NHS North West London
Operating Plan 2012/13
Cluster Operating Plan 2012-13
Cluster name: NHS North West London
Version:
0.7
Key Cluster Contacts:
Name and Title
Telephone
Executive Lead
Daniel Elkeles, Director 020 3350 4177
for operating
of Strategy
Email
daniel.elkeles@nw.london.nhs.uk
planning:
Finance:
Richard Jeffery, Head of 020 3350 4109
richard.jeffery@nw.london.nhs.uk
Finance
Workforce:
Maggie Gibbs, Interim
020 3350 4297
maggie.gibbs@nw.london.nhs.uk
Thirza Sawtell, Director 020 3350 4704
thirza.sawtell@nw.london.nhs.uk
Head of HR
of Delivery Support Unit
Performance:
Lisa Rees, Deputy
020 7009 4053
lisa.rees@nw.london.nhs.uk
020 3350 4661
aiden.walsh@nw.london.nhs.uk
020 3350 4692
matthew.bazeley@nw.london.nhs.uk
Director of Acute
Performance
Informatics:
Aiden Walsh, Chief
Information Officer
Commissioning
Matthew Bazeley,
Development:
Assistant Director of
Strategy
1
Engagement/ Sign off:
Supporting statement outlining process of consultation and engagement with stakeholders in
development of Operating Plan for 2012-13.
NHS NWL’s commissioning strategy is based on clinical leadership and CCGs are leading this
throughout. To meet the requirements set out in the Revision of the Operating Framework
2010/11 and the existing duties of section 242 of the NHS Act 2006 our plans have been developed
in conjunction with the Patient and Public Advisory Group, the Cluster’s Provider Strategy Group,
local LINKs and Health and Well Being Boards. Further detail can be found in NHS NWL’s
Commissioning Strategy Plan.
This Operating Plan has been signed off at NHS NWL Cluster Board, following approval from each
sub-Cluster board meeting and NHS NWL Clinical Executive Committee, comprising the Chairs of
each Clinical Commissioning Group.
Cluster Medical
Director
Dr Mark Spencer
Cluster Director
of Nursing
Cluster CEO
Denise Chaffer
Dr Anne Rainsberry
Emerging CCG
Leads
Dr Ethie Kong, Chair, Brent GP Federation
Dr Mohini Parmar, Chair, Ealing CCG
Dr Tim Spicer, Chair, H&F CCG
Dr. Amol Kelshiker, Chair,
Harrow GP Commissioning Consortium
Dr Ian Goodman, Chair, Hillingdon CCG
Dr Nicola Burbidge, Chair, Great West CCG
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Dr Fiona Butler, Acting Chair, West London CCG
Dr Ruth O'Hare, Chair, Central London Healthcare
Section One: Strategic Overview
Reproduce from your strategic plans for 2012/15 the key strategic priorities and the main
initiatives you have planned for 2012/13 to deliver these. Please indicate whether and how these
will impact on performance against the National Performance Measures as outlined in the Operating
Framework 2012/13 and other performance priorities:
NHS NWL Objectives
We have already made considerable progress in delivering against the plans we set out in the 201112 integrated business plan and this is detailed in the appendix. In 2011/12, the Cluster Board
defined four key objectives to be achieved during transition to the new systems and these
objectives remain.
1. Support the implementation of new models of care and best practice to deliver improvements in
clinical quality and patient experience across NWL. In particular;

Centralising the most specialist services to deliver better clinical outcomes and safer services
for patients

Localising routine medical services to improve access closer to home

Where possible, integrating primary and secondary care, with involvement from social care,
to ensure seamless patient care

Implementing our models of care in urgent care, planned care, end of life care, improving
primary care, prescribing and specialist services pathways.
2. Safely manage the transition of health services in NWL to the new system by 2014/15 by;

Establishing the organisational structures required to ensure core system functions are
maintained through transition

Establishing the governance structures in NHS NWL required to ensure the delivery of
statutory business, decision making and accountability

Maintaining talent and capability during transition and managing any staff reductions fairly
and effectively.
3. Support the development of the new commissioning and provider landscape in North West
London;

Overseeing collaboration across the system to agree which services will be provided in which
settings and from what sites

Overseeing and providing commissioning support to GP consortia ahead of their
authorisation in 2012/13
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
Supporting providers to become Foundation Trusts

Ensuring the ongoing development of NHS NWL’s commissioning and QIPP plan for 2014/15
is led by clinicians through the Clinical Strategy Group

Delivering improvements in patient information and choice.
4. Deliver £1bn of financial savings by 2014/15 to achieve financial balance, by;

Delivering ongoing management cost savings within the cluster

Delivery of proportion of QIPP commissioner savings through implementation of new models
of care pilots

Enabling providers to deliver their efficiency savings
The Cluster has been working throughout the year to understand key QIPP opportunities. Our CSP
describes the thorough formal process we are undertaking to produce realistic and useful QIPP
plans. The staged approach is described in the CSP.
Detailed milestones to deliver this strategy is included in our Commissioning Strategy Plan,
Commissioning Intentions and throughout this Operating Plan.
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Section Two: London Health Programmes
2.1 The key outstanding actions that need to be taken in 2012/13 in your cluster to ensure
completion of the cardiovascular, stroke and trauma programmes:
The cardiovascular project has been directed at those parts of the service that deal with some of the
more complex cardiovascular procedures and at some of those conditions that require emergency
or urgent treatment, because attention to specialist services and the promptness of treatment has
the biggest potential to save lives.
The Stroke programme has been focussed on the acute end of the pathway for all stroke and TIA
patients and is nearing completion. For stroke patients the area of focus is now shifting to
improving discharge and rehabilitation services.
NHS NWL have centralised vascular services at Northwick Park and St. Mary’s hospitals. St Mary’s
Hospital has been designated as the major trauma centre in North West London. Critical for NHS
NWL in 2012/13 is ensuring that the trauma pathway and our service reconfiguration programme
are aligned.
In addition, NHS North West London will be the pilot for the London Health Programmes work on
the adult emergency services implementation programme.
Milestones / Key Actions
Achievement Date
1. All NSTEACS providers will have passed the A2 quality standards.
September 2012
2. Direct LAS transfers of arrhythmia emergencies to identified units, capable
November 2012
to treat the emergency on 24/7 basis.
3. All devices and EP/ablations procedures are being delivered at units that
April 2012 through
meet the devices and EP/ablations quality standards.
to March 2013
4. Non-emergency mitral valve operations are undertaken by specialist mitral March 2013
valve surgeons who have performed at least 25 mitral valve operations in
2012/13.
5. Elective surgery for the thoracic aorta are undertaken by specialist
March 2013
surgeons who have performed at least 10 major thoracic aortic vascular
surgery cases in 2012/13. The caseload must be a combination of elective and
emergency cases.
6. Complex arterial vascular surgery is centralised on two sites, with ongoing
April 2012
discussions re the centralisation of amputee surgery.
7. Implementation of the Aortic dissection and new technologies work streams March 2013
by London Specialist Commissioning
8. Systematic assessment process against all the standards set out in London April 2012
5
Stroke Tariff completed.
9. Annual assessment process for stroke introduced with regular monitoring
April 2012
of standards via SINAP/SSNAP and visits, where necessary
10. All stroke rehabilitation providers will have met the 5 recommendations
March 2013
set out in the Commissioning Support for London Stroke Rehabilitation Guide
11. A scorecard will be in place to monitor performance against key
April 2012
performance metrics in stroke and cardiovascular.
12. Through the NHS NWL service reconfiguration programme, ensuring
Ongoing
alignment between the proposals for change and the trauma pathway.
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Section Three: Performance and Quality
3.1 Summarise performance in 2011/12 against the Headline and Supporting Measures, identifying
areas of weak performance which will need to be addressed in 2012/13
This section outlines current progress with the key performance indicators on Trust-wide
performance on national and local KPIs (Key Performance Indicators).
In headline terms, the Cluster has achieved the following:

Strong operational performance

Sustained delivery of the 95% Accident and Emergency (A&E) 4 hour target other than in one
Trust

Improved data quality against new A&E Clinical Quality Indicators and action plans from all
Trusts to improve performance

Sustained delivery of 18 weeks RTT in aggregate and identification of high risk organisations
supported by intervention

Completed review of Maternity Quality of Care and improvement monitored

PCT performance management embedded

Facilitation of shared learning and a consistent approach to delivery across sub clusters via a
‘Performance Leads’ forum
Access targets

Sustaining delivery of the 18 Weeks RTT standards remains high priority and the Cluster has
in place robust performance management and support to Trusts. While most Trusts are
delivering this standard, ICHT is not delivering the standards in a sustainable way. The
cluster has in place robust performance management and support for this Trust.

6 week diagnostic waits are not being delivered consistently by ICHT. Other NWL Trusts have
had varied performance in the year to date however, all Trusts have plans in place to ensure
sustained delivery going forward.

All Trusts except NWLH are meeting the 95% type 1 A&E 4hr wait target and 95% all types
target (YTD December).

Trusts are publishing performance data for A&E clinical quality indicators on their websites in
line with DH guidance. Improved performance for these 5 indicators has been seen across
the Cluster and Trusts continue work to improve data quality with support from the Cluster.
Choose and book.

All Trusts are meeting the NHS London target of 70% for choice of named consultant and
have improved performance against slot unavailability. This improvement is expected to be
sustained with Trusts meeting the target during 2011/12.
Ambulance performance

London-wide Cat A performance YTD November 2011 was both above target and trajectory.
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For NHS NWL, Cat A performance remains above the London average and above target for the
year to date.

All Trusts except NWLH continue to complete patient handovers within 30 minutes 95% of
the time and meet KPI 2. All Trust have action plans and trajectories in place to complete
patient handovers within 15 minutes 85% of the time and meet KPI 1.

Ambulance Clinical Quality Indicators. As of 1 April 2011 the Category B response time
target no longer applies and a set of 11 clinical indicators were introduced to measure the
quality of care delivered. October sees the LAS ranking as the top performing trust in the
country for 5 measures, and in the top quartile for 10 of the 9 measures.
Stroke Care

All Trusts have met the stroke standard YTD and are expected to continue meeting this
standard through 2012/13
Cancer waits

The 62 day wait target for receiving first definitive treatment of referral from an NHS Cancer
Screening Service remains a challenge across the cluster. The cluster performance team is
working closely with the NWL Cancer Network to facilitate improved performance.
Eliminating Mixed Sex Accommodation

This remains a priority both for patients and the public and this is reflected in national,
regional and Cluster performance management. A number of Trusts have had occurrences of
non-justified breaches of mixed sex accommodation and contractual sanction will continue
to be applied where breaches occur. A site visit to ICHT in May 2011 identified potential non
compliance in the Endoscopy Unit at the Charing Cross Hospital site. The Trust has now fully
implemented its remedial action plan and the Unit is now compliant.
Healthcare Associated Infections (HCAI)

Improvement has been made in recent years. Challenging targets were set for 2011/12.
Three Trusts have exceed their annual tolerance for MRSA and one Trust has exceed
tolerance for C.Difficlie (YTD December). In comparison to the previous year there has been a
significant reduction in the number of infections. The Cluster continues to closely monitor all
Trust performance and expects performance to improve during 2012/13.
Venous thromboembolism (VTE) Risk Assessment

The national CQUIN objective that 90% of all patients are risk assessed for VTE is currently
being achieved by two Trusts in NHS NWL. However the cluster position is expected to
improve by year end.
Quality metrics
The importance of delivering against all the existing quality metrics will continue in 2012-13. The
list of metrics to include in 12/13 acute contracts is being finalised with CCG input. Consideration
8
will be given to including the standards below to achieve further progress:

Increasing Breastfeeding initiation rates

Reducing the number of maternal women smoking at the time of delivery

Reducing the number of elective and non-elective caesarean sections

Ratio of 1:1 midwife care during delivery

Increasing the number of total births that take place as home births or Midwifery led units

Reducing the number of cancelled operations for non-clinical reasons

Reducing delayed transfers of care

Eliminating never events
Maternity
Quality standards for maternity are being led through the performance team. We have recently
developed a minimum data set, which is described in more detail in the following Quality and
Clinical governance paper.
final CG Framework
NHS North West London
These are being written into contracts and performance managed at monthly quality meetings.
Exception reporting will be to clinical quality and risk committee.
KPI’s dashboard for maternity have been developed for use across NWL with all the providers. These
are monitored through the monthly quality performance meeting with each Trust. Exception reports
are also reported to clinical quality and risk committee.
Maternity standards have also been developed for NWL are being discussed and will be signed off
after discussion at the newly established NWL maternity network.
The reconfiguration programme is aimed to address how these standards can be achieved through
potentially smaller number of sites.
Non-Acute Performance Indicators
In April 2011, responsibility for overseeing and managing PCT performance was delegated to the
Cluster by NHS London. PCTs are required to meet all national headline and supporting measures
as well as existing public health targets. 5 key priority areas have been agreed with NHS London to
achieve a level of focus and ensure performance improvement. These are:

Childhood Immunisation. There is a mixed picture for the take up of immunisations
across NHS NWL and this will remain a high priority in 2012-13
9

Tobacco Control. Quarter 2 data shows the target number of 4 week smoking quitters is
being met in all but two PCTs.

NHS Health Checks. Current PCT performance (quarter 2) shows that the target for
people receiving an NHS Health Checks is being met in 5 PCTs. In quarter 4 all PCTs will
have health check programmes in place.

Access to dentistry. Deterioration in performance against the planned trajectory can be
seen across the Cluster with the exception of one PCT area.

Breast Screening. Breast screening uptake in 53-70 year-olds is above target in two
PCTs.
PCT performance management has been embedded over 2011/12 and will be strengthen further in
12/13.
Community Services
In NHS NWL, the configuration of community services providers changed in 2011 as a result of the
Transforming Community Services national policy to divest community health provision from
commissioners. In North West London, the following providers serve the following Borough areas:

Ealing Hospital NHS Trust: Brent, Ealing and Harrow

Central London Community Healthcare NHS Trust: Kensington and Chelsea, Westminster,
Hammersmith and Fulham

Central and North West London NHS Foundation Trust: Hillingdon

Hounslow and Richmond Community Healthcare NHS Trust: Hounslow
NHS NWL will support organising community services around the Clinical Commissioning Groups to
support the delivery of integrated care as part of the out of hospital strategy. The funding for
commissioning community services is currently within PCT allocations and will be delegated to
Clinical Commissioning Groups.
In 2012/13, Clinical Commissioning Groups in NWL are working together to ensure that their
shared aims for community health services are commissioned in a co-ordinated way. As part of this
process, there are agreed requirements for reporting of information across NWL in 2012/13 that is
consistent with acute and mental health reporting requirements. As such information and quality
indicators with consequences attached are being negotiated into community contracts this year as
providers move to compliance with collection and reporting for the National Community Data Set by
2013/14.
The four contracting teams are aligning their performance management framework for monitoring
community contract compliance during 2012/13 and a dashboard that is consistent across with
local key indicators where appropriate. There has also been a North West London Commissioning
Strategy Project Board, with Clinical Commissioners, Networks and Commissioning Leads that has
been meeting regularly throughout the development of the commissioning and contracting process.
10
This has provided a mechanism to get engagement and agreement on commissioning and
performance decisions that are consistent across NWL.
More detail on the reporting requirements for community services is included in the attached paper:
Community
performance requirements.docx
Mental Health
With have a more co-ordinated and cohesive approach to mental health contracting across the
Cluster. With both the development of negotiating teams around each of our 2 main providers and
the development of our integrated approach to mental health, we have been able to identify key
actions, milestones and areas of QIPP across the constituent CCG’s.
QIPP savings for 2013/14-2014/15 have been identified by sub clusters based on local
commissioning intentions, full year effect of some initiatives and planned new schemes. However
with the generic integrated care models developing in both outer and inner North West London,
local CCG out of hospital strategies and the mental health integrated care model, we are currently
reviewing the savings targets for all CCG’s and PCT’s against the mental health domain to ensure
that the integrated care savings are phased across the three year cycle realistically and in line with
the agreed work plan.
Prior to 2012/13, mental health performance measures have been reported at a local level.
Although 2012/13 is a transition year, we will centralise the performance management of both
mental health indicators and quality requirements. This will enable us to identify issues earlier, hold
our provider organisations to account regularly standardise our approach across Trusts and
enhance our contract management function. Below is a process diagram depicting the monitoring
mechanism and report destination.
11
12
3.2 Summarise the Cluster's performance priorities and challenges for 2012/13:
Building on improvements made in 2011/12 the cluster will work to achieve the sustained delivery
of all national Performance Measures, existing commitments and local priorities through robust
performance management. During the transition year the need for a transparent and collaborative
approach will be required, with explicit agreement for required action across all stakeholders. CCGs
will be involved in contract meetings, in particular the Clinical Quality Group which will be
strengthened with a wider range of indicators monitored consistently across all contracts. A quality
report will be provided for each Trust to inform management action and key lines of enquiry, the
outcome of this discussion will then be embedded in contractual terms.
All national and local priorities will continue to be monitored through a monthly performance
dashboard with action reported to Cluster Executive Team and Cluster Board with detailed action
discussed at the Finance and Performance Committee. This is supplemented by further detailed
information where available, specifically;

A&E daily performance

HCAI dashboard

18 week RTT dashboard and analysis

Maternity dashboard

Quality metrics
The transition to the new role of the CSO provides an opportunity to strengthen the existing robust
performance management regime with an enhanced level of GP input and leadership. In turn the
rigour of the NHS North West London approach will support developing CCGs.
Input to the delivery of Public Health indicators has been strengthened which will further develop
during 2012/13 to ensure the necessary improvement. Efforts will continue on the current high risk
priorities with an increased emphasis on screening. The NHS North West London Screening
Committee is managed in collaboration between Public Health leads and the Performance
Directorate. This approach will support the performance management of screening programmes
and ensuring that service specification is explicit within provider contracts.
The NHS North West London approach to performance management of providers can be broadly
described as follows:

Provision of accurate and timely management information with analysis

Monthly contract monitoring meetings with CCG input

Executive level commitment to improvement where performance is sub optimal or at risk
with agreement of an appropriate trajectory

Agreed management action defined in a concise, time bound, action plan

Close monitoring of delivery with further analysis and attention to detail to identify further
risk

Formal performance review meetings at executive level followed by chief executive level
escalation is necessary where performance or progress is sub optimal
13

Consistent application of contractual levers and financial penalties

Reports on progress to Cluster Board through the Finance & Performance sub-committee,
Clinical Risk & Quality Committee

Reports on progress by Trust to CCGs
The purpose of the approach described above is to agree clear deliverables in a consistent
contractual process with executive commitment. Accelerated improvement will be achieved by
working closely with challenged organisations in a collaborative manner and offering the following
support:

Draw on available resources with a targeted intervention, for example National Intensive
Support Team for cancer, 18 weeks and A&E

Share best practice and learning via Cluster Director of Operations Forum

Provision of shared management information to facilitate peer benchmarking

Deliver workshops to facilitate learning and test system preparedness. For example Pressure
Surge Assurance Planning, A&E data quality, 18 weeks delivery
This approach is currently reflected in Bi Monthly meetings with sub clusters which will evolve over
2012/13. This will in part be dependent upon NHS London management arrangements during the
transition to the NHS Commissioning Board. However during this period of change in order to
prevent deterioration in performance the Cluster will:

Map existing action plans with executive leads and management leads to support efficient
handover

Good communications with stakeholders and a robust Interim Operating Model. The interim
Operating Model will be complete by the end of March for sign-off by sub-Cluster Board
meetings prior to their disestablishment.

Continue to provide support to Public Health and PCT led action plans until handover to a
model with agreed governance arrangements for future monitoring
With have a more co-ordinated and cohesive approach to mental health contracting across the
Cluster. With both the development of negotiating teams around each of our 2 main providers and
the development of our integrated approach to mental health, we have been able to identify key
actions, milestones and areas of QIPP across the constituent CCG’s. The collective mental health
QIPP challenge is detailed below by PCT and Trust. QIPP savings for 2013/14-2014/15 have been
identified by sub clusters based on local commissioning intentions, full year effect of some
initiatives and planned new schemes. However with the generic integrated care models developing
in both outer and inner North West London, local CCG out of hospital strategies and the mental
health integrated care model, we are currently reviewing the savings targets for all CCG’s and PCT’s
against the mental health domain to ensure that the integrated care savings are phased across the
three year cycle realistically and in line with the agreed work plan
The Cluster will take the following specific actions to mitigate risk and ensure delivery.
14
Milestones / Key Actions
Achievement
Date
1. 18 week RTT
A high level of priority is afforded to meeting all 18 week RTT standards with all
Already in place
Trusts required to meet the new 92% standard for incomplete pathways and
sustained delivery of the 90% admitted and 95% non admitted pathways. ICHT
presents a significant level of risk and will therefore:

ICHT will deliver 18 weeks from July 2012 and that this will be tested at the June 2012
end of June 2012

Deliver all 18 weeks standards sustainably across all specialties
March 2013
Risk/Mitigation
Risks: That the following won’t be achieved;
1. Achievement of 90% admitted and 95% non admitted thresholds
Q1 2012
across all specialities
2. Sustained delivery of the new 92% standard for incomplete pathways April 2012
by end March 2012
Actions:
All Trusts:
Actions
Take stock of performance in all specialities and identify further action
progressed
required
during Q4 –

Cluster to provide monthly dashboard and analysis
complete

Realign demand and capacity plans in non compliant specialities
End March 2012

Clinical engagement and consideration to be given to revised pathways of

care designed to control demand on acute Trusts and reduce unnecessary
steps in the pathway

Robust PTL management in place with real time validation

Access policy revised to ensure that it is suitably explicit and in line with
national best practice

Internal monitoring of performance against the 92% standard and escalation
to ensure appropriate management action
ICHT specifically:

Trust to ensure that IST recommendations and audit report actions have
been fully and consistently embedded with evidence

Trust to check compliance to access policy

Action plans submitted for non compliant specialties

Weekly reporting on performance and progress
2. A&E
Current performance will be sustained in all Trusts to ensure delivery of local and
April 12/13
national A&E standards to year end. Stretch local targets and robust performance
management will support achievement of national standards and prevent good
15
performance in Urgent Care Centres masking poor performance in other sites.
Improved performance will be required at NWLH given the significant level of risk
to delivery.
Risks: That the following won’t be achieved
1. Sustaining performance of 95% all types by site
2. Sustained performance of local target of 95% type 1
Actions:
All Trusts:

The local target of 98% by Trust remains to ensure no deterioration

The local priority of 95% type 1 performance within 4 hours by site remains
and all Trusts report by exception each week to this standard

Pressure Surge Assurance plans and Olympic Assurance plans are coordinated by the Performance Directorate

All plans are triangulated with Borough teams to ensure a Local Health
economy approach

Stakeholders will engaged with planning events

Analysis of data quality to SUS to ensure improvements in accuracy and
completeness continue

Work to improve A&E Clinical Quality Indicators continues as a supporting
mechanism
NWLH specifically:

NWLH will provide during quarter 4 an integrated remedial action plan that
clearly describes actions to ensure year end delivery of the A&E that has
been tested by IST and that reflects best practice

March 2012
NWLH will provide an agreed trajectory through Quarter 1 to meet national
95% target at the end of the 1st quarter that relates to improvements as
detailed in the integrated action plan

The NWLH and Brent and Harrow Health Economy will be required to
June 2012
demonstrate a mature and collaborative working arrangement to ensure
that triggers are clearly identified and appropriate action taken

The Cluster will support any further analysis to better understand
fluctuation in demand that could not have been predicted based on historic
patterns of attendance and potential surges in ambulance attendance
3. LAS patient Handover Times
There will be a continued and concerted effort to ensure that 85% of handovers are
within 15 minutes and 90% of handovers within 30 minutes.
All actions by
31st March
Risks:
Non achievement of KPI 1 and KPI 2 which will have a detrimental impact on LAS
performance
16
Actions:

Hospital Turnaround Recovery Action Plans with trajectories submitted by all
Trusts and signed off by the Cluster in conjunction with LAS
Commissioners.

Consistent performance review framework is in place to monitor and assess
action plans.

Weekly progress monitored against trajectories for performance and HAS
completeness.

Contract levers and financial penalties applied where appropriate

Process in place for accurate reporting of 60 minute breaches with defined
process for reviewing Root Cause Analysis and associated actions

Development of HAS reporting tool with functionality for real time review of
performance to facilitate improved HAS completeness
End February
2012
4. Cancer waits (62 day wait target for receiving first definitive treatment of referral
from an NHS Cancer Screening Service)
All Trusts will deliver all cancer standards at year end including 62 day screening
target with full and accurate data quality.
ICHT in particular will commence reporting end of June 2012
June 2012
Risks:
1. Data quality remains poor or incomplete and therefore
performance cannot be monitored accurately
2. Performance does not improve as data quality improves
Actions
All Trusts:

All Trusts required to take action as a high priority detailing the
requirements to improve performance and data quality

The cluster has strengthened process for review of action plans to support
April 2012
improved performance going forward.

Action plans will be reviewed by Cancer Network and detailed feedback
provided best on national best practice

April 2012
Cancer performance will be regularly raised at Cluster Director of Ops
Forum as a standing item to maintain focus and executive leadership

IST advice pan Cluster will be sought if required improvement is not seen by
July 2012

July 2012
Individual IST support will be requested if appropriate
5. Healthcare Associated Infections (HCAI)
All Trusts will be required to meet national trajectories during 2012/13.
Risk:
It is noted that some Trusts have a very low denominator which presents even
On-going
greater risk in 2012/13
17
Actions:

Robust performance management is in place. All Trusts at risk of meeting
the target have had CEO escalation meeting with actions agreed. Follow up
meetings will be held during 2012/13 to ensure that focus to improving
performance is maintained.

Progress against agreed actions are monitored via the Clinical Quality Group

All challenged Trusts have participated in the pan London Peer Review and
Critical Friend Project funded by the Cluster and coordinated by NHS
London. This provides constructive and supportive challenge to identify
means of improving performance based on best practice. Trusts will develop
and implement action plans based on recommendations following the April 2012
review by end of April 2012
6. PCT Performance Management
In 2011/12 5 key priority areas were agreed with NHS London to achieve a level
of focus and ensure performance improvement. These will remain a high
priority in 2012/13.

Childhood Immunisation

Tobacco Control.

NHS Health Checks

Access to dentistry

Screening (Breast/Cervical)
PCT performance management has been embedded over 2011/12 and will be
strengthen further in 12/13. Formal bi-monthly review of non acute
performance will continue in 12/13 in line with the SHA approach, and the
interim operating model. This will be adapted to revised governance
arrangements when sub cluster are dissolved. Performance management will be
On-going
strengthened through improved exception reporting and continued progress in
facilitation of shared learning. A consistent approach to delivery will be
supported via a ‘Performance Leads’ forum (the membership of which will
change) and ad hoc performance review.
a. Childhood Immunisation

Monthly exception reporting and follow up where performance is off plan
On-going
and discussion at bi-monthly reviews

Development of a child imms best practice action plan to facilitate shared
March 2012
learning to ensure delivery against World Health Organisation (WHO)
standards

Key actions:
On-going
18
o
Improvements in data recording, data sharing and reporting
o
Improved call and recall systems
o
Continued health promotion and support for GP Practice
6.2 Tobacco Control

Monthly exception reporting and follow up where performance is off plan
On-going
and discussion at bi-monthly reviews

Best practice shared across the cluster via the ‘Performance Leads’ forum
On-going
and Public Health network

Key actions:
o
Additional capacity commissioned in 12/13
o
Further marketing campaigns and GP Practice/Pharmacy support
o
Improving recall of users with no follow up status
On-going
19
6.3 NHS Health Checks

Monthly exception reporting and follow up where performance is off plan
On-going
and discussion at bi-monthly reviews

Weekly monitoring of remedial action plans to ensure commencement of
March 2012
new delivery programmes in Q4 11/12. Performance will be closely
monitored in Harrow and Hounslow where programmes commenced
in Q4 11/12.

Key action:
o
Implementation of plans to roll out health checks to all GP surgeries
Q1 2012/13
in NHS Harrow and NHS Hounslow
o
Review and sign up of incentive schemes for 12/13
April 2012
o
Ongoing review to improve data quality and reporting
On-Going
o
Continued promotion via targeted marketing and support for GP
On-Going
Practice
6.4 Access to dentistry

Performance improvement is delivered via the contract monitoring process
On-going
(by the Primary Care Contracting Team), monitoring of local plans by the
Performance Team
o
Recovery of finance from practices who failed to deliver contracted
On-going
activity on 12/13
o
Monitoring of practice performance against local productivity
On-Going
indicators

Discussion at bi-monthly reviews
On-going
6.5 Screening (Breast/Cervical)

London Screening Improvement Board established to ensure delivery of all
April 2012
London screening programmes. Action plans are being developed by end of
April 2012 and will monitor monthly.

Monthly exception reporting and follow up where performance is off plan
and discussion at bi-monthly reviews.

Key actions:
o
Improving access and capacity
o
12/13 contract with WOLBSS to be reviewed
o
Improving data quality
o
Continued promotion of the service via targeted marketing and
April 2012
support for GP Practice to facilitate telephone follow up of DNA’s
o
Full rollout of non-attenders to be sent 2nd follow up letters 4 months
Q1 12/13
after the DNA
20
21
7. Mental Health
Action
Milestone
Deadline
Identify negotiating teams,
Agreed by CSPB and Mental Health programme
31st January
strategy and QIPP Targets
Board
2012
Agree information, quality
Agreed with provider Trusts and signed off by
28th February
and CQUIN schedules
Mental Health Programme Board
2012
Identify specific areas within
Agreed local commissioner/provider efficiency
February
mental health spend where
schedules for 2012/13 including risk share
2012/13
both quality and productivity
arrangements
gains can be made per PCT
Identified savings potential
Business case for CCG/provider approval
from integrated care
completed
March 2012
approach
Integrated mental health
Phased work plan across three work streams
April 2012
Identified areas of efficiency
Monthly
implementation
Ensure QIPP deliver
22
Section Four: Priority areas
Priority areas
DH Requirement
Delegation Actions required to maintain or achieve
Achievement
To be inserted
to CCGs
requirement. Please include key risks and
Date
by NHSL once
(yes/no)?
mitigations.
Yes
NHS North West London is in line with the
Op Framework is
out
Health
 Clusters to work towards delivering provider-based
visitors/Family
2012/13 trajectories due to be issued by NHSL w/c 5th
service vision and family offer outlined in A
Nurse
December. This is in line with the Government
Call to Action working to secure a future health
Partnerships
commitment of an additional 4200 by April 2015.
visiting service that is universal, energised and
 Maintain existing delivery and continue expansion of
April 2015
fit for long-term growth.
the Family Nurse Partnership programme in line with
the Government commitment to double capacity to
Each Borough commissioning team has been
13,000 places by April 2015.
working with providers around the vision
(Section 2.13 of Operating Framework)
outlined in A Call to Action and has begun the
process of rebuilding, clarifying roles and
promoting expansion and take-up of training
places. North West London service
specifications for health visitors have been
framed around the four main themes:

Delivering the Health Child Programme
(HCP)

Growing the workforce;

Professional mobilisation to engage and
re-energise the health visiting
profession; promoting learning and
good practice; and
23

Aligning delivery systems, ensuring we
have robust commissioning,
measurement and incentives in place to
drive progress.
NHS North West London has been working to
the NHS London trajectories for health visitor
growth up to 2015. The staffing trajectories
for 2012/13 have been agreed for each service
in conjunction with productivity requirements
and key performance indicators, to ensure the
most effective use of the health visiting
resources available in each area and make a
difference to the health and well being of
children and their families.
The service vision and future projections have
been included in the Service Development
Improvement Plan (Section B Part 11) of the
National Standard Contract. Delivering this
vision will be through continuing effective
partnerships with GPs, Local Authorities and
the key early year’s services.
Providers within NWL currently have 225.6
health visitors which is planned to increase to
234.9 by April 2012 and 359.2 by April 2015.
This is outlined in the attached document.
24
111208_HV SIP
trajectories by Cluster Provider.xls 81211.xls
25
Olympic-
 Deliver business as usual performance levels, whilst
No
NHS NWL are ensuring this priority area is
April to
Paralympic
meeting any increase in demand associated with the
delivered through the NWL 2012 Assurance
September
Games-time
Games (“Games Effect”) at Games-time.
Programme. The programme builds on
2012
delivery
 Meet the bid commitments by providing LOCOG with the
necessary ambulance and paramedic resources at all
LOCOG Events and through the Designated Hospitals
(Non-designated hospitals if clinically appropriate)
providing free healthcare for the accredited members of
the Games Family.
 Provide appropriate contingency for health resilience at
Games Time in compliance with DH guidance as part of
the contribution to the Olympic Security and Safety
Programme.
existing business continuity and emergency
plans to account for and mitigate the impact of
the Games on business as usual service
delivery. The NHSL 2012 team have reviewed
the cluster plans to be fully ‘Games Ready’ by
April 2012, and this feedback is built into the
programme.
The Programme incorporates a number of
work streams to provide focus on key areas of
planning to mitigate risks including Emergency
A comprehensive NHS Games Planning toolkit and
Preparedness, Business Continuity, Transport,
reference pack has been produced by NHS London, this
Health Legacy, HR, Communications and
can be accessed at: http://www.london.nhs.uk/getting-
Finance.
fit-for-the-2012-games.
Games time is between the 9th of July 2012 and the 12th
September 2012.
A further 3 provider work streams are in
progress for Acute, non-acute (mental health,
community) and Primary Care, utilising
existing commissioning mechanisms to ensure
that all provider organisations have robust and
tested business continuity and emergency
plans in place.
Acute / Community / Mental Health / Primary
Care providers (including GPs and Pharmacies)
26
are being supported and furnished with the
necessary information to allow day to day
planning around staff / patient access and
supplier deliveries.
Organisations are engaging with local
boroughs to ensure that health input is fed
into licensing plans for events as well as
allowing event impact to be incorporated into
planning.
Organisations are taking part in relevant tests
/ exercises for command and control
arrangements with Clusters and NHS London
and operational planning between
organisations to test business continuity and
emergency planning. Lessons learnt are
shared at steering groups and incorporated
into planning.
Health Legacy activity is being led centrally and
encouraged throughout the Cluster and its
organisations. A Health Legacy lead from each
of the 8 PCTs meets regularly to coordinate
plans. Active Travel Champions are being
identified in each organisation to promote
active travel.
27
The workstream lead is working with health
legacy representatives from all organisations
to encourage participation in the NHS Sports &
Physical Activity challenge, through the NHS
walking challenge or an Active Travel challenge
to see which teams can get the most people
walking, running or cycling in the months
leading up to the Games.
Legacy initiatives for the wider population are
being collated across all NWL organisations.
Activity will then be coordinated and shared as
appropriate.
Staff will be sponsored to participate in the ‘5K
My Way Challenge’ and a Fitbug ‘Mount
Everest’ pedometer challenge is to be
launched. This challenge will be rolled out
before the Games but also provide a legacy
after the Games have ended.
Specific milestones have been identified for
each workstream with an aim for full assurance
against each to be achieved by 16th March
2012.
The milestone plan with specific dates is
attached here:
28
120222 NWL 2012
Assurance Milestone Plan V1.0.xls
The key risks relate to the impact of significant
transport disruption and the high number of
cultural events taking place within the
Cluster’s boundaries. These are likely to
impact on staff getting to work, patients
accessing healthcare and logistical
arrangements necessary to deliver a business
as usual service.
Other risks are factored into planning
including workforce availability, given the
potential leave requirements for summer
holidays and visiting, or volunteering at, the
Games.
Information, learning, support and guidance
from NHS London, Transport for London (TfL),
London Boroughs and other relevant
organisations is disseminated regularly to
2012 leads across the Cluster and its
organisations, to ensure that planning
assumptions are up to date.
29
Ambulance specific actions:
The London Ambulance Service (LAS)
Commissioning team within the Cluster have
been working with the LAS for the past 2 years
to ensure that the LOCOG requirement for
ambulance and paramedic resources within
Games venues is met.
The team meet with the LAS Olympic Planning
Office on a regular basis to ensure that
planning is on track and risks are mitigated
appropriately. Costs are monitored against
budget as planning progresses and assurance
reports are provided to NHS London regularly
as requested.
To ensure that the organisation is able to
deliver business as usual during Games-time,
whilst meeting LOCOG’s requirements, PrePlanned Aid from other, national ambulance
services is being provided.
The impact of the Games Effect outside of
venues is being planned for through regular
engagement with event planners, TfL and other
emergency services.
The LAS are working closely with the Met and
30
the London Fire Brigade to ensure that C3
arrangements are tested, aligned and robust.
C3 testing is also practiced regularly with
LOCOG, TfL and local authorities.
Operational plans are tested with a number of
stakeholders at specific venue test events.
LAS Operational plans, including venue plans
are due to be complete in March 2012.
The key risk for LAS Games-time delivery is
industrial action. If this takes place during
Games-time, the impact on venue resources
will be considerable, whether it be LAS or staff
from trusts nationally. Lessons learnt from the
Industrial Action on the 30th November 2011
are being incorporated into Games-time
specific industrial action plans that set out
mitigating actions at escalating levels of
decreased resource.
31
Innovation
 Evidence the PCT Cluster is preparing to implement the Yes,
NHS NWL is well placed to respond to the
Innovation Review. Please outline the key milestones
through
Innovation Review. Across the Cluster, we
that will ensure implementation of the review with
DSU
have in place a Delivery Support Unit which
particular reference to compliance with list of high
supports CCGs to deliver change across
impact innovations and accelerating adoption and
pathways that is innovative and shares best
diffusion of innovative best practice.
practice; so adoption, acceleration and
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digit
alassets/documents/digitalasset/dh_131784.pdf
Ongoing
diffusion of both bottom-up change and
‘compliance with… high impact innovations’.
The model we have to support commissioners
and providers deliver change enables rapid
application and diffusion of best practice.
It is through the DSU that we will roll-out telehealth innovations, for example. In this case,
we are also able to link this work to closely to
the NHS NWL Integrated Care Pilot and rapidly
scale-up the benefits of innovative
developments.
In addition, the process we have agreed with
providers in 2011/12 to control planned
procedures with a threshold of activity (PPWT)
is a good basis on which we can fully NICE
guidance.
Finally, we have in NHS NWL an active and
productive Health Innovation Education
Clusters (HIEC) and for Leadership in Applied
32
Health Research and Care' (CLAHRC), in
addition to an Academic Health Science Centre
which NHS NWL is supporting to provide
greater leadership in the research and
application of best practice.
The Cluster lead for innovation is the Director
of Strategy, Daniel Elkeles and our delivery
mechanism to share innovation across the
Cluster is the NHS NWL Delivery Support Unit.
The DSU will continue to deliver innovation
across the Cluster, including tele-health, and
this will be described in more detail in a final
business plan published later.
33
Informatics
 Include evidence of consideration of informatics
capability and capacity necessary to support the
transition.
Yes
Evidence of consideration of informatics
capability and capacity necessary to support
the transition?
Ongoing
 Include a credible proposal for giving patients on-line
access to their medical records, starting with their GP
A “Baseline study” of IM&T across the Cluster
records.
has been commissioned from KPMG, the
 Provide an achievable trajectory for providing Summary
outputs from this review are being compiled
Care Records by March 2013 to all residents who have
and are contributing to the development of the
been written to.
CSO development and other transitional work
(Section 3.26 of Operating Framework)
plans across the Cluster. The central and local
Informatics and IT teams are working together
and with the QIPP Delivery Support Unit, to
ensure coordinated strategies are pursued and
implemented effectively.
Are there plans in place to ensure access to IT
systems, sharing of data and access to health
intelligence in line with information
governance and business requirements during
transition and beyond transfer?
As above, with additional specific reference to
the ongoing process of development of a
Business Intelligence capability within the CSO.
Patient on line access to medical (GP) records?
In the short term, and in line with the national
34
position on this, the agreed protocol is that
patients make an appointment with their
practice and view their record with a clinician
who will guide them through the entries.
During the course of 2012 some boroughs /
CCGs, where their local practice systems
permit / facilitate, are expected to trial the
direct on line access by patients via the
facilities offered by the system provider. This
will be subject to considerations of business
case for investment, information governance,
and priority of available resources to perform
any required reviews or system changes.
Implementation plans for summary care
records by March 2013 for all residents
In 2012 some practices in NW London will be
carrying out pilots of uploading data from GP
Practices that use hosted systems. If successful
we shall roll this out to other Practices where
hosted practice systems are available or in
place. The overall strategy for NW London for
practice systems is to move to hosted systems.
As this progresses, the records for patients
covered by these practices will be migrated
over to SCR.
35
A copy of a report that outlines a baseline
study of Information Management and
Information Technology (IM & IT) for the NHS
North West London Commissioning Cluster
and the nature and depth of IM & IT services
currently being delivered is attached. NHS
NWL has also accepted the plan for how these
services should be consolidated and / or
transformed by April 2013 in order to facilitate
successful transition to the NHS
Commissioning Board, the Clinical
Commissioning Group (CCGs) and the
Commissioning Support Organisation (CSO).
8.0 111226 NWL
Exec Summary (release 2) v9 0.pdf
Business Continuity Disaster recovery of IT is
included in the scope of each NWL Sub Cluster
team’s role and remit. The Sub Clusters each
have locally specific DR plans for recovery of IT
in the event of a major incident. There are no
plans for a full business continuity planning
exercise in 2012-13, given the anticipated
transition of PCTs.
Patient Access Access to patient records by
36
patients remains an “off-line” arrangement,
due to a combination of technical and IG
factors. However, the Integrated Care Pilot in
Inner NWL is looking to investigate a pilot of
the http://howareyou.com
<http://howareyou.com/> platform to
provide ICP-related information to patients.
Summary Care Record: Plans in NWL to support
SCR are highly dependant on GP practice
moves to hosted systems, which are the
agreed strategic target platform for the
Cluster. Update from practices is being
encouraged and facilitated; however supplier
side availability will dictate the pace of
implementation. A pilot project has been
initiated in Hounslow migrating practice data
to the SCR with a selection of practices on
SystmOne. In Ealing and Hillingdon SCR is
subject to moving practices to hosted systems
and subject to funding allocations in 2012/13.
Brent & Harrow Sub-cluster is developing
plans to implement SCR by 31 March 2013:
plans have been submitted & approved for NHS
Brent; plans for NHS Harrow are expected to be
approved on the 7 March 2012.
Choose & Book: Core component of plans for
37
referral facilitation service (RFS) across Ealing,
Hillingdon and Hounslow. GP practices are
being encouraged to use C&B exclusively for
all referrals. The RFS will be using C&B
exclusively for all its business processes. As
part of contracting round acute providers have
been informed to pass on referrals not
received through C&B to the RFS. Community
and Mental Health providers have been asked
to have C&B compliant systems in place by
October 2012. In Inner NWL, C&B Support for
C&B continues to be provided on an as-needed
basis by the GP Computing. Capital work
completed in 2011/12 means that there are no
technical barriers to C&B in any of the Inner
Practices. In Brent & Harrow, C&B timetable is
being developed as business case/s are
approved.
Electronic Prescribing: Only Hillingdon has
been given Secretary of State sign off. This is
subject to practices migrating to EPS2
compliant systems. There is only one practice
with such a system in Hillingdon. In Brent &
Harrow, EPS timetable is being developed as
business case/s are approved. In Inner NWL,
EPS Business Case & Plans are currently in
development. At present there is no timetable
38
for approval, but this is likely to be achieved in
Q2 2012.
39
Public Sector
 Include assurance that due regard is given to the Public Yes
Equality Duty
Sector Equality Duty (PSED), both specific and general,
(PSED)
and that equality objectives are integrated into the plan
Detailed equality action plans are included in
Ongoing
the attached spreadsheet.
considering using the Equality Delivery System as the
framework.
(Section 2.4 of Operating Framework)
NW London Cluster
PSED Objectives 2012-2013 v5 (2).xls
NHS North West London in exercising their
functions as an employer and strategic
statutory body demonstrates due regard to the
PSED when making certain decisions about the
effect of their activities on their key
stakeholders including the workforce and
service users. In support of this, the Cluster
Board agreed their approach to delivering the
Equality Act by implementing the Equality
Council’s recommended tool the Equality
Delivery System (EDS).
The information that is considered in the
decision-making, both quantitative and
qualitative, and drawn from engagement with
our current key stakeholders however, this
information has not been disaggregated by all
protected groups and the Cluster therefore
recognise this as a gap and the potential for
inequality.
40
However the Cluster undertakes an overarching
Board level governance role to ensure the
operational responsibility for integrating the
PSED also lies with the current and future
commissioners of care, namely PCTs (through
the sub-Cluster structure in NWL) and Clinical
Commissioning Groups.
The responsibility extend to other functions
such as use of statutory discretion, QIPP,
Finance and performance, Informatics and
integrated governance including workforce
planning decisions, and contracting outside
the NHS. Therefore, this does not substitute
the need for PCTs and CCGs to consult on and
engage with service users and key
stakeholders when conducting equality impact
assessments on individual plans and policies
locally.
The following areas demonstrate The Cluster’s
current due regard:
(a) Governance and Leadership
(b) Engagement and Involvement
(c) Impact assessment of Strategic Plans
and documentation
(d) Analysis of workforce and Patient
41
informatics
The following highlights the current gaps in
compliance information and demonstrates how
the Cluster intend to mitigate any potential
inequality in outcome which underpins the
need for change:
Service Users Our models of care and service standard case
studies will reflect the diversity of the
protected characteristics including social
economic status where appropriate;
Strategic needs assessment data will be
disaggregated by the protected characteristics
in order that resources can be utilised more
effectively thereby reducing health inequalities;
QIPP Programmes to consider the needs
assessment, reflect the requirements of the
communities we serve, this again will enable
improvements in the healthcare outcomes and
meeting our financial targets 2014/15.
Workforce –
42
A desktop analysis of the Cluster’s workforce
data has been undertaken and how it currently
meets the requirements of the PSED. Generally
the quantitative data meets 80% of the
requirements with the new information ‘fields’
needing to be captured, information systems
allowing, across the protected characteristics.
In addition, in order to mitigate any
inadvertent inequality, the following has been
recommended:
-
All new hires’ information will be
captured on the new system,
-
Existing staff data will be up-dated as
activity dictates on an individual basis
-
Pregnancy and Maternity data review
-
Robust capture of disability data
-
Closer liaison with recruiting
management.
With new and existing channels, it is necessary
to make equality information accessible to
staff, patients, service users and the public.
Ensuring that both external and internal
colleagues are informed of the equality impact
assessment undertaken strategy as a whole.
To support the Cluster’s governance role we
43
will implement a reporting mechanism to
capture any relevant analyses so we can
understand the impact of any future strategic
planning and the impact it has across North
West London.
Finally, the Cluster is also in line to submit a
fuller compliance report to the Equality and
Human Rights Commission by 31st January
deadline. A synopsis of our intentions will be
submitted to the Cluster Board highlighting
our EDS priorities and actions for the coming
year 2012-2013.
A recent report, attached below, outlines NHS
NWL’s actions and intentions that will enable
compliance with the relevant legal duties, a
summary assessment of progress on the
Equality Delivery System (EDS) implementation
and the Cluster’s strategic actions and
intentions to integrate equality assessment
and ‘language’ into the commissioning plans
and the NW London case for change across the
nine priority issues to be addressed.
NWL_PSED_submissi
on_and_draft_equality_duty_priorities v2.pdf
44
45
Safeguarding
Children
 Ensure a sustained focus on robust safeguarding
Sub-
arrangements (to include how the Board assures itself). Clusters
 To work in partnership through Local Safeguarding
NWL NHS Cluster will continue to ensure a
sustained focus on robust safeguarding
arrangements, including work in partnership
Children Boards (LSCBs) and ensure ongoing access to
through Local Safeguarding Children Boards
the expertise of designated professionals.
(LSCBs) and Local Safeguarding Adult Boards,
 Work with developing CCGs to ensure they are prepared
for their safeguarding responsibilities.
(Section 2.43 of Operating Framework)
As attached
and to ensure ongoing access to the expertise
of Designated Professionals in line with local
need. They will work with CCGs as they
develop to ensure they are well prepared for
their safeguarding responsibilities and that
robust local arrangements, including future
input to LSCBs and Local Safeguarding Adult
Boards, are put in place. (NHS Operating
Framework 2012/13 DH, 2011)
To evidence this item, NHS NWL attaches a
Board paper and supplementary paper
outlining the arrangements and next steps for
safeguarding children in NWL.
Survery_Report_on_
Safeguarding
Safeguarding_Children.pdf children
46
Safeguarding
Adults
 Ensure a sustained focus on robust safeguarding
arrangements.
 Work with developing CCGs to ensure they are prepared
for their safeguarding responsibilities.
(Section 2.43 of Operating Framework)
Sub-
NWL NHS Cluster will continue to ensure a
Clusters
sustained focus on robust DOLS & SAAR
arrangements, including work in partnership
through Local MCA/ DOLS Forums/ Networks &
Safeguarding Adults Boards whilst ensuring
ongoing access to the expertise of designated
leads in line with local need. They will work
with Clinical Commissioning Groups (CCG’s) as
they develop to ensure they are well prepared
for their adult safeguarding responsibilities &
that robust local arrangements, including
ongoing input into local Safeguarding Adult
Boards (NHS Operating Framework 2012/13
DH, 2011) & MCA/ DOLS Forums/ Networks.
Arrangements for 2012/13
The CCG’s are expected to have delegated
authority for all the functions previously held
by the 8 PCT’s in NW London with the
exception of primary care contract
management from April 2012. Whilst the NW
London Cluster Chief Executive will continue to
hold overall accountability as the ‘accountable
officer’ for the 8 Primary Care Trust’s (PCT) the
CCG’s will be expected to operate with full
delegation during this shadow year. This will
require the operating model for the CCG’s -
47
two proposed management boards to ensure
they full fill the statutory requirements.
Next steps
During April 2012- April 2013 CCG
Accountable Officers will need to demonstrate
full understanding and evidence their
compliance for fulfilling their obligation for
MCA, DOLS & SAAR. They will be supported
during this process by the NWL Cluster
April 2013
Director of Nursing and the designated nurses
within the shadow CSO who will provide
support to them during this time. Following
full authorisation from the CCG Accountable
Officer the accountability will be fully
transferred from the Director of Nursing to
them.
Further detail on NHS NWL’s arrangements for
safeguarding adults at risk is included in the
following attachment:
Safeguarding
Adults.doc
48
Military and
veterans’ health
 Work with the London Armed Forces Network to ensure

Principles of the Armed Forces Network March 2012
the principles of the Armed Forces Network Covenant
Covenant reflected in contracts with
are met for the armed forces, their families and
providers.
veterans.

 Ensure that the Ministry of Defence/NHS Transition
commissioned service.
 PCT Clusters, and organisations they commission from,
March 2012
in NHS standard contract for all
Protocol for those who have been seriously injured in
the course of their duty is implemented in any
MoD/NHS Transition Protocol included

commissioned services.
Special leave
Cluster special leave policy confirms
policy in
support for staff who volunteer for
place;
reserve duties; for provider
contracts by
should be supportive towards those staff who volunteer
organisations, this is covered in the NHS March 2012
for reserve duties.
standard contract.
(Section 2.12 of Operating Framework)
49
Mental health
 Continue to meet expectations within No Health Without Yes
Mental Health and NHS Outcomes Framework.
 IAPT to meet 15% prevalence with recovery rate of at
least 50%.
NHS North West London is developing an
innovative and exciting approach to integrated
care in mental health. Commissioning and
provider organisations are collaborating to
 Focus needed on minority groups, older people, people
provide integrated physical and mental health
with serious mental illness and long term conditions.
provision which spans historical organisational
 Reduction of mortality from physical illness in those
with mental illness.
 Focus on joint working with National Offender
Ongoing
boundaries, whilst maximising the potential of
joint working between secondary, primary and
social care.
Management Service.
 Focus on mental health prevention in looked after
children and other young people at risk.
The approach to integration has prioritised 3
key themes:
 QIPP achievement monitored against MH Performance

Shifting settings of care
Framework covering new cases of psychosis served by

Better adherence to care plans for
EIT, gatekeeping of acute admissions by crisis teams,
7-day post discharge follow up for those on CPA.
 Elimination of mixed sex accommodation
people with long term conditions

Better mental health treatment in acute
hospitals
(Section 2.23 of Operating Framework)
Across the 3 themes, the focus of the approach
is to improve patient’s mental and physical
health, reducing the reliance on secondary and
inpatient care where unnecessary and
promoting primary and self care. It will include
better, more coordinated mental health
treatment for people with long term conditions
and better physical health for those with
mental illness by implementing a multidisciplinary group approach to patient care.
50
We are piloting 24/7 psychiatric liaison
services within 5 of our acute trusts,
supporting better identification and treatment
at both A&E and within hospital wards. Better
identification and treatment times will enable
patients to access the appropriate care
pathways quickly. This will also support
improvements in the identification of people
with dementia in hospital settings
As well as this discrete initiative, local PCT’s
and Clinical Commissioning groups are
developing their primary and community offer,
focusing on improved access and treatment for
people with mental health issues. Performance
of IAPT is variable across the cluster; however
action plans for all boroughs currently not
achieving the target are in place and have been
assured by NHS London. Local plans include
the delivery of community mental health
delivery workers who focus on BME and
vulnerable patients ensuring improved access
to psychological care
North West London have an ambitious QIPP
efficiency requirement within mental health,
focussing on agreed shifts in care settings,
51
redesign in primary and community care whilst
improving performance against the
performance framework indicators.
Performance of IAPT is variable across the
cluster; however action plans for all boroughs
currently not achieving the target are in place
and have been assured by NHS London.
Cluster performance in new cases of psychosis
served by early intervention teams and
treatment is good, however we continue to
work with our 2 main mental health providers
in ensuring that referral routes and protocols
and flexible crisis interventions are being
developed to meet the needs of our diverse
populations.
Our CPA follow up rates are excellent and we
will continue to focus on this indicator through
an improved quality and information schedule
within the national contract
PCTs jointly fund Looked After Children ‘virtual
health teams’ with Hammersmith & Fulham,
Kensington & Chelsea and Westminster local
authorities. Although slightly differently
configured in each area, each team has a core
nursing and CAMHS component, including
52
access to specialist paediatric and psychiatric
consultation as required. Services include:
annual health assessments; training and
support for foster carers; 1:1 intervention for
young people; regular completion of Strength
and Difficulties questionnaires; input on
placement stability, transitions and managing
challenging behaviour. We will work with our
specialised commissioning colleagues to
review tier 4 CAMHS services to ensure that
tiers 1 to 3 are robust and responsive to
reduce the number of tier 4 admissions, whilst
developing local pathways out of tier 4 to
minimise lengthy admissions.
North west London mental health trusts are
compliant and will continue to be, with the
mixed sex accommodation requirements.
Offender Health
The offender health work in the prison and
community is outlined in the Offender Health
Strategy which was signed off by the prison
health partnership board. A six-monthly
update of the strategy action plan is attached
and a full year evaluation will be produced for
the April partnership board meeting.
A summary of the key priorities for 2012/13
53
and beyond are:
Community
1. Work with providers to embed the new
criminal justice liaison and diversion service
model in custody suites and court across
2. Improve continuity of care between prison
and the community for all offenders and in
particular substance misusing offenders and
those with mental health and learning
disability needs.
3. Ensure relevant community and prison
services work together to reduce re-offending
within the agreed framework of integrated
offender management.
4. Ensure that the re-commissioned Drug
Intervention Programme (DIP) service
successfully introduces screening for mental
health and learning disabilities in custody
suites.
Prison
1. Produce an updated health needs
assessment
2. Improve identification of prisoners with
learning disabilities and autism spectrum
disorders in HMP Wormwood Scrubs.
3. Improve pathways from primary care to
54
specialist mental health services to reduce risk
of deaths in custody and improve management
of mental illness.
4. Improve information on healthcare needs
and treatment from the community to prison
healthcare services and back to the community
for releases.
5. Introduce a performance management
framework with Central London Community
Healthcare that is outcome focussed and
accurately reflects activity and quality,
including clinical governance structures,
service user feedback and improvements in
access to healthcare services.
6. Re-commission substance misuse psychosocial intervention service to integrate existing
services under a new model that puts greater
emphasis on delivering treatment recovery
outcomes.
A more detailed action plan is attached.
Offender
Health.docx
IAPT
55
Across the nation al mental health
performance indicators, the high risk is IAPT,
both in terms of referrals into the service
against prevalence (15%) and recovery rates
(50%). Action Plans are in place for all PCTs and
the key risks, milestones and actions are
summarised below
IAPT delivery
Risks
Mitigation
Timeline
GP’s unclear of referral route and scope of
Promotion of PCT services to GP population
June 2012
Inappropriate referrals taking up clinical
Review appropriateness of referrals in
March 2012 – June 2012
capacity
partnership with London health programme
service
clinical assurance process
Clinical capacity
Reduce waiting times
Monthly monitoring
Measure caseload target compliance
Reduce DNA’s
Local variation to clinical model and
Review psychological therapies e.g. Local
outcomes
counselling services against IAPT compliance
Service capacity ability to increase activity
Review interventions and evaluate different
June 2012
methods of intervention e.g. group work
56
Carers
 Publication by 30 September 2012 of Local Authority
Yes
Partnership working with our local authority
and PCT Cluster joint needs assessment with agreed
and voluntary sector organisations is well
plans policies and identified budgets with Local
established for carers services across NWL.
Authorities and voluntary groups to support carers.
Carers support services including personal
 To include identification of total budget to support
budgets schemes have been jointly funded
carers breaks and indicative number of breaks available
with each local authority in 2011/12 and this
within the budget.
will continue in 2012/13. The PCTs have also
(Section 2.11 of Operating Framework)
Ongoing
contributed funding to carers information,
advice and signposting services as well as
other local initiatives to improve carers health
and wellbeing.
Following a joint assessment of local needs,
Dates vary by
each Borough in NWL will agree policies, plans Borough
and budgets with local authorities and
voluntary groups to support carers, where
possible using direct payments or personal
budgets. For 2012/13 all Borough plans will be
in line with the national Carers Strategy and:
•
be explicitly agreed and signed off by
both local authorities and within the
Cluster;
•
identify the financial contribution made
to support carers by both local
authorities and within the Cluster and
that any transfer of funds from the NHS
to local authorities is through a section
256 agreement;
57
•
identify how much is being spent on
carers’ breaks;
•
identify an indicative number of breaks
that should be available within that
funding; and
•
be published on a website by 30
September 2012 at the latest
End Sept
2012
58
Dementia and
 Ensure providers are compliant with NICE quality
Yes
Dementia care has been prioritised across the Ongoing
care of older
standards and information published in provider quality
cluster within Clinical Commissioning group
people
accounts.
commissioning intentions. As part of our
 Work with GPs to ensure improvements in general
integrated approach to mental health, we are
practice and community services including improvement
piloting a 24/7 gold standard psychiatric
of diagnostic rates.
liaison service within 5 acute trusts. As well as
 Ensure participation in and publication of national
clinical audits.
 Outline initiatives to reduce inappropriate antipsychotic
prescribing.
supporting A&E, the service will be supporting
the identification and treatment of people with
mental health, and in particular dementia in
hospital settings.
 Continued drive to eliminate Mixed Sex
Accommodation. Reporting of inappropriate admission
We have developed a cluster programme Board
rates.
for mental health. This is made up of GP’s
 Non payment for emergency readmissions within 30
days of discharge from elective admission.
(Section 2.08 of Operating Framework)
from each of our CCG’s and will focus on
improvements in dementia care and diagnostic
rates across the cluster. We will continue to
develop local community teams to support
identification and referral from GP and are
reviewing the dementia pathway across all
PCT’s. The integrated care initiative will
support improved diagnosis rates not only
within GP practices, but across both health and
social care providers and supported by
secondary care expertise, and review
antipsychotic prescribing across the cluster.
As part of our national contracts, we are
ensuring that all providers across settings are
59
NICE complaint through new quality and
information schedules within the national
contract. Dementia care will be part of our
providers Quality Accounts and participation in
national and clinical audits a contractual
requirement.
Our mental health providers are compliant with
mixed sex accommodation requirements and
will continue to do so.
There are local initiatives and variation to
address in NWL for both the requirement to
increase the identification rates of dementia
across the cluster and the reduction in
antipsychotic prescribing rates in primary care.
Local CCG and sub cluster performance
management of progress against targets will
remain but feed into a centralised performance
management regime which will be overseen by
the Mental Health Programme Board and
cluster performance teams. Again, although
there is local variation, the key risks and
mitigations are listed below.
In collaboration with ONEL and INEL NW
London plan to hold an Older Person’s Summit
(May/ June 2012) whilst supporting the
60
development of local networking/ action
outcome groups.
Risks
Mitigation
Timeline
Patients are not identified appropriately
Training requirements across acute Trusts are
1st April 2012
contracted using the CQUIN mechanism
Promotion of PCT services to GP population
High risk patients not identified
Local plans to train a range of
Work undertaken across the year
professionals/organisations such as:

Local Nursing homes

Long term condition management
services

Falls services

SMS services
Local prevention and treatment services skills
Review local PCT memory services
and capacity
Review outcomes measures against best
September 2012
practice models of care
Review capacity and activity against
prevalence
Antipsychotic prescribing does not reduce
Baseline PCT antipsychotic prescribing levels
April 2012
at practice level
Mental Health providers contracted to support
March 2012
GP’s in prescribing behaviour
Medicines management QIPP targets set
against antipsychotic prescribing
April 2012
61
Any Qualified
Provider
 Extend patient choice of community and mental health Yes
We have described the work NHS NWL has
services to AQP in 3 service lines per Cluster between
undertaken to deliver the national MSK
April and September 2012.
framework and what each CCG is planning to
 Outcome-based service specifications should be
developed with input from CCGs and patients.
do for AQP next year. NHS NWL’s AQP
milestones are included below.
 The nationally developed provider qualification
questionnaire should be used to qualify providers.
 Include further service lines as per Government
announcement (expected in December).
(Section 3.21 of Operating Framework)
AQP Governance – risks (R) /mitigation actions
(MA):
R: Implementation of extended choice
comes with risk of increased demand and
higher spend than Budget.
MA: Strong contractual frameworks &
governance processes are agreed. Risk
sharing agreements in place & ensure an
effective care pathway is agreed as part of
AQP package.
R: Clinical governance risks moving from an
acute provider or sole provider with its
inherent supervision & links with other
expertise to support diagnosis & treatment
to independent community services that
don’t have the same infrastructure &
governance arrangements in place.
MA: clear quality assurance processes &
clinical supervision requirements &
monitoring as part of contractual
requirements.
R: Risk around having a collective
62
understanding & agreement of revised
pathways & scope and scale of extending
choice in each service – as viability of
service providers and consistency or rollout is key to success of AQP.
MA: Clear engagement & local ownership at
each step of the implementation process.
R: risk around capacity to roll-out the AQP
locally following establishment of the
business case and implementation plans by
Cluster.
MA: continued engagement & support
provided as required through the
implementation phase – taking on a
programme monitoring/support role.
AQP Implementation NWL
Actions:
Measure:
Timing:
 Analysis: market assessment/planning of
 AQP Case for Change around chosen service line
29 February 2012
market structure desired around each
to be commissioned locally presented and
service line with decision made by each
agreed by each CCG.
CCG around which service line to
implement locally in 2012/13.
 Preparation: Agreement of the pathways
and local requirements around the three
31 March 2012
 Notification of service variation provided to each
current provider.
 Established contact with England Qualification
31 March 2012
Centre of Excellence (QCE) leading each service
63
Actions:
Measure:
service lines: diagnostics, audiology and
line procurement process through Supply to
continence services.
Health and Memorandum of Understandings and
Timing:
procurement window agreed.
 Hold service line workshops with Clinical
15 April 2012
Commissioners and service line experts from
across London to agree elements of the pathway,
currency and thresholds for the specification.
 Preparation: Establishment of service
 Evidence of consultation with patient groups and
specifications, referral protocols &
key stakeholders (Health and Wellbeing Boards
thresholds for treatment, currencies,
etc.) around the draft service specifications.
contract requirements & performance
 Service specifications with referral protocols,
frameworks.
31 April 2012
30 May 2012
thresholds and currencies presented and agreed
by local CCG.
 Evidence of Testing of Tariff (if different to
30 May 2012
national implementation pack) to assess
acceptability and sustainability of the tariff.
 Preparation: Development of evaluation
 Service specification upload onto Supply to
process for assessing qualified providers,
Health by QCE includes the locally prescribed
including establishing key local / London
qualification criteria.
qualification criteria that potential
 Governance processes have been established
providers would need to meet to qualify to
and agreed by each Borough around the
provide services in NWL.
evaluation of potential local providers.
30 May 2012
30 May 2012
 Names of local Clinical Commissioners to be
involved in the evaluation process to be given to
the QCE taking forward their service line.
64
 Engagement: Engagement locally to ensure
 Evidence of engagement with existing and
local ownership of changes proposed.
potential providers around each service line
Engagement with existing providers around
(potential NHS London provider engagement
the changes and expectations of the
event in discussion).
April / May 2012
revised pathway and AQP process.
Engagement with potential providers
around local requirements & expectations;
process for engagement in AQP &
timeframes for the assurance process.
 Qualification Process: Publish advert &
 Local specifications and criteria are included in
qualification requirements in QCE windows.
relevant QCE’s June / July / August Procurement
Work with local providers to complete
window:
questionnaires as necessary (ensure they
 NE England QCE – Audiology
are aware of process, timeframe and
 NE England QCE – Continence
requirements). Complete the evaluation
 Midlands QCE - Diagnostics
process.
 Have local evaluation team events to undertake
June / July / August
2012
July / August 2012
the local evaluation components of the QCE
process
65
 Mobilisation: Agree contracts with
appointed providers in each specialty.
Agree timeframe (up to four months as per
 Contracts signed and in place for each Borough /
CCG to have choice of provider in AQP.
August / September
2012
 Brief each CCG with list of agreed providers that
DH guidance) for the provider to get IT
will offer choice locally and agreed process for
systems in place; engage with GP’s,
mobilisation.
community and acute service providers
locally; establish patient information
processes, estates/premises agreed and
equipped etc. as required; and staff and
clinical governance requirements in place.
 Mobilisation: preparation of CCGs and
 Established processes for each Borough around
GPs/Community services for offering choice
implementation of AQP – including protocols for
– protocols, referral systems, process for
offering choice for chosen service line, agreed
choice, patient leaflets, training etc. as
local referral systems to implement, processes
required
for choice including provider patient leaflets etc.
 Review: Hold a workshop with key
commissioners and stakeholders across
 Workshop held.
August / September
2012
Oct / Nov 2012
 AQP Review paper presented to the NWL Clinical
NWL to discuss lessons learnt in first
Executive Committee for discussion and
procurement round of AQP and how could
agreement of recommendations for improving
improve planning processes for future roll-
the process for future roll-out.
out of AQP in community services.
66
Integrated
Care Systems
Clusters are asked to describe how they plan to:








Y/N
The Inner ICP is already up and running and the
Enter text
Identify the geographies and population segments
outer boroughs will commence in April 2012. This here
the ICS will cover
includes Ealing Brent Harrow and Hillingdon.
Establish a coalition of leadership at the most
Integrated Management Groups will be formed at
senior levels
borough level which will provide borough based
Develop a business case, which defines clinical
leadership over the pilot and report to an
scope and financial model, approved by all parties
integrated management board which will lead the
(commissioners and providers)
Outer pilot from a cross borough perspective.
Develop a detailed operational plan, setting out
The business case is being approved by CCG’s
day-to-day working arrangements e.g. the
providers, the sub cluster board and the cluster
operating model of the MDGs, information sharing
board during March and April, and as part of this
protocols
process, they will be asked to formally indicate
Invite all parties to sign up to all elements of the
their intention to participate and to support the
operational arrangements, including information
business case. The business case demonstrates the
governance arrangements
5 year trajectory for savings.
Prepare for operational launch, including
The launch of the ICP involves both a clinical
establishment of the integrated management
summit kick off and IMG launch which have both
board with its independent chair.
been scheduled.
Develop local measures of integrated care that will
An innovation fund is being funded to enable
support improved delivery such as patient reported
providers to establish some of the areas where
experience of co-ordinated care.
need may exceed current capacity as a result of
Profile the expected point at which clinical benefits
the pilot.
and cost-savings will begin
67
Primary care Clusters are asked to describe how they plan to:
N
1. List cleansing: the once for London programme Jan-Mar
 Implement the full NHS Operating Plan
will be implemented across NWL.
requirements relating to Primary Care (list
12,
2. Practice boundary changes: practices are being planning
cleansing / practice boundary changes / practice
contacted and variations are being developed.
choice pilots)
3. Practice choice pilots; will use the PCC LES to
 Enable CCGs to develop primary care improvement
April 12,
implement
support patients who register elsewhere. Part of ation
intentions / transformation approaches for
the NSG for choice lists.
authorisation and to support integrated care / out
of hospital strategy
4. Once for London principles will be adopted
 Transition to using the GPOS and Once for London
where appropriate during 12/13
principles in 12/13
 Gear up for the Olympic games
5. Olympic steering group covers actions for
 Complete confirmed transition actions – contract
primary care. Currently on target with
stock take, premises stock take, LPN piloting
messages and plans.
6. Contract stock take completed on time,
currently resolving identified gaps and risks.
111
Clusters are asked to describe how they plan to:
 Develop NHS 111 service go-live plans that meet
London and national 111 service specifications

Y

developed with and endorsed by local CCGs
 Develop a business case and 111 local service
 Build contingency for service commencement
slippage built into the rollout plan.
 Put in place robust project management and
end of 11/12. The remaining 4 Boroughs in
d by
NWL will go live by the end of 12/13.
march 31
Business case and specifications signed off for 2013
4 Boroughs. Business case and specifications
meeting the April 2013 DH deadline.
specification approved by CCGs.
4 Boroughs will have gone live with 111 by the Complete
Y

currently being worked through with CCGs to
Complete
meet Batch 4 procurement timescales.
d by
DSU will work with the Borough teams to
March 16
ensure that there are robust arrangements for
2012
project management and governance at a local
level
68
governance arrangements to ensure delivery.

the DoS.
 Secure local clinical leadership, clinical governance
and clinical engagement of DoS and pilot

implementation plans.
Palliative care services are already mapped,
During
futher refinement needed once CMS release
12/13
new Z codes. Mental Health services engaged
 Further develop and refine the Directory of Services
with the inclusion of mental health crisis and
Clinical lead already identified and working on
and pathway mapping continuing.

Community, Mental Health and Acute contracts
specialist palliative care services, by linking with
within the Cluster all include the requirements
social care, local government and the third sector
of providers having an accurate reflection of
(to support veterans).
their services on the DoS which they maintain in
realtime.DSU to work with Boroughs to ensure
 Put in place contractual arrangements (agreed with
that they have systems in place to monitor the
providers) to ensure resilience and sustainability of
111 contracts and feedback on the impact of
the DoS.
 Monitor the performance of NHS 111 pilots post
111.

Coordinate my care included within the London
go-live – including patient experience &
wide specification and this will be agreed with
professional feedback and whole system impact
all the CCGs to be included in the 111 business
against agreed KPIs.
 Develop a single electronic end of life register for
London ‘Coordinate my Care’
 Agree electronic bookable appointment systems
case.

We can build on processes underway within Rolled out
current
NWL
pilots
and
learn
from
their through
experiences, but solutions will be dependent on 12/13
what software the procured 111 provider uses
across
Boroughs
between NHS111 service and DoS providers.
69
Patient Safety
NHS NWL will ensure providers are compliant with
(Health
NICE quality standards ensuring compliance with
Outcomes/
key areas of clinical quality and risk that impact on
Clinical
health outcomes/ clinical effectiveness, including:
Effectiveness)
VTE
VTE is a significant cause of mortality, long term
disability and chronic ill health. There is strong
clinical evidence that many deaths in hospital are
avoidable if a patient is assessed for the risk of
VTE on admission to hospital, with appropriate
prophylaxis then provided based on national
guidelines (NICE).
HCAI
HCAIs remain a significant risk in relation to
protecting patients from harm within healthcare
specifically MRSA Bacteraemia and C. Difficile.
Pressure Ulcers
Healthcare acquired pressure ulcers ie those
acquired whilst in receipt of NHS care (grade 3 and
4) remain a significant risk in relation to protecting
patients from harm.
Medication Errors
Errors in medication leading to sever harm or
death remain a key risk.
70
Actions
 Continue to ensure that key quality outcome
indicators are consistently reported on provider
dashboards and monitored in line with the NW
London Clinical Governance Framework.
 Working with CCG leads ensure robust systems
are in place to both monitor (through reporting)
and to seek robust clinical assurance (through
CQG Meetings) in relation to health outcomes/
clinical effectiveness and potential risk to
patients.
 Continue to provide ongoing support and
facilitation ensuring effective workplace cultures
that enable learning from SI’s and Never Events.
 Continue to triangulate ‘soft’ and ‘hard’ data
from all sources related to clinical quality.
Maintain methods of escalation (CQG Meetings and
Contract Review meetings) when concerns/ risks
are identified including escalation to the Cluster
Board and NHSL.
71
Section Five: Commissioning Development
PCT Clusters have an important role in the development of commissioning structures and processes
in their area during 2012/13. This includes:
successful establishment of the new commissioning architecture to ensure effective clinical
o
commissioning and handover by April 2013, comprising; commissioning support
organisations, or the transfer of commissioning responsibilities to the NHS Commissioning
Board, and nurturing clinical leadership through emerging CCGs,
and delivering full authorisation of as many CCGs as possible by April 2013 wherever emerging
o
CCGs are ready and willing to achieve this.
The following areas are subject to change depending on the passage of the Health and Social Care
Bill and the drafting of the commissioning development section of the NHS Operating Framework
2012/13.
5.1.
Summarise the PCT Cluster’s commissioning development priorities for 2012/13 and how these
will be implemented:
Attached at appendices 2 and 3 are a number of papers which describes the Cluster’s priorities for
2012/13.
In line with the 2012/13 Operating Framework NHS NWL will:

support all CCGs in making progress to full authorisation by the NHS Commissioning Board;

support exploration and the development of commissioning support offers from a range of
suppliers, which might include the independent sector, voluntary organisations and local
authorities, that will be responsive to the needs of CCGs;

establish an effective transition to the NHS Commissioning Board for a common model for
commissioning services for which the NHS Commissioning Board will be directly accountable;

prepare for formal transfer of staff to the new commissioning architecture, including
identification of staff who are eligible to transfer to the NHS Commissioning Board direct
commissioning functions in line with PTP when published;

demonstrate that they are allocating both non-pay running costs and staff to support
emerging CCGs, commensurate with the level of budgets for which emerging CCGs have
delegated responsibility; and

work with GP practices to undertake a full review of practice registered patient lists, ensuring
patient anomalies are identified and corrected by March 2013.
5.2.
A. Summarise how the PCT Cluster will oversee and ensure the delivery of commissioning
responsibilities that have been delegated, during 2012/13, including; setting out the
approach to delegation including eligible commissioning budgets allocating non pay running
72
costs and staff:
-
How delegated responsibilities will operate during 2012/13
-
How the experience of delegated responsibilities will be captured to support
emerging CCGs in developing a track record for Authorisation, and
-
Summarising plans for the transition of all commissioning responsibilities to
CCGs and others by the end of March 2013.
All our CCGs have been through the configuration risk assessment process and were rated green or
amber by NHS London in December 2011. The two CCGs that were amber rated have now delivered
on their action plans and are green rated in advance of the deadline of March 31 2012.
The delegation process in NWL has divided the commissioning budgets into low, medium and high
complexity commissioned services. The 8 CCGs in NWL have already successfully applied for low
complexity budgets and have been held this responsibility since summer. The budgets for these
services equate to approximately 30% of all commissioning budgets. CCGs will be applying for the
remaining commissioning budgets by the end of February. As well as key elements for delegation
such as finance, performance and risk management, the application will include evidence against
the 6 authorisation domains to start consolidation of the track record portfolio.
The applications will be reviewed internally and comments fed back, then a presentation panel will
be held. This process is scheduled to enable delegation to be in place in April 2013.
Prior to the application Anne Rainsberry and Daniel Elkeles are attending each CCG’s board meeting
to discuss progress around budgets delegated to date and their QIPP plans for 2012/13.
This staged delegation process has allowed time for CCGs to gradually increase their
responsibilities and experience and build their track record in preparation for authorisation.
The NWL Cluster is committed to all of the CCGs moving to full shadow delegation from April 2012
and are aiming for 100% devolvement in Quarter 1 in 2012/13, but doing this requires CCGs to
have their senior management teams in place.
To achieve this we have been working with all the CCGs on what management support
arrangements will best enable them to deliver this aspiration. We have been through a process
where CCGs have set out which management functions would be provided within the CCG and
which are best delivered by a commissioning support organisation. We have also identified the
biggest risks that CCGs face, how they are best mitigated and which management support options
best deliver the mitigation. These discussions have now lead to agreement about sharing senior
management support across CCGs and putting in place arrangements for the NWL CCGs to continue
to work together on areas of joint interest. It has been agreed that the CCGs will work as two
groups of four (Central London CCG, West London CCG, Hammersmith & Fulham CCG and Great
West CCG as one group; and Harrow, Brent, Ealing, and Hillingdon as another). Each group will
73
have one shared accountable officer and one CFO. There will also be some roles/functions that will
be shared across all 8 CCGs such as Strategy and Provider Management. The CCGs are actively
working on governance issues with the cluster, sub-cluster and borough PCT teams, and with their
L&OD providers.
As well as the management support, we need a vibrant CSO to be working in shadow form and this
is described in a subsequent section.
There is a transition team in place who are co-ordinating the development of the CSO and CCGs, as
well as the other receiving organisations (NHS Commissioning Board, Public Health etc).
CCGs are actively taking responsibility for the QIPP planning process as well as the delegated
budgets. They are also developing their own Out of Hospital strategies by end of March to support
the pan NWL service reconfiguration programme. NHS NWL will work with CCGs to systematically
collect evidence of delivery against their plans for the budgets that have already been delegated.
B. Summarise, including key milestones, how the PCT Cluster will support and develop its
pathfinders/emerging CCGs to prepare for and navigate the authorisation process. This
includes developing the ‘track record’ in preparation for authorisation. (e.g. on QIPP, primary
care, tackling health inequalities, relationships with local partners including participation in
emerging health and wellbeing boards, patient engagement and public involvement).
We have been supporting our CCGs to prepare for authorisation in a number of ways. The design of
our delegation process has ensured alignment with the authorisation process, so that the CCGS are
already building their portfolio of evidence.
We have also been supporting the Leadership and Organisational Development programmes for
each CCG. The CCGs are engaged in the programme and are working on each of their priority areas
with their providers, including significant work on governance issues and readiness for
authorisation.
The CCGs have the full support of the borough teams in leading initiatives (including QIPP, the
commissioning and contracting round, the out of hospital strategies etc) and thereby building track
record.
Good progress has been made in understanding our shared agendas in NWL. The need for Health
and Wellbeing Boards to understand and engage with service transformation agendas across health,
social care and children’s services was one of the key themes to emerge from a recent away day.
We share a common purpose in working together to achieve service transformation and to this end
we are planning a further event to analyse the biggest systemic risks that we face and the strategic
role of Health and Wellbeing Boards in mitigating them.
NHS North West London is committed to bottom-up development of cluster strategy through
74
Clinical Commissioning Groups and Health and Wellbeing Boards and to support those
organisations as they become established. Further details of an ‘Improving Health and Wellbeing in
North West London’ event, including summaries of the presentations and discussions (pages 4-5)
are presented in the attached letter and report.
HWB report
letter.doc
HWB event summary
report Dec 11.docx
NWL CCGs intend to apply for authorisation early on in the process, but the exact timescales,
guidance and information on batches has not yet been released.
Milestones / Key Actions
Milestones / Key Actions
1. Application for delegation including track record of
End February 2012
authorisation
2. Complete work with development provider
May/June 2012
3. Appoint senior leadership roles to CCGs
April 2012
4. Undertake pre-assessment for authorisation with NHS London
Timescales not yet known
5. Apply to NHS Commissioning Board for Authorisation
Timescales not yet known
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5.3.
Summarise, including key milestones, the PCT Cluster’s plan for the development of a
Commissioning Support Organisation to provide the required commissioning support for the local
market. This includes identifying local need, mapping the scope and scale of services to be
provided and developing cost models to ensure that the overarching strategic approach to
commissioning support will be affordable.
NHS NWL Migration Programme
The CSO development programme is a part of the NHS NWL Migration Programme. The Programme
was established by the Cluster Executive Team and is responsible for the delivery of the migration
to the receiving organisations. The detailed governance structure can be found in Appendix D. The
Programme board will provide assurance, monitor progress and authorise programme activities
through monitoring progress reporting from the SROs and Professional Leads. The board will
provide assurance of the Cluster Migration Programme through review of the following for each
receiving organisation and enabler programme.
The CSO Development Programme
The CSO development programme has involved a range of staff from across NHS NWL.
Summary
Our Vision
‘To provide high quality support to commissioners to improve health and wellbeing’
Our Values
To enact our vision we will create a team which operates with a clear sense of purpose and follows a
core set of values that means as an organisation and individuals we are responsible for:
Professionalism
•
Listening to our customers and responding to their needs
•
Maximising efficiency and effectiveness in all we do
•
Setting high standards and delivering against them
Integrity
•
Improving health outcomes, wellbeing and services
•
Delivering with respect and dignity
•
Taking ownership and finding solutions
Excellence
•
Delivering right first time
•
Leading and sharing best practice
•
Learning and growing to deliver continual improvement
Passion
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•
Remembering that patients/residents are affected by everything we do
•
Developing high performing people
•
Identifying opportunities for growth and achieving sustainability
Our aspirations
Ensuring local CCGs have a credible, viable CSO working for them is our priority as we support them
through the authorisation process. However, our ambition in the longer-term is to develop an
integrated support service that serves both health and social care commissioners; maintaining the
successful joint systems already in place and building new arrangements elsewhere. We have strong
commitment from local authorities and will be exploring options in more detail in early 2012.
As a CSO we want to be:

An organisation where our customers and their patients/residents are our focus

A world class support organisation that acts as the benchmark for others and continuously
strives for improvement and excellence

A learning organisation – learning and applying evidence from the best in public and private
sectors, at home and abroad

An excellent organisation to work for, that enables high achieving individuals and teams and
one that recognises their achievements.
We will know when we have achieved this when:

Our customers tell us that they are happy with our services

We retain our core customer base

New customers ask us to provide services for them

Our support brings about measurable improvement in health and wellbeing of our customers
patients/residents

We are commercially viable in an open market

We are able to recruit and retain high quality staff

We achieve industry recognition for our innovation.
The new commissioning architecture has shifted our role but not our commitment to tackling the
challenges facing local health and social care services in the years ahead.
Our customers
Our confirmed customer base is the 8 CCGs with the potential for this to extend to the 5 local
authorities, NHSCB support and pan-London support for services in which we have commissioning
experience and expertise.
Our CCGs support the development of the NWL CSO and wish to be strongly involved in the
operation of the organisation, which is reflected in the proposed governance arrangements.
We have a commitment from all CCGs in NWL to work with us to develop a CSO from the existing
77
commissioning services within PCTs. We have been working with our colleagues in CCGs to
understand both the services they would wish to purchase and the style of delivery. Within the
overarching Migration Programme we have worked with CCGs to understand their running costs and
internal operating requirements. Helping us to develop an offer that will be affordable and will
complement their plans for in-house management. Although further work is needed to finalise the
split of in-house and CSO services we have made significant progress in the last few months.
Our approach
The CSO will ensure that it supports the CCGs to continue to reap benefits of collaboration working
with any shared management or federations that are put in place. There is also a strong history of
working in partnership with Local Authorities in North West London. Whilst arrangements have
differed, there is a strong commitment from the local authorities to retain what we have and build
upon it to provide the integrated commissioning support. This will help to deliver the integration
agenda set out in the White Paper and ensure the most effective delivery of integrated care and the
strategy of Health and Wellbeing Boards. We have a joint commitment with the boroughs of Ealing,
Hounslow, Harrow, Brent and Hillingdon to explore and develop a proposal for a joint venture to
provide commissioning support for health and social care in North West London. The exact scope
and nature of this joint venture will be developed in the New Year. This provides us with an
excellent opportunity to ensure that we can best utilise the commissioning capability, capacity and
leverage across the NHS and local authorities to drive greater efficiency and stability in the
commissioning system. In the boroughs of Hammersmith and Fulham, Kensington and Chelsea and
Westminster, we will retain the integrity of the existing joint commissioning arrangements; a single
team covering both child and adult health and social care commissioning. Opportunities to develop
this model further will continue to be discussed as the new tri-borough arrangements across the
local authorities develops.
The core of the NWL CSO will be created from the commissioning teams working across the cluster.
These teams originate from some of the highest performing PCTs against the World Class
Commissioning competency framework. Building from this with the opportunity of a joint venture
with the local authorities, we believe that we can create a strong, capable and viable commissioning
support offer.
Our plans for migration
We have begun to develop our plans for migration; these are clearly subject to both national and
local guidance. The migration plan can be found in Appendix 1 and was developed using the
following assumptions;
•That the CSO vision will be confirmed once CCGs have confirmed their geography and intentions
to build commissioning capability in-house/buy services from the CSO (A stable view of this is
required to inform the development of the CSO Target Operating Model). This is expected to
happen at the CEC on the 12 January 2011.
•NWL Receiving Organisations will move to ‘shadow running’ by 1 April 2012
•NWL staff will initially migrate to align with potential destinations/receiving organisations by end
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of March 2012 to support shadow running
•NWL staff consultation will be required if the new target operating models indicate an expectation
of future redundancy in excess of the trigger levels for employee consultation. This is expected to
be 90 days according to assumptions made in the HR enabler workstream
•NWL staff will ‘transition’ to their destination receiving organisations following the consultation
period
•The products and services workstream will reach a point of ‘stable agreement’ with future client
organisations by end of March 2011 (where there is agreement on the scope and charges for
services that informs what and how the CSO delivers its services to match customer preferences –
possibly resulting in an MoU).
Next Steps
We submitted our CSO prospectus and supporting documentation on the 6th January to NHS London
and are working towards the delivery of the outline business plan by Mid March 2012
Milestones / Key Actions
Milestones / Key Actions
Complete the outline business plan and submit to DH as
31/03/2012
checkpoint 2
Develop CSO TOM
31/03/2012
Develop and begin to embed new behaviours and culture into the 31/03/2012
organisation
Develop and implement Corporate Governance
31/03/2012
Develop Commercial and delivery models
31/03/2012
Agree joint venture arrangements with local authorities
31/03/2012
Reach an agreement with future client organisations on how CSO
31/03/2012
will meet customer preferences
Final CSO offering defined
31/03/2012
Signed SLA with CCGs
31/03/2012
CSO operates in shadow form
01/04/2012
Define cost and pricing models to inform the final business model 31/08/2012
(and funding requirements)
Complete full business plan
31/08/2012
Completed estates needs assessment, leases agreed and ready for 30/09/2012
occupation
5.4.
Summarise, including key milestones, the PCT Cluster’s provision of development
support and leadership development for pathfinders, which will be delivered during
2012/13.
79
NHS NWL have been supporting the CCGs through the Leadership and Organisational
Development process, working with their chosen provider to undertake a range of OD activities,
as well as focusing on their priority areas. The borough teams are also providing significant
support to the CCGs and are well placed to understand their development needs. The cluster
will be changing its management arrangements for 2012/13 so that we are best set up to align
with and support the CCGs for the shadow year .
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5.5.
Summarise, including key milestones, the PCT Cluster’s role in the development of the single
operating model for the direct commissioning responsibilities the NHS Commissioning Board will
have (including primary care, dental services, armed forces etc.), and plans for handover to ensure a
safe and proper transfer of responsibilities in 2013 through an agreed process of convergence.
Attached slide pack includes further narrative and information about NHS NWL’s plans for
transition.
NWL Cluster
Migration Programme - Management of transition for NWL Operating Model
Milestones / Key Actions
Milestones / Key Actions
1. Benchmark audit of all primary care contracts, including
31.01.12 all contracts logged
identification of contracts in need of update and/or revision.
28.02.12 risk/issue log
completed and plan to address
contract risk developed
30.06.12 all contract revisions in
place
2. Performance framework for general practice in place (aligned
to the national development work).
01.11.11 sign off agreed
framework
31.03.13 first tranche of
contract reviews under new
framework completed (125)
3. Agree performance thresholds for general practice and a
framework for improvement planning.
28.02.12 agree thresholds
31.03.12 agree improvement
framework and escalation plans
01.05.12 onwards implement as
part of the contract performance
reviews.
4. Electronic database of contracts compiled including scanning
and archiving of all contracts.
01.10.11 identify which
contracts are stored
electronically
31.01.12 identify where hard
copies of un-scanned contracts
are currently held
31.03.12 all contracts scanned
and stored electronically and all
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hard copies archived.
5. Review of PMS contracts.
31.01.12 paper to CET outlining
proposal for review
28.02.12 parameters for review
signed off
30.06.12 review complete
6. Standardise local PCT policies in line with regional and national 31.10.11 identified local PCT
best practice
variaitons in policy and
procedures for primary care
contracts
31.12.11 consultation with LRC’s
about need to standardise
policy.
03.12.12 practices notified that
local policies shall be revised
and standardised.
7. Development of shadow LPN’s and clinical commissioning
teams
31.03.12 Paper to CET /Board(s)
setting out proposals for shadow
LPN’s for DOPs
31.03.12 Paper to CET setting
out proposals to develop CCT’s
across primary care
contracting/medical directorate
and performance teams
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5.5.
Development of shadow LPN’s and clinical commissioning teams
Summarise, including key milestones, how the PCT Cluster will develop with emerging CCGs and
local authorities the Joint Strategic Needs Assessment, Joint Health and Well Being Strategy, and
joint/integrated commissioning arrangements during 2012/13. How will the PCT Cluster ensure
successful handover to CCGs, NHS CB, and local authorities for these responsibilities?
The stage and focus of development of the HWBs varies across the cluster. Membership and
governance of HWBs is established although this will be kept in review as the Boards develop
further. The focus of that development has varied with differing balance of attention being directed
to members skills development and preparation, defining the role of the HWB – for example in
relation to scrutiny functions, reviewing JSNAs and developing JHWS, and initiating HWB actions.
This variation provides an opportunity for the different boards to learn from one another and the
cluster is committed to supporting this learning.
To this end, Anne Rainsberry hosted an event together with Michael Lockwood, CEO of the London
Borough of Harrow, on 5th December 2011 for members of Shadow Health and Wellbeing Boards
across North West London. Good progress was made in identifying the challenges health and
wellbeing boards face in providing leadership across health, social care and children’s services. A
further event to analyse the biggest systemic risks that we face and the strategic role of Health and
Wellbeing Boards in mitigating them is planned to take place in early 2012. Cluster representatives
are also actively involved in a number of London wide initiatives to support the development of
Health and Wellbeing Boards including:

the NHS London HWB simulation events steering group (which is planning for simulation
events across London in March 2012)

the NHS London’s Health and Wellbeing Network

exploring the development of a web based resource with London Councils intended to bring
together publically available HWB papers from across London, provide some analysis of
different approaches and a forum for discussion

the Joint Health and Wellbeing Strategy Special Interest Group.
All of the North West London Boroughs are early implementers of HWBs and have established
shadow boards with senior political, local authority officer and CCG representation. Relationships
with CCGs are positive across all boroughs and some boards have already been involved in review
of CCG commissioning intentions.
In consideration of the development of JSNA and JHWS specifically, again there is some variety
across the cluster but all have been involved in considering the extent to which exiting JSNAs are fit
for purpose in supporting HWBs. The Hounslow HWB has actually got so far as agreeing a JSNA and
JHWS and will keep these under review as the board becomes established. Others have focused
attention on strengthening processes to inform their JSNA and JHWS, for example in Harrow a large
consultation event has been held focused on building greater public engagement.
83
Whilst the development of JSNAs and JHWSs remain local responsibilities, there is local recognition
of the importance of sharing intelligence and of identifying shared priorities. The NHS NWL cluster
strategy and commissioning intentions have been derived through a bottom up process through
attention to local Clinical Commissioning Groups commissioning intentions and borough JSNAs.
Consensus on the health needs that span the cluster are reflected in the cluster case for change.
With regard to joint/integrated commissioning we are committed to maintaining current
arrangements where they are effective during the transitional period whilst building new
arrangements elsewhere. Whilst arrangements with local authorities have varied, there is a strong
commitment across NWL Boroughs to delivering the integration agenda set out in the White Paper
and ensure the most effective delivery of integrated care and the strategy of Health and Wellbeing
Boards.
The North West London CSO and five Local Authorities (Brent, Ealing, Harrow, Hillingdon and
Hounslow) have expressed a shared aspiration to develop a joint venture to provide integrated
commissioning support to the patients and residents of the five boroughs. The organisations have
decided to explore potential collaboration opportunities in information and business intelligence,
financial leadership and advice, strategic planning and service design, provider management,
procurement, governance, human resources, and communications and engagement. For areas
which are not ‘in scope’ for collaboration, the NWL CSO will provide these outside any integrated
arrangements. By committing to work together as full partners in a joint arrangement, NWL CSO and
the local Boroughs would be ideally placed to support the commissioning of cost effective,
integrated services. Crucially, this approach would help us all to avoid the fragmentation of
commissioning that seriously threatens to undermine integrated working at a local level. Next
steps include exploring more detail around the partnership opportunity, to feed into an Outline
Business Case by the end of March 2012. Providing commissioning support jointly will help to
support stability in the system during a time of great upheaval. A working group with
representatives of the CSO and each of the five boroughs has been established. It will convene
fortnightly and will give ongoing attention to understanding the risks and the timescales associated
with integrated arrangements.
The other local authorities (the tri-borough of Kensington and Chelsea, Westminster, Hammersmith
and Fulham) continue to be engaged in discussions and are open to participation at some point,
although this is likely to be in a different form or at a later stage than the other five. In the mean
time we will continue with the existing integrated commissioning arrangements.
Milestones / Key Actions
Milestones / Key Actions
1. NWL HWBs event (Dec 5th 2011)
1. HWB established (achieved)
2. NHS London HWB simulation event (March 1st 2012)
2. Existing JSNAs to be refreshed
3. NWL HWB risk assessment and mitigation (to be confirmed)
3. JHWS agreed
4. Ongoing engagement with NHS London health and wellbeing
4. HWB meetings open to public
84
network and Joint Health and Wellbeing Strategy Special Interest
Group
5. CSO business case developed with LA partners by March 2012
5. Joint commissioning plans
agreed
85
5.7.
Summarise, including key milestones, the PCT Cluster’s plan for the development of a Public Health
transition plan to ensure successful handover of responsibilities to local authorities and Public
Health England.
NHS North West London PCT Cluster is actively engaged in transition planning for public health:
1. All eight Boroughs coterminous with NHS North West London Cluster expect to have a
governance statement, in the form of a Memorandum of Understanding, signed by 1st April
2012.
2. Each Borough has an identified lead for public health transition and has an agreed
mechanism and process in place (e.g. a Public Health Transition Group or Board) to finalise
the transition plan. Arrangements for agreeing final sign-off of the plans (including the
timeline) at the appropriate levels in the Boroughs and NHS NWL Cluster are in development.
3. All eight Boroughs are currently in the process of developing public health transition plans
and will have submitted a plan to NHS NWL Cluster for review by the 31st March 2012. These
plans are based on Annex 6 of the planning guidance and will include: operating models for
delivering the public health functions including health improvement services, health
protection and the ‘core offer’ to clinical commissioning groups; Governance, IT, legal and
performance arrangements and communications plans; workforce plans subject to further
guidance on OD; and a clear indication on when future public health team structures will be
finalised. It is anticipated that there will be areas of these plans that will remain under
development pending further information and national guidance- see point 5 below. NHS
NWL Cluster will review these plans in early April.
4. As well as individual borough planning processes, the five ‘outer’ boroughs of Harrow, Brent,
Hounslow, Ealing and Hillingdon (along with the Borough of Barnet in NHS North Central
London), all part of the ‘West London Alliance’, have initiated a collaborative approach to a
design process for future public health functions and structures. This work is in progress.
5. There are several issues that are likely to impede implementation of public health transition:

The majority of Boroughs are investigating the implications of the recently announced
indicative ring fenced allocation and will be lobbying for a number of changes to the final
allocation

Clarity on processes for the transition of current public health staff to Local Government,
Public Health England or the NHS Commissioning Board is required

Resources are required to implement this transition. Boroughs are looking to the NHS to
jointly resource this

Proposals for sharing DsPH and public health specialist functions across Boroughs may
emerge; a process of due diligence is likely to be required to ensure these proposals could
86
be implemented.
Milestones / Key Actions
Milestones / Key Actions
All PCTs to have shared current contract details with Local
Government by end January 2012
All Boroughs to have developed a public health transition plan by
March 2012 to include:
a. Future public health team structures
b. Operating models for delivering the public health functions
including: health improvement services, health protection
and the ‘core offer’ to clinical commissioning groups
c. Plans for shadow working in 2012/13
d. Governance; IT; legal and performance arrangements
e. Communications plans
f. Workforce plans subject to further guidance on OD
87
5.8.
Summarise, including key milestones, how the PCT Cluster will develop plans for the transition of
specific responsibilities to local authorities , for example in addition to Public Health above, the
known areas of, Complaints and advocacy, information and signposting, and Independent Mental
Health Advocates (IMHA).
Subject to the passage of the Health and Social Care Bill, NHS NWL will support any necessary
changes in service following the allocation of funding for Local HealthWatch, NHS Complaints
Advocacy and, potentially, PCT Deprivation of Liberty Safeguards from October 2012.
Subject to the passage of the Health and Social Care Bill through Parliament, Local HealthWatch will
signpost people to information about health and social care services, which is one of a range of
services currently provided by the PCT Patient Advice and Liaison Services (PALS). It is the
signposting function of PCT PALS that Local HealthWatch will take forward and NHS NWL will
support this transition.
88
Section Six: QIPP
Summarise the Cluster's key QIPP priorities and challenges for 2012/13:
The NHS NWL QIPP target for 2012/13 is £120.8m. The QIPP plans submitted across the Cluster
have a combined expected benefit of £135.6m; this is £14.8m (12%) above the required target.
Two rounds of assurance have been undertaken by the Cluster thus far. Following the second round
assurance stage the post-assessed value of the plans was £119.9m, a reduction of £15.7m (12%)
from the pre-assessed value and £0.9m (1%) below the 2012/13 target. Actions have been agreed
with the Sub Clusters to address the risks identified with certain schemes and a third round
assurance process is being undertaken to finalise the NHS NWL 2012/13 QIPP plans by the end of
February 2012.
There were a total of 301 2012/13 QIPP schemes submitted across the Cluster. All of the schemes
were subjected to an external assurance process against a defined methodology which drew on
Deliverology1. The assurance process methodology reviewed the ‘likelihood of delivery’ of the
schemes alongside the expected impact on the quality of service.
The aim of the assurance process was to support the development of robust plans for QIPP in
2012/13. The core quality assurance team, involved in the assurance process, included the NHS
NWL QIPP Performance Management team and clinicians from Public Health and Primary Care. The
team reviewed the information submitted by the Sub Clusters and defined detailed RAG ratings per
scheme. Development actions were defined for any schemes indicating risk – a scheme with a final
RAG rating other than Green. The focus of the review team has been to provide additional impetus
and support to Sub Cluster Directors to assist development of improved QIPP plans for 2012/13.
The three key outcomes of the assurance process are:
–
Agreed RAG ratings per scheme, which were aggregated to provide a borough view
–
Agreement on actions required to progress the schemes with an Amber or Red RAG rating to a
Green-rating
Post-assessed scheme plan values – the NHS London reduction of 50% for a Red-rating, 25%
–
for an Amber-rating and 0% for a Green-rating was applied
The main areas of risk included:
1

concern over whether quality of service would be maintained

unclear justification of the planned scheme benefits

submitted scheme values exceeding the DSU-identified opportunity
‘Deliverology 101: A Field Guide For Educational Leaders’ by Michael Barber, Andy Moffit and Paul Kihn
89

a lack of detail regarding programme governance and risk management.
Outputs of the assurance process
The RAG outputs of the second round assurance stage were:

166 Green-rated schemes;

85 Amber-rated schemes;

8 Red-rated schemes;

42 schemes were closed by Sub Clusters between the first and second stages.
This led to a post-assessed value for the Cluster 2012/13 QIPP plans, once the NHS London RAG
ratings had been applied, of £119.9m, which is £0.9m under the target for 2012/13.
The rationale for the RAG ratings and the subsequent areas for development were communicated to
the Sub Clusters for each relevant scheme.
Across the Cluster the QIPP schemes have been grouped by type of scheme. The groupings are:

Contract Management – reducing the value of the contracts of acute, community and Mental
Health providers

Changing setting of care – moving patients into lower cost settings of care and care closer to
the home

Reducing demand – reducing overall demand for care

Pathway redesign – transformational changes to the patient pathway

Back office / corporate savings – corporate efficiency savings e.g. estates

Reducing drug spend – improving and realising savings from prescribing and medicine
management
Figure 1 shows the percentage breakdown of the number of 12/13 schemes by type. Figure 2
provides the percentage breakdown by type based on the 12/13 post-assessed scheme value. The
figures highlight that the main type of schemes (55% by number and 66% by value) are contract
management or contract value reduction schemes. The majority of these schemes are reducing
spend with providers.
Figure 1 – breakdown of number of schemes by type
90
NWL QIPP - number of schemes by type
9, 3%
12, 4%
Contract Management
39, 13%
Changing setting of care
Reducing demand
28, 9%
164, 55%
Pathway redesign
Back office / corporate savings
49, 16%
Reducing drug spend
 Financial impact
Figure 2 – breakdown of post-assessed value (£M) of schemes by type
NWL QIPP - post-assessed value (£M) of
schemes by type
1.2, 1%
Contract Management
8.1, 7%
5.5, 5%
Changing setting of care
8.7, 7%
Reducing demand
Pathway redesign
17.6, 14%
79.5, 66%
Back office / corporate savings
Reducing drug spend
The figures also show that 13% (39 schemes) of the total 12/13 schemes are focused on pathway
redesign which translates into 4.6% (£5.5m) of the post-assessed total plan value. The vast majority
of these schemes aim to reduce the number of contact points throughout the patient journey,
decreasing the time required from start to end and therefore improving the patient experience.
The risk resulting from such a balance of schemes, a potentially unsustainable reliance on contract
management schemes and high impact on acute providers, was highlighted to the Sub Clusters
during feedback from the first and second rounds of assurance. There should be a longer term
action to mitigate this risk as recommended in section 4.
A third round assurance process review will be conducted in February with the aim of agreeing the
91
full 2012/13 QIPP plans with the Sub Clusters by the end of February.
Shortfall from 11/12
The Outer NW London PCTs QIPP shortfall in 2011/12 has been managed with support from the
Cluster, some of which is repayable in 2012/13. The impact of this and the shortfall in the 2011/12
recurrent savings will be included in the Outer NWL PCTs Operating Plans for 2012/13, including
any additional QIPP requirement. These plans are currently being worked through by the PCTs and
the Cluster.
A description of future impact/plans for 13/14 and 14/15
The total spend in the NWL health economy is £3.5billion p.a., which represents 24% of health
expenditure in London. Based on current services, by 2014/15 we estimate we would need an
additional £1bn of funding to keep pace with expected increases in demand.
Our CCG’s have developed the Commissioning Strategic Plan understanding the need to
significantly change the current operating model across the health economy to be able to
accommodate the predicted additional demand with only a small annual increase in funding.
We are developing our Out of Hospital strategies in each of our CCG’s detailing the longer term plan
for healthcare in NWL where we will see an increase in care being appropriately provided in the
community through closer networking of our primary care practices and providers in the community
enabling high quality and reduced cost alternatives to care that is currently treated in acute
hospitals.
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 Risks
The key risks which have been identified are:
1. Inadequate delivery against target
2. Structural changes which cause instability to the delivery chain and governance structures
3. Lack of stakeholder engagement/involvement
 Mitigations and contingency plans
The mitigating actions include:
1. The Cluster has undertaken a detailed review of the 12/13 QIPP schemes to assure against the
expected benefits. On the whole the Borough have submitted plans above the target to allow for
any in year shortfall against target. In addition a monthly monitoring meeting will be held with
each Borough to ensure any variance against plan is discussed and clear mitigating actions are
agreed.
2. Sub cluster has been asked to submit the governance arrangements for 12/13 for the Cluster to
be assured that the delivery chain and governance structure is sustainable and will manage the
risks/issues as required.
3. All 12/13 schemes have been signed of by the relevant CCG. The Cluster is also identifying
ways in which CCGs can be involved in QIPP Performance Management next year.
 Governance of your QIPP programme (PMO and Leadership)
The Cluster will continue to monitor Sub Cluster delivery of the 12/13 QIPP plans on a monthly
basis through formal performance reporting and monthly QIPP Review meetings with Sub Cluster
Chief Executives, Directors of Finance and QIPP Directors. The Cluster will also continue to report
upwards to NHS London against the key milestones of the highest value schemes across the Cluster.
The key change to the performance management of QIPP in 12/13 will be to ensure appropriate
representation of Clinical Commissioning Groups (CCGs). The Sub Clusters involved CCGs during
development of the 12/13 plans and the Cluster will lead on engaging with the Sub Clusters to
ensure an appropriate model for CCG representation is put in place for 12/13.
 Shifts in the size of the QIPP challenge compared with 2011/12
Quality
The aim of QIPP is to ensure that the balance between delivery, quality and efficiency is preserved.
The assurance process maintained this focus throughout its assessment. The initiatives identified
in 12/13 support our Out of Hospital strategy to transfer appropriate care into an out of hospital
setting.
These initiatives have been developed with significant clinical involvement across the
different settings of care to ensure that quality standards can be achieved.
93
Innovation
The 2012/13 QIPP plans include a number of innovative schemes at Cluster and local borough level,
such as the ‘Hospital in the Home’ scheme and the 111 non-emergency telephone service (adopted
from the national trial) scheme. These schemes demonstrate the commitment to innovation taken
across the Cluster. It is important to recognise the level of risk involved in an innovative scheme
and that appropriate risk management is put in place before and during implementation. Despite
this associated risk it is clear that the profile of schemes across the Cluster will be expected to shift
further towards innovation schemes in 2013/14 and 2014/15 in order to move away from the
current focus on contract management / contract reduction, which will not be sustainable for
providers and move more towards improving quality of care i.e. through improvement to pathways
etc.
Productivity
Productivity is evident throughout the 12/13 QIPP plan submissions. Over half of the value of the
schemes submitted centred on acute hospital productivity (i.e. reducing lengths of stay, reducing
readmission rates, increasing day-case rates) alongside reducing contract spending with providers
by shifting care to more cost effective settings. There is an expectation, that providers will continue
to deliver care at the same quality, or better, despite the lower income they will be receiving. This is
seen as a key metric of increased productivity throughout the provider landscape.
Table 1 gives the top five schemes, by 12/13 scheme value, across the Cluster (not including ACV
schemes and schemes continuing from 11/12).
Table 1 – top five schemes, by 12/13 scheme value, across the Cluster
Borough
Scheme name
12/13 scheme value
(£000s)
£
2,216
H&F
Productive community services (CLCH). Improving contract efficiency and
productivity to achieve better cost and value of care.
Hounslow
Productive Mental Health Services. Mental Health Desirable Affordable
Sustainable (DAS) Challenge
£
1,988
Brent
Independent Prescribing Initiatives - Prescribing within budget
£
1,948
Westminster
Productive community services (CLCH). Improving contract efficiency and
productivity to achieve better cost and value of care.
£
1,700
Ealing
Productive Mental Health Services. Mental Health Desirable Affordable
Sustainable (DAS) Challenge
£
1,500
Prevention
Prevention is integral to the transformation ongoing within the health service and must form an
increasing aspect of the QIPP schemes. The 2012/13 QIPP schemes have identified many
opportunities to achieve savings through preventing patients accessing more expensive parts of the
NHS, such as the acute providers (e.g. 111, Referral Management Services). However there are
further opportunities for QIPP schemes, in 2013/14 and 2014/15, to focus on preventing
94
populations requiring any kind of healthcare interventions or limiting the point to which a patient’s
condition might escalate.
 Confirmation that Providers have agreed their element of your QIPP plans
Formal sign off of schemes and values is scheduled for the 27th February 2012, with each Sub
Cluster.
 Explanation of how the planned ‘future state’ will ensure that the LHE is sustainable both in
terms of improvements in quality and outcomes and also financial affordability?
NHS North West London’s Delivery Support Unit was established in August 2011 to facilitate a new
way of working across our 8 Clinical Commissioning Groups to support delivery of the
transformational changes required to meet the health and financial challenges facing the cluster in
the years ahead. Its task is to deliver our Out of Hospital Strategy, and enable the appropriate
transfer of thousands of units of activity from acute settings to out-of hospital settings at lower
cost and higher quality.
This is to be achieved through the direction of agreed funding to provide capacity to address
specific pieces of work based on the operating model of commissioners and providers working
together to deliver the changes to service provision required within the accelerated timescales. The
DSU-funded projects either have applicability and potential benefits for the cluster, or require active
management on behalf of all of NWL’s Clinical Commissioning Groups.
The four broad types of delivery options are set out in the schematic below. Which builds on both
applying learning from a single CCG to other CCG’s and centralising effort once as part of a cluster
initiative and applying locally to each CCG.
Example initiative
Continuity of Care
Example initiative
Primary care
transformation
Example initiative
Admissions avoidance
and rapid response
Example initiative
Any Qualified Provider
95
The DSU’s resourcing model is designed to allow flexibility; rather than employing a large
substantive team, the DSU sources project resources to meet the specific needs of the work
bringing in experts on a short term basis as this maximises efficiency.
Aiming to ensure that the right people are doing the right work at the right time, there are two main
ways in which work is therefore resourced: either through finding resources ‘in house’ where the
work will take place, or by ‘buying in’ support to meet a specific brief, including clinical experts,
and experienced provider and commissioner members.
The identification of the key initiatives to be supported align to our Out of Hospital strategy and can
be found in the diagram below, aligned to key work programmes.
Developing the Out of Hospital
strategy and vision
The DSU will provide
support, on request, to
CCGS in developing their
out of hospital plans, and
enhancing delivery capability
Supporting the development of Out of Hospital
Plans to deliver the strategy
Key work programmes
Scaling up Integrated
Care
• Integrated Care Pilots (INWL
and ONWL, inc. Diabetes,
Elderly, COPD, CHD)
• Integrated care for mental
health
Transforming Planned
Care
• Pathway redesign inc. MSK
• AQP procurement
• Referral order book
The DSU will manage the out of
hospital work programme to
enable the health system to
make the fundamental changes
required to achieve the planned
shifts in care, minimise risk and
ensure the maintenance of high
quality clinical services and
patient experience throughout
the transition process.
Provider change requirements
Transforming Urgent Care
• Rapid Response and Home
Care (STARRS)
• Enhanced Recovery services
• Telehealth/Assistive
technology
• NHS 111 implementation
Cost and Value of Care
• Community nursing
productivity
Primary Care
Community Care
Transformation
Nursing
productivity
All Providers
Integration of Care
Outputs of second round review of QIPP schemes(December 2011)
QIPP_Plan_Assuranc
e_second_submission_Cluster_v1_0_(2).pdf
96
Section Seven: Finance Planning
Please complete the financial planning spreadsheets attached as Annex A.
7.1. Overview of financial position
Delivery in 2012/13, including FCOT, risks, opportunities, non-recurrent matters, etc.

The NWL Cluster Board approved the financial strategy for 2011/12 at its March 2011
meeting. The strategy is underpinned by the principle that all NWL PCTs work collectively to
manage financial pressures in the cluster.

The cluster has operated a risk pooling strategy, which involved setting differential control
totals, differential CTB contributions and non recurring support being provided for NWL PCTs.

The NWL Cluster’s CTB has overseen the management of challenged trusts in NWL. There
were initially two challenged trusts in NWL (North West London Hospitals and West Middlesex)
and two challenged PCTs (NHS Hounslow and NHS Harrow). Pressures emerged at the
beginning of the year for Imperial College Healthcare, which set a deficit Plan. During the year
significant pressures also emerged in the remaining Outer NWL PCTs, NHS Ealing and NHS
Hillingdon.

The Cluster is working closely with Imperial College on its strategic plan to recover its
financial position and with North West London on its business case for merger with Ealing
Hospitals Trust. These will be further developed in 2012/13.

An independent review of the Outer NWL PCT’s position was carried out in December 2011,
which is likely to result in additional support being provided to the PCTs. The control totals
have been reduced to break-even but will meet their statutory financial duties.

Overall the Cluster will exceed its control of a £45m surplus by £10m all PCTs will meet their
statutory financial duties.

The QIPP target for 2011/12 was agreed by the cluster Board at £142m (4%). Following the
pressures in Outer NWL, there will be a shortfall of £10m against the plan, £6m in Ealing and
£4m in Hounslow.

NWL has used its 2% non recurring fund (£68m) to provide assistance to NWLHT (£9m) and
Imperial hospitals Trust (£15m). The remaining funds have been used for non-recurring
expenditure and support purposes in 2011/12 and are fully committed.

The cluster has delegated low-risk budgets totalling £771m (33%) to the emerging CCGs.
Plans are in place to ensure the shadow CCGs are able to take on delegated responsibility for
all of their future commissioning budgets from April 2012.

The main financial risks for 2011/12 remain the delivery of QIPP plans and SLA pressures.
These risks are higher in the Outer sub-cluster PCTs where there are significant financial
pressures. The use of pooled Cluster funds has enabled NWL to manage the in-year
pressures and ensure it meet its control total.
Pan-Cluster overview for 2012/13:
Financial Strategy Principles
97
The principles supporting the NWL financial strategy are set out below:
•
Commissioners will work collectively to manage financial challenges across NWL.
•
Financial Strategy recognises the capitation position of NWL PCTs.
•
Risk-pooling strategies will be applied differentially in 2012/13 to recognise financial
challenges in PCTs, resources will not be used to support unsustainable models of care.
•
A minimum 3.5% QIPP in 2012/13 will be achieved on a cluster-wide basis.
•
A minimum surplus of 1% will be achieved on a cluster-wide basis.
•
Commissioner budgets must be handed over to CCGs in underlying financial balance.
•
Every NWL PCT must be in underlying financial balance by 31st March 2012 or, in exceptional
cases, have a plan to achieve underlying balance by 31st March 2013.
•
The NWL CTB will continue to operate in 2012/13 and oversee the management of financially
challenged organisations.
•
Transitional support will be provided to trusts planning strategic change in line with the
Cluster’s strategic intentions.
•
From April 2012, commissioning budgets will be fully delegated to shadow CCGs
Overall Planning Totals
NHS NWL’s refreshed Strategic Commissioning Plan for the period 20012/13 to 2014/15 has
confirmed the scale of the QIPP challenge facing the commissioners. PCT capitation targets have not
been issued for 2012/13, but the funding per head of population confirms the different funding
positions of the commissioners. The NWL financial strategy reflects this in the differential surplus
and QIPP targets for 2012/13 each of the constituent PCTs.
In 2012/13, the Cluster is planning a surplus of £39.516m (1.1%). The QIPP target for 2012/13 is
£121m and there is a minimum sub-cluster requirement of 2.9% QIPP in 2012/13. Individual PCT
recurrent allocations and targets for 2012/13 are summarised as follows:
NHS Brent
Notified
Allocation
Planned
QIPP Target
Allocation
per head
Surplus
£'000
£
£,000
%
£,000
%
569,828
2,175
15,428
2.8
11,491
2.1
98
NHS Harrow
358,496
1,651
-
-
14,100
4.2
NHS Ealing
623,631
1,852
-
-
19,612
3.3
NHS Hillingdon
430,321
1,665
-
-
15,097
3.7
NHS Hounslow
416,174
1,722
-
-
14,518
3.7
NHS Hammersmith & Fulham
371,698
2,237
7,084
2
14,168
4
NHS Kensington & Chelsea
378,838
1,953
7,332
2
14,846
4
NHS Westminster
507,518
1,909
9,672
2
16,926
3.5
North West London
3,656,503
1,883
39,516
1.1
120,759
3.5
99
7.2. Key assumptions in 2012/13

The Planning Assumptions used in 2012/13 CSP are set out in the table below:
Generic Assumptions
2012/13
Revenue Growth
2.38%
Acute Tariff deflator
-1.50%
Non-Acute Tariff deflator (Excl.
P. Care)
-1.50%
Primary Care Tariff deflator
0.00%
0-
Prescribing Price Increase
3.00%
Contingency reserve
0.50%
Non-recurrent Headroom
2.00%
reserve
Borough-Specific Assumptions
0.4Demographic Growth
1.00%
Prescribing Activity Growth
5.00%
Acute Activity Growth
1-4.00%
Non-Acute Activity Growth
1-3.00%
The Cluster will fund demographic growth, based on the GLA low forecast. Non-demographic
growth and any other activity pressures will not be automatically funded but only included where
there is evidence that it is required and that the costs exist.
The subsequent publication of the Operating Framework for 2012/13 amended these assumption
slightly. Growth has been confirmed for PCTs at 2.8% and the Tariff Deflator for Non-PbR services
100
has been raised to an expected -1.8%. Alongside the benefits for commissioners however, the
contractual CQUIN payment to be made available to providers has been raised from 1.5 to 2.5%,
effectively increasing the potential growth pressure on the majority of healthcare spend by 1%. The
overall forecast net impact of these changes across the Cluster is:
Additional Growth
£14.3m
Additional Non-PbR Tariff Saving
£ 3.2m
Additional 1% CQUIN Pressure
-£21.5m
Net Impact:
£ 4.0m
Given the immateriality of the net impact, the 2012/13 Cluster surplus and QIPP targets have not
been amended at this stage. As the 2012/13 contracting round proceeds and the actual SLA values
and associated QIPP are known, the PCT operating plans will be updated.
NWL Risk Pooling Strategy
Approach
The Risk Pooling Strategy recognises that each PCT commences the financial year with a different
set of challenges. The risk pooling arrangements for 2012/13 are planned to support those PCTs
with significant financial challenges to make the appropriate arrangements to hand over budgets to
CCGs in underlying balance. Unlike the approach in 2011/12, other than planned CTB support,
there will be no transfer of non-recurrent funding between PCTs in 2012/13. In 2012/13, each PCT
must plan to commission services within their notified allocation. This will form the basis for
handing over commissioning budgets to CCGs in underlying financial balance. The Risk Pooling
Strategy has determined the transition levy and surplus that each PCT will plan to achieve.
Transition Fund
In 2010/11, the Cluster Board agreed to the establishment of the NWL Challenged Trust Board to
oversee the management of challenged organisations in NWL. In 2011/12, a total of £44m was
collected on a non-recurrent basis by the Cluster and re-distributed across NWL. In 2012/13, the
CTB Fund will be renamed the Transition Fund and will have a wider remit. Transition levies are
planned at £40.8m.
Contributions to the fund are planned on a non-recurrent basis and summarised as follows:
£’000
NHS Brent
NHS Harrow
NHS Ealing
10,856
5,923
101
NHS Hillingdon
-
NHS Hounslow
-
NHS Hammersmith & Fulham
7,084
NHS Kensington & Chelsea
7,332
NHS Westminster
9,672
Total
40,868
In 2012/13, the fund will be used to:

Provide CTB support to challenged organisations in NWL, in particular NHS Harrow which is
seeking cluster support of £14.6m 2012/13. Discussions on the PCTs recovery plan continue
and the required support will be reviewed once the outcome of the contracting round is
known.

Provide transitional support to trusts for potential reconfiguration of services in line with the
cluster’s strategic plan. Transitional support provided to trusts will be subject to agreement
of amounts and conditions. The Cluster reserves the right to subject any request for
transitional support to external review.

Fund the Delivery Support Unit for a second year to ensure QIPP is embedded across the
Cluster.

Fund the cost of commissioner’s consultation plan for the proposed merger of NWLHT and
Ealing Hospital, and the reconfiguration of services at Imperial Hospitals.

These latter developments are part of the strategic plan to develop a Pre-consultation
Business Case in the summer of 2012.

Contingency Reserves
All PCTs will maintain Contingency Reserves at 0.5% in 2012/13, totalling £17.5m, to be held as a
general risk reserve.
2% Non-recurrent Funds
The Cluster committed all of the 2% fund in 2011/12 to non-recurrent transitional support for
challenged organisations and to fund transitional ‘non-core’ costs across the Cluster, including the
DSU, CSO preparatory work and provider reconfiguration.
In 2012/13, the Cluster intends to take the same approach, reserving the funds to support strategic
change across the provider landscape and fund the substantial costs of preparing the PCTs and
shadow CCGs for the new commissioning structure. These funds will also support the development
of the NHS London Priorities for 2012/13.
102
Re-admission and Re-ablement Funds
The re-ablement funds allocated to PCTs in 2011/12 were used by commissioners to support joint
priorities with the Local Authorities. In 2012/13 this allocation is £6m for NWL (its share of the
£150m National allocation). CCG committees will work with their Local Authority colleagues to agree
priority areas for this budget, focusing on supporting the Out of Hospital strategy that is being
developed.
In 2011/12, the 75% of the identified re-admission funds were re-invested by PCTs in the acute
trust’s in support of agreed development plans to improve discharge and out of hospital care. 25%
was retained by PCTs for local developments. Further guidance is awaited from the DH (due in
February) regarding the use of the re-admission funds in 2012/13, but these are expected to be
retained by PCTs for development of local services.
Running Costs & Commissioning Support Organisation development
In 2011/12, the Cluster implemented management arrangements that reduced running costs to £35
per weighted population, excluding Transition Costs. The 2012/13 Operating Framework has stated
that CCGs will be expected to spend no more than £25 per head on their running costs. Further
guidance on the detail of this allowance is expected before CCGs may become statutory bodies,
however this allowance has been used to guide the draft Commissioning Support Organisation (CSO)
Prospectus and financial plan. The target cost per head of the NWL CSO is £17 per head from April
2013, with a transition pathway during 2012/13. The CSO plan is in its early stages and subject to
clarification of guidance and discussion with CCGs as their thinking regarding their configuration
and in-house requirements develops through the year. The CSO aims to retain and develop a highly
skilled workforce, while the remaining NWL staff will align with the new host organisations most
appropriate to their roles.
103
7.3. Key bridging movements from 2011/12 FCOT to 2012/13 plan
Including changes by revenue type, cost type, QIPP, overall surplus/deficit and underlying
surplus/deficit.
The financial bridge chart for the NWL cluster is set out below:
104
7.4. Delegation of budgets to pathfinders / CCGs
Including commentary on:

- £2/head GP development

- Budgets delegated to pathfinders / CCGs at 1st April 2012

- Timeline for delegation of budgets (if not fully delegated at 1st April 2012)
The CCGs in North West London are currently considering what the best configuration will be for
them and we expect this to be clarified before the end of January. It is likely they will form 8 CCGs,
largely co-terminus with current PCTs boundaries. The management currently expects that by April
2012 NWL will operate in shadow CCG / CSO form. All relevant commissioning budgets will be
delegated to the shadow CCGs In 2012/13 these committees will take full delegated responsibility,
supported by the developing Commissioning Support Organisation.
In 2011/12, one third of the identified CCG commissioning budgets have delegated to shadow CCG
committees.
CCG Delegated Budget
Annual Delegated Budgets
%
£000
Delegated
Brent GP Federation
112,026
29%
Harrow GP Consortia
38,609
14%
Total Brent & Harrow
150,635
23%
Victoria CCG
24,062
33%
West London CCG
106,708
33%
Central London Healthcare
53,446
33%
H&F CCG
79,674
34%
Total INWL
263,890
33%
Ealing CCG
140,616
30%
Hillingdon CCG
117,253
37%
Great Western CCG
98,482
34%
Total ONWL
356,351
33%
770,876
30%
`
Cluster 2011-12
The £2/head development funds have been largely claimed by CCGs supporting staff development
and systems development. It is expected that this will continue in 2012/13. The CCGs will use the
funds to embed their revised configurations and prepare for becoming statutory bodies.
105
106
7.5. Activity
Overall activity levels, split by providers where significant, specifically:
- Summarise your overarching objectives around activity across the Cluster in relation to

particular providers and settings

- Include intentions in relation to outpatient, elective and emergency growth / reductions in

comparison with forecast 2011/12 outturn

- Cover how this links to commissioning intentions and the QIPP priorities outlined in section

6

and your Milestone Tracker

- Cover how planned activity provides the capacity to deliver RTT

- Outline those productivity metrics to be met/achieved at key providers

- Include value of 70% emergency admissions threshold monies to the SHA
NHS NWL will include relevant ACV tables in here and any necessary commentary when the activity
plans for all settings of care are known. NHS NWL will share our proposed timetable for this if
required at this stage.
107
7.6. Triangulation
Describe the triangulation activity that has taken place to ensure robustness in respect of:

- Activity

- SLA values

- Workforce
The cluster CSP modelling included key elements of the NWL financial strategy and set out the level
of QIPP needed to deliver the PCTs plans. The Delivery Support Unit has worked with the Boroughs
to consolidate the Borough schemes and Cluster-wide QIPP schemes. A robust quality assurance
assessment was carried out and discussed with Borough leads to ensure the 2012/13 QIPP plans are
realistic, deliverable and avoid double-counting of savings across Borough, ACV and DSU schemes.
These refined QIPP schemes have been modelled into the draft contracting baselines prepared by
the ACV and will be a key part of the negotiation strategy for the acute contracts. The consolidation
of all of the Borough’s schemes into the ACV baselines has ensured the commissioner and provider
start point for negotiations are the same. Once the negotiation process is completed, the agreed
SLA values will be used in PCT Operating Plans. Significant financial pressures that occur as a result
of the outcome of the negotiations, whether for commissioners or providers, will be subject to
separate discussions between the Cluster and relevant organisations.
108
7.7. Key capital schemes
Include scheme name, values, purpose, funding source, etc.
The indicative capital plans for the NWL PCTs are set out in the table below. There are a small
number of significant premises developments and the balance will be used to maintain the retained
PCT asset base. The level of investment in IT systems may reduce considerably if the Cluster is
successful in its bid for a share of the additional capital released towards the end of 2011/12. All
new expenditure would be subject to SHA approval.
Operating plan 2012/13 - Indicative Capital Plans
Scheme
Ealing
£000
Hounslow Hillingdon
£000
£000
Yiewlsey Health Centre
Refurbishment
H&F
£000
Brent Harrow
£000
£000
2,000
White City Development
2,135
Shepherds Bush
1,500
Lisson Grove
Backlog maintenance
IT Information
Systems/Networks/Equip
ment
Capital Grants
K&C Westminster
£000
£000
1,000
1,000
1,100
1,500
1,500
1,000
1,500
4,620
300
5,920
3,210
300
4,510
4,360
300
7,760
750
500
6,385
750
500
2,750
750
500
3,750
3,000
3,000
TOTAL Brief Outline
£000
Full refurbishment of existing Health
2,000 Centre
Care Centre Project linked to the
Council Scheme with a total capital
outlay of £4.7m to complete in
2,135 2013/14. SHA approved scheme.
Redevelopment of West12 Shopping
1,500 Centre to accommodate GP Practices
1,200
1,000
11,800
1,200
14,440
2,400
35,275
Joint development with local
authority for a regeneration project £6m in total for completion in 2014/15
H&S, DDA, etc.
Extent of the request for new capital
may vary, subject to progress of
current 2011/12 bid.
Predominantly for GP premises.
109
7.8. Liquidity / cash flow / loan requirements
As in 2011/12, the Cluster expects to manage its cash requirements within the NWL PCTs
allocations.
110
7.9. Key financial risks and opportunities in 2012/13
RISK / OPPORTUNITY
Risk = Red
Opportunity = Green
Potential risk or
FULL
VALUE
(TBC)
Probability:
Low (25%)
EST.
Medium (50%) IMPACT
MITIGATING ACTIONS
High (75%)
opportunity =Amber
Shadow CCGs to be fully engaged with
the service changes required to deliver
QIPP Delivery - the
this, the majority will be in budget
Cluster has a major QIPP
areas they have delegated
programme of £121m of
M
responsibility for. This provides them
recurrent savings in
with a major opportunity to improve
2012/13
their financial positions before they
take full responsibility as statutory
commissioning bodies
SLA Negotiations and
Management – the
incorporation of the
NWL Quality Standards
The changes expected are part of the
and the QIPP savings will
longer term NWL commissioning
make the 2012/13
Strategy and will support the
contracting round
challenging for
commissioners and
development of provider service
M
reconfiguration options. Where
transitional support is provided
providers. Once the
conditions will limit the risk to
contracts have been
commissioners
agreed, Performance
and Activity
Management will be a
significant risk for
commissioners.
Provider
Reconfigurations – the
This represents an opportunity to
Cluster is preparing a
Pre-Consultation
Business Case in order
to carry out a major
engagement exercise in
establish a more clinically and cost
M
effective health system across NWL. A
fully resourced dedicated project team
is in place to manage this process.
the Summer 2012.
111
There are considerable
risks attached to this
due to the scale of the
changes believed
necessary.
CSO Development &
Transition – 2012/13
The CSO organisation will develop
will see the beginning of
through the year, becoming
significant changes to
increasingly responsive to the needs of
the way that staff work
the CCGs. Other staff will be preparing
across the cluster. Major
challenge will be to
M
functions and roles to transfer to the
National Commissioning Board and
maintain ‘business as
other future host organisations. A full
usual’ while so much
change management process will be in
transition work is taking
place, following national guidance
place and staff futures
are uncertain.
CCG Establishment the shadow CCGs in
NWL have revised their
configurations and
continue to develop
They will however have the full support
their views on how best
of the emerging CSO and will use the
to maximise the
effectiveness of their
M
commissioning support.
£2 per head development funding
(C£4m) to ensure all their members
and systems are fully prepared.
As they prepare to
become statutory
bodies, they face a steep
learning curve to fulfil
the responsibilities they
will have.
Pooled non-recurrent
The Cluster will use its pooled funds to
funds held by the
manage the local health system and
Cluster (CTB Fund, 2%
H
ensure a sound financial legacy is
NR, 70% NEL Marginal
available to the new commissioning
Rate)
organisations.
The values of quantifiable financial risks will be
completed once final Operating Plans are agreed.
112
113
7.10. Overall contingency / reserves
A 0.5 % contingency is held by each Borough, for general in-year pressures.
The Cluster will strategically use its pooled funds (Transition Fund/ CTB, 2% NR Fund, & 70% NEL
pool) totalling C£120m, to support the structural transition required for commissioners, support the
cluster’s challenged organisations to change and enable the reconfiguration of the NWL
commissioner and provider landscape into a clinically and financially sustainable operating model
for the future.
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Section Eight: Workforce
8.1. Workforce impact of strategic goals
Will your service vision for the cluster have a workforce impact for your
Yes
providers?
(delete as
Please provide a description of the anticipated impact for workforce within
appropriate)
local provider Trusts and Community providers as a result of the cluster’s
strategic initiatives e.g. describing anticipated increases / decreases for your
main providers and services that may see significant change.
The expectation is that for each service change, the workforce impact should be described:
E.G. Vision for maternity services will mean a re-configuration of our current service provision of
three acute trust providers to two acute trust providers with two maternity-led birthing centres. It
is envisaged that there will need to be an increase in midwifery staff and the maternity support
worker across our providers as a result and a reduction in obstetrician staff as there will only be two
acute providers. Please see a copy of the information submitted to us as part of this process as
evidence.
There are four key drivers for the need to change services:
1. The need to ensure care is delivered in the most appropriate setting – a high volume of
patients use acute services who could be treated closer to home by primary care or
community care.
2. The need to make better use of the medical workforce - a key element of the quality
standards is better workforce provision. Research demonstrates that consultant-delivered
services achieve better clinical outcomes.
3. The need to centralise some services – there is increasing evidence that busier units and
greater clinical specialisation achieve better clinical outcomes.
4. Need to make effective use of resources and achieve financial sustainability for
commissioners and providers in NWL
(source: Commissioning Strategy Plan 2012-15, November 2011)
Delivering each of these will result in changes to the workforce:

There will be a reduction in activity in the acute sector and an increase in the activity in
primary and community care. The outcome of this movement will be a reduction in the size
of the workforce for acute providers and a potential corresponding increase in community
provider workforce numbers though this will be offset by the need for greater community
provider efficiency.

Consolidating some services onto fewer sites would mean consolidation of the associated
workforce; including supporting a move towards 24/7 consultant presence in key specialties
(e.g. in A&E, obstetrics ward).
The specific workforce changes will be worked up within the detail of each relevant project once
service changes and productivity changes are determined. High level workforce changes have been
estimated within the benefits calculation for each of the QIPP schemes.
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For example, to deliver against driver number 1, we are developing an Out of Hospital Strategy
(alongside our CCGs). There are a range of initiatives that will be needed to deliver this strategy,
many of which will have some workforce impact. These include:

Scaling up integrated care (Integrated Care Pilot - Diabetes, Elderly, COPD, CHD; Integrated
care for mental health)
-
The likely workforce impact would include increased cross-organisation working,
transition to integrated teams; and changes in skillmix.

Transforming Urgent Care (Rapid Response and Home Care (STARRS); Enhanced Recovery
services; Telehealth/Assistive technology; NHS 111 implementation)
-
The likely workforce impact would include the introduction of new roles and teams
(e.g. 111) and new training requirements.

Transforming planned care (MSK redesign; AQP procurement; Referral order book; NWL
prescribing formulary)

The likely workforce impact would include training and role redesign.
Cost and value of care (Mental Health productivity; Community nursing productivity)
-
The likely workforce impact would include training and role redesign.
As the Out of Hospital strategy is developed and consequently the initiatives needed to deliver it, a
workforce workstream will be set up for each one to ensure the impact is understood, planned and
managed effectively.
We are also working in partnership with our education providers to ensure that as new roles,
responsibilities and new settings of care are developed, the impact of this is rapidly fed into
training to ensure the workforce has the appropriate skills to meet the changing environment.
NWL providers have been submitted their workforce plans to NHS London, who have been collating
them across London on behalf of the clusters and providing initial feedback on their quality and the
completeness. Feedback sent to the providers has also been fed back to the cluster for final review
including the opportunity to add further cluster feedback. The plans set out the annual targets for
staff-in-post growth and should give assurance around the practice teacher capacity and capability
to deliver this staff growth. Additional feedback has been given to providers focussing on the
triangulation between activity plans, workforce plans, QIPP plans and finance plans. This feedback
has also been shared with the clusters for review. Providers have been asked to resolve any data
quality and triangulation issues for the final draft of the operating plans which are due on 9th March
2012. They have also been asked to ensure that their plans demonstrate commitment to meeting
the Department of Health sickness target.
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8.2. Effective communication with providers
Does your organisation have a process in place by which it can assure the
Yes
workforce strategies of its provider organisations are fully integrated with
(delete as
service and financial plans; have clinical ownership and aligned with the
appropriate)
cluster’s vision as highlighted in its commissioning intentions communicated
to its providers?
The expectation here is that the Cluster has an assurance process in place that enables them to
request sufficient information from their providers to provide assurance that the plans that their
providers have submitted to them are finance/service/workforce integrated.
E.G. As part of the contracting process, we require our providers to demonstrate how they
undertake service planning in an integrated way with finance and workforce to provide evidence
that they will be able to deliver what we are contracting them to deliver. We look for evidence that
the provider’s process involves clinicians, evidence of the templates they use and the governance
framework that these plans are approved through. Please see a copy of the information submitted
to us as part of this process as evidence.
The performance team have led a assurance process against QIPP plans which is to ensure suitable
processes sit against the QIPP schemes. This will be managed on an ongoing basis.
For schemes happening at cluster level there is a governance process which includes ensuring
adequate clinical, and managerial sponsorship at project exec level (the Clinically Responsible
Officer, and Senior Responsible Officer). In addition they include representation from NHS NWL,
each of the CCGs, the borough commissioners, each of the providers and a LINKs/ patient/ public
rep.
The workforce implications are then considered within the program hub. For example, the out of
hospital work underway is planned around three key stages: setting the vision; developing the plan;
and making it happen. The second phase is where the majority of the workforce assessment will
take place. In a series of interviews and workshops with CCGs and providers, the method for
quantifying workforce requirements, clinicians will:
Identify high
priority
initiatives
Calculate
volume of new
activity in OOH
Calculate WTE
and resources
required to
deliver this
new activity
Compare total
WTE needed
after
productivity
against current
workforce
Calculate space
required for
total WTE
Calculate total
cost to
providers and
evaluate
financial
impact
This will ensure that the plans developed include an integrated view of the finance, activity and
workforce changes, and are driven by service improvement.
Overall, NHS NWL has a Communications and engagement strategy. One of the communication
objectives is benchmark and track support among target audiences over time, both before and
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during consultation. This will form part of the assurance that providers are involving clinicians and
other members of the workforce in service transformation.
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8.3. Quality of service / education considerations
8.3.1 Has the cluster made clear to their provider organisations that their
Yes / No
education and training funding should be used to transform their workforce
(delete as
to support the delivery of the cluster’s service vision, and does the cluster
appropriate)
have mechanisms in place to assess whether provider organisations have
appropriate plans to support this objective?
The expectation here is that the Cluster has an assurance process in place that enables them to
request sufficient information from their providers to provide assurance that their education and
training plans support the cluster vision for service and a process in place to monitor delivering of
the plan.
E.G. As part of the contracting process, we require our providers to submit their education and
training plans so that we can review them and be assured that they are aligned with our service
vision. On a quarterly basis, we ask our providers to submit an update report on their education
and training plan, so we can monitor that the plan is being delivered and that the workforce they
have are fit to deliver our service vision. Please see a copy of the information submitted to us as
part of this process as evidence.
The cluster has made it clear to provider organisations and their commissioners that workforce
transformation must be underpinned by appropriate education and training. This will be assured
via a range of methods:

Declaration that all staff have appropriate training and qualifications within the providers’
contracts.

A workforce component of the risk assessment used to sign off service changes by the
clinically led programme boards.

The introduction of a cluster workforce group as part the reconfiguration programme (name
TBC).
-
For example, it is anticipated that we will request providers to provide an update
report on how education and training funding will be used to transform their
workforce and support delivery of the cluster’s service vision
8.3.2 Does the cluster have processes in place to ensure that provider
Yes / No
organisations carry out appropriate workforce risk assessments and address (delete as
appropriate)
capability or capacity issues ahead of the changes that the Cluster’s local
service vision will require?
The expectation here is that the Cluster has in place a process to provide assurance that their
providers are not transforming their workforce in any way that will risk patient safety. As
commissioners of service, they have a responsibility to ensure that those trusts they commission
from, deliver a safe service on their behalf.
E.G. As part of the contracting process, we require our providers to provide information to
demonstrate that their workforce planning process is integrated with finance and service with a
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clear governance process, that it has been validated by their clinicians and deemed to be safe for
patients, with mitigation plans developed for any risks identified. Please see a copy of the
information submitted to us as part of this process as evidence.
Patient safety and the quality of the care are at the heart of service transformation. Service changes
will be assessed and signed off via a robust programme governance structure as illustrated in the
diagram below.
NHS NWL Board
(Joint Committee of NWL PCTs)
Clinical Executive
Team
Delivery Board
(monthly Clinical
Executive Committee)
Strategy
directorate
SROs,
CROs
Performance
directorate
NHS NWL
Provider Strategy
Group
Delivery Support Unit
Programme
boards
Transforming Primary Care
SRO: Daniel Elkeles
CRO: Mark Spencer
Transforming Pathways of Care – Planned Care
SRO: Nick Relph
CRO: Ethie Kong
Transforming Pathways of Care – Urgent Care
SRO: Rob Larkman
CRO: Andrew Steeden
Scaling up Integrated Care
SRO: Thirza Sawtell/Andrew Howe
CRO: Amol Kelshiker/Fiona Butler
Cost and value of care
SRO: Simon Weldon
CRO: Arjun Dhillon
This process is led by clinicians who are responsible for the commissioning of safe services. The
programme boards will review the workforce plans in conjunction with finance and activity changes
as well as key risks and issues along with mitigation strategies. This will provide a forum to
escalate capacity and capability issues which have not been resolved locally. The risk management
process is discussed in more detail within section 8.6.
Furthermore, as part of the contracting process, providers must declare that care is provided in a
safe and appropriate environment.
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8.4. Statutory workforce obligations
Does the organisation have a process in place by which it can assure
Yes / No
statutory workforce obligations (e.g. EWTD, mandatory training, % appraisal
(delete as
rates, quality of appraisals, medical revalidation) are delivered within its
appropriate)
provider organisations?
The expectation here is that the Cluster has in place a process to provide assurance that their
providers are responsible employers. As commissioners of service, they have a responsibility to
ensure that those trusts they commission from, deliver a legal service on their behalf.
E.G. As part of the contracting process, we require our providers to provide information to
demonstrate how they adhere to the statutory obligations around employment of workforce. We
ask them to demonstrate their planning, tracking and reporting arrangements for EWTD
compliance, mandatory training, etc. Please see a copy of the information submitted to us as part
of this process as evidence.
As part of the contracting process, we require our providers to provide information to demonstrate
how they adhere to the statutory obligations around employment of workforce.
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8.5. Monitoring and performance management
Does the cluster include workforce metrics, benchmarking, trends and plans Yes / No
within its contract performance process with its providers? Are these metrics (delete as
incorporated with related quality metrics and intelligence, and used to
appropriate)
identify and raise concerns about future trends and performance? Where the
workforce indicators of a provider raises concern, please describe the
process that the cluster will take to resolve the risk identified? How will the
cluster ensure that CQC and Monitor have been involved as appropriate?
The expectation here is that Clusters monitor workforce in their providers to ensure that any issues
are highlighted in relation to workforce before patient safety is put at risk.
E.G. The Cluster has negotiated as part of its contract with its providers the provision of the
following data on a quarterly basis: 12-month rolling sickness and turnover rate, vacancy rate,
agency usage as part of its total staff pay bill, progress against training plan and progress against
its staff health and well-being plan. If any of these areas reported on are rated red, they form part
of the discussion for example in the quarterly workforce review session which we hold with each of
our providers. Please see a copy of the template which shows this information is submitted to the
Cluster as evidence.
The monthly workforce dashboard which is produced by NHS London is fed into the performance
meetings with the providers so that workforce issues can be picked up as part of overall
performance. These meetings are led by the Director of Commissioning and Acute Performance
and the Acute Commissioning Vehicle. If there are any issues of concern, they will be dealt with at
these meetings.
Staff responsible for monitoring the contract will be aware of the role of the CQC and Monitor and
the process for involving them where appropriate.
In addition, intelligence will be gathered during routine and ad hoc contact with the healthcare
community and its population.
We have also signed up to using the National Workforce Assurance Tool (NWAT) and will be actively
supporting its roll out.
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8.6. Managing of workforce risk
Where workforce changes have been identified, please describe the risks that Yes / No
these changes may have to patient care standards during the transition and
(delete as
the process by which the Cluster will mitigate these risks with the providers? appropriate)
The expectation here is that the Clusters having identified the risks that their service vision has on
the workforce within their providers, put a process in place to mitigate these risks as part of their
remit as a responsible commissioner.
E.G. The Director of Workforce Transformation has a monthly meeting with all the HRDs in its
cluster to review workforce issues across the cluster. At these meetings, any identified risks are
discussed and plans are agreed across the cluster to mitigate the risks identified. Please see
attached a copy of the agenda for these meetings as evidence.
NHS NWL will consider how to deploy the NWAT tool to support transparency and early warning on
workforce issues that may arise for acute providers through four lenses: activity, workforce, quality,
safety and finance. NWL will follow guidance from NHS London about the implementation of this.
As described previously, the detail on how the workforce will change will be developed as part of
the implementation planning. Risks will be assessed using the following:
#
Description
Likelihood of
occurrence
pre-m itigation
(1-5)
Im pact on the
program m e
prem itigation
(1-5)
Overall
score &
RAG prem itigation
Risk m itigation
Im pact on the
Overall
Likelihood of
program m e post- score &
occurrence postm itigation
RAG postm itigation (1-5)
(1-5)
m itigation
Ow ner
Date logged
Open/
Closed
Issues will also be captured and managed within the same process:
ID
Description
Impact on the
programme
(High/Med/Low)
Issue Owner
Date logged Mitigating Actions
Status
The highest risks and most severe issues will be escalated to the programme boards via a
workstream report update as follows:
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Patient care during the transition will be of the upmost priority. This would be assessed and
managed as a risk, with mitigating actions such as a day one plan and communications for staff and
related organisations forming part of the mitigation.
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