Commissioning Strategy 2012/16
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Document Control Sheet
Name of document:
Commissioning strategy 2012-16
Version:
22 (version for use in public consultation)
Owner:
Mark Taylor
File location / Filename:
Mark Taylor
Date of this version:
25th September 2012
Produced by:
Synopsis and outcomes of
consultation undertaken:
Synopsis and outcomes of
Equality and Diversity Impact
Assessment:
Approved by (Committee):
Mark Taylor
8 week consultation 12/11/12 – 7/1/13 currently
underway.
Date ratified:
18th September 2012
Copyholders:
Mark Taylor & Kevin Sharman
Next review due:
3/1/13
Enquiries to:
Mark Taylor
Not undertaken at this stage
Executive Group
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CONTENTS
INTRODUCTION
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About North Norfolk Clinical Commissioning Group
Health issues in the population
Mission and values
Strategic commissioning goals
What will be different by 2016/17
4
6
7
7
8
CONTEXTS AND KEY CHALLENGES
9
Joint Strategic Needs Assessment
Policy context
Insights from patients, public, clinicians and local partners
Provider landscape and key performance issues
Patient experience, quality and safety
Financial picture
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COMMISSIONING INTENTIONS 2012 ONWARDS
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Commissioning and market development strategy
Programmes and initiatives
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IMPLEMENTATION AND DELIVERY
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GLOSSARY
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INTRODUCTION
This section gives an overview of North Norfolk Clinical Commissioning Group as an
organisation, summarises the health issues in the population and sets out the vision
and strategic goals to tackle these.
About North Norfolk Clinical Commissioning Group
North Norfolk and Broadland is a rural and coastal area to the north and east of the city of
Norwich. North Norfolk Clinical Commissioning Group (NNCCG) was formed in 2011/12 as
a Sub Committee of NHS Norfolk and is seeking to achieve authorisation to operate as the
commissioner for health services in North Norfolk from April 2013. The CCG is one of five
being created in the current NHS Norfolk and Waveney Primary Care Trust Cluster
(NHSN&WC) area.
NNCCG comprises 20 General Practices, across the whole of North Norfolk District Council
(NNDC) and the majority of Broadland District Council (BDC), many of whom have a long
history of working together.
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NN CCG is a local membership organisation led by family doctors that is responsible for
planning and paying for healthcare services. We do not provide healthcare like a GP
Practice or hospital. Our role is to make sure the appropriate NHS care is in place for the
people of North Norfolk, within the budget we have. The CCG has a small core team of staff
who support the work of the Council of Members and the Governing Body.
Formed in 2012 following the Health and Social Care Act 2012, NN CCG are made up of 20
GP practices in North Norfolk and rural Broadland. These practices are all members of the
organisation. The member doctors will lead the decisions about which hospital services,
mental health services and the community healthcare services are needed for the 167,800
people living in the North Norfolk area.
Primary care services, which are GPs, dentists, pharmacies and opticians, will be organised
by the NHS Commissioning Board (NCB) from April 2013.
NN CCG aims are:
To work with patients, staff and stakeholders to offer care that is high-quality, good
value for money and delivered (where possible) closer to home
To maximise the potential of primary care to deliver excellent services for patients
To provide information to our GPs to help inform work and planning
To involve patients in decision making
To reduce health inequalities
To aid educational opportunities for staff in GP surgeries to improve services
At the moment NN CCG is a ‘shadow’ organisation with a delegated budget and the
authority to take decisions. The CCG will officially take over the planning of healthcare
services from April 2013 from NHS Norfolk and Waveney (a Primary Care Trust or PCT).
When planning and buying services the CCG will work with other nearby CCGs in Norfolk to
help make sure local services are consistent and to secure greater leverage with providers
on delivery. NNCCG will also play an active role in wider commissioning networks organised
by the emerging National Commissioning Board Local Area Team which is driving strategic
change and service redesign, for example Stroke.
A memorandum of agreement is in place with the emerging NHS Norfolk Commissioning
Support Unit (NCSU) for those functions which the CCG presently wishes to outsource –
procurement, contracting and performance management – as well as back office functions.
NNCCG has grasped the opportunity to focus on service redesign and community and out of
hospital services in the locality. This is being delivered locally in strong partnership with key
providers and Norfolk County Council. New structures and processes have been introduced
to ensure that this alignment with partners delivers both better services for local people and
better value for money. North Norfolk Healthcare Referrals Management Centre will be key
to systematically enabling choice, pathway redesign and tackling unwarranted variation.
This commissioning strategy sets out the vision of the member Practices, and the start of a
practical work programme which will deliver real benefits to the population, whilst
recognising the challenge of improving quality and access in a climate of financial restraint
within the NHS. It is the means by which Practices can hold the CCG to account and in turn
the CCG can expect support and commitment from Practices to deliver.
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Health issues in the population
The health of people in NNCCG’s area is generally better than the England average.
Deprivation is lower than average, life expectancy for both men and women is higher than
the England average. Approximately one third of NNCCG’s population is aged over 65 and
the current predictions are that this will rise to about 40% by 2028. Over the last 10 years,
all cause mortality rates have fallen as have early death rates from cancer and from heart
disease.
However, the overall level of health status masks variations between localities, with some
with poor health status largely linked to deprivation, unemployment and the low level of
educational attainment. Whilst it is important to tackle the traditional killer diseases such as
heart disease, respiratory disease and cancer, it is equally important to focus upon the
health challenges of obesity, chronic alcohol misuse, long term conditions, mental health and
dementia, and the needs of young people.
This commissioning strategy is being shaped by the health needs of and the unique service
delivery challenges faced by the rural and coastal populations of NNCCG:
an older population living longer often with at least one long term condition
a large rural area with poor transport infrastructure making access to services
challenging and the need to deliver more care at or closer to home
unwarranted variation in health status and outcomes in particular parts of the
locality particularly for young people
a need to promote healthy lifestyles and improve quality of life
the need to prioritise resources accordingly in a time of economic constraint
All of these characteristics present a challenge to NNCCG in designing services which excel
at both preventing and managing the effects of long term conditions, avoiding unnecessary
reliance on acute hospital admission, and that promote well-being and independent living
amongst the whole population but especially older people. NNCCG aims to focus initially on
areas where it can have the greatest impact by reviewing pathways and seeing how they
can be adapted to meet the challenges set out above.
The CCG’s success will be measured by its ability to make consistent, incremental
improvements in outcomes and cost effectiveness, and to tackle unwarranted variation,
across its whole programme of commissioning activity in order to free up the resources to
address future health needs.
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Mission and values
The purpose of NNCCG’s mission and values is to create a strong sense of purpose and direction. They
will be the guiding principles by which NNCCG will conduct business and on which this
commissioning strategy has been shaped.
The mission of the CCG is the statement of intent, setting out ambition for the future. NNCCG has
agreed this mission to guide its commissioning as follows:
The mission of NHS North Norfolk Clinical Commissioning Group is
to improve health and wellbeing; to support people to be mentally and
physically well; to get better when they are ill; and when they cannot
fully recover, to stay as well as they can to the end of their lives
The values which underpin this mission are:
 Putting patients first and working in partnership
 Treating people with respect, dignity and compassion, ensuring no one is
excluded
 Taking responsibility for our patients in the NHS or social care wherever they
are
 Delivering quality and coherence in primary care practice
 Aspiring to deliver high quality outcomes not merely process driven
 Working to tackle the unique challenges in our population
Strategic commissioning goals
The CCG’s strategy is to commission the best possible health services & outcomes for local
people in financially challenging times by:
Critically reviewing & maximising the value of our current investment in
services (which could lead to disinvestment)
Rigorously driving up the quality, effectiveness and efficiency of our
commissioned services by better engagement of clinicians and intelligent but
rigorous performance management of contracts
Relentlessly reviewing Primary Care quality markers, such as referral rates,
prescribing and outcomes across our Practices so as to minimise
unwarranted clinical variation, the Referrals Management Centre is key to
achieving this
Commissioning care in the right setting, at the right time by the right team
and practitioner
Delivering fully integrated community health and social care teams as the
norm, working in full partnership with local General Practice to support
people in their homes
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What will be different by 2016
The development of this strategy has been led by and with GPs. The next three years will
have a number of characteristics, these will include:
the delivery of this strategy will be led by GPs, working with clinicians and patients
the patient and their quality of care will be the focus of the CCG’s work
collaboration across Practices, and with key partners will build relationships and
ways of working to benefit patients, clinicians, and other local professionals.
engagement with patients and the public and their involvement in the CCG’s
decision making processes will build a new partnership between a statutory
commissioning organisation and the local population it serves
using clinical expertise and ideas from others to develop opportunities for
innovation.
More recently NNCCG has been developing its vision of what differences its residents would
experience in healthcare by 2016/17. This is that the whole population, but especially older
people and those with long term conditions which impact their quality of life, will have access
to a fully integrated primary and community health and social care service, and access to
more specialist care which is evidence based, safe, and delivered with compassion and
dignity.
Our emerging vision of integrated care includes:
 Fully integrated health and social care delivery teams which fully support the 20
General Practices
 Services being arranged around patients’ GP surgeries with access to a wider range
of social, voluntary and housing related services
 A single assessment process across health and social care
 Identified key workers who understand individual patient’s social as well as medical
contexts
 Greater local access to services which are planned and appropriate for delivery in the
locality
 Services which are simple to use and can be “switched on” via a single call and
assessment
 A universal expectation that all services delivered at or close to home will be
delivered with respect, compassion and a personalised approach to care.
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CONTEXTS AND KEY CHALLENGES
This section gives a selected extract from the Joint Strategic Needs Assessment of
the big health challenges facing NNCCG; provides insights from partners and the
community on health issues concerning them; describes the national and regional
strategic context for this strategy; describes the local provider market and its
performance; and sets out the CCG’s financial context.
Joint Strategic Needs Assessment
The Norfolk-wide Joint Strategic Needs Assessment (JSNA) has been disaggregated to
provide a rich picture of the health needs of the population. The full JSNA can be accessed
at www.norfolkinsight.org,uk
Key highlights are set out below.
Population demographics
The registered population of NNCCG is approximately 167,800. The population profile is
older than the English average with correspondingly fewer people under the age of 44.
Projections suggest that this trend will continue. Horsford has the youngest population and
Mundesley and Sheringham the oldest.
In the north of the CCG area small declines are projected in all of the under 20 age groups
over the next 25 year period, in particular for children aged 5-10, however, in the Alysham,
Taverham and Horsford areas each of the five-year age groups is projected to increase up to
2030, the largest increase being in the 5-9s and the smallest in the 15 -19s.
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Health needs and inequalities
The health of people in NNCCG is generally better than the England average.
The 2010 Index of Multiple Deprivation (IMD) did not identify any part of the CCG as being in
the most deprived quintile in England. Whilst deprivation is lower than average, about 1 in 10
children in the CCG area live in poverty. The overall level of health status does, however,
mask variations between localities where health status is poor, largely linked to deprivation,
unemployment and low level of educational attainment. In general terms, Cromer Group
Practice and Ludham and Stalham Green Surgery serve the most deprived communities in
the CCG but there are also significant issues for Wells, Fakenham, Aldborough and the
Practices covering the east coast area.
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Social determinants of health – deprivation
For the period 2008-10, average male life expectancy at birth in the CCG area was 80
compared to the England figure of 78.6. The absolute gap between the lowest part of the
area and the highest was 6.6 years and this has decreased very slightly from the last
recording period. The Practices in areas with the lowest life expectancy are Coltishall,
Stalham Staithe, Acle, Cromer and Sheringham. Sheringham has the lowest male life
expectancy in the CCG area.
In the same period, average female life expectancy at birth for the CCG was 84.7 compared
to the England figure of 82.6. The gap between the area with the lowest life expectancy and
the area with the highest is 11.6 years. This gap is decreasing in the south of the CCG area,
but increasing in the north.
The Practices in areas with the lowest female life expectancy are Drayton, Birchwood and
Paston. Drayton has the lowest life expectancy in the area with a higher than average all
age all cause mortality for women. The rural area around North Walsham is the other lower
area and may relate to the high number of care homes in the area.
Premature mortality
On average, premature mortality in men is better than the national average in North Norfolk
CCG, however, there is still a wide inequality between the best rate of 151 deaths per
100,000 and the worst of 375 per 100,000. The England figure is 345 per 100,000. The
highest rates for men are in the Fakenham, Holt, Sheringham, Cromer, Horsford, Stalham
and Wroxham areas.
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In women, again, the average is better than the national rate of 219 per 10,000 with a range
of 100 at best to 221 at worst. The North Walsham area has the highest female premature
mortality in the CCG area.
Circulatory disease
Male and female premature mortality from circulatory disease is on average lower than the
national average. The rates for each area, however, vary substantially with some areas
being above the national average. For men, the range in rates is from 40 to 113 per
100,000, compared to a national average of 95.
For women, the variation is from 5.9 to 47, with a national average rate of 41. Clearly
although rates are relatively low there are substantial inequalities in outcome within the
CCG. For men, the highest rates are around Cromer, Horsford and Acle. For women, the
area with the highest rate is from North Walsham to Aylsham.
Cancer
This follows the same pattern as for circulatory disease. The average rates are lower than
the national average, but again there is a large variation within the CCG. For men the rate
varies from 50 to 126 per 100,000 and for women from 45 to 126. The Practices who
have a significant number of patients from high rate areas are Cromer, Holt, Fakenham,
Acle, Reepham and Coltishall for men and for women, the highest rates are in the Holt, Acle
and Ludham Practice areas.
Chronic respiratory disease
The average standardised mortality rate for men in England is 29 per 100,000. In North
Norfolk CCG, the rate varies from 0 to 42 by area, with the highest rate being in
Sheringham. For women, the average national rate is 20 per 100,000, with CCG variation
from 0 to 25.4 in the North Norfolk District. Accurate data is not available for the
Broadland part of the CCG. The highest areas are Horsford, Drayton, Reepham and
North Walsham.
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Premature mortality causes 2008-10
Health profiles
Health profiles incorporating a range of direct and wider determinants of local population health are
produced annually. These provide a snapshot of the overall health of the local population with
national and regional comparisons. Compared with the England average, NNDC and BDC show
significantly better health outcomes for the majority of indicators.
Areas where NNCCG is significantly worse highlighted in the Health Profiles 2012 include:
in BDC – statutory homelessness and physically inactive children
across NNCCG, diabetes and physically inactive children
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Assessing need - health and wellbeing overview
Broadland
Indicator
North Norfolk
SPOT analysis
NNCCG has reviewed the spend and outcomes (SPOT) analysis published by the Yorkshire
Public Health Observatory in September 2012 for the NHS. This analysis does not show any
substantial outliers for NNCCG though the data must be viewed with caution as this is the
first cut at a CCG level and most of the data are Norfolk wide.
Hospital utilisation
The dataset published in September 2012 by the West Midlands Quality Observatory shows
NNCCG to have high hospital admission rates for Falls, Dementia, COPD and Heart Failure
relative to England. Whilst these rates may be expected for a population of the CCG’s
demography, these rates are still high when compared to comparator cluster CCGs.
East of England Public Health Observatory (ERPHO) analyses of Hospital Episode Statistics
(HES) provisional data 2011/12) show that the Directly Standardised Rates (DSR) for
cystoscopy and prosthesis of lens (cataracts) procedures are higher than for England, the
region and comparable areas elsewhere in the country, the DSR for arthroscopies was also
high in the last quarter of 2011/12. ERPHO analyses also show that the Standardised
Admission Rates (SAR) for the Urology, Ophthalmology and Dermatology specialties are
higher than for England, the region and geographically comparable areas.
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Access to services
Access to services is not uniform across NNCCG, evidence suggests that differences occur
amongst older people and in those with disabilities. Barriers to access include cost,
availability and accessibility by public transport.
The map below shows the location of key NHS health services in NDC locality which, on its
own, covers a geographical area of 373 square miles. BDC covers a further 213 square
miles. The map shows that most of the services are located close together in the main towns
and access from many villages is challenging.
Location of key NHS services in NDC
Source: CACI (2010)
Key challenges emerging from population demography and epidemiology:
 reducing the health inequalities within the population - whilst the CCG covers
a population which enjoys relatively good health, the district level population
data mask variation at lower super output level
 a larger than average ageing population and the percentage of older people
with one or more long term conditions, such as diabetes, chronic obstructive
pulmonary disease (COPD) and dementia
 rurality and access to treatment and care
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Policy context
The NHS Outcomes Framework 2012-13 published by the DoH in December 2011, together
with the Adult Social Care Outcomes Framework, and the Public Health Outcomes
Framework published in January 2012 set the national policy context and describe a range
of indicators by which performance and outcomes for the NHS will be measured. These
policy documents support NNCCG’s desire to improve integration of services.
The NHS Outcomes Framework is structured around five domains, which set out the highlevel national outcomes that the NHS should be aiming to improve. They focus on:

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
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
Preventing people from dying prematurely.
Enhancing quality of life for people with long term conditions.
Helping people to recover from episodes of ill health or following injury.
Ensuring that people have a positive experience of care.
Treating and caring for people in a safe environment and protecting them from
avoidable harm.
 Improving outcomes and supporting transparency.
The NHS Commissioning Board, supported by NICE and working with professional and
patient groups, is developing the Commissioning Outcomes Framework (COF) to measure
the health outcomes and quality of care, including patient reported outcome measures
(PROMS) and patient experience. NNCCG will use the COF to evidence achievement
against key milestones developed for its commissioning programmes and projects and to set
future priorities.
The Public Health Outcomes Framework consists of two overarching outcomes that set the
vision for the whole public health system of what is to be achieved for the public’s health.
The outcomes are:
 increased healthy life expectancy, i.e. taking account of the health quality as well as
the length of life
 reduced differences in life expectancy and healthy life expectancy between
communities (through greater improvements in more disadvantaged communities).
Strategic clinical networks hosted and funded by the NHS Commissioning Board (NHSCB),
will cover conditions or patient groups where improvements can be made through an
integrated, whole system approach. These networks will help local commissioners of NHS
care to reduce unwarranted variation in services and encourage innovation.
The conditions or patient groups chosen for the first strategic clinical networks are:
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

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Cancer
Cardiovascular disease (including cardiac, stroke, diabetes and renal disease)
Maternity and children’s services
Mental health, dementia and neurological conditions
NNCCG clinical leaders will play an active part in these networks and support the
development of quality improvement in local services.
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Commissioning for quality improvement and safety
The National Quality Board (NQB) published a report on 16th August 2012 setting out how
quality will be maintained and improved in the new health system. This report focuses
predominantly on how the new system should prevent, identify and respond to serious
failures in quality. It is also anticipated that the learning, when published in the new year,
from the Mid Staffordshire NHS Trust Francis Inquiry report into failures in care and
treatment will have significant implications for the NHS.
In NNCCG, quality will be at the core of commissioning. The CCG will use all available
contractual levers to ensure that quality is central to service delivery. Clinical leaders wish to
play a full and active part in the new quality surveillance groups and will work with regulators
and other organisations in a culture of open and honest cooperation.
NHS Norfolk and Waveney Cluster Integrated Plan 2012
The NHS Norfolk and Waveney Cluster (NHSN&WC) Integrated Plan 2012 sets out how the
Cluster will deliver national mandates defined in the Department of Health’s National
Operating Framework including the 4 top priorities of:
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Carers
Dementia and Care of Older People
Military Veterans
Health Visitor and Family Nurse Partnerships
The Cluster plan also describes actions to deliver the current regional priorities detailed in
the NHS Midlands & East Cluster’s Commissioning Framework which includes delivery of
five ambitions to drive further service transformation. These are:
The National Commissioning Board Local Area Team may wish to review these ambitions. In
the meantime, the NNCCG has included, where relevant, those plans that now need to be
driven forward by the CCG to ensure that national and regional priorities are delivered.
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Insights from patients, public, clinicians and local partners
NNCCG has worked closely with GPs and member practices through the shadow Members’
Council to develop its vision and aims. The CCG has also held a number of engagement
workshops with patients and stakeholders, including provider organisations, local authority
and other statutory and non-statutory organisations, to explore opportunities through the new
and emerging clinical commissioning system.
As a ‘shadow’ organisation NNCCG was keen to develop a dialogue with local stakeholders
as early as possible. A key stakeholder event held in July 2012 provided a rich source of
insights into issues concerning partners, patients and other key individuals and
organisations. NCCG clinical leaders and staff met approximately 60 stakeholders from a
range of organisations. The main aims of the event were:
 To view the current Public Health needs assessment data for the area
 To hear from the GP Chair of NNCCG about the proposed commissioning priorities
for the CCG
 To give local stakeholders an opportunity to feedback their views
 To provide an opportunity for networking.
During the event there were question and answer sessions, workshops and the opportunity
to review and comment on public health maps. Feedback from the event was captured and
some priorities identified.
A number of key messages to support the drive for integration emerged from the
event which included:
•The health needs of particular groups must not be overlooked e.g.
people with learning difficulties, children and young people, carers
Inequalities (young and old), disabled people, drug and alcohol misuse
Integrated
care
•There were a number of issues that required joint working e.g.
social isolation, prevention, importance of wider factors in
influencing health outcomes, developing a single point of access
and a single point of entry to services, joined up and holistic
working
Access
•Potential barriers to effective joint working needed to be
addressed e.g. data sharing – confidentiality issues, access –
transport, mobility, educational, social, disempowered patients –
finding the system too difficult and confusing to navigate
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To support ongoing delivery of this strategy, NNCCG has developed a Communications and
Engagement Strategy. The communications and engagement strategy sets out how NNCCG
will engage with people at all stages of decision-making about their health and healthcare
through patient, carer and public involvement in the context of existing NHS policy, best
practice and legislation.
Provider landscape and key performance issues
The current provider market in NNCCG is similar to that of other rural shire counties and
includes:
a large acute services provider, Norfolk and Norwich University Hospitals NHS
Foundation Trust (NNUHFT), to the south of the city of Norwich to which access is
a challenge from some parts of NNCCG, the FT also operates a Minor Injuries and
Ambulatory Care Unit from Cromer Hospital on the north Norfolk coast;
community services that are principally delivered by one county wide provider
services organisation, Norfolk Community Health and Care (NCHC), the
organisation also operates from 4 community sites in the CCG with up to 68 beds;
a large mental health and learning disabilities NHS Foundation Trust, Norfolk and
Suffolk NHS Foundation Trust (NSFT) provider; and
a range of independent and voluntary sector providers.
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Acute hospital services
NNUHFT provides around 90% by of NNCCG’s acute hospital services. There are fairly
small referral flows to the east, to James Paget University Hospitals NHS Foundation Trust
(JPUHFT), and west, to Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
(QEHKLFT). NNUHFT is the by far the largest and most influential acute services provider
with whom the CCG needs to work in partnership to deliver service redesign.
The governance risk rating for the NNUHFT was amended by MONITOR from AMBER-RED
to RED in May 2012 due to a failure to meet healthcare targets in quarter 4 2011/12.
Performance has been variable against the Accident and Emergency (A&E) 4 hour wait
standard and the Trust is failing to deliver on the 18 week wait referral to treatment times
standard, largely due to Orthopaedics. Whilst A&E 4 hour wait performance has improved in
2012/13 the Trust continues to fail to deliver on RTT with a forecast recovery date of
February 2013.
Independent sector acute provision is limited with a small SPIRE facility adjacent to the
NNUH site. Other independent sector providers are in King’s Lynn, Cambridge and
Peterborough, a 1-2 hour journey away from Norwich by car, almost inaccessible from rural
and coastal areas by public transport.
Urgent care sector
East of England Ambulance Services NHS Trust (EEAST) provides a wide range of
emergency and patient transport services across eastern region covering six counties
including Norfolk and the CCG area. EEAST is currently in the Foundation Trust pipeline
with MONITOR.
Performance for category A (8 minutes) and category B (19 minutes) responses is variable
even at times when demand is relatively low.
This is an area of specific concern to NNCCG. There is a consistent failure to achieve
performance targets primarily because of issues of rurality and distances to be travelled
which is of significant concern to patients and General Practitioners.
Mental health sector
NSFT was formed by merger in 2011 of the former Norfolk and Waveney Mental Health NHS
Foundation Trust and Suffolk Mental Health NHS Partnership Trust to provide mental health
services. About 8% of the CCG’s allocation is invested in services delivered by NSFT.
Learning disability services are run by Hertfordshire Partnership NHS Foundation Trust.
The governance risk rating for NSFT was amended by MONITOR from AMBER-RED to
AMBER-GREEN in May 2012 due to improvements in compliance with CQC essential
standards. The financial risk rating for the Trust was changed from FRR4 to FRR3 at quarter
4 2011/12 due to deterioration in the Trust's financial position.
The Trust generally performs well against the four mental health targets - the number of new
cases of psychosis treated by the early intervention teams (EIT), performance of crisis
resolution home treatment, care programme approach (CPA), 7 day follow up and improved
access to psychological therapies (IAPT).
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Community services
NCHC provides over 95% by value of NNCCG’s out of hospital care services. NCHC is
currently in the pipeline to become a Community Foundation Trust (CFT). NNCCG gave
conditional support for this organisational form in July 2012. The Trust runs bed based
services from sites in Holt, Cromer, Fakenham and North Walsham.
Independent sector
There are over 150 care homes in the North Norfolk and Broadland, one of the highest areas
of concentration of care home providers in England.
There is also a thriving third sector with a high degree of ‘social capital’ in the community.
Strengths, weaknesses, opportunities and threats in current provider market
Weaknesses:
Strengths
Provider monopoly for a number of
services which has arguably led to
a lack of ambition in service
delivery
Choice operates more within
providers rather than through
competing providers given the
challenges of access to other parts
of the region
Generally high quality local
service provision
FTs are largely financially stable
Opportunities
Threats
Potential for good collaboration
between secondary and primary
care to reform pathways
Potential for greater integration of
care at a local level
Use of contracting levers
including CQUINs to drive up
performance
•
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Financial challenges impact upon
maintaining and improving quality
and performance
Ensuring delivery through
challenging times
Patient experience, quality and safety
Ensuring people have a positive experience of care
The population in NNCCGG generally enjoy a positive experience of care. NNCCG
performed well in the GP Patient Experience Survey 2011/12 with 92.8% of patients
reporting the experience of making an appointment as good, and 91.8% reporting a good
overall experience of their GP Surgery.
These scores are above the NHSM&E Cluster and the national average. NNUHFT was one
of the highest performing organisations across the NHSM&E against the Inpatient Survey
2011-12 results.
A new commissioning for quality and innovation target (CQUIN) to measure patient feedback
was implemented from May 2012 in NHSN&WC – the net promoter score (NPS). Patients
are asked if they would recommend the treatment they have just received to a friend or
family member. Patient feedback is converted to an overall score out of 100. The scores for
NNUHFT were have been around 65% per month, the threshold for CQUIN payment, but
deteriorated to 62.42% in August.
Treating and caring for people in a safe environment and protecting
them from harm
Performance in NHSN&WC has been variable though improving against the Methicillin
Resistant Staphylococcus Aureus, Clostridium Difficile and hospital related venous thromboembolism (VTE) key targets. There were, however, 4 never events during 2011-12 at
NNUHFT.
Whilst not a key target yet in this domain, NCHC reported an increased prevalence of new
grade 2, 3 and 4 pressure ulcers in May 2012. The national Intensive Support Team has
been supporting NCHC to develop a robust action plan to eliminate pressure ulcers.
Care Quality Commission (CQC) concerns
There were no CQC concerns in relation to NNUHFT, NCHC and NSFT.
CQC visited EAAST in March 2012 as part of its schedule of routine visits to review
compliance. EAAST was found to be compliant on the outcomes reviewed but a number of
key issues were raised in relation to hospital Trusts in NHSN&WC. These issues related to
ambulance handover and turnaround times at NNUHFT in the main.
Compared with other ambulance services, EAAST had one of the highest number of hours
lost due to delays at hospital in England. In terms of hospital delays, analysis undertaken by
EAAST showed a high level of correlation between delays at hospital of over 60 minutes and
their underperformance on response times.
22
Financial picture
To make the commissioning strategy viable it is important for the CCG to ‘live within
its means’. Those means translate to spending no more on average than £1,320 for
every person in the population of North Norfolk in 2013/14.
We presently work in a context where as part of the NHS, we along with partners in
social care and other public services will be responding to the needs of increasing
numbers of people with long term conditions and an ageing population. Though the
amount of funding we are given by the government is favourable compared to other
public sector partners (who are facing funding reductions) the additional funding
(above inflation increases) received by the NHS in recent years has now stopped.
This means we will require our providers to manage their increasing costs within
existing resources. As commissioner we will work with providers to find a
combination of working the same way but for less cost (increasing efficiency and
productivity) and implementing new ways of working (transformation and innovation).
23
COMMISSIONING INTENTIONS 2012 ONWARDS
This section describes the strategic goals and initiatives that NNCCG has developed
to respond to the health needs of the population. These are the areas which have
been selected as key priorities for action.
The diagram below identifies five programme areas and key initiatives that will drive delivery
of NNCCG’s commissioning strategy.
Older people
•Developing integrated pathways of care
•Integrating health and social care delivery
•Risk identification and stratification
Mental health
•Improving access to psychological
therapies
•Improving the management of dementia
•Mobilising a new substance misuse service
Planned care
•Redesigning elective care pathways
•Reviewing thresholds for surgical
intervention
•Reforming pathology services
Unplanned care
•Avoiding uneccessary hospital admission
•Reforming the emergency care system
•Improving the quality of care and outcomes
for Stroke
Children
•Improving access to child and adolescent
mental health services
•Making sure our childrens services support
families and young carers
24
These programmes will be underpinned by three key strands of commissioning activity:
Managing hospital and health service utilisation by
driving out unwarranted variation
Robust contract management and using contracting
levers to secure improvements in quality and
outcomes
Enabling choice and using competition where
appropriate to deliver change
Commissioning and market development strategy
NNCCG Practices formed a Community Interest Company (CIC) in 2010, called North
Norfolk Healthcare primarily to operate a Referral Management Centre (RMC) which peer
reviews, logs and offers choice to patients for most acute referrals. The original aims of the
RMC were:
to drive up the standard and consistency of referrals
to reduce the number of unnecessary referrals to secondary acute care
to introduce peer review processes into Practices to support and challenge referral
behaviour
to provide a robust database from which pathway and service redesign priorities
could be identified and developed
to improve the Choose and Book service to patients
The RMC has made good progress against all of these aims. As well as immediate feedback
on individual referrals, RMC feedback presentations to individual Practices are delivered
every six months and have been well received. The RMC database has been used to
identify the most utilised referral specialities and referral reasons and this information has
been used to inform decisions on service redesign activities. Feedback from patients
contacted to offer choice and book appointments has also been very positive.
Practices have readily accepted the RMC and the concept of peer review, indeed 34 GPs
from participating practices have trained as Referral Review Clinicians. Around 20% of all
referrals processed by the RMC have an intervention. Of these, around 4% are due to a
clinical query / intervention, such as an upgrade from routine to an urgent 2 week wait
cancer/emergency/urgent appointment, redirection to an alternative service or speciality etc.
25
The CCG believes that the continuing proactive management of, and collection of detailed
clinical information on, referrals is central to how the CCG will drive up standards of referral,
and drive out unwarranted clinical variation in primary care utilisation of secondary care.
Similarly the operation of Choose and Book through the RMC will allow the CCG to ensure
that any opportunities to promote choice for patients in North Norfolk will be maximised in
the context of the challenges presented by the near monopoly provider landscape North
Norfolk faces.
NNCCG will use market management techniques appropriately to optimise productivity,
efficiency and health outcomes of the current range of providers. There are a number of
actions to support this aim:
To develop effective and productive working relationships with current and potential
new providers
To maintain robust business processes for managing these relationships including
contract management, performance management and service development
To ensure that business processes for working with providers are transparent, nondiscriminatory and ensure equality of treatment
To develop a portfolio of standard and consistent contracts with providers that
enable delivery of the objectives in this commissioning strategy
To ensure that all providers support the CCG’s requirements to continually improve
understanding and the timely access to information about the needs of patients and
utilisation of services
Compare performance with other providers, including the private sector, in order to
identify ‘best in class’ and learn from good practice
To encourage the development of providers to enable continual improvement in the
quality and value for money of services
To develop a balance of review mechanisms and contractual incentives and
penalties in order to manage both the level of supply and the quality of services
provided.
Commissioning for Quality Improvement and Innovation (CQUINs)
The CQUIN scheme for standard NHS contracts with providers continues in 2012/13 as a
framework for ensuring the delivery of national and local priorities. Providers have CQUIN
schemes which in 2012/13 are 2.5% of their total contract value to address the needs of
each local population. NNCCG will be fully involved in the monitoring of these schemes with
local providers.
It is anticipated that the learning from the Mid Staffordshire NHS Trust Francis Inquiry report
will have significant implications for the NHS. Through linking real time patient and carer
experience directly to provider CQUIN payments, NNCCG aims to ensure the failings
identified in the report will never happen to patients. Protecting the most vulnerable
members of the population, for example by setting challenging Dementia CQUINs to be
delivered by local providers, will be a high priority.
26
The CQUIN scheme will also be used to further embed the NHS Outcomes Framework.
It is anticipated that patient choice in general will have a marginal impact upon the local
providers given the significant difficulties with access to more distant providers. However, it
should be noted that Norfolk has had some success in the past in moving patients from the
local acute provider, NNUHFT, to other NHS and independent sector providers particularly
where travel costs and costs to carers are covered e.g. Orthopaedics. This CCG will not
hesitate to undertake similar initiatives if service quality and access issues warrant it.
It is more likely that choice of care setting and/or care team will impact upon the local acute
provider e.g. for end of life care, but this should have a positive effect releasing hospital beds
for more appropriate acute care. NHSN&WC had around 75% of first outpatient
appointments booked using the Choose and Book system in quarter 1. Around 40% of
bookings are where access to a named Consultant led team was available.
NNCCG will work with the emerging NCSU, and in collaboration with other CCGs, to
stimulate new entrants to the provider market to deliver its commissioning strategy where
appropriate - the Referrals Management Centre will be central to enabling this to happen.
The CCG wishes to strike a sensible balance between collaboration and competition to
secure the best outcomes and maintain a stable health care delivery system without
detriment to patient care. The areas likely to be subject to competitive procurement are:
Acute hospital sector – offering choice of treatment elsewhere via the Referrals
Management Centre where waiting times for access to treatment are unacceptably
long; using the Any Qualified Provider (AQP) process to enable greater choice e.g.
Audiology services
Diagnostics and technology sector - reference has been made elsewhere in this
strategy of the importance of technology to deliver outreach health care solutions to
patients who do not routinely access health services particularly our more deprived
populations, there is potential for growth in this market segment in a number of our
programme plans e.g. exploring the potential, as part of care pathway reviews, of
procuring and deploying more mobile diagnostic capacity and capability into the
community and using telemedicine to support people with long term conditions to
maintain independence at home
Mental health sector - reviewing the substantial new investment in primary mental
health services i.e. improving access to psychological therapies with a view to
varying the current NSFT contract or retendering
Where new health improvement interventions and health care service needs are identified in
this strategy, the general presumption will be that market testing will apply, except where it
makes sense to collaborate with an existing provider e.g. no other potential providers in the
market or seeking to enter the market, or where service concentration for certain services
precludes choice.
27
Programmes and initiatives
Programmes and
initiatives
•Older people
•Mental health
•Planned care
•Unplanned care
•Children
Older people
Diabetes modelling suggests there is much undiagnosed diabetes in NNDC
Hospital admissions for diabetes are currently higher as a percentage of weighted
list size than the national average, this may in part be due to the age of the
population but also indicates a need to review local pathways and service provision
Diabetes prevalence is predicted to rise sharply in the next twenty years with almost
all of the increase being due to obesity
There is unexplained Practice variation across NNCCG in secondary prevention for
both Coronary Heart Disease and Diabetes
Emergency admissions for fractures in the over 65s are not significantly worse than
elsewhere in Norfolk, but show a twofold variation between the best and worst
practice areas and the rate has increased slightly over the last three years
Flu immunisation uptake is significantly worse than the national average
The excess winter death rate in the NNDC area is significantly worse than the
national average and the CCG variation is from no excess deaths in one area to the
worst in Norfolk in another
28
What initiatives will NNCCG undertake to tackle these demographic and health
challenges?
Older people
•Frail and elderly case management
•Integrating health and social care
•Risk stratification and case management of
long term conditions
Frail & elderly case management
NNCCG Practices were in the first wave of a roll out of a NHSN&W Cluster led project, Care
of the Frail and Elderly, which incorporates intensive case management, the use of
telemedicine, local step-up/admission avoidance beds, and access to local Medicine For the
Elderly (MFE) advice. An investment of £1 million was made in this project. A major joint
evaluation with NHSN&W has identified some reduction in admission rates for those patients
who have been case managed though it is not yet clear whether this is due to the
interventions of the project or regression to the mean.
NNCCG will, on the basis on this evaluation, refine and develop its approach to the Care of
the Frail and Elderly, Integrated Care and Care Home initiatives, seeking to build on the
successful elements of each but equally decommissioning any services found not to be
effective. Closely linked to this, NNCCG has redefined its Community Nursing Service
specification, seeking to simplify and better performance manage the service provided by
NCHC. NNCCG will also review access to therapy services and improving communication
between Practices and therapy services.
NNCCG’s emerging vision of integrated care includes:
A single assessment process across health and social care
Identified key workers who understand individual patient’s social as well as medical
contexts
Services which are simple to use and can be “switched on” via a single call and
assessment
Services being arranged around patients GP surgeries with access to a wider range
of social, voluntary and housing related services
29
A single point of access (SPA) to the range of services available in both health and
social care
A universal expectation that all services delivered at or close to home will be
delivered with respect, compassion and a personalised approach to care.
Integrated care
3 Practices (Fakenham, Wells and Holt) participated in the DoH’s Integrated Care Pilot
which is addressing the provision of a more joined up and intensive case management of
known high risk patients involving General Practice, NHS community and adult social care
services. Both the national and local evaluations were published in 2011. Early indications
were that the Practices achieved a reduction in their overall admission rate with reference to
the rest of Norfolk and non pilot sites.
A key focus of integrated care is the need to achieve increased levels of integration of
service delivery across services provided by different providers, both NHS and beyond, in
order to improve service quality, efficiency and clinical outcomes. NNCG is developing a
performance management framework which will drive integration through measurement
against a range of key indicators. Examples include;
Reduction in number of visits to site and no repeated tests
Patients only give information once
Patients provided with public health / well being advice at each visit
Risk stratification and case management
NNCCG is part of the NHSM&E Cluster’s long term conditions (LTC) implementation
programme which aims to improve the quality and effectiveness of holistic care of people
with long term conditions across the health economy.
The local NNCCG LTC programme, in summary, is designed to facilitate and enable local
health teams to deliver change at pace, in a measured and supported way that delivers the
aim above and:
Escalates the pace of integrating health and social care service commissioning and
delivery
Improves patient experience through self management
Upholds the principle of “no decision about me without me”.
The programme builds on the developments and foundations that the current Frail Older
Person and ICO projects have provided, particularly that of the case management approach
and the embedding and strengthening of the Practice based MDT meetings. Its scope
includes:
developing an implementation plan to align with the National Outcomes Framework.
reviewing the options for risk stratification tools and designing a bespoke combined
model.
establishing and developing a multi-disciplinary professional leads network to
spread learning and ‘troubleshoot’ operational issues.
refinement of the performance and monitoring framework for delivery
30
strategic review and value for money assessment of the utilisation of 'step up’
community beds'
undertaking a strategic review and value for money assessment of the Social Work
Link Workers impact within the model and the strategic decision to cease this for
2012/13
developing, with the Head of Social Care, a revised and defined pathway for
Practices and GPs for access and referrals to Social Work professionals
Development of a Care Home locally enhanced scheme (LES)
Whilst the initiatives above are targeted on the known at risk population, NNCCG also
wishes to design a more proactive approach to identifying those older people at risk who
rarely, if ever, have any contact with the health and social care system, and who present at
times of crisis generally into the acute hospital system as emergencies.
Actions to be taken
2012/13
 Refine and develop the approach to integrated care
 Performance manage delivery of community nursing services against the new
contract specification
 Review the provision of therapy services
 Continue participation in the DoH LTC programme
 Roll out the Care Home LES
 Undertake research to identify approaches to at risk but unknown individuals in the
community who present in crisis
2013/14
 Decommission any services found to be ineffective
 Implement a single assessment process for health and social care
 Implement a placement without prejudice process for continuing health or social care
 Design a model for SPA
 Develop a performance framework to measure the impact of integrating health and
social care
 Implement the SPA model
 Continue to learn from and implement best practice in the management of LTCs via
the DoH programme
31
 Design a proactive approach to risk management of individuals unknown to the
health and care system
2014/15
 Commission a fully integrated health and social care system
Mental health
Mental Health admissions vary considerably between Practices and may in some
cases reflect the presence of specialist care home facilities. The presence of these
facilities may place a currently unquantified demand on GP and community services
A number of mental health conditions are also likely to increase in the CCG area in
the coming years, prevalence of depression in BDC is higher than the NHS Norfolk
and England averages
In the NNDC coastal towns of Mundesley and Cromer there is a high number of
claimants of working age benefits where the reason is mental health
There is considerable variation in percentage dementia prevalence between the
CCG Practices, with most exceeding the national average and two being more than
twice the national average figure
Dementia prevalence is projected to continue rising, and a higher than average
percentage of Practices’ list size with dementia is currently being admitted to
hospital
While mortality fell for liver disease alcohol related admissions are rising year on
year
What initiatives will NNCCG undertake to tackle these health challenges?
Mental health
•Improving access to psychological therapies
•Review referrals for pathway redesign
•Evaluate the newly commissioned dementia
service
•Continue to support evaluation of the new
substance misuse service
32
Improving access to psychological therapies
Prevention of low mood and depression can be improved by advocating increased physical
activity and cognitive behavioural counselling interventions such as IAPT (Increased access
to psychological therapies). NHSN invested over £1 million in IAPT and awarded a 3 year
contract to NSFT which is due to expire in 2014.
NNCCG will continue to refine this contract and agree thresholds for access to the service as
part of renegotiating, in collaboration with other CCGs, an extension to the contract or a full
re-procurement.
Mental health referral and pathway review
General Practitioners have identified as a priority a need be develop clear protocols,
guidelines and referral routes into the range of services now provided by NSFT. The RMC
will undertake a short focussed review of mental health referrals to identify those pathways
which are a priority for service redesign. This will also support the introduction of Payment by
Results (PbR) in mental health for which NSFT is a pilot site.
New pathway design may be linked to the development of a single point of access (SPA)
following evaluation of the pilot currently underway in West Norfolk.
New Dementia service evaluation
NHSN&W Cluster, with the support of CCGs, made a number of investments in new
Dementia services in 2011/12 in line with the national strategy and aimed at reducing
unnecessary admissions to hospital/reducing length of stay/improving the quality for people
with dementia.
33
These included:
General Practice attached primary care practitioners in Dementia
The commissioning of a Dementia Intensive Support Team (DIST) across Norfolk at
a cost of £1.2million to reduce acute bed utilisation and save an equivalent amount
A DIST in NNUHFT to reduce length of stay and avoid excess bed costs as well as
signpost individuals to more appropriate out-of-hospital care services
Cognitive stimulation therapy programme
NNCCG will undertake a review of the effectiveness of these investments during 2012/13
and base further commissioning intentions on this review.
Support evaluation of new substance misuse service
NNCCG is working with the Drug and Alcohol Action Team (DAAT) on a countywide rollout
of new substance misuse services procured in 2011/12. A lead NNCCG General Practitioner
took an active part in the tender evaluation and contract award and NNCCG continues to
provide clinical input to the mobilisation of the new service.
Actions to be taken
2012/13
 Review the lessons from the evaluation of the West Norfolk mental health SPA pilot
 Review the newly commissioned dementia service
 Review outcomes of the new substance misuse service
2013/14
 Review and refresh the specification for the IAPT service
 Undertake a systematic review of referral guidelines and protocols for access to the
full range of mental health services
 Implement new care pathways possibly via a single point of access use clear
protocols and algorithms
2014/15
 Recommission the IAPT service via a contract extension or new procurement
34
Planned care
East of England Public Health Observatory (ERPHO) analyses of Hospital Episode
Statistics (HES) provisional data 2011/12) show that the Directly Standardised
Rates (DSR) for cystoscopy and prosthesis of lens (cataracts) procedures are
higher than for England, the region and comparator cluster CCGs, the DSR for
arthroscopies was also high in the last quarter of 2011/12
ERPHO analyses also show that the Standardised Admission Rates (SAR) for the
Urology, Ophthalmology and Dermatology specialties are higher than for England,
the region and comparator cluster CCGs
What initiatives will NNCCG undertake to tackle these demographic and health
challenges?
Planned care
•Redesigning elective care pathways
•Reviewing thresholds for surgical
intervention
•Reforming pathology services
Role of the Referral Management Centre in reforming planned care
The RMC will play a pivotal role in reforming planned care by enabling:






Systematic, evidence and outcome based pathway reviews
Engagement of CCG clinicians in peer review and challenge of referral practice
Identifying priorities for pathway redesign
Developing new clinical guidelines, thresholds and protocols
Re-auditing the impact of new pathways
Renegotiating or where necessary re-procuring relevant services
Redesigning care pathways
Spinal pathway
As part of a programme of collaborative work on Orthopaedics with local CCGs, the RMC
commissioned and progressed a piece of patient engagement work through an external
company to test out people’s experience of local services for lower back pain.
35
The results identified a number of issues and challenges which will be taken forward to
reshape local orthopaedic, pain management and physiotherapy services.
Building on the existing review of the spinal pain pathway, this project will also extend to a
review of the current pathways for hip and knee conditions which are areas of high referral
volume for NNCCG. This will include a review of the current Orthopaedic Triage service so
as to ensure that it adds clinical value to the pathway, the development of clear referral
guidelines and the potential role of the RMC in better management of these referrals. An
initial aim will be to develop referral guidelines for MRI scans within a defined pathway. This
may deliver a 10% reduction in MRI scans.
Adult audiology
NNCCG is working with other Norfolk CCGs to redesign adult audiology services locally
using the Any Qualified Provider (AQP) model. The new model will offer increased choice to
patients and enable them to avoid having to travel to acute hospitals for this common
intervention. It will also ensure consistent delivery of audiology services across CCG
practices and is expected to deliver cost efficiencies.
24 hour ECG
All Practices have implemented local ECG services aimed at reducing unnecessary referrals
to Cardiology and improving access for local people. This service includes providing
information on maintaining a healthy heart for patients who do not need a referral. NNCCG
expects to see an increased take up of this in 2012/13 with a concomitant reduction in
referrals to NNUHFT Cardiology department.
Urology lower urinary tract symptoms (LUTS)/haematuria
NNCCG, supported by the RMC, undertook a review of these common urological conditions
and their management across primary and secondary care. Improved referral guidelines
were published in December 2011 and have been followed with GP education sessions.
NNCCG intends in due course to commission a local community-based “one stop” service
for these conditions.
Dermatology
Work is also planned with NCHC and GPs from the CCG to develop a community based
service for treatment of a range of dermatological conditions.
Reviewing thresholds for surgical intervention
Analysis of the hospital utilisation data as part of the local JSNA shows that the CCG has
high rates of intervention in the specialities of Urology, Dermatology and Orthopaedics. A
review of these specialties will be undertaken to determine whether the protocols, guidelines
and pathways for certain procedures are robust e.g. level of visual acuity for cataract
operations, to identify pathways for redesign and whether the need for surgical intervention
is appropriate.
36
Reforming pathology services
The NHSM&E reforming pathology services project aims to bring about delivery of the Carter
recommendations. In the east of England, hospitals are being encouraged to work together
to deliver GP requested pathology services. Via a clear and transparent process, hospitals
are demonstrating how they have the appropriate capacity and capability to deliver safe and
effective GP requested pathology services in the future. The likely outcome is that there will
be a number of hubs in the region, supported by teams working in other hospitals. A hub is
the centre of a hub and spoke model of delivery, with the hub providing all the “cold”
pathology services and the spokes working at the local hospital to deliver all the urgent or
“hot” pathology services.
NNCCG will be proactive in engaging with this project to ensure that the performance and
outcomes of any new preferred provider respond to the needs of a highly dispersed General
Practitioner community.
Actions to be taken
2012/13
 Redesign of pathways for spinal pain management and therapy
 Commission an external review of demand and capacity in Orthopaedics at NNUHFT
 Review of surgical thresholds in three specialties
 Improve access to diagnostics via AQP for audiology services
 Recommission new pathways for Urology
 Review capacity for colonoscopies as part of the bowel screening programme rollout
 Review referral rates for Cardiology as a result of implementing 24 hour ECG
 Improve access to diagnostics via AQP for MRI and non Obstetric Ultrasound
 Participate in and influence the reform of pathology services as it relates to NNCCG
2013/14
 Decommission current Orthopaedic triage services
 Recommission new pathways for Orthopaedics
 Implement primary care management of selected dermatological conditions
2014/15
 Optimise the RMC as a centre for pathway management and tackling unwarranted
variation
37
Unplanned care
Standardised emergency admissions are generally low in the CCG area by
comparison with the County average, the Norfolk rate is lower than the England
rate, only one North Norfolk Practice is an outlier terms of high emergency
admission rates.
There is, however, a high degree of variation between Practices for emergency
admissions to hospital - range minimum = 4556 DSR per 100,000 - max = 7964
DSR per 100,000
The majority of emergency admissions are admitted for at least a day and this
proportion is rising faster than zero length of stay
Repeated emergency readmissions and emergency readmissions within 28 days of
discharge are both lower than the national mean
Whilst the Ambulatory Care Sensitive (ACS) emergency admission rate in the CCG
is high as a percentage of Practice list size, it is lower than the NHSN rate and East
of England rate when standardised to take account of the demographics,
suggesting that there are few preventable admissions
Although they represent a higher than average proportion of emergency admissions
by Practice list size, admissions for both Circulatory Disease and COPD are lower
than the NHSN average, and that in turn was lower than the East of England
average
What initiatives will NNCCG undertake to tackle these demographic and health
challenges
Unplanned care
•Avoiding uneccessary hospital admission
•Improving the quality of care and outcomes
for Stroke
•Reforming the emergency care system
Early diagnosis and avoidance of hospital attendance/admission
NNCCG, in association with Public Health and NCHC Community Nursing, is exploring the
referral rates and reasons for emergency admissions which have urological problems as a
prime diagnosis, especially urinary retention and catheter care, and renal colic. A new
pathway will be developed to manage these interventions in the community or, if sent to
NNUHFT, assessed in A&E rather than admitted.
38
Minor injury services
NNCCG, supported by the RMC, will review the function and accessibility of minor injury
services across the CCG area to ensure an equitable and cost effective model of service
delivery. The first phase of this will involve a clear audit of the use and cost effectiveness of
the MIU at Cromer Hospital and a review of current Minor Injury services provided by
Practices. The CCG has initially agreed with NNUH to decommission all follow up MIU
attendances.
Improving quality of care and outcomes for Stroke
It is well recognised that significant improvements in stroke prevention and care were
required across NHSM&E to maximise reduction in morbidity and mortality. This includes
identification of patients at risk, prompt recognition and action on symptoms, effective
management of transient ischaemic attacks (TIA) and access to thrombolysis. NNCCG is
working with NHSM&E who are leading a region-wide review of Stroke services following the
success in London in outcomes for hyper acute care. This includes development of
hyperacute Stroke care at centres of excellence. This will directly reduce the incidence of
stroke and its associated morbidity and mortality.
Reforming the emergency care system
The population of NNCCG is highly dispersed and this presents a significant challenge for
the delivery of urgent first response and emergency ambulance services. In order to
influence the future direction of service development in EAAST, which is an aspiring
Foundation Trust, NNCCG will play an active role in the commissioning of these services
across the East of England on a collaborative basis.
Actions to be taken
2012/13
 Continue GP education programme for the management of common
urological conditions
 Redesign the pathway for renal colic
 Re-audit emergency Urology admissions for pathway compliance
 Review the role of MIUs in the urgent and emergency care system
 Decommission follow ups in MIU settings
 Participate in and influence the reform of Stroke services
 Play an active role in performance management and review of the EAAST
urgent and emergency care services contract in collaboration with other
CCGs
39
2013/14
 Recommission MIUs as appropriate
 Actively participate in the evaluation of proposals for the reform of Stroke
services
 Prioritise and respecify EAAST services as necessary
2014/15
 Recommission EAAST to deliver optimum response times particularly in rural
areas
Children
Based on benefit data, there are approximately 2,600 children in NNDC affected by
income deprivation, similar data are not currently available for the rest of NNCCG
but overall this is about one in ten children on CCG Practice lists
In the region of 1,500 children in BDC are estimated to have a diagnosable mental
health condition, and a similar number are estimated to have emotional or
behavioural problems
What initiatives will NNCCG undertake to tackle these demographic and health
challenges
Children
•Review the impact of the recently
reconfigured child and adolescent mental
health services
•Undertake a baseline review of investment
in children's services
•Make sure our services support families
•Commission services that encourage active
lifestyles
•Support Young Carers
40
Child and adolescent mental health services
NHSN&WC, with the support of CCGs, invested substantial new resources in the
reconfiguration of tiers 1-4 of the child and adolescent mental health services pathway in
2011-12. These new services will be reviewed for their effectiveness and impact upon quality
and value for money.
Undertake a baseline review of investment in children's services
NNCCG will undertake a full baseline review of its current range of commissioned children’s
services with a view to setting priorities going forward.
Family and carer friendly services
NN CCG will aim to make sure the services they commission support families and young
carers. The CCG will also work with Public Health and other partners to promote healthy
active lifestyles for children and young people.
Actions to be taken
2012/13
 Review the impact of the recently reconfigured child and adolescent mental
health services
 Undertake a full baseline review of commissioned children’s services
2013/14
 Recommission services identified as priorities
2014/15
 Performance manage delivery of any redesigned services
IMPLEMENTATION AND DELIVERY
NNCCG has implemented a project management approach to its commissioning programme
which will be further developed in 2012/13. All proposed commissioning initiatives require
sign off by the CCG Executive Group with the joint clinical and management sponsors
required to identify at the outset clear benefits in terms of improved patient outcomes,
access, experience and/or reduced cost against which projects will be measured. Projects
also have to demonstrate use of a relevant evidence base and plans for patient/public
engagement and robust evaluation in order to get project approval.
NNCCG Executive Group will monitor delivery of the programme above regularly during
2012/13 using this methodology.
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APPENDIX 1
GLOSSARY
A&E
ACS
AQP
BDC
CCG
CFT
CIC
COF
COPD
CPA
CQC
CQUIN
DIST
DoH
DSR
ECG
EEAST
EIT
ERPHO
FRR
FT
GP
HES
IAPT
ICO
IMD
JPUHFT
JSNA
LES
LTC
LUTS
MFE
MIU
MONITOR
NCB
NCC
NCH&C
NCSU
NICE
NHSM&E
NHSN
NHSN&WC
NNCCG
NNDC
NNUHFT
NQB
NSFT
OOH
PbR
PROMS
QEHKLFT
QIPP
RMC
SPA
SPOT
TIA
VTE
Accident and Emergency
Ambulatory Care Sensitive
Any Qualified Provider
Broadland District Council
Clinical Commissioning Group
Community Foundation Trust
Community Interest Company
Commissioning Outcomes Framework
Chronic Obstructive Pulmonary Disease
Care Programme Approach
Care Quality Commission
Contracting for Quality and Innovation
Dementia Intensive Support Team
Department of Health
Directly Standardised Rates
Electrocardiogram
East Anglian Ambulance Services NHS Trust
Early Intervention teams
East of England Public Health Observatory
Financial Risk Rating
Foundation Trust
General Practitioner
Hospital Episode Statistics
Improving Access to Psychological Therapies
Integrated Care Organisation
Index of Multiple Deprivations
James Paget University Hospital Foundation Trust
Joint Strategic Needs Assessment
Locally Enhanced Scheme
Long Term Conditions
Lower Urinary Tract Symptoms
Medicine for the Elderly
Minor Injuries Unit
NHS Foundation Trust Regulator
NHS National Commissioning Board
Norfolk County Council
Norfolk Community Health and Care services provider organisation
Norfolk Commissioning Support Unit
National Institute for Health and Clinical Excellence
NHS Midlands and East
NHS Norfolk Primary Care Trust
NHS Norfolk and Waveney PCT Cluster
North Norfolk Clinical Commissioning Group
North Norfolk District Council
Norfolk and Norwich University Hospitals Foundation Trust
NHS National Quality Board
Norfolk and Suffolk NHS Foundation Trust
Out of Hours
Payment by Results
Patient Reported Outcome Measures
Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust
Quality, Innovation, Productivity and Prevention
Referrals Management Centre
Single Point of Access
Spend and Outcome relative to other CCGs
Transient Ischaemic attacks
Venous thrombo-embolism
42