north central london strategic planning unit 5 year strategic … · community, outside of hospital...
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North Central London
Strategic Planning Unit
5 Year Strategic Plan draft submission 4 April 2014
Draft as at 3 April 2014
Appendix: 5.1a
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North Central London health economy is a system comprised of partners from Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG, and Islington CCG who have come together to agree, refine and implement the following strategic intent: To drive improvement in the delivery of high quality, evidence-based and compassionate services, defined and measured by outcomes not process, to the population of north-central London.
System Objective One
Reducing the number of years of life lost by 9.2%
System Objective Two
Improving the health related quality of life of those with 1+ long-term conditions by 4.3%
System Objective Three
Reducing the amount of time people spend avoidably in hospital through
better and more integrated care in the community, outside of hospital by 5.3%
System Objective Four
Increasing the proportion of older people l iving independently at home
fol lowing discharge from hospitalTrajectories to be finalised for next draft
System Objective Five
Reducing the proportion of people reporting a very poor experience ofinpatient care by 5.9%
System Objective SixReducing the proportion of people reporting a
very poor experience ofprimary care by
19.8%
System Objective SevenMaking significant progress towards el iminating avoidable deaths in our
HospitalsTra jectories to be finalised for next draft
Delivered through Commissioning for Value Based Outcomes (VBC) CCGs in north-central London are working collaboratively to move to a VBC
approach. This is beginning with work on Older People with Frailty, mental health and diabetes and will be expanded to cover more areas in the future. We are individually focussing on integrated care, with a focus on populations. This includes: •Improved management and outcomes for children and young people. •Improvement in management of care in the community. •Maximising the time spent at home during and after treatment.
•Promoting collaboration and communication between patients, staff and carers. •Better alignment of physical and mental health services to improve outcomes for vulnerable groups experiencing high levels of mortality or ill -health. •Developing collaborative packages with other CCGs .Models and priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy.
Each of the CCGs plan to work with all providers to improve outcomes for patients with Long Term Conditions, this will include: •Improving recorded prevalence of Long Term Conditions. •Primary and Secondary Prevention. •Pathways redesign. Models and priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy.
Primary Care We have a focus on developing Primary Care through our collaborative investment
budget. All 5 CCGs are committed to working closely with NHS England to improve quality and access to primary care. North Central London CCGs have in place Primary Care Strategies, with dedicated resource for implementation. Key goals include: •Primary care strategy implementation. •Development of primary care networks. •Demand management within primary care.
•Improvement of patient experience. •Improvement of capacity within primary care. •Increasing Primary and Secondary Prevention. Priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy.
Delivered through local IntegrationAll 5 CCGs are :
• developing models of integration which offer a range of prevention, early intervention and supported self management delivered by a variety of providers, including health, local authority and voluntary and community organisations , working together in different ways to support people and families more effectively.
• progressing plans for the Better Care Fund (BCF) in collaboration with colleagues from the respective London Boroughs for agreement by CCG Governing Bodies and
Health and Wellbeing Boards.
Overseen through the following governance arrangementsOur collaborative arrangements are overseen by the North London Clinical Commissioning Committee, comprised of CCG Chairs, COs and with NHS England in attendance. • we collaborate on financial risk share, Primary Care, BEH Clinical Strategy,
Whittington Transformation, Royal Free Acquisition and Strategic and Operational Planning.
• Development of plans is via a cross CCG Planning and Contracting Organisational Group.
• Al l plans approved by each CCG Governing Body and Health and Wellbeing Board. • Col laboration embedded through Lead Commissioner arrangements. • Regular workshops with NCL CCGs (Chairs and Cos) with NHST CEOs, Medical
Directors, plus NHSE and UCLP.
Measured using the following success criteria All NCL CCGs are aiming to achieve a minimum surplus of 1% and sound recurrent
underlying financial position. However, for some this will be a continued challenge within normal business rules. QIPP schemes are being designed to achieve most efficient financial outcomes with care in appropriate settings. Funding allocations will continue to be a discussion the CCGs will want to have throughout the next five years.• Success criteria to be developed in line with the work on Value Based Commissioning
focussed on improved health outcomes.
• All organisations within the health economy perform within financial plan each year up to and including 18/19, through local risk share arrangements ensuring a better and sustainable legacy by 18/19, recognising different starting positions across the 5 CCGs.
• Delivery of the NHS Mandate and NHS Constitution standards for all patients. • Delivery of the system objectives
• No provider or commissioner under enhanced regulatory scrutiny due to performance concerns.
• Incremental implementation of Value Based Commissioning through to 18/19. • Achievement of Operating plans e.g. 1% surplus, 0.5% contingency, staying with
running costs .
System Values and principles –
As a group of CCG's we are taking the approach of collaborating where its adds value and localising where necessary. This means that a large amount of work is being done
locally driven through health and wellbeing boards and local partnerships.
Across the five CCGs we share a set of values about commissioning for outcomes, using clinical models to drive change and creating supportive commissioning models that
deliver the outcomes and clinical model. We aim to drive improvement in the delivery of high quality evidence – based and compassionate services to do this we think that
adopting shared approaches to commissioning and collaboration around shared providers through a value based commissioning model offers us the strategic framework
in which to achieve our aim.
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Barnet and Chase Farm AcquisitionNCL CCGs believe that the acquisition of Barnet
and Chase Farm Hospitals by the Royal Free Hospital is a significant opportunity to delivering the aims of VbC at scale. CCGs and Trusts working together to develop service models that focus upon patient outcomes, quality, safety and patient experience.
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Barnet, Enfield and Haringey Clinical Strategy (BEH)The BEH Clinical Strategy Programme aims to deliver: Expansion and redevelopment
of emergency services at Barnet Hospital (BH) and North Middlesex University Hospitals (NMUH); Expansion and redevelopment of maternity and neonatal services at BH and NMUH; Development of urgent care services at CFH and the expansion of planned surgery at CFH.
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Section Two | Key lines of enquiry (KLOE)
Segment Key Line of Enquiry Organisational Response Supported by
Submission details
System vision
Which organisation(s) are completing this submission?
The following organisations are included in the submission of North Central London (NCL) Strategic Planning Unit’s (SPU) Five Year Strategic Plan 2014/19.
1. Barnet Clinical Commissioning Group 2. Camden Clinical Commissioning Group 3. Enfield Clinical Commissioning Group 4. Haringey Clinical Commissioning Group 5. Islington Clinical Commissioning Group
The senior leaders from the above organisations have worked together drafting the Strategy and will work together in its implementation. Not included in this submission but actively part of our local SPU are:
1. NHS England 2. Health Education North Central and East London
Additionally the SPU has widely and consulted with the following organisations in the development of the Strategy:
1. Local providers 2. Local authorities 3. Health and Wellbeing Boards
This plan provides a high level summary with details provided in the supporting documents and it should be read in conjunction with the five separate CCG local KLOE documents and Better Care Fund documents.
Plan on the Page
Appendix 1
NCL CCGs KLOE
In case of enquiry, please provide a contact name and contact details
William Roberts, Director of Strategy and Planning
Email: [email protected]
Tel: 02036881739
What is the vision for the system in five years’ time?
North Central London (NCL) health economy is a system comprised of partners from Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG, and Islington CCG who have come together to agree refine and implement the following strategic intent: To drive improvement in the delivery of high quality, evidence – based and compassionate services, defined and measured by outcomes not process, to the population of north-central London.
Plan on the Page – Appendix 1
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Across NCL there are a number of key challenges:
Inequalities in health outcomes due to a range of demographic, socio-economic, cultural and access issues
A plethora of individually high quality providers (across health and social care) but working within organisational boundaries that result in often fragmented and disjointed care
An increasing demand on services from an aging population
Very high levels of serious mental health illness
High levels of childhood obesity and vulnerable children
Commissioning that has not always focussed on quality or been clinically driven
Significant current and future financial pressures
Our intent is to transform services through clinically-led, innovative service re-design in order to deliver the CCGs’ visions. We are committed to delivering the system objectives identified in the accompanying plan on a page, and are working collaboratively to move to a Value Based Commissioning (VbC) approach. This is beginning with work on frail elderly, mental health, and diabetes and will be expanded to cover more areas in future. In addition:
We are individually focussed on integrated care, with a focus on populations.
Each of the CCG plans to work with all providers to improve outcomes for patients with Long Term Conditions.
We have a focus on developing Primary Care through our collaborative investment budgets, and are committed to working closely with NHS England to improve quality and access to primary care.
Models and priorities vary by CCG, and the specific detail for each will be captured in local 5 year plans. Delivering our ambition will only be achieved through working in closer partnership across the local health and social care system to:
Engage and involve the local population so that they can work with commissioners to define outcomes that are important and meaningful to them.
Engage with Public health and the Health and Well-Being Boards (HWB) on innovative prevention and health promotion schemes in our schools, environment and work places.
Empower CCGs member practices that now play a key role in defining local priorities and commissioning intentions, working to improve primary care quality and access and to monitor the quality and effectiveness of all our providers.
Continue to collaborate with all providers and partners across Health, Local Authority,
1 - NCL Horizon Scanning Workshop
11.02.14
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Social Care and Voluntary Sectors who have already demonstrated commitment to developing the integration of the system to work across organisational boundaries.
Employ technological advances around sharing IT and information to improve communications across the whole system.
Ensure commissioning is outcome-focussed rather than process driven with governance arrangements that see responsibility for delivering population outcomes across pathways of care not within individual organisations.
Ensure the outcomes of providers are accessible to patients to enable and inform choice.
Extend existing links with local academic institutions, across CCGs and with NHS England with whom we will have a co-commissioning role across specialist commissioning and primary care and an assurance partnership to assist in delivering the CCG’s priorities.
There should be no illusions about the challenges ahead; working collaboratively is easy in theory but more difficult in reality and breaking down the barriers across organisations to ensure the patient is at the heart of what we do will not be easy culturally or contractually. Finding the shared incentives to drive this will be key. Patients and clinicians will need to feel confident of both the evidence-base and quality and safety of delivering services in new ways and settings. These challenges will need to be met with determination and steadfastness. Our collective success in delivering improved outcomes depends on sharing, throughout the local health system a mutual understanding and respect for each other’s roles and skills and a sense of collective responsibility for the effective use of limited resources; it also relies on developing and utilizing the skills of those within the wider CCGs. We are convinced that core to making this happen is personal leadership, responsibility and accountability at all levels; within the member practices, in our Governing Bodies, across our local health economies and wider afield. We have already started this journey within our CCGs and recognize how colleagues across CCGs and partner organisations have already risen to the challenge. We look forward to collectively delivering this strategic intent.
How does the vision include the six characteristics of a high quality and sustainable system and transformational service models highlighted in the guidance?
A) Ensuring that citizens will be fully included in all aspects of service design and change and that patients will be fully empowered in their own care.
The SPU is committed to working more closely with patients, carers, local people, voluntary and community groups and other agencies in order to build healthier communities together. Over the next five years, we will explore how best to develop new ways of communication with our residents so that they are better placed to get information and access support in a way which suits them. CCG’s detailed communications and engagement strategy is embedded in the supporting
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Specifically:
1. Ensuring that citizens will be fully included in all aspects of service design and change, and that patients will be fully empowered in their own care
2. Wider primary care, provided at scale
3. A modern model of integrated care
4. Access to the highest quality urgent and emergency care
5. A step-change in the productivity of elective care
6. Specialised services concentrated in centres of excellence (as relevant to the locality)
evidence section.
The CCGs work in partnership with other public sector organisations to co-ordinate the planning and delivery of local health services. This includes working with the relevant London Boroughs on Joint Strategic Needs Assessments (JSNA), and CCG representation on the HWBs. CCGs involve service users in redesigning patient pathways wherever possible and work closely with expert service users including maternity network, carers groups and patient groups, to understand how we can continue to improve services. Each CCG has undertaken significant engagement with our local populations and these are detailed communications and engagement strategies are embedded in the supporting evidence section of their KLOEs. B) Wider primary care, provided at scale
The SPG has a clear focus on developing Primary Care to deliver at scale. Priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy and are described in the improvement intervention. C) A modern model of integrated care
All CCGs are developing models of integration which offer a range of prevention, early intervention and supported self-management delivered by a variety of providers, including health, local authority and voluntary and community organisations, working together in different ways to support people and families more effectively. The designs reflect local variation and need and are described in each CCGs local KLOE document. Plans are in progress for implementing the Better Care Fund (BCF) in collaboration with colleagues from the respective London Boroughs for agreement by CCG Governing Bodies (GB) and HWBs.
All models share a value and principle set as described in section E and the approach is described in the improvement intervention VbC. We will continue to commission services that:
• Ensure that all elements of the system act as a single system to provide care and that care is delivered in the most appropriate setting for the patient.
• Identify people as early as possible when they are going into a health and/or social care crisis.
• Assess, care plan and provide appropriate interventions with patients to enable patients to be stabilised, using the array of resources available.
• Ensure that patients are a critical part of care planning and are actively engaged in decisions about what care they may receive.
• Manage activity and cost across health and social care such that no unnecessary
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activity and costs are incurred within the system in order to achieve a sustainable long term system.
D) Access to the highest quality urgent and emergency care
Attainment of the A&E performance target ensures all patients who need it are seen quickly. Access to primary care is also a key issue here, ensuring A&E resource is available to those who need it most. Growth of Urgent care centres can assist to see many patients quickly and in a more streamlined way. Major trauma centres, cardiac centres and stroke units are designated and provide higher level clinical skills. The CCGs will:
Support self-care- we will provide easily accessible information about self-care options through schemes such as the ‘choose well campaign’
Help people with urgent care needs to get the right advice or treatment in the right place, first time.
Consider approaching 111 and Out of Hours procurement strategically across NCL
Ensure that people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise to maximise chances of survival and a good recovery
Ensure connectivity throughout the whole urgent and emergency care system.
E) A step-change in the productivity of elective care
As a SPU we are all trying to reduce the volume of activity taking place in acute care settings so that we reach national average targets and aim for upper quartile targets for both first appointments, follow up appointments and procedures. We will achieve this through a range of initiatives:
Greater management of patients within primary care through agreed pathways and focused educational sessions.
Improved performance of the referral management service though: Better contract management New KPIs and performance metrics Consistent approach to clinical triage with senior decision makers ensuring
patients are booked into right services
Reduction in duplicate diagnostics through agreed pathways with acute trusts.
Agreed primary/secondary care discharge protocols ensuring that patients do not stay “in the system” for longer than is necessary.
Ensuring that practice visits and the Learning Through Peer Review schemes are focused on areas which differ most from the norm.
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Increased use of Technology ensuring that the advice and guidance through choose and book is used and that GPs have ready access to all referral forms/pathways etc.
This will be delivered through local integrated care schemes described in the local CCG KLOE documents and in part in the value based commissioning improvement intervention and across Barnet, Camden and Enfield CCGs through the Royal Free acquisition of Barnet Chase Farm, as described in the improvement intervention and primary care development. F) Specialised services concentrated in centres of excellence (as relevant to the
locality)
NHSE – Specialised Commissioning The national agenda for specialised commissioning will continue to develop over the years. There is currently work underway to assess the number of specialised centres required nationally with the figures 15-30 based on the Academic Health Science Networks being used as a guide. Whatever the final number and recommendations it is highly likely that there will be a recommendation to concentrate specialised services on fewer sites to improve care. This will impact on London in particular because of the number of Trusts who have some specialised services. Work will continue on specialised services specifications which will further impact on the long term provision of specialised services. The financial position for specialised services both regionally and nationally remains challenging. QIPP will be used to address this position as well as increasing understanding of the services being provided. Historically most specialised services QIPP has been delivered through transactional schemes and the emphasis needs to shift to transformation. As specialised services are only part of the patient pathways the Specialised Commissioning Team (SCT) will be seeking to work in partnership with London CCGs and local authorities on a whole pathway approach increasingly focused on outcome based commissioning. The SCT would also want to work more closely with CCGs in terms of contract performance management and service quality.
Our SPU Programme includes:
Supporting NHSE in: Finalising the 5 year cancer strategy and supporting implementation through the specialist Cancer and Cardiac reconfiguration.
Local schemes to improve early detection & population.
Reducing variation: implementing best practice commissioning pathways & clinically agreed protocols.
How does the five year vision address the
A - Delivering a sustainable NHS for future generations? All five CCGs financial projection across the SPU has been completed and the plans to
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following aims:
a) Delivering a sustainable NHS for future generations?
b) Improving health outcomes in alignment with the seven ambitions
c) Reducing health inequalities?
address this are being further developed and refined. All plans leading to 2018/19 will be designed to deliver a balanced plan. All five financial plans and the unitary financial plans are undergoing risk assessment to ensure sustainability. There are parts of the SPU that will require business rules to be suspended and there is recognition of the need to ensure both risk share and transformation funding is available within the SPU to enable the change to happen. What is clear is that some of the solutions will need to be delivered through a local focus with the Health and Wellbeing Boards but those as described in this document will need to be delivered across a wider geography to support sustainability. To address the financial variation and to develop a system capable of delivering high quality affordable care we have adopted a VbC approach across the five CCGs. To us this means changing how healthcare is organised, measured and reimbursed in order to improve the value of services. This approach will be rolled out to further areas over the five year period. The high level principles we have agreed are to:
Define our population groups
Co-create an NCL outcomes framework for each population group
Set up delivery projects
Build a business case for change
Develop and appraise contract and reimbursement options for each segment and build capability for contracting around outcomes
B - Improving health outcomes in alignment with the seven ambitions The level of ambition in each CCG varies dependent on the need and population and is described in each local CCG KLOE document. There are some consistent factors across all CCGs that will contribute to achievement of local ambition, these are described below. 1. Securing additional years of life for the people of England with treatable mental
and physical health conditions. All CCG focus on shifting balance of spend from acute and residential care services towards self-managements and prevention whilst providing a coordinated and integrated care support to patients. The development of NCL wide outcomes means that we will be able to ensure that the outcomes that matter to patients are achieved whilst increasing the quality and timeliness of care received.
2. Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions. As described in the VbC improvement intervention, this work focusses on improving the outcomes for people with long term conditions (including frailty and mental ill health).
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3. Reducing the amount of time people spend avoidably in hospital through better
and more integrated care in the community, outside of hospital. A priority for the SPU is greater integrated working within the partnership to achieve
integrated health and social care, 7 days services and enablement. This will also enable
the CCGs to shift balance of spend from acute and residential care services towards self-
managements and prevention whilst providing a coordinated and integrated care support
to patients. The development of NCL wide outcomes means that we will be able to
ensure that the outcomes that matter to patients are achieved whilst increasing the
quality and timeliness of care received.
4. Increasing the proportion of older people living independently at home following discharge from hospital. The local KLOE documents and Better Care Fund submissions describe how the CCGs are aiming to achieve this and the position reflected in this document is an aggregate of the local plans and is described in detail in each CCG KLOE document.
5. Increasing the number of people with mental and physical health conditions
having a positive experience of hospital care. Improvements in this area are delivered through a composite of local plans in each CCG and through the shared Value Based Commissioning work on mental health in Camden and Islington.
6. Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community. We expect improvements in this area to be delivered through a combination of the primary care improvement work and the various projects integrating care across the CCGs, from service user involvement we have identified that joining up care is key to improving patient experience.
7. Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. We have well established Clinical Quality Review Groups that are shared across the CCGs within the SPU through a collaboration agreement that means the lead commissioner works closely with each provider to ensure quality of care. The collaborative interventions described in this plan aim to use IT and multi-disciplinary care groups to better manage the quality of patient care with the a focus on lead providers within the VbC work to ensure accountability across the system to deliver the care patients want.
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C - Reducing health inequalities? The individual CCG KLOE documents detail how inequalities are being addressed at the local level through the local improvement interventions and Health and Wellbeing Board.
Who has signed up to the strategic vision? How have the health and wellbeing boards been involved in developing and signing off the plan?
The CCGs developed a shared strategic vision that was reviewed and agreed by the NCL Clinical Commissioning Committee. As an SPU we agreed to identify a range of work that could be shared across the five CCGs and the areas that for purposes of integration with the local authority and local providers would remain at a CCG level. These discussions we captured in a session we held with the senior managers of the CCGs and the clinical cabinet. All CCGs participated in a high level of engagement with the HWB on the strategic vision and on the development of the plan. For example there have been development sessions allocated to engage and discuss the SPU strategic vision and intentions. NHS England have been part of the SPU and following a provider workshop, we have decided to extend the membership of the SPU to include providers.
2 North Central London Strategic Intent
3 NCL 5 Year Strategic Plan NHS Provider Trusts and CCG Engagement workshop
How does your plan for the Better Care Fund align/fit with your 5 year strategic vision?
Each CCG has developed their BCF submission with their local authorities and these have been developed to support the local interventions and the wider NCL improvement interventions.
What key themes arose from the Call to Action engagement programme that have been used to shape the vision?
Some of the key themes that have come out of the respective CCG’s engagement work in 2013-14 include:
Better access to GPs and primary care services.
Integration of services across health and social care.
Promoting joined up approach to health and wellbeing.
Ongoing community engagement to help build strong, local networks.
Improved communications with residents, in a variety of formats, to help people better understand the health care system (in particular, the urgent care system).
Better links with community groups and support groups.
Better use of technology in delivery of patient care.
Improving the knowledge of health providers of the availability of access to services along a patient pathway and third sector support for patients
Look at the whole family situation not just the child, to ensure the child’s and the family’s needs are met.
Improving Patient education and Clinician education.
Importance of carer support and education.
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Is there a clear ‘you said, we did’ framework in place to show those that engaged how their perspective and feedback has been included
The NCL CCGs are committed to showing the public how their feedback has been used to
inform commissioning and impacted on the development and quality of local services.
Examples of this are available within each CCGs local KLOE document.
Current position
Has an assessment of the current state been undertaken? Have opportunities and challenges been identified and agreed? Does this correlate to the Commissioning for Value packs and other benchmarking materials?
Working as a collective group within NCL our approach has been to develop plans within
each CCG, in combination with the local authority, and to collaborate where we have shared
areas of work either across the five CCGs or any combination within the five CCGs.
The CCGs’ commissioning and planning priorities have emerged from the JSNA and
development of specific initiatives and projects has been informed by the Commissioning for
Value packs and the Commissioning Resource pack developed by the North and East
London Commissioning Support Unit (NELCSU).
Across NCL there are a number of key challenges:
Inequalities in health outcomes due to a range of demographic, socio-economic, cultural and access issues
A plethora of individually high quality providers (across health and social care) but working within organisational boundaries that result in often fragmented and disjointed care
An increasing demand on services from an aging population
Very high levels of serious mental health illness
High levels of childhood obesity and vulnerable children
Commissioning that has not always focussed on quality or been clinically driven
Significant current and future financial pressures.
Each CCG has local issues and these are described within the individual CCG KLOE
documents.
Do the objectives and interventions identified below take into consideration the current state?
The objectives and interventions in this plan is based on the known position in NCL, looking
at our demographic needs and predicted changes, such as projected population growth and
changes to the age profile, and our current spend and utilisation of services. This data
allows us to identify where we have gaps in current service provision, poorer outcomes for
patients and value for money opportunities. Services will need to fit in with people’s lives and
provide improved and more flexible access, strengthen and extend partnership working and
specifically promotes and supports self-care where appropriate.
The detailed work carried out in each CCG is described in the local CCG KLOE document.
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Does the two year detailed operational plan submitted provide the necessary foundations to deliver the strategic vision described here?
As noted above the operating plan uses the data available to us to assess our performance
against peers and to identify areas for improvement as well as the appropriate levels of
ambition. For the Ambitions for Improving Outcomes, we used the available data to
benchmark against our peers and to set out improvement scenarios, using our current
position to look at whether a move to top decile, top quartile or a commitment to increase by
a set percentage is stretching and achievable. Our ambitions in relation to the Quality
Premiums draw on our known challenges at our current baseline position and seek to move
towards our desired position in two years as part of our five year plan. This operational plan
will require close monitoring to ensure that the improvement required is being realised within
the timescale and to allow the five CCGs to build on this achievement towards the five year
plan.
Improving quality and outcomes
At the Unit of Planning level, what are the five year local outcome ambitions i.e. the aggregation of individual organisations contribution to the outcome ambitions?
Ambition area Metric Proposed
improvement by
18/19
Reducing the number
of years of life lost by
the people of England
from treatable
conditions
Potential years of life lost – Rate per
100,000 population
-9.2%
Improving the health
related quality of life of
those with 1+ long-
term conditions
Average EQ-5D score for people
reporting having 1+ long term
conditions
4.3%
Reducing the amount
of time people spend
avoidably in hospital
through better and
more integrated care
in the community,
outside of hospital
Emergency admissions composite
indicator
-5.3%
4 NCL SPU 5 Year Projections from baseline
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Increasing the
proportion of older
people living
independently at home
following discharge
from hospital
Proportion of older people (65 and
over) who were still at home 91
days after discharge from hospital
into reablement/rehabilitation
services (effectiveness of the
service)
Baselines have
been established;
however
trajectories will be
available in the
final plan.
Reducing the
proportion of people
reporting a very poor
experience of inpatient
care
Patient experience of hospital care 5.9%
Reducing the
proportion of people
reporting a very poor
experience of primary
care
Patience experience of GP services
and out of hours services
19.8%
Making significant
progress towards
eliminating avoidable
deaths in our hospitals
Incidence of healthcare associated
infection, MRSA and C.Diff.
Baselines have
been established;
however
trajectories will be
available in the
final plan
How have the community and clinician views been considered when developing plans for improving outcomes and quantifiable ambitions?
We know from talking and listening to our local population the range of things the public want
from their local health care services. These include safe services, high quality services that
treat patients with dignity and respect, and services that they can access easily in a place
and at a time that they want. We know the most services we have are of a high quality and
effective. However we know that we don't always get it right and that patients sometimes
have poor experience and don’t receive services that meet their needs or expectations.
Consultation has informed us that the public are worried about the wider impact of the
economy on the NHS and their concerns about potential impacts of privatisation and hospital
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closures or services being removed due to financial constraints. We are also aware that the
diverse communities of NCL require and expect culturally sensitive local services.
We are clinically led organisations and have worked closely with our governing body,
localities and clinical leads to develop our plans. The initiatives we have developed have
been co-created with clinicians working within our providers and the approach we have
taken to commissioning, focussing on outcomes and the value we derive from our services.
The detailed work carried out in each CCG is described in the local CCG KLOE document.
What data, intelligence and local analysis were explored to support the development of plans for improving outcomes and quantifiable ambitions?
Each of the metrics and trajectories were developed using insight from an in depth
understanding of the context, demographics and known behaviours of the population.
The following materials were locally available, the output from which was used in setting
each trajectory:
1. The Joint Strategic Needs Assessment that highlights variation in need and inequalities in uptake and provision of services;
2. The Public Health Outcomes Framework which benchmarks outcomes against other similar boroughs.
3. The Health and Wellbeing strategy which highlights segments of the population who can be encouraged to access and utilise health services Provider Activity including emergency admissions and bed capacity.
4. Other local strategies. 5. Value Based Commissioning Study. 6. Local Strategic Reviews. 7. Barnet Enfield and Haringey (BEH) Clinical Strategy.
Broader knowledge of the population accessed through the local authority business
intelligence team. Detailed information is provided in each CCGs submission.
How are the plans for improving outcomes and quantifiable ambitions aligned to local JSNAs?
CCG ambitions and plans are aligned with key priorities identified in the JSNA and Health
and Wellbeing strategy, particularly for the short and mid-term. This has been a local
process and is described in greater detail in the local KLOE documents.
How have the Health and well-being boards been involved in setting the plans for improving
Engagement with the Health & Wellbeing Board is continuous with HWB representation on
the CCG Governing Body (GB) and GB representation on the HWB. CCGs are working
closely with the Health and Wellbeing Boards in their area and local processes are described
in greater detail in the local KLOE documents.
3 NCL 5 Year Strategic Plan NHS Provider Trusts and CCG
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outcomes?
To ensure broader sign up to the strategic vision CCGs have held public engagement events
as well as a joint workshop with the SPG and Providers/Trusts on the 21st of March to set
out our plans, align our plans to Providers CIP Plans and agree a common vision. A further
public event and a joint Local Authority, NCL and Provider Trust event will be held in May
before final submission of our plan in June.
Engagement workshop
Sustainability Are the outcome ambitions included within the sustainability calculations? I.e. the cost of implementation has been evaluated and included in the resource plans moving forwards?
CCG commissioners have been working with providers of health services to control and
manage the financial challenge. Changes in service delivery are currently being discussed
with providers in order to deliver efficiencies to close the financial gap.
NCL sector as a whole is currently planning a deficit in 2014/15 of £14.9m (0.9% of RRL).
However, a surplus is planned for the remaining years up to 2018/19. In 2018/19 a surplus
is forecast of £17m (0.9% of RRL). For a detailed breakdown by CCG, see the supporting
document.
The surpluses are after taking account of QIPP savings in 2014/15 of £61.4m (3.5% of RRL)
and in 2018/19 of £43.9m (2.3% of RRL).
5 NCL Financial Planning Assumptions 28 March 2014
Are assumptions made by the health economy consistent with the challenges identified in a Call to Action?
“A Call to Action” published by NHS England, identifies the financial challenge facing the
health economy in England is £30bn, on a do nothing scenario, based on current trends and
funding levels. This is after taking account of current QIPP schemes.
Control of the financial challenge will also be supported by the Better Care Fund which is
planned to be £6m in 2014/15 and £85.6m for the remaining years to 2018/19 (between 2%-
2.7% of RRL). The BCF will be a pooled fund held by Local Authorities. Plans are being
drawn up to ensure funds are used to enable better provision of healthcare between CCGs
and Local Authority authorities. (See Table 1, below).
Can the plan on a page element be identified through examining the activity and financial projections covered in operational and financial templates?
QIPP schemes and demand management will translate into better models of care and
reduction in secondary care activity. The activity modelling is currently on-going and as such
QIPP schemes will be incorporated in to the activity modelling within the operating plan
submissions. See the table below.
Table 1: Summary of NCL 5 Year Financial Plans (£m)
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Table 2: NCL CCGs Surplus/Deficit Table 3 – NCL Planning Assumptions
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NCL CCGs have aimed to operate sound financial management by adopting sound business
rules as advised by NHS England guidance. Any variance from these business rules will be
agreed with NHS England.
Improvement interventions
Please list the material transformational interventions required to move from the current state and deliver the five year vision. For each transformational intervention, please describe the :
Overall aims of the intervention and who is likely to be impacted by the intervention
Expected outcome in quality, activity,
Intervention 1 - Primary Care development (PC)
Each CCG is working with GP practices so that they develop new ways to provide primary care at greater scale. Already the practices work together in localities. The local CCG Primary Care strategies aim is to take this much further, to change the shape of local provision, with each collaborative using a variety of organisational vehicles, rather than a one size fits all approach: for example for some it may be a loose association, for others a merger, and for others a new legal entity such as a federation. Alongside this, practices will undertake a programme to improve access by investigating and balancing their demand and capacity. This will also feed into working at scale. The CCGs will also continue to invest in information technology for practices. Expected Outcomes Primary care working at scale (one of the six characteristics), with improved access and
6 NCL CCC
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cost and point of delivery terms e.g. the description of the large scale impact the project will have
Investment costs (time, money, workforce)
Implementation timeline
Enablers required for example medicines optimisation
Barriers to success
Confidence levels of implementation
The planning teams may find it helpful to consider the reports recently published or to be published imminently including commissioning for prevention, Any town health system and the report following the NHS Futures Summit.
more developed information technology, will result in:
Improved equity of provision, for the whole population
Improved equity of health outcomes, for the whole population
Primary care able to contribute more effectively to five of the seven ambitions:
Securing additional years of life for the people of England with treatable mental and physical health conditions.
Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions.
Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital.
Increasing the proportion of older people living independently at home following discharge from hospital.
Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community.
Investment costs This is currently under assessment.
Implementation timeline
2014/15 Collaboratives agree new ways for practices working at scale, and some commence
2015/16 main development of working at scale
2016/17 – 2018/19 benefits of working at scale realised
Enablers required
Continued CCG focus on primary care development
Strategic solutions for premises requirements, including local Council opportunities from regeneration.
Concurrent development activity by NHS England, on performance and contract management, and on premises development
Education and training for the workforce
Integrated Care developments in community and social care services
Development of contract models to support new way of working
Barriers to success
Relationships and trust between individuals and organisations
Legal complexities of working at scale
Competing approaches, as practice members focus on internal solutions alongside
VbC Phase 2 sign off
7 NCL CCGs and NHS Trust VbC Workshop 12-12-14vi
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collective solutions
Premises solutions and opportunities are scarce, uncertain and with long timescales
End of three-year Primary Care Strategy funding after 2014/15.
Confidence levels of implementation Given the potential barriers to success, the confidence level is Medium.
Intervention 2 - Value Based Commissioning (VbC)
The NCL SPU agreed in September 2013 to work collaboratively with Provider Trusts in
developing the VbC programme across the North London health economy and share our
aims of developing a clinical and contractual model that:
Supports the integration of care by reflecting best clinical practice
Creates incentives for continuous improvement in value through reducing delays, readmissions and avoidable complications
Promotes provider control and accountability for outcomes and costs across the system
Separates payment from activity
Balances financial risks between providers and commissioners more effectively both in year and across a longer planning horizon
There also is a strong consensus that an overriding principle in taking forward the aims and objectives of VbC is to have the patient at the centre and keep asking ‘”what is the best way forward to improve patient outcomes”. Four projects were selected from a number of potential projects across NCL 1. Diabetes: Islington (as project lead) and Haringey 2. Older People with Frailty: Camden (as project lead) and Barnet 3. Older People with Frailty: Haringey (as project lead) and Enfield 4. Mental Health: Islington (as project lead) and Camden Two further projects are to be brought within scope of the programme as a later tranche of work: • Diabetes: Enfield. Learning the lessons from Project 1 • Mental Health: Barnet, Enfield and Haringey. Work is being developed to include this in
the VbC work. The following programme has been agreed upon:
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Phase 1: Sept – Dec 2013 , now successfully completed
Define our population groups for frail older people, people with mental health problems and people with diabetes in each CCG; and
Co-create an NCL outcomes framework for each population group
Identify/develop Methods of Measurement
Phase 2: Objectives
Set up delivery projects for Older People with Frailty, Diabetes and Mental Health
Engage clinical leaders, providers, commissioners and service users in designing the clinical and delivery models
Build a business case for change, supported by activity and finance modelling and a baseline view of performance against outcome measures.
Demonstrate success through early adoption of the new delivery models for identified segment populations
Develop and appraise contract and reimbursement options for each segment and build capability for contracting around outcomes
Work has begun on the Older People with Frailty project, below is the brief summary of
current progress:
Both Camden and Barnet CCG Leads have reviewed and accepted (in principle) the scope of segmentation and outcome hierarchy from VBC phase 1 as being agreeable to their respective organisations for the purposes of the Project.
A Frailty outcome hierarchy has been developed and will be used across CCGs, involved providers include: • Barnet and Chase Farm Hospitals NHS Trust • Royal Free London NHS Foundation Trust • University College London Hospitals • Central and North West London NHS Foundation Trust • Barnet, Enfield and Haringey Mental Health Trust • Nominated / representative GP practices • Social Care Providers
A detailed project plan has been drafted and the project is appropriately resourced for delivery. Governance arrangements have been drafted.
Intervention 3 - Barnet and Chase Farm acquisition
Royal Free London has expressed an interest in acquiring Barnet and Chase Farm NHS
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Trust and is preparing a business case for the Trust Development Agency. Subject to this
business case successfully making the case for the acquisition, the NCL CCGs will support
the Royal Free London to acquire Barnet and Chase Farm Hospitals Trust.
NCL CCGs believe that the acquisition of Barnet and Chase Farm Hospitals by the Royal Free Hospital is a significant opportunity to delivering the aims of VbC at scale. The aim of the business case is to develop an organisation that is able to deliver high quality
affordable care. The business case requires Royal Free London to develop secondary health
care services that focus upon patient outcomes, quality, safety and patient experience for
patients currently using services provided by the Royal Free (London) NHS Foundation Trust
and Barnet and Chase Farm NHS Trust. By developing models of care that support an
integrated approach to care and the implementation of the Barnet, Enfield and Haringey
Clinical Strategy. Delivering service changes that are effective and efficient delivering QIPP
savings for CCGs and CIP for the Trust.
Expected outcome in quality, activity, cost and point of delivery terms e.g. the description of the large scale impact the project will have:
– CCGs and Trusts working together to develop service models that offer: – Senior Clinical Triage with access to multidisciplinary triage where appropriate – The majority of outpatient care managed within a community or primary care based
service – Community services supervised by senior clinicians – Diagnostics ordered once and only when clinically necessary – One stop service/co-location to improve patient experience – Effective clinical follow-up only when necessary – Patient centred, safe services
Investment costs (time, money, workforce) Costs are detailed in the business case but process has the aim of ensuring that the secondary care expenditure for NCL residents does not increase over the five years despite demographic (age and population growth driven) growth. The benefit of achieving this means that the CCGs would be able to deliver a financially viable landscape by the end of the period of the business case
Implementation timeline Commences July 2014 with completion by the end of 2019
Enablers required for example medicines optimisation – Educational support for primary care through training and development led by senior
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clinicians – Provision of health and advice telephone lines for clinicians – Integrated IT – Use of technology to deliver virtual services
Barriers to success This is currently under assessment.
Confidence levels of implementation – High
Intervention 4- Barnet, Enfield and Haringey Clinical Strategy (BEH)
Since 2007, the three CCGs(formerly PCT’s) have been engaging with local residents, patients and health professionals on the best way to deliver high quality health services locally.The BEH Strategy identified the need to deliver better healthcare for people in Barnet, Enfield and Haringey . Local clinicians developed the Barnet, Enfield and Haringey Clinical Strategy with the aim of improving the health of local people, tackling health inequalities and delivering higher quality healthcare services. Significant work has been carried out over the last 18 months to implement the BEH Clinical Strategy. The strategy has now been implemented and is now being assimilated into main stream business as usual. The BEH programme was designed to deliver:
Safer , more effective care for patients with a medical or emergency
Concentrated clinical expertise to meet latest quality standards
More consultants, doctors, nurses, midwifes and clinical personnel
Improved hospital buildings and modern facilities
Lower rates of infant and adult mortality
The BEH Clinical Strategy Programme aims to deliver service changes that will provide safer and better healthcare for the populations of Barnet, Enfield and Haringey. Resources include a capital investment of £114.6m and £23.6m of transitional costs to deliver the following:
Expansion and redevelopment of emergency services at Barnet Hospital (BH) and North Middlesex University Hospitals (NMUH)
Expansion and redevelopment of maternity and neonatal services at BH and NMUH,
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including the development / expansion of midwife led birthing units at both sites
Development of urgent care services at Chase Farm Hospital (CFH), including assessment centres for children and older people
Expansion of planned surgery at CFH
Investment costs Capital investment of £114.6m and £23.6m of transitional costs Implementation timeline All key programme milestones have been achieved with a successful transition of maternity and Neonatal services on 20 November 2013 followed by the closure of A&E at Chase Farm at 3am on Monday 9 December 2013. Enablers required This is currently under assessment. Barriers to success This is currently under assessment. Expected Outcome
A decrease in mortality rates
A decrease in patient safety incidences
Adherence to London Quality Standards
A decrease in annual incidence of healthcare acquired infection
A decrease in readmission rates
An Increase in patient satisfaction and experience (Friends and Family Test)
An Increase in staff satisfaction
Non-clinical cancellations of elective surgery
Decrease in number of breaches of 4hr wait target (emergency care standard)
An Increase in patients treated in ambulatory care Confidence levels of implementation All key programme milestones have been achieved.
A benefits realisation plan (BRP) is in place which sets out the benefits to be realised for the selected areas for measurement. Performance monitoring arrangements for the review of the BRP is in place and is carried out via a benefits tracker scorecard against the agreed KPIs.
Governance What governance NCL Governance is as follows:
The NCL collaborative arrangements are overseen by the North London Clinical Governance
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overview processes are in place to ensure future plans are developed in collaboration with key stakeholders including the local community?
Commissioning Committee, comprised of CCG Chairs, COs and with NHS England in attendance. The Committee collaborates on financial risk share, Primary Care, BEH Clinical Strategy, Whittington Transformation, Royal Free Acquisition and Strategic and Operational Planning.
Development of operational and strategic plans is through a cross CCG Planning and Contracting Organisational Group. All plans are approved by each CCG Governing Body and Health and Wellbeing Board.
Collaboration is further embedded through Lead Commissioner arrangements across NCL.
Regular workshops are held with NCL CCGs (Chairs and COs) with NHST CEOs, Medical Directors, NHSE and UCLP.
At CCGs level strategic plans are discussed at and signed off by our Governing Body which includes local clinicians, local authority, Healthwatch and lay representatives. There are regular programme of meetings with the Health and Wellbeing Board at which CCGs’ strategic vision and approach has been agreed.
Diagram
Appendix 2
Values and principles
Please outline how the values and principles are embedded in the planned implementation of the interventions
As a group of CCGs we are taking the approach of collaborating where its adds value and localising where necessary. This means that a large amount of work is being done locally driven through health and wellbeing boards and local partnerships. Across the five CCGs we share a set of values about commissioning for outcomes, using clinical models to drive change and creating supportive commissioning models that deliver the outcomes and clinical model. We aim to drive improvement in the delivery of high quality evidence – based and compassionate services to do this we think that adopting shared approaches to commissioning and collaboration around shared providers through a VbC model offers us the strategic framework in which to achieve our aim. There are a number of areas that will are described in this plan that we will collaborate on to deliver an effective health care system by 2019.
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Appendix 1
North Central London Strategic Planning Unit
Plan on a Page
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North Central London health economy is a system comprised of partners from Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG, and I slington CCG who have come together to agree, refine and implement the following strategic intent: To drive improvement in the delivery of high quality, evidence-based and compassionate services, defined and measured by outcomes not process, to the population of north-central London.
System Objective OneReducing the number of years of life lost by
9.2%
System Objective TwoImproving the health related quality of life of those with 1+ long-term conditions by 4.3%
System Objective Three
Reducing the amount of time people spend avoidably in hospital through
better and more integrated care in the community, outside of hospital by 5.3%
System Objective FourIncreasing the proportion of older people
l iving independently at homefol lowing discharge from hospital
Tra jectories to be finalised for next draft
System Objective FiveReducing the proportion of people reporting a
very poor experience ofinpatient care by 5.9%
System Objective SixReducing the proportion of people reporting a
very poor experience ofprimary care by
19.8%
System Objective SevenMaking significant progress towards el iminating avoidable deaths in our
HospitalsTra jectories to be finalised for next draft
Delivered through Commissioning for Value Based Outcomes (VBC) CCGs in north-central London are working collaboratively to move to a VBC approach. This is beginning with work on Older People with Frailty, mental health and diabetes and will be expanded to cover more areas in the future. We are individually focussing on integrated care, with a focus on populations. This includes: •Improved management and outcomes for children and young people. •Improvement in management of care in the community. •Maximising the time spent at home during and after treatment. •Promoting collaboration and communication between patients, staff and carers. •Better alignment of physical and mental health services to improve outcomes for vulnerable groups experiencing high levels of mortality or ill-health. •Developing collaborative packages with other CCGs.Models and priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy. Each of the CCGs plan to work with all providers to improve outcomes for patients with Long Term Conditions, this will include: •Improving recorded prevalence of Long Term Conditions. •Primary and Secondary Prevention. •Pathways redesign. Models and priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy.
Primary Care We have a focus on developing Primary Care through our collaborative investment budget. All 5 CCGs are committed to working closely with NHS England to improve quality and access to primary care. North Central London CCGs have in place Primary Care Strategies, with dedicated resource for implementation. Key goals include: •Primary care strategy implementation. •Development of primary care networks. •Demand management within primary care. •Improvement of patient experience. •Improvement of capacity within primary care. •Increasing Primary and Secondary Prevention. Priorities vary by CCG and the specific detail for each will be captured in the local 5 year strategy.
Delivered through local IntegrationAll 5 CCGs are :• developing models of integration which offer a range of prevention, early
intervention and supported self management delivered by a variety of providers, including health, local authority and voluntary and community organisations , working together in different ways to support people and families more effectively.
• progressing plans for the Better Care Fund (BCF) in collaboration with colleagues from the respective London Boroughs for agreement by CCG Governing Bodies and Health and Wellbeing Boards.
Overseen through the following governance arrangementsOur collaborative arrangements are overseen by the North London Clinical
Commissioning Committee, comprised of CCG Chairs, COs and with NHS England in attendance. • we collaborate on financial risk share, Primary Care, BEH Clinical Strategy,
Whittington Transformation, Royal Free Acquisition and Strategic and Operational Planning.
• Development of plans is via a cross CCG Planning and Contracting Organisational Group.
• All plans approved by each CCG Governing Body and Health and Wellbeing Board. • Collaboration embedded through Lead Commissioner arrangements. • Regular workshops with NCL CCGs (Chairs and Cos) with NHST CEOs, Medical
Directors, plus NHSE and UCLP.
Measured using the following success criteria All NCL CCGs are aiming to achieve a minimum surplus of 1% and sound recurrent underlying financial position. However, for some this will be a continued challenge within normal business rules. QIPP schemes are being designed to achieve most efficient financial outcomes with care in appropriate settings. Funding allocations will continue to be a discussion the CCGs will want to have throughout the next five years.• Success criteria to be developed in line with the work on Value Based Commissioning
focussed on improved health outcomes. • All organisations within the health economy perform within financial plan each year
up to and including 18/19, through local risk share arrangements ensuring a better and sustainable legacy by 18/19, recognising different starting positions across the 5 CCGs.
• Delivery of the NHS Mandate and NHS Constitution standards for all patients. • Delivery of the system objectives• No provider or commissioner under enhanced regulatory scrutiny due to
performance concerns.• Incremental implementation of Value Based Commissioning through to 18/19. • Achievement of Operating plans e.g. 1% surplus, 0.5% contingency, staying with
running costs .
System Values and principles –As a group of CCG's we are taking the approach of collaborating where its adds value and localising where necessary. This means that a large amount of work is being done
locally driven through health and wellbeing boards and local partnerships.
Across the five CCGs we share a set of values about commissioning for outcomes, using clinical models to drive change and creating supportive commissioning models that
deliver the outcomes and clinical model. We aim to drive improvement in the delivery of high quality evidence – based and compassionate services to do this we think that
adopting shared approaches to commissioning and collaboration around shared providers through a value based commissioning model offers us the strategic framework
in which to achieve our aim.
4
1
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3
6
7
Barnet and Chase Farm AcquisitionNCL CCGs believe that the acquisition of Barnet and Chase Farm Hospitals by the Royal Free Hospital is a significant opportunity to delivering the aims of VbCat scale. CCGs and Trusts working together to develop service models that focus upon patient outcomes, quality, safety and patient experience.
4
Barnet, Enfield and Haringey Clinical Strategy (BEH)The BEH Clinical Strategy Programme aims to deliver: Expansion and redevelopment of emergency services at Barnet Hospital (BH) and North Middlesex University Hospitals (NMUH); Expansion and redevelopment of maternity and neonatal services at BH and NMUH; Development of urgent care services at CFH and the expansion of planned surgery at CFH.
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Appendix 2
North Central London Strategic Planning Unit
Governance Diagram
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