Seven Priority Outcome Ambitions

BCF National and Local KPIs

1-2 year KPIs; Quality Premium; Activity Plans

Outcome Measures

Locally defined measures from HWB Strategy

Nationally Defined Surplus

CCG Primary Care Strategy

Direct Commissioning Measures

NHS Constitution, Activity

7 Outcome Ambitions

Del

iver

y P

lan

s

HWB Commissioning

Recommendations

Local Outcome Priorities

Strategies to deliver Local Priorities

Key To be Updated In development 6

The Relationship Between the Health and Wellbeing Strategy and Current Plans in development

CCG Mental Health Strategy 7 Outcome Ambitions

Local Organisational Context Financial Recovery

Luton CCG is a relatively new organisation currently in its first year of delivery of its statutory responsibility as the main commissioner of healthcare in Luton. As is the case with many CCGs, Luton was placed in the Financial Recovery Process in October 2013 which reflected an escalation in demand for acute services but also the recognition that the CCG – and the PCT before it – had been underfunded when considering the high levels of deprivation and health inequalities that exist in the town.

This Operational Plan should be read in conjunction with the CCGs Financial Recovery Plan published in Jan 2014.

1. Context of Plan

7

Luton’s Population and Health Profile at a glance • Population 204,000 • BME equals 55% of the population and 66% of school children • High levels of deprivation – 12,000 children live in poverty. Life expectancy lower than England average • Life expectancy gap for most deprived areas is 8.9 years for men, 6.4 years for women • 23.2% of Year 6 children are obese, worse than the England average. Breast feeding and smoking in

pregnancy worse than England. Teenage pregnancy and alcohol specific hospital stays among the under 18s are better than the England average.

• Infant mortality is above the England average • Low rates of adult physical activity and high levels of adult obesity • CVD mortality worse than England • Dementia in over 65’s to increase by 10% between 2012 and 2016

DRAFT

2. Luton CCGs Vision, Mission and Values

8 DRAFT

Our Vision, Mission and Values

9

Whilst the CCG Vision and Values developed during the formation of the CCG as a shadow commissioning organisation in 2012 have served the organisation well, the Board chose to revise these in 2013 in the light of the Francis enquiry and subsequent associated reports and recommendations. As a result, our Vision, Mission and Organisational Values now more accurately reflect our focus on the needs of the community and patients, the need to respond to and learn from feedback and deliver high quality and safe outcomes as a priority.


DRAFT


“We will work in partnership with patients, their carers, providers and

other partners to deliver a high quality and cost effective NHS to the people of

Luton, empowering them to lead healthy and independent lives"

Our Mission

Our Vision

“Together for a Healthier Luton”

Where we want to be

How we will get there

DRAFT 10

Our focus is patients and the

community

The needs and views of patients are more important than the

needs of the organisation We act with

honesty, integrity and compassion

We will continuously improve quality

through application of learning and best

practice

We will enable strong clinical

leadership to drive positive change

We value and invest in our staff,

their skills and their wellbeing

We are a listening, responsive

organisation and we act on feedback

We work in partnership with

patients and providers towards a shared

vision

Our decisions are made in a transparent way, based on sound

evidence

We will act to safeguard the

vulnerable and reduce inequalities Our Values

2. Luton CCGs Vision,

Mission and Values

11

Drivers of culture and

priorities

DRAFT

3. Outcome Goals

12 DRAFT

Our Outcome Goals 2014/15-2015/16

3. Outcome Goals

13

Introduction

National Planning Guidance requires CCGs to submit trajectories to support the seven outcome ambitions (see System Five Year Strategy):

Securing additional years of life or people with treatable mental and physical health conditions

Improving the quality of life of people with Long Term Conditions

Reduce the amount of time spent avoidably in hospital

Increasing the proportion of older people living independently at home following discharge from hospital

Increasing the proportion of people with a positive experience of hospital care

Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital

Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care

CCGs are also required to submit trajectories for the following:

C. Difficile reduction

Dementia diagnosis

IAPT coverage and recovery

A local measure for the Quality Premium

DRAFT

Outcome Ambition 1: Securing additional years of life or people with treatable mental and physical health conditions

14

3. Outcome Goals

Indicator: Potential Years of Life Lost (PYLL – Rate per 100,000 from causes considered amenable to healthcare (adults and children)

Luton Current Position: Baseline 2012 – 2669 Luton – Bottom Quintile

2014

Reduce from

Baseline by 7% to

2394

2015 Reduce

from Baseline

by 13% to 2313

2018 Reduce

from baseline

by 19% to 2194

Ambitions

DRAFT

Outcome Ambition 1: Securing additional years of life or people with treatable mental and physical health conditions - Trajectory

3. Outcome Goals

y = -81.655x + 166847

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

2003 2005 2007 2009 2011 2013 2015 2017 2019

DSR

pe

r 1

00

,00

0 E

uro

pe

an p

op

ula

tio

n

Year

Drivers of Improvement Early detection of cancer Improved diagnosis and management of diabetes / COPD Flu Vaccination Immunisations

DRAFT 15

Outcome Ambition 2: Improving the quality of life of people with Long Term Conditions

16

3. Outcome Goals

Indicator: Uses EQ5D tool in GP Patient Survey. Score out of 100

Luton Current Position: Baseline 2012/13 – 74.1 Luton – Middle Quintile slightly better than England

2014/15 Increase

from baseline by 2% to

76

2015/16 increase


77

2018/19 Increase


80

Ambitions

DRAFT

Outcome Ambition 2: Improving the quality of life of people with Long Term Conditions - Trajectory

DRAFT 17

3. Outcome Goals

Drivers of Improvement

• Better Together programme

• Reconfiguration of Mental Health and Community Services

• Transforming Primary Care

• Transforming Urgent Care

Outcome Ambition 3: Reducing Avoidable Admissions to Hospital

18

3. Outcome Goals

Indicator: Rate per 100,000 comprised of: Unplanned hospitalisation for chronic ACS; Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s; Emergency admissions for acute conditions not usually requiring hospital admission; Emergency admissions for children with lower respiratory tract infections

Luton Current Position: Baseline 2012/13 – 2668 Luton – Bottom Quintile

Ambition

2014/15 to 2018/19. We plan to halt the increase in avoidable emergency admissions to maintain the current position for the next five years just below the

baseline position of 2668

DRAFT

Outcome Ambition 3: Reducing Avoidable Admissions to Hospital - Trajectory

3. Outcome Goals

0

500

1000

1500

2000

2500

3000

3500

4000

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Axi

s Ti

tle

Avoidable Emergency Admissions per 100,000 : Luton CCG

Luton Historic

Luton Forecast

Linear (Luton Historic)

Drivers of Improvement Better Together Programme Social Media Campaign Children – Rapid Response EOLC Pathway Local Tariffs Acute Home Visiting Service Hospital at Home Ambulatory Care

DRAFT 19

Outcome Ambition 5: Increasing the proportion of people with a positive experience of hospital care

20

3. Outcome Goals

Indicator: Total number of poor responses divided by total number of respondents (Inpatient Survey)

Luton Current Position: Baseline 2012 – 155 Luton – Quintile 4

2014/15

Reduce by 1.3 % from

baseline to

153

2015/16 Reduce by 2% from baseline

to 152

2018/19 Reduce by 6% from baseline

to 146

Ambitions

DRAFT

Outcome Ambition 5: Increasing the proportion of people with a positive experience of hospital care- Trajectory

3. Outcome Goals

120

125

130

135

140

145

150

155

160

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Nu

mb

er

of

ne

gati

ve r

esp

on

ses

pe

r 1

00

Negative Responses per 100 patients Drivers of Improvement: • CQUIN (Friends and

Family, Medicines Management)

• Quality monitoring (SI Process, Complaints Process)

• Discharge Processes • Quality Meetings • EMSA • L&D Outpatient

transformation programme

• L&D Additional diagnostics services

• EOLC Pathway

DRAFT 21

Outcome Ambition 6: Increasing the number of people having a positive experience of care outside hospital

22

3. Outcome Goals

Indicator: Total number of negative responses per 100 patients (GP Patient Survey)

Luton Current Position: Baseline 2012 – 8.1 Luton – Bottom Quintile

2014/15 Reduce

from baseline

by 2.5% to 7.9

2015/16 Reduce


7.8

2018/19 Reduce

from baseline

by 10% to 7.1

Ambitions

DRAFT

Outcome Ambition 6: Increasing the number of people having a positive experience of care outside hospital - Trajectory

3. Outcome Goals

6.6

6.8

7

7.2

7.4

7.6

7.8

8

8.2

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Po

or

Re

spo

nse

s p

er

10

0 P

ati

en

ts

Proportion of People Expressing Poor Experience of GP or Out of Hours Services Drivers of Improvement: • Practice Visit

Programme (Towards Excellence)

• Access improvement programme

• Enhanced Services • Peer Group

Programme • GP Practice Peer

Group review • Practice

Engagement • Primary Care

Investment Scheme

Reducing the Incidence of C. Difficile

3. Outcome Goals

Indicator: The Total Number of C. Difficile Infections a commissioner level

EAS5 April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Number of C. difficile infections

3 3 3 3 3 3 3 2 2 2 2 2

Objective for 2014/15

24 DRAFT

Drivers of Improvement: • System wide C Diff action group • Implementation of national best practice • Full review of all cases • Review of antibiotics policies • Care Home Care Bundles and training

Improving the Diagnosis of Dementia

3. Outcome Goals

Indicator: The number of people diagnosed with dementia as a proportion of predicted prevalence

Objective for 2014/15 – 2015/16

25 DRAFT

Number of people diagnosed

Prevalence of dementia

% diagnosis rate

2014/15 931 1799 51.8%

2015/16 990 1835 54%

Drivers of Improvement: • CQUINs in place to drive improved diagnosis:

• Mental Health Trust • Community Services • Acute Trust

• Increased capacity of Memory Assessment Service • Implementation of Liaison Psychiatry Service

Improving Access to Psychological Therapies (IAPT) Coverage

3. Outcome Goals

Indicator: The proportion of people who enter treatment against the level of need

Objective for 2014/15 – 2015/16

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 2015/16

Proportion of Patients Who Enter Treatment with IAPT

26 DRAFT

Drivers of Improvement: Implementation of full IAPT Service via new provider

Improving Access to Psychological Therapies (IAPT) Recovery

3. Outcome Goals

Objective for 2014/15 – 2015/16

27 DRAFT

The number of people who have completed

treatment and reached recover

The number of people who have completed

treatment % recovery rate

2014/15 1888 4035 46.8%

2015/16 2121 4175 50.8%

Drivers of Improvement: Implementation of full IAPT Service via new provider

Local Measure for Quality Premium

3. Outcome Goals

28

The CCG has chosen the indicator “Proportion of people feeling supported to manage their long term condition” as the local priority for the Quality Premium. The reason for this choice is that we see this as an important measure of the effectiveness of the system working in collaboration to meet the needs of patients

Current Baseline: 62.7%

Objective for 2014/15: 63.3%

DRAFT


29 DRAFT

Ensuring High Quality and Safe Outcomes

30


Managing the Impact of Financial Recovery

Strong clinical leadership is required to deliver high quality, responsive and safe services for patients. There is a risk that quality of patient safety, outcome and experience could suffer due to increased financial constraints. Luton CCG will take a proactive approach to mitigating this risk through a range of measures, including:

A robust quality KPI monitoring process with our providers through contract quality schedules. This is backed up by a quality governance process to manage performance proactively and also to respond reactively where needed.

QIPP schemes will be subject to a Quality Impact Assessment and Equality Impact Assessment. This will ensure that potential quality issues are identified, and where possible mitigated, prior to schemes being initiated.

Clinicians are being engaged through our planning processes and will continue to be engaged going forward.

Appropriate to individual QIPP schemes; scheme-level KPIs will be introduced to provide a mechanism to mitigate any negative quality impact.

The quality impact of our QIPP programme will be monitored along with financial impact to ensure we keep a real-time view on performance.

GP Practices will be empowered to provide continued feedback to the CCG on any negative quality impact of QIPP schemes or other financial recovery impact on our providers.

DRAFT

31


CQUIN

Clinical leads are involved in the construction of the CQUIN’s for 2014/15 and any work stream leads pertinent to a specific CQUIN included in the development to ensure best fit with LCCG commissioning intentions and planned QIPP schemes. For example; the Medicines Optimisation team has been developing the Medicines CQUIN with the L&D to ensure robust and supporting milestones. The CQUIN indicators are reported through Patient Safety and Quality Committee, Clinical Commissioning Committee and to Board for assurance of strategic fit and benefit. CQUIN will not identify financial savings but by means of improving quality, clinical effectiveness and patient safety will have an effect on finance. For example; preventing a pressure sore will reduce the cost for that patient’s care, not having to treat the pressure ulcer, and improve their experience and quality of life.

Quality Governance

The CCG promotes and assures quality improvement through its local mechanisms, which include:

• Quality Impact Assessments of developments;

• On-going dialogue with stakeholders;

• Complaints info, equality data, national survey & patient experience data;

• Patient Survey;

• Balanced scorecard; and

• Quality performance monitoring framework.

All providers are monitored for quality, patient safety and patient experience. The processes used are supported by inclusion in provider contracts and supported by a framework of data monitoring, reports, face to face meetings and where necessary ‘deep dives’ in to areas of concern. Specific issues which may impact on quality, patient safety and patient experience are identified and monitored even if they are not areas causing immediate concern, for example transition of providers or low staffing numbers. DRAFT

32


Eliminating Healthcare Acquired Infections (HCAI) - MRSA

All actions are monitored and overseen by the Infection Prevention and Control Nurse employed by the CCG:

• Strengthening of root cause analysis on each case of MRSA bacteraemia, implementation of the newly introduced national post infection review process to include joint reviews between the Commissioning and providers.

• Feedback and embedding the learning from root cause analysis with all providers

• Monthly MRSA screening compliance for elective and non-elective cases in-patient areas.

• Mandatory training for all in-patient stay providers to includes screening and management of MRSA (assurance from provider infection control committees/reports)

• KPI’s in provider contracts with active monitoring

Friends and Family Test F&F is in all main NHS provider contracts via National CQUIN indicators. Any further guidance release for 2014/15 and 2015/16 will be included in the CQUIN in the contracts. LCCG monitor all CQUIN’s to ensure progress via the CQUIN Panel and appropriate payment is made based on evidence of achievement. Any non- achievement is not paid and actions to address any non-achievement is supported through the

Quality Monitoring Process set out in provider contracts.

DRAFT

33


Eliminating Healthcare Acquired Infections (HCAI) – Clostridium difficile

• Increased engagement and whole health economy working by formulation a system-wide C-diff action group to review all aspects of Clostridium difficile. Membership was from all acute and community providers, Public health England, CCGs and Public health. This committee will continue to meet next year with development of a new action plan.

• Development and implementation of an action plan based on the DOH and HPA guidance “Clostridium difficile infection: How to deal with the problem” to ensure best practice throughout. Issues reviewed and actions included:

• Each provider to review and update their local C-diff policy

• Full review of all cases of CDI with feedback to all relevant parties including clinicians, GPs and other provider services highlighting lessons learnt

• Review of all antibiotic prescribing policies for all providers and surveillance of antibiotic prescribing.

• In-patient stay area reviews for staff training, isolation facilities and environmental cleanliness.

• Ensure all in-patient stay providers carryout MDT rounds to review all patient with CDI at least weekly

• Ensure use of SIGHT mnemonic and Bristol Stool chart by all providers,

• Review and update patient information leaflet

• Development of a care bundle for care home settings

• Review of teaching available for care homes and primary care and development of a plan to roll out training in these areas.

• Communication among all providers and ways to improve this.

• Review of the community antibiotic guidelines and republication of updated version

• Medicines management continue to monitor GP antibiotic prescribing

• Full root cause analysis and feedback of all cases of CDI with lessons learnt highlighted

• Emphasis on rapid isolation and testing for all patients with diarrhoea

DRAFT

5. Our Commitment to Patients

34 DRAFT


The NHS Constitution

Luton CCG plans to ensure that the requirements of the NHS Constitution are delivered to the local population. The CCG has put in place robust governance arrangements to ensure that that all performance measures required by the NHS Constitution are delivered and any performance issues addressed with providers in a timely fashion. Performance against the following standards will be reported to the CCG Board every month, the current position is RAG rated in column 3

What National Standard

Current YTD Position**

Referral To Treatment waiting times for non-urgent consultant-led treatment Admitted patients to start treatment within a maximum of 18 weeks from referral

90% 92.85% (Year to October

2013)

Non-admitted patients to start treatment within a maximum of 18 weeks from referral


2013)

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral


2013)

Diagnostic test waiting times

Patients waiting for a diagnostic test should have been waiting no more than 6 weeks from referral


2013)

A&E waits Patients should be admitted, transferred or discharged within 4hours of their arrival at an A&E department

95% 95.81% - L&D Only (Year to October

2013)

No waits from decision to admit to admission (trolley waits) over 12 hours*

Zero Zero

Ambulance Handovers

All handovers between ambulance and A & E must take place within 15 minutes and crews should be ready to accept new calls within a further 15 minutes. Financial penalties, in both cases, for delays over 30 minutes and over an hour*

100% 629 delays – L&D Only

(Year to November 2013)

Standards and Current Performance 1

* Measures which are supplementary to the NHS Constitution ** Latest data available

35 DRAFT




What National Standard Current YTD Position**

Cancer waits – 2 week wait Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP


2013) Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)


2013)

Cancer waits – 31 days Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers

96% 100% (Year to October

2013) Maximum 31-day wait for subsequent treatment where that treatment is surgery


2013) Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen


2013) Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy

94% 95.73 (Year to October

2013) Cancer waits – 62 days

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer


2013) Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers


2013) Maximum 62-day wait for first definitive treatment following a consultants decision to upgrade the priority of the patient (all cancers)

No Operational Standard set

100% (Year to October

2013)

36 * Measures which are supplementary to the NHS Constitution ** Latest data available

DRAFT




What National Standard Current YTD Position**

Category A ambulance calls

Category A calls resulting in an emergency response arriving within 8 minutes. Red 1

75% Luton CCG 88% EEAST 74.91% (Year to November 2013)

Category A calls resulting in an emergency response arriving within 8 minutes. Red 1

75% Luton CCG 89.37% EEAST 72.06%


Category A calls resulting in an ambulance arriving at the scene within 19 minutes

95% Luton CCG 98.5% EEAST 93.59%


Mixed Sex Accommodation

Mixed Sex Accommodation Breaches 54 Minimise breaches 16 (L&D) (Year to November 2013)

Cancelled Operations

All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice.

100% TBC

No urgent operation to be cancelled for a second time

Zero Zero

Mental health

Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period

95% 100% * Measures which are supplementary to the NHS Constitution ** Latest data available

37 DRAFT

6. Key Programmes 2014/15 to 2015/16

38 DRAFT

Introduction to Key Initiatives - The Big Three Programmes Our high level strategic initiatives articulated in the System Five Year Strategy are the mechanism through which we will achieve the transformational change required to deliver better health outcomes through a financially sustainable system . These are Better Together (Integration of Health and Social Care), Transforming Primary Care, the Reconfiguration of Mental Health and Community Services and Transforming Urgent Care.

The diagram on the next page shows how these initiatives translate into specific programmes for the period covered by this Operational Plan. Each initiative is at a different stage of delivery, the Transformation of Urgent care initiative for example is well advanced with a number of key programmes already delivered and others which will shortly become “Business as Usual”.

Over the next one to two years we must apply specific focus to the delivery of three priority programmes:

.

DRAFT 39

The Re-procurement of Mental Health and Community Services

The Frail Elderly Programme

Building the capacity and capability of

Primary Care

The re-procurement programme is a key enabler of the Better Together Integration Programme as it gives us the opportunity afforded by placing new providers in place to drive the collaborative working required to build services around the needs of individual patients. The Frail Elderly programme is a core component of Better Together, delivering greater independence for our most needy and vulnerable citizens. Building the capacity and capability of Primary Care is critical to the delivery of high quality care nearer to peoples homes

Summary of Key Initiatives

40

6. Key Programmes 2014-16 to 2015/16

Better Together – Integration of Health and Social Care

•Building personalised services around the needs of patients

•Switching the focus towards prevention and early intervention

Transforming Primary Care

•Driving a transformation in the capacity and capability of primary care to deliver a broader range of high quality and safe services in the community.

Reconfiguring Mental Health and Community Services

•Redesign of community and mental health services to drive improved health outcomes, system integration and financial sustainability

Transforming Urgent Care

•Redesign of unscheduled care provision to ensure the right level of care delivered appropriate to the needs of the patient.

Strategic Initiatives (from Five Year Strategy) Key Programmes 2014/15 to 2015/16

Re-procurement of mental health and community services

Transition and Mobilisation

Better Together Workstreams: Frail Elderly, Disabled Children, Data Sharing, Shared Services / Joint Procurement, Organisational Change, Seven Day Working, Home Care Plus Other Workstreams: Intermediate Care, Children and Young

People, Long Term Conditions

• Towards Excellence in Primary Care • Access Improvement Programme • Primary Care Investment Scheme • Enhanced Services

NHS 111 Luton, Hospital-at-Home, Rapid Acute Home Visiting Service, Ambulatory Care,

Ambulance Response - care at home Clinical Navigation Team, Social Marketing –

promotion of self-care

Planned Care: Walkthrough Programme, Contract Developments, Repatriation

Medicines Optimisation: Diabetes, nutrition, CCG Formulary, Continence, Dermatology, Hypnotics,

Antipsychotics, ACHEIs, Managed Repeats

Other Value for Money Schemes

DRAFT

Building the capacity and capability of primary care

Better Together Programme 1

41


Frail Elderly Project

• Our vision to keep older people safe and well and out of hospital has three elements: a personal electronic plan, a plan leader (coordinator) and seven day working.

• In order to increase the number of patients receiving care outside of an inpatient setting, each older frail person will have a personal electronic health and care plan drawn up by all the professionals involved in conjunction with the customer and their family.

• This will be available to all health and care professionals, so an ambulance crew called out to an older woman would be able to read her care notes before they arrive and see that admission to hospital should be avoided for some known conditions .

• They can then call the plan coordinator and arrange for them to take over care at home so that the customer does not need to be taken to A&E.

• Seven day a week working will ensure that the coordinator is available at weekends and, through an ‘on-call’ system at other times of the day and night.

• Other parts of the care and health economy including care homes and GPs will also be available seven days a week at a sufficient level to prevent unnecessary hospital admission.

• The electronic personal health and care plan and coordinator will also speed up hospital discharge

• Back at home, health and care visits will be coordinated through the plan and where possible professional visitors will ‘multi-task’ so as to avoid unnecessary callers.

Disabled Children Project

There are three strands to this project:

• Luton parents will have a ‘one-stop shop’ information service for school, care and health services for them and their disabled or SEN children (web or children centre)

• A single holistic assessment of all their needs, covering education, social care and health will enable the development of a single plan for children and young people who have SEN up to the age of 25

• An integrated OT service will ensure that specialist equipment is commissioned and provided based on the joint assessment for ‘whole life’ use and as such can be used at school and at home or elsewhere it is needed.

The seamless service approach will also strengthen safeguarding as partners develop their agreement on shared risk and accountability. As a result, parents will be able to gain direct access, or assisted access through a children centre for example, to information about services that can help them and their child. From there they can either choose to follow-up one or more specific service without formal intervention, or they can start the ball rolling on getting a holistic assessment for their child and family. The effect should be that the parent or parents feel they have greater knowledge about options open to them and that they are in the driving seat when it comes to planning and choosing what’s right for them and their child. They won’t have to repeatedly explain their story and once an assessment has been made the relevant information will be used by each partner to tailor their service accordingly.

DRAFT

Better Together Programme 2

42

Information Sharing Project

• In order for health and social care professionals to have a single view of the customer, each organisation in the BT partnership will share relevant personal information by creating and maintaining an electronic personal plan using the NHS number in all cases. This plan will centre on the needs and wishes of the person and where relevant and appropriate their family or carer. The plan will be accessible to authorised personnel on mobile devices and will inform them about the relevant history and current treatment and care plan. Importantly the plan will contain contact details of the other professionals involved in providing care and support and will name the whole system lead person. The plan will be based on having informed client consent that will have been obtained once for the whole sector and will be available to the client on request.

• The project initiation documents for the three sub-projects cover protocols and procedures, employee engagement and IT development.

• The information sharing protocol and procedures ‘sub-project’ will deliver a common set of rules and guidelines for actively sharing client information to enable better health or social care service delivery and a whole system approach to obtaining informed client consent to share information.

• The staff engagement ‘sub-project’ will deliver a shared ethos about the permission to share personal information (as well as the importance of doing so) for the ‘higher purpose’ of improving the health and social care of our clients.

• The IT ‘sub-project’ will deliver a standalone web-based service that can be accessed on mobile as well as static devices enabling authorised professional service providers to see and update the client electronic personal plan.

Shared Services and Joint Procurement Project

Work is underway in this area on a case by case basis. The project team will need to consider with all BT partners whether there is a case to be made for agreeing a collective approach to future joint procurement of back office functions of sharing services.

Organisational Change Project

The ‘Organisation’ block is responsible for developing and delivering the transformational shift from many organisations with their own vision and purpose to a collective vision and purpose. A key milestone on this transformation journey will be the leadership summit planned for mid December. At the same time practical issues that are arising from the project work in other areas will fall within the remit of this area: developing common delivery protocols, policies or procedures; enabling activity to create multi-agency, multi-disciplinary teams. Issues include, moving to seven day working, redesigning job scopes, e.g. for potential ‘homecare’ plus role.

Seven Day Working Project

The purpose of this project is to deliver seven day working for health and care services in Luton with the aim of preventing unnecessary hospital stays and maximising service user and patients’ independence

Homecare Plus Project

The purpose of this project is to explore the possible role of a ‘Home Care Plus’ worker, in support of the vision of multi-tasking professionals whose job is to keep people safe at home, maximising their independence, whilst reducing the potentially confusing and inefficient number of house callers. It will develop a job brief and description for the new proposed role. DRAFT


Children and Young People

43

The Children's’ work stream has adopted an integrated model of care, working closely with General Practice, Acute and community care. There is increasing quality and reduction in duplication.

The rollout of the 2nd phase of the rapid response project will include primary care. Urgent care pathways will be incorporated into practice systems to increase their use. The pathways are also being converted into an application for Androids.

Monitoring of referral activity monthly and supporting practices where necessary. Investing in areas that are delivering quality and savings e.g.Telehealth.

The prevalence of mental Health issues are higher in Luton children and with the recommissioning of CAMHs and integrated working with Local Authority, there will be more access to lower level interventions.,

Plans are monitored against delivery monthly and reported through the appropriate Governance route.

A Stepped Model of Care for children and young people is currently being implemented within Luton. The model is designed to ensure the effective use of low cost, generic services prior to using expensive specialist resources. This includes actively including voluntary sector and community services in the pathway redesigns. The CCG is investing in building skills and capacity across acute, primary and community services, to increase prevention, early identification and self-management..

Paediatric Urgent Care

Consolidation of the paediatric urgent care pathways includes the roll out of the second phase of the Acute and Community Rapid Response Team integrated working model within Luton. A team of children’s advanced nurse practitioners who are skilled in assessing ill children, making diagnoses, ordering investigations and treatment including prescribing medication providing services in a range of settings to support the shift of care back into the community.

The model will reduce the level of A&E attendance/re-attendance, reduce the inappropriate use of inpatient beds, facilitate early discharge from inpatient wards, reduce anxiety about hospitalisation in children and families, and facilitate health education and empowerment of parents/carers in order that services are more effectively used.

Paediatric Planned Care

Working with the adult planned care work stream there is a commitment to undertake, where appropriate, specialty care pathway reviews to ensure best practice, enable more effective health care delivery and more efficient use of resources, as well as opportunities to circulate information on health and health care more rapidly.

DRAFT


44

Paediatric Telehealth Care

The aim of the projects is keeping children out of hospital and where inpatient care is necessary reducing length of stay in tertiary and secondary care facilities and providing alternative community based care as part of the patient’s individual care plan. The aim is to work collaboratively with patients and their carers to empower them with the skills, knowledge and resources to give them the confidence to care for themselves and their condition effectively so that they are able to maintain independence for as long as possible. Luton has adopted an acute consultant-led model working with specialist acute nursing staff and in partnership with community specialist nurses and GPs

Children and Young People

Child and Adolescent Mental Health (CAMHS)

The Children’s Services Commissioning Intentions sets out a plan to support the development, implementation and provision of integrated CAMH services to best meet the needs of the Luton population.

The overarching objective of this project is the genuine provision of best value integrated children and young people’s services to meet the needs of the local population now and into the future. Through dialogue with clinical staff across the workforce and other stakeholders the project will develop a comprehension of current models, culture, activity and pathways identifying gaps, pressures and opportunities in services.

Priority Areas for 2013-2016 • Fully established and operational rapid response integrated model of care in Luton •Development of computer urgent care pathway template and performance reports as part of the GP’s computer systems. •Development of a ‘new mums application’ (Android) to provide access to the paediatric urgent care patient information advice leaflets and providing automatic contact to the community rapid response team where appropriate •Accreditation and further development of the local Children’s Assessment, Knowledge and Examination Skills programme (CAKES): * Develop a train the trainer programme * Develop a bite size GP programme • Roll out further telehealth applications across children and young people with long term conditions. • Planned care specialty pathway reviews. • Fully integrated and seamless approach to the delivery of evidence based CAMHS services across Tiers 1; 2; 3 and aligned with Tier 4 services for children and young people in Luton.

DRAFT


Long Term Conditions

45

A Stepped Model of Care for patients with Long Term Conditions is currently being implemented within Luton. The model is designed to ensure the effective use of low cost, generic services prior to using expensive specialist resources.

This includes actively including voluntary sector and community services in the pathway redesigns. The CCG is investing in building skills and capacity across primary and community services, to increase in prevention, early identification and self-management.

The aim is to significantly reduce demand on the acute services for older people with Long Term Conditions through the development of integrated services health and social services for these patients and the development of an Integrated Care Hub in central Luton.

The Hub will manage increasingly complex patients in the community setting with consultant support, GPwSI and the use of remote monitoring through web based consultations, telehealth and telemedicine.

High risk patients with long term conditions will be identified through risk stratification and benefit from proactive, individualised and coordinated care planning across health and social care.

Links to other Work streams Primary Care CQUIN and QOF Intermediate Care Urgent Care, especially ambulatory care, models for managing urgent care in the community. Planned Care – reconfiguration of planned care services across acute and community Public Health – wellbeing strategy Financial Impact International evidence suggests that there could be a 7% reduction in terms of A&E attendance, admissions and outpatient appointments through redesigning the model of care for people with long tern conditions. Current LTC QIPP interventions are already demonstrating savings and the work stream will continue to build upon these services that are demonstrating positive outcomes. High level Outcomes The Stepped Care Model for Luton reflects best practice evidence from sources such as The King’s Fund (2012); NESTA (2013) which suggest that implementing such a model would achieve the following outcomes; An increase in service efficiency and productivity by using an integrated service model Reduction in A&E attendance and admissions for adults with Long Term Conditions Reduction in outpatient appointments Improved health outcomes and patient satisfaction

Priority Areas for 2013-2016

Fully established and operational Integrated Care Hub in Luton (2014)

Early Supported Discharge for Stroke patients (2015)

Expansion of Diabetes, Cardiovascular and Respiratory disease services in Luton

Development of Neurological Services and repatriation of patients with Acquired Brain Injury

A reduction in acute admission for palliative care and End of Life patients.

DRAFT


Transforming Primary Care

46

Towards Excellence in Primary Care CCG has recently refined it’s ‘towards excellence in primary care’ programme of visits to member practices. This approach looks to tackle variations in practice performance across Luton. Each visit is made by a CCG Clinical Director and supported by the Primary Care Development Manager and a Senior Finance Lead. The visit involves a two hour meeting with GPs and the practice manager and covers the following (and other) topics:

- Practice activity and benchmarking report - Primary care web tool – NHS England practice KPIs - Finance report – practice activity cf. commissioning budgets - Engagement & implementation of Primary Care CQUIN (PCC) - Access – review of national patient survey - Health checks delivery - Cancer screening uptake

Approach for these visits has recently changed ensuring that the visit is not perceived as a performance management intervention but a clinically led coaching style improvement initiative, offering direction and support where necessary. The visit enables development and implementation of an agreed improvement plan. This improvement initiative links in with, and informs engagement of, peer group analysis. PCC can be utilised to allow further exploration of areas of outlying performance.

Primary Care Investment Scheme The CCG, recognising the need to drive improvements in Primary Care in Luton has operated an investment scheme in 2013/14 to drive the achievement of local priorities such as improved end of life care and, reducing avoidable emergency admissions. The scheme has also attempted to drive innovation by making funds available to practices to pilot new services to drive better outcomes. We will learn from the delivery of the current scheme to deliver primary care on a wider scale through formal collaboration between practices, thus supporting our drive to shift funding away from hospital based care and into preventative and early intervention approaches Therefore, the LCCG Primary Care Investment Scheme (PCIS) for 2014/15 looks to refine and build on the 2013/14 scheme, with a focus on enabling continuation of peer review in the absence of QoF QP incentivisation. The scheme will encourage groups of GP practices to continue to foster and grow collaborative working arrangements to deliver co-ordinated care and integrated services close to patients’ homes. The adapted scheme consists of 3 components 1. Development of Practice Groups 2. Emergency Admissions (Benchmarking and achievement of

thresholds)

DRAFT


47

Transforming Primary Care Primary Care Access Improvement Programme Improving the results of Luton practices for the four questions relevant to access in the GP Patient Survey remains a priority for Luton CCG and for NHS England. For one or more of the key four questions relating to access, currently three Luton practices are ranked in the top decile of the 324 practices covered by the Herts and South Midlands Area Team, and 11 Luton practices are ranked in the bottom decile. Luton CCG Primary Care Development (PCD) Team staff have been working with the practices in the bottom decile, taking a collaborative approach to exploring solutions, sharing ideas and best practice. Key activities: • Access Working Group meets 3-monthly, facilitated by PCD staff • A review of literature and historical PCT activity has been

completed by PCD staff • A checklist has been produced (see Appendix 2) based on national

quality standards against which practice managers in the group have agreed to review their practices

• The group has circulated a document outlining how a continuing focus on access supports the priorities of LCCG

• The group has developed a list of suggested actions for practices to consider, including case studies from across the country

Formalising a Primary Strategy The CCG is working closely with the NHS England Area team to formalise a shared strategy for transforming primary care in Luton A Primary Care Transformation Programme: Quality Improvement and Innovation Workstream Board has been established to deliver the following: • A Strategy for Primary Care Improvement relevant to CCGs’

commissioning intentions with sufficient freedom for local variation and sufficient cohesion for equality of patient outcomes and experiences (where appropriate) across the Area.

• A number of projects (each with specific deliverables and success measures) that will enable achievement of common/shared challenges by co-commissioners of primary care (e.g. premises, workforce development, creation of new models of primary care and providers willing and able to deliver them so as to achieve commissioners’ strategic plans).

DRAFT


Mental Health & Community Services Re-procurement

48

Rationale for Re-Procurement

• The contracts for Mental Health and Community Health services with South Essex Partnership Trust (SEPT) and Cambridge Community Services will end at the end of March 2014. A market engagement process in Spring 2013 demonstrated a wide range of providers would be interested in bidding for these services in Luton so re-procurement was selected by the CCG as the most appropriate method to achieve improved patient outcomes and better value for money. There are also opportunities to seek integration, in the context of the Luton (CCG and Council) programme ‘Better Together’, and to bring together physical and mental health services in a more holistic way around patients/service users and their families.

• A re-procurement programme has been established, comprising Luton CCG as lead commissioner, with co-commissioners Luton Borough Council and NHS England Area Team for Herts and South Midlands, supported by Central Eastern CSU/Attain procurement support. Competitive Dialogue was selected as the most appropriate procurement route.

• An advert was placed on 6th November and this first phase of PQQs closes 4th December. Rounds of dialogue will be held over the Spring 2014 with new contracts being mobilised by September 2014. The services are being let in 4 lots : Adult Mental Health, CAMHS, Community Health services, Intermediate Care. Potential providers may bid for all lots or any combination. Current providers are intending to submit PQQs.

Programme Delivery and Benefits Realisation

• Programme delivery is via 5 dedicated work streams (WS) as follows:

• WS 1 Clinical Design and Specification

• WS 2 Financial modelling

• WS 3 Communication and engagement

• WS 4 Technical, procurement and commercial

• WS 5 Assets and liabilities

Benefits Realisation

• Built on firm foundations of preparatory market testing and partnership working.

• Improved Commissioning and Contractual arrangements

• Safe, high quality services

• Patient and public engagement informing the process and outcomes

• Potential for innovative change (maximised through process of procurement)

• Quality and productivity improvements

• Longer term sustainability

• Synergy and integration

• Development of needs driven integrated pathways of care.

DRAFT


Mental Health & Community Services Re-procurement : Governance

49 DRAFT


Mental Health

50

The Mental Health Stepped Model of Care continues being implemented within Luton. The model is designed to ensure the effective use of low cost, generic services prior to using expensive specialist resources. This includes actively including voluntary sector and community services in the pathway redesigns. The CCG has invested in building skills and capacity across access to psychological therapies services through IAPT which will focus on early identification and self-management of people with mild to moderate mental illness and prevention of escalation to a more serious mental illness. The aim in time, is to significantly reduce demand on secondary care mental health services and allow secondary care service redesign that targets those who are most vulnerable and require more intensive support and acute inpatient facilities.

Outcomes The Stepped Care Model for Luton reflects best practice evidence from sources such as The King’s Fund (2012); NESTA (2013) which suggest that implementing such a model would achieve the following outcomes; An increase in service efficiency and productivity by using an integrated service model Reduction in A&E attendance and admissions for adults with a mental illness Improved health outcomes and patient satisfaction Improved recovery rates for people as they are accessing early intervention and preventative services.

Priority Areas for 2013-2016 • Fully established and operational Integrated Hub in Luton

for the delivery of IAPT services • Early intervention and prevention, including suicide

prevention (Public health). • Fully compliant NICE recommended treatments for

secondary care (PbR) clustered patients. • Recovery focused services within community based

settings. • Primary Care Link Workers (Mental health practitioners) in

every GP practice in Luton

DRAFT


Intermediate Care

51

Intermediate Care features as one of the elements within the re-procurement of mental health and community services programme. Currently services operate effectively but work in October 2013 identified further opportunities to increase the number of people accessing the services and to increase the number of people stepping up from the community as opposed to stepping down from Hospital. This work will focus on:

• 7 day working for the Community Assessment and Rehabilitation Team (CART) to speed up the progress of people receiving rehabilitation and support hospital discharge at the weekend

• Developing a business case and full service model for a Step Up nursing care home based service to prevent hospital admissions, in conjunction with the existing services available across health and social care

Links to other Work streams Urgent Care, especially ambulatory care, models for managing urgent care in the community. Long Term Conditions Mental Health, especially people with dementia who are excluded from some existing intermediate care / rehabilitation services Integration Financial Impact A previous study by the Oak Group at L&D in 2010 as many as 68% of beds in DME acute wards could be re-provided in a different way, including 17% in intermediate care (care home plus nursing / rehab) settings and 13% home with nursing services. A full business case is required to assess the impact of these changes financially, alongside the impact on the individual patients. High level Outcomes Improving rehabilitation and intermediate care services will achieve the following outcomes: • Reduction in hospital admissions • Improved functioning, so leading to a reduction in on-going

health and social care input • Improved health outcomes and patient satisfaction

DRAFT



52

111 The NHS 111 Service provides a sign-posting of patients who have an urgent care need, to the most appropriate health provider. • Present Status: NHS 111 Luton pilot, which ran from 2010 was to be

replaced by a substantive service from April 2013, but did not happen. An interim arrangement is in place.

• Planned Development: a new NHS 111 Luton (Caretaker) Service, provided by South Central Ambulance Service (SCAS) will run from February 2013

• High Level Outcomes: to increase the number of people using NHS 111 and reducing the number of people attending A&E; to reduce pressure on A&E and numbers of short-stay admissions.

• Financial impact: reduced costs from reduction in A&E attendances and A&E short-term admissions

Hospital at Home An arrangement whereby patients who under the care of a hospital consultant are discharged home, supported by the Hospital-at-Home nursing team, under the direction of the Consultant. • Present Status: a pilot has been completed with notable number of patients

being discharged from hospital earlier. • Planned Development: to continue service, and expand across a broader

range of surgical and other specialties. • High Level Outcomes: reduce of Length of Stay in hospital, providing greater

flexibility and reduction in bed capacity, with care closer to home for patient.

• Financial impact: reduced bed costs in hospital, supported by agreed financial arrangements for discharged patients, resulting in cost reduction overall.

Rapid Acute Home Visiting Service To provide a supporting service to GPs, undertaking home visits to patients earlier in the day, addressing care needs in the home, or arranging ‘early day’ attendance at A&E. • Present Status: proposals for service are well advanced, with

implementation expected by December 2013. • Planned Development: to trial the Service in a limited area, provide

feedback of effectiveness, and to roll out across all areas. • High Level Outcomes: reduced A&E attendances, reduced ambulance call

outs, reduced interruptions for GP surgeries; reduced admissions, with patients who do attend A&E having earlier resolution of health concerns, enabling a return to home.

• Financial impact: reduced costs for ambulance call outs, A&E attendances and short-stay admissions; investment resulting in net savings.

Ambulatory Care Patients attending A&E who are mobile and meet certain criteria are streamed early to a dedicated service, e.g. respiratory team, which can provide speedy resolution of care needs, and discharge patient home, with follow-up as required. • Present Status: already in place at hospital for a small range of patients. • Planned Development: to expand the number of ‘streamed care

pathways’; to extend service hours into early evening. • High Level Outcomes: reduced waiting times in A&E; earlier decision-

making and streaming; reduced number of admissions; improved patient experience.

• Financial impact: reduced number of short-stay admissions.

DRAFT



53

Ambulance Response – Care at Home Ambulance paramedics can support patients at home, for example where the patient has a respiratory concern, the paramedic can use matrix-tool to determine whether the patient needs to attend hospital or can stay at home, with referral to community respiratory team. • Present Status: initial work underway for respiratory patients • Planned Development: facilitate roll-out across area; support development

into other symptom groups. • High Level Outcomes: reduction in ambulance journeys, A&E attendance

and short-stay admissions. • Financial impact: Cost saving through reduction in A&E attendance an short-

stay admissions • Links to other work-streams: long-term conditions

Clinical Navigation The nurses in the Clinical Navigation Team CNT provide holistic direction to patients being discharged from A&E and EAU, to ensure they receive follow-up care from the most appropriate provider in the community. • Present Status: the CNT has been piloted and extended. • Planned Development: To embed the CNT into hospital discharge

arrangements • High Level Outcomes: patients are directed to community services, rather

than admitted; reduction in short-term and long-term conditions • Financial impact: cost reduction of admissions, providing cheaper and more

cost-effective community services. • Links to other work-streams: Long term conditions

DRAFT


Planned Care

54

Service Development – Acute Walkthroughs The CCG is undertaking a programme of walkthroughs in each acute speciality. This is enabling us to understand in detail how each patient pathway works, how these can be improved and how the current activity and monitoring mechanisms reflect what really happens to patients. As this programme progresses the CCG has identified a number of areas where pathways and services can be redesigned. This change programme will be implemented over the next three years with the highest priority areas being implemented in 14/15. Financial implications Improved processes and contractual changes will ensure savings in Procedures of limited clinical value and Better care better value ratios Links to other workstreams In order to reduce the demand on planned care services it is necessary to have effective management of long term conditions. Pathway development will therefore address the whole patient journey. These pathways will also look at the urgent care aspect of care. Outcomes: • Reduce secondary care elective activity • More local care for patients • Improved patient experience • Faster and more efficient pathways of care reducing unnecessary steps.

Contractual changes Parallel to the walkthroughs the CCG is undertaking a review of clinical notes to ensure that patient management is of good quality and in line with contractual agreements. Issues being reviewed are: • Consultant to consultant referrals • Procedures of Limited clinical value • Non-consultant appointments • Daycase to Outpatient procedures • Coding errors • Referrals from A+E • Direct Referral pathways As a result of these reviews the CCG anticipates that it will be able to challenge the invoices for 13/14 and achieve significant savings. Additionally the CCG is developing new processes for the management of PLCV which will reduce inappropriate referrals and ultimately elective activity. It is also the intention of the CCG to negotiate a new protocol for consultant to consultant referrals in the contract from 14/15. Financial The note reviews will support contract challenge for 13/14 and new processes for C2C and PLCVs will have an on-going impact in future years. Outcomes Reduction in inappropriate referrals Improved pathways of care Improved data quality.

DRAFT


Medicines Optimisation

55

Medicines Optimisation is about ensuring that patients get the best possible outcomes from their medicines, through using medicines that are evidence based and safe, through involving patients more and embedding medicines optimisation as part of routine practice for all healthcare professionals. Medicines are the most common intervention in healthcare and are part of the great majority of healthcare pathways. David Nicholson is quoted as saying that ‘Medicines optimisation is a vital agenda, not an agenda added on to something else we are trying to do, this is absolutely central to it.’

Medicines Optimisation and QIPP The CCG recognises that there remains good potential to deliver the QIPP agenda by ensuring that prescribers utilise the most cost effective routes to deliver quality outcomes for patients. The CCG is currently reviewing 18 potential QIPP schemes for delivery in the period 2014-2016to deliver savings of £1.5m. These include (annual savings in brackets):

Diabetes needles (53k) Diabetes insulin (75k) Diabetes DDPAS (75k) Nutrition sip feeds (80k) Nutrition Gluten Free (20k) Formulary (97k) Continence, stoma (50k) Dermatology Emollients (75k) Overactive Bladder (15k)

Hypnotics review(150k) Antipsychotics / ACHEIs (75k) Diabetes DDPAS (75k) Managed Repeats (500k Nutrition Gluten Free (20k) Formulary (97k) Continence, stoma (50k) Dermatology Emollients (75k) Overactive Bladder (15k)

Plaque psoriasis (30k) Dressings (75k) Respiratory COPD (75k) Respiratory LABA (20k) Disinvestment – herbal (45k) Formulary (97k) Continence, stoma (50k) Dermatology Emollients (75k) Overactive Bladder (15k)

QIPP Programmes

DRAFT


Prevention

DRAFT 56


The CCG works closely with Luton Borough Council’s Public Health team on the planning and delivery of prevention programmes . The CCG as an organisation consisting of its member practices has an opportunity to drive the delivery of Primary and Secondary Prevention programmes though Primary Care

Delivery of NHS Health Checks NHS health checks are a key preventative initiative and act to identify people at risk of early death or disability from vascular related disease so as to enable and promote lifestyle and behaviour change to reduce that risk. LCCG has identified NHS health checks as a local priority and has committed to improving delivery (both uptake and quality) through general practice in order to better address health inequalities in Luton.

Finding the “Missing Thousands” There are estimated to be around 2000 people with undiagnosed diabetes living in Luton. Data indicates that there is similar under-diagnosis in a range of long term conditions. It is vital that people in need of appropriate health care interventions receive these in a timely and proactive way in order to reduce the likelihood of complications, exacerbations, avoidable admissions and early death. LCCG has committed to helping find these ‘missing thousands’ and ensuring that people receive active management and early intervention where it is appropriate to do so.

Delivery of public health service agreements Public Health Service Agreements such as top smoking, chlamydia screening, sexual health, HIV and NHS health checks are commissioned from primary care by the LBC Public Health team. These agreements are important initiatives aimed at prevention and early intervention for a range of lifestyle and behaviour risk factors. LCCG is committed to encouraging and promoting the uptake of these public health service agreements with general practices and will actively seek to address the variation in uptake and quality of provision of these services in order to ensure equity and address health inequality


57 DRAFT

58


Contract Management Contract Management underpins all of our commissioning work streams as it is a key enabler for the CCG to deliver value for money in service delivery by providers. Our commissioning, finance and quality teams will work with our Commissioning Support Unit to ensure effective contracts management to deliver commissioned services to financial plan. Key initiatives • Robust management of our main acute contract – through data validation and reconciliation, led by the finance team supported

by CSU. In addition, we will work with the Luton & Dunstable Foundation Trust to ensure that there is a shared local strategy for the control of activity with CCG and Trust responsibilities clearly outlined.

• Greater focus on our other Acute contracts, starting with a comprehensive review of the existing contract arrangements and spend by our CSU.

• Community Services as key enablers for out QIPP programme held to account over delivery through issue of contract query notices and jointly agreed remedial action plans.

• CCG is unsatisfied with level of delivery from CSU and has issued a Contract Notice on BI (Business Intelligence) and Contracts management. • Short term action already taken to recruit interim Business Analyst / Contracts Manager • Board currently considering longer term future options for commissioning support Focus on Non-Contracted Activity, principally mental health where we will continue to repatriate our out of area patient back into the SEPT block contract and continue to challenge all requests from SEPT for an out of area patient placement. High level Outcomes • Ensure ALL provider contracts especially L& D Contract is managed within agreed finance and activity plan • Community Services Contract is managed such that the key QIPP deliverables support the management of appropriate activity in

the community • All mental health patients treated within Luton other than in exceptional cases • All other acute contracts and non-contracted activity is within or below plan Priority Areas for 2013-2016 Data validation and challenge; clinical walk-throughs and audits; new methods of counting and coding; reduction of Non-contracted activity.

DRAFT

59


Practice Engagement Peer Groups Currently five GP peer groups across Luton. CCG Clinical Directors have been aligned to GP practices and their peer groups to ensure active and open dialogue between the CCG leadership team and member practices. Clinical Directors roles are expected to play within peer groups has been defined to ensure a commonality of approach. This mechanism builds on the knowledge and expertise of individual practitioners and gives all practices the opportunity to play an active part in the work of the CCG. Peer groups have been in existence for a few years. Practice peer group model is being reviewed to ensure enough traction and challenge is in place with practices and referring to other CCG models to learn best practice

Further Development of Peer Groups Building on the positive experience of a number of other CCGs, we are planning to drive a more formal approach to Peer Groups as a key enabler for the management of primary care driven activity and using agreed pathways more effectively. This means that the current five Peer Groups will merge into four new Peer Groups or “Clusters”. In order to support this we will recruit two Peer Group Managers and Finance / Business Intelligence Support. The first meetings to establish Governance arrangements will take place in May 2014, with fully operational meetings reviewing practice level and Peer-Group level activity, cost and performance data in June 2014

DRAFT

Protected Learning Time (PLT) PLT is a key communication channel to enable a strong practice role in strategic delivery. The CCG will re-launch PLT in April so that agenda’s reflect strategic priorities and drive the skills knowledge and resources to deliver. Clinical directors will effectively own the agenda to drive priority initiatives.

Members Forum The Forum has been in place since the CCG existed in shadow form and is designed as a platform for practices to hold the CCG to account and vice versa. Our key challenge in the immediate future is to ensure that a greater proportion of practices are represented at the meeting. We aim therefore to increase this from the current baseline of 50% to 80% in the first half of 2014/15.

Workforce Transformation

60


• The CCG is developing 5 year workforce plan for Luton with key partners across the health and social care system. This takes into account the current difficulties in recruiting into Adult Community Nursing and Specialist Services.

• In order to provide higher acuity care for adults older people and those with long term conditions , the community nursing and social care workforce will need to be enhanced both in terms of numbers and skills.

• Forecasted workforce requirements will be an integral part of the procurement process for Community health services and the Better Together integration strategy for Luton

• The CCG is implementing its Organisational Development Plan which includes the development of primary care clinicians and attracting primary care leadership talent to the area

• A scheme is being developed by the CCG to recruit GPs into Luton, working with the GP Tutor, Health Education England and University of Bedfordshire. The scheme will take 2 GPs per year for a three year programme, with sessions in practices, the CCG and the University.

DRAFT

8. Financial Plan

61 DRAFT

Financial Recovery

62

8. Financial Plan

Financial Recovery Luton CCG is a relatively new organisation currently in its first year of delivery of its statutory responsibility as the main commissioner of healthcare in Luton. As is the case with many CCGs, Luton was placed in the Financial Recovery Process in October 2013 which reflected an escalation in demand for acute services but also the recognition that the CCG – and the PCT before it – had been underfunded when considering the high levels of deprivation and health inequalities that exist in the town. The funding gap is however beginning be addressed via financial allocations for 2014/15 – 2015/16 A separate Financial Recovery Plan has been developed and this provides more detail on the Financial Plan for the next 5 years

Key Elements of Financial Recovery Plan The CCG is currently forecasting a financial deficit of £5.3m at the end of the current financial year. This is in the main due to unexpectedly high levels of activity at the local acute trust, the Luton and Dunstable Hospital. The CCG plans to delivery a breakeven financial position by the end of 2014/15 and will achieve this by: • The implementation of newly identified QIPP programmes delivering additional savings • Utilisation of the 2% transformation fund of £5.3m The CCG plans to deliver a surplus by the end of 2015/16 and in subsequent years through the delivery of further additional QIPP programmes.

DRAFT

QIPP Strategy and Challenge for 2014/15

63

8. Financial Plan

QIPP Strategy Within the context of the Five Year Strategic Plan, 2 year Operational Plan and three year Financial Recovery Plan, there is an opportunity and need for integrated QIPP planning across the system that is bold and innovative. Luton CCG will work with NHS England, Providers and Luton Borough Council to ensure that we work in collaboration to achieve a system wide solution. The key themes are: • Invest to disinvest – for example stepped care models • Innovative and transformational commissioning • Integration through the Better Together Programme is an imperative to support the above We are forecasting £5m QIPP programmes to be delivered in 2013/14

DRAFT

QIPP Challenge 2014/15 • The CCG requires QIPP delivery of £6.1m in order to achieve a breakeven position by March 2015. • We assume 70% delivery of all agreed QIPP programmes which means that we must plan for delivery

of £9.4m which includes an investment of £0.7m • At March 14th the CCG has identified £8.6m QIPP programmes which means that a further £0.76m

must be identified by final plan submission on April 4th • A summary of current QIPP Programmes for 2014/15 is shown on the next slide

DRAFT 64

100% Delivery 70% DeliveryScheme-ID Scheme-Desc Project ID SIG Savings From Gross Savings Investment Net Savings Net Savings

14/15-00A QIPP FYE of 13/14 (Dipyridamole to Clopidogrel,Branded Generics & Patent Expiry) 14/15-00 Meds Optimisation April 100,000 0 100,000 70,000

14/15-00A QIPP FYE of 13/14 (Dipyridamole to Clopidogrel,Branded Generics & Patent Expiry) 14/15-00 Meds Optimisation April 60,000 0 60,000 42,000

14/15-01A Diabetes Needles 14/15-01 Meds Optimisation April 53,000 -15,000 38,000 26,600

14/15-01B Nutrition- SIP feed 14/15-01 Meds Optimisation April 80,000 -32,238 47,762 33,433

14/15-01C Dermatology- Emollients 14/15-01 Meds Optimisation June 40,000 0 40,000 28,000

14/15-01D Diabetes Insulin 14/15-01 Meds Optimisation June 60,000 -46,196 13,804 9,663

14/15-01E Diabetes DPP4S 14/15-01 Meds Optimisation June 50,000 0 50,000 35,000

14/15-01F Nutrition - Gluten Free 14/15-01 Meds Optimisation April 20,000 0 20,000 14,000

14/15-01G MH- Hypnotics Review 14/15-01 Meds Optimisation April 150,000 -45,000 105,000 73,500

14/15-01H Mental Health 14/15-01 Meds Optimisation April 50,000 0 50,000 35,000

14/15-01I Managed Repeats 14/15-01 Meds Optimisation April 400,000 -35,000 365,000 255,500

14/15-01Q Dermatology- Plaque Psoriasis 14/15-01 Meds Optimisation April 60,000 0 60,000 42,000

14/15-01J Dressings 14/15-01 Meds Optimisation April 75,000 0 75,000 52,500

14/15-01K Resp - COPD 14/15-01 Meds Optimisation April 75,000 -46,196 28,804 20,163

14/15-01L Resp - LABA 14/15-01 Meds Optimisation April 20,000 0 20,000 14,000

14/15-01M Disinvestment - Herbal 14/15-01 Meds Optimisation April 45,000 0 45,000 31,500

14/15-01N Continence- Stoma 14/15-01 Meds Optimisation April 50,000 -6,000 44,000 30,800

14/15-01O Medicine - Branded To Generic 14/15-01 Meds Optimisation April 100,000 0 100,000 70,000

14/15-01P Specials 14/15-01 Meds Optimisation April 100,000 0 100,000 70,000

14/15-01Q Branded Generics 14/15-01 Meds Optimisation April 100,000 0 100,000 70,000

14/15-01R Rosuvastatin to Atorvastatin 14/15-01 Meds Optimisation April 65,000 0 65,000 45,500

14/15-01S Blood Glucose Testing Strips 14/15-01 Meds Optimisation April 35,000 0 35,000 24,500Medicines Optimisation Sub Total 1,788,000 -225,630 0 1,562,370 1,093,659

14/15-02A Rapid Response 14/15-02 Paed April 105,409 -25,424 79,985 55,990

14/15-02B CAMHS Health & Wellbeing 14/15-02 Paed October 222,000 -190,000 32,000 22,400

14/15-02C Telehealth Children 14/15-02 Paed April 47,500 0 47,500 33,250Paeds Sub Total 374,909 -215,424 159,485 111,640

14/15-03A Planned Care Walkthrough review of services 14/15-03 Planned Care June 924,803 -105,770 819,033 573,323

14/15-05A PCI - Bedford Hospital 14/15-05 Planned Care April 777,734 0 777,734 544,414

14/15-05A PCI - Royal Brompton 14/15-05 Planned Care April 969,257 0 969,257 678,480Planned Care Sub Total 2,671,794 -105,770 2,566,024 1,796,217

14/15-04A Hospital at Home 14/15-04 Urgent Care April 370,000 -157,000 213,000 149,100

14/15-04B Ambulatory Care 14/15-04 Urgent Care April 100,211 0 100,211 70,148

14/15-06B Ambulance Response Team 14/15-06 Urgent Care April 8,637 0 8,637 6,046Urgent Care Sub Total 478,848 -157,000 0 321,848 225,294

14/15-06A Acute - Contract Challenge (Non L&D) 14/15-06 Acute April 1,428,571 0 1,428,571 1,000,000

14/15-07A Acute - Contract Challenge (L&D) 14/15-07 Acute - L&D June 1,857,143 0 1,857,143 1,300,000Acute Sub Total 3,285,714 0 3,285,714 2,300,000

8,599,266 -703,824 (A) 7,895,442 5,526,809

14/15-08A Unidentified Schemes 14/15-08 Meds Optimisation June 150,000 0 150,000 105,000

14/15-09A Unidentified Schemes 14/15-09 Continuing Care April 300,000 0 300,000 210,000

14/15-10A Unidentified Schemes 14/15-10 Acute April 165,740 0 165,740 116,018

14/15-11A Unidentified Schemes 14/15-11 Acute - L&D April 150,000 0 150,000 105,000To Be Identified and Verified Sub Total 765,740 0 (B) 765,740 536,018

Grand Total 9,365,006 -703,824 (C) 8,661,182 6,062,827

2014/15

8. Financial Plan Summary of QIPP Programmes– 2014/15

9. Governance

65 DRAFT

DRAFT 66

9. Governance

Governance and Delivery Assurance

Introduction The CCG has adopted a formal process of governance to manage the implementation of the Operational Plan, including the delivery of QIPP. The process - shown diagrammatically on the following page – is intended to provide the Board with delivery assurance through regular performance monitoring in a number of forums at which clinicians and managers are called to account for delivery. The key principles of this are •The detail of discussion and reporting decreases from Executive to Clinical Commissioning Committee (CCC) to Finance and Performance Committee to Board. •Executive holds programme leaders from the Strategic Implementation Groups to account and functions as a problem solver. The Executive functions a Delivery Programme Board and devotes one meeting per month for this purpose. •The CCC holds Clinical Directors to account and drives full understanding of the barriers and solutions in place. The CCC meets monthly. •The Finance and Performance Committee meets monthly to assures itself that plans are being delivered and that solutions are in place to overcome any barriers. This committee provides additional assurance to the Board that financial objectives are on track and that contractual issues with providers are being addressed • The Patient Safety and Quality Committee provides assurance that quality and safety aspects are addressed •The Board is assured of delivery and has an understanding of key barriers and solutions

DRAFT 67

9. Governance

Governance and Delivery Assurance Clinical Commissioning Committee The Clinical Commissioning Committee is “engine room” of the CCG and makes the key clinical commissioning decisions and ensures the delivery of our plan. A key remit of the committee is the approval of Business Cases for service transformation. The committee then reviews the implementation of key programmes which drive the delivery of the Operational Plan including QIPP. The committee comprises senior CCG clinical leadership, together with key CCG management and local allied health professionals.

Strategic Implementation Groups Luton CCG has established eight SIGs to implement our strategic priorities. Each SIG reports directly to the CCC via a designated Clinical Director with clear individual accountability for the successful implementation of each strategic priority, the financial and operational performance and for patient experience, quality and safety.

•Prevention •Children and Young People

•Mental Health •Planned Care •Primary Care

•Long Term Conditions •Urgent Care •Prescribing

Governance and Delivery Assurance – High Level Structure

DRAFT 68

9. Governance

11/22/2013 41

Finance and Performance

Committee

CCG Board

Clinical CommissioningCommittee

Executive Committee (Functions as a “QIPP Programme Board” reviewing

detailed programme reports and holding programme leads to account)

Executive DirectorsClinical Directors

Challenge, Exception Reporting; Mitigation;

Quality and Safety ImpactEquality and Diversity Impact

Inputs / OutputsAccountability

Executive DirectorsClinical Directors

Clinical Directors

SIMsExecutive Directors

Challenge, Exception Reporting; Detail on Solutions; Quality and

Safety ImpactEquality and Diversity Impact

Agree Board Report

Challenge, Achievements; Barriers; Understanding

Solutions; Quality and Safety Impact

Equality and Diversity Impact

Challenge ,Achievements; Barriers; Problem solving; Quality and Safety Impact

Equality and Diversity Impact

Patient Safety and Quality Committee

Strategic Implementation Groups DELIVERY Practices

Governance and Delivery Assurance – Reporting Cycle

DRAFT 69

9. Governance

CCG Board Last Tuesday of

every month

Strategic Implementation

Groups

Executive Committee

1st Thursday of every month

Clinical Commissioning

Committee

2nd Thursday of every month.

Patient Safety and Quality Committee

3rd Wednesday of very month

Finance and Performance Committee

2nd Thursday of every month. Peer Groups

Practice Visits

Members Forum

Protected Learning Time

Peer Groups

Practice Visits

Members Forum

Protected Learning Time

10. Activity Plan

70 DRAFT

DRAFT 71

Planning Round 2014-1506P NHS LUTON CCG

E.C.1 E.C.2 E.C.3 E.C.9 E.C.10 E.C.11 E.C.4 E.C.5 E.C.12 E.C.6

CCG Activity

Elective

Admissions -

Ordinary

Admissions

Total Elective

Admissions -

Day Cases

(FFCEs)

Total Elective

FFCEs

GP Written

Referrals

(G&A)

Other referrals

(G&A)Total Referrals

Non-elective

FFCEs

All First

Outpatient

Attendances

First

Outpatient

Attendances -

following GP

Referral

All Subsequent

Outpatient

Attendances

(All specialities)

2014/15 April 403 1467 1870 3312 2329 5641 1796 3196 5052 -

May 433 1486 1919 3700 2603 6303 1842 3181 5367 -

June 467 1476 1943 3033 2052 5085 1743 3297 5552 -

July 544 1658 2202 3533 2487 6020 1793 3767 6277 -

August 470 1482 1952 3116 2243 5359 1818 3171 5427 -

September 467 1545 2012 3440 2375 5815 1747 3645 5968 -

October 503 1683 2186 3789 2666 6455 1969 3738 6291 -

November 475 1530 2005 3419 2404 5823 2007 3672 6115 -

December 490 1561 2051 3391 2374 5765 1849 3549 5941 -

January 429 1360 1789 2973 2094 5067 1605 3093 5175 -

February 389 1263 1652 2775 1959 4734 1522 2866 4797 -

March 397 1285 1682 2845 1994 4839 1534 2953 4926 -

Quarter 1 - - - - - - - - - 21382.18504

Quarter 2 - - - - - - - - - 24212

Quarter 3 - - - - - - - - - 22796.59252

Quarter 4 - - - - - - - - - 23503.79626

2014/15 Total 5467 17796 23263 39326 27580 66906 21225 40128 66888 91894.57382

2013/14 Forecast Outturn 5322.226871 17299.70009 22621.92697 38199.64984 26787.76884 64987 20631.31219 38973.41872 64944.91065 93950.002

Forecast growth in 2014/15 2.7% 2.9% 2.8% 2.9% 3.0% 3.0% 2.9% 3.0% 3.0% -2.2%

2015/16 April 415 1509 1924 3407 2396 5803 1847 3295 5218 -

May 445 1528 1973 3795 2670 6465 1893 3280 5533 -

June 479 1518 1997 3128 2119 5247 1794 3396 5718 -

July 556 1700 2256 3628 2554 6182 1844 3866 6443 -

August 482 1524 2006 3211 2310 5521 1869 3270 5593 -

September 479 1587 2066 3535 2442 5977 1798 3744 6134 -

October 515 1725 2240 3884 2733 6617 2020 3837 6457 -

November 487 1572 2059 3514 2471 5985 2058 3771 6281 -

December 502 1603 2105 3486 2441 5927 1900 3648 6107 -

January 441 1402 1843 3068 2161 5229 1656 3192 5341 -

February 401 1305 1706 2870 2026 4896 1573 2965 4963 -

March 409 1327 1736 2940 2061 5001 1585 3052 5092 -

Quarter 1 - - - - - - - - - 24894

Quarter 2 - - - - - - - - - 24939

Quarter 3 - - - - - - - - - 24916

Quarter 4 - - - - - - - - - 24927

2015/16 Total 5611 18300 23911 40466 28384 68850 21837 41316 68880 99676

Forecast growth in 2015/16 2.6% 2.8% 2.8% 2.9% 2.9% 2.9% 2.9% 3.0% 3.0% 8.5%

- - - - - - - - - -

- - - - - - - - - -

2016/17 Total 5745.949186 18839.38761 24585.33679 41715.40207 29478.08145 71193 22461 42540 70932 102664


2017/18 Total 5899 19344 25243 42854 30064 72918 23109 43788 73044 105740


2018/19 Total 6043 19896 25939 44102 30928 75030 23769 45072 75216 108908


The above plan does not yet take account of QIPP impact or the outcome of contract negotiations

10. Activity Plan

Impact of QIPP on Acute Activity

DRAFT 72

10. Activity Plan

PROVIDER PROJECT WORKSTREAM Start Date

E.C.1 - Elective

G&A Ordinary

Admissions

(FFCEs)

E.C.2 - Elective

G&A Daycase

Admissions

(FFCEs)

E.C.3 - Elective

G&A Total

Admissions

(FFCEs)

E.C.9 - GP

Referrals Made

(All specialties)

E.C.10 - Other

Referrals Made

(G&A)

E.C.11 - GP

Referrals Made

(G&A)

E.C.4 - Total

Non-elective

G&A

Admissions

(FFCEs)

E.C.5 - All 1st

Outpatient

Attendances

(G&A)

E.C.12 - GP

Referrals Seen

(All specialties)

E.C.6 - All

Subsequent

Outpatient

Attendances

(All specialities)

A&E (separate

template)

L&D Rapid Response Paediatrics April 367

L&D CAMH Health & Wellbeing Paediatrics July 34

L&D Telehealth (LTC) Paediatrics April 24 62

L&D PCI & Angiograhy Planned Care April -70 -64

Royal Brompton PCI & Angiograhy Planned Care April 45 115

Bedford Hospital PCI & Angiograhy Planned Care April 25 127

L&D Ambulance Response Team Urgent Care April 296 296

0 0 0 0 0 0 899 0 0 62 296

Please note this is work in progress and requires impact of Better Care

Fund Initiatives

luton ccg operational plan - draft

Documents