Governing Body Meeting (in public)
Agenda
Thursday 12th March 2015 – 10:30 to 12:30
The Jubilee Room, The Gateway, Gatehouse Road, Aylesbury, Bucks
Clinical Chair: Dr Graham Jackson
No
Agenda Item
Desired Outcome(s)
Contributor
1
Welcome & Apologies
Dr Graham Jackson, Clinical Chair
2
Declarations of Interest
Dr Graham Jackson, Clinical Chair
3
Minutes of the meeting held on 12
Feb 2015 & action points update
4
Questions from the public
Papers
Page: 3
Dr Graham Jackson, Clinical Chair
Corporate and Governance
5
Chief Officer’s Report: To inform the
Governing Body of local and national
developments in the context of NHS
Aylesbury Vale CCG
For information
Louise Patten, Chief Officer
Paper to follow
Clinical Commissioning
6
Co-commissioning Plan including
Terms of Reference
Decision
Louise Smith, Locality Business
Manager
Page: 14
Plus background reading to Cocommissioning plan
Page: 49
7
BCF S75
Decision
Lesley Perkin, Bucks CC
Page:
Quality & Performance
8
Quality Report: To update the
Governing Body on quality issues of
commissioning service across the local
health economy.
For information
Alison Foster, Director of Quality
Paper to follow
9
Performance Report & Dashboard:
For information
Colin Thompson, Director of
Page: 114
Update on progress against National
Operating and Outcome framework
Operations and Performance
10
QIPP: Update on progress against
Quality Innovation Productivity and
Prevention (QIPP) plans
For information
Colin Thompson, Director of
Operations and Performance
Page: 129
11
15/16 Planning
Decision
Colin Thompson, Director of
Operations and Performance
Page: 157
Finance
12
15/16 Financial Plan
Decision
Robert Majilton, Deputy Chief
Finance Officer
Page: 246
13
Chief Finance Officer’s Report: To
update the Governing Body on the
financial status of the CCG
For Information
Robert Majilton, Deputy Chief
Finance Officer
Page: 256
14
Delegated Authority: Annual report
and draft account
Decision
Robert Majilton, Deputy Chief
Finance Officer
Page: 277
For Information
15
Executive Team – Minutes of the
th
meeting held on 29 Jan 2015
For information
Page: 280
16
Commissioning for Quality - Minutes
th
meeting held on 17 Dec 2014
For Information
Page: 295
Meeting agendas will be published on the www.aylesburyvaleccg.nhs.uk
Anyone may ask questions relating to the agenda in advance either by post, telephone or email, or on the day in the question time slot at
the start of the meeting. Questions about topics not included in the agenda are welcome by post, telephone or email and they will be
answered, depending on the number, either in or outside of the meeting. All questions and answers will be published on the website.
By post: Aylesbury Vale Clinical Commissioning Group, First Floor, The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF
Tel: 01296 585900
Email: avccg.feedback@nhs.net
Website: www.aylesburyvaleccg.nhs.uk
If you would like to attend a meeting and need extra help to do so, for example because of a disability, please contact us as early as
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For further information about these meetings please contact: Administration team on 01296 585900 or email avccg.feedback@nhs.net.
Governing Body Meeting Minutes
Thursday 12 February 2015 – 10:30am – 12:30pm
Olympic Meeting Room, The Gateway, Gatehouse Road, Aylesbury, Bucks
Governing Body Present:
Dr. Graham Jackson, - Chair (GJ)
Louise Patten, Chief Officer (LP)
Robert Majilton, Chief Finance Officer (RM)
Dr. Karen West, Joint Commissioning & Partnership Working (KW)
David Lunn, Lay Member & Audit Committee Lead – Vice Chair (DL)
Dr. Jonathan Fielden, Secondary Care Consultant Specialist (JF)
Crystal Oldman, Registered Nurse Specialist (CO)
Graham Smith, Lay Member Patient & Public Engagement (GS)
Other Attendees:
Paul Hutt – Assistant Director of Operations and Performance (PH)
Alison Foster – Director of Quality (AF)
Apologies:
Colin Thompson – Director of Operations and Performance (CT)
Support:
Elaine Baldwin – Minute taker (EB)
Jessica Walsh – Visuals (JW)
Page 1 of 12
Commonly used acronyms:
AVCCG
CCCG
GB
TV
BCF
BHT
CQC
CSU
IFR
OUH
CSCSU
BAF
MCP
ORCE
JET
CQUIN
MK
Aylesbury Vale Clinical Commissioning Group
Chiltern Clinical Commissioning Group
Governing Body
Thames Valley
Better Care Fund
Buckinghamshire Healthcare Trust
Commissioning of Quality Committee
Commissioning Support Unit
Individual Funding Request
Oxfordshire University Hospital
Central Southern Commissioning Support Unit
Board Assurance Framework
Multi-speciality Community Provider
Operational Resilience & Capacity Planning
Joint Executive Team
Clinical Quality Innovation
Milton Keynes General
1
Welcome & Apologies
GJ welcomed GB to the February Meeting. No apologies received.
2
Declarations of Interest
Change to agenda with Item 8, Clinical Update being replaced by Co-commissioning presentation.
GJ & KW declared interest in relation to co-commissioning presentation but confirmed that they will remain in the
meeting during the presentation as it is a discussion point.
3
Minutes of the meeting held on 11 December 2014 & 15 January 2015 and Action Points update
Amendments - 11 December 2014
Item 7 – Risk Management Framework was formally ratified and minutes didn’t capture this.
Item 9 – Saving on excess bed days of £24k should have read £240k.
Amendments - 15 January 2015
Meeting close time is incorrect and needs to be amended.
Previous minutes approved with above changes.
4
Questions from the public
Questions raised by Bill Russell:
Co-commissioning - What will be happening in Buckinghamshire from April 1st 2015. What engagement
has taken place, or will take place, with the public on changes to way in which Primary Care will be
provided? Will you please consider having someone from the Practice Patient Participation Groups on
your Co-Commissioning Board as a non-voting member?
LP: AVCCG has applied to NHS England to jointly commission primary care services from April 1st. This means
that if we are successful the CCG will assume responsibility for jointly commissioning primary medical services
(General Practice) with the NHS England Thames Valley area team (who are responsible for doing this at the
moment).
Aylesbury Vale CCG believes co-commissioning is a tool that will help us to more effectively plan and improve
services for the benefit of patients and local populations. This is because it enables us to develop our out of
hospital services and to influence the commissioning of GP Practice services in order to ensure these services
Page 2 of 12
are delivering locally what patients and the public want and need for their health care.
NHS Aylesbury Vale CCG continues to engage with the public on our Buckinghamshire wide primary care
strategy, with public events in each locality and the use of our Let’s Talk Health Forum. Any changes to our
services will be dependent upon consultation with the public and once agreed, co-commissioning may be the
appropriate commissioning route to use.
We do require our lay Governing Body members to sit on the joint co-commissioning board; in addition
Healthwatch have a standing invitation as a non- voting member of the committee. In terms of wider public
engagement, we will of course consider how we link into and involve the PPGs. The exact membership of
committee is not yet finalised so this remains an opportunity; however the influence for PPGs may be better at
the services design or improvement stage rather than at the technical commissioning stage.
Feedback from Engagement Events - Could you please inform us about the comments made by
members of the public at your engagement events (on and off-line). Will you please consider having a
page on your website for this sort of feedback together with the action taken as a result of the input from
the public?
LP: We have a report today to the Governing Body on our recent public engagement and will be interested in
comments about the format for these reports and how best to report them to our wider audiences (public,
voluntary sector, member practices). Your point about a dedicated part of our website is a very good suggestion
and I will take this forward with the communications team.
Better Care Fund - One of the targets for the Better Care Fund, due to start in April 2015, is to reduce
unplanned admissions to hospitals for the frail elderly, as well as provide better care. Could you provide
the data on unplanned admissions in this group of patients for the last three quarters for which there is
data? This will act as a baseline for us to measure the success of this important new way of working.
What other Key Performance Indicators will be used & what are the baseline data for these indicators?
LP: Work continues on setting our baseline data against which we can measure the effectiveness of the BCF.
Currently the measures are:
Rate of emergency admissions;
Number of permanent admissions to care homes;
Reablement patients – proportion remaining at home after 91 days;
Page 3 of 12
Number of delayed transfers of care;
Number of emergency readmissions after 28 days;
Measure of patient experience (social care);
Measure of patient experience (acute care);
Patients >65 years old who are discharged to the same address;
Number of occupied bed days.
Most of these metrics are already collected and reported, but will be brought together in regular reporting for the
BCF. The challenge is that because there are so many contributory factors, it will be difficult to understand how
much the BCF has or has not contributed to these measures. However, this is a challenge for all across the NHS
rather than just our CCG so we recognise the need for ongoing shared learning.
5
Chief Officer’s Report
LP took GB through the CO report.
LP raised systems resilience and how the whole system worked together to deliver. BHT declared black 3 times
but system worked really hard to main the quality of care. Lots of learning and this will be fed through Systems
Resilience Group. Unprecedented demand is being looked into.
Co-commissioning – now made all necessary changes in constitution and our Conflict of Interest Policy.
One of member practices recently became a single handed GP practice. AVCCG were able to support given
back up information. GJ requested LP circulate to GB the letter of support that contains figures backing up our
reason to support.
CSCSU – Received letter informing of intention to merge with 2 other CSU’s. This gives us the opportunity to
review all of the services that we buy in.
6
Board Assurance Framework
RM tool GB through the Board Assurance Framework highlights.
Risks 1, 5 and 13 have had their risk scores increased mainly due to:
Risk 1 – Reflects increased risk relating to cross-partnership working on safeguarding and whole system
improvement following the ofsted report.
Risk 5 and 13 – Relates to capacity and capability within support services and reflects that an improvement
notice has been issued regarding the Quality support line
Page 4 of 12
Risk 10 – QIPP and Cost Pressures has been decreased back to 16 reflecting the work to review and mitigate
the level of risk in 15/16 and also the increased allocation notified in December 2014. The risk remains the
acceptable level mainly due to the current level of unidentified QIPP and remaining risk particularly with the
major contracts.
7
Membership, Public & Nurses Engagement
LP took GB through Engagement document.
Further work needs to be done to create common format for collating all data as this will be something that will
be put onto the website enabling people to see all information.
This will become a standard agenda item to come back to GB every quarter with links to the website. Exercise
to be undertaken to cross reference output to see if there are common themes or conflicting themes. LP to
follow this up with Comms Lead.
8
Co-commissioning Presentation
Dr Malcolm Jones, Dr Stuart Logan & Louise Smith took GB through presentation
3 different tiers of co-commissioning; the lowest tier is a CCG acting in an advisory capacity to the local Area
Team, the middle tier is a CCG working jointly with the Area Team through a committee in common managing
jointly the budget for commissioning General Practice, the highest tier is full delegated responsibility to the CCG
for managing the General Practice budget.
Nationally almost all CCGs have expressed an interest in co-commissioning and within the Thames Valley area
all CCGs except 1 are opting for the middle tier.
Governing Body and members practices approved changes to the CCG constitution to allow for cocommissioning.
Proposal is to use co-commissioning as a tool to embed a personalised care planning approach for patients with
long term conditions and to also embed that approach across primary care providers. Also propose to fine tune
the proactive care direct enhanced service.
Seeking GB approval to go out to Member Practices and to the public to consult on the more specific plans
around co-commissioning with aim to present a full business case for approval at the March GB Meeting.
Discussion was had regarding items that should be included in the full business case when it is presented to GB
Page 5 of 12
in March.
GB gave approval to consult on more specific plans with Member Practices and the public.
9
NHS 111 Thames Valley Reprocurement
RM advised GB that paper tabled to ensure GB is comfortable to go Thames Valley wide on the procurement of
111.
The paper sets out some of the areas that are believed to be best delivered at scale. In terms of governance the
expectation is that it will report through the Accountable Officers Forum. There are a number of Gateways
where it will come back to GB in terms of approving the development of the 111 process with this being the first
Gateway.
Discussion regarding the risk of a CCG withdrawing with RM confirming we have good commitment across
Thames Valley CCGs. The issues will be delivering a core specification across all 10 CCGs whilst allowing
some CCGs to go faster and further with 111 than others. Across CCGs the requirement of the core is very
similar and there’s not a lot of disparage but one of the Gateways is this going to all GBs in Thames Valley and
then we can gauge if there are any specific issues.
GB formally approved the process to go Thames Valley wide on the procurement of 111.
10
New Models of Care Bids
PH took GB through the New Models of Care Bids in CT’s absence.
Process was put in place for different health economies to express an interest in establishing New Models of
Care and the deadline for expressions of interest was Monday 9th February 2014.
2 expressions of interest have gone in for the Buckinghamshire system:
i)
a commissioner led expression around Multi-specialty Community Provider, and
ii)
a provider led expression of interest around Primary & Acute Care Systems
PH confirmed that we won’t know for some time what the results of these expressions of interest are or whether
or not we will be invited to join the group of forerunners. If we are it’s expected that there will be some national
resources and support released to help accelerate the progress towards the new models. If we are not invited
into that group then we are still making plans locally to be able to take plans forward as fast as is feasible.
11
Quality Report
AF took GB through the highlights of the Quality Report.
Page 6 of 12
BHT – working with BHT regarding the spike in mortality in Dec. They are conducting audits and reviews of the
activity to understand what was driving it. Anecdotally some of the info fed back at Commissioning for Quality
meeting was that there felt to be a lot of people from care homes coming in and dying almost immediately.
Ongoing concern around the numbers of pressure ulcers in terms of consistently keeping those numbers down.
Trajectory they have said they will bring it down by 25% over the year and they are on target to achieve that.
Quality monitoring development - to help people to feedback as much as possible created email address to
enable people to email quality concerns to us. Also created a central issues log that catches and monitors to
track concerns through.
Discussion regarding the Patient Experience because staff attitude jumps out. AF explained how they are
working on this using the example of visits and how they are increasing Clinical and Commissioner visits to the
provider.
12
Quality Strategy 15/16
AF requested GB input into Bucks Quality Strategy as it develops over the next few weeks. Quite a lot of
development has already happened around putting together a wider picture. Any input or comments into
strategy would be welcomed. GB to think about input and bring to development workshop in March.
AF confirmed looking to take to Commissioning for Quality board either in March or April.
13
Performance Report & Dashboard
PH took GB through the key quality highlights and assurance issues of the Performance Report.
•
A&E 4 hour waiting time – The 4 hour waiting time standard was not met in December at any local Trusts
with performance declining at BHT, OUH and MK. The position has continued to be challenged into January,
but performance at BHT recovered to above 95% for the week ending 18 January 2015 according to local
data (although validation needs to be completed).
•
Ambulance Targets – Category ‘A’ 8 minute response time Red 2 and Category ‘A’ 19 minute response
time targets were not met in November at CCG level. At Thames Valley level all 3 targets: Category ‘A’ 8
minute response time Red 1and Red 2 targets and Category ‘A’ 19 minute response time were not met.
•
18 week Referral to Treatment standards – In November, for the third consecutive month, the CCG met
RTT standards. There was, however, one patient whose admitted pathway on an unadjusted basis was over
52 weeks. When the pathway is adjusted to allow for clock pauses, however, it was less than 52 weeks.
•
Cancer waiting time targets – In November, 2 cancer targets were not met for the CCG overall:
Page 7 of 12
- The 31 Day Wait (Subsequent Treatment – Surgery)
- The 62 Day Standard (Referral from screening service)
Discussion regarding if harm assessments are done for patients over 18 weeks, particularly those over 52 and
also if we have any feedback from key colleagues as to whether or not patients are at risk if they are in that
group. PH confirmed that it’s not something he has seen routinely done but will look into.
14
QIPP
PH took GB through the QIPP highlights
15
•
The year to date position at month 9 is £1,754k QIPP savings achieved against identified planned savings of
£2,664k (66% achievement)
•
However, there remains £460k of unidentified savings which makes the total QIPP target £3,123k, giving a
56% achievement.
•
£1,092k mitigation has been allocated to QIPP overall giving a final position of 91% achievement through
use of headroom.
•
The elective care, urgent care and early years programmes are assessed as only partially delivering on
QIPP savings at 72%, 49% and 0% achievement to date.
•
The forecast position is for year-end delivery of 84% of plan following mitigation.
Chief Finance Officer’s Report
RM took GB through the Finance Report.
To the end of December the CCG is reporting an in-year surplus of £76k against a budgeted spend of
£157,346k (0.05%). This is in line with plan. The CCG has increased the forecast surplus to £2,577k as
directed by NHSE in light of the return of £484k due to the underspend on the CHC Legacy Risk Pool.
The report highlights:
• The year-to-date (9 months) surplus is £76k with an in year forecast of £101k.
• Actual spend within Planned and Unscheduled Care is based on the available month 8 Contract Reports and
estimated for month 9. The adverse variance of £2,242k is mainly on OUH and BHT as a result of
movements in reported spend from Trusts and include a release of £2,250k from Reserves.
Page 8 of 12
• The adverse variance of £249k in Joint and Continuing Care mainly reflects current monthly activity within
continuing care, which is now showing an increase in spend as anticipated.
• £84k has been released from the commissioning reserves in month to cover acute overspend on
programme.
• Other services show a favourable variance of £1,100k due to slippages in projects and the release of legacy
accruals.
• Running costs favorable variance of £431k is a result of staff vacancies and slippage on non-pay.
At this stage the forecast position is on plan.
16
Executive Team – Minutes of the meeting held on 27 November 2014
Information Only
17
Commissioning for Quality – Minutes of the meeting held on 19 November 2014
Information Only
18
Audit Committee – Minutes of the meeting held on 26 November 2014
Information Only
Meeting Closed at 12:35
Page 9 of 12
Action / Decision Log – Governing Body
Meeting Date: Thursday 12 February 2015
Action
No.
Action
Owner
Open/
Closed
1
Item 5: LP to circulate to GB the letter of support that contains figures backing up our reason to
support.
Louise Patten
Open: 12/02/15
2
Item 7: Engagement summary to become a standard agenda item to come back to GB every
quarter with links to the website.
Louise Patten
Open: 12/02/15
3
Item 7: Exercise to be undertaken to establish common themes from our engagement. LP to
establish summary document as part of quarterly report to GB.
Louise Patten
Open: 12/02/15
4
Item 8: GB gave approval to consult on more specific plans with Member Practices and the
public.
DECISION
5
Item 9: GB formally approved the process to go Thames Valley wide on the procurement of 111.
DECISION
6
Item 13: PH to look into 2 areas – i) if harm assessments are done for patients over 18 weeks,
particularly those over 52 ii) Do we have any feedback from key colleagues as to whether or not
patients are at risk if they are in that group?
Paul Hutt / Colin
Thompson
Open: 12/02/15
Owner
Open/
Closed
Meeting Date: Thursday 15 January 2015
Action
No.
Action
1
Item 3: Update and more detailed overview regarding bids to be brought to Feb Meeting.
Louise Patten
Open: 15/01/15
Closed: 12/02/15
4
Item 10: Evidence of clinical leadership fronting issues to be brought to next meeting.
Alison Foster
Open: 15/01/15
Page 10 of 12
Meeting Date: Thursday 11 December 2014
Action
No.
Action
Owner
Open/
Closed
Elaine Baldwin
Open: 11/12/14
Closed: 12/02/15
1
Item 5: Collated report on membership, public and nurses engagement to be on the agenda for
the next GB meeting.
2
Item 5: CT to looked at the Armed Forces Covenant to see if it needs to come through Governing
Body
Colin Thompson
Open: 11/12/14
3
Item 6: RM to annotate and note on report Risk 10 is scored at a forward view.
Robert Majilton
Open: 11/12/14
Closed: 12/02/15
6
Item 10: Radiology 10,000 figure is incorrect – AF to correct figure.
Alison Foster
Open: 11/12/14
Closed: 12/02/15
7
Item 10: AF to get clarity of 5 child deaths are still births or neonatal.
Alison Foster
Open: 11/12/14
Closed: 12/02/15
8
Item 10: AF to add Bucks section and Oxford Health Section to report going forward.
Alison Foster
Open: 11/12/14
Closed: 12/02/15
9
Item 12: Question raised regarding the accuracy of the diabetes statistic (Pg 11 of QIPP report).
The quote of 1 in 7 people affected by diabetes to be checked by CT. Updated: Paul Hutt to
follow up.
Colin Thompson
Open: 11/12/14
Updated: 12/02/15
Karen West
Open: 11/12/14
Item brought across from Confidential actions list.
Item 4: KW to look into if a formal process should be set up where GP registrars rotate and do
some time in CCG. Update: ST4’s for support and projects & ST3’s for education (more
shadowing). To be taken to PUBLIC minutes and agenda item at March meeting.
Updated: 12/2/15
Meeting Date: Thursday 11 September 2014
Agenda
Item No.
4
Action
LP to bring to future Governing Body Hertfordshire Valley Strategic Review and Milton Keynes &
Bedford Strategic Review. Update: To be brought to the strategy discussion in January.
Page 11 of 12
Owner
Open/
Closed
Louise Patten
Open: 11/09/14
Update 12/02: Will be brought to next GB for information not discussion and will have website
link included in documents.
Updated: 09/10/14
Updated: 13/11/14
Updated: 12/2/15
6
GB to feedback to NCM and suggestions on who and how to best action Lay representation on
the Terms of Reference for the Safeguarding Steering Group and the membership.
Keep live as issue because waiting to hear if Bucks CC are going to be allowed to have their
own improvement board or whether it has to be chaired by an external person from the
Department of Health. LP has been asked to join that board and if changes will be happening
across the system then it may affect membership of our own steering group.
New chair just appointed who is reviewing everything and result of this will be confirmation of
what is needed at Safeguarding Steering Group. LP to feedback to GB following review.
Update: Will be picked up in Quality report going forward so action closed.
Page 12 of 12
Governing Body
Open: 11/09/14
Updated: 09/10/14
Updated: 13/11/14
Closed: 12/2/15
Agenda item:
Governing Body Meeting
12 March 2015
Primary Care Adoption of Care and Support Planning
Purpose of Paper
Following the presentation made to the governing body in February on cocommissioning and care planning a business case for care and support planning is
presented which details the proposal, finances involved and current engagement
with member practices and the public. Recognising that ultimately commissioning of
this new way of working needs to be a joint decision between the CCG and NHS
England through the joint committee the governing body is asked to
 approve the business case and the non-recurrent investment of up to £500k
to be made available from either the CCG head room or over 75s fund.
 make a recommendation to the AVCCG and NHS England joint committee
that this service is commissioned.
Executive Summary
In order to deliver our vision of transformed out of hospital services as articulated in
the Buckinghamshire Primary Care strategy it will be necessary to address both the
health challenges of our population brought on by long-term conditions,
comorbidities and increasing age but also the challenges of current ways of working.
It is considered that in refocussing the unplanned admissions direct enhanced
service (UA DES) on end of life care with robust advanced care planning and
introducing care and support planning for those with long-term conditions,
comorbidities and the elderly we will
• improve the quality of care for those at the end of life,
• Bring about the change in care culture to supported self-management.
• Improve communication between patients and the multidisciplinary team
• Contribute to the system wide implementation of care and support planning
which has started to happen.
• Achieve the vision across Bucks of transformed out of hospital care through
delivery of the following goals aligned to the primary care strategy
 Enable people to take personal responsibility for their own health
and wellbeing, and for those that they care for, with access to
validated, localised and readily available educational resources.
 Health, social care and voluntary sector providers working together
to offer community based, person-centred, co-ordinated care which
proactively manages long term conditions, older people and end of
life care out of the hospital setting.
 Improve health outcomes for our whole population through
adopting best practice, stimulating innovation and aspiring to

improve.
A commitment to invest in and support our primary care providers
in helping build our out-of-hospital services.
It is proposed that this change is implemented through the co-commissioning
mechanism noting that a similar conflict of interest would need to be managed if
delivered through a locally commissioned service (LCS). Uniquely co-commissioning
means that the CCG in agreement with NHS England can
• remove the requirement to deliver aspects of a nationally mandated service
that may not be appropriate to our population
• provide room to implement innovations by suspending national reporting
requirements.
The CCG proposes to utilise this by enabling the nationally set UA DES and Quality
and outcome framework to be enhanced in order to support changes without
prejudice to the rights of practices to their GMS entitlements being negotiated and
agreed nationally.
AVCCG will support primary care teams in adopting and embedding care and
support planning (including the creation of headroom) in a number of ways:
• Adapting the national unplanned admissions (or proactive care) DES to be
specifically focussed on end of life (EoL) care;
• Reducing the formal reporting requirements of some elements of the Quality
and Outcomes Framework (QOF);
• Hosting extensive personalised care planning training sessions for each
practice;
• Providing CCG leadership as champions of care planning.
The cost of this investment will be £200k. However recognising that the move to this
outcomes-based care planning approach will take time, resource and a significant
cultural shift a further support fund is proposed for practices adopting the approach.
This additional fund totals £300k for further training and implementation. Because
of the links to the UA DES and targeted QOF the full amount of funds targeted at the
changes proposed will be £2.6m if all practices work toward full delivery on EoL,
diabetes, dementia and respiratory disease.
Actions Required
Noting the potential conflict of interest the governing body is asked to
1) approve the business case for changes to the UA DES to focus on end of life
care and the introduction of care and support planning in primary care
2) Confirm that the use of co-commissioning is an appropriate delivery method,
3) Approve the non-recurrent investment of up to £500k to be made available
from the CCG head room or over 75s fund.
4) Make a recommendation to the Aylesbury Vale joint committee that this
service should be commissioned.
2
Objectives supported by this Paper (Please Tick)
Support delivery of in-year performance and the financial plan
Support transition to clinically led commissioning
Support development of the CCG to take on the commissioning role
Development of the working relationship between the Commissioning
Support Services (CSS) and AVCCG
Supports Quality Agenda
X
X
X
X
.•
3
Stage 1 Business Case
Business Case
Title:
Primary Care Adoption of Care and Support Planning
Author:
Louise Smith
Clinical Lead:
Dr Malcolm Jones / Dr
Stuart Logan
Date Created:
4 March 2015
Date Approved
by Clinical Lead:
5 March 2015
1. Problem Analysis
The following business case is presented in response to the challenges faced not only in
primary care but also the wider health and social care system where population health needs
are increasing and commissioned services may not be fit for purpose. It is our aim that the
proposed solution not only contributes to the transformation of primary care as described in the
primary care strategy but also makes use of evidenced based care and opportunities afforded
CCGs through new commissioning arrangements with NHS England.
The health challenge
30% of individuals in Buckinghamshire will be living with a long term condition (LTC), many of
which will have co-morbidities. People with LTCs utilise the most healthcare resource and
account for 70% of the money spent on health and social care. The majority of those with LTCs
will spend just a few hours per year with healthcare professionals and more than 99% of their
lives managing their conditions themselves. As such, they become experts in their own health
and make most of the day-to-day decisions which affect their health but usually without the
support to do so. It is therefore necessary for the system to support individuals to develop the
knowledge, skills and confidence to manage their own care. This is an observation made
through the diabetes redesign as well as our Live Well pilot in which patients are proactively
encouraged to self-management with professional support.
The value challenge
Where attempts have been made to support the proactive management and co-ordination of
care it has not been administered as effectively as it could be. The unplanned admissions direct
enhanced service (UA DES) is just one example in which positive intentions at a national level
have lost value in translation at primary care level.
Buckinghamshire Primary Care Strategy – Our vision of out of hospital care
“Everyone working together to provide high quality, personalised care to help keep
Buckinghamshire people happy and healthy, optimising value from our collective efforts”
This collective vision for out of hospital care across Buckinghamshire as articulated in the
primary care strategy can only be achieved through the transformation of our existing primary
care services. In order to deliver this it is necessary to develop a much more integrated
approach to our delivery of commissioned services. It is recognised that such a seamless way of
working requires a new model of delivery across the whole health and social care system,
including primary care.
Through the primary care strategy Chiltern and Aylesbury Vale CCGs identified a number of
goals which would enable us to ultimately deliver the vision.
• Enable people to take personal responsibility for their own health and wellbeing, and for
those that they care for, with access to validated, localised and readily available
educational resources.
• Health, social care and voluntary sector providers working together to offer community
based, person-centred, co-ordinated care which proactively manages long term
conditions, older people and end of life care out of the hospital setting.
• Improved and appropriate access for all to high quality, responsive primary care that
makes out- of-hospital care the default.
• Develop clearly understood care pathways that offer consistent and co-ordinated care,
using bed-based services only when necessary.
• Improve health outcomes for our whole population through adopting best practice,
stimulating innovation and aspiring to improve.
• A commitment to invest in and support our primary care providers in helping build our
out-of-hospital services.
The Value of Care Planning
There is a strong evidence base that care planning improves patient knowledge and skills to
better enable self-care and as a consequence leads to improved measured outcomes. It also
increases job satisfaction for health care professionals and reduces health inequalities across
populations: http://www.yearofcare.co.uk/impact-and-benefits. AVCCG see the widespread
adoption of care and support planning for patients with long term conditions and
advanced care planning for those at the end of life as a key enabler to achieving the
transformation of care highlighted above from our primary care strategy.
The Value of Co-commissioning
Co-commissioning is a significant opportunity for AVCCG to increase its involvement in the
commissioning of primary care through a joint committee with the area team. It is a key enabler
for developing seamless, integrated out-of-hospital services as it allows the CCG to commission
care across the whole patient pathway through different sectors including primary care. Of
relevance to the proposal outlined below co-commissioning allows for local flexibilities for
contracts and incentive schemes to enable innovation and optimal local solutions. This is without
prejudice to the rights of practices to their GMS entitlements being negotiated and agreed
nationally. As such in agreement with NHS England it is possible for the CCG to strengthen
current service delivery to align it to other locally commissioned services by enhancing specific
elements of the existing incentive schemes commissioned nationally by NHS england. The
value of this over and above commissioning a separate locally commissioned service (LCS)
from general practice is that it will
•
remove the requirement to deliver aspects of a nationally mandated service that may not
be appropriate to our population
•
provides room to implement innovations by suspending national reporting requirements.
Such changes to contracted incentives have the potential to benefit the clinical executive but this
is no different to the LCS which we commission. Under co-commissioning there are robust
arrangements to manage this conflict of interest which are stipulated nationally including the
agreed terms of reference for the joint committee with NHS England. Appendix a shows the
current draft which will be approved at the first meeting of this committee expected to be within
the month. In the absence of this forum the current business case is presented to the governing
body.
2. Proposed Solution (including health benefits/outcomes)
Care Planning in General Practice
There are several different examples of care planning. In AVCCG, together with the Strategic
Clinical Network and other CCGs in Thames Valley, we are focusing on the ‘Year of Care’
model. This aligns with clinician feedback from our diabetes redesign workshop and nationally
has support from the RCGP, Kings Fund, NHS England and many third sector organisations
working together as the Coalition for Collaborative Care.
In developing the proposal below we have prioritised our strategic goal of increasing supported
self-care and the priority areas for our locality populations - end of life care, diabetes, dementia
and respiratory conditions. The scheme seeks to minimise the burden to general practice of the
transition to a care and support planning approach and is aligned to transformation in other
sectors. For example the acute hospital and community service Commissioning for Quality and
Innovation (CQUIN) payment will endeavour to facilitate a similar change in these sectors. If
agreed with the service the payment for this as part of the CQUIN for specific long-term
conditions will be 0.5% of the contract estimated to be a maximum of £500k for the care
planning element.
The primary care scheme specifically utilises our ability through co-commissioning to alter
current incentives to focus more on our population needs as identified in our strategy and
alleviate the need to continually report whilst implementing a significant change in practice. In
particular
• Focussing the current national unplanned admissions DES on Advanced Care Planning
for those patients nearing the end of their lives. There is good evidence from other
systems which underpinned the initial Electronic Palliative Care Coordination System
(EPaCC) work that where applied in a carefully targeted manner there was a large
increase in individuals being able to die in their place of choosing avoiding an
unnecessary hospital admission.
• Suspending the current requirement of the process-driven Quality and Outcomes
Framework (QOF) to provide a one year window to implement care and support planning
for those with specific long-term conditions (aligned to our population needs).
The risks of changing practice in such a way during this 12 month period will be managed
through alternative monitoring arrangements as detailed for the schemes below and shadow
monitoring of QOF to ensure no significant fall in specific quality measures likely to be aligned to
NICE.
Scheme Outline
AVCCG plan to support primary care teams in adopting and embedding care and support
planning (including the creation of headroom) in a number of ways:
• Adapting the national unplanned admissions (or proactive care) DES to be specifically
focussed on end of life care;
• Reducing the formal reporting requirements of some elements of the Quality and
Outcomes Framework (QOF);
• Hosting extensive personalised care planning training sessions for each practice;
• Providing CCG leadership as champions of care planning.
It is proposed that practices can choose their level of engagement and will therefore be offered a
numbers of options from which to choose their level of participation. The options for practices
are summarised below.
Option 1 – No change, QOF & unplanned admissions DES as per 15/16 national requirement
Practices can choose to provide patient care and work as per current anticipated 15/16
arrangements, adhering to the nationally directed QOF and unplanned admissions DES and
receiving the associated funding.
• The DES requirements and financial incentive will remain the same as expected
nationally.
• QOF requirements will remain as they are currently with the same number of points
available and monitoring and achievement thresholds.
Option 2 – Change of national incentives, suspension of unplanned admissions DES and QOF
elements.
Practices can choose to change the way in which care is currently provided using the care
planning approach developed by the year of care partnership. Practices could opt for
suspension of the national unplanned admissions DES requirements alone, or for this, PLUS
suspension of the formal reporting requirements of parts of the QOF, depending on the level of
commitment chosen by the practice.
All levels are linked specifically to AVCCG priority areas as described in the locality needs
assessments, strategy and operational plan.
Level 1 – Unplanned admissions Direct Enhanced Service (UA DES)
Practices opt for suspension of the national unplanned admissions DES requirements. Practices
will receive the maximum financial allocation possible for their practice; for this the practice
adopts an advance care planning approach with the main focus of care on patients near the end
of life. It is estimated that these are about 1% but a reasonable expectation initially would be
0.5% of the practice’s population.
Practices will be expected to ensure key Read Codes are entered into relevant patient’s record,
and to review deaths at least every 3 months with special focus on those who did not die at their
preferred place of death, drawing out recommendations for commissioners of local health
services.
Practices will need to enter data in line with CCG guidance; this will allow the CCG to monitor
compliance through EMIS Enterprise, therefore reducing the reporting burden on the practice.
QOF requirements will remain as they are currently with the same number of points available
and monitoring and achievement thresholds.
Level 2 – UA DES and diabetes, CVD, hypertension, CKD, obesity and smoking domains
of QOF
These have been chosen as related vascular issues, linking to the Diabetes Strategy.
There will be suspension of the administration of QOF associated with diabetes for 15/16 to
factor in the effects of transition on patient recall but not quality of care.
Practices would be expected to adopt a care planning approach with their diabetic and at risk
CVD patients.
QOF Domain
QOF Indicator 15/16
QOF Points
Clinical (Diabetes)
Public Health
Diabetes
86
Hypertension
26
CKD
6
CHD
35
Stroke & TIA
15
Obesity
8
CVD
10
Blood Pressure
15
Smoking
64
Total QOF points associated to
Diabetes
265
Total QOF points 15/16
559
Diabetes associated QOF points as
a % of QOF Achievement
47%
Level 3 – All levels 1& 2 plus dementia
There will be suspension of the administration of QOF associated with dementia for 15/16 to
factor in the effects of transition on patient recall but not quality of care.
Practices would be expected to adopt an advance care planning approach with their dementia
patients.
QOF Domain
QOF Indicator 15/16
QOF Points
Clinical (Diabetes)
Diabetes
86
Hypertension
26
CKD
6
CHD
35
Stroke & TIA
15
Clinical (Dementia)
Dementia
50
Public Health
Obesity
8
CVD
10
Blood Pressure
15
Smoking
64
Total QOF points associated to Diabetes &
Dementia
315
Total QOF points 15/16
559
Diabetes & dementia associated QOF
points as a % of QOF Achievement
56%
Level 4 – All levels 1,2,3 plus respiratory
There will be suspension of the administration of QOF associated with diabetes, dementia and
respiratory disease for 15/16 to factor in the effects of transition on patient recall but not quality
of care.
Practices would be expected to adopt a care planning approach and where appropriate an
advance care planning approach with these groups of patients.
QOF Domain
QOF Indicator 15/16
QOF Points
Clinical (Diabetes)
Diabetes
86
Hypertension
26
CKD
6
CHD
35
Stroke & TIA
15
Asthma
45
COPD
35
Clinical (Dementia)
Dementia
50
PH
Obesity
8
CVD
10
Blood Pressure
15
Smoking
64
Total QOF points associated to diabetes,
respiratory & dementia
395
Total QOF points 15/16
559
Clinical (Respiratory)
Diabetes, respiratory & dementia associated
QOF points as a % of QOF Achievement
71%
Expectations of Participating Practices
Practices will be expected to be trained and practically competent to deliver care planning by
April 2016. In the transition year there may be a need to look at process achievements rather
than clinical outcomes (e.g. demonstration of whole practice participation in training, use of
model in practice) in order to make payment. AVCCG will be working with CCGs across Thames
Valley and the SCN to provide a system of quality assurance for practices but also benefit from
lessons learnt elsewhere.
Whilst the provision of care planning training at no additional cost to the practice will be
deemed beneficial it is the ability to create headroom in an increasingly busy general
practice that will be essential to the success of this proposal. Through co-commissioning it
is envisaged that current contracted requirements are suspended for a limited period of time
where they do not affect the quality of care thus allowing time for the practice to change and
embed a new way of working. It would be expected that these contracted requirements would be
reinstated once the process of care planning was adopted unless alternative suitable outcome
measures which add value to patient care could be agreed between all stakeholders through the
specific redesign programmes. Experience has suggested that the historic level of QOF
attainment will be achieved, if not exceeded, within two years as a by-product of the care
planning initiative.
Support and Payment Details
Year of care training will be available to all staff at no cost to the practice and there will be
support available for its implementation from local champions. Making the transition from
clinician-centred care to the person-centred, outcomes-based care planning approach
will take time, resource and a significant cultural shift. Training must involve the whole team
and patients must buy-in to the approach. Consultation techniques will be different and practice
working arrangements may need to change. In recognition of this fact practices will be provided
with the funds associated with their historical level of achievement in the UA DES and QOF in
their chosen domains. In addition the practices will be offered a support fund to assist the
facilitation of care planning. This will be at a percentage of historic QOF achievement (to be
agreed ranging from 0 – 20%) in the specific clinical area aligned to their level of commitment to
the programme. Section 4 below outlines the full cost of the project.
Clinical champions for care and support planning
There are currently clinical champions for care and support planning across the
Buckinghamshire health care system and Thames Valley from whom we will receive support in
implementation at practice level. In addition clinical executive members may want to adopt care
and support planning in their practices so that they are able to promote the strategy to the wider
membership and system. At present there would be no plans to recruit a further clinical lead.
The concept of Beacon Practices would be pursued further with the Allied Health Professions
Deanery with the intention that such sites would be able to demonstrate ‘how to’ deliver care
planning at a practical level to those interested in going forward and offer mentorship at all levels
(Project manager/nurse/Healthcare assistant/GP/admin) to those starting on the journey.
Implementation
The CCG will ensure that the project becomes operational and delivered according to agreed
timescales through a project group which will consist of local experts with the following expertise
project management, care and support planning, information and technology management,
consultation skills, long-term conditions (relevant specialties), education, nursing and practice
management.
The following is an estimation of project timescales
Mar-15
Apr-15
•
•
•
•
•
May-15
•
Nov-15
•
Feb-16
•
Mar-16
•
•
•
Apr-16
Confirmation of joint commissioning arrangements
Agreement of proposal with GB & Joint committee
Practice sign up to proposed scheme
Care planning taster sessions
Commence practice training & care planning
implementation
Planning for second wave practices to implement care and
support planning
Agreement of second wave practices to implement care
and support planning
Full care planning arrangements in place and full
assurance against criteria met
All practices who signed up to care planning must go live
Full QOF reporting will resume unless alternative health
outcome measures have been agreed in year.
The % population for advanced care planning for EoL will
increase
3. Key Stakeholders
The key stakeholders either influential in the development of care and support planning or
affected by it the most are listed below.
• Patients and their families and careers in Aylesbury Vale with Long Term conditions
• General practice in Aylesbury Vale CCG – including GPs and practice nurses
• Aylesbury Vale CCG including locality leads
• Chiltern CCG
• Oxford Health NHS Foundation Trust – Healthy Minds Service
• Thames Valley strategic clinical network
• Coalition of Collaborative Care - Action for LTCs
• Buckinghamshire Healthcare Trust – Community provision
General Practice Feedback
All AVCCG practices have received a copy of the proposal for care and support planning
together with a draft of the Buckinghamshire primary care strategy. Practices have been given
an opportunity to provide the CCG with comments on these proposals in time to inform the
governing body discussions. Where practices have responded to this opportunity to comment
initial feedback has been favourable. It appears that a number of practices have recognised the
value of the care and support planning approach and may have given thought to adopting this
approach already. In contrast a few practices have not been aware of this concept and have
been willing to find out more. There has been reasonable uptake on the care and support
planning taster sessions available with some practices choosing to send their whole team.
In addition initial discussions with the Local Medical Committee (LMC) have shown them to be
broadly receptive to the concept of care and support planning.
Where the CCG has seen very positive feedback is to the changes proposed to the UA DES.
This is currently felt to add little value to patient care in its current form and has largely become
a mechanical exercise with a group of patients who may not be the most likely to benefit.
Public engagement on care and support planning
It is proposed that there will be a full programme of engagement with the public about care and
support planning. The public have already received through the press and individual practice
patient participation groups an invite to attend care planning taster sessions available in each
locality. In addition public friendly resources from National Voices on care and support planning
have been publicised through the press. Patient Participation Groups will have an ongoing role
in promoting/advertising the work outlined in this proposal to ensure that patients are not
passive recipients of information about what is happening but active participants in the process
of change.
4. Financial Investment & Benefits
SUMMARY OF ASSOCIATED FUNDING, COSTS ON CCG ALLOCATION AND
POTENTIAL PRACTICE INCOME 2015/16
Option 1
From CCG Allocation
Note
Option 2
Level
1
Level
2
Level
3
Level 4
£'000
£'000
£'000
£'000
New
costs
Training
£0
£140
£140
£140
£140
CCG Leadership
£0
£50
£50
£50
£50
Enabling IT
£0
£10
£10
£10
£10
£0
£300
£300
£300
£300
£0
£500
£500
£500
£500
£583
£583
Transitional support
**
From NHS England
Allocation
Unplanned
admissions DES
**
&
£583
£583
QOF - Level 2
**
&
£0
£1,008 £1,008 £1,008
QOF - Level 3
**
1
&
£0
£0
£193
£193
QOF - Level 4
**
1
&
£0
£0
£0
£322
£583
£1,591 £1,784 £2,106
Total Practice income associated
with care planning
£883
£1,891 £2,084 £2,406
Total Costs / Funding to support
move to care planning
£1,083 £2,091 £2,284 £2,606
Narrative to support financials (e.g. what money will be spent on; what savings will be
from)
Notes
** Practice income
& Payment of DES & QOF would continue and costs would be in line with FOT / Achievement
but are not shown as would not be targeted at care planning approach proposed
1 - Additional QOF suspended at each level
These costings are for the direct implementation of the proposal (£200k) and also the indirect
costs which will be seen in the practices as a consequence of implementation funded through
a ‘support / transition’ fund of up to a further £300k therefore totalling a maximum investment
of £500k. Because of the links to the UA DES and targeted QOF the full amount of funds
targeted at the changes proposed will be £2.6m if all practices work toward full delivery on
EoL, diabetes, dementia and respiratory disease (level 4).
Is this a collaborative agreement?
Yes
NO
If yes, who are the other partners?
What is the percentage split?
Aylesbury CCG
XX%
NA
XX%
5. Workforce Changes
Workforce
Increases
Decreases
Net Increase or (Decrease)
15/16
16/17
17/18
Narrative to support workforce changes (e.g. description of workforce changes)
6. Finance Approval
Has the budget been identified?
Cost centre to be used?
Name of Budget Manager to approve invoices
Approved
Rejected
Date of Decision
7. Supporting Papers
The following is recommended reading and provides an overview of the model and
its impact nationally:
Angela Coulter, Sue Roberts, Anna Dixon (October 2013) Kings Fund, Delivering
better services for people with long-term conditions, Building the house of care
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/delivering-betterservices-for-people-with-long-term-conditions.pdf
National Voices (2013). A Narrative for Person-Centred Coordinated Care. London:
National Voices. Available at: http://www.england.nhs.uk/wpcontent/uploads/2013/05/nv-narrative-cc.pdf (accessed on 9 January 2015).
NHS England (Nov 14), Next Steps Towards Primary Care Co-commissioning.
Available at: http://www.england.nhs.uk/commissioning/wpcontent/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf (accessed on 9 January
2015).
http://www.yearofcare.co.uk/impact-and-benefits
The Holmside Story is a useful case study:
http://www.yearofcare.co.uk/sites/default/files/pdfs/The%20Holmside%20story%20Fi
nal%20August%202014_1.pdf
Appendix A
Terms of reference for joint commissioning arrangements
including scheme of delegation
Introduction
1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014
that NHS England was inviting Clinical Commissioning Groups (CCGs) to
expand their role in primary care commissioning and to submit expressions of
interest setting out the CCG’s preference for how it would like to exercise
expanded primary medical care commissioning functions. One option available
was that NHS England and CCGs would jointly commission primary medical
services.
2. The NHS England and NHS Aylesbury Vale Clinical Commissioning Group
(AVCCG) joint commissioning committee is a joint committee with the primary
purpose of jointly commissioning primary medical services for the people of
North Buckinghamshire.
Statutory Framework
3. The National Health Service Act 2006 (as amended) (“NHS Act”) provides, at
section 13Z, that NHS England’s functions may be exercised jointly with a CCG,
and that functions exercised jointly in accordance with that section may be
exercised by a joint committee of NHS England and the CCG. Section 13Z of
the NHS Act further provides that arrangements made under that section may be
on such terms and conditions as may be agreed between NHS England and the
CCG.
Role of the Joint Committee
4. The role of the Joint Committee shall be to carry out the functions relating to the
commissioning of primary medical services under section 83 of the NHS Act
except those relating to individual GP performance management, which have
been reserved to NHS England.
5. This includes the following activities:
•
GMS, PMS and APMS contracts (including the design of PMS and APMS
contracts, monitoring of contracts, taking contractual action such as issuing
branch/remedial notices, and removing a contract);
•
Newly designed enhanced services (“Local Enhanced Services” and “Directed
Enhanced Services”);
•
Design of local incentive schemes as an alternative to the Quality Outcomes
Framework (QOF);
•
Decision making on whether to establish new GP practices in an area;
•
Approving practice mergers; and
•
Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).
6. In performing its role the Joint Committee will exercise its management of the
functions in accordance with the agreement entered into between NHS England
and Aylesbury Vale CCG, which will sit alongside the delegation and terms of
reference
Geographical coverage
7. The Joint Committee will comprise NHS England Thames Valley Area Team,
and the Aylesbury Vale CCG. It will undertake the function of jointly
commissioning primary medical services for North Buckinghamshire, as defined
within the Constitution.
Membership
8. The Joint Committee shall consist of:
a) The following members:
•
Director, TVAT
•
Primary Care Relationship Manager, TVAT
•
Lay Member (Vice chair) AVCCG
•
Lay Member AVCCG
•
Chief Officer AVCCG
•
•
•
Clinical Executive Member AVCCG
Clinical Chair AVCCG
Finance and Contracting AVCCG
•
•
Quality and Assurance AVCCG
Primary Care Transformation Manager (Non-Voting)
Co-opted members to be invited depending on expertise required all which will be
non-voting:
• Premises
• Further Lay Members
• Non-conflicted GPs from other CCGs
b) The membership will meet the requirements of Aylesbury Vale CCG’s
constitution.
9. The Chair of the Joint Committee shall be the Lay Member of Aylesbury Vale
CCG.
10. The Vice Chair of the Joint Committee shall be the medical director of the
Thames Valley Area Team.
11. Furthermore, there will be a standing invitation (non-voting) to:
•
a representative of the LMC;
•
a HealthWatch representative, and
•
a Health and Wellbeing Board representative.
Meetings and Voting
12. The Joint Committee shall adopt the Standing Orders of Aylesbury Vale CCG
insofar as they relate to the:
a) Notice of meetings;
b) Handling of meetings;
c) Agendas;
d) Circulation of papers; and
e) Conflicts of interest
13. Each
member of the Joint Committee shall have one vote. The Joint Committee
shall reach decisions by (a simple majority of members present). A pragmatic
approach will be taken to achieving the status of a single operating joint committee
with NHS England.
a) In terms of applying the voting principles to AVCCG operating as an single entity
with NHS England, the number of votes needs to be fairly and evenly weighted.
Voting arrangements will be 2 votes per organisation, or an equal number to both
NHS England and AVCCG higher than two each, if this is declared at the beginning
of the meeting (the latter is to be used only when there are significant numbers of
Committee Members present).
b) NHS England has a casting vote for any functions within NHS England’s statutory
obligations.
c) AVCCG has a casting vote on any of the CCG’s statutory functions that are
included within the scope of the joint committee’s responsibilities.
d) AVCCG will reserve the right to choose to extend the joint committee to include
Chiltern CCG as part of its unit of business planning.
e) In the event of a joint committee being formed between NHS England and more
than one CCG (AVCCG and Chiltern CCG), NHS England will have an equal vote in
respect of NHS England functions. This will be through a weighted vote
arrangement, where each NHS England vote counts as 2 because the joint
committee is with 2 CCGs.
f) Decisions relating to the exercise of NHS England functions in relation to an
individual CCG will be made between that CCG and NHS England, with the
remaining joint committee members abstaining from the decision in question. NHS
England will have the casting vote in relation to these decisions.
g) AVCCG members will have a casting vote on any of the AVCCG’s statutory
functions that are included within the scope of the joint committee’s responsibilities,
with other non - Aylesbury Vale CCG committee members abstaining from the
decision in question.
14. The Joint Committee will be quorate to make decisions if there is:
•
at least two representatives from the Thames Valley Area Team;
•
at least two members of the Aylesbury Vale CCG Governing Body
present;
•
and the number of voting non-GP representatives out numbers the
number of voting GPs.
15. The Joint Committee will usually meet every month for one and a half
hours.
16. Meetings of the Joint Committee:
a. Shall, subject to the application of 7(b), be held in public.
b. The Joint Committee may resolve to exclude the public from a meeting that
is open to the public (whether during the whole or part of the proceedings)
whenever publicity would be prejudicial to the public interest by reason of
the confidential nature of the business to be transacted or for other special
reasons stated in the resolution and arising from the nature of that business
or of the proceedings or for any other reason permitted by the Public
Bodies (Admission to Meetings) Act 1960 as amended or succeeded from
time to time.
17. Members of the Joint Committee have a collective responsibility for the operation
of the Joint Committee. They will participate in discussion, review evidence and
provide objective expert input to the best of their knowledge and ability, and
endeavour to reach a collective view.
18. The Joint Committee may call additional experts to attend meetings on an ad
hoc basis to inform discussions.
19. Members of the Joint Committee shall respect confidentiality requirements as set
out in the Standing Orders referred to above unless separate confidentiality
requirements are set out for the joint committee in which event these shall be
observed.
20. The secretariat to the Joint Committee will be provided by Thames Valley Area
Team
21. The secretariat to the Joint Committee will:
a) Circulate the minutes and action notes of the committee with 3 working
days of the meeting to all members.
b) Present the minutes and action notes to Thames Valley Area Team of
NHS England and the governing body of Aylesbury Vale and Chiltern
CCGs.
22. These Terms of Reference will be reviewed from time to time, reflecting
experience of the Joint Committee in fulfilling its functions and the wider
experience of NHS England and CCGs in primary medical services cocommissioning.
Decisions
23. The Joint Committee will make decisions within the bounds of its remit.
24. The decisions of the Joint Committee shall be binding on NHS England and
Aylesbury Vale CCG.
25. Decisions will be published by both NHS England and Aylesbury Vale CCG.
26. The secretariat will produce an executive summary report which will be
presented to Thames Valley Area Team of NHS England and the governing
body of Aylesbury Vale CCG each month for information.
Key Responsibilities
27. The Joint Committee will undertake the responsibility for:
Strategic direction
•
To oversee the realisation of the primary care strategy, influencing priorities
across the system •
•
To oversee the development of the Primary care workforce
•
To consider implications and oversee implementation of issues arising from
the national, regional and local reviews
•
To make recommendation to the Governing Body on all issues relating to
Primary Care Development.
Quality & Performance Management
•
To oversee the management of the annual budget for the commissioning of
Primary Care services in the relevant area.
•
To Oversee the Quality Outcome framework (QOF)or local incentive scheme
(LIS)
•
To agree contract variations and to undertake reviews of primary care
services where appropriate, within delegated limits
•
To consider contract breaches and appropriate enforcement actions and
make recommendation to the Governing Body, on all issues to do with
Primary Care Development.
•
To oversee programme management and delivery of the primary care
strategy as relevant
•
To oversee the financial management of GP contracts for Core and enhanced
services
•
To report to the Governing Body as appropriate on issues that need
escalation.
General Issues
•
To agree key risks for inclusion in Risk Register for primary care
commissioning
•
To coordinate issues for/and oversee negotiations with the Representative
Body
•
The Committee will produce an annual report summarising its work and
present to the Governing body.
•
To consider and act on the ‘conflict of interest’ of General Practitioners with
reference to Primary care Commissioning.
Review of Terms of Reference
28. These terms of reference will be formally reviewed by Thames Valley Area Team
of NHS England and Aylesbury Vale CCG in April of each year, following the
year in which the joint committee is created, and may be amended by mutual
agreement between Thames Valley Area Team of NHS England and Aylesbury
Vale CCG at any time to reflect changes in circumstances which may arise.
Signature provisions – To be added following agreement at first meeting
Schedule 1 – Delegation by CCG to joint committee, to be added
Schedule 2 - List of Members
Schedule 2
ROLE
Lay
CCG
Director, TVAT
NHS
England
x
VOTING
RIGHTS
YES
Primary Care Relationship
Manager, TVAT
Lay Member AVCCG
x
x
Lay Member AVCCG
x
YES
YES
YES
Chief Officer AVCCG
x
Clinical Executive Member
AVCCG
Clinical Chair AVCCG
x
YES
YES
NO
Finance and Contracting
AVCCG
Quality and Assurance AVCCG
NO
NO
Primary Care Transformation
Manager
Health & Well Being Board
representation
Health Watch Bucks
representation
Additional input as required
(e.g. Data analyst, contracting
etc.) - non voting
NO
NO
NO
NO
Appendix B
Unplanned Admissions Direct Enhanced Service - Current Practice Requirements
1) Identifying and creating a register of 2% of the practice list most at risk of UPA.
2) Improved access:
a. For care/healthcare staff to enable interventions that might avoid unplanned admission: practices will implement a
dedicated line for this.
b. For same day telephone conversations/appointments for patients on the register.
3) Personal Care Plan for patients on the register:
a. To ensure vulnerable/at risk patients are in receipt of planned consistent care.
b. To ensure that patients’ wishes are taken into account when their care is planned.
c. To put in an escalation plan for interventions if their health deteriorates.
d. Review and oversight of effectiveness of the practice UPA plan.
Quality & Outcomes Framework - Current Practice Requirements
14/15
QOF ID
15/16
QOF ID
NICE
ID
Indicator wording
15/16
Points
CLINICAL
Hypertension (HYP)
15/16 Pts
HYP001
HYP001
-
The contractor establishes and maintains a register of patients
with established hypertension
6
HYP006
HYP006
-
The percentage of patients with hypertension in whom the last
blood pressure reading (measured in the preceding 12 months) is
150/90 mmHg or less
20
Stroke and transient ischaemic attack (STIA)
15/16 Pts
STIA001
STIA001
-
The contractor establishes and maintains a register of patients
with stroke or TIA
2
STIA008
STIA008
-
The percentage of patients with a stroke or TIA (diagnosed on or
after 1 April 2014) who have a record of a referral for further
investigation between 3 months before or 1 month after the date
of the latest recorded stroke or the first TIA
2
STIA003
STIA003
-
The percentage of patients with a history of stroke or TIA in whom
the last blood pressure reading (measured in the preceding 12
months) is 150/90 mmHg or less
5
STIA009
STIA009
-
The percentage of patients with stroke or TIA who have had
influenza immunisation in the preceding 1 August to 31 March
2
STIA007
STIA007
-
The percentage of patients with a stroke shown to be nonhaemorrhagic, or a history of TIA, who have a record in the
preceding 12 months that an anti-platelet agent, or an anticoagulant is being taken
4
Secondary prevention of coronary heart disease (CHD)
15/16 Pts
CHD001
CHD001
-
The contractor establishes and maintains a register of patients
with coronary heart disease
4
CHD002
CHD002
-
The percentage of patients with coronary heart disease in whom
the last blood pressure reading (measured in the preceding 12
months) is 150/90 mmHg or less
17
CHD007
CHD007
-
The percentage of patients with coronary heart disease who have 7
had influenza immunisation in the preceding 1 August to 31 March
CHD005
CHD005
-
The percentage of patients with coronary heart disease with a
record in the preceding 12 months that aspirin, an alternative antiplatelet therapy, or an anti-coagulant is being taken
CHD006
-
NM07
The percentage of patients with a history of myocardial infarction
(on or after 1 April 2011) currently treated with an ACE-I (or ARB if
ACE-I intolerant), aspirin or an alternative anti-platelet therapy,
beta-blocker and statin
Chronic kidney disease (CKD)
7
15/16 Pts
CKD001
CKD005
NM83
The contractor establishes and maintains a register of patients
aged 18 or over with CKD
Diabetes mellitus (DM)
6
15/16 Pts
DM017
DM017
NM41
The contractor establishes and maintains a register of all patients
aged 17 or over with diabetes mellitus, which specifies the type of
diabetes where a diagnosis has been confirmed
6
DM002
DM002
NM01
The percentage of patients with diabetes, on the register, in whom
the last blood pressure reading (measured in the preceding 12
months) is 150/90 mmHg or less
8
DM003
DM003
NM02
The percentage of patients with diabetes, on the register, in whom
the last blood pressure reading (measured in the preceding 12
months) is 140/80 mmHg or less
10
DM004
DM004
-
The percentage of patients with diabetes, on the register, whose
last measured total cholesterol (measured within the preceding 12
months) is 5 mmol/l or less
6
DM006
DM006
-
The percentage of patients with diabetes, on the register, with a
diagnosis of nephropathy (clinical proteinuria) or microalbuminuria who are currently treated with ACE-I (or ARBs)
3
DM007
DM007
NM14
The percentage of patients with diabetes, on the register, in whom
the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12
months
17
DM008
DM008
-
The percentage of patients with diabetes, on the register, in whom
the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12
8
months
DM009
DM009
-
The percentage of patients with diabetes, on the register, in whom
the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12
months
10
DM018
DM018
-
The percentage of patients with diabetes, on the register, who
have had influenza immunisation in the preceding 1 August to 31
March
3
DM012
DM012
NM13
The percentage of patients with diabetes, on the register, with a
4
record of a foot examination and risk classification: 1) low risk
(normal sensation, palpable pulses), 2) increased risk (neuropathy
or absent pulses), 3) high risk (neuropathy or absent pulses plus
deformity or skin changes in previous ulcer) or 4) ulcerated foot
within the preceding 12 months
DM014
DM014
NM27
The percentage of patients newly diagnosed with diabetes, on the
register, in the preceding 1 April to 31 March who have a record of
being referred to a structured education programme within 9
months after entry on to the diabetes register
Dementia (DEM)
11
15/16 Pts
DEM001
DEM001
-
The contractor establishes and maintains a register of patients
diagnosed with dementia
5
DEM002
DEM004
-
The percentage of patients diagnosed with dementia whose care
plan has been reviewed in a face-to-face review in the preceding
12 months
39
DEM003
DEM005
Based
on
NM09
The percentage of patients with a new diagnosis of dementia
recorded in the preceding 1 April to 31 March with a record of
FBC, calcium, glucose, renal and liver function, thyroid function
tests, serum vitamin B12 and folate levels recorded between 12
Asthma (AST)
6
15/16 Pts
AST001
AST001
-
The contractor establishes and maintains a register of patients
with asthma, excluding patients with asthma who have been
prescribed no asthma-related drugs in the preceding 12 months
4
AST002
AST002
-
The percentage of patients aged 8 or over with asthma
(diagnosed on or after 1 April 2006), on the register, with
measures of variability or reversibility recorded between 3 months
before and anytime after diagnosis
15
AST003
AST003
NM23
The percentage of patients with asthma, on the register, who have 20
had an asthma review in the preceding 12 months that includes
an assessment of asthma control using the 3 RCP
AST004
AST004
-
The percentage of patients with asthma aged 14 or over and who
have not attained the age of 20, on the register, in whom there is
a record of smoking status in the preceding 12 months
6
Chronic obstructive pulmonary disease (COPD)
15/16 Pts
COPD001
3
COPD001
-
The contractor establishes and maintains a register of patients
with COPD
COPD002
COPD002
-
The percentage of patients with COPD (diagnosed on or after 1
April 2011) in whom the diagnosis has been confirmed by post
bronchodilator spirometry between 3 months before and 12
months after entering on to the register
5
COPD003
COPD003
-
The percentage of patients with COPD who have had a review,
9
undertaken by a healthcare professional, including an assessment
of breathlessness using the Medical Research Council dyspnoea
scale in the preceding 12 months
COPD004
COPD004
-
The percentage of patients with COPD with a record of FEV1 in
the preceding 12 months
7
COPD005
COPD005
NM63
The percentage of patients with COPD and Medical Research
Council dyspnoea grade ≥3 at any time in the preceding 12
months, with a record of oxygen saturation value within the
preceding 12 months
5
COPD007
COPD007
-
The percentage of patients with COPD who have had influenza
immunisation in the preceding 1 August to 31 March
6
PUBLIC HEALTH DOMAIN
Cardiovascular disease - primary prevention (CVD-PP)
CVDPP001
CVDPP001
NM26
15/16 Pts
In those patients with a new diagnosis of hypertension aged 30 or 10
over and who have not attained the age of 75, recorded between
the preceding 1 April to 31 March (excluding those with preexisting CHD, diabetes, stroke and/or TIA), who have a recorded
CVD risk assessment score (using an assessment tool agreed
with the NHS CB) of ≥20% in the preceding 12 months: the
percentage who are currently treated with statins
Blood pressure (BP)
BP002
BP002
15/16 Pts
NM61
The percentage of patients aged 45 or over who have a record of
blood pressure in the preceding 5 years
Obesity (OB)
OB001
OB002
15
15/16 Pts
NM85
The contractor establishes and maintains a register of patients
aged 18
Smoking (SMOK)
8
15/16 Pts
SMOK002 SMOK002 NM38
The percentage of patients with any or any combination of the
25
following conditions: CHD, PAD, stroke or TIA, hypertension,
diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective
disorder or other psychoses whose notes record smoking status in
the preceding 12 months
SMOK003 SMOK003 -
The contractor supports patients who smoke in stopping smoking
by a strategy which includes providing literature and offering
appropriate therapy
2
SMOK004 SMOK004 NM40
The percentage of patients aged 15 or over who are recorded as
current smokers who have a record of an offer of support and
treatment within the preceding 24 months
12
SMOK005 SMOK005 NM39
The percentage of patients with any or any combination of the
following conditions: CHD, PAD, stroke or TIA, hypertension,
diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective
disorder or other psychoses who are recorded as current smokers
who have a record of an offer of support and treatment within the
preceding 12 months
25
Appendix C
Care and Support Planning - Expectations of General Practice for the Future
Effective care and support planning as described in the year of care model requires
signing up to a new way of working, not only within primary care, but also across
traditional healthcare divides; and it offers a method of integrating community,
primary care, specialist and secondary care services.
There needs to be strong clinical and managerial leadership to support this approach
including engaging and supporting clinicians to work differently. Individual practices
will find some of the challenges associated with implementing care planning difficult
to overcome, however year of care have developed and continue to develop
resources to help with this. The CCG will also work with practices to identify local
challenges and ways of addressing these.
Consultations – consultations with the care planning cohort has a focus on better
conversations with the patient emphasising the importance of the care planning
process itself in achieving outcomes, rather than the written care plan that may
emerge at the end. In the consultation the information that the patient can contribute
about living their life with their LTCs, what matters to them and their own goals is
actively sought and given equal prominence to traditional information about tests and
examinations. More consultation time may need to be allocated to patients. To
accommodate the change in length or frequency of consultations the appointment
system of a practice may need to change. In addition some thought may need to be
held around who is best placed to meet with the patient at each step (described
below) GP, nurse or healthcare assistant.
Personalised care plans – care plans developed during care and support planning
consultations are very different from traditional treatment plans developed by
healthcare professionals on behalf of patients. The patient is an active participant
and ‘owns’ the developing care plan.
Process - The diagram below describes a two ‘contact’ Year of Care approach in
general practice.
Preparation is crucial to both the Health Care professional and the person living with
the long term condition. For people with some conditions, such as diabetes or
chronic lung disease, there may be a need for tests or investigations as part of their
routine monitoring. These would be done at the first contact and the results would
be sent to the person a few days later, prior to their care planning consultation. This
gives them the opportunity to consider their test results, and what these mean to
them, along with family and friends as needed. They will also be provided with an
agenda setting prompts to help them reflect on life with their LTCs and what they
would like to discuss in the consultation. For other conditions, there may be no need
for specific monitoring tests and no results to share. However people should still be
provided with tools to enable their preparation ahead of the care planning
consultation (including agenda setting prompts, self-assessment or reflective tools).
This emphasises a core principle of care planning, which is that everyone should
have the opportunity to prepare for the care planning discussions in advance to
ensure they are in a much better position to contribute fully to the discussions and
decisions made.
The second contact is the care planning consultation with a healthcare professional
trained in partnership working, aiming to help the person identify their priorities,
develop personal goals and action plans and identify services available to support
these.
The agreed discussions and actions are summarised into a care plan, which is
shared with the patient either immediately or subsequently by post or electronically.
Primary Care in Buckinghamshire
Our strategy for proactive, co-ordinated,
out-of-hospital care.
NHS Aylesbury Vale and NHS Chiltern Clinical Commissioning Groups
Engagement - integrated and partnership working ......21
Dynamic and responsive localities ................................21
Contents
Next steps .............................................................................22
Introduction ............................................................................ 4
Appendix 1: Design Principles (adapted from Edwards, Smith
and Rosen’s work (2014)) .....................................................23
What is primary care? ...................................................... 4
Appendix 2: ...........................................................................27
Foreword ................................................................................ 3
One System, 7 Localities, 53 Practices ........................... 5
Design Principles .............................................................. 5
The case for change............................................................... 7
Our local population and health inequalities .................. 7
Primary Care – Voice of the People................................. 7
Our vision ............................................................................... 9
Our goals: achieving the transformation ............................... 11
Supporting the change: enablers and critical success factors18
The Better Care Fund ..................................................... 18
Information Management and Technology (IM&T) ....... 18
Practice premises and community assets .................... 19
New contracts and incentives ........................................ 19
Workforce ........................................................................ 20
Programme management ............................................... 20
Engagement - Patient and Community Empowerment 21
2
people are living with complex, long-term medical conditions, like
diabetes, heart disease and dementia. It is not unreasonable to
say the future success of our National Health Service, as a
whole, depends upon getting Primary Care right. Although the
challenges are daunting, we believe there is now a unique
opportunity for transformational change. The recently published
NHS 5 Year Forward View, which places Primary Care at the
heart of the NHS, illuminates the possibilities ahead of us.
Foreword
We are proud to introduce our primary care strategy for
Aylesbury Vale and Chiltern CCGs, for the period 2015 – 2018.
Shaped by the Public, our Member Practices and other
stakeholder contributions, we hope that by reading about our
plans for transformation of primary care services, you will share
our excitement for the real opportunities this provides us to
deliver a better service for our patients and service users.
Technology will facilitate the empowerment of patients. The
recent advent of co-commissioning will, for the first time ever,
mean that clinicians are playing a part in the design and
The construction of this Primary Care Strategy began in summer
commissioning of all parts of the wider healthcare system.
2014; AVCCG hosted a half day event for practices, with the
LMC, Local Authority and Bucks Healthcare Trust in attendance. This strategy reflects the collective view of both CCGs across
We specifically started with ‘a blank sheet’ to encourage
Buckinghamshire, Chiltern CCG having engaged with partners in
participants to freely think about future options of service
the south of the county.
delivery.
In short, there has never been a more exciting time to create a
In the autumn a Clinical Executive Board member visited each of vision for a transformed primary care.
our Member Practices to discuss ideas with GPs, nurses and
other team members. Public engagement events were held in
all 3 of our localities to gain views and opinion from potential
users of future health services and we linked all relevant public
comments from our previous consultations such as the Out of
Dr Malcolm Jones
Dr Graham Jackson
Hours services work.
Clinical Chair AVCCG
Primary Care in England faces unprecedented challenges.
Challenges so great, that failure to meet them head on is not an
option. Putting it simply, people are living longer and many more
3
Primary Care Lead AVCCG
What is primary care?
Introduction
Broadly speaking, primary care could include any part of the
healthcare system that has first contact with a patient embarking
on an episode of care. Traditionally, primary care services have
been thought of as general practice, community pharmacy,
dental services and optometry. The scope of primary care
however is much wider and could also include appropriate selfcare interventions, mental health support, community healthcare
In order to ensure our proposed primary care strategy is fit for
teams that incorporate nursing and other multidisciplinary care.
purpose, a group of some thirty individuals from across local
Given that general practice has been such a large element of
commissioner and provider organisations was created and
worked under the guidance of NHS Improving Quality on a large- what has traditionally been viewed as primary care, it will be a
core component of this document.
scale transformational change programme from June to
September 2014. The outputs of this change programme have
This strategy will also consider the role of other providers and
significantly contributed to this work.
professionals like community pharmacy in delivering a more
personalised and proactive model of care that builds our out-ofAlthough it is strongly focused on the role of general practice in
hospital services. We aim to keep people healthy and
primary care, the implementation of the strategy will require the
independent, ensuring those who require treatment or care are
support of independent contractors, nurses, therapists, hospital
treated in the most appropriate place by the right person.
doctors and all other clinicians and managers involved in the
delivery of primary and community care.
The two Buckinghamshire CCGs consider this strategy to be a
transformational journey for building patient centred, out-ofTogether, NHS Aylesbury Vale and NHS Chiltern Clinical
hospital care which will be realised over a number of years. A
Commissioning Groups (CCGs) aim to ensure that primary and
community care is offered as part of a whole system network to key area of focus will be on improving outcomes for patients and
provide person-centred care as accessible and close to home as thinking beyond traditional boundaries as system leaders.
possible.
This is the Primary Care Strategy that underpins our vision
across Buckinghamshire for proactive, co-ordinated, out-ofhospital care. We have involved our local patients, stakeholders
and the professionals directly involved in delivering primary care
services in developing the strategy.
4
linked thorough the Health and Wellbeing Board, where our
overarching strategy for Health and Wellbeing is developed.
One System, 7 Localities, 53 Practices
Buckinghamshire has 53 GP practices forming two CCG
member organisations, Aylesbury Vale and Chiltern CCGs.
Within the CCGs, clusters of GP practices have formed into
seven geographical locality groups.
Design Principles
Aylesbury Vale and Chiltern CCGs aim to commission out-ofhospital care services that have the eight characteristics
described below. These principles will be widely adopted and
systematically applied in any future commissioned service.
At locality level, there is a greater understanding of the current
health needs of the population, the views of the community on
healthcare and the assets available to them in that community.
As such, the locality clinical leads can act as the driving force
behind localisation and implementation of services appropriate
to their population needs – making this model a very effective
way to deliver change.
In Buckinghamshire we are committed to a primary care which
will be:
Safe and high quality - care will be evidence-based
whenever possible and clinical decisions will be informed by
peer support and review.
At CCG level, the wider population current and future health
needs are taken into account, including monitoring hospital
activity and trends of healthcare challenges. Commissioning is at
greater scale at this level and enables greater value for money.
Comprehensive – with access to a wide range of
professionals in order to meet the majority of the patient’s
physical and mental healthcare needs; to include wellbeing
and prevention, acute and chronic care (e.g. multi-specialty
community providers).
Across Buckinghamshire, the two CCGs actively work together,
addressing the countywide health needs and sharing
commissioning responsibilities on behalf of their populations to
maximise efficiencies. The two CCGs share the same
community, main acute, mental health and social care providers
and act as a single unit of planning. At this level, the county wide
system of health and social care works closely together, formally
Person-centred and holistic – recognising the impact of
broader life influences such as housing, education and family
circumstances on a patient’s health and care. Patients and
5
their carers will be at the centre of decision making about
their care and treatment and will be offered continuity of care.
Population orientated – focused on the needs of those
resident in a specific geographical location, and/or individuals
in certain population groups such as those with specific long
term conditions, the frail elderly or the homeless.
Maximising care in the community setting –
acknowledging patients and clinicians agree that more care
could move further away from traditional hospital based care
into community settings.
Co-ordinated across a whole system – accountable for
transitions between providers; building and sustaining open,
clear coordination and communication between the patient
and their care teams.
Accessible – responsive to the patient’s needs with
appropriate waiting times for initial consultation and advice,
diagnosis and care.
Sustainable – viable for the future in terms of finance and
workforce. Maintain public trust and fit with the wider health
system.
Further reading
Edwards, Smith and Rosen’s work (2014) on primary care offers
a framework for developing primary care services and plans that
has influenced our strategy.
6
In order to respond to these growing health challenges, general
practice will need to operate at greater scale and in greater
collaboration with other providers and professionals as we all
move towards a whole system transformation.
The case for change
Our local population and health inequalities
As our population ages and more people are living longer with
disease and multiple illnesses, the demand for healthcare
services in every sector of health and social care is increasing.
These factors, and the enabling features of new medicines and
technology, change the focus of healthcare requirements and
mean that current models of care delivery need review. This is
very much the case in primary care where around 90 per cent of
patient interaction with the NHS occurs.
This will not necessarily require changes in organisation form
and mergers, it will be achieved through practices working in
partnership and networking.
More evidence on the case for this change and the benefits of
networks/federations is outlined in the Kings Fund and Nuffield
Trust Report on Securing the Future of General Practice (2013).
The interactive diagram below summarises some of the key data
from our CCG and locality health profiles.
Primary Care – Voice of the People
Both CCGs have undertaken stakeholder engagement, the
outputs of which have been used to inform this strategy. During
October and November 2014 engagement with the public,
patients, primary care clinicians and secondary care was
undertaken with a series of meetings and online surveys.
From August to November 2014, Buckinghamshire County
Council’s Health and Social Care Select Committee undertook a
robust and comprehensive inquiry into access to GP services
and have shared with us their final report.
Further reading
The Joint Strategic Needs Assessment and the CCGs’ Locality
Profiles.
7
In early autumn, Bucks HealthWatch consulted the public on
urgent care services and the headline findings relevant to this
strategy have been taken into account.
Our work with NHS Improving Quality and other stakeholder
feedback included:
 There are opportunities in working differently and in
closer collaboration
 Improving communication between providers using
information technology
 Reducing duplication by improving care co-ordination and
system integration
 Patients would prefer care in the community
 Acknowledgement of a greater role for community
pharmacy
Public and patient involvement in developing this strategy
identified four common themes:
 more support for people to manage their own care;.
 greater use of technical solutions including shared health
records
 increased access to GP services
 a co-ordinated approach across all providers
Our stakeholder feedback included:
Our Member Practices told us:
There were a number of common themes which emerged across
localities, with GPs acknowledging challenges, but also
welcoming the opportunity to establish the “direction of travel”
within a Primary Care Strategy:
.
 Patient’s needs are becoming more complex, requiring
more time and resource
 Need to improve information sharing between providers
 Joined up care from community nurses and social
services needs to significantly improve
 The increase in workload means less time to think
innovatively or to manage the changes required
 The reducing GP workforce needs to be addressed.
The Bucks Health and Social Care Select Committee (HASC)
GP Inquiry Report. This covers the area of access to general
practice in some detail. The key findings in respect of access
were:
 Demand for urgent appointments is being met
 A lack of capacity for non-urgent appointments has led to
variation in waiting times
 There is a need to reduce avoidable appointments with
GPs
 There is a need to promote and support more people to
self-care
8
With more people managing their own health (in tier two), at
times they will require input from GPs or other primary care
clinicians. This might be because they require some additional
support in managing their long term condition(s) or to check an
unexpected health concern. This tier of care, mainly planned
appointments with some urgent interventions from time to time,
forms the core elements of care provided by all GP practices.
Our vision
Our collective Buckinghamshire vision, developed with all our
local stakeholders and agreed across the system’s health and
social care providers and commissioners is:
Everyone working together to provide high quality,
personalised care to help keep Buckinghamshire people
happy and healthy, optimising value from our collective
efforts
In moving care out-of-hospital and closer to home, an additional
“Tier Three Plus” is created, with services that were historically
provided in hospital now being available in the community, led
by local healthcare teams with access to specialist advice as
required.
In order to achieve this, we must develop a much more
integrated approach to our delivery of commissioned services.
Such a seamless way of working requires a new model of
delivery across the whole health and social care system,
including primary care.
Development of this tier is the real transformation of
primary care, with proactive patient-centred care being coordinated through GPs at the heart of a seamless integrated
health service.
Our population’s health needs can be broadly categorised into
four tiers of care (see diagram on page 10). These tiers of care
are recognised by the Health and Wellbeing Board and enable
us to develop a framework for all our health, social and voluntary
services, which clarifies for patients exactly what levels of
support will be delivered at each level of service.
This transformation will develop across Buckinghamshire,
significantly changing the way we work as a health and social
care system. Transformation will also take place at CCG locality
level, as different communities have different health needs and
different local facilities available.
Tier Three – Transforming Primary Care
Our Primary Care Strategy focuses mainly on Tier Three, when
patients need support from a primary care clinician or
professional.
Exactly which services are moved out of hospital and into
primary care for local delivery is subject to a number of other
factors.
9
10
Our goals: achieving the transformation
We have identified six goals which we believe will achieve
our vision.
Defining these goals and identifying what we mean is only the
beginning. They are a starting point to help us work with you
over the next five years to develop and implement innovative
solutions which meet our shared vision and aspirations.
This could include group-based educational and selfmanagement courses, as well as encouraging “expert by
experience” peer support.
How it could happen – the patient’s perspective: Jo Smith is
boasting about the new man in her life – her husband of 20
years. Pete has been transformed by a health coach.
He was overweight, drank too much, smoked, and never
exercised. Only in his 40s, he had developed heart disease and
diabetes. When he lost his job he sank into depression and took
little interest in anything other than the telly.
So we can stimulate ideas about the way we deliver these goals,
we have given examples describing how our goals could be
Jo went online to get support and found out about steps Pete
delivered. We hope this encourages everyone to think about the could take to help himself, but he wasn’t interested. Then a
best way of getting the outcomes we need.
community forum member told Jo about health coaches, who
help individuals find the best solutions for their health and
wellbeing challenges.
Our Goal: Enable people to take personal responsibility for
their own health and wellbeing, and for those that they care
The best part about it was that Jo could ask the health coach to
for, with access to validated, localised and readily available
come and see Pete, it didn’t rely on him making the first move.
educational resources.
It took a few weeks for Pete to accept that he needed to change,
but once he did he hasn’t looked back and working with a group
What this means: People will be encouraged to manage their
of other people with similar problems has meant they are all
own mental and physical health and wellbeing (and those they
helping each other, as well as themselves.
care for) so they stay healthy, make informed choices about care
How it could happen – the clinician’s perspective: Fiona, a
and treatment to manage their conditions, and avoid
GP in her mid-40s had become increasingly frustrated in
complications.
recent years.
11
She felt under severe pressure from a huge growth in demand
for her practice’s services. She felt particularly frustrated that
many patients were coming to see her for self-limiting minor
illnesses while many of her complex patients with serious long
term conditions grumbled that they could never get to see her.
She was sceptical when her practice manager bought a webbased self-help programme for patients to access through the
practice website. However, over the course of a couple of years,
she noted a definite drop in the number of people consulting for
minor illnesses. On the other hand, through her training in “year
of care” care planning, she felt more enabled to assist her more
complex patients to better manage their health and wellbeing.
Moving away from the traditional barriers between different caregiving and wellbeing organisations, so people’s needs are
understood and shared between the different organisations with
which they come into contact.
People understand their needs are being met through proactive
teamwork and they do not have to distinguish between different
caregivers.
How it could happen – the patient’s perspective: Ethel
Walker has always been house-proud. When her husband
Albert died she thought it would mean giving up and
She was able to engage Pete in the care planning process. Pete moving into a home.
for the first time was taking his heart disease and diabetes
What was worrying her particularly was giving up Albert’s
seriously and Fiona felt optimistic about his future care.
beloved dog Jack. Ethel suffers from arthritis and breathing
difficulties, so Albert had done most of the housework, walked
Jack and had made sure Ethel took her pills and ate well.
Our Goal: Health, social care and voluntary sector
providers working together to offer community based, personcentred, co-ordinated care which proactively manages long
term conditions, older people and end of life care out of the
hospital setting.
What this means: Combining resources and expertise so that
people receive joined-up care.
Grieving over Albert and worrying about the future were taking
their toll on Ethel. But then Emma came into her life. Emma, a
nurse, was part of an integrated locality team and called in a few
days after Albert died. She explained she was Ethel’s first point
of contact for any problems she had. Emma made sure Ethel’s
care needs were assessed, got her some benefits advice and
ensured she got proper home help.
12
Emma worked with the locality team to assess Ethel’s medical
treatment and made sure they understood what Ethel wanted
out of life and how they could all work together to make it
happen. She even took the trouble to find a local charity which
offered volunteer dog walking services, so every day Ethel has a
visitor who takes Jack and Ethel out for a walk, a trip to the
shops or just for a cup of tea and a chat.
The locality team had a more proactive and holistic approach to
assessing and managing a patient’s risk of decline and Fiona felt
the team was providing a level of service to Ethel that could
never have been emulated by Fiona’s efforts alone.
Our goal: Improved and appropriate access for all to high
quality, responsive primary care that makes out- of-hospital
care the default.
How it could happen – the clinician’s perspective: Fiona had
been Ethel and Albert’s GP for many years. Ethel had lots of
health issues but with her husband’s support, had generally
What this means: Making sure people can access good quality
only come to the surgery when required.
advice and care in the most suitable and convenient way
When Albert died, Fiona was worried that Ethel would rapidly
possible, as early as possible to prevent problems becoming
deteriorate both mentally and physically and become
more serious.
housebound. Fiona was worried how she, as Ethel’s GP might
Understanding that not everyone needs to “see someone” and
best meet her changing needs. Her experience in similar
situations in years gone by suggested there would be inexorable that care can be provided by phone, email or online and, when
decline towards a health or social crisis point, which would result needed, face-to-face anytime, day or night.
in hospitalisation and placement in a care home.
However, Fiona referred Ethel to the integrated locality team –
comprising district nurses, social workers, physiotherapists,
occupational therapists, with input from all the local general
practices and the community gerontology and older people’s
mental health services.
13
How it could happen – the patient’s perspective: Paul Jones
doesn’t even know what his GP looks like. A fit and busy 54year-old, he can’t remember the last time he had to go to the
doctor.
make this work? However, by pooling the resources of the other
locality practices, it became clear that commitment to working
some extended hours was nowhere near as onerous as she
feared.
But just lately he’s seen all the adverts about bowel cancer on
his commute into London and he’s worried because there is
some blood in his poo.
In fact, working one later evening a fortnight quite suited her as it
meant she had a later morning start at the practice once a
fortnight – which made for a much less stressful school run and
gave her valuable daytime hours to get other household jobs
done.
He goes online while he’s travelling to work and the advice tells
him to go and see the doctor if the symptoms persist for more
than three days. Days later he can still see blood in his poo so
he phones his GP surgery on the way home from work. They
aren’t open late that evening, but make an appointment for him
the same evening at another surgery in the locality.
She enjoyed her late evening clinics – they tended to have a
different “feel” to them than her daytime surgeries and the
patients often expressed great satisfaction with the service.
He actually has haemorrhoids and is given advice and access to
online resources about how to manage his condition. They also
book him in for an NHS health check with the practice nurse at
his usual surgery.
How it could happen – the clinician’s perspective: Fiona,
Paul’s GP, perpetually felt it was a struggle to keep her
work-life balance right – especially given the ever changing
needs of her young family.
When discussions were mooted about her practice extending its
hours, she felt both anxious and angry – how could she possibly
Our goal: Develop clearly understood care pathways that
offer consistent and co-ordinated care, using bed-based
services only when necessary.
What this means: Giving people access to specialist support in
their community, working with a named responsible clinician.
Working together, they would identify a clear plan about the type
and level of care the patient needs. This would be provided by a
team of clinicians, who may be from different providers, but they
14
all have access to a shared care record which will also be
available to the patient.
All the clinicians in her practice had been trained in this
approach and most of the care planning was done by the
practice nurses.
Care would be regularly reviewed so potential issues are
identified and dealt with early and locally.
As a consequence the practice was achieving better glucose
and blood pressure control with its diabetic population
How it could happen – the patient’s perspective: When
Harry Evans’ dad got diabetes in the 1980s he was in and
out of hospital all the time, went blind and had to have a leg
amputated. So when Harry developed diabetes himself he
expected the worst.
Fiona was only directly involved in the care planning of the more
complex patients. It was of great benefit to her to be able to
share electronically her patients’ care plans with the local
community diabetes consultants. This enabled Fiona to get the
best advice for her complex patients more conveniently, and
expediently.
But he worked with a diabetes nurse, Jenny, who talked him
through what was going to happen and how he would be
working with a team of people to help him manage his condition.
She arranged for him to meet a nutritionist and they sorted out
his diet and he had regular meetings with Jenny on Skype, so he
didn’t even have to leave work to have a check-up.
Jenny also arranged for an ophthalmologist to assess his
eyesight so they could understand how his vision might be
affected by the diabetes.
How it could happen – the clinician’s perspective: Fiona
found the “year of care” approach to care planning had led
to a transformation within her practice.
Our goal: Improve health outcomes for our whole population
through adopting best practice, stimulating innovation and
aspiring to improve.
What this means: Working together on prevention, not just as
professionals but with communities and individuals.
Reducing variation and inequalities in health outcomes by
increasing health screening and early interventions, in particular
targeting groups of people whose health outcomes are not as
good as they should be.
15
How it could happen – the patient’s perspective: Becky now
has the courage to be the mum she always wanted to be
and give her son, Sam, the best possible start in life.
Our goal: A commitment to invest in and support our primary
care providers in helping build our out-of-hospital services.
When Sam was born Becky was on her own and she didn’t think
she had what it took to be a good mum.
What this means: Making sure people being cared for at home,
or in their care home, is the default and that services are
But her health visitor set her up with a mentor, Heather, who
focused on this.
helped Becky discover for herself what she needed to do for the
best and introduced her to other mothers nearby.
Co-commissioning with NHS England to shift investment to
primary and community care. Using this investment to improve
Becky is even looking after herself better now, using online
infrastructure, provide more comprehensive services which
resources, knowing how important it is to stay healthy so she
support GPs to enable more care in the community, to enhance
can care for Sam and set him a good example.
training for community nurses and other primary care staff
How it could happen – the clinician’s perspective: Jean was including extended use of community pharmacists.
Becky’s community midwife. She had seen many young,
socially disadvantaged single mums over the years and
often worried how they would fare during those early years
of parenthood.
However, the local health visiting team, in conjunction with the
family nurse partnership, had become more aware of those at
risk during the early years and were employing a much more
proactive strategy for engaging with their clients.
How it could happen – the patient’s perspective: Keeping
Sally at home isn’t easy for her daughter, but the team
supporting her makes it as smooth as possible.
As Sally has dementia it is always difficult if she has to go into
hospital, but just lately she has been able to stay at home, even
when she got a chest infection, because the team monitors Sally
and has a plan to manage any risks to her health.
Using a pre-agreed care plan, Sally’s daughter called the
integrated locality team as soon as her mum appeared to be
unusually breathless. A qualified healthcare professional came
out to assess her.
16
They decided with the right medication, regular checks by the
care co-ordinator and a package of support from the locality
team, there was no need to send her to hospital.
How it could happen – the clinician’s perspective: Fiona
was half way through a busy morning surgery when a
message from the locality integrated team appeared on her
screen.
The message was to let Fiona know that they had received a call
from Sally’s daughter at 8am, saying that Sally was very
breathless. Fiona had been Sally’s GP for more than 10 years,
over which time the combination of dementia and COPD was
proving a real challenge; Sally had been hospitalised on a
number of occasions.
Fiona was relieved to have the assistance of the integrated
locality team – under other circumstances, she would not have
been able to visit Sally until mid-afternoon, by which time she
might have become more unwell.
The locality team was treating Sally at home with intravenous
antibiotics and oral steroids and were going to continue to
manage this acute episode until Sally was fit for discharge back
to GP care.
Fiona was able to keep abreast of events, as the locality team
were able to access Sally’s medical record from the same IT
platform that Fiona used in her practice.
17
Supporting the change:
enablers and critical success factors
In order to achieve the vision and goals set out in the strategy a
number of key enablers and critical success factors will be vital.
Click on each link to find out why these are so important and
how we plan to develop them locally.
This creates an opportunity to bring resources together to
address immediate pressures on services and lay foundations
for a much more integrated system of health and care.
However, the funding is not new or additional money; part of it
comes from CCG allocations, in addition to NHS money already
transferred to social care. This means that the integration of
services needs to happen swiftly, in order to achieve value for
money and shift activity and resource from hospitals to the
community.
Enablers
Critical Success Factors
Information management &
technology
Engagement – Patient &
community empowerment
Practice premises &
community assets
Engagement – Integrated &
partnership working
Information Management and Technology (IM&T)
New contracts & incentives
Dynamic and responsive localities
Workforce
Better Care Fund
In order to deliver our strategy we need to exploit the
opportunities offered by the information revolution, we should
significantly enhance our use of information and technology.
Programme Management
The Better Care Fund
The Better Care Fund (BCF) is a single pooled budget for health
and social care services to work more closely together in local
areas, based on a plan agreed between the CCGs and the local
authority.
Buckinghamshire’s comprehensive IM&T strategy is designed to
deliver this, setting out clear goals to leverage maximum benefits
from existing systems and deploying new systems to fill
identified gaps.
Those goals can be summarised into four key themes:
 commissioner enablement
 shared records interoperability
 Use of patient centred technology (including Telehealth)
18

New contracts and incentives
developing an enabling infrastructure across our whole
system and beyond.
In order to achieve the ambition of care delivered in alternative
settings with a shift into the community, it will be necessary to
understand the premises assets and challenges across the
whole health and social care system.
The methods by which we commission services will be influential
in shaping how providers can respond effectively. There are a
number of different approaches being piloted nationally and the
CCGs will want to test some of these. New models of
commissioning and new payment arrangements such as lead /
prime provider and joint ventures which encourage organisations
to work collaboratively to improve patient outcomes could be of
great benefit.
Joint working across all local commissioners and providers will
be required to do this. This includes NHS England which has
committed to supporting the preliminary stages of this work with
an audit of estate encompassing fitness for purpose and usage.
This will enable the CCGs to understand what the opportunities
and challenges are across the system so that informed decisions
can be made on the best use of existing resources and the
investments required.
The CCGs will work with providers to develop contractual
mechanisms, approaches to measurement and rules of
behaviour that facilitate the development of new models of care
while managing any associated risks. These new models of care
could include multispecialty community providers, primary and
acute care systems, or enhanced health in care homes as
described in the Five Year Forward View or the development of
other innovative and transformational models.
Working with partners across the system will also enable the
CCGs to not only be aware of planned housing growth and the
associated increase in demand for healthcare services, but also
to work with the local authorities as part of the planning decision
making process. NHS England offers a national commitment to
support and invest in the development of primary care
infrastructure and both CCGs are keen to maximise this
opportunity.
Co-commissioning will be a significant opportunity for CCGs to
increase their involvement in the commissioning of primary care.
It is expected to be a key enabler in developing seamless,
integrated out-of-hospital services as CCGs will be able to
commission care across the whole patient pathway through
different sectors including primary care. This is an opportunity
that the CCGs will take up with their members support.
Practice premises and community assets
19
Workforce
The current primary care workforce will be very challenged to
deliver this transformation of service delivery. In line with the
national picture, Buckinghamshire has an increase in the
proportion of part-time workers and declining numbers of GPs
and practice nurses which creates pressure in the system.
mapping, describe potential new roles and identify subsequent
educational and recruitment needs.
In the meantime, the CCGs will actively work with partners to
review recruitment and retention locally and consider initiatives
such as making posts more attractive and encouraging people
back to work after maternity leave, career breaks and retirement.
This could be supported in part by offering education to
healthcare professionals that ensures they are competent not
only to deliver the essential requirements of primary care
(ongoing education and “back to work” courses), but also
Additional capacity is unlikely to be met by investing in additional courses offering a higher degree of competence for the new
enhanced levels of out-of-hospital care where some specialist
people alone - simply providing more of the same is not the
answer for the future. Providers will look to create new roles with skills and knowledge will be required.
different skills that adapt to the patient’s changing health needs
in order to improve productivity and create a seamless care
Programme management
service for our patients.
This transformation of service delivery into out-of-hospital
services creates significant workforce requirements that are a
challenge to the whole health and social care system.
As new models of care develop and existing roles change, there
will be a need to understand the changing educational needs of
our workforce and how we meet these future requirements.
The CCGs will continue to work with partners including Health
Education Thames Valley (HETV), Oxford Academic Health
Sciences Network (AHSN), and The Institute of Integrated Care
at Bucks New University (IIC) to undertake local workforce
In order to do this effectively, a programme management
structure will be put in place designed to ensure that the most
appropriate people are working together, that changes made
continue to be relevant, that responsibilities for delivery are clear
and that risk is managed.
20

Engagement - Patient and Community Empowerment
A key element to success will be the ongoing and meaningful
engagement of patients, carers, communities and
stakeholders.



The CCGs recognise the need to work differently with our
communities to maximise their input into designing services
and decision making. For each individual project area the
most appropriate way to engage with the target population will
be considered.
understand local nuances and variation in service
delivery, healthcare roles, patient needs, behaviours
and cultures
align expectations
ensure clarity and continuity of message
ensure effective delivery.
Where necessary this will be through informal relationships
and networks, also more structured approaches as required.
Dynamic and responsive localities
The aim will be to involve the relevant community in the most
effective way, thereby attempting to engage with those that
have historically been described as “hard to reach”.
The importance of locality working in achieving our ambition
has been highlighted earlier in this document.
Our vision for increased out-of-hospital care is clear. It is
strongly believed that different localities may wish to adopt
different approaches to delivering our overarching Primary
Care Strategy to their particular population and the diversity of
innovation required would be supported.
The outcome of this will be to empower patients to have a say
in the services that affect them and their community. This will
be supported by a multichannel communication plan which will
define a number of communication methods available
including group sessions, expert patients and web based
discussion forums.
Engagement - integrated and partnership working
Achieving transformation of out-of-hospital care will require
effective partnership working to:
21
model (see appendix 2), care planning approach and
Public Health plans for a lifestyle gateway. This work
will contribute to the general practice demand
management action plan as recommended from the
HASC inquiry and linked to NHS England under cocommissioning.
Next steps
The next step on our journey for primary care and increased
out-of-hospital provision is to get the strategy out to our
stakeholders so that they know and understand the positive
intention for primary care. This will take a concerted
communications effort and some of this work has started as a
work stream under the diabetes redesign. This requires
responsive and capable providers so work will be ongoing to
assist providers to respond effectively to this strategy.
This is a five year strategy which will be delivered through a
number of operational plans owned by the relevant CCG
locality and project teams. These plans will be more focused
with clear deliverables expected over a one to two year period
depending on the scope and complexity of work. The plans
will be reviewed each year to ensure alignment with the
strategy, local ambition and subject to agreed programme
management structures.
During year one it is our ambition to deliver the following:

Primary care workforce audit and plan in
collaboration with partners including NHS England,
HETV, Oxford AHSN, and The IIC.

A whole system programme to increase selfmanagement building on the Live Well – Stay Well
22

An integrated 24/7 patient record building on the
work started with the Bucks Co-ordinated Care Record
and implementation of the Medical Interoperability
Gateway (MIG).

Implementation of system-wide care planning
approach to care supported by the House of Care
Model developed by the Year of Care Partnership. Our
aspiration is to embed a new system of working to
deliver a care planning “Quality Standard” across
services using diabetes as the preliminary focus and
then systematically rolling it out.
Appendix 1: Design Principles (adapted from Edwards, Smith and Rosen’s work (2014))
Access and Continuity
23
Patients and Populations
24
Information, Outcomes and Engagement
25
Management and Accountability
Organisation and
Management
Primary care has
professional and expert
management, leadership
and organisational support
to make strategic and data
driven decisions, long term
and large scale investments
and transformation of
practice operations
Standardise
Primary care needs to do
more to standardise
processes and ways of
working
New models of primary care
will need to be
professionally managed and
any networks/organisations
will require expertise in
population health needs
assessment, information
systems, human resources,
process improvement,
strategic planning and
general management
Contracts for
Value
Commissioners need to
move away from contracts
that count visits or require
large amounts of box ticking
towards outcomes. The
more primary care providers
are able to take full
responsibility for their
populations the more
straightforward this
becomes
Rigorous accountability for
outcomes and transparent
govenrance are still required.
Public confidence in the
choices their primary care
practitioners make must not
be undermined
26
Appendix 2:
27
Agenda item:
Governing Body Meeting
12th March 2015
UPDATE: Better Care Fund
Purpose of Paper:
To update on progress on implementation of the BCF and seek approval for the S75.
Executive Summary:
The BCF begins in April 2015. Progress is being made on implementation and the
alignment of services to drive benefits across the system and for the people of
Buckinghamshire. A s75 between the CCGs and Buckinghamshire County Council
will underpin the work and Governing Body approval is sought for that agreement.
Actions Required:
To note progress on implementation and agree the principles of the S75 agreement
that underpins the BCF.
Objectives supported by this Paper (Please Tick)
√
Support delivery of in-year performance and the financial plan
Support transition to clinically led commissioning
Support development of the CCG to take on the commissioning role
Development of the working relationship between the Commissioning
Support Services (CSS) and AVCCG
√
Supports Quality Agenda
BUCKINGHAMSHIRE
….
better together
Integrated Care Programme
Better Care Fund S75
Background
The Better Care Fund (BCF) S75 is a national requirement of every health and social care economy.
The pooled budget must be established by April 2015. Buckinghamshire County Council, Aylesbury
Vale and Chiltern CCGs have jointly submitted BCF plans which were finally approved by the
Secretary of State in December 2014.
These plans and the underpinning s75 pooled budget build on the work on integration which has
taken place over the last few years in Buckinghamshire. A clear commissioning strategy has been
developed which articulates the changes that will be made. The first priority is a county wide Rapid
Response & Reablement Service.
BCF Plan
The BCF plan describes a 4 tier model of care:
There are several key components for the delivery of this new model: a county wide Rapid Response
& Reablement Service, Integrated Locality Teams that operate both at the stage of early intervention
and prevention and in the delivery of long term care and community lifestyle hubs that support
people to care for themselves, living, ageing and staying well. A Commissioning Strategy has been
developed which will drive the service improvements.
Page 1
BUCKINGHAMSHIRE
….
better together
S75 Pooled Budget
The S75 is made up of a variety of elements and creates a joint commissioning budget which will
drive change in the provision of care. The vast majority of funding will come from the NHS with the
exception of the social care capital grant and the Disabled Facilities Grants.
Key principles of the S75 are:
•
•
•
•
•
The pool will be governed as other joint commissioning budgets through the Adult JET
The pool will be held by BCC with responsibility for overspends and underspends being
technically held by CCGs and BCC respectively in line with the original commissioning
organisation. The responses and allocation of funds in the event of over and underspends
will however be discussed and agreed by the Adult JET.
A joint commissioner funded by the pool will lead on commissioning the services funded by
the pool
£7.66m has to be allocated to ‘protecting social care’ in line with national conditions
£1.5m must be spent on DFGs, £1.4m on Care Act Implementation and £0.9m on social care
capital
Risks are monitored through the Integrated Care Programme Board, Adult JET and the Health and
Wellbeing Board.
The Governing Body is asked to note progress to date, the key principles underpinning the pooled
budget and support the Accountable Officer to sign the S75 agreement.
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BCF Integrated Care Commissioning Strategy
th
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Commissioning Strategy: Integrated Care
for Frail Older People (Final)
February 2015
Report owner: Lesley Perkin
BCF Integrated Care Commissioning Strategy
th
Last Updated 18 February 2015 (Lesley Perkin)
Table of Contents
Table of Contents....................................................................................................................... 2
Glossary ...................................................................................................................................... 4
Executive Summary .................................................................................................................... 5
The context of a developing partnership ................................................................................... 7
Vision for integrated care in Buckinghamshire .......................................................................... 9
Dependencies and developments ................................................................................ 12
Section 2 - Operating Model .................................................................................................... 14
Tier 1 and 2 – Living well, prevention and early intervention ................................................. 15
Preventative services .................................................................................................. 15
Introduction to the pathway ............................................................................................ 15
Future model for preventative services ........................................................................... 15
Proactive case finding and referrals ................................................................................. 17
Integrated case management (delivered by Integrated Locality Teams) ........................ 18
Tier 3 – Integrated Rapid Response and Reablement.............................................................. 19
Current model of service delivery ................................................................................ 19
Introduction to the pathway ............................................................................................ 19
Current model of Admission Avoidance (step-up) services in Buckinghamshire ............ 19
Current model of Discharge Support (step-down) services in Buckinghamshire ............ 21
Establishing the opportunity and improvement potential ............................................ 22
Key opportunities in the As-Is process ............................................................................. 22
Future model of Admission Avoidance and Discharge Support services in
Buckinghamshire ........................................................................................................ 23
Overview .......................................................................................................................... 23
Key elements .................................................................................................................... 25
Tier 4 – Integrated Long Term Care ......................................................................................... 31
Current model of service delivery ................................................................................ 31
Introduction to the pathway ............................................................................................ 31
Establishing the opportunity and improvement potential ............................................ 32
Key opportunities in the As-Is process ............................................................................. 32
Future model of Integrated Locality Teams in Buckinghamshire ................................... 33
Overview .......................................................................................................................... 33
Key elements .................................................................................................................... 33
Appendix 3 – Individuals who have inputted into the development of this FBC. ...... Error!
Bookmark not defined.
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BCF Integrated Care Commissioning Strategy
th
Last Updated 18 February 2015 (Lesley Perkin)
Version Purpose/Change
Number
0.1
Initial draft programme board
0.2
0.3
0.4
Final
Author
Date
L Perkin/M
05/12/2014
Dearing/T O’Connor
Updated draft including comments from L Perkin/M
19/12/2014
Rachael Rothero/Ali Bowman/Susie
Dearing/T O’Connor
Yapp/Karen West/David Williams/Annet
Gamell
Updated draft including comments from L Perkin
19/01/2015
key stakeholders
Changes made following Integrated
L Perkin
09/02/2015
Care Programme Board
Final document
L Perkin
18/02/2015
This document builds on the Integrated Care Outline Business Case – approved by CCGs, BCC
(May 2014) and Health and Wellbeing Board (26th June 2014).
It also links with the Better Care Fund templates submitted in February 2014, September
2014 and November 2014.
It underpins the s75 BCF pooled budget agreement between Buckinghamshire County
Council, Aylesbury Vale and Chiltern Clinical Commissioning Groups.
3
BCF Integrated Care Commissioning Strategy
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Last Updated 18 February 2015 (Lesley Perkin)
Glossary
ACHT
AVCCG
BCC
BHT
Bucks Care
CCCG
Home
MuDAS
OBC
OPAT
Patient
Rapid Response
Reablement
Rehabilitation
SPR
Adult Community Healthcare Team
Aylesbury Vale Clinical Commissioning Group
Buckinghamshire County Council
Buckinghamshire Healthcare NHS Trust
Buckinghamshire Care
Chiltern Clinical Commissioning Group
Refers the place of “home” which may be another place
e.g. residential home
Multidisciplinary assessment service
Outline Business Case
Outpatients Parenteral Antimicrobial Therapy
Patient and service user are interchangeable terms within
this document
Provide a swift response to people’s health and social care
needs
Services for people with poor physical or mental health to
help them accommodate their illness by learning or
relearning the skills necessary for daily living
Rehabilitation is an active, collaborative process. It uses all
possible measures to help an individual to restore or
maintain physical, psychological and social functioning
Single Point of Referral
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Executive Summary
This Commissioning Strategy for Integrated Care builds on Buckinghamshire’s Better Care
Fund submission and the Outline Business Case completed in June 2014 and, along with an
accompanying S75, presents the first stage of the case for change for integrated care in
Buckinghamshire.
We need to commission and provide person centred care that supports people to stay
independent for as long as possible. We know that continuing as we are in a disjointed and
fragmented system is not sustainable for the organisations involved and is not meeting the
needs of the people who use our services even if at this stage it is hard to prove that there
will be significant financial benefit.
Millions
Increasing demographic and financial pressures on the health and social care system means
that maintaining the status quo is not an option. The OBC reviewed £103.4m of services
commissioned by BCC, AVCCG and CCCG and forecast that if these services continue to be
delivered as-is, over the next 5 years, income growth will fail to match demographic growth
and cost inflation and the annual gap increases to £11.9m by 2018/19, with the total deficit
over the period being £41.0m (the assumptions used factor in the effect of QIPP and MTP
savings plans). The whole system profit and loss project (P&L) has re-enforced the financial
challenge within the system and estimated the affordability gap to be £185m by 2018/19.
£130
£125
£11.9m
£120
Funding
£115
Expenditure
£110
£105
£100
13/14 14/15 15/16 16/17 17/18 18/19
We know that the context is constantly changing and evolving and we must design services
that promote integrated working and are flexible enough to respond to other system wide
changes. The aim is to move away from silos, not create new ones. The scope of this plan is
focussed on the development of an integrated approach to commissioning the first £28m of
a potential £100m of spend. It is a critical initial step on a journey to jointly finding solutions
to the known challenges and developing capability and capacity of the system and the
people working in it to effectively manage future challenges.
Given the data currently available and local and national experience this strategy advocates
a staged programme of transition to integration supported by a pooled budget. In the first
instance commissioners will work with existing providers to align capacity within the system
and strengthen the system-wide approach to meeting individual need. As commissioners
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and providers develop increased knowledge and understanding around the effectiveness of
integrated working they will be able to further innovate to derive even greater benefits to
meet the future needs of Buckinghamshire residents. In a changing health and social care
economy, locally and nationally, the recommended approach provides a sustainable
foundation on which to build.
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The context of a developing partnership
It is impossible for health and social care organisations in Buckinghamshire to continue with
the status quo of service provision and deal with the rising tide of costs driven in part by the
demographic pressure. Whilst there is no cast iron evidence that integrating commissioning
and provision will solve the problem there is evidence that it improves the quality of care to
the people receiving those services which in turn will yield efficiencies in the system.
The OBC identified over £100m of current expenditure that is being spent on services that
operate in what would become Tiers 1 to 4 of the new model. The OBC also identified, from
use of the LGA toolkit, that changes to service models in this area can yield financial
benefits. For example an extrapolation of the introduction of an integrated rapid response
and reablement service in Greenwich1 suggests that savings of £9m could be made in
Buckinghamshire for health and social care partners. Whilst in the first instance this strategy
concentrates on the £28m that is spent on tier 3, the potential opportunity is clear.
The Five Year Forward View2 gives a clear indication that there will be opportunities to
develop new service delivery models such as Multi Specialty Community Providers and
vertically integrated providers that include general practice. These models are not yet fully
defined but any developments in services in Buckinghamshire must be flexible and
responsive as the future unfolds.
Work on developing partnership between health and social care is aligned to recent
government policies and statements outlined in the table below:
Partnership Working Policy Context
Policy
Date
NHS Restructuring
Health & Social Care Act
2012
Deficit reduction and
rebalancing the
economy
2013 Spending Round plans for government
spending, including
departmental
settlements, for the year
2015 to 2016
Local service reform Sustainable and
affordable health and
Autumn Statement
December 2013
1
2
Summary
Important background for the Better
Care Fund as it established much of
the current health system, giving a
high degree of autonomy to clinical
commissioning groups and establishing
their relationship with NHS England.
The government made better
cooperation between local services a
main objective for the 2013 spending
round with the goal of maintaining the
quality of services while reducing the
cost to the public. It announced the
Better Care Fund (then known as the
Integration Transformation Fund)
The 2013 Autumn Statement set out
the government’s intention to support
local areas that want to deliver
Royal Borough of Greenwich Integrated Reablement Service
Five Year Forward View, NHS, 23rd October 2014
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social care system
Reform of Adult Social
Care
Care Act 2014
services differently if they can show it
will save money, including by: “making
sure pooled funding is an enduring
part of the framework for the health
and social care system beyond 201516”.
Under the Care Act 2014, NHS England
can direct clinical commissioning
groups to use and pool money to
integrate health and social care
services. NHS England can also impose
conditions regarding plans to spend
this money, and may withhold or
recover payments where conditions
are not met.
Following the agreement of an initial outline business case, and agreement of the Better
Care Fund submission, commissioners in Buckinghamshire have all signed up to deliver the
vision of integrated for care for older residents in the county. This has been supported by
the nationally prescribed requirement for local areas to progress integration across health
and social care and create a pooled budget for this.
The partners in Buckinghamshire have clearly articulated in a number of forums that the
current delivery model is not sustainable and needs to change to manage increasing
demand. This commitment has been supported by national and local experiences
demonstrating joint working across health and social care can improve patient outcomes
(for example locally in mental health services). In Buckinghamshire there are already welldeveloped partnerships and examples of integrated care particularly in mental health
services.
Nationally there is a lack of robust empirical evidence for the benefit of integration to fall
back on and it is recognised that local solutions and conditions mean a local solution is
always required (Five Year Forward View). The national direction of travel, as mirrored
locally, is being informed by wider strategic ambition for collaboration and an intuitive
knowledge that a joined up approach will deliver improved patient outcomes more
efficiently.
Whilst at a strategic level the direction of travel is agreed, in building this case for change a
number of system wide challenges have been identified which have impacted the partners
ability to accelerate the delivery of a new model and evidence the benefits of
implementation. These include:
 Data – at a local level there is a lack of consistent data surrounding the demands and
costs across the system
 Confidence in partnerships – arguably driven in part by data, there is a lack of service
performance visibility, which in turn impacts the level of trust between the partners
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


Provision – existing providers deliver a range of wider services and there is a desire to
maintain stability within these at a time of rising demand and there are existing
contractual arrangements that need to be taken into consideration
Knowledge – operational teams work in very discrete silos and there is a need for more
alignment to allow teams to build improved knowledge of each other’s operational
practices
Geography – many of the wider national evidence relates to smaller urban centres where
it could be argued integration does not pose the same risk to wider operational delivery
Development of the partnership journey is already underway but current contracts for
health and social care services dictate the requirement for a phased implementation
approach with the first opportunity to re-commission integrated rapid response and
reablement services being in 2016. In the interim period work will start on the alignment
between providers of existing services, developing joint understanding of the systems and
building the operational, financial and quality performance framework to drive continuous
improvement. Staged benefit review points using the key indicators of non-elective hospital
admissions, nursing home admissions bed occupancy and proportion of patients not
requiring services after reablment will assess the impact and effectiveness of partnership
working. Whist often viewed as a healthcare measure, hospital admissions are a key proxy
for system wide benefit, given that reductions in hospital admissions and shorter stays are
widely known to reduce dependency on health and social care services.
Vision for integrated care in Buckinghamshire
The partners in Buckinghamshire are seeking to remove the overlap within, and streamline
patient pathways across, health and social services. This will be supported by the
development of joint plans and the pooling of budgets to deliver person centered care in, or
as close as possible, to people’s homes. Whilst older people will be the primary focus of
services, many of the proposed changes will have a wider impact.
Success will be when there is:
 An all-inclusive, personalised service for the citizens of Buckinghamshire
 Service delivery without duplication
 Seamless, high quality, safe and effective pathways of access
 Users driving services and a robust and sustainable model of community engagement
 Evidenced multiagency working through integrated care pathways and excellent care
navigation optimising the use of resources
 The full integration of prevention into care pathways
The key partners in delivering the vision are listed in the table below:
Partner
Ambulance Service
Aylesbury Vale Clinical Commissioning Group (AVCCG)
Aylesbury Vale District Council
Buckinghamshire Care
Commissioner Provider




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Buckinghamshire County Council (BCC)
Buckinghamshire Healthcare NHS Trust (BHT)
Chiltern Clinical Commissioning Group (CCCG)
Chiltern District Council
Oxford Health NHS Foundation Trust
Primary Care providers
Private sector organisations
South Bucks District Council
Voluntary sector organisations
Wycombe District Council











Closer working across partners in the system will facilitate a model that invests more funding
in lower level and wider preventative support, shifting the balance of spending and care over
time. Initially the intention is to align existing service provision to develop better system
wide understanding, release efficiencies, test new ways of working and monitor benefits
realisation. This will allow delivery risks to be managed and as partner confidence develops
this may lead to a formal recommissioining of services, which may include provider
integration.
Buckinghamshire has a strong track record of collaborative working, and to ensure maximum
buy-in from key stakeholders (providers, commissioners, GPs and other professionals), the
integrated care programme will build on the already strong platform of joint initiatives.
What this means for Buckinghamshire is optimising and growing the things that are working
well, as well as radically transforming elements of provision that are not.
For Integrated Care, Buckinghamshire has used the Kings Fund model of health and social
care services to help design ‘what better would look like’ informing the development of a
new, 4-tier integrated model for health and social care in Buckinghamshire. The four tiers of
the integrated service are shown in the table below:
Tier
1. Living,
ageing and
staying well
Objective
Providing coordinated, responsive and
sustainable health promotion services,
and bringing partners together to tackle
negative lifestyle choices, to transform
the overall health of Buckinghamshire
2. Prevention
and early
intervention
Identification of and support for
individuals who are vulnerable, and at
risk of requiring support in the future
3. Rapid
response and
reablement
Co-ordination of services to individuals
during a period of rapidly escalating
health or social care need, in order to
Components
a. Multi-agency prevention
strategy
b. Behaviour Change
programmes
c. Integrated Lifestyle Service
d. Planning for older age
a. Proactive case finding and
referrals
b. Integrated case management
c. Community based
prevention services
d. Digitalisation, adaptation,
equipment and housing
a. Rapid response
b. Reablement
Focusing on step up as well as
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4. Integrated
long-term
care
avoid attendance at hospital or the
requirement for a long-term care
package
Reshaping long-term care services
around a common understanding of
service users’ needs and establishing a
single approach to market management
across the health and social care
economy
step down.
a. Integrated locality teams
b. End of life care
The operating model will be implemented over the next five years and represents a radical
shift from traditional models of service delivery. It moves away from providing services that
can create dependency, discourage self-care and undermine people’s confidence, to those
that inform and empower individuals to manage their own health and wellbeing and make
informed and personalised decisions. We will provide targeted and tailored approaches
that provide individuals with effective support to take personal responsibility for their own
health and wellbeing.
30s, 40s, 50s, 60s, 70s, 80s, 90s ►
70s, 80s, 90s ►
Self-management
Planning
for old
age
Healthy
life
choices
Integrated end of
Person-centred,
life pathway
dignified, long term
care
Early intervention
and prevention
for vulnerable
individuals with
sub-threshold
needs
Living
well
+
Crisis /
deterioration
Rapid
response &
reablement
a) Case
management
Primary Care
b) Care packages
Ageing
well
Living, ageing & staying well
Early intervention & prevention
Integrated rapid response &
reablement
Integrated long-term care
There are a number of underpinning national conditions in the Better Care Fund and we are
seeking to use these to inform our integrated working agenda. These are:
 Plans to be jointly agreed
 Protection for social care services
 As part of agreed local plans, 7-day services in health and social care to support
patients being discharged and prevent unnecessary admissions at weekends
 Better data sharing between health and social care, based on the NHS number
 Ensure a joint approach to assessments and care planning and ensure that, where
funding is used for integrated packages of care, there will be an accountable
professional
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
Agreement on the consequential impact of changes in the acute sector.
Dependencies and developments
Since the original vision was agreed as part of the outline business case there has been a
need for things to develop as the local health and social care system was unable to sit still.
There is a need to ensure that these developments and their implications are factored into
future delivery plans.
The following table lists the key developments and their leads.
Ref Development
D1 Primary Care
Strategy
Date
March
15
Lead
Dr Chris North, Dr
Malcolm Jones,
Nicola Lester,
Louise Smith
D2
March
15
Tracey
Ironmonger
April 15
Susie Yapp
Ongoing
Robert Majilton
Ongoing
Dr Becky MallardSmith, Dr Kevin
Suddes
John Lisle, Colin
Thompson
D3
D4
D5
D6
D7
D8
D9
Impact/Risk
Overarching strategy considering
future models with impact on activity
in Tier 1, 2, 3 and 4
Maintain a programme approach to
ensure models of care are aligned
Public Health
Developing model for Tier 1 and part
Strategy
of Tier 2
Maintain a programme approach to
ensure models of care are aligned
Care Act
Implementing early advice activities
implementation
which links to Tier 1
Maintain a programme approach to
ensure models of care are aligned
Profit and Loss
Finance model being developed for
the whole system
Harder to see system wide impact of
changes with model
System Resilience In year service changes
Planning
Ensure re-commissioning decisions
account for future plans
Over 75 Fund
In year service changes
Ensure re-commissioning decisions
account for future plans
Single Point of
Developing interim SPR to support inReferral
year development
Estates Review
Review of estate across the system
(including community hospital
provision)
Maintain a programme approach to
ensure milestones are aligned
IT Interoperability Enabling integrated IT across the
system
Maintain a programme approach to
ensure milestones are aligned
14/15 &
15/16
Feb 15
Mar 15
&
ongoing
April 15
Jeanie Brown
(PM)
David Williams
Colin Thompson
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Section 2 - Operating Model
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Tier 1 and 2 – Living well, prevention and early intervention
Preventative services
Introduction to the pathway
Tier 1 comprises a universal, community based primary prevention and self-management
offer to all residents of Buckinghamshire. Notably, as demographics vary across the county,
delivery of locality based services need to be flexible and where necessary, tailored to
particular groups and/or needs.
The key components of this tier will be:
 A multi agency prevention strategy
 Behaviour Change programmes and tools through online support
 An integrated lifestyle service
 Planning for old age
Tier 2 services are for those that have gone beyond the services of Tier 1 but currently drop
below the threshold for the crisis response, reablement and long term care services of Tiers
3 & 4. We believe those people include older people with escalating health needs, adults
identified as having a moderate to high risk of developing a long term condition, adults with
established long term conditions but current social care needs are sub-threshold and
residents who have received a period of reablement but do not currently require long term
care interventions.
The key components of this tier are:
 Proactive care referrals
 Integrated case management (Link to Tier 4)
 Community based prevention services (including Prevention Matters)
 Digitalisation, adaptations, equipment and housing
The Joint Strategic Needs Assessment identifies the challenge facing Buckinghamshire
related to the level of unhealthy behaviours among the adult population. Factors such as a
sedentary lifestyle, smoking, obesity and drinking alcohol above recommended levels are
fuelling increases in preventable long term conditions such as heart disease, stroke and
diabetes. These conditions are contributing to rising social care needs.
Future model for preventative services
The Public Health team in BCC is developing the Buckinghamshire Public Health Strategy for
March 2015. This will encompass the key elements of Tier 1 and some of the elements of
Tier 2 as well as encompassing the key elements of the Care Act. The following section
outlines their initial thinking in developing this approach.
The Care Act identifies prevention as a key component in managing demand for social care
services and three levels of prevention defined within the Care Act:
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1. Primary prevention – this is aimed at individuals with no current care needs. It
includes universal services to promote healthy lifestyles and action to tackle the
wider determinants of health
2. Secondary prevention - this is aimed at individuals at higher risk of developing
disease, disability and care needs. It includes screening and early case finding and
action to prevent deterioration
3. Tertiary prevention – this is aimed at minimising the effects of disability or
deterioration in people with existing health and care needs
Primary and secondary prevention require a whole system approach to prevention and
multi-agency responses to tackling the wider determinants of health. It aims to enable
individuals to be encouraged and where required supported to self manage and take
personal responsibility for their health. The action of partners on the wider determinants of
health should aim to make healthier choices the easier choices. Tertiary prevention requires
prevention activities to be fully integrated into care pathways. The integration activities for
all tiers will draw upon the existing County Council responsibilities for public health, the
prevention priorities in the new 5 year plan for the NHS, the existing multi-agency strategies
and work programmes and be coordinated by the Healthy Communities Partnership.
Buckinghamshire aspires to deliver large scale access to behaviour change support for all
and targeted activities to enable those at greatest risk of poor health to improve their health
and wellbeing. Work is currently being undertaken to develop a public health strategy and a
model for living, ageing and staying well which provides coordinated behaviour change
services. The approach for this model will incorporate:
 Action throughout the lifecourse - This recognises the impact of health pre-birth and
in early years on health in adult life
 Proportionate universalism – This requires the provision of universal services, but
with targeted action where the scale and intensity is proportionate to the risk of poor
health.
 Acknowledging and working with the role of communities and social networks –
these factors shape social norms. Work will include engaging communities and social
networks in the planning and implementation of key programmes and through this
shaping social norms and behaviours. This should include innovative approaches to
engage communities who are ‘seldom heard’
 Tackling the wider determinants of health
Prevention programmes will focus on a number of key priorities:
 A focus on healthy pregnancy and early years
 The Big 4 lifestyles (being physically active, reducing smoking, maintaining a healthy
weight and drinking alcohol within recommended limits)
 Promoting mental wellbeing (including preventing loneliness and social isolation)
 Falls prevention and bone health
 Drugs misuse and alcohol treatment services
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A summary of the key components of the prevention programme are provided below:
Level
3. Primary
Prevention Living, ageing
and staying
well
4. Secondary
Prevention
early
intervention
Objective
Components
Providing coordinated,
responsive and sustainable
health promotion services, and
bringing partners together to
encourage and make healthy
choices the easier choices, to
transform the overall health of
Buckinghamshire
Identification of and support for
individuals who are vulnerable,
and at risk of requiring support
in the future
a. Integrated lifestyle services,
including effective use of digital
tools and social media
b. Multi agency prevention
programmes
c. Planning for older age
a. Proactive case finding and referrals
b. Use of behaviours such as being
more physically active, stopping
smoking and losing weight
therapeutic approaches to reduce
the progression of long term
conditions
c. Integrating prevention into the
management of long term
conditions
d. Community based early
intervention services such as
Prevention Matters
In addition to the existing prevention work programmes, action will be taken within the next
year to:
 Commission a web and app based digital personal health management tool to
support residents to assess their current lifestyles, identify personal health goals and
tools to support lifestyle changes
 Work with the CCG’s and Social Care to integrate prevention into care pathways and
front line activity. The Making Every Contact Count training programme will be a key
aspect of this activity.
 The development of a model for integrated behaviour services to inform a longer
term commissioning and resourcing strategy
Proactive case finding and referrals
Buckinghamshire has invested in the development of MAGs (multiagency teams) that
operate at almost every GP practice in the county. The model involves key members of all
relevant teams coming together to identify and discuss the most vulnerable people on their
caseloads that they believe would benefit from a more holistic approach to enable them to
maintain their independence.
Early evaluation both qualitative and quantitative has shown benefits from this approach
including improved working across teams and reduced hospital admissions. Work will
continue in the following areas:
 refine the model
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


ensure that all teams can be fully involved for the benefits of all the patients whether
known to them or not
make best use of technology to support team engagement
support patients who live in boundary areas and evaluate the impact on individuals.
MAGs will be a key component of the future model in terms of supporting the identification
of people at risk. It is further expected that the model will develop to link appropriately to
Integrated Locality Teams and community geriatricians.
Integrated case management (delivered by Integrated Locality Teams)
The integrated case management element of Tier 2 will be to ensure early interventions are
taken which will minimise the risk of a crisis developing that requires a rapid response &
reablement response, a hospital admission and/or an increase in long term care packages.
This element of care will be delivered in practice by the Integrated Locality Teams who will
also be operating at Tier 4. They will be linked to GP practices and attend MAGs, undertake
early interventions and support people with long term care needs. The teams will be
supported by specialists operating from secondary care to maximise the benefits from long
term condition management in the community.
Future enhancements
In the first instance these teams will be created by co-location and alignment but in future
we would expect to see the creation of synergies realised between domiciliary care
providers, the ACHTs, practice nurses, mental health staff and social workers as well as the
integration of various voluntary sector providers.
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Tier 3 – Integrated Rapid Response and Reablement
Current model of service delivery
Introduction to the pathway
The focus of this tier is to coordinate the delivery of a range of services to support
individuals to remain independent at home with reduced admission of the frail elderly to,
and accelerated discharge from, hospital settings and reduced demand for social care
support with improved outcomes and reduced costs across the system. Whilst the patient
may be deemed as “not in need of acute services” their individual circumstances mean that
their ability to function safely at home cannot be assured. As such some form of intervention
is required which would traditionally be covered by community health and/or social care. It
is well established that a frail elderly person starts to decompensate after 4 hours in a
hospital setting which affects both their health and social care needs from then onwards.
This cohort is in part common to health and social care partners and if unmanaged they will
become a pressure for all service commissioners. To address this the Rapid Response and
Reablement services are intended to put in place support on a time-limited basis to support
independence. The preference is for these services to be delivered in the home, but in
limited cases it may be appropriate to be provided in a bed based facility.
Overall the outcome is to minimise unnecessary hospital stays and/or delay the requirement
for social care packages. This not only improves patient life outcomes, but also reduces costs
in terms of acute hospital bed days and a lower complexity of care packages.
The tier is considered from two perspectives:
A. Avoidance (of additional long-term social care services and/or hospital admission – StepUp) – a range of interventions to support people with health and/or social care needs to
stay at home to avoid additional service needs, admission to hospital or other long-term
care. The service would apply to people in their own homes or at a hospital
B. Discharge (Step-Down) – Enabling discharge from hospital settings, ideally returning to
home
It is the expectation from commissioners that the emphasis is increasingly on the avoidance
element of service to use facilities to ‘step up’ care for an individual to avoid a hospital stay
or need for more permanent social care services.
Current model of Admission Avoidance (step-up) services in Buckinghamshire
The entry point is for patients in the community. Patients may self-refer in, but it is more
common to be referred in by a professional to either the: Locality ACHT (including rapid
response); Hospital via Ambulance; or directly to Social Care (CR&R). The patient undergoes
an assessment by the receiving organisation who determine whether a service is required to
meet the identified needs.
Where necessary the assessing organisation will seek to put in place a support service or
refer on to another organisation – currently the service provided may vary depending on the
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organisation and their service contracts. Rapid Response services are currently only Nursing
led, whilst there are two different reablement focused services available: one health therapy
led service provided by the ACHTs; and one social care led service provided by
Buckinghamshire Care (Bucks Care). Whilst there are different service provision
arrangements to meet individual needs (e.g. meal preparation vs meals on wheels), there is
a recognised level of similarity and service overlap.
Services are intended to be short term, normally 2-3 weeks for ACHT and up to 6 weeks for
Bucks Care, (and are not subject to financial eligibility issues), after which the intention is
that patients are able to care for themselves at home. Where a patient is not deemed fit for
discharge, supporting services continue to be provided, impacting capacity, whilst an
assessment for longer-term services (typically social services) is undertaken.
Patients can be referred from a GP into a ‘step up’, bed which is almost always a community
hospital facility. This is arranged by registering the patient on the Strata (electronic referral)
system. The community hospital beds are managed by the Elderly and Community
Directorate at BHT. At present approximately 15% of the community hospital beds are used
for step up services.
Family/Friend
Referral
Ambulance
A&E
Acute Hospital
Step Down
Crit ic
al
# patients
No Service
pa
t ie
nt
s
Community
Hospital
# patients
#
Professional
Referral
GP
DN
Etc.
# patients
Assessment
(ACHT/Locality)
# patients
#p
at ie
n
At home support
(ACHT)
Assess fit to
discharge
(ACHT)
ts
# patients
# patients
No Service
Self-referral
CR&R
# patients
Reablement
Homecare
Res care
Nursing care
No Service
Step-up As-is
Figure 1 - Hospital Admission & Long-term care avoidance
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Current model of Discharge Support (step-down) services in Buckinghamshire
The entry point is for patients in a hospital setting. When the patient is declared medically fit
for discharge on the ward (agreed at daily meeting) they are currently either discharged,
transferred to a community hospital (referred via the Strata system) or referred for an
assessment for support to enable discharge.
The assessment may be undertaken by ward based staff, the Community Transfer of Care
Team or for more complex cases the Complex Discharge Team. For routine cases within the
acute setting, the ACHT will assess the patient and put in place a package of rehabilitation
support to enable the patient to return home. If following intervention, further support is
deemed necessary then a referral will be made to the Local Authority for access to
reablement and / or a formal assessment for social care.
In the case of a complicated discharge, the Complex Discharge team co-ordinate a range of
assessments within the acute setting to review the specific needs of the patient. This could
include a continuing healthcare assessment, mental health assessment and local authority
assessment (hospital social work team).
# patients
# patients
Discharge
Discharge
# patients
# patients
Community
Hospital
# patients
# patients
Ward Based DFM
Patient medically
fit for discharge
ACHT
Reablement
# patients
# patients
Health services
CHCT
# patients
Complex
Discharge
MHT/PIRLS
# patients
# patients
# patients
CMHT/Acute
Psych Care
# patients
Bucks Care
reablement
LA Team
# patients
# patients
# patients
Discharge
Other Service/
placement
# patients
# patients
CR&R
Discharge
Step-down As-is
# patients
Figure 2 - Discharge support as-is process
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Establishing the opportunity and improvement potential
Key opportunities in the As-Is process
Current Model
Improvement Opportunity
Duplicated points of entry for reablement
 Single contact and co-ordination point
services within ACHT and Bucks Care
 Single multi-disciplinary assessment process to
(reablement assessors). Both go on to assess
streamline care need planning
for entry into respective services, in addition to  Confidence in service to deliver services in a
in hospital assessments.
timely fashion
 Assessment carried out as part of service delivery
where possible
Some commonality in service provision across  Pool collective reablement resources to increase
ACHT and Bucks Care – in addition there are
access to a range of services available for all
some differential service standards between
patients through the pathway
the two providers.
 Ensure most appropriate resource is utilised
based on patient need
Professional skills are not optimised – some
 Optimise use of professional capacity and
tasks may be undertaken by overly skilled staff
maximise available resource
Services are operated from different bases with  Collaborative working and co-location exploited
ACHT’s operating from 7 sites across the county
to enable knowledge sharing and joint working
and Bucks Care operating a field based delivery
(e.g. joint assessments)
model
 Technology used to maximise access to relevant
patient insight
Multiple points of referral for ward based
 Single point of referral to co-ordinate response
teams
 Faster response for patients
Several hand-offs in process to manage transfer  Reduce handoffs and improve patient experience
from hospital into reablement services
Fit for discharge from reablement patients
 Consider onward service requirement earlier and
remain in service whilst further assessments
align start of onward services with the end of
and services are being arranged (ACHT/Bucks
reablement
Care)
 Increase capacity
In-built delay as a result of adherence to
 Application of lean principles to manage demand
statutory timeframe (e.g. section 2s and 5s)
as it arrives and reduce ongoing dependency
Community hospital/bed based provision used  Shift the focus to prevention by putting the
predominantly for step down capacity
control of the beds into the Rapid Response and
Reablement team to support the avoidance
element of the service
Different operating hours and entry points:
 Align and extend operating hours to maximise
limited hospital social work and CR&R at
outcomes for patients
evenings and weekends. ACHT operate 24/7
Patients can receive duplicate assessments –
 Establishment of common assessment processes
hospital and community clinical staff, hospital
and community social workers
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Future model of Avoidance and Discharge Support services in Buckinghamshire
Overview
The future model will provide an integrated service pathway coordinated and triaged by a
single clinically led point of referral. The entry points will be from community and ward
based professionals, but at its core will be a common rapid response and reablement
function delivered through aligned rehabilitation and reablement services with a focus on
preventing the need for admissions to hospital and minimising the need for long term care
packages. The services will initially be delivered through an alignment of the existing
providers. The principle of continual assessment will be used throughout the reablement
service pathway to allow follow-up services to be arranged, enabling a seamless transfer of
care as appropriate.
The Reablement service will be directed following the referral depending on need. The most
appropriate response and intervention lead will be identified so that the initial response has
the best chance of meeting initial needs. The following figure provides a matrix to exemplify
the multiple different options which may apply and as a patient progresses they may move
from one lead to another.
Figure 3 - Response / Intervention Lead matrix
The service will be operated as an aligned county wide multi-disciplinary team. However
there would be at least 3 bases for the staff across the county from which field based
resources can be co-ordinated. This would support a person centred approach that is rooted
in a locality. The professionals in the multi-disciplinary team will include: nurses,
occupational therapists, physiotherapists, social assistants, and multi-skilled healthcare
assistants (drawn from ACHTs) and reablement workers and assessors (from Bucks Care).
Some existing social workers will be embedded into the team to reduce hand-offs, facilitate
better quality assessment reflective of longer term needs and minimise risk of delay in
arranging care.
The multi-disciplinary team could be developed further in the medium term to include
consultant geriatrician, pharmacists, older adult mental health, GPs (inc. out of hours) and
paramedics. This may then lead in the longer term to the option for the integration of
services within a single entity responsible for the multi-disciplinary team.
The rapid response and reablement pathway will be common to both admissions avoidance
and discharge processes. The entry points will be from professional referees and is outlined
in Figure 4 below.
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Family/Friend
Referral
Professional
Referral
GP
DN
Etc.
Ambulance
A&E
Acute Hospital
Step Down
Process
Rapid Response & Reablement Pathway
CR&R
Figure 4 - Avoidance and discharge To-Be pathway framework
The rapid response and reablement pathway (see Figure 5) is delivered through a multidisciplined approach and comprises three principle steps: a single point of referral (SPR),
common assessment and aligned service interventions.
Interventions
Assessment/Care
Planning/
Intervention
Nursing
Intervention
Rapid
Response
<3 hrs
SPR
- clinician led
- triage function
No Service
Home-based
Reablement
Next Day
Response
Bed-based
Reablement
Standard
Response
Multi-disciplinary Team
Nursing/OT/HCA/
Reablement Worker/
Social Care/GP/
Consulatant Geriatrician/
Pharnacist
+ Access to MH
Services
Social Services
ACHT
Maximising
Independence
(DV/PT)
Ongoing
Assessment
Figure 5 - Rapid Response and Reablement To-Be pathway
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Key elements
Single Point of Referral







Single countywide telephone based referral coordination point to ensure all onward
assessment and rehabilitation needs are met. This access point may not be the same
contact point for patients once known and in a service.
Clinically led service with administrative support.
The service will be operational 24h/7d. To maximise existing operational cover
requirements it is proposed that the 21:00-7:30 response will be provided by the ACHT
Night Teams to ensure that appropriate rapid response can be mobilised.
The teams will have access to relevant Health and Social Care systems to ensure all
patient records are reviewed.
GP maintains accountability for the patient, but the SPR team is responsible for getting
access to appropriate rapid response and rehabilitation service. (which may include bed
based care). Update on action taken will be provided at the end a rehabilitation episode.
A future development will be realtime progress updates on the shared patient file.
Home from Hospital (Red Cross) service would continue to be used to enable supported
discharge as part of triage services.
The service would manage referrals for community hospital beds to support the
emphasis moving to step up provision.
The referral point is aimed at professionals including:
 Ward based team (for step-down)
 GPs and practice nurses
 GP out-of-hours service
 A&E and other hospital staff
 Community health and social care services
 Ambulance crews
 Nursing and residential care homes
An initial triage conversation will be undertaken with the professional referee to inform and
agree the most appropriate pathway for intervention and assessment. Following this the
appropriate service response will be mobilised in line with the options in Figure 3.
The service will be operational 24h/7d to ensure rapid response can be facilitated. The core
hours for maintaining a full service will be 15h/7d. Currently there are approximately 24,000
referrals to ACHT, 4,500 to the Hospital Social Work teams and 600 to Bucks Care (in
addition to Hospital referrals).It is estimated that 33% of ACHT referrals relate to rapid
response and reablement, and 100% of referrals to Hospital Social work and Bucks Care will
be seeking a reablement assessment. As such the it can be assumed that the number of
referrals to the SPR will be c.13, 000 per year. The staff cover for telephone and electronic
referral needs to be sufficient to meet this demand without excessive wait times for
professionals and the rota needs to be developed to account for call profile and annual
variation in demand.
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Experience from elsewhere
Sunderland3 has created a single point of referral, known locally as the Intermediate Care
Hub. This provides a triage function to ensure people are redirected onto the right pathway.
 Currently operational up to 8pm seven days a week, the next step is to take it to 24/7
 Collects and compiles the data on referrals as well outcomes which allows analysis to be
undertaken
 Staffed by Band 6 Nurses and Social Care staff, with admin support
Feedback from a range of Health and Social Care professionals indicate that the hub has
helped to simplify the supported discharge pathway into intermediate care and reablement
services.
 The service deals with 400 – 500 referrals per month, 74% are for step down from
hospital and an increasing number of referrals are coming from GPs for prevention to
admission into hospital
 Feedback from providers of services indicate they are better informed and are not
receiving numerous requests for services or inappropriate discharges
Future considerations/enhancements





3
Development of closer operational links with GPs (including out of hours) and CR&R
Technology used to enable e-referrals from the ward or professionals whilst in the
home (reducing need to relay the requirement by phone), options may include web
chat
Technology to enable triage assessment to be undertaken by referring professional
to enable automatic allocation to reablement professional
Development of a single staff scheduling system
As part of wider service offer commission a single organisation to provide SPR
Integrated Care Hub: A Sunderland Approach, 2012
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Multi-disciplinary delivery team











Countywide aligned team of professionals drawn from a range of providers with a
manager to coordinate deployment to respond to needs of patients to provide: nursing
and therapy interventions, care planning, short term support and care.
Professional accountability lines will remain in place and where the whole team is not
aligned to the new service, individuals will need to be identified to be part of the team
and its operational rotas.
Operational availability 24h/7d for rapid response, with majority of planned service
interventions undertaken between 7:00 and 22:00
The initial triage screening by the SPR will be used to direct the most likely profession to
lead the first response. This professional lead will have access to the wider team to
discuss options whilst in the patients home.
Working to a single rehabilitation assessment and planning tool.
Able to offer a range of services delivered by different disciplines which could range
from: nursing interventions to manage health conditions, therapy interventions to
support mobility, reablement to support daily tasks of independent living and an
enhanced diagnostic assessment (e.g. MuDAS)
Combined team will enable resources to be allocated to maximise the utilisation of skills
and experience available
Professionals will have easier access to appropriate support from other disciplines to
seamlessly manage the issues presented in more complex cases
Home based services will be the primary model of care with the same pathway being
used for all patients
Bed-based support could be utilised for part of a patient’s pathway where they are not
able to safely remain at home or where part of the response is more effectively delivered
in a care setting. This could be through utilisation of existing bed capacity across the
county (both public and private facilities).
Where initial assessment and patient response suggest ongoing care is likely to be
required the social workers within the team will undertake a care assessment and plan
care as required
To illustrate how this would work a couple of fictionalised scenarios have been developed.
Reg’s story
Reg lives on his own and is 77 years old. He had an entirely appropriate
admission to hospital following a short illness. The ward team decide that he
probably can’t manage at home and so discuss him at the ward based MDT
meeting.
What would have happened before…DFM met, agreed need for ongoing
support and send referrals to both the ACHT and the social care team at the
hospital. 5 days after the medics had said Reg was medically fit he went
home. The ACHT therapist visited and developed a rehab plan for him. After
about 10 days they decided that he would probably struggle to fully care for
himself at home so referred him to social care (CR&R). It took a week before
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Reg was referred to the Reablement service during which tome the ACHTs
continued to provide his care. Once the reablement service took over they
saw him for a further 6 weeks but during that time they realised that
although he wouldn’t need four visits a day he would need some long-term
care so made a referral back to social care. CR&R completed the full
assessment within a week but then it took a further two weeks for the care
package to start during which time the reablement service continued to visit.
What will happen in future…with new services in place, the ward would have
referred him straight to the Rapid Response and Reablement service who
would plan his care. If there were complicating factors they would have sent
someone up to the ward to do an assessment but ideally that would have
been completed once he was home. He would have gone home under their
care and received support to regain as much independence as possible with
input from therapists and reablement workers. Throughout his reablement
journey the team would have been assessing his ongoing care needs and once
it became apparent that he would be unable to manage fully on his own in
the future, the social worker in the team would have started the full
assessment process and care would have been arranged to start as his
reablement pathway came to an end.
Ethel’s story
Ethel lives on her own and has been coping since the death of her husband
two years ago. She’s 81 and has no children living nearby. She felt a bit under
the weather last week and didn’t go on any of her usual excursions to bridge
or the shops. She’s now feeling much worse to the extent that she called the
GP practice. The GP made a house call a few hours after her call to the
surgery. He was concerned that she would deteriorate even further left at
home on her own although unable to pin point a particular new medical issue.
What would have happened before…her GP called the medical registrar at the
hospital and requested an ambulance to take Ethel to the hospital.
Ethel was admitted with dehydration and put on CDU. Whilst in hospital Ethel
was kept in bed and lost confidence in her ability to look after herself.
She stayed in hospital for 6 days and then came home with support from the
ACHT. They provided care and support with visits 3 times a day for a fortnight
and then referred her to social care via CR&R. Five days later she was
transferred to the care of the Bucks Care Reablement Service. They provided
visits twice a day for a further 3 weeks and then discharged her.
What will happen in future…with new services in place, the GP would have
made a call from Ethel’s house to the Rapid Response and Reablement team
where a clinician would have made a decision about who to send to see Ethel.
That professional would have, provided some immediate support, made an
assessment and arranged care from the wider team. If Ethel’s dehydration
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could not have been managed at home, she could have gone to a bed based
reablement service for 24/48hrs which would also have been arranged by this
team. She would then have received some reablement support at home for a
few days or a week and then returned to normal.
The different disciplines would support the provision of three principle service responses:
Rapid (<3hrs), Fast (<1 day) or Normal (<3 days). The most appropriate professional (based
on patient need and issues identified by referee/SPR) will be deployed to undertake the
initial response and assessment. This will then be used to inform the future reablement care
planning and service mix. If when assessed or whist receiving services, it is determined that
the primary need would be better served by another discipline then the patient will be
transferred to another professional without referral.
It is proposed that the multi-disciplinary team is resourced by aligning staff from ACHT,
OPAT, MuDAS, Bucks Care and BCC. This will initially be undertaken without formally
changing contracts and providers will be asked to agree to a Memorandum of Understanding
to facilitate open and effective improvement and information sharing.
Delivery settings
The intention is that the majority of care is delivered in the person’s own home to support
continued independence. It is recognised that for a small number of patients a bed-based
reablement service will be more appropriate. This may be as a result of an inappropriate
home setting or the need for diagnostic services alongside reablement. Whichever setting is
used it is intended that broadly the same service response is put in place where appropriate.
The level of bed-based services available for rehabilitation and reablement needs to be
appropriately scaled and work is ongoing by BHT to inform this process. The recent acuity
audit suggests 50% of the existing community hospital beds in Buckinghamshire are being
utilised by patients who could be supported in an alternative residential/nursing care setting
– Appendix 1 (Estimating capacity of community beds to support step-down/step-up)
includes additional information).
Future enhancements






Single contract for delivery of multidisciplinary team achieved by either provider
collaboration towards an alliance contract or formal recommissioning
Ensure community bed based facilities are profiled effectively to appropriately meet the
needs of patients at the lowest cost
Community bed based facilities are used as bases for the multidisciplinary teams.
Night sitting service developed to enable more patients to be supported to live in their
own home particularly those on a non-weight bearing pathway
GP out of hours services to be fully linked in and aligned
Addition of other professions, e.g. pharmacists
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Experience from elsewhere
Greenwich has put in place integrated health and social care teams to provide a wholesystem response to intermediate care, hospital discharge, urgent care, and community
rehabilitation. The service is configured around three integrated teams:
 Community Assessment & Rehabilitation Teams (CARs) to provide rehabilitation, social
care and manage intermediate care beds
 Joint Emergency Team (JET) - Fast immediate multi-disciplinary responses works in A&E,
Ambulatory Medical Unit and in the community to prevent ambulance service call-outs
and reduce admissions 7 days a week
 Hospital Integrated Discharge Team (HID) - Facilitates discharge by maximising use of the
re-ablement services and intermediate care beds
These changes has been achieved with no changes made to the staff employers or contracts,
where there is a health team manager, there is an assistant manager from social care, and
vice versa.
The operational model has seen improvements across the system including:
 On average, 64% of people entering the new pathway require no further services after
completion of the pathway
 Reduction in A&E admissions - 147 prevented in Q1 2013 by working with GPs to refer to
JET rather than hospital
 Reduction in hospital admissions - 172 prevented in Q1 2013 by maintaining a presence
in A&E and AMU, 8am-8pm, 7 days
 7% reduction in admission to care homes per annum
 In the first 12 months, the redesign enabled an immediate 5.5% productivity saving on
the health services alone. The social care budget was reduced by £900,000
No new investment has been required to achieve the change as savings were made through
shared management arrangements.
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Tier 4 – Integrated Long Term Care
Current model of service delivery
Introduction to the pathway
There is a disparate range of professionals operating across the county. Some are deployed
at a county wide level, whereas others operate at a locality level to provide services across
Tiers 2, 3 and 4. Whilst there are some formal interfaces only a limited amount of this
activity is currently coordinated.
The main professional groups are:
ACHTs
There are seven multi-disciplinary teams offering rapid response, reablement
and maximising independence pathways. Maximising independence is the
most relevant pathway for Tier 4 and is delivered predominantly by District
Nurses. The service ranges from annual visits to three times per day and is
mainly for people that are housebound.
Referrals are made from GPs where the patient is at home or from the
hospital ward if there has been an in-patient stay to each localities referral
access point.
Social Care
There are three teams of Social Workers and Assistants covering the north,
middle and south of the county. The teams are responsible for reviewing and
changing care packages. Packages are setup by the CR&R team based out of
BCC offices at County Hall or hospital social workers – ideally after a period of
reablement. The packages of care are provided by private domiciliary care
providers and supplementary services such meals on wheels.
Referrals from GPs and ACHTs for new packages are sent to CR&R who
undertake and assessment and set up services before handing over client to
the community team.
GPs and other health care professionals contact the social work team via
CR&R if they need to discuss a client and their changing needs.
Mental
Health
There are two teams for Older Adults Mental Health based in the north and
the south of the county. The teams are responsible for providing community
based adult mental health services
GPs
GPs are an integral part of this pathway and use MAGS as the mechanism to
coordinate all of the above teams around the needs of the patient
Specialist
Nurses
In some specialities there are integrated nursing teams , with access to
consultant support, supporting GPs and ACHTs to care for people at home,
e.g. respiratory and heart failure
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Primary
Care Team
Each practice has a wide range of staff supporting the GP, in particular
practice nurses
The current model of care is not patient centric and given the direction of travel towards a
multidisciplinary approach to reablement (see Tier 3), the current delivery model needs to
change to ensure sustainability.
Establishing the opportunity and improvement potential
Key opportunities in the As-Is process
Current Model
Services are operated from different bases
with ACHT’s operating from 7 sites across
the county and social care operating from
three bases
Duplication of ongoing care in health and
social care
Some commonality in service provision
across ACHT and Domiciliary Care Providers.
Some commonality of assessment across
ACHT and Social Care
In new model of Tier 3 – creation of an
integrated rapid response and reablement
service reduces the size of the remaining
delivery organisations
Improvement Opportunity
 Collaborative working and co-location
exploited to enable knowledge sharing
and joint working (e.g joint assessments)
 Technology used to maximise access to
relevant patient insight
 Ensure that a patients care is being
managed to account for wider
interventions “health leg vs. social care
leg”
 Joined up patient experience – not having
to repeat condition updates to different
professions
 Account for Health interventions when
planning Dom Care
 Consider expansion of packages to meet
wider needs
 Common assessment approach and
sharing of data
 Merge remaining functions to increase
operational scale and associated
efficiency benefits
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Future model of Integrated Locality Teams in Buckinghamshire
Overview
The future model will see integrated teams operating across the County providing
coordinated, person centric care to individuals in their own homes. These teams will be
comprised of resources managed at an area level (likely to be three teams). Depending on
need they will be assigned to one or more locality bases from which they will provide a
seamless service based on the needs of individuals.
It is important that the professionals are able to operate effectively at a locality level and
build a sense of team around the patient and GP practices, but they do not need to work or
be managed solely at this level. Through the use of technology the field based workers will
be enabled to work with their patients and maintain effective links with their teams and
managers. For management and synergy purposes three locality teams are proposed but the
staff within those teams would be aligned at least to the level of the 7 localities and in some
cases to smaller groupings within those where population and geography supports that.
Key elements
Integrated Team






Three area aligned teams of professionals drawn from a range of providers with a
manager in each to coordinate deployment.
Professional accountability lines will remain in place and where the whole team is not
aligned to the new service, individuals will need to be identified to be part of the team
and its operational rotas.
Day time only service with ‘roving professionals’ being assigned to patients in line with
need.
Streamlined access to local services with a strong sense of local place to build patient
trust, facilitate voluntary and community sector involvement and build on wider local
opportunities to improve outcomes.
Clear oversight of all patient interactions (health and social care) to coordinate provision,
reduce duplication and exploit wider opportunities for optimising service interactions as
part of a wider package and reduce the level of specialist input (e.g. using existing home
care to support low-level nursing interactions).
Individuals will have simpler access to appropriate support to seamlessly manage the
issues presented when care needs change.
To illustrate how this would work a couple of illustrative scenarios have been developed, see
below.
Mary’s story
Mary lives on her own and is 83 years old. Following a stay in hospital and
a period of reablement she continues to require ongoing nursing and home
care support to manage her diabetes, medicines and tasks of daily living.
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What would have happened before…numerous different people from
different organisations have assessed Mary’s changing needs. Then a
variety of workers visit throughout the week to facilitate Mary’s different
needs. There seems to be little recognition by each visitor of the various
other services and Mary can get quite confused and agitated as to whom is
due to visit and for what reason.
What will happen in future…a key worker undertakes an assessment for all
Mary’s needs and arranges with colleagues a holistic package of care. The
main care provider agrees to undertake the majority of the requirement,
including monitoring Mary’s self-medication compliance. This reduces
duplication and enables the nurse to visit less frequently. However, when
the nurse does visit she is fully briefed on Mary’s progress and the services
she has been receiving.
It is proposed that the integrated locality team is resourced by aligning ACHT, Oxford Health
and BCC staff into three teams. Locality hubs will be created in existing buildings (link to
estates review work) with the ability to be public facing and support the development of
wellbeing centres (Tier 1).
Future enhancements






Potential to create integrated access points which take responsibility for contacts within
a given area. This would need to be assessed in more detail to establish the synergies
with the existing CR&R service and ACHTs.
Opportunities to use technology to enhance long term condition management.
Development of organisational efficiency associated with new way of working.
Consider links to practice nurses as they are experts in managing long term conditions
and so there are synergies in working practices.
Examine skill sets across existing silos particularly in nursing (practice nurses, district
nurses and specialist nurses).
Different organisational models for service delivery.
Experience from elsewhere
Torbay4 have operated an integrated delivery model for some time with community staff
ultimately transferring to the NHS. It is recognised that there is no ‘best way’ of integrating
care. As such the model is reflected in local relationships, structures and networks, but with
the following attributes:
• Teams based on GP registration and not home address to enable allocation of work,
simplify access and make co-ordination of effort easier.
• Sound, joint governance and shared leadership and single management arrangements
for all professionals
4
Integrating health and social care in Torbay, The King’s Fund, 2011
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•
Flexible use of pooled budgets with prioritisation of continuity of care at home
The operational model has seen improvements across the system including:
 Inter-professional trust and shared assessments – improved relationships with stronger
capacity to do their jobs, clear professional identity, improved training opportunities and
employment security within a changing health and social care landscape
 Single point of contact within zones improve access and speeded up responses which
GPs found invaluable
 Emergency bed day use has fallen on average by 28% for age groups from 75+ and is the
lowest in the SW region against a rising national trend
 Reduction in the use of nursing home and care home beds
 Quicker decisions and arrangements for care to be put in place with no arguments on
funding responsibility
 Improved performance of the LA against national benchmarking data/CQC
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GOVERNING BODY
CORPORATE PERFORMACE REPORT
12 March 2015
Purpose of Paper
To inform the Governing Body of the performance of commissioned services against national and local
performance measures and to request assurance of actions being taken where expected standards
are not being achieved and to request actions.
Executive Summary
This report, the Organisational Performance Report for February 2015, provides assurance on the
performance of the CCG and the providers of health care with which it commissions services
against nationally and locally set quality and performance measures.
The report provides a summary of Aylesbury Vale CCG performance against national and local
indicators for the year to date up to Month 9 or 10 (December 2014 or January 2015) dependent on
data availability.
Headlines for the month:
The key quality highlights and assurance issues for this report are as follows:
•
•
A&E 4 hour waiting time – The position has continued to be challenging in January and 4 hour
waiting time standard was not met at any local Trusts (Buckinghamshire Healthcare Trust (BHT),
Oxford University Hospital (OUH) and Milton Keynes General (MK)). Performance at BHT
recovered to above 95% for the week ending 18 January 2015 but fell below target in
subsequent weeks.
Ambulance Targets – Category ‘A’ 8 Minute Response Time Red 1 and Red 2 along with
Category ‘A’ 19 minute response time targets were not met in December either at CCG level or
Thames Valley level.
•
18 week Referral to Treatment standards – In December, for the fourth consecutive month,
the CCG met all RTT standards. There were, for the first month this year, no over 52 week
waiters on either incomplete or completed pathways at any providers.
•
Cancer waiting time targets – In December, one cancer target was not met for the CCG
overall:
The 62 Day Standard (Referral from screening service)
-
Actions requested / recommendation
The Governing Body is asked to note the report.
1
Strategic Objectives supported by this
Paper (Please Tick)
Improve people's health and reduce
Enhance quality, safety and experience of
Ensure local people have greater influence
Deliver financial sustainability with headroom
Perform well as a CCG
Equality Analysis completed




Yes
Not
applicable
Lead Director(s) responsible for this area
of work
Colin Thompson, Director of Operations &
Performance
(please tick )
Author of paper
Paul Hutt AV CCG
Katherine Woolley, CSU
2
No
Organisational Performance Report
February 2015
Section One - Introduction and overall performance
Introduction
This report, the Organisational Performance Report, is designed to provide assurance to the Clinical
Commissioning Group Executive team and Governing Body on the performance of the CCG and the
providers of health care with which it commissions against nationally and locally set quality and
performance measures.
The report provides a summary of Aylesbury Vale CCG performance against national and local indicators
for the year to date up to Month 9 or 10 (December 2014/January 2015), depending on data availability.
The indicators are those that will be used by NHS England to assess the CCG’s performance against the
CCG Assurance Framework, i.e.:
•
•
•
Quality markers used in the Assurance Framework Assuring Quality of Care (Are local people
getting good quality care?) (NB these measures are presented on a provider basis)
Achieving Patient Standards (Are patients’ rights under the NHS Constitution being met?)
Improving Health Outcomes: CCG outcome measures grouped into their specific domains; (Are
health outcomes improving for local people?)
From January onwards, the report includes additional indicators for mental health and community services
and it is intended that these will continue to be refined and added to as we move forward.
Most indicators have a RAG (Red, Amber and Green) assessment and these are shown in the dashboard
in Section Two. Where an area is assessed as ‘Amber’ or ‘Red’ a short summary of issues generating
these concerns is provided, with assurance of the actions being taken to improve delivery in Section Three.
This section also contains a short summary of the overall performance within each category. The full set of
indicators included in each area is provided separately.
Headlines
Locally the pressure on urgent care services reflects the situation which has been widely reported
nationally with a number of targets not met in January:
•
•
A&E 4 hour waiting time – The position has continued to be challenging in January and 4 hour
waiting time standard was not met at any local Trusts (Buckinghamshire Healthcare Trust (BHT),
Oxford University Hospital (OUH) and Milton Keynes General (MK)). Performance at BHT
recovered to above 95% for the week ending 18 January 2015 but fell below target in subsequent
weeks.
Ambulance Targets – Category ‘A’ 8 Minute Response Time Red 1 and Red 2 along with Category
‘A’ 19 minute response time targets were not met in December either at CCG level or Thames Valley
level.
•
18 week Referral to Treatment standards – In December, for the fourth consecutive month, the
CCG met all RTT standards. There were, for the first month this year, no over 52 week waiters on
either incomplete or completed pathways at any providers.
•
-
Cancer waiting time targets – In December, one cancer target was not met for the CCG overall:
The 62 Day Standard (Referral from screening service)
3
Section 2 - Performance Indicator Summary for all providers
NHS CONSTITUTIONAL SECTION
Aylesbury Vale CCG
INDICATOR
OPERATIONAL
LOWER
STANDARD THRESHOLD
Referral to Treatment waiting times for non urgent consultant led treatment
Admitted patients to start treatment within a maximum of 18 weeks from
referral
Non-admitted patients to start treatment within a maximum of 18 weeks
from referral
REPORT
MONTH
MONTH
ACTUAL
YTD
Performance
Movement
90%
85%
December
93.8%
89.7%

95%
90%
December
96.1%
96.1%

Patients on incomplete non emergency pathways (yet to start treatment)
should have been waiting no more than 18 weeks from referral
92%
87%
December
92.2%
92.1%

Number of patients waiting more than 52 weeks (admitted (unadjusted))
0
December
0
5
Number of patients waiting more than 52 weeks (admitted (adjusted))
0
December
0
3
Number of patients waiting more than 52 weeks (non-admitted)
0
December
0
3
Number of patients waiting more than 52 weeks (Incomplete)
0
10
December
0
7
RTT - Admitted Pathways
Median
Not Rated
Not Rated
December
6.0
6.7
RTT - Incomplete Pathways
Median
Not Rated
Not Rated
December
8.0
8.0
RTT - Admitted Pathways
95th %ile
Not Rated
Not Rated
December
18.9
22.8
RTT - Incomplete Pathways
95th %ile
Not Rated
Not Rated
December
21.1
21.1
Diagnostic test waiting times
Percentage of Patients waiting 6 weeks or more for a diagnostic test
1%
6%
December
1.5%
0.6%
A&E waits
[BHT ]Patients should be admitted, transferred or discharged within 4
95%
90%
January
90.8%
93.2%
hours of their arrival at an A&E department
[MKGH] Patients should be admitted, transferred or discharged within 4
95%
90%
January
87.6%
92.8%
hours of their arrival at an A&E department
[OUH]Patients should be admitted, transferred or discharged within 4
95%
90%
January
83.5%
90.4%
hours of their arrival at an A&E department
Cancer patients - 2 week wait
Maximum two-week wait for first outpatient appointment for patients
93%
88%
December
93.6%
94.3%
referred urgently with suspected cancer by a GP
Maximum two week wait for first out patient appointment for patients
referred urgently with breast symptoms (where cancer was not initially
93%
88%
December
99.0%
94.3%
suspected)
Cancer waits - 31 days
Maximum (31 day) wait from diagnosis to first definitive treatment for all
96%
91%
December
100.0%
99.0%
cancers
Maximum 31 day wait for subsequent treatment where that treatment is
94%
89%
December
100.0%
98.7%
surgery
Maximum 31 day wait for subsequent treatment where the treatment is
98%
93%
December
100.0%
100.0%
an anti-cancer drug regime
Maximum 31 day wait for subsequent treatment where the treatment is a
94%
89%
December
94.4%
89.3%
course of radiotherapy
Cancer waits - 62 days
Maximum (62 day) wait from urgent GP referral to first definitive
85%
80%
December
87.9%
87.7%
treatment for cancer
Maximum 62 day wait from referral from an NHS screening service to first
90%
85%
December
66.7%
94.6%
definitive treatment for all cancers
Maximum 62 day wait for first definitive treatment following a consultants No operational No operational
decision to upgrade the priority of the patients (all cancers)
standard
standard
Category A ambulance calls
SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST
Category A calls resulting in an emergency response arriving within 8
75%
70%
December
67.4%
73.6%
minutes (Red 1)
Category A calls resulting in an emergency response arriving within 8
75%
70%
December
62.0%
70.7%
minutes (Red 2)
Category A calls resulting in an ambulance arriving at the scene within 19
95%
90%
December
88.0%
92.7%
minutes
Mixed sex accommodation breaches
Breaches of Same Sex Accommodation
0
10
January
1
4
4
























INDICATOR
Cancelled Operations
(BHT) All patients who have operations cancelled, on or after the day of
admission (including the day of surgery), for non-clinical reasons to be
offered another binding data within 28 days, or the patient's treatment to
be funded at the time and hospital of the patient's choice
(BHT) Number of urgent operations cancelled for a second time
(OUH) All patients who have operations cancelled, on or after the day of
admission (including the day of surgery), for non-clinical reasons to be
offered another binding data within 28 days, or the patient's treatment to
be funded at the time and hospital of the patient's choice
(OUH) Number of urgent operations cancelled for a second time
(MKG) All patients who have operations cancelled, on or after the day of
admission (including the day of surgery), for non-clinical reasons to be
offered another binding data within 28 days, or the patient's treatment to
be funded at the time and hospital of the patient's choice
(MKHFT) Number of urgent operations cancelled for a second time
Mental Health
Care Programme Approach (CPA): The proportion of people under adult
mental illness specialities on CPA who were followed up within 7 days of
discharge from psychiatric inpatient care during the period
Care Programme Approach (CPA): The proportion of people under adult
mental illness specialities on CPA followed up within 7 days of discharge
from psychiatric inpatient care during the period (Monthly) (Adult)
Care Programme Approach (CPA): The proportion of people under adult
mental illness specialities on CPA followed up within 7 days of discharge
from psychiatric inpatient care during the period (Monthly) (Older Adult)
All patients on CPA have a documented risk assessment (Adult)
All patients on CPA have a documented risk assessment (Older Adult)
Patients on CPA have a crisis contingency plan (Adult)
Patients on CPA have a crisis contingency plan (Older Adult)
Delayed Transfers of Care (Number - Adult)
Delayed Transfers of Care (Days - Adult)
Delayed Transfers of Care (Number - Older Adult)
Delayed Transfers of Care (Days - Older Adult)
OPERATIONAL LOWER
STANDARD THREASHOLD
REPORT
MONTH
MONTH
ACTUAL
YTD
Performance
Movement
Not Rated
Not Rated
Q3 2014/15
0
1

0
0
December
0
0

Not Rated
Not Rated
Q3 2014/15
6
20

0
0
December
0
0

Not Rated
Not Rated
Q3 2014/15
0
0

0
0
December
0
0

95%
90%
Qtr 3
2014/15
97.2%
97.0%

95%
90%
December
100%
97%

95%
90%
December
100%
100%

99%
94%
81%
97%
0
0
0
0
93%
93%
75%
58%
0
0
7
113





12%

100%
December
95%
December
not rated
not rated
December
not rated
not rated
December
Mental Health measure IAPT - the proportion of people that enter treatment
against the level of need in the general population (the level of prevalence
addressed or ‘captured’ by referral routes)
15%
Q3
2014/15
4.3%
Mental Health measure IAPT - the proportion of people who complete treatment
who are moving to recovery.
50%
Q3
2014/15
66.1%
Dementia Diagnosis rate
67%
January
56.8%
January
5
Learning Disabilities
Transforming Care
GP Health Checks
Local Indicator
Improve the % of type 2 diabetics who on mono-therapy alone achieve a
HbAic of 48m/mols or less
0.3500%
5




56.8%

INDICATOR
OPERATIONAL LOWER
STANDARD THREASHOLD
REPORT
MONTH
MONTH
ACTUAL
YTD
Performance
Movement
OUTCOME MEASURES BY DOMAIN
1. Preventing people from dying prematurely
Maternal smoking at delivery 1
2. Enhancing quality of life for people with long term conditions
Unplanned hospitalisation for chronic ambulatory care sensitive
conditions (adults)
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
People with long-term conditions feeling independent and in control of
their condition
3. Helping people to recover from episodes of ill health or following injury
Emergency admissions for acute conditions that should not usually require
hospital admission
Emergency admissions for children with lower respiratory tract infections
>11%
not rated
70
Baseline
9
Baseline
53%
138
Baseline
11
Baseline
Patient reported outcome measures for elective procedures: hip
replacement
Patient reported outcome measures for elective procedures: knee
replacement
Patient reported outcome measures for elective procedures: groin hernia
Qtr 3 2014-15
9.2%
9.0%

December
106
735

December
13
84

Jan 2015 Pub*
55.0%
December
163
1590

December
79
189

Apr13 to Mar14
n/a
0.429

Apr13 to Mar14
n/a
0.254

Apr13 to Mar14
n/a
0.107

n/a
0.046

Patient reported outcome measures for elective procedures: varicose
Apr13 to Mar14
veins
4. Patient Experience - Ensuring that people have a positive experience of care
Patient experience of GP out-of-hours services
70%
Jan Pub*
5.Patient Safety - Treating and caring for people in a safe environment and protecting them from avoidable harm
Risk Assessment of venous thromboembolism (VTE) (BHT)
95%
November
Risk Assessment of venous thromboembolism (VTE) (OUH)
95%
November
Risk Assessment of venous thromboembolism (VTE) (MKHFT)
95%
November
6.Outcomes - Safety
Incidence of healthcare associated infection (HCAI) i) MRSA - Includes Post
Yearly target
0
January
Infection review
Cumulative
Incidence of healthcare associated infection (HCAI) ii) C difficile
38
January
Target

68.0%

95.2%
94.6%
96.6%
95.9%
93.8%
96.4%



0
1

2
41

* GP Out-Of-Hours - The latest data is from the January 2015 publication, collected during Jan-March 2014 and July-Sept 2014
** Performance movement -  equals improvement,  equals decline,  equals no movement
Number of women known to be Smokers At Time Of Delivery (SATOD) 1
MRSA - June MRSA case previously assigned to AV CCG has now been assigned to Provider (OUH) after PIR review.
VTE - Proportion of all adult inpatients that have been assessed for risk of VTE on admission to hospital using the criteria set out in the National VTE Risk Assessment tool
(achievement must be at least 95%)
6
NHS Constitution & Supporting measures
Waiting times: 18 week, diagnostic &
Admitted
52 week waits (December)
A&E 4 Hour wait (January)
BHT
NonAdmitted
MKHFT
31 Day 1st
Breast 2ww
Treatment
All 2ww
Ambulance response times (Dec)
Handover delays (Jan)
Red 1 - 8
Red 2 - 8
Cat A 19
BHT
OUH
MKGH
BHT
OUH
MKGH
CPA
(Q3)
>52 nonadmit
>52
Incomplete
31 Day
(Surgery)
31 Day
(Drugs)
31 Day
(Radio)
62 Day
Standard
62 Day
(Screen)
62 Day
(Upgrade)
SMH 30+
HWH 30+
OUH 30+
MKGH 30+
SMH 60+
HWH 60+ OUH 60+ MKGH 60+
OUH
Cancer waiting times (December)
Cancelled Operations on or after day
of admission not re-offered within
28 days - threshold to be set
(quarterly) Q3 2014/15
Urgent operations cancelled for a
2nd time (Dec)
Mental Health CPA Q3 2014/15 and
Monthly (Dec) : Risk Assessment/
Contingency/Dementia (Dec)
>52 admit
Incomplete Diagnostic
CPA
CPA
Risk
Risk
Contingency
Contingency
Adult
Older Adult Assessment Assessment
Plan (Older
Plan (Adult)
(Adult)
(Older Adult)
(Monthly) (Monthly)
Adult)
Dementia
Diagnosis
CCG Outcome measures
1 - Preventing people from dying
prematurely (quarterly)
SATOD Q3 2014/15
2- Enhancing the quality of life for
people with long term conditions
(July/six monthly)
Unplanned Admits (Dec)
3 - Helping people to recover from
episodes of ill health following
injury (Nov)
Emergency Admits (Dec)
HSMR 80
BHT
HSMR 80
OUH
Maternity
(SATOD)
Unplanned People with
Unplanned
Admits
LTCs Feeling
Admits ACS
LTCs <19
in control
Stroke: to
Stroke: 90% Stroke: to SU Emerg Admits
Stroke: 90%
Stroke: 90% Stroke: to SU
children lower
SU <4 hrs
on SU
<4 hrs
on SU BHT
on SU OUH <4 hrs OUH
resp
BHT
MKGFT
MKGFT
4- Patient Experience (April (GP OofH
six monthly)) Complaints (August)
Friends &
Family
tests
GP Out Of
Complaints Complaints
Hours
BHT
OUH
survey
5- Patient safety - CCG measures
(Jan)
MRSA: CCG C Diff: CCG
5- Patient safety - Pressure Sores
(Aug) VTE (Nov) Serious Falls (Aug)
Pressure
Pressure
Pressure
Sores BHT Sores OUH Sores MKGH
Roll Out
VTE
BHT
VTE
OUH
VTE
MKGH
Serious Falls
BHT
Recovery
These charts reflect current position: i.e. Data to latest month available
Not Met
PROMS
measures
tbc
Serious
falls OUH
Serious
Falls
MKGH
Complaints
MKGH
Ambition Outcome measures
Local Measure - Diabetes percentage of people with diabetes
on step 1 therapy who have an
HbA1c less than or equal to 48
mmol/mol
IAPT - proportion entering treatment
and proportion moving to recovery
Q2
Emergency
Admits not
normally
needing it
Above or
close to
Threshold
Met
7
Target not
set
Data not
available
Section 3 – Exception reports
NHS Constitution Standards
Exception reports are included for the following indicators which are amber/red for this month/quarter:
•
•
•
•
•
•
•
•
Ambulance response times;
Ambulance Handover Delays over 60 minutes.
A&E four hour waits.
Cancer Waiting time targets
RTT Targets – all met this month but not being met year-to-date.
Diagnostic Waiting time
Cancelled operations on or after day of admission (OUH).
Mental Health targets: Care Programme Approach: Dementia: Winterbourne Register
Ambulance Response Times
Ambulance Clinical Quality- Category A 19 Minute
Transportation Time
Ambulance Clinical Quality Category A 8 Minute Response
Time - Red 2
100%
78%
98%
95%
76%
96%
90%
74%
94%
72%
92%
70%
68%
90%
66%
Actual
88%
Actual
Dec-14
Oct-14
Sep-14
Nov-14
Jul-14
Aug-14
Jun-14
Apr-14
Lower Control Limit
May-14
Jan-14
Feb-14
Mar-14
Oct-13
Mean
Dec-13
Sep-13
Jul-13
Oct-14
Dec-14
Sep-14
Upper Control Limit
Nov-14
Jul-14
Jun-14
Aug-14
Apr-14
Lower Control Limit
May-14
Jan-14
Feb-14
Mar-14
Dec-13
Oct-13
Mean
Nov-13
Sep-13
Jun-13
Jul-13
Actual
Aug-13
Apr-13
84%
Nov-13
86%
May-13
Oct-14
Dec-14
Sep-14
Upper Control Limit
Nov-14
Jul-14
Aug-14
Jun-14
Apr-14
Mar-14
Lower Control Limit
May-14
Jan-14
Feb-14
Dec-13
Sep-13
Oct-13
Mean
Nov-13
60%
Jul-13
60%
Aug-13
62%
Jun-13
65%
Apr-13
64%
May-13
70%
Jun-13
75%
Aug-13
80%
Apr-13
85%
May-13
Ambulance Clinical Quality Category A 8 Minute Response
Time - Red 1
Upper Control Limit
These indicators monitor the time it takes for an ambulance to respond to a 999 call. Category A calls
are the most serious, and are monitored as Category A8 and A19, which are calls that resulted in an
emergency response arriving at the scene of the incident within 8 minutes and within 19 minutes.
Category A8 is further split into two parts, Red 1 and Red 2. Red 1 calls are the most time critical and
cover cardiac arrest patients who are not breathing and do not have a pulse, and other severe
conditions such as airway obstruction. Red 2 calls are serious but less immediately time critical and
cover conditions such as stroke and fits. Red 1 patients account for less than 5% of all ambulance
calls. The service is contracted at Thames Valley level for performance rather than CCG level.
Performance at a CCG level is reported by SCAS for information.
SCAS is currently commissioned and the CCGs are monitored for performance at a Thames Valley
contract level and not at CCG level. SCAS is required to deliver performance on an annual basis at
Thames Valley contract level. It is noted that SCAS is short on performance for Red 2 year to date
and this target is likely to continue to be challenging during the winter period.
Performance against targets for December was:
Category A 8 Minute Repose Time:
• At Aylesbury Vale level 67.4% of RED 1 incidents were responded to within 8 minutes which is
below the KPI target of 75%. (33 of 49 patients seen within target). YTD performance is below
target at 73.6%.
• At Thames Valley level, monthly performance was below target at 66.6%. YTD performance is
also below standard at 74.2%.
8
Category A 8 Minute Response Time:
• At Aylesbury Vale level 62.0% of RED 2 incidents met the 8 minutes response target, against
the KPI target of 75%. This equates to 455 of 734 patients seen within target, and remains a
disappointing performance. YTD performance is below target at 70.9%.
• At Thames Valley level, monthly performance was below target at 66.5%. YTD performance is
below standard at 72.9%.
Category A 19 Minute Transportation Time:
• At Aylesbury Vale level the 95% target has not been met in December with performance below
target at 88.0%. (686 of 780 patients seen within target). YTD performance is below target at
92.7%.
• At Thames Valley level, performance in December was below target at 92.0%. YTD
performance is slightly below standard at 94.9%
Monthly reporting on performance
There was a significant impact on performance for December in Red 1, Red 2 and Red 19 due to the high
demand, worse than normal handover delays and hospitals on ‘Black’.
SCAS reported increased Red activity following the move to NHS Pathways which impacted its
performance for September, October and November. It expects this to continue for a couple of months
before it settles back down as staff familiarise themselves with the new triage system.
SCAS has acknowledged it is at risk of failing Red 2 at contract level but will do everything to recover its
position on Red 1.
In terms of activity, there were 2317 incidents for Aylesbury Vale in December which is an increase of
347 compared to November’s figures. There was an increase in calls made by the public to 999 and in
see & treat and see, treat and convey. There continues to be a good increase in hear and treat activity
now that NHS Pathways has been implemented.
Ambulance Handover Delays (January)
2014/15
Ambulance handover delays
over 60 minutes
High Wycombe
Stoke Mandeville
Oxford University Hospitals
Milton Keynes General Hospital
April May June July
0
6
3
22
0
4
4
27
0
9
4
14
0
14
3
35
Aug Sept
0
2
8
17
0
11
6
15
Oct
Nov
Dec
Jan
0
2
5
25
0
4
4
15
0
74
14
41
0
50
23
16
Buckinghamshire Healthcare Trust – The number of over 30 minute handover delays has decreased in
January (124 compared to December’s 222). The number of over 60 minute delays has also decreased
(50 compared to December’s 74).
Milton Keynes General Hospital - The number of over 30 minute handover delays has decreased in
January (122 compared to December’s 170). The number of over 60 minute delays has also decreased
(16 compared to December’s 41).
Oxford University Hospital - The number of over 30 minute handover delays decreased in January (111
compared to December’s 124). The number of over 60 minute delays has however increased (23
compared to December’s 14).
9
A&E – Four Hour Waits
This indicator is a measure of the time that patients wait within an A&E department (or Minor
Illness/Injuries Unit) before either being admitted, treated & discharged or transferred to another
hospital and is measured by provider to ensure patients are seen within a nationally set time limit. The
main hospitals Aylesbury Vale CCG residents attend are Buckinghamshire Healthcare Trust (BHT),
Oxford University Hospitals (OUH) and Milton Keynes Hospital (MKFT).
Consistent with the National picture, performance has dropped significantly over the last 3 months at all 3
local providers, (see charts below). Of these three providers Oxford University Hospital saw the poorest
performance through January in terms of the A&E 4 hour waiting time standard.
A&E -BHT Performance
A&E Performance - All Providers
100%
100.0%
98.0%
96.0%
94.0%
92.0%
90.0%
88.0%
86.0%
84.0%
82.0%
80.0%
98%
96%
94%
92%
0.96
Lower Control Limit
Jan-15
Dec-14
Oct-14
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
Apr-14
May-14
Mar-14
Jan-14
Feb-14
Dec-13
Oct-13
Sep-13
Jul-13
Actual
Aug-13
Jun-13
Apr-13
May-13
88%
Nov-13
90%
BHT
Upper Control Limit
MK
OUH
Target
In January:o BHT did not meet the A&E standard (95%) with performance below target at 90.8%. YTD
performance remains below the standard at 93.1%.
o MKGH did not meet the A&E standard (95%) with performance at 87.6%. YTD performance
is below target at 92.8%.
o OUH did not meet the A&E standard (95%) with performance at 83.5%, YTD performance
remains below standard at 90.4%.
National A&E performance in January continued to be significantly worse than last year due to
increased hospitalisation and mortality due to influenza. The seasonal influenza immunisation has only
been 3% effective this year compared to the usual 50% effectiveness, due to a strain mutating after
the immunisation was produced. This has led to more cases than in any of the previous three years,
particularly amongst the elderly, which peaked in week commencing 5th January. The increased length
of stay required by these elderly patients has had an on-going impact on the capacity of acute
hospitals to manage demand throughout January.
BHT escalated to black status (the highest level) to focus all resources on mitigating the effects and
triggering additional staff and bed capacity, which resulted in very co-operative joint working, rapid
learning and implementation of solutions across the system. However, these actions were clearly
insufficient to prevent significant delays for patients. Although better than OUH and MK General
hospitals, performance at BHT was worse than the national average for the first half of January but
quickly recovered and performed better than the national average towards the end of the month. As a
result it is very unlikely that BHT will achieve the Q4 target of 95% even with an additional ward which
opened in late January, as significant pressure is expected to continue through the winter.
10
Cancer waiting time targets
•
The 31 Day Wait Radiotherapy target (94%) was met in December with performance at
94.4%. However, although improving, year to date performance remains under target at
89.3%. AVCCG expects to maintain the improved level of performance following changes made in
the service by OUH (See Chart on left below).
•
The 62 Day Standard (Referral from Screening service) target of 90% was not met in
December with performance at 66.7%. This equates to 2 out of 3 patients being seen within
target, the breach occurred at Buckinghamshire Healthcare Trust and was due to patient
declining offered dates. This target has been met in seven out of nine months of 2014/15 and
is being achieved on a YTD basis.
62 Day Standard - Screening
31 Day Standard - Radiotheraphy
105%
120%
100%
100%
95%
80%
90%
60%
85%
Actual
Upper Control Limit
Mean
Lower Control Limit
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
Apr-14
Dec-14
Oct-14
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
Apr-14
Lower Control Limit
May-14
Mar-14
Jan-14
Feb-14
Dec-13
Oct-13
Mean
Nov-13
Sep-13
Jul-13
Actual
Aug-13
0%
Jun-13
70%
Apr-13
20%
May-13
75%
May-14
40%
80%
Upper Control Limit
Referral to Treatment (RTT)
The number of patients with Referral to Treatment pathways greater than 52 weeks:
Any patient waiting beyond 52 weeks for treatment is considered to be a breach and will trigger a red
rating. In December there were no breaches for AVCCG patients on either completed or incomplete
pathways at any provider.
Admitted Pathways (90% Standard):
In December the target was achieved with 93.8% of patients being admitted in less than 18 weeks. The
YTD position, however, remains under target at 89.7%. The specialties that missed the target were
Gynaecology and Plastic Surgery.
There has been a decrease in the median waiting times from an average of 6.9 weeks in 2013/14 to 6.7
weeks in December. The 95th percentile has reduced to 19.8 weeks, against an average of 24.9 weeks in
2013/14.
Performance against 18 weeks targets is monitored on a weekly basis, with the Access & Performance
Management meeting at BHT in place to discuss and manage 18 weeks pathways and balance clinics
around the weekly pressures to support this. The CCG attends these meetings to obtain assurance over
the robustness of review and actions taken in this area. Early indications through this meeting are that the
January performance at BHT was above the target level, which is expected to mean the CCG level
performance in January also continues to exceed 90%.
Diagnostic Waiting times
The diagnostics waiting time target of 1% or less patients waiting more than 6 weeks for a test was missed
for only the second time in 2014/15 in December. This was due to an issue within the Audiology
department at BHT around the Christmas period. This has now been resolved, with no Audiology breaches
reported locally at the end of January, and Trust level performance back at the required level.
11
Cancelled operations on or after day of admission (BHT & OUH)
This indicator is measured quarterly by provider. It states:
“All patients who have operations cancelled, on or after the day of admission (including the day of surgery),
for non-clinical reasons to be offered another binding date within 28 days, or the patient's treatment to be
funded at the time and hospital of the patient's choice”.
The target is set as 0 cases and anything above that is rated as amber or red. Although BHT did cancel a
number of operations through Q3 for non-clinical reasons, all patients were offered another binding date
within 28 days. Six patients at OUH were not offered a date within 28 days. Pressure is expected to
continue on this target during Q4, as pressures from urgent care continue to cause operational issues for
providers. However, we are assured that providers are taking steps to avoid cancellations in the first place;
and where they are necessary, to offer a binding date within the requisite period.
BHT
OUH
2014/14 Q1
1
7
2014/14 Q2
0
7
2014/14 Q3
0
6
Mental Health Indicators
Care Programme Approach – Monthly Reporting
Patients on Care Programme Approach to have a documented risk assessment:
The target is for 100% of all patients on Care Programme Approach have a documented risk assessment.
While this is currently not being achieved, it has increased to 99% in December from a Year to Date
average of 93% for adults and increased to 94% in December from 93% for older adults in 2014/15.
Patients on CPA to have a crisis contingency plan
The target is for 95% or all patients on CPA have a crisis contingency plan. On a Year- To- Date basis for
2014/15 this has increased from 72% to 75% of all adults and has also increased from 30% to 58% in older
adults when compared to performance in 2014/15.
On a Quarterly basis CPA is meeting is national targets.
Dementia Diagnosis Rate
Aylesbury Vale CCG is performing above the national average, but is still under the national target of 67%.
In Buckinghamshire a local Dementia Diagnosis Plan has been initiated to increase diagnostic rates across
the county, using the NHS England South of England Protocol for dementia data harmonisation. Local
initiatives to improve this rate include:
•
Memory Clinics – these are now located at BHT and some GP practices through the Memory
Assessment Closer to Home (MACH) initiative.
•
Age UK Memory Advice Service – Age UK has worked with over 600 patients and their families,
providing advice, signposting and helping with access to services. The service supports anyone who
may have a suspected memory issue or dementia.
•
Care Home Matron - appointed to visit care homes with low dementia diagnosis rates to help identify
patients who may have dementia
•
Memory-Friendly Communities are a new initiative in Buckinghamshire, helping communities to support
and empower those with dementia. Involving engagement with stakeholders (e.g. Chiltern Railways,
12
Lloyds Group); identifying three villages/towns to be pilot Memory-Friendly Communities. The launch
event took place on 29th January 2015 in Stokenchurch.
•
In addition to these CCG initiatives, two Buckinghamshire GP practices including one in AVCCG have
won bids to transform their sites into dementia friendly practices.
Transforming care for People with Learning Disabilities
The “Transforming care for People with Learning Disabilities (LD)” register is used to monitor
inpatient placements of people with learning disabilities i.e. specialist hospital places for people
with learning disabilities who may present challenging behaviour or have mental health issues;
and whose needs can only be met within specialist LD services.
As of 31st January 2015 AVCCG had five inpatients; (two are in specialist hospitals out of the area;
three are in the local unit).
There is no movement/change from the December report.
In addition to the above Buckinghamshire has five individuals who have been placed by Specialist
Commissioning services, which work across the both the region and nationally. The people in this
group are forensic cases funded by NHS England specialist commissioning and will be placed in
low, medium and high secure units outside of the area. Decisions regarding discharge will be
made by the Ministry of Justice.
Note: Standard deviation in all charts is 2.
13
Outcome Measures
Exception reports are included for the following indicators which are red for this month:
•
•
Emergency and unplanned admissions for specific conditions
Patient experience of GP out-of-hours services (GP patient survey results)
Emergency and unplanned admissions for specific conditions (CCG measure)
Measure
Monthly Baseline
(Rate of emergency admissions)
(2013/14)
Chronic ambulatory care sensitive
70
conditions (adult)
asthma, diabetes and epilepsy in under
9
19's
For acute conditions that should not
138
usually require hospital admission
Emergency admissions for children with
11
lower respiratory tract infections
April
May
June
July
August
Sept
Oct
Nov
Dec
YTD
103
84
71
75
72
61
76
87
106
735
11
6
7
7
11
4
14
11
13
84
187
196
182
173
163
160
182
184
163
1590
7
9
5
3
5
5
23
53
79
189
This suite of indicators incorporates emergency admissions to hospital of persons with acute conditions
(ear/nose/throat infections, kidney/urinary tract infections, heart failure, among others) that usually could
have been avoided through better management in primary care.
They measure the level of emergency admissions for long term conditions and for conditions which are not
normally considered to require admission i.e. they are a proxy measure for avoidable admissions. The red
ratings indicate an increase from last year’s baseline and are consistent with the increase seen in
emergency admissions as a whole. However, they are also partially a result of a change in counting as
CDU and SAU attendances were not counted as admissions in 2013/14 but are in 2014/15.
Patient experience of GP out-of-hours services and People with long-term conditions feeling
independent and in control of their condition
This indicator is taken from the GP patient survey which has taken place twice a year since July 2011.
Questionnaires are sent to a selection of around 2.7 million adults who are registered with a GP in England
over the course of the year. The latest GP survey data published relates to the period January-Sept 2014
and was published in January 2015.
For the indicator on overall experience of GP Out-of Hours the score has increased from 61.0%.to 68.0%,
which is just below the 70% target.
Mixed Sex Accommodation
There was one same sex accommodation breach for Aylesbury Vale CCG in January which occurred at
Oxford University Hospital. YTD total breaches are 4.
MRSA
There have been no MRSA bacteraemia cases reported in January for Aylesbury Vale CCG.
C.Diff
Aylesbury Vale were 2 cases below trajectory in January which brings them one below their overall
trajectory. The CCG has the potential to end the year within trajectory if cases remain low over the next 2
months. The C.Difficile objective for 2015-16 has now been released with Aylesbury Vale CCG set at 49
cases. A paper with full details will be submitted to the February Commissioning for Quality Committee.
14
Other outcome measures
In addition to the exception reports on the previous page, indicators on pages 3 to 6 show issues with performance
levels against:
•
•
•
Stroke indicators, specifically admissions to a stroke unit in under four hours at BHT and MKFT;
Patient complaints at BHT; and
Pressure sores at BHT and VTE at OUH.
These items will be featured in the Quality Report.
15
OPERATING PLAN & QIPP MONITORING
REPORT – GOVERNING BODY
12 March 2015
Purpose of Paper
This report presents to the Governing Body a view of delivery against the Operating Plan
key QIPP programmes and outcomes. This assessment has been taken from milestone
reporting from programme leads.
Executive Summary
This report provides an overview of progress against milestones and planned quality or
activity improvement targets and associated planned productivity savings.
•
•
•
•
•
The year to date position at month 10 is £2,049k QIPP savings achieved against
identified planned savings of £3,160k (65% achievement).
However, there remains £511k of unidentified savings which makes the total QIPP
target £3,671k, giving a 56% achievement.
£1,267k mitigation has been allocated to QIPP overall giving a final position of 90%
achievement through the use of headroom.
The Elective care, urgent care and early years programmes are assessed as only
partially delivering on QIPP savings at 68%, 44% and 0% achievement to date.
The forecast position is for year-end delivery of 89% of plan following mitigation.
Actions requested / recommendation
The Governing Body is asked to note the report.
Strategic Objectives supported by this Paper (Please Tick)
Improve people's health and reduce inequalities
Enhance quality, safety and experience of patient services
Ensure local people have greater influence and management of own care
Deliver financial sustainability with headroom to invest
Perform well as a CCG
Equality Analysis completed
(please tick )
Author of paper
Paul Hutt, AV CCG
Katherine Woolley, CSU
Yes





No
Not applicable
Lead Director(s) responsible for this area
of work
Colin Thompson, Director of Operations &
Performance
QIPP (Quality Innovation Productivity & Prevention)
Monitoring report, February 2015
(Reporting month 10, January 2015)
1.0 Introduction
QIPP (Quality, Innovation, Productivity and Prevention) as a concept has been part
of the NHS for a number of years. Driven by a fundamental financial shortfall
between available funds for the NHS and projected costs in a ‘no-change’
scenario, commissioning organisations have been challenged to undertake actions
to improve quality, innovation, productivity and prevention in their local health
economies. QIPP in its true sense involves removing costs from a health economy
– either by avoiding activity in the first place, through prevention, improved
quality or refined pathways; or by undertaking necessary activity in a more
efficient way – using innovative techniques and becoming more productive.
Simply moving a cost pressure from one NHS organisation to another will help to
balance the books of the beneficiary, but does not help to establish a sustainable
system.
To tackle the disease burden and for planning purposes Aylesbury Vale CCG
(AVCCG) has adopted a life course approach – from pre-conception through
pregnancy, infancy, early years, childhood, adolescence and teenage years, and
through to adulthood and preparing for older age. There are specific
opportunities and challenges at each stage of the life course and action is needed
at all ages to avert the short- and long-term consequences of the main disease
groups described above.
1.1 Link to strategic plan
The Buckinghamshire Commissioners five year strategic plan from April 2014
recognises that investment is required in areas of the health and social care
system to deliver a system of integrated care, where available money is spent in
the most efficient and effective way, as shown below:
2
There are many facets to CCG strategic planning, and ultimately the QIPP plan is
just one element, but in order to be successful it needs to connect with and
support other areas of planning. Within the context of the CCG’s wider strategy,
specific programmes and projects are in place to deliver the change required to
move the system in the desired direction of travel, and deliver QIPP savings.
The ambition to transform and integrate services is aligned with the national
aspiration to transfer 15% of acute activity into community based services, by
implementing an integrated model of care which has the capability to respond to
a wide range of levels of need and support individuals to remain at home. It is
anticipated that the rebalancing of care will be most evident in sub-acute care of
older people, i.e. those over 75.
1.2 Link to outcomes
The main drive of the Operating Plan is to improve key quality outcomes, in order
to improve the lives of our population (value based commissioning). The priorities
for improvement have been identified at both locality level through detailed
public health profiles and then aggregated to give CCG wide prevalence rates. The
objective is to give a clear understanding of disease burden across the CCG. This
allows the team to target through an evidence based model, the most visible
opportunities to improve outcomes.
The individual programme sections of this report provide a summary of the
outcomes identified which require improvement, and how progress against them
is being monitored. The report also tracks activity reduction aligned to delivery of
the QIPP projects (activity and finance) and the assessment of delivery from the
highlight reports (milestones).
1.3 Link to finance
1.5 QIPP management arrangements
The QIPP challenge for Aylesbury Vale CCG (AVCCG) for 2014/15 is £4,763k. Table
1 in section 2 shows this challenge, split between the main programmes within
which multiple projects are under way. In the year to date, £2,049k of a required
£3,671k has been delivered (56%). Use of financial headroom provides some
mitigation (£1,267k) to achieve 90% of the year to date QIPP requirement.
As part of a continuous improvement drive, AVCCG is reviewing the processes and
procedures it has in place around QIPP. Current project planning and
authorisation arrangements, as well as in year monitoring and reporting can be
improved, in order to:
Within the framework of system transformation, and focusing on value based
commissioning, the QIPP programmes should all lead to an improvement in
quality, effectiveness, efficiency or a combination of all. While there is an overarching QIPP challenge for the CCG to meet, not all QIPP schemes will necessarily
have a positive financial impact within the current year. As such, while
programmes have financial values associated with them, it is not always possible
to do the same at a project level. This does not mean that delivery of all projects
is not important in order to ensure sustainability of the system now and into the
future.
1.4 Forecast
The finance tables within this report indicate that 65% of identified savings in the
year to date have been delivered. This is expected to decrease to 61% delivery of
identified savings by year end. Use of headroom of £1,700k is planned to bridge
much of the remaining gap to a forecast 89%. A key risk within the forecast is that
the planned delivery of identified schemes is loaded towards the end of the year.
£3,160k was planned to be delivered by month 10. This is 76% of the full year
plan for identified schemes, so 24% more needs to be delivered in the final two
months of the year just to maintain the percentage of plan delivered.
This report highlights the key issues and risks in Month 10, although much of the
supporting data analysis relates to month 8 and 9. As this report outlines, the
majority of programmes are experiencing under-delivery in the year to date.
Mitigating actions are planned in order to maximise the delivery of savings during
the year. These are outlined in section 4.
3
•
More clearly link outcome measures to individual projects with agreed
baseline and reporting timelines;
•
Directly map financial implications of QIPP schemes to those schemes
wherever possible, including recognition of investments and savings;
•
Developing consistency of project milestone establishment, monitoring
and reporting, including a mechanism to flag when intervention is
required to bring a project back on track.
QIPP planning for 2015/16 is at an advanced stage. Schemes have been identified
by a detailed review of JET papers and other sources. Outcome measures have
been identified wherever possible, and work is taking place to establish baselines
for each scheme against which delivery can be measured. This will improve the
accuracy and focus of QIPP reporting for 2015/16. A paper outlining the plans will
be taken to the March Executive meeting.
2.0 Headlines - QIPP Performance (Finance)
Table 1 below provides a summary of monthly QIPP achievement by programme
and a forecast position for year end in financial terms.
The shortfall in meeting the QIPP savings target this month is assessed as being
due to:
•
However, there remains £511k of unidentified savings which makes the total
QIPP target £3,671k, giving a 56% achievement
Schemes delivering no savings to date which are mostly related to acute
activity - reducing variation in out-patient procedures; A&E remodelling; and
early years projects related to acute activity savings.
•
These are partially offset by additional savings in running costs and the
reducing variation in radiology scheme.
•
£1,267k mitigation has been allocated to QIPP overall giving a final position of
90% achievement through the use of headroom.
For each of these schemes there are a number of projects which contribute to
delivering the savings. These are cross referenced within the programme
milestone reports set out in the next section.
•
The Elective care, urgent care and early years programmes are assessed as
only partially delivering on QIPP savings at 68%, 44% and 0% achievement to
date.
•
The forecast position is for year-end delivery of 89% of plan following
mitigation.
•
The year to date position at month 10 is £2,049k QIPP savings achieved
against identified planned savings of £3,160k (65% achievement).
•
4
Achievement by project is shown in the Table 2 over the page.
Table 1 – QIPP Achievement by Programme
Month 10 Forecast Position
Year to Date Year to Date Year to Date Achieved
Actual
Budget
Variance Year to Date
£000
Corporate
Chronic Disease & Medicines Mgt
Urgent Care
Elective Care
Early Years
Total Identified Savings
Unidentified QIPP
Total Net QIPP Programme
Mitigation - use of headroom
Gross QIPP Programme (incl mitigation)
(358)
(1,101)
(417)
(1,200)
(83)
(3,160)
(511)
(3,671)
0
(3,671)
£000
£000
(397)
(657)
(183)
(812)
0
(2,049)
0
(2,049)
(1,267)
(3,316)
39
(444)
(234)
(388)
(83)
(1,111)
(511)
(1,622)
1,267
(355)
Impact
Rating
%
111%
44%
68%
0%
65%
56%
90%
Annual
Budget
Forecast
Actual
Forecast
Variance
Forecast
Achievement
£000
£000
£000
%
138%
55%
40%
57%
0%
61%
53%
(430)
(1,520)
(500)
(1,600)
(100)
(4,150)
(613)
(4,763)
0
(4,763)
(593)
(830)
(200)
(920)
0
(2,543)
0
(2,543)
(1,700)
(4,243)
163
(690)
(300)
(680)
(100)
(1,607)
(613)
(2,220)
1,700
520
Annual
Budget
Forecast
Actual
Forecast
Variance
Forecast
Achievement
£000
£000
£000
%
Risk
Rating
89%
Table 2 - QIPP Achievement by Programme
Month 10 Forecast Position
Year to Date Year to Date Year to Date Achieved
Variance Year to Date
Budget
Actual
£000
£000
£000
%
Impact
Rating
Medicine's Management
(433)
(657)
224
152%
(520)
(830)
310
160%
Long Term Conditions
(668)
0
(668)
-
(1,000)
0
(1,000)
0%
Running Costs
(208)
(352)
144
169%
(250)
(548)
298
219%
Follow Ups
(667)
(453)
(214)
68%
(800)
(489)
(311)
61%
Reduce variation in Radiology
(176)
(359)
183
204%
(211)
(431)
220
204%
Reduce variation in outpatient procedures
(158)
0
(158)
0%
(189)
0
(189)
0%
Recommissioning Anti Coagulation Services
(200)
0
(200)
-
(400)
0
(400)
0%
Joint Care
(150)
(45)
(105)
30%
(180)
(45)
(135)
25%
FYE A&E remodelling
(167)
0
(167)
0%
(200)
0
(200)
0%
Increasing Medical Support to Care Homes
(167)
(150)
(17)
90%
(200)
(200)
0
100%
(83)
(33)
(50)
40%
(100)
0
(100)
0%
(83)
(3,160)
0
(2,049)
(83)
(1,111)
0%
65%
(100)
(4,150)
0
(2,543)
(100)
(1,607)
0%
61%
(511)
(3,671)
0
(2,049)
(1,267)
(3,316)
(511)
(1,622)
1,267
(355)
0%
56%
(613)
(4,763)
(4,763)
(613)
(2,220)
1,700
(520)
0%
53%
90%
0
(2,543)
(1,700)
(4,243)
SCAS
Early years
Total Identified Savings
Unidentified QIPP
Total Net QIPP Programme
Mitigation - use of headroom
Gross QIPP Programme (incl mitigation)
5
(3,671)
89%
Risk
Rating
3.0 Programmes Delivery
The programmes are reported under the following headings which are all
programmes overseen by Joint Executive teams (JETs). It should be noted that the
adult joint care programme does not have QIPP savings associated with it at this
stage. Investment in schemes in this programme is designed to release savings in
acute care. It is proposed to include a further section which we have called
“localities” which will include reports from the locality structure within the CCGs.
However, this needs to be discussed further.
Programme
Children & Young People
Adult Joint Care
Right Care
Urgent Care
Medicines management, Long Term
Conditions (LTC) & End of Life care (EoL)
6
Activity
1. Children & Young People
2. Adult Joint Care
3. Right Care (elective care)
4. InPACT (urgent care)
5. Medicines management, LTCs & End of Life care
Finance
Milestones
3.1 Children & Young People’ Board
Children & Young People
December 2014
Key messages
The maternity needs assessment is now complete and we are starting the
process of looking at high priority areas where we could potentially make an
impact. The terms of reference for an advisory group to work on the findings
are being agreed. The report is due to the CYP JET in January 2015, and
should follow to CCG Executive committees in February.
Urgent care communications were completed ahead of the winter peak.
This was supplemented with a PLT planned with the TV strategic care
network to promote asthma care for children in primary care.
Work has been initiated to develop self-harm awareness in special schools
and primary schools.
Clinical lead
RAG Ratings: (see
below)
Activity
Finance
Milestones
Outcome measures
Dr Juliet Sutton
2014/15 Savings:
YTD
Planned
Actual / Forecast
Over / (under)
(83)
(83)
2014/15 full
year
(100)
(100)
Admissions of children to hospital: When paediatric services across all
sectors of the NHS and social care are working effectively, it could be
expected that the rate of admissions of children into acute care would be at
its lowest. Appendix 1b show graphs for non-elective admissions of children
aged 0-19; fever admissions of children aged 0-4; and bronchitis admissions
of children aged 0-4. There is currently no discernable reduction visible, but
otherwise expected growth has been contained. There was, however, a
spike in admissions of children in October to a level notably higher than any
month since April 2012.
Low birth weight of term babies: Over the period since 2001,
Buckinghamshire County has been consistently below national average for
the percentage of low birth weight babies. However, from 2010 to 2012
(the latest available data) there was a notable increase in the rate in
Buckinghamshire, seeing the gap to the national average eroded. See
appendix 1b for graphs. Improvements in this area will reduce the number
of low weight births back to the rates previously experienced in the County,
which will lead to improved outcomes for this cohort of children and fewer
demands on neonatal and paediatric services.
Infant mortality: Since 2001, Buckinghamshire County typically experienced
infant mortality rates lower than the national average. From 2004 – 2007
the rates increased to be above national average (although the national
average was also falling at the same time). See appendix 1b for graphs. By
improving maternity services infant mortality could be brought back below
the national average, improving outcomes for those affected in a number of
significant areas.
7
3.2 Adult Joint Care
Adult Joint Care
December 2014
Key messages
The costs for the increasing demand for dementia care pose a significant risk
across health and social care. There is also significant national attention on
dementia diagnosis rates.
AVCCG has established through the Emis Enterprise system an ability to
show numbers of patients diagnosed and recorded using specific read codes
on the Emis system. As such, the CCG can now monitor progress towards
the 67% dementia diagnosis rate set for the CCG in 2014/15. Currently
performance is approximately 56% to December, with an additional 272
diagnoses required to achieved 67% based on expected prevalence rates.
8
Clinical lead
RAG Ratings: (see
below)
Activity
Finance
Milestones
Outcome measures
Dr Karen West
2014/15 Savings:
YTD
Planned
Actual / Forecast
Over / (under)
-
2014/15 full
year
-
Dementia diagnosis rates: The CCG target is to achieve 67% dementia
diagnosis rate based on the national prevalence calculator by 31 March
2015. Appendix 2b contains the latest data held in respect of this, showing
progress made towards this target.
Other outcome measures relevant to this programme are in the process of
being identified for future reporting.
3.3 Elective Care (Right Care Steering Group)
Elective Care
December 2014
Key messages
Work is ongoing with the MSK pathway, dermatology and gynaecology. An
independent firm of clinical auditors has conducted an audit of procedures
of low clinical value at BHT, looking at data from the first six months of
2014/15. Draft findings were discussed at a workshop on 19 January, and
work is underway to finalise the review, plan a workshop involving the
provider in order to improve processes and procedures for 2015/16, and to
make the necessary links to other providers to ensure the same rigour is
applied to them.
Clinical lead
RAG Ratings: (see
below)
Activity
Finance
Milestones
Outcome measures
Dr Christine Campling
2014/15 Savings:
YTD
Planned
Actual / Forecast
Over / (under)
The outcome indicators are measured at county level. The measures and
Buckinghamshire’s position compared to the national average are:
•
Excess weight in adults – Buckinghamshire at the national average
•
Excess weight in children: measured at reception year and year 6 ie
children aged 4-5 and 10-11 classified as overweight or obese –
Buckinghamshire better than the national average and in the top
quartile for both age groups.
•
Percentage of physically active and inactive adults – Buckinghamshire
better than the national average and towards the top quartile for active
adults.
Information can be found in appendix 3b.
9
(1200)
(812)
(388)
2014/15 full
year
(1,600)
(920)
(680)
3.4 Urgent Care (Unscheduled Care)
Urgent Care
December 2014
Key messages
Contract activity data from the main acute providers show over-performance
in non-elective admissions even after taking account of the inclusion of
CDU/SAU activity in the non-elective admission data.
As noted in the Performance Report for December, all local A&E providers
have experienced a very challenging period through December and into
January in terms of delivering the A&E 4 hour target. BHT missed its agreed
recovery trajectory for Q3. The ORCP continues to be robustly implemented,
and by mid-January performance appears to have recovered, but
sustainability is yet to be proved.
Clinical lead
RAG Ratings: (see
below)
Activity
Finance
Milestones
Outcome measures
Dr Kevin Suddes
2014/15 Savings:
YTD
Planned
Actual / Forecast
Over / (under)
(417)
(183)
(234)
2014/15 full
year
(500)
(200)
(300)
AVCCG emergency admissions to BHT: See appendix 4b. Generally above
prior year levels and above mean levels. Supported by BHT contract activity
reporting.
AVCCG emergency admissions to BHT for over 75s: See appendix 4b. The
early part of the year saw a step increase in admissions, most likely driven by
the CDU/SAU counting as emergency admissions for PBR purposes this year.
Significant reductions took place in September and October, however, to be
near prior year levels.
A&E Attendances to BHT from AVCCG GP Practices: See appendix 4b.
Activity has been around plan throughout most of the year, with the largest
variance arising in October. December information is not yet available.
Emergency Admissions from Care Homes for AVCCG Practices: See appendix
4b. April and June and September were a clear step above prior year,
however May, July and August were not. October and November saw
admissions below prior year levels. Patterns within this data need to be
analysed and understood in order to derive conclusions.
ACHT contacts per 1,000 population: See appendix 4b. Largely consistent
through 2014/15 to date, with CCG wide performance at around 100 contacts
per 1,000 population.
ACHT Caseload per 1,000 population: See appendix 4b. Largely consistent
through 2014/15 to date, with CCG wide performance at around 30 individual
patients per 1,000 population.
10
3.5 Medicines management, Long term conditions and End of Life
Medicines management, Long term conditions and End of Life
December 2014
Key messages
Diabetes represents 10% of the total cost of the NHS. In AVCCG it is actually
closer to 12% and could rise if not managed to 16% by 2020. The disease
affects 1 in 7 people. This has been the focus of reporting of data to
practices through the year, and a wider project is underway to take this
further. A project Clinical lead has been appointed. Work will be done to
identify the full cost of the disease in the CCG area, and attempt to track the
impact of actions and patient outcomes against that cost.
The anti-coagulation service has been re-commissioned.
Work will be completed to link actions being undertaken in the area of long
term conditions to outcome measures which can be tracked and monitored.
Clinical lead
RAG Ratings: (see
below)
Activity
Finance
Milestones
Outcome measures
Dr Stuart Logan
2014/15 Savings:
YTD
Planned
Actual / Forecast
Over / (under)
(1,101)
(657)
(444)
2014/15 full
year
(1,520)
(830)
(690)
Diabetes prevalence: The prevalence of diabetes in Aylesbury Vale, as
measured by practices has shown a steady increase since March 2010.
Reduction in EQ5D scores at aggregate level: This is directly standardised
average health status (EQ-5DTM) score for individuals aged 18 and over
reporting that they have a long-term condition, weighted for design and nonresponse This data is collected twice a year from the GP patient survey:
Baseline data is given in the table below compared to the national average.
Percentage of patients dying in their preferred place of death: This data is
not yet available due to Information Governance issues to do with access to
data. These are being worked through with partners.
11
4.0 Mitigating actions
Below is a summary of the latest position of key schemes within different underperforming programmes, and what mitigating actions are under way.
•
Procedures of Limited Clinical Value (PLCV) – The CCG has commissioned
an independent firm to perform a clinical audit of PLCVs at BHT.
Mitigation – The audit was completed in December, with a draft report
presented to the CCG on 19 January. Further actions are underway to
finalise the findings and arrange a workshop with BHT to take actions
forward.
•
Outpatient procedures – Over-performance at BHT is £729k to Month 8
for outpatient procedures. The CCG has raised this both with BHT in
terms of obvious un-notified counting changes and also with the CSU in
terms of the tariff and how are they engaging with monitor over this.
Mitigation – Quarter one close dispute on payment of certain codes,
which will be repeated through the year.
4.1 Elective / Right care schemes update
•
•
12
Follow ups – the QIPP report shows a challenge of £800k, which has been
revised downward in the full year forecast to £536k. The month 8 SLAM
report from BHT indicates £580k over-performance against plan on follow
up outpatients. Extrapolating to year end means this could become a
£870k. However, review of those specialties with QIPP targets indicates
some are delivering savings, and across a number there has been an
improvement in new to follow up ratio at BHT – over-performance is
being driven by an increase in first attendances. Some of this is likely to
be linked to 18 week backlog clearance work.
Mitigation –a dedicated project manager has been assigned to the project
from mid-September until the end of March, who has been working
within BHT to drive actions and projects aimed at unlocking decreases in
face to face follow ups. Review of data has been conducted to enable
prioritisation of the remainder of her time on the areas with most
potential, which currently appears to be T&O and rheumatology. General
Managers within BHT have been asked to work with their clinicians over
the next four weeks to scope out stretching but realistic targets and plans
going into 2015/16.
Radiology – the CCG has worked with member practices to decommission
radiology procedures of limited clinical value. However in month five the
main provider BHT has put forward a new cost of £250k direct access
costs. No patient level data has been received.
Mitigation – Challenged successfully through the contract executive
assurance meetings.
Summary – The level of ‘will’ from providers to reduce follow up costs and lose
income has not being demonstrated through the year, however there are signs
that this position is shifting. The system needs to understand this and further
discuss options to achieve this change through a system wide approach on risk.
The project on PLCV is a win/win to the commission and provider in terms of
maximising surgical capacity in the system and for patients guaranteeing
appropriate surgical procedures are being completed at the best waiting time.
The CCG needs to work further through localities to engage member practices in
regard to referral levels to both outpatients and to radiology and diagnostic
services. To help this further work on practice level information is required as part
of mitigation.
4.2 Early years
•
The annual QIPP target is £100K which is currently forecast not to be met.
The current resilience programme has not prioritised any additional
support for children’s emergency care over the winter. From the system
wide profit and loss work attendance’s of children aged four and under is
an outlier in Buckinghamshire.
Mitigation – includes the completion of implementation of the five
children’s urgent care pathways and the need to identify frequent
attenders to general practice.
•
Mitigation – AVCCG has worked in partnership with member practices to
commission additional support for the over 75’s population for this
winter. AVCCG has an over 75’s population of 14,577 and has set a target
to reduce admissions by 3.5% or 510 episodes of care. Potential for
savings of £350k based on a notional tariff of £1,800. CSU analysis
indicates over 75 emergency admissions cost AVCCG on average £2,390,
making the opportunity closer to £1,200k.
•
Mitigation – discharge co-ordinator at MKFT was an investment of £60K
from the over 75’s fund, aim to reduce costs on access bed days of £200K.
•
Mitigation – BCCR (Bucks co-ordinated care record), produced from a
directed enhanced service payment which was already within the primary
care quantum. Through sharing of the information with out of hours
services, end of life services and carers bucks aim to reduce emergency
admissions by estimated 50 episodes, producing QIPP saving 100K. (Still
to be validated).
4.3 Urgent care/LTC
13
•
Introduction - £1m saving has been badged against long term conditions
in the original QIPP however this on review is not appropriate. The real
challenge is overall containment / reduction of emergency admissions set
against the significant level of investment in schemes to reduce
emergency pressures. Unless the considerable system wide investments
in BCF, resilience funding and social care show delivery it will be
challenging to show the financial gain from the quality improvements we
are clearly seeing in the’ live well’ programme, the COPD nursing service
and improvements in Diabetes control. While it is too early to conclude
on a pattern, data through Q3 is showing some reduction in admissions of
over 75s, but this has been more than replaced with other admissions.
•
System resilience plan – The Bucks system will see an investment of
£2.7m over the six months to 31 March 2015 to support the system in
maintaining performance over the winter period. The challenge to the
QIPP will be the establishment of an additional in-patient ward at BHT
ahead of the improvement and development of an Ambulatory care unit.
The system is also seeing investment of approximately £2m from ‘social
care money for outcomes’ which should be launching a same day
response service and the start to seven day working.
Appendix 1a – Project milestones – Children & Young People
Project
Milestone
Due date
Market testing
April
Stakeholder engagement programme has
been agreed with BCC
Commissioning model and approach
confirmed/ Building Specification
Procurement Process / Tender
Commences
Finalise service specification & launch
procurement process
Sept
Tender evaluation and decision on
procurement outcome
Tenders have been
submitted. Tender
moderation & provider
presentations fixed for
February
Start date for new contract
PID sign-off
October 15
April
Complete
Advisory Group set up, Royal Colleges
involvement agreed, stakeholder
consultations drawn up
May
Complete
September
Update to C&YP
programme board of
needs assessment and
stakeholder engagement
Engagement events held
and GP survey planned for
October
complete
Completed in January
Needs Assessment analysis and options
paper drawn up
Engagement plan starting
Tariff work started
First meeting of working group for
national data set
Maternity Needs Assessment to CYP JET January
Maternity Needs Assessment to CCG
February
Execs
Ensure recommendations are picked up in March
14
Contract Extension signed
for 6 months. Practices to
be involved in
procurement intentions
through on line survey
Final Business Case to
CCG Exec and Stakeholder
Event completed in
October
May
Self harm information on public health
website. Pilot school training and delivery
plan. GP films rolled out.
November
February 2015
Maternity
Needs
Assessment
First draft of project communications
plan. First draft of Asthma leaflet pathway
completed and jaundice leaflet sign off.
July
Agreed 6mth extension to contract
Stakeholder and bidder workshops to
inform service model
April
Complete
June
August
CAMHS
Retender
specifications and quality schedules for
BHT & HWP 2015/16 contracts
Commentary/ exception
report
Now required for February
Paediatric
Urgent Care
June
New paediatric urgent care framework
rolled out.
July
Review programme to date.
Initiate work to develop self-harm
January
awareness in special schools & in primary
schools
Ensure recommendations are picked up in March
specifications and quality schedules for
BHT & HWP 2015/16 contracts
Complete. Plan to
relaunch bronchiolitis
pathways with
asthma/wheeze pathway
in September ahead of
Autumn bronchiolitis peak.
PLT planned with TV
strategic care network to
promote asthma care for
children in primary care
(November 2014)
Self harm booklets for
schools launched with
training day and pilot
started.
Further conversations
taken place with A&E to
ensure implementation of
self harm pathway in
practice
July self harm evaluation
was sent out to schools
Children’s website re
launched with media
coverage-agreement
reached to redesign so
compatible with
smartphones/app.
Work with CSU to further
map impact of revised
paediatric pathways on
urgent care has
commenced in October.
complete
Paediatric physio produce first draft for May
consultation. Specific liaison with project
leads for early years and disability
(physio).
Physiotherapy
Workshop with physiotherapy team to
Review
include OH and SALT.
June
September
share physio review with provider
November
Data capture of acute and community
paediatric activity
May
Complete
Map total provision including services that June
report to Paediatricians
July
Paediatric
Community
Services
Stakeholder engagement
Options appraisal to JET
SEN Reforms
15
Slight delay-first draft to be
presented at Children’s
programme board in July
Options for Physiotherapy from
consultation process drawn up
in August.
Shared with BHT in January
New Physiotherapy pathway testing with
parents.
October
Participate in the recruitment of 2 new
January
paediatric consultants
Work with provider to ensure Designated February
Doctor cover is provided & recruitment
gaps resolved
Children and families bill to receive Royal
Assent. Working with parents and young
people to develop local offer. Agreed with
April
BCC how to take this forward. Training and
support offered to service providers
affected by the reforms.
Draft SEN code of practice approved.
Working with parents and young people
to develop local offer. Training and
support offered to service providers
affected by the reforms.
Working with parents and young people
to develop local offer. Training and
support offered to service providers
affected by the reforms.
May
June
Personal budgets available from Sept 2014
for Children’s Continuing Healthcare.
September
(phased intro)
Mapping of services complete
Meeting with clinical
commissioners and
paediatricians to confirm service
capacity and structure
Now scheduled for November
JET
Implementation of new EHC plans
September
SEN Reforms
(continued)
Children with
Complex needs
Business Case
and disabilities
July
Autism strategy and action plan in place.
December
Autism commissioning manager in place
Autism Commissioning Manager
January
appointed
Autism Commissioning Manager in post;
Health and Social Care self- assessment
February
data collection & submission signed off by
27/02
Update localities re progress of
Children's SEN Health Plans.
Ensuring that health have
agreed their element of the local
offer.
Agree process for Personal
Health Bs; Follow up core group
and Bucks system group to
review initial progress.
Business case in July was agreed
for looking at a model for
providing an integrated
provision of care for these
families with a single point of
access. Funding for a project
manager to head up this project
has been agreed between health
and the local authority intended
by September. Engagement and
feedback from families and
providers was gained earlier in
the year.
Appendix 1b – Outcome measures – Children & Young People
Infant mortality
The outcome indicators are measured at county level:
• Buckinghamshire is just better than the national average in terms of the
proportion of low birth weight babies and for infant mortality
• However, the difference in mortality rates between areas of highest
deprivation (DQ5) compared to the lowest (DQ1) is significant and mortality
rates in the highest areas of deprivation are above the England average. See
chart below.
Trends in Infant mortality in Buckinghamshire by deprivation, 2001/03 – 2010/12
Urgent care
The urgent care element of the CYP programme has focused on developing
pathways for specific diseases and the emergency admissions for these pathways
are being monitored to review the impact of the schemes.
Key points to note - There is no discernable reduction in admissions of young
children to BHT with bronchitis and fever but otherwise expected growth has
been contained. Admissions for these conditions show marked seasonal variation
and showed a sharp increase in November as winter infections hit.
16
Appendix 2a – Project milestones – Adult Joint Care
Project
Milestone
Integration:
Integrated
Falls Service
This is now a service and no longer a
project
through main contract.
Due date
April
Roll out of Project Centaur. Alignment
of current services ahead of more
radical re-commissioning as part of BCF
implementation.
Single access point through ACHTs
operational in all localities
June
September
Integrated
Community
Teams
Ensure alignment with other urgent
response services (older people's
mental health, BUC)
Second draft tier 3 service design to
Urgent Care forums; cross links to
primary care strategy
PQQ for single service
Staff recruitment completed and team
fully established – delayed to May
Final agreement on monitoring
progress of service. Resource to be
working in A&E, EAU wards including
HW and SM monthly monitoring
17
Centaur project - Single
access point through
ACHTs operational in all
localities.
s 256/BCF agenda transfer of care
pathway project group
launched and first
meeting in September ;
Wexham Park system
pulled together into a
Bucks wide single
pathway to ensure
standardised pathway
for all bucks patients.
June
Audit of service from patients, BHT
staff, GPs.
End of year report on service delivery
and options
Recruit Memory Friendly Communities
Co-ordinator.
Review Diagnostic Rates for 2013/14
and action improvement plan.
Complete Memory Clinic Set up in 4 GP
practices (MACH).
Initiate Workforce Training group to
assess current provision and need
across whole system.
Review progress across care home
projects and identify need for future
planning.
Dementia
Run Whole System Partnership
Workshop to identify gaps in pathway
and evaluate national good practice
examples.
Full complement of
staff in post from June.
Confirmation of office
base required, team at
present based in John
Hampden.
Berkshire liaison model
agreed.
December
Set up Memory Friendly Communities
Strategy Group.
Community matron in post
Provide practices with advice and
guidance on Dementia review and stats
Review national CQuIn - agree
continuation with BHT/HWWP
Assess capacity in memory clinics for
15/16; metrics at practice level;
Revised model
implemented –
providing PIRLS to all
adult wards in SMH
March
On Track
April
On Track
May
June
Hospital Befriending Scheme at Stoke
Mandeville Hospital commences
Evaluate Age UK Memory Advice
Service and Alzheimer's Primary Care
Worker.
March
PIRLS
Audit of service
Managed under the
integration pathway
and project is a sub set
of the s256 funding ;
start date to be
announced soon and
will be communicated
to the localities
February
April
September
Commentary/
exception report
September
Met to discuss new
diagnostic target
process and agreement
to look at overlap
between dementia
support workers and
other services
Memory Friendly
Communities Strategy
Group set up
Business case/options
appraisal for Dementia
services across Bucks
considered by
Dementia Board
December
January 2015
February 2015
March 2015
Awaiting national
guidance
Dementia
(continued)
Neuro Rehab
Review
Community
Equipment
Flagging mechanism for GPs
identification of dementia carers
agreed.
Work with Strategic clinical networks
to agree baseline
Develop terms of reference for LTNC
network group
Review against revised spec for fit as
part of monthly reporting
Contract review of service profile inc
backdated data.
Ensure 2015/16 contract with BHT
reflects agreed data requirements
Preferred contract provider announced
for community equipment
Contract awarded to new community
equipment provider
Start date of new service for CEls
Notice given by CSU to BHT for phase 2
transfer of continence & wheelchair
products 30/09
Continence
Service and
Wheelchair
service
18
Ensure current commissioning gaps in
CYP understood & addressed for
2015/16
Specification update for Wheelchair
service
Ensure 2015/16 contract with BHT
reflects agreed change in service
New service commences
April
May
June
December
March
April
May
October
November
January 2015
February 2015
March 2015
April 2015
Complete
Complete
complete
Quarterly data being
reviewed
Discussions underway
with BHT
Complete
Complete, new
community equipment
provider identified.
Determine KPI for
urgent response times
at 98%Contract
awarded to new
provider. Section 75
sign off
Step-up preparation for
phase 2 for 01/04/15 golive
need confirmation of
funding to be extracted
- potential financial risk.
Escalated to contract
negotiation issue
Appendix 2b – Outcome measures – Adult Joint Care
Dementia Diagnosis: The chart below shows the number of dementia diagnoses
across each locality within the CCG. Data has been extracted from the Emis
Enterprise system. It is dependent on dementia diagnosis being recorded under
certain ‘read codes’, and does not count any results for practices not using Emis.
Data validation has been underway from October. The 67% target is what the CCG
is being assessed on through its assurance reviews with the Area Team. National
monitoring of performance is also being undertaken, and the local CCG data
reconciles back to the national view.
Currently AVCCG is at approximately 56% of expected diagnoses. To get to 67%
requires an extra 272 diagnoses. Work is under way to review patients on
dementia drugs but without a QOF-recognised dementia code; and patients with
a code which indicates potential dementia but without a QOF-recognised
dementia code. There are approximately 1,000 patients in these scenarios, a
number of whom may legitimately be recorded with QOF-recognised dementia
codes.
19
Appendix 3a – Project milestones – Elective Care
Project
Milestone
Project
Due date
April
Define actions to be taken forward
during Q1 and Q1 project plan
Outpatient
follow-ups
(completion
of 13/14
project)
June
End project report
Project refreshed
Digitalisation
of outpatient
consultations
June
Investigate and map current AT system
use and processes: Initial investigation
of available AT options in the market
place and other Health Service
providers
Working with Service Delivery Units,
commence planning the
implementation of any “quick win”
initiatives including business process
mapping where required
End project report
Dermatology
20
December
Outline business case
Commentary/
exception report
Engagement with BHT
clinician at RCSG
Monthly reporting at
the RCSG and escalation
via contract for over
performance
CSU has identified a
member of staff to
work with BHT to
develop a clear action
plan ( follow on from
the inter mountain
project) and this team
working closely with
plan for greater clinical
change across chosen
specialities;
Action-plan is now in
place for refreshed
project
Presented Q1 findings
of AT outpatient
appointment project.
Steer from RCSG is that
project should focus on
telephone clinics now
and agree with
recommendation to
suspend CSU project
mgt and replace with AT
Project Officer
Milestone
Gateway decision
Full business case
Due date
June
July
August
Gateway decision
Project implementation
September
October
Service spec
November
Specification completed and shared
with GPs
Exec agreement of specification and
procurement plan
Develop tendering suite
Radiology
Publish plan- demand and spend
analysis.
Establish metrics.
September
Care UK contract monitoring
compliance with clinical guidelines and
any corrective action
Delay – business case to
be considered at
November CCG
executive meeting
Timetable reset-
February 2015
March 2015
May
MRI by practice
information received.
June
Governance group
established and actions
agreed and Contract
challenge to BHT for
coding errors requested
via the CSU.
Data received split by
provider in September;
monitoring of MRI
referrals will continue
March 2015
Previous business case
is under review. CSU is
sending information on
CCG agreed that
business case to be
updated and considered
at November executive
team meetings.
As above
January 2015
Radiology governance group to meet
to validate BHT and other provider data
to assure future planning assumptions
May
Commentary/
exception report
replies to the PIN
together with initial
service specifications
and original business
case. CCG will decide
next steps.
June
Project
Milestone
Receive regular MRI reports
Choose &
book advice
& guidance
Due date
Project documentation produced
June
July
Preparation
August
Commence pilot of advice and
guidance in 4 Specialties (Urology,
General Surgery (inc Breast) ENT
Respiratory)
Pilot finishes: End project report
21
Project
Milestone
Consultant to
Consultant
Referrals
Agree Audit process with BHT
May
BHT to complete C2C Audit
June
Agree pathway changes
July
January
May
PID approved
Commentary/
exception report
against this baseline for
BHT to deliver
predicted savings
through governance at
the RCSG; current
trajectory showing a
marginal improvement
on demand but not
savings that requires
further evaluation.
January 2015
Awaiting a paper from
CSU which will go to
Executives and start
date for project agreed.
Business case complete
Procurement decision
to execs
Creation of Guidelines
6- 10.
Embed
pathway/guideline
referral letters.
Establish Clinical
Reference point for
guideline approval
All current clinical
guidelines pulled
together for review
and
current clinical
contents sent to BHT
clinicians for clinical
reviews/sense check in
September. Clinical
lead reports milestones
are ambitious and likely
to be delayed.
Pilot now underway but
start was delayed
Due date
End project report
August
No further action agreed
January
Review and
Recommission
Local
Improvement
Schemes
Wound Care
services –
review and
recommission
LCS
MSK Service
review
Commentary/
exception report
Scope and process
agreed by BHT awaiting
date.
Audit now completed
and results being
reviewed
Initial milestone plan to
be revisited by CSU who
will progress this.
Governing Bodies approve new LES for
Wound Care
April
Right care approved in
April
New LES implemented
May
Signed off by Executive.
Agree process for specialist treatment
June
Workshop completed and project
initiated to assess re-commissioning
options
November
Appendix 3b – Outcome measures – Elective care
The outcome indicators are measured at county level. The measures and
Buckinghamshire’s position compared to the national average are:
•
Excess weight in adults – Buckinghamshire at the national average
•
Excess weight in children: measured at reception year and year 6 ie children
aged 4-5 and 10-11 classified as overweight or obese – Buckinghamshire
better than the national average and in the top quartile for both age groups.
•
Percentage of physically active and inactive adults – Buckinghamshire better
than the national average and towards the top quartile for active adults.
Key Indicators for QIPP Savings (Finance)
Outpatient Activity – Aylesbury Vale CCG : The two charts show the trend in first
and follow-up outpatient attendances at BHT compared to plan. The blue lline on
the chart shows GP referral rates.
Key Points to note:
22
•
First outpatient attendances have been above plan since April 2014, except
for in August when there was a reduction due to with the holiday period. The
increase was mostly in specialties associated with the waiting list backlog
clearance and can be largely attributed to this. There is funding available to
mitigate the financial impact of this.
•
Follow-up appointments show a similar pattern: increasing March to July, a
dip in August, then back to an increasing trend in September and October.
Work continues to bring the project to reduce follow-ups back on track.
Appendix 4a – Project milestones – Urgent Care
Project
Milestone
Due date
Care Homes
Practices sign up to care homes LES
Review of Care Homes Initiatives
commences
April
June
Care Homes Initiatives Review Report
completed with recommendations to exec
October
Go/no go for Care Home LES;
January
Medicines standards to BCC;
Pilot pharmacy risk management tool live
Stock-take of Care Homes/ patients and January
support
ACHT Reform
April
Benchmarking performance across
localities and nationally
May
Implementation of iPads by locality
(mobile working solution)
Audit and evaluation of demand and
May
productivity of 2 OOH Teams model pilot
completes
HR processes begin to implement new
July
team structure
ACHT Review
tbc
To be confirmed
Out of Hours Re-procurement process on track.
service recommissioning
23
tbc
Commentary/ exception
report
Complete
On target
Outcome of workshop on
strategic way forward
being considered.
On target
complete
Crystal Oldman has now
made contact with Jackie
Allain to support this
process
The countywide roll out is
scheduled to begin late
July in the South CCCG
locality and then moves
northwards. The
anticipated roll out for
AVCCG is late September.
Awaiting the audit report
or summary from BHT
New team structure – no
further update at present.
First meeting scheduled
11 September
ACHT will be led by Lesley
Perkins on behalf of the
system with support from
Karen West
OOH Programme Board
established and
procurement timeline.
Extension of current
provision being finalised.
Moving to engagement
phase.
Out of Hours Outline specification completed;
service (cont)
January
complete
Appendix 4b – Outcome measures – Urgent care
ACHT contacts per 1,000 population by locality
Caseload per 1,000 population by locality
(Number of different patients seen per month)
Emergency Admissions to BHT
from SLAM for Aylesbury Vale CCG Practices
No of Admissions
1600
1400
1200
1000
800
600
400
200
0
Apr May
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb Mar
1055 1244 1238 1450 1101 1036 1217 1175 1311 1022 1144 1305
2014/15
976 1048 873
Aylesbury Vale BHT 2014/15 Plan 926
24
Jun
2013/14 inc. CDU/SAU
957
926
952 1050 956 1174 1035 1097
957
927
957
957
926
957
Key points to note:
The trends in activity from the SLAM report – Chart 3 in column one above, show
that emergency admissions continue to be above plan but not as much as last
year after CDU & SAU figures are added in.
•
From April 2014 at BHT all CDU & SAU activity is counted as emergency
admissions. The all admissions data for 2013/14 has been adjusted to take
account of the change by adding CDU/SAU into actual activity. This shows
that there was an increase in admissions from March to May but it is within
the boundaries of normal variation. The QIPP schemes are planned to deliver
a 17.5% reduction in short stay admissions for people over 75. However, year
to date activity shows a similar pattern and volume as last year bearing in
mind that in this case no adjustment has been made to 2013/14 figures
because an age breakdown of CDU activity is not available.
•
Admissions from care homes have been above last year for most months but
were below last year for the month of December.
•
ACHT contacts per 1,000 are stable across the CCG through the year to date,
and amount to approximately 100 per 1,000 per month. Aylesbury North is
notably higher than Aylesbury South and Central.
•
ACHT caseload per 1,000 population is similarly stable at around 30 for the
CCG as a whole. It is notable that though Aylesbury North is again a step
above the other localities, it is by a smaller margin that the number of
contacts per 1,000 population. This may indicate that proportionally
Aylesbury North community patients receive more visits than other localities
on average.
25
Appendix 5a – Project milestones – Medicines management, long term
conditions, end of life
LTC- Live well
1) 1st 100 patients
evaluation
2) Addition of physical
trainer to pilot
Addition of nutritional
support to pilot
Year 1 evaluation of pilot
project commences
Decision to commission roll
out of Live well to all
localities
LTC: Integrated
Community
Diabetes
Service
AV CCG diabetes quality
map
1) AVCCG PLT diabetes
event to engage members
2) Bucks wide diabetes
stakeholder event
Bucks diabetes redesign
project plan
Implementation of service
redesign proposals
commences
Launch event to agree
workstreams, leads, vision,
principles; define best
patient experience.
26
April/ May
June
Delayed until August; nutrition
support to Live Well now to be
provided from dietetic service
rather than via existing physical
trainer role.
LTC: Extending
Access to
Advanced Care
Plans
July
September
April
Decision delayed. Evaluation
process and funding agreed.
Complete
Complete
May
June
September
January
Complete
May
June
ISAs signed by all urgent
care network providers
(hospices/OUH/MKG)
July
BCCR viewable by all
partners to Urgent Care
Network
September
top 2% of most vulnerable
patients to have
personalised care plans
Development of plan on hold
while resource allocation from
CSU to support service redesign is
agreed.
Project scoping to commence in
parallel with clinical lead
appointment from July
Agreement at June JET to appoint
clinical lead for diabetes redesign,
shared resources across
Buckinghamshire; service
implementation now expected
from April 2015.
completed
Local Guidance to support
Unplanned Admissions DES
to be published/ BCCR
updated to reflect
requirements of DES
Practices sign up to
Unplanned Admissions DES
September
PROJECT COMPLETE NOW
BAU
Recommissioning
Anti
Coagulation
Services
Business case for BCCR for DES
agreed in principle pending
operational framework replacing
previous investment line for ACP.
Exec approved BCCR payment.
Communication via newsletter
out to members. BCCR visible to E
Berks OOH and A&E planned for
October.
BCCR report now up and running
on a monthly basis (December) data quality issues to be fed back
to practices to ensure
improvement
Finance checks on
modelling
April
Complete
Service spec finalised
May
Complete
PID approved
May
Complete
Patient and public
involvement planning
Patient and public
involvement commences
Notice served on existing
providers (6 Months)
May
Planning underway but not
completed
June
Delay to July
July
complete
Prescribing forums
July
AQP process published
(invitation to apply)
July
Provider information day
th
confirmed for 17 July
MM JET approves AQP
process followed and makes
recommendation to Exec
Award contracts/ Agree
mobilisation with providers
Medicines
Management:
Wound Care
services
Medicines
Management
Nutrition
27
November
December
Mobilisation commences
January 2015
Contracts let and service
commences
March/April
2015
New ONPOS contract in
place
Re-audit initial high
prescribing practices
initiate joint formulary
review of supplements
Review meeting timetable
to be identified.
Take audit
recommendations to
Forums.
Meeting with procurement
to agree retendering
programme (SIP feed
contract)
Training to Care home on
MUST
Develop COPD and
nutrition PIL
Review BHT policy re
monitoring gastrostomies
and tube feeding guidelines
Service specification agreed
across multiple
organisation; business case
for care nutrition dietician
to Exec
New gluten-free policy
communicated to GPs;
design taper down policy
for 16/17
On track
July
Mobilisation discussions continue
– solutions to issues with
reporting being negotiated.
New provider identified – target
date of September to have
contract in place
Complete
April
April
May
Complete
Complete
Meeting reconvened to late June
May
June
complete
complete
September
complete
January 2015
January 2015
GF policy decision made, comms
materials to be complete Feb 15
Medicines
Management
Stoma
Project cannot commence until
project support agreed.
Appendix 5b – Outcome measures – Medicines management, long term
conditions, end of life
The prevalence of diabetes in Aylesbury Vale, as measured by practices has shown
a steady increase since March 2010.
Key Indicators for QIPP Savings (Finance)
The headline KPIs to be reported are to be agreed but include:
Reduction in EQ5D scores at aggregate level: This is directly standardised average
health status (EQ-5DTM) score for individuals aged 18 and over reporting that
they have a long-term condition, weighted for design and non-response. This data
is collected twice a year from the GP patient survey: Baseline data is given in the
table below compared to the national average.
Period
July 2012 to
March 2013
July 2012 to
March 2013
July 2011 to
March 2012
July 2011 to
March 2012
Indicator
value
Average
health status
for all
respondents
National
10Y: Vale of
Aylesbury CCG
0.74
National
10Y: Vale of
Aylesbury CCG
Region
Denomi
nator
Numerator
0.82
458774
335769
0.78
0.85
1581
1227
0.74
0.83
471670
344338
0.80
0.87
1510
1181
Percentage of patients dying in their preferred place of death: This data is not yet
available due to Information Governance issues to do with access to data. These
are being worked through with partners
28
Governing Body Meeting
NHS Aylesbury Vale CCG Operating Plan Refresh 2015-16
12 March 2015
Purpose of Paper
To present the Governing Body with the draft CCG Operating Plan refresh and QIPP programme for
2015/16, outlining the process undertaken to date and the next steps to ensure appropriate
governance is followed to facilitate the plan being signed off by 31 March 2015.
Executive Summary
Operating Plan
In April 2014 the CCG published its two year operating plan, covering 2014/15 and 2015/16. In
October 2014, NHS England published Five Year Forward View. Subsequent planning guidance for
CCGs have been produced and reviewed by AVCCG. The 2015/16 operating plan has been refreshed
using this guidance to ensure alignment with Five Year Forward View and compliance with any new
planning requirements. Subject matter experts across the CCG including Joint Commissioners have
contributed to relevant areas of the plan. An update on the planning process was prepared for the
Executive in January 2015, which has links to the existing plan and guidance, and is attached at
Annex A to this report.
NHS England required an Executive Summary of the operating plan refresh to be produced for their
assurance purposes, along with completion of an assurance template which they will use to review
and assure our draft plan. This was accompanied by financial plans and activity and performance
plans submitted via Unify. Additionally, a copy of the full draft plan was provided. These documents
are annexed to this report as follows:
Annex B – Operating Plan Executive Summary for NHSE – 20150227 submission v2
Annex C – NHS Aylesbury Vale CCG Narrative Op Plan Assurance Template
Annex D – Operating Plan 2015-16 v5.1
Feedback is expected from NHS England by mid-March, although no specific date has been
confirmed.
QIPP Planning
The finance plan is subject to a report from the Director of Finance. The Operating Plan confirms the
high level details of the finance plan, that it meets the required business planning rules, and what
the QIPP programme for the year is. Work has been undertaken to ensure that the finance and
operating plans align. The main area of detail which overlaps is the QIPP planning. An outline of the
QIPP planning process, the output and the position included in the draft operating plan refresh
submitted to NHS England on 27 February 2015 is included at Annex E.
1
Actions requested / recommendation
The Governing Body is asked to review the planning documents, including QIPP planning. Feedback
from the Executive has been requested ahead of 12 March 2015, and an oral update will be provided
to the Governing Body. Feedback from local and regional NHS England review processes is expected
around mid-March, and if received before the Governing Body, an oral update will be provided. As
such, there is likely to need to be minor amendments to the operating plan documents. No material
changes are anticipated, however.
The Governing Body is requested to: provide comments and feedback on the operating plan; and
give delegated authority to an appropriate individual(s) to sign off the plan by 31 March 2015.
Strategic Objectives supported by this Paper (Please Tick)
Improve people's health and reduce inequalities
Enhance quality, safety and experience of patient services
Ensure local people have greater influence and management of own care
Deliver financial sustainability with headroom to invest
Perform well as a CCG
Equality Analysis completed
Yes
(please tick )
Author of paper
Paul Hutt, AV CCG
No





Not applicable
Lead Director(s) responsible for this area
of work
Colin Thompson, Director of Operations &
Performance
2
1
NHS Aylesbury Vale CCG
2015/16 Planning update
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www.aylesburyvaleccg.nhs.uk
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
2
Outline – to date
•
•
•
•
•
•
Planning guidance has been received and reviewed.
Planning workshop led by Area Team attended by Finance and Ops & Performance.
High level finance and activity templates submitted mid-Jan.
Trajectories for operational targets and constitutional measures submitted 28 Jan.
All information submitted to date is draft and subject to refinement and
amendment between now and the end of March.
Activity assumptions have been based on 2014/15 to date, and forecast figures for
Q4 based on growth experienced in the year to date.
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3
Financial Context
•
•
•
•
•
•
•
•
•
Uplift in Programme baseline from £202,185k to £212,461k = growth £10,276k.
Decrease in Running Costs allocation from £4,906k to £4,425k = decrease £481k
Winter resilience funding included in baseline of £1,099k.
Business rules applied in setting aside 1% surplus, 1% headroom and 0.5% contingency
Requirement to use £1.3m of the Headroom to contribute to the CHC Legacy Risk Pool.
Requirement to invest in Mental Health services at the same level of total growth – this is 5% =
£0.9m.
Cost pressures and outturn £10m, Net deflation £1.3m and growth £5.5m
Qipp requirement £2.5m with stretch to £3.5m
Other investments/projects must be self funding by generating savings.
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4
Outline – going forward
•
•
•
•
•
•
2015/16 plan is an evolution of the 2014/15-2015/16 Operating Plan developed last
year. This is part of a continuous process rather than a completely new plan.
NHSE is not looking for a re-writing of the entire operating plan, requiring only an
executive summary (3-5 pages) plus assurance statements on the attached
spreadsheet, which incorporates the national planning guidance, QIPP and the Five
Year Forward View.
Draft plans are to be submitted by 27 February, and will go through an assurance
process with the Area Team.
Plans must be approved and signed off by Governing Bodies by 31 March.
Final plans must be submitted to the Area Team by 10 April.
There are several touch-points and feedback loops through the process from now
until the end of March.
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5
http://www.englan
d.nhs.uk/wpcontent/uploads/20
14/12/forwardview-plning.pdf
http://www.england.nhs.uk/wpcontent/uploads/2014/10/5yfvweb.pdf
http://www.englan
d.nhs.uk/wpcontent/uploads/20
14/12/plan-guidnhse-annx231214.pdf
National
Planning
Guidance
Review Performance reports
and Quality Reports
Review of the
year so far and
current
performance
issues
Review JET papers
and minutes, discuss
with clinical leads
and managers
JET
programmes of
work
Five Year
Forward View
Research,
investigation,
analysis etc
2014/15 –
2015/16 plan
developed a
year ago
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2015/16
Operating
Plan
Horizon
scanning for
new / additional
opportunities
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
6
Next Steps
•
•
•
•
•
A high level outline draft of the Operating Plan will be in place by COP 2/2/15.
This will take significant elements of the previous year plan which either need
updating or amending, or refer to the prior year plan where things remain as
previously planned.
A lot of detail will remain to be included, to which appropriate individuals across the
CCG will be asked to contribute.
An opportunity to review the full draft may not exist through formal governance
channels, however a review process will be in place to ensure appropriate oversight
of all submissions to the Area Team.
March Exec and GB will receive the full plan and proposed submission to the Area
Team.
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Operating Plan Executive Summary for
NHS England Assurance purposes
1. Background
operating plan was developed. Where necessary, plans have
been further developed to ensure compliance with FYFV and
the direction it sets for the NHS.
This document is the draft Executive Summary of the NHS
Aylesbury Vale CCG (AVCCG) operating plan refresh for
2015/16, for the purposes of providing assurance to NHS
England.
In the original operating plan, AVCCG identified that to help
the NHS survive, we need to: get better at preventing disease,
not just treating it; increase everybody’s participation in and
responsibility for managing their own care; and integrate
services to provide seamless care. These three priorities were
validated by the three key elements in FYFV, and AVCCG is
now planning to go further and faster in its pursuit of these
aims.
AVCCG has an existing two year operating plan, approved for
the 2014/15 and 2015/16 years. Alongside this is the wider
Buckinghamshire Commissioners 5 Year Strategy. Publication
in October 2015 of Five Year Forward View (FYFV), along with
subsequent planning guidance for commissioners, has
required a refresh of the operating plan. This has been
completed and a refresh of the operating plan produced.
In addition to FYFV, developments specifically around cocommissioning, but also prevention, Better Care Fund and
operational performance issues have been reflected.
Accompanying this Executive Summary for NHS England
assurance is the upload of national operational planning
templates through UNIFY, and the regional assurance
documentation outlining a high level summary of QIPP
schemes for 2015/16, assurance against Annex A, and
assurance against Forward View into Action.
3. The model for change
AVCCG is working with the Institute for Healthcare
Improvement’s Triple Aim model. The Triple Aim is a
framework that describes an approach to optimising health
system performance. New designs must be developed to
simultaneously pursue the three dimensions of: improving
patient experience of care (including quality and satisfaction);
improving the health of populations; and reducing the cost
per capita of health care.
2. AVCCG – current position
All elements of FYFV and associated planning guidance have
been reviewed by subject matter experts within the CCG.
Consideration has been given as to whether existing plans
meet requirements and guidance, or whether additional
actions are required – either based on new guidance, or
based on performance and developments since the original
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The CCG’s operating plan refresh narrative uses the structure
of FYFV, and links each element to the Triple Aim. In this way,
1
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Operating Plan Executive Summary for
NHS England Assurance purposes
the CCG has plans aligned to FYFV which utilise a world-class
model for change to maximise delivery.
digital health records being in place by April 2018.
Personal Health Budgets began to be offered to adults and
children eligible for Continuing Healthcare in 2014/15. A
scoping exercise will inform the CCG’s strategy for extending
the availability further during 2015, including to those with
mental health conditions and learning disabilities. We are
also developing areas linked to Personal Health Budgets for
joint working with Buckinghamshire County Council (BCC).
4. Prevention and Public Health
The first of three key elements in FYFV is focused on
prevention and public health. This is also one of the Triple
Aims (Improve the health of populations), and is a key
element of the CCC wide and locality plans for the future.
Existing plans set out detailed descriptions of the public
health interventions planned in the system. In addition to
those existing plans, programmes of work will be undertaken
in relation to :
5.1 Patient Choice
AVCCG will assess the current provision of choice to patients,
and identify where there are areas which need to be
improved. The right to choice extends to mental health
services, and AVCCG is committed to delivering this. In
addition, work is ongoing to ensure that effective choice
exists in relation to maternity services.
• Maternity / early years and healthy lifestyle; and
• Communicable disease and emergency planning.
FYFV outlines six approaches to improving health and
wellbeing. Some of these areas are a continuation of the
work already underway through the existing operating plan
and Five Year Strategy. Others will require new actions to be
taken in 2015/16.
5.2 Carers
AVCCG is working alongside BCC to identify unknown carers,
including young carers and carers aged over 85. A Health and
Social Care Needs Assessment of Unpaid Carers in the county
is underway, as is a project using GP texting services to
contact patients and identify those who are unpaid carers.
5. Empowering patients
The second key element outlined in FYFV is about
empowering patients to give them more control of their own
care. A project is underway to ensure online access to GP
records is delivered in a systematic way across the CCG; and
we will use the tools within the NHS Standard Contract to
ensure demonstrable progress towards fully interoperable
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6. New Models of Care
The third key element in FYFV requires the NHS to break
down the barriers in how care is provided. It outlines a
2
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Operating Plan Executive Summary for
NHS England Assurance purposes
levels or national average (where there are no targets), or
where performance is deteriorating. Ambitions and
priorities currently remain as established in the existing
operating plan.
• Ongoing delivery of core constitutional standards around
elective care, as well as the successful introduction of access
standards for mental health services.
number of proposed new models of care for local health and
social care economies to work with. There are currently two
separate plans affecting AVCCG relating to new models of
care. The first is a commissioner led plan to implement a
multi-specialty community provider in the North locality. The
second is a provider led plan involving the integrated Acute
and Community provider, Mental Health Trust, Ambulance
Trust, Out of Hours and Social Care.
8. Alignment of plans
AVCCG operates in a complex system with other healthcare
commissioners, a range of providers, direct links to social care
and other public services. All of these factors have to be
taken into account when planning for the year ahead.
7. Impact of delivery these three priorities
By focusing the CCG’s efforts on delivery of plans in these
three key elements, the following outcomes will be delivered:
• Better access to primary care (through the Prime Minister’s
Challenge Fund) in better premises (through the premises
and infrastructure monies) incentivised in a way which
drives improvements for the system (through cocommissioning).
• Convenient access for everyone, through new models of
care, as well as investments in mental health services.
• Improved urgent and emergency care (through Urgent and
Emergency Care Network; strengthened ability of NHS 111
to meet people’s needs without onward referral; working
with providers to implement improvements to GP OOH
services; and extending use by the Ambulance Trust of Fire
and Rescue services as first responders). The agreed
recovery plan for Q4 14/15 will be seen to a conclusion.
• Improved delivery against outcomes framework standards
and local priorities where AVCCG is either behind target
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AVCCG has discussed planning assumptions with other
commissioners, and its main providers. Contractual
negotiations are ongoing with all providers at the current
time, however the planning gap is significantly less than a
year ago at this stage. Plans are being built based on actual
activity with adjustments for either known changes, or
changes which are expected on the basis of planning and use
of benchmarks (looking at activity data and programme costs
for comparable health economies, for example). At present it
is expected that any variances are immaterial, or will be
worked through to a commonly agreed position before final
planning concludes.
3
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Operating Plan Executive Summary for
NHS England Assurance purposes
setting a very clear direction of travel for AVCCG.
AVCCG has been engaged in discussion with its main provider,
particularly around the anticipated impact of not repeating
RTT backlog clearance exercises, including the outsourcing of
significant activity to the independent sector, alongside the
expected significantly greater compliance by providers with
CCG commissioning policies around procedures of limited
clinical value.
This document will pass through a final Executive level review
process prior to being submitted to the Governing Body for
review, comment and ultimately sign off. The Governing
Body meeting is 12 March 2015, and it is expected that
delegated authority will be given to the Chief Officer to
approve any final amendments which may be required to the
plan in order to reach finalisation by 31 March 2015.
9. Better Care Fund
Buckinghamshire’s (BCF) plan aims for a reduction in the rate
of non-elective admissions of 1.6%. This was carefully
considered as it is lower than the 3.5% reduction which was in
related guidance, but analysis of the evidence alongside a
suite of work undertaken by the local system established that
both rate of emergency admissions and the rate of
admissions for ambulatory care sensitive conditions were
notably below the national average. As such, delivering 3.5%
reduction was not considered a realistic target. Experience
over the winter has shown that setting a lower reduction
target was more realistic, and while it remains a challenging
target to meet there is no desire to amend it.
Alongside the process of agreeing and finalising its own
operating plan, AVCCG will triangulate where possible with
the plans of relevant organisations (accepting that plans of all
organisations are likely to be incomplete at that stage) in
order to quantify any risks to its own plan resulting from any
remaining misalignment.
11. Recovery plans
AVCCG has been experiencing underperformance in relation
to A&E for some time. Recovery plans are in place with the
Area Team through to the end of Q4, beyond which it is our
aim to achieve 95%. Assurance can be given that the system
is working very cohesively and with great determination to
once again reach the required standard, and further actions
included in the ORCP plan are in the pipeline. However, there
remains a risk to the delivery of 95% in Q1, and potentially Q4
of 2015/16 (when historic Q4 delivery is considered). All
possible lessons learned from the current situation, and an
10. Operating Plan Assurance Process
The operating plan refresh exercise has been conducted with
the contribution by subject matter experts across the CCG in
all areas. A single, cohesive document aligned to FYFV and
structured around the IHI Triple Aim model has been drafted,
meeting all planning requirements of CCGs for the year and
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Chief Officer: Louise Patten
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Operating Plan Executive Summary for
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ability to plan with much more certainty around the funding
of ORCP in the future means we expect performance to be
improved, however.
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5
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
2015/16 Planning round assurance: CCG template
NHS Aylesbury Vale CCG
Instructions for completion
This template is for completion by CCGs.
The CCG return will then be reviewed by NHSE sub regional teams as part of the 2015/16 planning round assurance process
There are three tabs to complete:
1. Assurance on Annex A - this tab is for the CCG to provide evidence that its 2015/16 plans reference to each 'ask' referenced in Annex A of the NHS
England publication 'Supplementary information for commissioner planning, 2015/16' which is available from NHS England's website.
2. QIPP - this tab is a simple list of all QIPP schemes and requires the CCG to define which schemes it considers 'material'. CCGs should also submit to their
sub region supporting papers on each 'material' QIPP scheme.
3. FVIA - this tab is for the CCG to provide evidence that it has referenced additional 'asks' included in the NHS England publication 'The Forward View into
Action, Planning for 2015/16' .
The assurance on annex A and FVIA tabs require the user to select a response from a drop down list and then add additional comments to support the
response.
Please save the file using the following file format, "xxxx CCG Narrative Op Plan Assurance Template" where 'xxxx' is the full name of the CCG
This template must be submitted to the Head of Assurance at your sub regional team by 27th February 2015 (draft plans) and again by 10th April
2015 (final plans)
NHS Aylesbury Vale CCG
Annex A: fundamental elements of operational plans
Ref
CCG to complete
To what extent is this element
featured in your plans? - CCG to
select response from drop
down list
Fundamental element
Please provide a short statement of assurance following from your
response in column D, max 100 words. Please include within this cross
references to relevant sections of main op plan narrative and/or other
existing plans (e.g. ORCP, recovery plans etc)
Outcomes
A1
A2
A3
A4
- Your understanding of your current position on outcomes as
- The
Delivery across the five domains and seven outcome measures set out in the NHS outcomes framework
actions you need to take to improve outcomes
Improving health
Reducing health inequalities
Parity of Esteem
Working with HWB partners, your planned outcomes from
talking the five steps recommended in the "commissioning for
prevention" report.
- Identification of the groups of people in your area that have a
worse outcomes and experience of care, and your plans to
close the gap.
Implementation of the five most cost effective high impact
interventions recommended by the NAO report on health
inequalities
Implementing EDS2
Examination of how the organisation compares against the first
NHS Workforce Race Equality Standard
- The resources you are allocating to mental health to achieve
parity of esteem
Identification and support for young people with mental health
problems
- Plans to
reduce 20 year gap in life expectancy for people with severe
mental illness
- The planned
level of real terms increase in spending on mental health
services
Featured
Featured
Contained within section 4.1 of 2015/16 Op Plan refresh. Includes tables of
performance, with narraitve to explain actions and plans in any area where CCG
is either declining in most recent data, or is below its ambition or national
average (as appropriate).
Contained within section 2.1.1 of 2015/16 Op Plan refresh. Includes link to
Commissioning for Prevention report and explains 5 year strategy and existing
operating plan set out detailed descriptions of interventions planned.
Contained within 2015/16 Op Plan refresh pervasively. Discussion of poorest
outcomes around infant mortality in particular (section 2.1), but also around
vulnerable groups and general health services. Also cover CCG review against
NHS Workforce Race Equality Standard (section 2.6).
Featured
Featured
The existing plan has much more detail on inequalities and ongoing work to
tackle this. It also contains implementation details of EDS2. See link bottom of
page 12 for existing op plan.
Mental health featured extensively throughout op plan refresh, including; Section
2.2.2 personal health budgets; section 2.2.5 Patient Choice - mental health;
section 3.5 conventient access for everyone; section 4.1 Quality and Outcomes;
section 4.5 mental health; section 6.3.3 2015/16 planning assumptions
Access
A5
A6
Convenient access for everyone
- How you will deliver good access to the full range of services,
including general practice and community services, especially
mental health services in a way which is timely, convenient and
specifically tailored to minority groups.
- Plans to improve early diagnosis for cancer and to track oneyear cancer survival rates
Meeting the NHS Constitution standards
- That your plans include commissioning sufficient services to
deliver the NHS Constitution rights and pledges for patients on
access to treatment as set out in Annex B and how they will be
maintained during busy periods.
- How you will
prepare for and implement the new mental health access
standards.
Quality
Featured
Featured
Contained within section 3.5 of 2015/16 Op Plan refresh for convenient access
specially to mental health community services, memory assessment, diagnostics
and CAMHS. Section 3.4 covers primary care access. Section 3.8 covers
cancer services.
Section 4.4 of the 2015/16 Op Plan refresh covers the NHS contstitution,
including how AVCCG has factored this into planning. Discussion of the ORCP
throughout the document but specifically at 4.4 and 3.6. Mental health access
standards are covered at 4.5.
A7
A8
A9
A10
Response to Francis, Berwick and Winterbourne View
Patient Safety
Patient Experience
Compassion in practice
A11
Staff satisfaction
A12
Seven Day Services
A13
Safeguarding
- How your plans will reflect the key findings of the Francis,
Berwick and Winterbourne View reports - including how your
plans will make demonstrable progress in reducing the number
of inpatients for people with learning disability and improve the
availability of community services for people with a learning
disability
- How you will address the need to understand and measure
the harm that can occur in healthcare services, to support the
development of capacity and capability in patient safety
improvement
- How you will
increase the reporting of hard to patients, particularly in primary
care and focused on learning and improvement
- Your plans for tackling sepsis and acute kidney injury
How you will improve antibiotic prescribing in primary and
secondary care
- How you will set measureable ambitions to reduce poor
experience of inpatients care and poor experience in general
practice
- How you
will assess the quality of care experienced by vulnerable
groups of patients and how and where experiences will be
improved for those patients
- How you will
demonstrate improvements from FFT complaints and other
feedback
- How you will ensure
that all the NHS Constitution patient rights and commitments
given to patients are met
- How you will ensure you
meet the recommendations of the Cadicott Review that are
relevant to the patient experience
- How your plans will ensure that local provider plans are
delivering against the six action areas of Compassion in
Practice implementation plans
How the 6Cs are being rolled out across all staff
- An in-depth understanding of the factors affecting staff
satisfaction in the local health economy and how staff
satisfaction locally benchmarks against others
How your plans will ensure measureable improvements in staff
experience in order to improve patient experience
- How you will make significant further progress in 2015/16 to
implement at least 5 of the 10 clinical standards for seven day
working
- How your plans will meet the requirements of the
accountability and assurance framework for protecting
vulnerable people
The support for quality improvement in application of the
Mental Capacity Act
How you will measure the requirement set out in your plans in
order to meet the standards in the prevent agenda
Featured
Francis, Berwick and Winterbourne View specifically covered in 4.2.1. More
details around services for people with learning disabilities and Winterbourne
View report is at section 4.6
Section 4.2.1 covers provider quality, measuring harm and development of
capacity and capability, culture etc. Sepsis and AKI included in terms of
recognising priority and use of natoinal CQUINs. Antibiotic prescribing covered
in section 4.3
Featured
Section 4.2.1 includes improving inpatient patient experience, and patient
experience of primary care. FFT feedback is mentioned in various places in
section 4, as is how the CCG reports improvement in provider quality and is
actively used by the CCG. Section 4.4 covers the NHS constitution rights. 4.2.1
covers the caldicott recommendations.
Featured
4.2.1 covers how we address the 6Cs
Featured
Section 4.2 contains an outline of staff survey results and issues contained.
Featured
Section 3.6.3 covers this.
Featured
4.2.2 provides details of support for the Mental Capacity Act. 4.2.1 outlines
arrangements regarding Prevent
Featured
Innovation
A14
Research and innovation
Delivery Value
- How your plans fulfil your statutory responsibilities to support
research
- How you
will use Academic Health Science Networks to promote
research
- How you
will adopt innovative approaches using the delivery agenda set
out in Innovation Health and Wealth: accelerating adoption and
diffusion in the NHS
Section 6.6
Featured
Section 6.3 covers all elements of finance planning
A15
- Meeting the business rules on financial plans including
surplus, contingency and non-recurrent expenditure
Financial resilience; delivery value for money for taxpayers and Clear and credible plans that meet the efficiency challenge and
patients and procurement
are evidence based, including reference to benchmarks
- The clear link between service plans, financial and activity
plans
Featured
Note: Please submit detailed QIPP plans for all material schemes to supplement the information you have provided
within this template
QIPP plan title
MSK Pain
Radiology
Advice & Guidance
PLCVs
Excess Bed Days - OUH
Follow Ups
Anti-coagulation
Over 75s
Better Care Fund
Coding challenges
Total value
QIPP plan value
(£000's)
76
88
186
500
80
250
1564
500
164
200
3608
Material scheme Y/N
No
No
No
Yes
No
No
Yes
Yes
No
No
Forward View into Action
To what extent is this element
featured in your plans? - CCG
to select response from drop
down list
FV1
Confirmation that the CCG recognises that winter pressure
funds are within the 2015/16 baseline
Featured
FV2
Confirmation that plans reflect the local impact of national
investment in primary care (the £250m)
Featured
FV3
FV4
Confirmation that plans reflect the six approaches to prevention
Confirmation of plans to expand the offer & delivery of personal
health budgets
Featured
Featured
Please provide a short statement of assurance following from your
response in column C, max 100 words. Please include within this cross
references to relevant sections of main op plan narrative and/or other
existing plans (e.g. ORCP, recovery plans etc)
Section 6.3.1
Section 3.4
Section 2.1.4
Section 2.2.2
Section 2.2.5
FV5
Confirmation that the CCG has plans to ensure MH patients
are offered choice
Featured
FV6
Confirmation that the CCG will review locally available
maternity choices
Featured
FV7
Confirmation that the CCG is working with local authorities to
identify carers, particularly young carers & carers aged over
85.
Featured
FV8
Confirmation that the CCG will review its own policy towards
staff who are carers
Featured
Section 2.4
FV9
Confirmation that the CCG has plans to bid for a share of the
Prime Minister's Challenge Fund
Confirmation that the CCG has plans to bid for a share of the
£250m premises & infrastructure fund
Confirmation that the CCG will use CQUINs to implement the
findings of the urgent and emergency care review
Confirmation that the CCG will participate in the new urgent &
emergency care network from April 2015
Featured
Section 3.4
Featured
Section 3.4
Featured
Section 3.6.4
Featured
Section 3.6.4
Confirmation that the CCG plans to use CQC inspection
reports in its work to assure quality of care
Confirmation that the CCG will work with providers to embed
the practice of clear clinical accountability
Confirmation that plans address the need to have adequate &
effect liaison psychiatry services in place
Featured
Confirmation plans are in place to prevent young people or
vulnerable adults undergoing MH assessment in police cells.
Confirmation that the CCG will work with other commissioners
to invest in children & young people's MH
Featured
FV10
FV11
FV12
FV13
FV14
FV15
Section 2.2.6
Section 2.4
Section 4.2.1
Featured
Section 4.2.1
Featured
Section 4.5.3
Section 4.5.3
FV16
FV17
Featured
Section 4.5.4
FV18
Confirmation plans are in place to use the contract to enforce
use of the NHS number as the primary identifier
Featured
FV19
Confirmation plans target 60% of GP prescriptions to be sent
electronically to pharmacies by 31st March 2016
Featured
FV20
FV21
FV22
FV23
FV24
FV25
FV26
Confirmation plans to ensure electronic discharge summaries
are in place by October 2015
Confirmation plans target 80% of GP referrals to be sent
electronically to providers by 31st March 2016
Confirmation that a roadmap for fully interoperable digital
records will be in place by March 2016
Confirmation plans to work with the LETB on workforce
planning
Confirmation the CCG has plans in place on how to invest the
50% balance from margin tariffs on investment to reduce nonelective admissions
Confirmation whether the BCF non-elective reduction trajectory
has been revisited
Confirmation that CQUINs are in place for up to 2.5% of annual
contract values
Section 5.1
Section 5.1
Featured
Section 5.1
Featured
Section 5.1
Featured
Section 5.1.1
Featured
Section 5.2
Section 6.4
Featured
Featured
Section 6.4
Featured
Section 6.5
Excellent
Good
Acceptable
Under development
Not yet developed
Please select
Yes in 2014/2015 Plans
No - to be added to 15/16 Plans
Director of Finance
Director of Commissioning
Director of Assurance and Delivery
Director of Nursing and Quality
Please select
Featured
Partially featured
Not featured
Please select
Assured
Assured with support
Not Assured
[DRAFT] Operating Plan 2015/16
Refresh of the two year Operating Plan for
2014/15 and 2015/16
Bringing clinical leadership to local health needs
www.aylesburyvaleccg.nhs.uk
1
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Version Control
Version
Date
Description
Author
V1.0
19/02/15
Draft One – collation of planning elements contributed by
SMEs
PH
V2.0
25/02/15
Draft Two – review by Director of Ops and Performance
PH
CT
V3.0
26/02/15
Draft Three – add in quality sections
PH / AF
RM
V3_RM
26/02/15
Comments and amendments from RM
RM / PH
V4
27/02/15
Final contributions included (workforce, quality)
PH
V4.1
27/02/15
Quality control check
PH
VP
V5
27/02/15
Draft submission to Area Team
PH
Area Team and Exec
V5.1
04/03/2015
Minor corrections for submission to Governing Body
PH
Governing Body
Bringing clinical leadership to local health needs
www.aylesburyvaleccg.nhs.uk
2
DRAFT Operating Plan refresh for 2015/16
Circulation
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Contents
Section
1.
1.1
1.2
1.3
1.4
2.
2.0
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.3
2.4
2.5
2.6
3.
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.6.1
3.6.2
3.6.3
3.6.4
3.7
3.8
Title
Page
Glossary
Executive Summary
Preface
Setting the context
Forward View
AVCCG Operating Plan
The change model – IHI Triple Aim
Creating a new relationship with patients and communities
Link to Triple Aim
Prevention and Public Health
Getting serious about prevention
Maternity / early years and healthy lifestyle
Communicable disease and emergency planning
Six approaches to prevention
Empowering patients
Access to health records
Personal Health Budgets
Integrated Population Based Outcome Commissioning
Patient Choice
Patient Choice – Mental Health
Patient Choice – Maternity
Engaging Communities
Supporting carers
Charities and Volunteers
Workforce Race Equality Standard
New models of care
Link to Triple Aim
Multi-specialty Community Provider (MCP)
Integrated Primary and Acute Care System (PACS)
Successful transformation
Primary care
Convenient access for everyone
Urgent and emergency care
Background
Further developments
Seven day working
Urgent and emergency care CQUIN
Maternity services
Cancer services
Bringing clinical leadership to local health needs
www.aylesburyvaleccg.nhs.uk
Section
4
5
10
11
11
12
12
14
15
15
15
15
16
16
17
17
17
18
18
18
19
19
19
19
19
20
21
21
21
22
22
23
23
23
24
24
24
25
25
3.9
4.
4.0
4.1
4.1.1
4.1.2
4.1.3
4.2
4.2.1
4.2.2
4.2.3
4.3
4.4
4.5
4.5.1
Title
Page
25
26
27
27
27
27
28
31
31
32
33
33
33
34
34
4.5.2
4.5.3
4.5.4
Specialised care
Operational Delivery
Link to Triple Aim
Quality and outcomes
Background
CCG outcomes framework
Local improvement measures
Assuring Quality
Provider quality
Mental Capacity Act
Staff satisfaction
Antibiotic prescribing
The NHS Constitution
Mental Health
Improving services for people with dementia and their
carers
Delivering and improving IAPT
Mental health access standards
Child and Adolescent Mental Health Services (CAMHS)
4.5.5
4.5.6
4.5.7
4.6
5.
5.0
5.1
5.1.1
5.2
5.3
6.
6.0
6.1
6.2
6.3
6.3.1
6.3.2
6.3.3
6.4
6.5
6.6
Paediatric physiotherapy service
Enuresis services
Parity of esteem – CAMHS
Transforming care of people with Learning Disabilities
Enabling Change
Link to Triple Aim
Harnessing the information revolution and transparency
Interoperable digital health records
A modern health and care workforce
Accelerating useful innovation
Driving efficiency
Link to Triple Aim
Review of existing plans
Forward view
NHS funding 2015/16
Background
2014/15 review
2015/16 planning assumptions
Joint working
CQUINs
Research & Innovation
38
38
38
39
41
42
42
43
44
45
46
47
47
48
49
49
50
51
51
52
52
3
DRAFT Operating Plan refresh for 2015/16
35
35
37
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Glossary
Acronym
Description
Acronym
Description
A&E
Accident & Emergency
IPOC
Integrated Population based Outcome Commissioning
AVCCG
NHS Aylesbury Vale Clinical Commissioning Group
LTC
Long Term Conditions
BCC
Buckinghamshire County Council
MACH
Memory Assessment Closer to Home
BCF
Better Care Fund
MCP
Multi-specialty Community Provider
BHT
Buckinghamshire Healthcare NHS Trust
MKFT
Milton Keynes Hospital NHS Foundation Trust
CAMHS
Child and Adolescent Mental Health Services
NHS
National Health Service
CCCG
NHS Chiltern Clinical Commissioning Group
NICE
National Institute for Health and Care Excellence
CCG
Clinical Commissioning Group
OHFT
Oxford Health NHS Foundation Trust
CHC
Continuing Health Care
ORCP
Operational and Resilience and Capacity Plan
CQUIN
Commissioning for Quality and Innovation
OUH
Oxford University Hospital NHS Trust
EIP
Early Intervention in Psychosis
PACS
Primary and Acute Care System
FYFV
Five Year Forward View
SDIP
Service Development and Improvement Plan
GP
General Practitioner
SHFT
Southern Health NHS Foundation Trust
HEE
Health Education England
SRG
System Resilience Group
IAPT
Improving Access to Psychological Therapy
TB
Tuberculosis
IHI
Institute for Healthcare Improvement
Bringing clinical leadership to local health needs
www.aylesburyvaleccg.nhs.uk
4
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Executive Summary
In October 2014, NHS England published ‘Five Year Forward
View’ (FYFV), which outlines very clearly the direction for the
NHS, showing why change is needed and what it will look like.
Three key elements set out in FYFV are:
The existing operating plan, supplemented by this refresh for
2015/16, details the actions we intend to take over the next
year.
The model for change
• The future health of millions of children, the sustainability
of the NHS, and the economic prosperity of Britain all now
depend on a radical upgrade in prevention and public
health;
• When people do need health services, patients will gain far
greater control of their own care; and
• The NHS will take decisive steps to break down the barriers
in how care is provided.
AVCCG is working with the Institute for Healthcare
Improvement’s (IHI) Triple Aim model. The Triple Aim is a
framework that describes an approach to optimising health
system performance. New designs must be developed to
simultaneously pursue the three dimensions of: improving
patient experience of care (including quality and satisfaction);
improving the health of populations; and reducing the cost
per capita of health care.
Under the framework of FYFV, NHS Aylesbury Vale CCG
(AVCCG) has revisited its two year operating plan covering
2014/15 and 2015/16. This document provides a refresh of
the existing Operating Plan, to ensure that it aligns with FYFV.
This document uses the structure of FYFV, and links each
element to the Triple Aim. In this way, the CCG has plans
aligned with FYFV which utilise a world-class model for
change to maximise delivery. Key elements of FYFV are
outlined below, followed by a mapping of those areas to the
IHI’s Design of a Triple Aim Enterprise.
Much of the existing plan remains valid. AVCCG had already
recognised that to help the NHS survive, we need to: get
better at preventing disease, not just treating it; increase
everybody’s participation in and responsibility for managing
their own care; and integrate services to provide seamless
care. To achieve this we said we needed to:
Prevention and Public Health
The first of three key elements in FYFV is focused on
prevention and public health. Existing plans set out detailed
descriptions of the public health interventions planned in the
system. In addition to those existing plans, programmes of
work will be undertaken in relation to :
• Respond better to patient’s individual needs;
• Encourage patients to take more control over their own
health; and
• Get better at using new technologies to involve
communities and individuals in managing their own care.
Bringing clinical leadership to local health needs
www.aylesburyvaleccg.nhs.uk
• Maternity / early years and healthy lifestyle; and
5
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Executive Summary (cont)
• Communicable disease and emergency planning.
services, and AVCCG is committed to delivering this. In
addition, work is ongoing to ensure that effective choice
exists in relation to maternity services.
FYFV outlines six approaches to improving health and
wellbeing. Some of these areas are a continuation of the
work already underway through the existing operating plan
and Five Year Strategy. Others will require new actions to be
taken in 2015/16.
Other
AVCCG is working alongside BCC to identify unknown carers,
including young carers and carers aged over 85. A Health and
Social Care Needs Assessment of Unpaid Carers in the county
is underway, as is a project using GP texting services to
contact patients and identify those who are unpaid carers.
Empowering patients
The second key element outlined in FYFV is about
empowering patients to give them more control of their own
care. A project is underway to ensure online access to GP
records is delivered in a systematic way across the CCG; and
we will use the tools within the NHS Standard Contract to
ensure demonstrable progress towards fully interoperable
digital health records being in place by April 2018.
AVCCG recognises the key contribution that charities and
volunteers make to the local health economy. The CCG will
make use of the tools and arrangements being developed in
2015/16 to enhance the impact of volunteers and lay people.
New Models of Care
Personal Health Budgets began to be offered to adults and
children eligible for Continuing Healthcare in 2014/15. A
scoping exercise will inform the CCG’s strategy for extending
the availability further during 2015, including to those with
mental health conditions and learning disabilities. We are
also developing areas linked to Personal Health Budgets for
joint working with Buckinghamshire County Council (BCC).
The third key element in FYFV requires the NHS to break
down the barriers in how care is provided. It outlines a
number of proposed new models of care for local health and
social care economies to work with. There are currently two
separate plans affecting AVCCG relating to new models of
care. The first is a commissioner led plan to implement a
multi-specialty community provider in the North locality. The
second is a provider led plan involving the integrated Acute
and Community provider, Mental Health Trust, Ambulance
Trust, Out of Hours and Social Care.
Patient Choice
AVCCG will assess the current provision of choice to patients,
and identify where there are areas which need to be
improved. The right to choice extends to mental health
Bringing clinical leadership to local health needs
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6
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Executive Summary (cont)
of the CCG’s plans to April 2016, and further developments
since the existing Operating Plan was produced include:
leading participation in the Urgent and Emergency Care
Networks; strengthening the ability of NHS 111 to meet
people’s needs without onward referral; working with
providers to implement improvements to out of hospital
services starting with GP out of hours services; and extending
the Ambulance Trust’s use of the Fire and Rescue service as
first responders. We are also working across the System
Resilience Group to develop urgent care outcomes and
metrics to better track the overall urgent care system.
Primary care
Primary care is central to the population-based health care
models described in FYFV. AVCCG has applied to undertake
co-commissioning of primary care alongside NHS England, to
allow more influence over the whole local health economy.
A bid has been made to access money through the Prime
Minister’s Challenge Fund to improve access to general
practice. In addition a number of practices within AVCCG
have made bids to access money to improve premises and
infrastructure. If successful, improvements will lead to an
easier to access services delivered in better premises.
Seven day working remains a key programme to implement,
and a service development and improvement plan is
anticipated to be in place at BHT.
Convenient access for everyone
Alongside the improvements in primary care, our mental
health provider has redesigned services to provide 7 day and
extended evening hour community services. It has also
introduced a single point of access to facilitate improved
access from primary care to mental health services.
Operational delivery
The primary reason for looking to deliver the FYFV and its
vision of the NHS is to maximise outcomes for patients, using
the available resources to ensure value for money. That
means delivering standards set out in the NHS Outcomes
Framework, alongside locally set ambitions.
Other services including Child & Adolescent Mental Health
Services (CAMHS) also have significant plans in place to make
access more convenient.
AVCCCG routinely reviews available data in relation to the
Outcomes Framework or our locally set ambitions, and
assesses where its performance needs to improve. Where
latest data indicates underperformance, the CCG either has
plans in place which will improve performance, or has an
understanding of changes since the period to which the latest
Urgent and emergency care
Nationally and locally Urgent Care and Emergency Services
are under increasing pressure. Assessment of local services
against the Urgent and Emergency Care Review is at the heart
Bringing clinical leadership to local health needs
www.aylesburyvaleccg.nhs.uk
7
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Executive Summary (cont)
data relates and confidence that improvements have been
made.
NHS constitution
During 2014/15, AVCCG suffered from the national
experience of a variety of issues leading to not achieving the
A&E four hour standard. Over winter schemes were
implemented which mitigated these pressures. Although
better performance is expected in 2015/16, delivery in all
periods of the 95% standard will be extremely challenging
based on recent performance, the system is committed to
making this improvement.
Assuring quality
Assuring the quality of providers is an important and complex
part of the role of a CCG. The Care Quality Commission
assesses quality across the health service, and the reports
they produce are part of the toolkit used by AVCCG to assure
itself of the quality of care it commissions.
We monitor providers in their delivery of harm free care,
using quality metrics around patient safety, mortality levels
and patient experience, and consider the understanding of
staff in relation to patient safety.
A significant amount of time and resource has been invested
in delivery of elective pathway constitution standards, and
AVCCG enters the new year in a significantly improved
position in terms of its waiting list than 12 months ago. Work
will go on to ensure this improved position is maintained.
AVCCG reviewed the Francis, Berwick and Winterbourne View
reports as they were released. It approach to quality
assurance has been informed by these important reviews.
Mental health services have received a significant focus
through the planning round for 2015/16. Improvements will
continue to see: improving services for people with dementia
and their carers; improved quality of and access to IAPT;
introduction of mental health access standards; investment
in CAMHS services; ongoing developments in relation to
services for people with Learning Disabilities, particularly in
response to the Winterbourne View report.
The CCG has been successful in joint bid with Chiltern CCG for
funding of a project to increase knowledge and compliance
with the Mental Capacity Act to care and treatment decisions.
This important project will help practitioners, service users
and their families.
The CCG reviews staff survey results for all main providers,
and considers the impact of results on patient safety and
experience. These are reviewed through the contract quality
governance processes in place with our providers.
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Enabling Change
A number of key enablers are vital in order to support
delivery of the changes needed in the local health economy to
8
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
Executive Summary (cont)
secure ongoing delivery of constitutional standards and
improving outcomes for patients. Key enablers described in
the main report include a range of IT and data related items.
In addition, workforce across the whole health economy is
fundamental to the changes taking place successfully.
Understanding the workforce needs are a vital part of
planning and implementation for any change process. Finally,
accelerating innovation will enable many of the local and
national priorities to be delivered quickly and effectively.
is now part of the baseline funding.
Driving efficiency
The diagram below shows suggested components of a Triple
Aim Enterprise. Through the plan, which is structured around
FYFV, all of the components are addressed by AVCCG. This
provides a strong level of confidence that planned changes
and improvements in the system will be delivered.
Within the financial planning is a £3.6m QIPP programme for
2015/16. This is considered to be achievable with careful
management, but leaves little scope for ability to absorb
under-delivery. QIPP schemes include a combination of
rolling forward ongoing schemes which will continue to have
QIPP impact in 2015/16, alongside new initiatives.
Design of a Triple Aim Enterprise
AVCCG has had a challenging year in 2014/15, but is forecast
to deliver its target surplus. This has required application of
all non-recurrent headroom, contingency, and slippage on
investments to offset higher than expected costs within
planned and unscheduled care commissioning budgets.
For 2015/16 AVCCG has a revenue allocation £218m,
alongside a running cost budget of £4.4m. This is a total
increase of just over 5% in resource allocation. The CCG has
applied planning assumptions and guidance issued by NHS
England in constructing its financial plans for the 2015/16
year, reviewed and adapted to reflect local conditions. The
CCG is required to increase the available resources in mental
health services at the same level of growth in total CCG
resources, which is reflected in the scale and amount of plans
related to mental health services going forward. The CCG will
develop plans during the course of the year on how best to
utilise the Operational and Resilience Capacity funding, which
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9
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
2. Creating a new relationship with patients and
communities
3. New models of care
4. Operational delivery
5. Enabling change
6. Driving efficiency
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
1.1 Setting the context
to have a co-commissioning role in relation to primary care, in
order to more effectively influence the whole system of
health services locally.
NHS Aylesbury Vale CCG (AVCCG) was authorised from 1 April
2013 to commission health services on behalf of the
approximately 200,000 people living in the northern parts of
Buckinghamshire – covering an area between Buckingham,
Princes Risborough, Thame and Edlesborough. It is a
membership organisation made up of all 19 of the GP
practices in these areas and is led by clinicians from these
practices.
1.2 Forward view
In October 2014, NHS England published ‘Five Year Forward
View’1 (FYFV). This document outlines very clearly the
direction for the NHS, showing why change is needed and
what it will look like. Three key elements outlined in FYFV
are:
•
The future health of millions of children, the
sustainability of the NHS, and the economic prosperity
of Britain all now depend on a radical upgrade in
prevention and public health;
•
When people do need health services, patients will gain
far greater control of their own care; and
•
The NHS will take decisive steps to break down the
barriers in how care is provided.
FYFV explains that England is too diverse for a ‘one size fits
all’ care model, but cautions that letting a thousand flowers
bloom is also not the answer. Rather, local health
communities will be supported to choose from a small
number of radical new care delivery options, and then given
the resources and support to implement them where
appropriate.
Commissioning health services means being responsible for
the design and specification of services, putting in place
contracts for their delivery, and ensuring that they are safe,
high-quality and work smoothly for the patient. It includes
the involvement of citizens, carers and residents to help
shape the services and working with partner organisations to
prevent or delay people getting sick and encourage good
health.
AVCCG commissions acute or hospital care needed in an
emergency or for planned treatments; community services
such as district nursing, palliative and hospice care as well as
care home packages and nursing home placements and
jointly commissions mental health services and services for
people with learning disabilities.
AVCCG does not commission primary medical care which
includes GP practices, dental services or opticians,
responsibility for which rests with NHS England. However, in
common with other CCGs, AVCCG has applied to NHS England
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1 Five Year Forward View is available at http://www.england.nhs.uk/wpcontent/uploads/2014/10/5yfv-web.pdf
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DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
1. Preface (cont)
1.3 AVCCG Operating Plan
AVCCG places improving outcomes for patients at the heart of
its work. It recognises that the outcomes of any system
depend on how that system is built. The existing operating
plan, supplemented by this refresh for 2015/16, detail the
actions we intend to take over the next year to make the
necessary changes to secure our health services for the
future. This plan sits within a wider five year strategic vision
which is shared by our partners, the aims and objectives of
which have guided the development of the Plan.
Under the framework of FYFV, AVCCG has revisited its two
year Operating Plan covering 2014/15 and 2015/162. This
document is intended to provide a refresh of the existing
Operating Plan, to ensure that it aligns with FYFV, and reflects
any changes and evolution in plans which have happened
since the two year plan was produced in April 2014. This
document is not intended to be a full revision of the existing
Operating Plan, and should be read in conjunction with the
existing document. Where any areas have been amended or
updated, this document is the most current and should be
referred to.
1.4 The change model – IHI Triple Aim
In order to deliver the necessary change, AVCCG will utilise
the Institute for Healthcare Improvement’s (IHI) Triple Aim
model3. The Triple Aim is a framework that describes an
approach to optimising health system performance. New
designs must be developed to simultaneously pursue three
dimensions, which IHI calls the Triple Aim.
Many aspects covered by FYFV were already recognised by
AVCCG. As such, much of the existing operating plan remains
valid. AVCCG recognised that to help the NHS survive, we
need to: get better at preventing disease, not just treating it;
increase everybody’s participation in and responsibility for
managing their own care; and integrate services to provide
seamless care. A year ago AVCCG said that to achieve this,
we will need to:
•
Respond better to patient’s individual needs;
•
Encourage patients to take more control over their own
health; and
•
Get better at using new technologies to involve
communities and individuals in managing their own
care.
Figure 1 – IHI Triple Aim
2 AVCCG 2014/15 – 2015/16 Operating Plan is available at http://www.aylesburyvaleccg.nhs.uk/wpcontent/uploads/2014/07/FULL-PAPERS-AVCCG-Governing-Body-Agenda-10-April-2014.pdf
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3 Visit http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx for more information
12
DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
1. Preface (cont)
IHI recommends a change process that includes a number of
elements. These are reflected below along with translation
into the AVCCG plans.
Some of the areas of health reform discussed in the Triple
Aim material are already operating to an extent within AVCCG
and the NHS more generally – such as sanctions for avoidable
events, such as hospital readmissions or infections; but many
are in their infancy in terms of development and
implementation – such as innovative funding approaches,
new models of primary care, and the integration of
information technology. The five components in the boxes to
the right of Figure 3 below are suggested by IHI as an initial
set of components of a system that would fulfil the Triple
Aim. AVCCG plans also map to these components.
Figure 2 – Change process
IHI Triple Aim
Identification of target
populations
AVCCG
implementation
Localities and disease
groups
Figure 3 – System components
Definition of system
aims and measures
CCG outcomes
framework and local
priorities
Development of
portfolio project work
that is sufficiently strong
to move system level
results
Plans for New models
of care across localities
and providers being
developed alongside
primary care strategy
and co-commissioning
Rapid testing and scale
up that is adapted to
local needs and
conditions
Elements of plans will
be piloted and
developed within
localities to be ‘lifted
and shifted’ across the
CCG
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Throughout this plan, which follows the structure of FYFV, the
start of each chapter outlines how AVCCG is applying the
Triple Aim concept to deliver the FYFV and secure a high
quality, effective and sustainable health service into the
future.
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
2. Creating a new relationship with patients and
communities
3. New models of care
4. Operational delivery
5. Enabling change
6. Driving efficiency
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
2. Creating a new relationship with
patients and communities
2.0 Link to Triple Aim
country’s future economic prosperity, in the long term.
Creating a new relationship with patients and communities
means involving individuals and groups in different ways and
in all aspects of health – from prevention and taking
responsibility for lifestyle choices, to taking an active role in
managing long terms conditions (LTCs) and being part of
decisions about their care through personal health budgets,
or access to their primary care record. It needs volunteers to
be involved – either in patient groups helping to inform and
steer the direction of health services locally, or as carers. The
CCG needs to continue its work to identify and support carers,
recognising the vital role that they play for many vulnerable
people.
In November 2013 Public Health England and NHS England
published ‘A Call to Action: Commissioning for Prevention’4,
which contained a five-step framework. The five year
strategy for the two Buckinghamshire CCGs5, as well as the
existing operating plan, set out detailed descriptions of the
interventions planned. In addition to these existing plans, the
following programme of work will be undertaken:
2.1.2 Maternity / early years and healthy lifestyle
• We will work on the challenge of low birth weights through
targeted involvement in areas where mothers are most at
risk via easy to access health information; increasing the
numbers of pregnant smokers accessing evidence based
smoking cessation support; and by supporting dietary and
physical activity changes both before and during pregnancy;
We will work to reduce health inequalities by removing
variations in the uptake and access to antenatal care and
other health services;
• We will improve flu immunisation uptake amount pregnant
women to meet the target of 75%;
• We will ensure access to specialist clinics for women at risk
of premature labour to reduce rates of prematurity, low
birth weight and perinatal mortality;
• We will work with Primary Care and NHS England to improve
uptake of antenatal and new-born screening programmes;
Getting this right will deal with the ‘Population Health’ point
of the Triple Aim, and the ‘Individuals and Families’ and
‘Prevention and Health Promotion’ components of the of the
system.
2.1 Prevention and Public Health
2.1.1 Getting serious about prevention
AVCCG is actively engaged with partner organisations such as
Buckinghamshire County Council (BCC), NHS Chiltern CCG
(CCCG), the Health and Wellbeing Board, providers and
patient groups. It is recognised that while actions can be
taken to improve the efficiency and effectiveness of NHS
services, greater emphasis on prevention and public health is
needed to secure the sustainability of the NHS, and the
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4 A call to Action: Commissioning for Prevention’ is available at http://www.england.nhs.uk/wpcontent/uploads/2013/11/call-to-action-com-prev.pdf
5 Buckinghamshire Commissioners 5 Year Plan is available at [xxxxxxx]
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DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
2. Creating a new relationship with
patients and communities (cont)
• We will improve access to breastfeeding support to mothers
in maternity wards in our local hospitals and community;
We will ensure that GP practices are providing good access
to long acting reversible contraception (LARC) and
opportunistic chlamydia screening to 15 to 24 year olds are
working to best practice guidelines; and
• We will work with key partners to ensure that a new robust
termination service is in place with clear pathways to GP
and other contraceptive and sexual health services and
support the implementation of the new Buckinghamshire
Sexual Health Strategy.
2.1.3 Communicable disease and emergency planning
2.1.4 Six approaches to prevention
FYFV outlines six approaches to improving health and
wellbeing. Some of these are a continuation of the work
already underway through the existing operating plan and
Five Year Strategy, and some will require new actions to be
taken in 2015/16. The six approaches are:
1. CCGs should work with local government partners to set
and share in 2015/16 quantifiable levels of ambition to
reduce local health and healthcare inequalities and
improve outcomes for health and wellbeing;
2. Support comprehensive, hard-hitting and broad based
national action on prevention;
3. Support the national evidence based diabetes prevention
programme;
4. Act on proposals to be developed by NHS England by
autumn 2015 for improving NHS services for helping
individuals stay in work, or return to employment, while
saving downstream costs at the Department for Work and
Pensions;
5. Act on NHS England findings on the potential to extend
incentives for employers in England who provide effective
NICE recommended workplace health programmes; and
6. Take significant action as an NHS employer to improve the
physical and mental health and wellbeing of our staff.
• We will ensure increased uptake of influenza immunisations
for those in risk groups aged under 65 years old, and will
monitor uptake in at risk groups by practice over the flu
season and ensure that all practices aim for the highest
possible uptake. We will ensure all practices submit data on
numbers immunised to reach the 75% uptake target. We
will ensure year on year reduction in cases of TB, including
early identification of cases to reduce onwards spread and
improve patient outcomes.
• We will promote knowledge of infectious diseases,
particularly TB, amongst GPs and other practice staff and
ensure that commissioned services for TB and infectious
hepatitis meet national guidelines in quality and staffing.
• We will ensure all commissioned services are able to
respond to outbreak and emergency situations.
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DRAFT Operating Plan refresh for 2015/16
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2. Creating a new relationship with
patients and communities (cont)
2.2 Empowering Patients
and control. This will inform the CCG’s strategy for extending
Personal Health Budgets further during 2015 and beyond.
2.2.1 Access to health records
There is significant evidence that Personal Health Budgets
have a positive impact on individuals, and can enhance choice
and parity of esteem. Recognising this, and the role that
integrated Personal Health Budgets can play in developing
person-centred community support, we are developing areas
for joint working with BCC. This will include the provision of
direct payments, and working with education and social care
to better support young people with their educational needs.
The NHS has committed to improving the information to
which people have access. A project is underway to ensure
online access to GP records is delivered in a systematic way
across the CCG. In addition, AVCCG will use the tools within
the proposed 2015/16 NHS Standard Contract to ensure
providers show demonstrable progress towards fully
interoperable digital health records being in place by April
2018.
AVCCG will also be exploring the extension of Personal Health
Budgets to those with mental health conditions as part of our
support for delivering recovery and extending choice.
As a significant encouraging development, one of the two
new models of care being developed which will impact on the
AVCCG system is a provider-led scheme to develop a Primary
and Acute Care System, much of which requires integration of
systems to ensure access to records by different areas of the
health economy.
In support of our work to deliver the Winterbourne View
Concordat and action plan, and recognising the findings of the
recent Bubb review, we will ensure that Personal Health
Budgets are available to support the community placements
of those with learning disabilities and high support needs that
are not well served by conventional service approaches. We
will build on our recent experience of co-designing bespoke
packages with individuals, their families and carers to ensure
patients on the Winterbourne Register who are clinically
assessed to be in appropriate settings are provided with the
community support they require.
2.2.2 Personal Health Budgets
In relation to Personal Health Budgets, in 2014/15 we
established a policy for adults and children who are eligible
for Continuing Healthcare. We established interim brokerage
arrangements through the Essex Coalition for Disabled People
who provide information and support to individuals to ensure
that they are able to exercise this extension of choice. AVCCG
has recently commissioned a scoping exercise to ensure that
the CCG maximises its opportunity to offer Personal Health
Budgets to others who may benefit from additional flexibility
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DRAFT Operating Plan refresh for 2015/16
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2. Creating a new relationship with
patients and communities (cont)
2.2.3 Integrated Population Based Outcome Commissioning
understand the current provision of choice to patients and
identify where there are areas which need to be improved.
The existing operating plan describes how the CCG is moving
towards Integrated Population Based Outcome
Commissioning (IPOC). This approach will see a revolution in
commissioning, taking a fresh approach to the delivery of
care, brining in individual centred models for payment,
involvement and reporting of outcomes. The plan laid out
five key deliverables in the development of IPOC:
1. Integrated IT platform;
2. Joint risk assessment stratification;
3. Improving outcomes and experience;
4. Pathway tariffs and episode based payments; and
5. Integrated health and social care commissioning.
2015/16 is a continuation of the plans to realise IPOC for
AVCCG. Many steps have been taken against all of the
deliverables during 2014/15, and work continues in the
second year of the plan to fully enable to IPOC approach to
become the standard.
2.2.5 Patient Choice – Mental Health
The right to choice extends to mental health services. It is
recognised nationally that embedding the right to choice in
mental health will take time, nevertheless the CCG is
committed to delivering this. Our plans include:
• Publicising patients’ rights to choice in mental health,
ensuring that they are appropriately directed to accurate
information about services that will help them make
appropriate choices;
• Supporting GPs so that they understand eligibility for choice
in mental health and are able to support patients with
making clinically appropriate choices;
• Working with our contracted providers to ensure
transparency for patients is provided, about the services
available, the outcomes they offer, and the experience of
patients currently using these services;
• Working with providers to ensure that choice is provided,
that GPs are able to book on Choose & Book and that there
are referral protocols in place; and
• Ensuring that the financial and contractual mechanisms we
already have in place to support patients accessing services
from other providers are suitable to support the potential
for an increase in non-contracted activity.
The extension of Personal Health Budgets, as described on
page 17, will also support choice in mental health.
2.2.4 Patient Choice
FYFV sets out that only half of patients say that they were
offered a choice of hospitals for their care, or were involved
in decisions about their care and treatment. While statistics
on the issue are limited, AVCCG takes patient choice and its
responsibilities to provide this extremely seriously. The CCG
will take steps to ensure that the requirement to offer patient
choice routinely is re-emphasised in the health economy. At
the same time, it will engage with patient groups to
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
2. Creating a new relationship with
patients and communities (cont)
2.2.6 Patient Choice – Maternity
those who are Unpaid Carers. Those identified are offered a
range of advice and support through local carers services. A
review of the pilot during the final quarter of 2014/15 will
inform plans for a wider rollout across the county. In
addition, the focus on carers will extend to the CCG reviewing
its own policy towards staff who are carers.
A comprehensive needs assessment of the current
commissioning arrangements and maternity services
accessed by Buckinghamshire women and their families was
agreed in May 2014. The project covered the full range of
services across all settings. It involved capacity reviews,
considered the potential impact of rising population and
increasing birth rates, and the needs and complexities of the
women and families experiencing poorer outcomes. There
was stakeholder engagement and work around finances and
pricing. This identified where women could give birth and the
choices available to them. Work has been identified and
included in recommendations which will further facilitate
choice for women.
2.5 Charities and Volunteers
A vital group of individuals and organisations involved in
delivering health care to the public is the volunteer group.
Engagement with volunteers is key to the CCGs ability to work
in the heart of the communities we serve. The CCG will make
use of the tools and arrangements being developed in
2015/16 to enhance the impact of volunteers and lay people.
Throughout 2014/15 AVCCG used a variety of approaches to
engage with communities and individuals, including
Healthwatch. These were outlined in the existing operating
plan, and will continue to be utilised and further developed
during 2015/16.
The CCG’s use of the voluntary sector through formal
contractual routes is increasing (such as the recently
commissioned Over 75s service in the North locality). The
ability to use less onerous grant agreements rather than the
full NHS Standard Contract in appropriate circumstances will
make working with the NHS more practical for many small
voluntary organisations in the future.
2.4 Supporting carers
2.6 Workforce Race Equality Standard
AVCCG is working alongside BCC to identify unknown carers,
including young carers and carers aged over 85. A Health and
Social Care Needs Assessment of Unpaid Carers in
Buckinghamshire is underway. A project is in pilot phase
using GP texting services to contact patients and identify
AVCCG recognises the new NHS workforce race equality
standard, and welcomes its implementation. It is
acknowledged that guidance around the application of this
standard is being finalised, however the CCG confirms that it
is committed to complying with all guidance in this area.
2.3 Engaging Communities
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
2. Creating a new relationship with patients and
communities
3. New models of care
4. Operational delivery
5. Enabling change
6. Driving efficiency
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
3. New models of care
3.0 Link to Triple Aim
3.1 Multi-specialty Community Provider (MCP)
Figure 3 on page 13 shows that within the components of a
system achieving the Triple Aim, two key elements are
‘integration’ and ‘definition of primary care’.
AVCCG has developed plans to implement an MCP in the
North locality. Fundamental aspects of the plan are
consistent with the direction of travel set out in the existing
operating plan, but will be taken further, faster in order to
maximise the benefit to patients. The main objectives of the
proposal are:
A significant amount of debate has been ongoing for many
years around integration, but tangible examples of successful
integration at scale are limited. However, FYFV explains the
need for the NHS to move forward from models of care which
are no longer sustainable, and offers a range of options for
local consideration. AVCCG is well placed to move forward in
this area. The existing operating plan sets out a direction of
travel towards new models of commissioning, and using our
locality structure this can be tailored to match local needs
across our geography.
• To achieve a membership model, providing citizens with an
indicative membership plan using our already established
capitated budgets;
• Advanced risk stratification, developed in co-production
with patients and their carers; and
• Access to the primary care record.
Elements of the model will be readily transferable to other
localities, having been developed and road tested in the
North. Some aspects may be developed within other
localities, and then lifted into the MCP in the North, in order
to utilise the strengths of all localities and the scarce
resources within them in the most effective way. All localities
will ultimately have their own model to suit their local needs
and requirements. A wide range of stakeholders have been
consulted with and engaged in the development of plans. It is
crucial that the wider health and social care economies own
and fully engage with plans that are developed, in order to
maximise this real opportunity and work in a different way.
NHS England put a process in place to receive expressions of
interest in being fore-runner sites, which would contribute to
learning and provide pilot sites for rapid rollout of new
models. Two expressions of interest affecting AVCCG have
been submitted, but regardless of receiving ‘fore-runner
status’ there is a commitment to take these plans forward.
AVCCG is moving into a new phase of how it works with
primary care. Using the Primary Care Strategy and planned
mechanisms which will be available as a result of the
anticipated co-commissioner status which the CCG will have
will enable a much greater influence over this pillar of the
local health economy.
3.2 Primacy and Acute Care System (PACS)
A second scheme is being led by providers across
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
3. New models of care (cont)
Buckinghamshire, including the integrated Acute and
Community provider, Mental Health, Ambulance, Out of
Hours and Social Care. With an initial focus on integrating
urgent and emergency care the CCG is supporting the
development of this approach. Early priorities include out of
hours primary care and rapid access to improvements,
including: more integrated working across the front door of
A&E; access to relevant clinical information such as test
results; and improved patient experiences and outcomes.
facilitate transformation;
• Generally good healthcare services in respect of quality and
outcomes;
• Plans in progress for the development of IT to support
transformation; and
• Willing and able staff committed to making the
transformation a success for the benefit of the local
population.
3.4 Primary care
3.3 Successful transformation
Primary care is central to the population-based health care
models described in FYFV. Imminent workforce issues
nationally are being tackled by NHS England and Health
Education England (HEE) alongside the Royal College of GPs
and the General Practitioners Committee. CCGs have been
asked to choose between a range of primary care cocommissioning options, which will give them a greater
influence over the local design of primary care. In addition,
£100m has been made available nationally through the Prime
Minister’s Challenge Fund to improve access to general
practice. AVCCG has made a bid to access a share of this
money for two purposes:
AVCCG is ambitious in terms of the changes and
improvements it wants to make to positively impact on the
health outcomes for the population it serves. There is a deep
appreciation of the key ingredients which will make change
successful, and no illusion that any of the positive changes
which are planned will actually be delivered without the hard
work of dedicated staff and partners at all levels of the local
health economy. In relation to some of the key conditions for
future transformation, AVCCG has:
• Stable, ambitious and collective leadership able to oversee
and drive the transformation process;
• Engagement across a broad range of organisations within
the health economy, covering commissioner, providers,
local authority, health and wellbeing board, patient groups
and other relevant organisations;
• Strong clinical leadership and engagement;
• Good patient and community engagement;
• A tight but focused and prioritised financial plan which will
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• Implementation of locality acute hubs forming a locality
urgent care model; and
• Further development of primary care capacity using a novel
personalised care model. Specific patient needs will be
matched with locality healthcare provision rather than the
one size fits all approach of existing general practice.
A further £1bn is being made available nationally over four
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
3. New models of care (cont)
years to improve premises and infrastructure of primary care.
All practices in England were invited to submit bids by 16
February 2015 to access the money, and needed to
demonstrate how the investment would offer more patient
contact time, and to help reduce emergency admissions of
frail and elderly people. Practices in AVCCG will make full use
of any opportunities to access funding and improve services.
people and professionals, and to improve parity of mental
health, the Child and Adolescent Mental Health Services
(CAMHS) commissioning from OHFT now provides named link
workers to GP practices and secondary schools, and each
Children’s Centre now has a named Speech and Language
Therapist and Occupational Therapist.
During 2014/15 commissioners established a
Buckinghamshire perinatal mental health network. This
brings together midwives, health visitors, CAMHSS, Adult
Mental Health services, Public Health, commissioners and GPs
to better coordinate support to mothers and their young
children. A series of postnatal depression groups has recently
been launched and these will be evaluated during 2015/16.
3.5 Convenient access for everyone
In 2014/15 our mental health provider, Oxford Health NHS
Foundation Trust (OHFT) redesigned services to provide 7 day
and extended evening hours community services.
Furthermore, it introduced a single point of access to
facilitate improved access from primary care to mental health
services. To better support local access it is commissioned to
supplement its hospital based Memory Assessment Clinics to
provide capacity in GP practices under an initiative known as
Memory Assessment Closer to Home (MACH).
3.6 Urgent and emergency care
3.6.1 Context
The context and fundamental establishment of the local
urgent and emergency care system remain as described in the
existing Operating Plan. Development and refinement is
required to meet growing challenges in this area.
During 2015 we will build on the changes made in 2014/15 to
provide a more rapid diagnostic ‘one-stop-shop’ service which
patients and their carers have told us they value. These plans
sit alongside the provider-led plans to develop an integrated
PACS, maximising the value of sharing information with
providers of different services, working in a very different way
to the past. This will have the consequential benefit of
making access to all forms of healthcare easier, whatever
time of the day or night.
Nationally and locally Urgent Care and Emergency Services
are under increasing pressure. Ambulance call rates are
increasing by 6% and of these calls only 10% are life
threatening. At the same time, as many as 40% of A&E
attendances are inappropriate (meaning that alternative
services should be better placed to deal with the patient’s
condition). A local assessment of services against the Urgent
To improve access and better support children and young
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23
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
3. New models of care (cont)
and Emergency Care Review in the following areas is at the
heart of our plans for the two years to April 2016:
• Connecting the system;
• Helping people get the right advice in the right place, first
time;
• Providing highly responsive urgent care services outside of
hospital so people no longer choose to queue in A&E; and
• Ensuring that people with serious or life threatening needs
receive the best care.
3.6.2 Further developments
We will continue to develop a set of urgent care outcomes
and metrics to support these that the system can use to
assess the overall effectiveness and patient experience.
3.6.3 Seven day working
In December 2013, Professor Sir Bruce Keogh provided a
report to the Board of NHS England on seven day working6. In
it he set out ten clinical standards which need to be
implemented to enable seven day working. Locally, many
elements that will support the delivery of these ten standards
have been put in place. The SRG has carried out a gap
analysis against what is required. Further work will be
undertaken on this in 2015/16, as it is seen as a key priority in
enhancing system resilience. A Service Development and
Improvement Plan (SDIP) is anticipated to be in place at BHT.
Developments since the existing Operating Plan was
published include:
• The CCG will lead participation in Urgent and Emergency
Care Networks which will build on the existing System
Resilience Group (SRG). This will provide system wide
governance of implementation of the findings of the
national Urgent and Emergency Care Review;
• We will strengthen the ability of NHS 111 to meet people’s
needs without onward referral by increasing clinician input;
• We will work with providers to implement improvements to
the GP out of hours service. The intention is to incentivise
the services to integrate further with primary and secondary
care services, to deliver care to improve the quality of
service for patients, where possible avoiding the need for
admission to hospital; and
• In 2015/16 the ambulance service will extend its use of the
fire and rescue service as first responders in order to
improve response times.
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3.6.4 Urgent and emergency care CQUIN
The CCG awaits publication of guidance on the national
urgent and emergency care CQUIN. Its clear aims are to use
this as a vehicle through which it can incentivise significant
work across health and Adult Social Care to achieve the four
hour A&E standard, by reducing queues of patients awaiting
beds for admission to hospital. This can only be achieved
when health and social care have put in place adequate
capacity to meet demand from patients each day.
Acute providers are in the process of selecting between tariff
options available to them for 2015/16. One option will not
6 NHS England Board Report on Seven Day Working is available at
http://www.england.nhs.uk/wp-content/uploads/2013/12/brd-dec-13.pdf
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
3. New models of care (cont)
allow CQUIN schemes, the other will. It is expected that our
local providers will opt for the Enhanced Tariff Option which
will allow for CQUIN schemes.
were being achieved on a year to date basis for 2014/15, with
the exception of the maximum 31 day wait for subsequent
radiotherapy treatment. Performance was at 89.3% on a year
to date basis against a target of 94%. Known pathway issues
at the main provider (OUH) have been addressed, and
performance has been improved since September 2014. 14
day access standards for diagnosis are routinely delivered.
3.7 Maternity Services
A Maternity Needs Assessment has been carried out locally,
the outcomes from which are being assessed currently in
order to ensure that services are optimised to meet local
needs and offer choice to women.
The CCG Operating Framework for 2015/16 will include
cancer one-year survival rates. This indicator will be
monitored and reported through the CCG’s performance and
quality reports. We will look at improvements in rates for
different patient cohorts, against regional and national level
data, in order to assess outcomes for the local population.
Where there is underperformance we will work to understand
why that is the case and make appropriate changes.
In addition, NHS England is conducting a review of maternity
services – including perinatal mental health – which is
expected to be completed by autumn 2015. AVCCG will
follow appropriate recommendations from this review.
3.8 Cancer services
Section 2.1 discusses existing and newly planned actions
around prevention and public health. AVCCG will continue to
support and promote programmes aimed at improving
lifestyle choices which will help to prevent cancer.
3.9 Specialised care
In relation to specialised care services, the NHS is continuing
to move towards consolidated centres of excellence. The
population covered by AVCCG now benefits from fully
implemented receiving units for cardiac and stroke at the
Wycombe Hospital site. Specialised services at OUH are
continuing to integrate effectively with the local health
system, with joint multi-disciplinary team sessions between
OUH and BHT in a number of areas. One of our concerns
moving forward is to be able to work more closely with
Milton Keynes NHS Foundation Trust (MKFT), specifically in
relation to its stroke unit.
The CCG is represented at the Thames Valley Cancer Network,
which is working to increase cancer survival, deliver better
patient experience, improve treatment and recovery, and
improve support and information. The CCG also has links to
MacMillan, which among other initiatives has offered to
support GPs around early diagnosis work.
The CCG monitors on a monthly basis access standards
around cancer services. As of December 2014 all standards
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25
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
2. Creating a new relationship with patients and
communities
3. New models of care
4. Operational delivery
5. Enabling change
6. Driving efficiency
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
4. Operational delivery
4.0 Link to Triple Aim
4.1 Quality and outcomes
One of the Triple Aims is to improve the patient experience of
care (including quality and satisfaction). Another is improving
the health of populations. In addition, a key part of the
design of a Triple Aim Enterprise illustrated in Figure 3 on
page 13 is system-level metrics. Being able to measure
elements of interest in the system and track improvements in
response to changes made is a vital part of implementing the
Triple Aim.
4.1.1 Background
The focus of everything AVCCG does as a commissioner needs
to be on maximising quality and outcomes for patients, using
the available resources to ensure value for money. That
means delivering standards set out in the NHS Outcomes
Framework, alongside ambitions set locally.
The CCG’s performance is measured by, among other things,
the CCG Outcomes Indicator Framework. This is made up of a
significant number of outcome indicators spread across five
domains. Some of the indicators are well established and
some are in development. Table 1 on page 29 shows the
latest published performance, with previous data and
national comparison where possible.
There is a plethora of indicators and measures focusing on a
wide range of issues in the NHS. Some tell us how healthy the
population is and contribute to our understanding of the
burden of different disease groups, and the associated costs.
Some tell us about performance, including operational
performance and quality, of services we commission. Others
focus much more on the outcomes we derive for the local
population. All have their place in contributing to the CCG’s
ability to manage the wider health economy.
Alongside the national framework, the CCG is working to
improve outcomes on local priority measures. There is some
overlap with the national indicator set. Table 2 on page 30
shows the latest position on the local indicators, along with
the ambitions for performance set in the existing Operating
Plan.
In implementing the Triple Aim, being clear over the system
level metrics which are important for any single project or
portfolio of projects is critical. At the same time, the CCG
must monitor and react to data on nationally mandated
standards in order to ensure delivery of the NHS constitution,
compliance with the CCG Outcomes Framework and other
priority areas.
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4.1.2 CCG Outcomes Framework
In relation to enhancing the quality of life for people with
LTCs, AVCCG scores better than the national average (as
measured through the GP survey). However, the score
marginally decreased between 2012/13 and 2013/14. A
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
number of initiatives underway in the area focus of those
with LTCs, aiming to help them manage their condition and
avoid lapsing into crisis.
first half of 2014/15 indicates better than average confidence
and feelings of support by people with LTCs. Many of the
most significant plans in relation to new models of care will
directly benefit people with long term conditions, as access to
appropriate services quickly is key. In addition, all providers
having all of the relevant medical details about any specific
patient will greatly improve service effectiveness.
In relation to patient experience of GP out of hours services,
there has been a drop in the scores recorded in the 2013/14
GP patient survey, and was below national average. It has
quickly recovered to be above national average in the first
half of 2014/15, but not yet quite back to the 2012/13 levels.
Many of the plans linked to IT improvements and patient
centred ways of working across services provided by different
organisations should help to improve the overall experience
associated with out of hours services.
The proportion of people reporting poor inpatient experience
is red rated as it has increased from the restated baseline
between 2012 and 2013. This is a period where the main
acute provider was placed into special measures with
significant quality concerns. BHT has now successfully
managed those quality concerns, and Trust level friends and
family data shows better participation in the surveys for BHT
patients than the national average, and stronger scores
awarded. As such, when this indicator catches up with the
current position it is expected to show a significant
improvement.
4.1.3 Local improvement measures
AVCCG saw a small drop in the score concerning the health
related quality of life for people with one or more LTC,
including mental health conditions. This metric uses
questions in the GP Patient Survey to show people who
identify themselves as having one or more long standing
health conditions, along with problems walking about;
problems performing self-care activities; problems
performing usual activities; have pain or discomfort; or feel
anxious or depressed. AVCCG remains clearly above national
average, being the 15th best CCG in the country in 2013/14,
however the reduction in the CCGs score compared to
2012/13 is noted. It is expected that this will recover and
continue to be a strong performer against the national
position, as the most recent GP Patient Survey covering the
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The proportion of people reporting poor experience with GP
out of hours services is covered in the previous section on
CCG Outcomes Framework indicators.
The dementia diagnosis rate in AVCCG has been ahead of the
regional and national position through 2014/15. It has
plateaued recently and plans are being developed to push
further towards the 67% national target. It is important to
diagnose people with dementia in order to ensure they have
access to all appropriate support services early on.
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
Table 1 – NHS Outcomes Framework
Measure
12/13
13/14
14/15
England
(latest)
Comment
Domain 1 – Preventing people from dying prematurely – potential years of life
lost from causes considered amenable to healthcare: adults, children and young
people
1,541.7
1,377.3
Tbc
2,027.4
Revised methodology introduced for 13/14 data
released Sept 2014, affecting the values.
Domain 2 – Enhancing quality of life of people with long term conditions –
Health related quality of life for people with long term conditions
0.779
0.773
Tbc
0.743
Data is from GP Patient Surveys, run July –
March each year.
Domain 3 – Helping people to recover from episodes of ill health or following
injury – emergency admissions for acute conditions that should not normally
require hospital admission
858.7
821
Tbc
1,181.9
2013/14 data is provisional
Domain 3 – Helping people to recover from episodes of ill health or following
injury – emergency readmissions within 30 days of discharge from hospital
Tbc
Tbc
Tbc
Tbc
Latest data is for 2010/11 and 2011/12 years
only . AVCCG = 10.2 and 10.3 respectively.
National figures not available.
Domain 4 – Ensuring that people have a positive experience of care – patient
experience of GP out of hours services
72.7
61.0
68.2
67.9
Data is from GP Patient Surveys, run July –
March each year. Latest is second half of 13/14
and first half of 14/15.
Domain 4 – Ensuring that people have a positive experience of care – patient
experience of hospital care
N/A
73.9
Tbc
Tbc
National figures not available
Domain 4 – Ensuring that people have a positive experience of care – friends
and family test for acute inpatient care and A&E
-45
(Apr 13)
38
(Mar 14)
93%
(Dec 14)
86%
(Dec 14)
71
(Apr 13)
80
(Mar 14)
98%
(Dec 14)
95%
(Dec 14)
Figures are from Friends and Family test results
for BHT, as the Outcomes Framework CCG
level indicator is in development. The scoring
methodology changed from the net promoter
score to a straight percentage for 14/15.
28.78
Tbc
Tbc
Tbc
Domain 5 – Treating and caring for people in a safe environment and protecting
them from avoidable harm – patient safety incidents reported
Figures are for April – September 2013.
Calculated as weighted average per 1000
provider bed days as commissioned at the top
five providers for the CCG.
CCG improving on prior period and better than national average
CCG either improving on prior period or is better than national average
CCG not improving on prior period and not better than national average.
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29
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
Table 2 – Local improvement measures
Measure
Baseline
14/15
ambition
Latest data
15/16
ambition
16/17
ambition
17/18
ambition
18/19
ambition
(1) Reducing potential year of life lost to causes amenable to
healthcare (rate per 100,000)
1,556.2
1,546.2
1,377.3 (2013 data,
released Sep ‘14)
1,536.3
1,526.3
1,516.4
1,506.4
(2) Improving the health related quality of life for people with one
or more LTC, including mental health conditions
77.4
77.5
76.8 (13/14 data)
77.6
77.8
78.0
78.2
(3) Reducing the amount of time people spend avoidable in
hospital through better and more integrated care in the
community, outside of hospital (emergency admissions composite
indicator)
1,400.9
1,369
1,306.1 (13/14
data)
1,337
1,305.1
1,273.1
1,241.2
(4) The proportion of people reporting poor patient experience of
inpatient care (indicator revised and scores affected quite
significantly. Ambition to be revisited in light of this).
146.3
145.4
125.5 (2013
results, but
baseline recalc’d to
115.6)
144.5 (to be
revisited
following
indicator
revision)
143.6 (to be
revisited
following
indicator
revision)
142.7 (to be
revisited
following
indicator
revision)
142 (to be
revisited
following
indicator
revision)
(5) The proportion of people reporting poor experience of general
practice and out of hours services
6
5.9
7.9 (13/14 data)
5.8
5.7
5.6
5.5
(6) Mental wellbeing – percentage of people who enter
psychological therapy against the estimated level of need in the
population
15%
15%
11.99 (Q3 14/15,
on track for >15%)
Will be set to meet national standards as a minimum
(7) Mental wellbeing – improving the rate of dementia diagnosis
67%
67%
56.82% (Dec 14)
Will be set to meet national standards as a minimum
(8) Improve the percentage of type 2 diabetics who on monotherapy along achieve HbA1c of 48m/mols or below
35%
35%
59% (Dec 14)
35%
35%
35%
35%
Improving and better than 14/15 ambition
Improving or better than 14/15 ambition
Not improving and not better than 14/15 ambition
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
4.2 Assuring quality
improve services for patients with learning disabilities.
4.2.1 Provider quality
As recommended by the Academy of Medical Royal Colleges
‘Guidance for taking responsibility: accountable clinicians and
informed patients’, AVCCG will work with providers to embed
the practice of clear clinical accountability, with a named
doctor responsible for a patient’s care, within and across
different care settings.
Assuring the quality of providers is an important and complex
part of the role of a CCG. The Care Quality Commission assess
quality across the health service, and the reports they
produce are part of the toolkit used by AVCCG to assure itself
of the quality of care it commissions.
NHS England has identified tackling sepsis and acute kidney
injury as two specific clinical priorities for improving patient
safety in 2015/16. These form National CQUINs which
providers have agreed to sign up to.
We monitor the progress of providers against ambitions to
increase the levels of harm free care, using the Safety
Thermometer indices. BHT delivers 98% harm free care,
which is 3% above the national target. AVCCG works with all
providers with which it contracts to ensure that quality
metrics reflect the need for improved patient safety;
mortality levels in acute providers; patient experience; and
the understanding of staff in relation to patient safety and
experience. AVCCG attends the internal clinical governance
meetings of its main providers, and monitors the governance
structures and processes of those providers.
The CCG is committed to improving patient experience of
provider inpatient services and primary care. We will develop
meaningful and measurable targets and monitor patient,
carer and public survey results in both areas, along with
necessary improvement plans. It is noted that BHT receives
strong inpatient friends and family test scores currently, but
there will always be scope for improvement; and
performance at other providers is not consistently as good.
We will work to ensure that recommendations of the
Caldicott Review which are relevant to patient experience
implemented in our sharing of patient sensitive information,
and support the introduction of patient access to electronic
GP records in 2015/16.
AVCCG has reviewed the Francis, Berwick and Winterbourne
View reports as they have been released. It has considered
how it approaches quality and patient safety and the
assurance it has in relation to its providers. Alongside the
quality indicators and metrics we collect and review with
providers on a regular basis, we work with providers to
enhance their patient safety cultures, and the understanding
that staff have of their role in relevant issues. See section 4.6
particularly in relation to Winterbourne View and work to
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We are working with providers to ensure the six action areas
of Compassion in Practice are integrated into our:
•
Provider quality schedules and CQUINS
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DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
•
•
•
•
Provider assurance process for our site visits
Provider standard monthly quality monitoring and
reporting processes
CCG 2015/16 quality strategy
Bucks wide 2015/16 nursing strategy
4.2.2 Mental Capacity Act
AVCCG and CCCG were successful in a bid submitted to the
Area Team for funding a project Can I, can you? to increase
knowledge and compliance with the Mental Capacity Act
(MCA) to care and treatment decisions. The project will plan,
develop and implement a resource that can be used by
practitioners, service users and their families/representatives
to answer the question ‘Can I?’ regarding whether a person
can make their own decision(s) and ‘Can you?’ with regards to
whether practitioners can help a person to do so.
The CCG and provider organisations will submit quarterly
Prevent returns to NHS England. These returns will provide
assurance from organisations on their implementation of the
Prevent strategy including identification of organisation’s
Prevent Lead, inclusion in organisational policies, compliance
with Prevent training requirements for staff and numbers of
referrals made.
The CCG will deliver this project across Buckinghamshire and
Oxfordshire with colleagues in the Local authority and other
providers and the work will have a strong focus on patients,
carers and families. The project, in brief, will involve
developing an App and paper based resource on the use of
the MCA. Development and training for the resource aims to
involve mixing practitioners with service users and carers to
share experiences about decision making.
The CCGs have a Prevent Lead who works with Regional
coordinators to ensure that health are contributing to the
local implementation of Prevent including representation on
the local Channel panel. The CCGs will update multi-agency
partnerships such as the safeguarding boards on compliance
with the Prevent agenda as part of their assurance function.
The CCG uses provider highlights reports and its Governing
Body Quality Report to show where positive improvements in
provider services have been achieved. Friends and Family
Test results are monitored monthly at the Clinical Quality
Review Meetings and provider improvement plans are in
place where issues of quality have been identified.
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A further successful bid to the Area Team has enabled us to
start planning an seminar Application of MCA in General
Practice with a presentation from a guest speaker with
expertise in this field. It will be open to GPs and Practice
nurses and will aim to build confidence in applying the MCA
across our member practices. We intend to have this seminar
filmed and sessions available in a podcast to disseminate
widely and maximise the benefit of this opportunity.
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Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
4.2.3 Staff satisfaction
reporting of staff survey results. The CCG has access to the
Boards of its providers in order to raise concerns and discuss
issues. Staff survey results will also be a feature of the Clinical
Quality Review Meetings with providers in order maintain a
formal governance process around these issues.
Across the health economy, generally the staff survey results
indicate a good degree of staff satisfaction, and have been
relatively consistent for some time. The most recent formal
NHS staff survey results relate to the 2013 survey (2014
survey results are expected imminently). These show
generally very good levels of feeling among staff at the
ambulance trust, and the mental health trust. However, BHT
has a significant number of areas in which notably higher
numbers of staff completing the survey reported issues than
for other acute providers.
4.3 Antibiotic prescribing
Buckinghamshire has a joint formulary and antibiotic
guidelines are in place across the health economy to ensure
evidence based use of antibiotics. Prescribing of antibiotics is
monitored monthly in primary care and prescribing behaviour
will be challenged where appropriate by our Medicines
Management team in order to deliver the Quality Premium
target. Secondary care will be set the Antibiotic Quality
Premium target and monitored against it.
BHT has identified this and fed the results into its People
Strategy, and also conducts local quarterly staff surveys which
are indicating material improvements in key areas. The
proportion of staff who would recommend the Trust has
improved from 47% to 53%, and the number of staff feeling
encouraged to raise concerns has increased from 62% to 89%.
In the context of the position of BHT at the time of the 2013
survey, when it was in special measures and facing significant
issues, it is considered that there is likely to have been a good
improvement when the 2014 survey results are released.
Indicators such as the Friends and Family Test (where patients
are asked whether they would recommend the service to
friends and family) are currently stronger than the national
average and the Thames Valley average for BHT, and patient
experience often goes hand in hand with staff satisfaction.
4.4 The NHS Constitution
During 2014/15 AVCCG suffered from the national experience
of increased demand due to flu and reduced hospital capacity
due to more beds being unavailable due to delayed transfers
of care. This led to not achieving the A&E four hour standard,
in spite of significant improvements to the inpatient
emergency pathway. Over winter schemes were
implemented which mitigated these pressures.
Moving into 2015/16 the SRG is actively planning how to best
use the year round Operational and Resilience Contingency
Plan (ORCP) funding and improvements in seven day working
to maintain resilience. The aim is to fully utilise the predictive
Part of the contractual requirements with providers is the
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
4. Operational delivery (cont)
modelling of demand which local providers already have in
place, to enable capacity planning across the system.
Additional capacity will then be made available flexibly
through the ORCP in response to unpredicted surges in
demand. This will be focused on bank holiday weekends and
through January 2016, which are expected to be times when
normal capacity may be insufficient. SRG also has a plan of
work to improve patient flow across health and social care,
which is linked to BCF integrated working.
significant amounts in the independent sector; initiatives
planned for 2015/16 which will assist in ensuring that
appropriate activity is undertaken and paid for by the CCG;
and estimates for the impact demographic growth.
The greatest pressure on elective care standards are expected
through winter periods, when the level of emergency activity
is at its peak. This can lead to beds being unavailable for
planned admissions or theatre capacity being diverted from
elective to emergency cases. Through the ORCP actions
discussed above, it is anticipated that elective care standards
will be maintained throughout the winter period, as well as
the rest of the year.
In relation to elective care pathways, a significant amount of
additional activity was undertaken throughout 2014/15 in
order to reduce the number of patients waiting more than 18
weeks for their treatment to start, and to minimise the
number of people waiting more than six weeks for a
diagnostic procedure. Initiatives were planned with our main
provider, and funding was included in the 2014/15 contract
from the start of the year. Subsequently, nationally
mandated schemes provided a framework for additional
initiatives in order to further reduce waits. AVCCG became
compliant with all referral to treatment standards from
September 2014 onwards. Since January 2014 the number of
patients waiting over 18 weeks for their treatment has
halved. These initiatives are not expected to continue
through 2015/16, as local providers are in a far stronger
position in relation to their elective waiting times, and now
need to work to maintain the improved position.
4.5 Mental health
There are various areas in which the delivery of mental health
services is developing and improving in order to ensure parity
of esteem. Section 2.2.2 includes details of how Personal
Health Budgets link to mental health services; section 2.2.5
describes the application of choice to mental health services;
and section 3.5 describes enhancements to ensure
convenient access to mental health community services as
well as CAMHS services. The following paragraphs explain
further details of plans around the operational delivery of
mental health services.
4.5.1 Improving services for people with dementia and their
Carers
Planning by the CCG has factored in the backlog clearance
activity in 2014/15 across a range of providers, including
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The impact of an ageing population means that the
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4. Operational delivery (cont)
prevalence of dementia is expected to increase by 30% to
2020. An early diagnosis of dementia is vital to supporting
patients and their families to plan their care ahead, while they
are still able to make important decisions regarding their care
and support needs, as well as on financial and legal matters.
At the end of 2014 AVCCG was estimated to have 56.8% of
the expected number of patients with dementia identified
and diagnosed. The CCG is a high performer against the
target within the Thames Valley area, and continues to
prioritise this in its endeavour to reach the national standard
of 67%. Alongside this we are working closely with providers
to ensure that memory clinic waiting times are kept to a
minimum – currently 88% of patients are seen within 40 days
from referral.
the nationally regarded Healthy Minds Services. The CCG is
on track to deliver the 15% access standard and 50% recovery
rate by the end of quarter 4 2014/15 (see Table 2 on Page
[X]). Indeed, the recovery rate stood at 66.1% in quarter 3
(against the 50% standard) and these impressive outcomes
have been subject to a personal letter of recognition from
Normal Lamb, Secretary of State.
Recovery rates are subject to natural levels of fluctuation but
we will ensure that our provider continues to deliver IAPT
services of the highest quality whilst also rolling out IAPT to
support long term conditions, such as diabetes. In addition,
to further reduce inequalities and drive further parity, work is
under way to try to develop a regional British Sign Language
IAPT service for those with hearing loss and impairment.
AVCCG is an active stakeholder in refreshing the Dementia
Strategy for Buckinghamshire and has committed to a
continuing programme engaging all services that support
patients and families with dementia. Priority initiatives
include:
• Living well in care homes;
• Memory Assessment Closer to Home (MACH);
• Memory Advice Service;
• Working towards a Dementia Friendly Buckinghamshire;
• Primary Care Worker Pilot; and
• CamCog rollout.
4.5.2 Delivering and Improving IAPT
Mental health service access standards will apply to IAPT.
These are discussed in section 4.5.3 below.
4.5.3 Mental health access standards
In October 2014 NHS England outlined a set of waiting time
standards which were reaffirmed in the NHS Mandate and
reflected in the Forward View into Action and subsequent
guidance. Improvements towards meeting the new standards
designed to reduce health inequalities and deliver parity of
esteem, with effect from 2016, will be delivered during the
course of this year.
To support this, as part of the 2015/16 contracts, SDIPs will
be in place with our main providers to deliver these access
The CCG commissions IAPT from OHFT, which is delivered by
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4. Operational delivery (cont)
and waiting time standards for early intervention in psychosis
(EIP) for both adults and children & young people. By
2016/17, more than 50% of people experiencing a first
episode of psychosis will be treated with a NICE approved
care package within 2 weeks of referral. Most initial episodes
of psychosis occur between early adolescence and age 25 so
we will work across both the adult and CAMHS service of this.
It is well established that failure to engage and intervene
effectively in early psychosis leads to poorer outcomes for
individuals and their families. The provision of evidence based
care earlier can prevent the development of psychosis in a
significant proportion of cases and can prevent further illness,
disability and distress. In this way greater parity of mental
health will be achieved.
We will also work with our CAMHS provider to ensure we are
able to respond to further access and waiting times for
children & young people that will be developed in 2015/16 for
introduction in 2016 and to ensure that they are working
regionally on plans to develop improved community based
eating disorder services.
Achieving better Access to Mental Health Services by 2020 set
the expectation that by 2020 all acute Trusts will have in
place liaison psychiatry services for all ages. During 2014/15
the CCG supported the roll-out of a pilot Psychiatric Liaison
Service (PIRLS) at Stoke Mandeville and Wycombe Hospitals.
The service is currently being evaluated and the CCG has
committed to investing in this service for 2015/16. The acute
Trust BHT is a signatory to the Buckinghamshire mental
Health Crisis Care Concordat and recognises the importance
that liaison psychiatry has in acute settings.
A second SDIP will be in place with our main provider to
deliver access and waiting time standards for IAPT. The
provider will be required to set out how they will prepare for
and deliver a service whereby 75% of adults referred will be
treated within 6 weeks and 95% will be treated within 18
weeks.
In addition to the PIRLS service itself, the team also provides
invaluable mental health awareness training to staff working
in the acute Trust which is another important component of
our commitment to reducing health inequalities and
delivering greater parity with physical health.
Plans will need to include an analysis of current levels of NICE
concordance, the current waiting times, capacity required to
clear the backlog, an understanding of CCG demand and
capacity required to deliver the standard on an on-going
basis. Providers will also be required to demonstrate that
they have appropriate data collection mechanisms to
demonstrate performance against these standards
transparently to both commissioners and service users.
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The Joint Commissioner for Mental Health in
Buckinghamshire has led the co-ordination of the county’s
Mental Health Crisis Care Concordat and Action Plan.
Signatories include the OHFT; SHFT; South Central Ambulance
Service; Thames Valley Police; and BCC. Delivery of the
consequent action plan will be overseen by the county’s
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4. Operational delivery (cont)
Health and Well-being Board. Discussions are already
underway between health partners and the police to ensure
that vulnerable adults and young people do not undergo
assessments in police cells.
assessments to meet emergency mental health needs. The
new provider will also be expected to deliver a specialist
emergency mental health assessment and home intervention
service in order to prevent and provide alternatives to inpatient admission.
The mental health Trust has recently opened a new in-patient
unit in the Whiteleaf Centre in Aylesbury and this has
significantly improved s136 capacity. The introduction of the
psychiatric liaison service to support the A&E at Stoke
Mandeville Hospital and supplement the community crisis
team has also improved care provision and new better
integrated self-harm pathways have been introduced at the
hospital for children and young people. The CCG was
successful in its joint bid with CCCG for mental health winter
resilience funds to roll out a Street Triage project during the
course of 2015. This project builds on the successful pilots
that have been implemented in Hampshire and Oxfordshire,
both of which saw a significant reduction in the use of police
cells and s136 suites.
4.5.4 CAMHS
The introduction of the Children’s and Families Act, which
became law in 2014 has significant implications for the
provision of integrated health, social and educational support
for children and young people from birth to 25 years. The Act
replaced statements and learning difficulty assessments with
a new birth- to-25 Education, Health and Care Plan, extending
rights and protections to young people in further education
and training and offering families personal budgets so that
they have more control over the support they need. The Act
requires improved cooperation between all the services that
support children and their families, particularly requiring local
authorities and health authorities to work together; and to
publish a ‘local offer’ of support. During 2014/15 we have
worked closely with CCCG and BCC. We have in place pooled
or aligned budgets for CAMHS, Speech and Language Therapy,
Occupational Therapy and Community Equipment. We have
introduced Personal Health budgets and are working with
education and social care to ensure a better integrated and
publicised “local offer”
AVCCG together with CCCG and BCC have, under a S75 pooled
budget agreement, sought to procure a new service model to
better support Children and Young people with mental health
conditions in the county. Tenders are currently under
evaluation so as to enable a new model to be provided from
October 2015. The revised specification, which was informed
by the views of service users, carers and professional
stakeholders including GPs, schools and social care, requires
the successful bidder to provide 24 hour 7 days a week
CAMHS consultant to undertake specialist mental health
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In Buckinghamshire, 3,849 children and young people are
currently known to services that have a disability or special
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4. Operational delivery (cont)
educational needs with prevalence estimated at 3-5.4% of the
total population. This number is expected to increase along
with complexity of conditions. The CCG together with CCCG
and BCC have recognised that further work is required to
conduct an in-depth needs analysis of this high need cohort of
children. To this end a joint pilot project for 2015 has been
funded to:
• increase our shared understanding of children aged 0-4 with
complex needs and the needs of their families;
• improve access to a range of early years services through
integrating referral routes and assessments, supporting both
professionals and families;
• provide clear activity and financial mapping
• improve co-ordination of services where children are using
at least 2 services;
• improve pathways of care into locally commissioned
services/placements across health, education and social
care to achieve optimum pathways of care; and
• improve parent/carer satisfaction of locally commissioned
services.
The project will be piloted within Aylesbury. As several
children’s services are already co-located in the town, current
multi-agency interfaces with the key medics (paediatricians)
are more established than in the south of the county. Local
intelligence from maternity and therapy services also
identifies rising severity and complexity of need in Aylesbury
Vale.
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4.5.5 Paediatric Physiotherapy Service
To support the development of the local offer for children and
young people with Special Educational Needs and Disabilities
we commissioned a review of the needs and current access
and service provision in paediatric physiotherapy. The findings
have been shared with the current provider BHT and we will
work with them on a service development plan in 2015. We
will also work with families and professional stakeholders to
look at opportunities and benefits of procuring an integrated
children’s therapies service incorporating physiotherapy,
occupational therapy and speech and language therapy.
4.5.6 Enuresis Services
The Enuresis service has been historically provided by school
nurses with supervision from community paediatricians.
Provision of the service has varied between localities and a
gap analysis has identified opportunities to develop and
improve the service offered for all children including children
with complex needs. We will develop a commissioning
strategy for a new continence service which meets the needs
of all children irrespective of their age and disabilities.
4.5.7 Parity of Esteem – CAMHS
Mental Health affects all aspects of a child’s development
including their cognitive abilities, their social skills as well as
their emotional wellbeing. As a CCG we are committed to
supporting and improving the emotional resilience of children
with mental health issues. The contract that we hold for
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DRAFT Operating Plan refresh for 2015/16
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4. Operational delivery (cont)
CAMHS services expires in September 2015. During 2014
commissioners have reviewed the service with professional
stakeholders including social care, schools and GPs and with
families and service users. A re-procurement process has
been launched and the contract will be awarded in April 2015
for implementation in October 2015. Young people and
parent representatives have been involved in the design of
the new service model and in the evaluation and scrutiny of
the bids. The revised service specification builds on the
pooled budget arrangement that already existed between
AVCCG, CCCG and BCC. The new service specification:
• Requires the service provider to remodel CAMHS to
incorporate the role of the Targeted Mental Health Service
in Schools (TaMHS) and the psychology services provided to
the social care adoption, Looked After Children and Care
Leavers teams.
• Sets out a requirement for a more integrated and seamless
Tier 2 Targeted and Tier 3 Specialist CAMHS
• Prioritise a focus on early intervention and improved access
• Provide a single point of access across services, providing a
comprehensive and responsive mental health assessment
and treatment service
The specification, agreed before the national announcements
on waiting times, requires the new provider to complete 95%
of assessments within 6 weeks of referral in year 1 and 90%
within 4 weeks by the end of year 2. Assessments for Looked
After Children will be prioritised and seen within 5 working
days of referral.
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Following tender award commissioners will require the new
provider to review the emerging national access standards
and provide plans for delivering compliance against these for
implementation in early 2016.
4.6 Transforming care of people with Learning Disabilities
Specialist Learning Disability Health Services are provided for
the county by Southern Health Foundation Trust (SHFT). In
response to a number of serious incidents at the Ridgeway
Unit, commissioners suspended new admissions for 3 months
in early 2014 to enable the service to address the concerns
raised. The Clinical Commissioning team worked with SHFT to
implement a robust improvement plan before re-opening at
the end of March. Since then monthly clinical quality review
meetings have been held to ensure continued transparency
and support the maintenance of the improvements made. We
will continue to work closely with the current provider to
ensure that the quality improvements made in 2014 are
sustained and that the services provided are safe, evidencebased and of high quality.
More broadly, there have been some concerns regionally and
nationally about services for the learning disabled. After the
Winterbourne View scandal, the Government and a large
number of partners signed a Concordat pledging action on
care for people with learning disabilities and/or autism who
present behaviour that challenges and/or complex mental
health problems. The Concordat promised: “health and care
commissioners will review all current hospital placements and
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4. Operational delivery (cont)
support everyone inappropriately placed in hospital to move
to community-based support as quickly as possible as and no
later than 1 June 2014”.
joint programme board with the County Council has been
established and a procurement plan agreed. Greater
integration of health and social care are seen as key to
delivering improvements to both the efficiency and quality of
services. A new service model will be developed with our
partners and informed by the views of service users, their
families, carers and advocates. The key priorities for the new
service are:
• In response to Winterbourne, the development of
community based solutions so that people are supported in
the least restrictive environment as possible;
• Individuals who do require in-patient care with receive an
integrated assessment and support plan to ensure that they
are discharged with additional support back to their local
communities as soon as they no longer require in-patient
services; and
• To reduce health inequalities and deliver greater parity of
esteem by improving access to mainstream primary and
secondary health services wherever possible, ensuring that
annual health checks, health action plans and access to
screening programmes are maximised.
Core features of an integrated service model will be:
seamless, consistent, standardised and equitable; Client
focussed/person centred, maximising choice and control;
Single assessment process; Early intervention with access to
the right help from the right person at the right time; and
more intensive community support to prevent avoidable
admissions to hospital and to reduce length of stay when an
admission is required.
This has been undertaken in Buckinghamshire and, although a
number have been transferred out of inpatient care, a similar
number have been admitted over the same period. This local
position is in line with the national experience and the
number of patients on the Winterbourne Register appears
largely unchanged. The CCG has a robust review process in
place and reports on at least a monthly basis to the Regional
Area Team on progress and barriers to progress. It is also
reported internally to the Commissioning for Quality (C4Q)
meeting. In line with the recommendations in the recent
Bubb Report (2014), Commissioners are supporting the
resultant Care and Treatment Reviews. We will build on our
recent experience of co-designing bespoke packages with
individuals, their families and carers and ensure that personal
health budgets are available to support the community
placements of those with learning disabilities and high
support needs that are not well serviced by conventional
service approaches.
The CCGs have agreed that they will procure a new Specialist
Health Service to support people with a learning disability and
behaviours that challenge with effect from 1st April 2016.
Commissioners have advised SHFT of their intention to
retender the service for 2016. During 2015/16 we will work
with all stakeholders to develop a new service specification
for an Integrated Community Learning Disability Service. A
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40
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
2. Creating a new relationship with patients and
communities
3. New models of care
4. Operational delivery
5. Enabling change
6. Driving efficiency
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
5. Enabling change
5.0 Link to Triple Aim
5.1 Harnessing the information revolution and transparency
The IHI Triple Aim is the change model being used by AVCCG.
This document refreshes the existing two year Operating Plan
published by the CCG in April 2014, ensuring it is consistent
with FYFV. The structure of the document matches FYFV, and
the start of each section includes a section explaining how it
links to the Triple Aim.
There is a significant amount of data and information across
all types of NHS services. The more we can make them work
effectively together, the more holistic and patient centric
information can be, helping to make service more effective,
more efficient and safer.
The 2014/15 NHS Standard Contract included requirements
for providers to use the NHS number within patient level
activity information for many services, with financial
consequences where certain threshold levels were not met.
The proposed 2015/16 contract includes extended powers to
enforce this more widely through service conditions related
to information breaches. All tools available to enforce this
will be used to maximise the quality of information provided
to commissioners.
Figure 3 on page 13 shows the suggested components of a
Triple Aim Enterprise. All of the elements are covered
through other sections in this document, however a key
element is enabling the elements to combine as effectively as
possible. Maximising the use of information technology, and
integrated workforce planning are fundamental to enabling
change.
Figure 2 on page 13 sets out recommended elements of the
change process which also includes rapid testing and scale up
that is adapted to local needs and conditions. As well as
utilising the locality model existing with the CCG to develop
and pilot elements of new models of care, which can then be
replicated across localities, the CCG itself needs to support
and utilise nationally driven change. Accelerating useful
innovation is a crucial part in delivering the level of successful
change that the NHS needs.
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Patients should have access to an easy to use electronic
prescription serve. AVCCG has already met the national target
of 60% of practices being able to send prescriptions
electronically, with 63% of practices live with EPSR2.
Utilisation in the live practices is meeting the national target
of 40%.
Following on from local success in the implementation of the
appointment booking and repeat prescription requesting
elements of online services; a two stage implementation is
underway to deliver the additional capabilities of online
services. The first phase encompasses access to the
information held in the Summary Care Record, Immunisations
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DRAFT Operating Plan refresh for 2015/16
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5. Enabling change (cont)
and Test Results with a target of the end of March 2015. The
second phase includes online access to wider elements of the
patient record to be implemented by the end of March 2016.
5.1.1 Interoperable digital records
Healthcare organisations around the world are looking at
models of delivery based on population health. One of the
main proposals is the use of Accountable Care Organisation
(ACOs) as a delivery mechanism. The aim of ACOs is similar to
ours: improve quality and control cost. However one of the
main problems for ACOs is getting data flowing between
different organisations. Throughout our plan we describe
new models of care involving an ever increasing number of
organisational partners. Just coming together as an ACO will
not change organisational behaviour or patient services. We
must continue to give patients the tools to support their own
care, no matter what organisational structure exists.
There is a programme in place to achieve the delivery of
electronic discharge process for our main provider through a
CQUIN in 2014/15. The implementation of the pilot
commenced in respiratory in Q3 with roll out to the division
of medicine in Q4. In 2015/16 Q1 & Q2 we will be monitoring
the roll out to the remainder of the trust through our service
development and improvement plans. In Q3 &Q4 this will
transfer to be part of our Quality Schedule for the remainder
of the year.
AVCCG will work with GP practices, support services and local
acute providers to agree plans to increase the use of
electronic referrals across the area. Plans will take account of
the forthcoming change to the Choose and Book system, with
a new e-referral system due to be launched nationally in
2015/16.
The system has been successful, with AVCCG leading the
implementation of the Medical Interoperability Gateway
(MIG). This is the first stage to achieving interoperability of
patient level records across health and social care. It is a
move towards the national mandate of ‘all patient and care
records being digital, real-time and interoperable by 2020’.
AVCCG use data and information in a variety of ways to
analyse, investigate, review and understand health related
issues, patterns of service use in the area, and to plan and
prioritise for the future. We recognise the immense value
that initiatives such as care.data bring, while also
acknowledging the right of individuals to opt out of having
their data used in this way. We will watch the development
of the care.data pathfinder areas with interest, and look
forward to the national rollout of the scheme.
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In 2015/16 the Bucks system aims to commence the second
stage of interoperability. The Bucks wide leadership
community has supported a project Charter to take forward
system wide IM&T platforms. A joint Chief Information
Officer will be appointed working to the Healthy Bucks
Leaders forum and hosted by one of the organisations.
Strategically this will fit to enabling our plans for care planning
at patient level.
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5. Enabling change (cont)
• work through its development of a Multi-speciality
Community Provider (MCP) model. We will focus on
developing two new pharmacy roles. A pharmacy post that
supports care planning focused on patients with Long term
Conditions including training in talking therapies and
extended roles in supporting elderly discharge.
5.2 A modern health and care workforce
The CCG is committed to working with our Local Education
and Training Board (LETB) who are responsible for the training
and education of NHS staff, both clinical and non-clinical,
within our area. We aim to work with them to improve the
quality of care delivered to patients by focusing on the
education, training and development of current and future
healthcare staff, (better training better care).
• Prevention –We are working with Thames Valley HEE to
review the health education needs association with our
integrated pathway. We are currently focussing on:
Three main areas have been identified for support going
forward:
• Paramedics – the Paramedic Evidence Based Education
Project (PEEP) report, published by the Allied Health
Professionals Health Education Advisory Group in August
2013 recognised that paramedics are very well regarded by
the general population and noted that closer engagement of
this workforce with pre-hospital urgent care and prevention
of hospital admissions would be of benefit to the wider
community. This work has been identified as a priority with
our local ambulance service, South Central. We are
currently working with them and LETB to agree a plan to
train paramedics up to degree level over the next three
years.
• Pharmacy – Health Education England (HEE) has been asked,
in its 2014/15 Mandate to take forward the proposals to
reform the planning, funding and delivery of pharmacists
education developed by the Modernising Pharmacy Careers
(MPC) Programme Board. The CCG wants to build on this
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(1) a training needs analysis for primary care clinicians in
relation to diabetes;
(2) the expansion and evaluation of the workforce required
to deliver our enhanced lifestyle changes model; and
(3) a review of education and training provision to enhance
the delivery of both care planning (Year of Care) and our
flagship ‘Live Well’ (an integrated multidisciplinary
network approach for the management of LTCs in
primary care) which seeks to provide a holistic response
that treats both physical and mental health / emotional
needs on a par with each other, ensuring parity of
esteem.
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5. Enabling change (cont)
As outlined in this document, the local health economy has
seen two expressions of interest made to NHS England in
February 2015 in relation to New Models of Care. One is in
relation to a Multi-specialty Community Provider model in the
North locality of the CCG, which is a commissioner lead
proposal. The other relates to a Primary and Acute Care
System (PACS) and is lead by a consortium of local providers
across the range of major services making up the local health
economy (including acute, community, mental health,
ambulance, primary care out of hours, as well as social care).
NHS England is receiving expressions of interest in concepts
such as these from across the country, and will select those
which it believes can most quickly and successfully be realised
to support as fore-runner sites. AVCCG is committed to
taking forward New Models of Care regardless of the success
or otherwise of the expressions of interest in being forerunners. We recognise the specialist skill set that will be
needed to make the New Models of Care a reality, and will
look to both participate in and benefit from the work of the
new Workforce Advisory Board in developing and maintaining
a health and care workforce will the skills to support the
implementation of the new models of care.
5.3 Accelerating useful innovation
Innovation is a key factor in creating and maintaining a
sustainable health service at whatever level the
commissioning of services takes place. Just as NHS England is
looking to accelerate innovation in new treatments and
diagnostics, much of which has a focus on specialised services
commissioned nationally, AVCCG is working towards local
prioritisation through place-based commissioning and
population budgets. While the system is some way from
single comprehensive population budgets, work around the
diabetes care pathway, for example, is looking to areas such
as year of care tariffs.
There are many large scale innovations under-way in the NHS
at the current time. Of note is the plan for the NHS to
sequence 100,000 whole genomes by 2017. AVCCG
acknowledges the work being undertaken by NHS England in
relation to Genomic Medicine Centres, of which 11 have been
announced in the first wave, including Oxford NHS GMC, led
by Oxford University Hospitals NHS Trust. NHS England is
further re-procuring Genomics Local Laboratory Hubs during
2015/16 to work at a more local level. As the project
progresses, AVCCG will stay abreast of any actions which are
required to be taken by local commissioners to support the
ambition.
December 2015 will see the introduction of nursing and
midwifery revalidation, which will set new requirements of
nurses and midwives when they renew their registration
every three years. AVCCG will work with its providers ahead
of the introduction to ensure that plans are in place to
prepare for this and any consequences of it.
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45
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
1. Preface
2. Creating a new relationship with patients and
communities
3. New models of care
4. Operational delivery
5. Enabling change
6. Driving efficiency
Bringing clinical leadership to local health needs
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46
DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
6. Driving efficiency
6.0 Link to Triple Aim
6.1 Review of existing plans
The whole concept of the Triple Aim is to optimise health
system performance by simultaneously pursuing the three
dimensions of improving patient experience (including quality
and satisfaction); improving the health of populations; and
reducing the cost of health care. Ultimately organisations
which achieve the Triple Aim will have healthier populations.
New models of care will be able to more effectively identify
problems and offer solutions outside of acute healthcare.
Pathways will be less complex and more coordinated. The
burden of illness will decrease. In these ways the cost of
healthcare will reduce, helping to ensure the sustainability of
NHS services into the future.
Our two-year operating plan published in April 2014 listed a
number of projects which were planned to contribute
towards a step change in the productivity of elective care.
This is necessary in order to ensure sustainability of services
into the future, and is one of the six characteristics for high
quality, sustainable health and care systems as defined by
NHS England, and is a feature in the Buckinghamshire
Commissioner’s 5 Year Plan. Individual projects outlined in
the two year operating plan from April 2014 are listed below,
along with an update on progress made to date:
• InterMountain (Digitisation of Outpatient Attendances) –
this evolved into a wider project to reduce face to face
follow up outpatient attendances. A dedicated project
manager was appointed in the autumn and has helped BHT
to take forward priority projects. There remains much to
do, but a number of pathway changes and initiatives are in
motion, with ongoing work in this area planned through
2015/16.
• Review of musculoskeletal (MSK) services – this review has
been being undertaken across both Buckinghamshire CCGs,
and reported through the Right Care Stakeholder Group. It
will conclude in April 2015 on recommendations for the
future model of the MSK service.
• Re-design of the pain pathway – a project is progressing to
review the pain pathway for opportunities to improve
quality and patient experience, and to incorporate mental
health and psychological therapies.
The plan has made links to the components of a Triple Aim
system – from individuals and families, through prevention
and health promotion, to primary care and the integration of
the wider health system under new models of care to
improve performance and outcomes, which will lead
reduction in the cost per capita of services.
This section outlines the financial position of the CCG and
where opportunities in the system may exist through QIPP
and other initiatives. The Triple Aim model is an over-arching
concept which will steer high level significant system change,
beyond the level of a typical QIPP scheme. However below
this there is a significant and complimentary QIPP programme
in place.
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DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
6. Driving efficiency (cont)
• Anticoagulation –re-procured during 2014 under an AQP
scheme, there is now improved access and quality with
county wide provision of near patient testing level 4
warfarin monitoring (‘gold standard’ of care). New
contracts are now operating. Close monitoring of service
provision and outcomes will ensure the improvements
patients are expected to experience is realised.
• Reduce referrals into pathology and direct access
radiological services – benchmarking indicates that
Buckinghamshire benchmarks quite high in relation to the
use of CT and MRI scans. Work to understand the outcomes
for patients from this high level of testing will be undertaken
in 2015, with a view to identifying areas where a lower level
of activity would not impact on the quality of patient care
and the outcomes they experience.
6.2 Forward view
we plan for the new year, providers have two tariff options,
but we have no formal decision over which will be selected.
Each has implications for assumed efficiency savings coming
out of the provider. Regardless, we will continue to work to
review the savings requirements and plans of our providers to
ensure that they do not compromise patient safety or give
rise to quality concerns. Our providers are keen to engage in
discussion around new ways of treating patients – through
technology and service delivery models. This is best
demonstrated by the provider-led expression of interest to
NHS England to establish an integrated Primary and Acute
Care System (PACS) in Buckinghamshire.
The largest and most important asset of any health economy
is its workforce – across the frontline of service delivery to
patients, the management working to provide the best
environment and infrastructure for patients and their health
professionals, and the range of support functions necessary
to keep services running in the most effective and efficient
way. Whether it is through the pressures experienced by staff
of provider organisations, particularly through very busy
periods; or potential uncertainty generated from
organisational changes (or even changes to individual
elements of an organisation or its services), the welfare of
staff working in the NHS is a matter of significant concern.
Understanding and responding to issues arising through the
regular staff surveys is an important mechanism for
commissioner and provider organisations, and AVCCG is
launching its own local staff survey for its staff. Equally
In addition to activities in these areas, a greater focus on
procedures of limited clinical value being undertaken at the
CCG’s main providers will help to ensure that the activity
which is undertaken in the system is appropriate activity.
A recognised source of opportunity to generate savings in the
NHS is through productivity gains made possible by
technological advancement, alongside improvements to
service delivery. Typically the national tariff includes an
element each year which places the onus on providers to
work to realise some of these potential gains. Issues in the
consultation process for the 2015/16 tariff mean that, as
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
6. Driving efficiency (cont)
important are other formal and informal channels of
communication between staff and their managers, either
through appraisals, 1 to 1s or simply fostering an environment
where staff can raise issues affecting them and expect a
constructive and understanding response. This will ultimately
improve staff retention and motivation, lead to less sick leave
and help to avoid the need to use costly short-term options to
cover vacancies.
providers have also signed up to create a Primary and Acute
Care System, working across the system in an entirely patient
centric way, maximising the opportunities that new IT
provides to share information and ensure that patient care is
the best it can be at all times. Part of the longer term
opportunity depends on initially understanding total cost data
for patients across multiple health and care settings, in order
to understand the impact of actions in one area of the total
cost to the public. NHS Aylesbury Vale CCG intends to initially
focus on the total cost of health and social care to diabetes
patients as part of a large programme of work being
undertaken in that area, and will look to learn from other
areas in relation to this and its understanding of total costs in
other disease and condition areas.
The CCG’s QIPP and other plans include a range of items
including those expected to generate short term quality,
patient experience and cost benefits, and those resulting
from longer term initiatives which are expected to have a
longer period before returns on investment can be realised.
Significant work is underway on the local diabetes pathways,
for example, which should see significant improvements for
patients and the impact of the condition on their lives. While
ultimately financial savings are also expected to follow, none
are reflected in QIPP plans for 2015/16, as the intention is to
reinvest savings generated this year back into the project, in
order to maximise the impact of the work in this area.
6.3 NHS funding 2015/16
6.3.1 Background
The AVCCG Operational Financial plan is intended to support
the delivery of commissioning aspirations for the period
2015/16. It considers the financial resourcing requirements
locally, compares this to the funding available to the CCG and
identified level of efficiencies or changes in uses of funds
required to secure a sustainable financial position, and the
associated risks.
The local health economy has submitted to expressions of
interest to NHS England in relation to implementing new
models of care described in the Five Year Forward View. The
CCG is leading an initiative to establish a Multi-specialty
Community Provider in its North locality, working across
service boundaries to provide efficient, effective care closer
to home and utilising IT to ensure a seamless transition for
patients from one service to another. A collaborative of
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In 2013 “A Call to Action” identified a requirement for the
NHS across England to make c£30bn of efficiency savings by
2020/21. The main assumptions driving this level of
efficiencies are:
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DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
6. Driving efficiency (cont)
• Underlying projected available NHS funding will grow in line
with economy wide inflation over the seven year period.
This is termed “flat line” funding (i.e. no underlying growth
in allocation).
• Demographic pressures i.e. population growth, aging trends,
and existing unmet need are met from within existing
resources
• Non-demographic pressures such as medical advances and
increased expectations of the population are met from
within existing resources
• Inflationary pressures above economy wide inflation are
met from within existing resources. As an example historic
data demonstrates that prescribing inflation has been twice
that of the national inflation measure.
It could be argued that this is an overly pessimistic position as
flat line NHS funding over a seven year period is
unprecedented. However the level of variation in projected
future growth in the UK economy published by the Office of
Budgetary Responsibility (0% to 5.5%); the continued national
structural budget deficit and the signals from government of
further reductions in total public sector spending beyond
2015/16 indicate that this is a prudent position in terms of
financial planning.
6.3.2 2014/15 Review
The financial plan is impacted on the historic financial
position of the CCG. The CCG had a recurrent programme
budget of c£205M and an additional running budget for
running costs of £5M giving a combined resource limit of
£210m. A target surplus of £2m was planned in 2014/15
representing 1% of the programme resource limit, before the
revised surplus of £2.5m in December 2014. The additional
£0.5m relates to the return of the CHC Risk Pool underspend
which the CCG contributed to and cannot be spent within
2014/15 but will carry forward to 2015/16.
The latest forecast outturn in February 2015 shows that the
target surplus will be achieved. However this is after the
application of all non-recurrent headroom, contingency, and
slippage on investments held in reserves in 2014/15 to offset
spending higher than expected costs within planned and
unscheduled care commissioning budgets. The pressure on
these budgets is c 5% within 2014/15 compared to the uplift
in CCG allocations of 4.5% excluding the Operational and
Resilience Capacity funding. The 1% Non-recurrent headroom
will be spent on setting aside the CCG contribution to the
national CHC Risk Pool with the balance available to mitigate
risk or provider further transformational funding.
In the Autumn statement further funding for the NHS was
announced. This resulted in total growth monies of c5% for
this CCG, including £1m of Operational and Resilience
Capacity funding which has now been moved from nonrecurrent funding to be part of the CCG Recurrent Baseline.
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The start point of the plan assumes that the CCG is broadly in
a break-even position recurrently going into 2015/16 and will
drawdown £0.4m of the cumulative surplus to support new
models of care.
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DRAFT Operating Plan refresh for 2015/16
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Clinical Chair: Dr Graham Jackson
6. Driving efficiency (cont)
underspend.
Pool on the same basis as 2014/15. Within the CCG baseline
there is an additional £3m of funding in relation to the Better
Care Fund (BCF) which is jointly operated by CCCG and BCC.
AVCCG will also be party to the Oxfordshire BCF due to its
boundary with Oxfordshire County Council.
6.3.3 2015/16 Planning Assumptions
The Medium Term Financial Plan is built up from a number of
planning assumptions and is in line with technical guidance
issued by NHS England in December 2014, reviewed and
adapted to reflect local conditions. There have been protests
concerning the tariff implications with the result that until a
decision is made the 2015/16 original guidance has been
applied.
Through the planning process the contract envelopes have
been worked up using the above assumptions and refined to
take account of activity movements relating to projects,
impact of Better care fund, growth in areas of care,
transforming pathways of care.
The CCG has applied the following planning assumptions:
Allocation growth
Running cost reduction
5.00%
(10.00%)
Provider efficiencies
Cost increases in tariff
Demographic growth
Non-Demographic growth – acute
Non-Demographic growth – Joint & CHC
Non-Demographic growth – Prescribing
Contingency
Surplus
Non-recurrent spend
(3.80%)
3.00%
1.09%
0.51%
0.91%
7.59%
0.50%
1.00%
1.00%
The CCG will develop plans during the course of the year on
how best to utilise the Operational and Resilience Capacity
funding, being proactive rather than reactive, so that the
population of Buckinghamshire will benefit.
We currently do not have a decision over which tariff option
our providers will opt for. It is expected that they will choose
the Enhanced Tariff Option, which is estimated will place an
unfunded £1.1m pressure on the CCG finances for 2015/16. It
will be a challenging, transformational year to enable best
value to be achieve for the patients of Buckinghamshire.
6.4 Joint working
Buckinghamshire’s BCF plan aims for a reduction in nonelective admissions of 1.6%. This was carefully considered as
it is lower than the 3.5% reduction which was in related
guidance, but analysis of the evidence alongside a suite of
work undertaken by the local system established that both
The CCG is also required to increase the available resource in
Mental Health services at the same level of the growth in
total CCG resources and to contribute to the CHC Risk Share
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DRAFT Operating Plan refresh for 2015/16
Chief Officer: Louise Patten
Clinical Chair: Dr Graham Jackson
6. Driving efficiency (cont)
rate of emergency admissions and the rate of admissions for
ambulatory care sensitive conditions were notably below the
national average. As such, delivering 3.5% reduction was not
considered a realistic target. Experience over the winter has
shown that setting a lower reduction target was more
realistic, and while it remains a challenging target to meet
there is no desire to amend it.
partnership with Bucks New University, including on their
Institute of Integrated Care. The mission of this Institute is to
promote, develop and disseminate best practice in systems of
care that seamlessly integrate health and social needs, are
patient-centred, effective, sustainable and safe.
Alongside participation in these enterprises, AVCCG is moving
forward with innovative approaches to commissioning, as
demonstrated throughout this document. Application of the
IHI Triple Aim model in the development and implementation
of locality based MCPs, for example, is a significant step away
from the accepted model of healthcare delivery. But it is
essential, as set out in FYFV, if we are to have a sustainable
NHS for the future.
6.5 CQUINs
Our 2015/16 Locally developed CQUINs are focussed on
improving outcomes for:
•
Dementia, Diabetes and End of Life care
•
Frail elderly
•
Premature birth rate and stillborn rates
•
Maternal Mental health
We have commitment to the national CQUINs in addition to
this, and expect all eligible providers to have CQUINs agreed
at 2.5% of their contract values by 31 March 2015.
6.6 Research and Innovation
In December 2011 the Department of Health published
Innovation Health and Wealth, Accelerating Adoption and
Diffusion in the NHS. Part of this document set out the
‘Delivery Agenda’, which essentially requires us to put
innovation at the heart of everything the NHS does. This
requires a cultural and behavioural shift; the building of
understanding, awareness and advocacy; making innovation a
priority; requires the re-casting of incentives and rewards;
and encourage copying, continuous development and
improvement. The 2015/16 plan embodies the Delivery
Agenda, which is intrinsically linked to the key plans over the
next year.
CCGs have a duty to support research and innovation. AVCCG
is a partner of the Oxford Academic Health Science Network,
and is represented of the networks Partnership Board. The
Network is structured around a number of Oversight Groups,
many of which had their inaugural meetings in 2014/15. The
Best Care Oversight Group, for example, provides strategic
guidance to the Best Care programme, acting as a critical
friend to the network. The Clinical Chair of AVCCG is a
member of the Best Care Oversight Group. We also work in
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Clinical Chair: Dr Graham Jackson
AVCCG QIPP Planning 2015/16
Background
Clinical Commissioning Groups, like Primary Care Trusts before them, have become familiar with the
clear need to deliver sustainability improvements through quality, innovation, productivity and
prevention (QIPP) initiatives. The operating plan outlines some significant changes which are
planned in the structure of service delivery in the future, however savings are required to be
achieved within 2015/16 in order to ensure financial balance in the year as well as an ability to invest
in additional transformative programmes.
In previous years, there has been an issue with unidentified schemes leaving a QIPP gap at the start
of the year, and potentially unrealistic expectations regarding delivery. In addition, there has been a
lack of clarity over how savings and delivery of individual schemes can be monitored and translated
into financial savings. A further issue noted by internal audit review has been a lack of
documentation around schemes. Looking back, it is arguably more the case that AVCCG has had a
lack of coordinated and consistent documentation, but this has meant that ensuring tight control
over monitoring, reporting and responding to delivery issues in the QIPP programme has been
potentially hampered. The QIPP planning process for 2015/16 has sought to rectify these
weaknesses in the processes of the past.
2015/16 QIPP planning process
The Operations and Performance team has undertaken a two phase review of activity across the
CCG in order to build the 2015/16 QIPP programme:
1. Meeting minutes and supporting documentation for all JETs through 2014/15 have been
reviewed to identify the projects and initiatives which are underway and may reasonably be
expected to have a QIPP impact in 2015/16; and
2. Considered their knowledge of the contractual and process issues prevalent within the CCG
currently, and the steps being taken to resolve them, and assessed the QIPP impact which
these may have in 2015/16.
For each item identified, a QIPP Project Outline Form has been drafted, with links to other
documentation (business cases, PIDs, supporting calculations etc). These will ultimately be finalised
and reviewed and signed off by both Operations and Performance and Finance. These forms will
build the basis of QIPP project documentation for 2015/16. Their use was outlined in a Proposed
QIPP Process document which went to the Executive Committee in November 2014.
A draft position (including documentation) was distributed to members of the Executive on 11
February 2015 for review and comment prior to the draft CCG planning submission to NHS England
on 27 February 2015.
2015/16 QIPP programme
The February 2015 finance plan update for the Executive outlined that the QIPP target for 2015/16
was 1.5% of the CCG’s allocation, or £3.4m. Of that value, a minimum of £2.5m was required for
financial balance. At the time, the risk assessed QIPP programme identified £2.0m as the ‘most
likely’ value achievable for the year, leaving £0.5m as an unfunded risk. By the time of the
submission of the draft operating plan, the following had been identified:
2015/16 QIPP
Target £
Risk Assessment
Worst Case £
Likely Case £
30,254
45,395
53,061
55,876
200,000
300,000
32,000
48,000
100,000
150,000
362,264
652,332
Best Case £
75,659
88,435
186,252
500,000
80,000
250,000
1,180,346
MSK Pain
Radiology
Advice & Guidance
PLCVs
Excess Bed Days – OUH
Follow Ups
Right Care Total
75,659
88,435
93,126
500,000
80,000
250,000
1,087,220
Anti-coagulation
Anti-coagulation – Stroke
LTC & EoL Total
1,325,736
237,888
1,563,624
530,294
95,155
625,449
795,442
142,733
938,175
1,325,736
237,888
1,563,624
Over 75s
Localities
500,000
500,000
150,000
150,000
270,000
270,000
500,000
500,000
Better Care Fund
Adult Joint Care Total
164,000
164,000
164,000
164,000
164,000
164,000
164,000
164,000
Coding challenges
Other Total
200,000
200,000
80,000
80,000
120,000
120,000
200,000
200,000
3,514,844
1,381,713
2,144,506
3,607,670
Total Identified
Appendix 1 contains a high level scheme by scheme summary, and the individual draft QIPP Project
Outline Forms are also appended which provide a greater level of detail. These forms are work in
progress, and will be finalised with relevant input from relevant individuals, and signed off by both
Operations and Performance and Finance.
Each scheme has been risk assessed in order to determine the best case, likely case and worst case
delivery expected during the year. The overall programme value is the best case, or £3.6m.
Work has been done to calculate the value which should reasonably be taken out of provider
contracts for these schemes, which is £2.9m. In the majority of cases, if the QIPP schemes do not
deliver and activity is not avoided, contracts will over-perform where QIPP values have been
deducted. This means that just negotiating the QIPP deductions into the contracts does not mean
the CCG will realise the saving. Other amounts, such as coding challenges or potentially more
challenging to predict impacts such as anti-coagulation – stroke, will be realised through the year
based on events and activity.
As mentioned above, the finance plan requires a minimum of £2.5m QIPP delivery for financial
balance in the year. If the likely case scenario is realised, that means based on current schemes, a
£0.4m unfunded risk. Work is ongoing to mitigate this down further, through identification of
further schemes. It is noted that currently no value has been included for improvements resulting
from CQUIN delivery (as schemes are still being finalised) or drugs issues such as Lucentis / Avastin,
which are likely to have a national solution which AVCCG may benefit from but ultimately has little
control over the outcome. Also, if all schemes deliver their best case value, there will be £1.1m for
further CCG investment.
QIPP Monitoring
Some of the schemes identified will have clear links to financial outcomes which are straight forward
to monitor and report on (such as coding challenges). Most, however, are more complex and for a
true reflection of QIPP delivery, need consideration of what constitutes delivery and how that
translates into value. Each scheme has one or more indicators which are being prepared with
baselines and with regular reporting channels in order to feed the QIPP Monitoring Report for
2015/16. Some of these schemes (particularly the Over 75s fund and Better Care Fund) target the
same core outcome (reduction in non-elective admissions for older people), and so it is also
important to ensure no double counting of savings. Where this is a risk, schemes will be reported
alongside each other to ensure that consolidated delivery reporting to the CCG is accurate.
The indicators which have been selected for monitoring each scheme are detailed in Appendix 1
with the scheme summaries.
There will be other areas of work which currently have no QIPP value attached to them which are
developed during the year. For example, the significant on diabetes should start to have an impact
on the cost of the disease in 2015/16. However, to build momentum it is assumed that savings
generated by that project will be reinvested within it. However, there needs to be tracking of
progress in order to identify additional savings which can be invested. Also, with items such as
consultant to consultant referrals, there is likely to be an opportunity but traditional reviews of
activity against policy have not identified a pervasive issue. It is proposed that a deep dive into the
data is undertaken to enable a focus on specific pathways, which may be a more constructive way of
approaching the issue.
Next steps
The QIPP programme as outlined in this document reflects the QIPP elements in draft plans
submitted to NHS England. They have business cases where appropriate, or sound reasoning and
clear, measurable expected outcomes where an issue is in the earlier stages of being worked
through but is still expected to realise some savings in 2015/16. The Executive has been asked to
review the schemes, provide challenge to them and ultimately agree them. The programme as
documented will be presented to the Governing Body on 12 March 2015, but will also form part of
the planning work which will require delegated authority to ensure sign off by 31 March 2015.
Appendix 1 – QIPP Summary by Scheme
MSK Pain
Target £
Worst Case £
Likely Case £
Best Case £
MSK Pain
75,659
30,254
45,395
75,659
This scheme is based on the MSK Pain Pathway PID, which is embedded in the QIPP Project Outline
Form at Appendix 2. The project expects to see a reduction in spend on analgesic medication and
outpatient follow ups in secondary care, both by 5%. This will be delivered through the roll out of a
web-based pain tool, funding for which is with BCC.
The spend in analgesic medication is monitored through medicines management reports and a
reduction will be measurable by direct comparison with prior year and the baseline period. The
baseline period in the business case was August 2012-July 2013.
Outpatient follow ups are monitored through provider activity reports and a reduction will be
measurable by direct comparison with prior year and the baseline period. The baseline period was
September 2012 – August 2013, looking at both the absolute number of outpatient follow ups, but
also the ratio of new to follow up attendances and cross checking to outpatient waiting lists.
There is a total projected saving in the business case of £75,659, spread evenly through the year.
The QIPP programme assumes a likely case of 60% delivery based on historic delivery.
Radiology
Target £
Worst Case £
Likely Case £
Best Case £
Radiology
88,435
53,061
88,435
MRI activity in Buckinghamshire benchmarks high compared to other health systems. MRI activity at
BHT is also running at historically high levels. A detailed analysis of activity and outcomes has been
requested to be completed by the CSU and Trust, in order to understand where the demand
pressure is originating from (primary care, secondary care, other) and to investigate whether the
large volume of scans is supporting positive patient outcomes. This analysis will be completed
during the year, and should lead to an understanding of a larger opportunity moving forwards. In
the meantime, there has been a surge in demand from September 2014, and the potential savings
detailed assume that levels can come back to a longer term average for BHT. The rationale for this is
that BHT is currently undertaking a significant amount of additional scans to clear a backlog as we
conclude the 2014/15 year, so the waiting list going into 2015/16 will be less than it has been. In
addition, highlighting the issue through Executive leads to primary care and through the Access &
Performance meetings at BHT, alongside driving an investigation into patient outcomes will have the
impact of encouraging referrers to consider more deeply if an MRI is required.
QIPP Project Outline Form is at Appendix 3.
MRI scans will be measured through provider activity returns, and cross checked with diagnostic
waiting lists.
Total projected saving in the business case is £88,435, spread evenly over 7 months from September
2015 to March 2016 (the period of the surge above average levels of demand). Worst case is that no
savings are delivered for MRI, but the likely case assumes 60% can be delivered.
Appendix 1 – QIPP Summary by Scheme
Advice & Guidance
Target £
93,126
Worst Case £
-
Likely Case £
55,876
Best Case £
186,252
Advice &
Guidance
Utilisation of the Advice & Guidance function in Choose & Book can reduce the number of
outpatient first attendances. This has been demonstrated in numerous health economies across the
country. The QIPP Project Outline Form at Appendix 4 includes the project business case, which at
the lower end of Choose & Book utilisation (25%) estimates £15.5k per month saving, or £186k per
year. For the likely case, 60% of half of this opportunity has been estimated, as there is a new
electronic referral system due to be launched nationally in 2015/16, prior to which it may be
counter-productive to invest in significant promotion of Choose and Book.
Choose & Book data should enable a review of the number of requests for advice and guidance by
specialty, and review of activity will identify the outcome for patients (i.e. ongoing management of
condition outside of hospital or referral to secondary care). The number of avoided outpatients will
therefore be possible to identify.
Projected savings have been spread evenly over the second half of the year, assuming the new
electronic referral system will be implemented during the first half.
PLCVs
Target £
Worst Case £
Likely Case £
Best Case £
PLCVs
500,000
200,000
300,000
500,000
AVCCG has a suite of policies relating to procedures of low clinical value. Where activity is not
conducted in accordance with policies, payment should not be made to providers (who in turn
should not be undertaking the activity). An audit in December 2014 of PLCV activity at BHT indicated
approximately £1m of recurrent activity across Buckinghamshire which should not be taking place.
Recommendations to refine a number of policies, and to refine the data challenge ‘script’ are
expected to lead to a further £0.5m of inappropriate activity being identified. Also, private providers
such as BMI are undertaking PLCV activity. Audits are in the process of being arranged at significant
independent sector providers. Appendix 5 has the QIPP Project Outline Form.
The number of PLCV procedures and their associated cost will be visible through SUS data submitted
by providers on a monthly basis.
Projected savings have been apportioned between AVCCG and Chiltern CCG, with the likely case of
activity savings being delivered estimated at 60%. These savings have been spread evenly through
the year.
Appendix 1 – QIPP Summary by Scheme
Excess Bed Days - OUH
Target £
80,000
Worst Case £
32,000
Likely Case £
48,000
Best Case £
80,000
Excess bed days –
OUH
In 2014/15 a successful project has been run to reduce excess bed days for AVCCG patients at Milton
Keynes FT. It has been identified that there is an excessive level of excess bed days at OUH.
Following a similar model to that in Milton Keynes, AVCCG proposes to pay for a discharge coordinator to work at OUH. Appendix 6 contains the QIPP Project Outline Form.
Savings will be identified by direct comparison with the prior year charges for excess bed days in the
OUH contract.
Project savings are net of the cost of the discharge co-ordinator, and are anticipated to arise evenly
throughout the year. Likely case is to realise 60% of the overall opportunity.
Follow Ups
Target £
Worst Case £
Likely Case £
Best Case £
Follow Ups
250,000
100,000
150,000
250,000
This item is currently a placeholder in the QIPP programme while BHT service lines identify their
potential to reduce follow up outpatient attendances. In 2014/15 there was an £800,000 item for
AVCCG, of which it is projected approximately 60% will be delivered by year end. A number of
initiatives are underway at BHT which will reduce outpatients, however the provider is being given
the opportunity to work up values in order to encourage it to own the plan, rather than have a plan
forced upon it. Risk assessments mean the risk to the current project value is minimal, and it is
expected that the actual value which will be attributed to the project will be higher. Phasing of the
savings in financial plans is even across the year.
Anti-coagulation
Target £
Worst Case £
Likely Case £
Best Case £
Anti-coagulation
1,325,736
530,294
795,442
13,25,736
Anti-coagulation
237,888
95,155
142,733
237,888
– Stroke
Through 2013/14 and 2014/15 a project was undertaken to re-procure community anticoagulation
services on an AQP basis. 2015/16 is expected to begin to see the savings that this project was
designed to generate. Appendix 7 contains the QIPP Project Outline Form.
Savings are expected to be derived in two ways. Anti-coagulation activity under the AQP contracts
should cost less than the traditional outpatient setting. Financial plans include the projected AQP
contract costs, as these contracts are in place going into 2015/16. The £1,325,736 target saving
shown in what the business case identified as anti-coagulation activity in the BHT contract under the
old pathway. However, an assumption was made that all activity in the clinical haematology
specialty was anti-coagulation and could be avoided, when in fact a proportion of it is not. The likely
Appendix 1 – QIPP Summary by Scheme
case 60% delivery is considered much closer to the true anti-coagulation activity value. This will be
tracked through activity returns from BHT. Savings have been assumed evenly throughout the year.
Monitoring of this project is proposed to cover four elements:
1. Anti-coagulation secondary care spend;
2. The number of patients under the AQP contracts compared to target numbers under the
business case;
3. Assess the number of patients with Atrial Fibrillation and a CHADS2VASC score monitored in
primary care; and overlay the number of Atrial Fibrillation patients with a CHADS2VASC
score ≥2 and on anti-coagulant. We aim to see an increase in AF patients with a
CHADS2VASC score, and an increase in the proportion of AF patients with CHADS2VASC ≥2
and on anti-coagulant; and
4. Analysis of the number of stroke cases in the CCG by direct comparison with prior year, using
statistical analysis to protect against natural variation due to small numbers.
The second element around stroke cases is likely to realise savings after patients have been on the
new pathway for a period, and tracking of stroke case numbers for the CCG with statistical analysis
(required due to small numbers) will identify savings being realised. These have been profiled
evenly over the second half of the year.
Over 75s
Target £
Worst Case £
Likely Case £
Best Case £
Over 75s
500,000
150,000
270,000
500,000
A significant amount of work is ongoing across the CCG in relation to over 75s aimed at reducing
non-elective admissions, A&E attendances and ambulance conveyances. A suite of documentation
supporting the projects and reporting of outcomes is in place, across each individual locality in the
CCG. Currently planned investments of £716k, with an additional approx. £300k, is earmarked in the
financial plans. An expectation of a minimum £1 for £1 reduction means that £1m savings at gross
tariff cost is expected. While the acute tariff for 2015/16 has some uncertainties around it at
present, the originally proposed tariff included marginal rate emergency tariff (MRET) of 50%, so the
actual cash saving to the CCG of £1m activity would be £0.5m. Appendix 8 contains the QIPP Project
Outline Form.
Savings have been phased evenly over the year. As mentioned, a significant amount of monitoring
documentation is in place which will feed QIPP reporting. However, QIPP reporting will need to
monitor Over 75s performance alongside the Better Care Fund, as both projects target the same
activity.
Appendix 1 – QIPP Summary by Scheme
Better Care Fund
Target £
Worst Case £
Likely Case £
Best Case £
BCF
164,000
164,000
164,000
164,000
BCF planning is linked through the QIPP Project Outline Form at Appendix 9. The expectation is that
BCF projects will contribute to a 1.6% reduction in non-elective activity, which is worth £328k at
gross tariff for AVCCG. Marginal rate (while subject to confirmation) will reduce that value by an
estimated 50%. As such £164k has been estimated as savings for the year, which has been phased
evenly across the year.
Coding challenges
Target £
Worst Case £
Likely Case £
Best Case £
Coding challenges 200,000
80,000
120,000
200,000
There are a significant number of elements of acute contracting where data analysis can identify
elements of concern, and can point to areas where technical challenges may be successfully made.
This will require work over and above the robust implementation of the standard contract challenge
set – detailed analysis and enquiry into SUS and SLAM data, and external benchmarking sources,
through the year to identify potential issues and raise them through formal contractual routes are
necessary. It is known that BHT has budgeted £0.5m for this. It is not unreasonable to consider that
this level of challenge should be achievable of a £200M+ contract across Buckinghamshire. Appendix
9 contains the QIPP Project Outline Form.
Savings have been evenly phased at the end of each quarter in the year, as they will be confirmed
through the contract quarterly reconciliation process.
Appendix 2 – 151601 MSK Pain QIPP Project Outline Form
JET
Project name
Outline of project
Right Care
MSK Pain Pathway
See attached PID.
MSK Pain Pathway
PID.docx
Expected impact
Reduction in spend on analgesic medication and reduction of outpatient follow ups in
secondary care, both by 5%. Spend in analgesic medication monitored through MMT report.
Reduction in follow ups measured through BHT SLAM reports. £11.3k of outpatient
appointments to come out of BHT contract.
Clinical Lead
Project lead
Key Resource requirements
Dr Christine Campling
Name of project manager
Outline resources required to undertake this project, including whether this utilises existing resources and
capacity; utilises existing resources which will need backfilling (and ensure backfill costs are reflected in the
investment section); or utilises resources that need to be brought into the organisation (and ensure costs are
reflected in the investment section).
Milestone 1
Target Date
Describe each milestone in turn, and insert the expected date of completion of the milestone in the relevant
‘Date’ box. Milestones should be significant points in the project’s life-cycle, rather than basic monthly progress
updates.
Milestone 2
Target Date
Milestone 3
Target Date
Milestone 4
Target Date
Milestone 5
Target Date
Milestone 6
Target Date
Milestone 7
Target Date
Savings projected
£
Analgesic spend – 5% of baseline. 12/13 Bucks wide spend was £3,179,792. Pro-rating this
according to outpatient spend between the CCGs indicates 40.5% or £1,286,834 for AVCCG.
5% is £64,342. Monitored through MMT reports.
Milestone 8
Target Date
Milestone 9
Target Date
Outpatients – business case expects 2015/16 to be £215,022 as opposed to planned £226,339
in 2014/15. Reduction of £11,317. Monitored through BHT SLAMs.
Milestone 10
Target Date
Investment Required
£nil
Minimal investment from CCGs other than input of time. Main resource requirement is for
web-based pain tool, funding for which is through BCC.
Total projected savings £75,659. Spread evenly through year.
Expected bottlenecks and roadblocks
Explain any foreseen material bottlenecks and roadblocks which may jeopardise the project’s
successful delivery. Mitigation to these will then be followed up on.
Reviewed and approved by Operations and Performance
Sign and date
Reviewed and approved by Finance
Sign and date
Appendix 3 – 151602 Radiology – MRI reduction
JET
Project name
Outline of project
Right Care
Radiology – MRI reduction
Clinical Lead
Project lead
Key Resource requirements
Dr Christine Campling
Name of project manager
MRI activity at BHT is running at historically high levels, creating pressure on capacity at the hospital and cost to
Analytics capacity required to undertake data analysis around demand and outcomes. This will
commissioners. A detailed analysis of activity and outcomes has been requested to be completed by the CSU and the need input from BHT and CSU. Once conclusions are able to be drawn, clinical and project input
Trust in order to understand where the pressure is originating; and investigate whether the large volume of scans are will be required to take the opportunity further.
supporting positive patient outcomes or not. It is expected that once the analysis is completed, a project can be
developed to address growing areas of referrals where impact on outcomes is limited. In the mean time, it is
expected that a reduction back down to the 14/15 average from a spike experienced from September to December
will be achieved as BHT nears the end of backlog clearance work and eradicates a backlog of scans in M11 and M12
14/15 funded by national RTT monies (so there will a smaller order book carried into 15/16)
Expected impact
Reduced number of MRIs to be carried out in 2015/16, with reduced cost to commissioners. Initially estimate 641
fewer scans for AVCCG based on sustaining the 14/15 average without the surge experienced around M9.
Milestone 1
Target Date 31/03/2015
Completion of data analysis considering all MRI activity demand at BHT, and what the outcomes
at a patient level have been for patients receiving MRIs, and how these have changed over time.
Milestone 2
Further develop project around conclusions derived from analysis
Target Date 30/04/2015
Milestone 3
Target Date
Milestone 4
Target Date
Milestone 5
Investment Required
£nil
Initial investment is time and resources in CSU and BHT informatics teams. Once analysis is completed, and conclusions
are reached, an appropriate project to tackle areas of pressure can be developed and further savings be assessed.
Milestone 6
Target Date
Milestone 7
Target Date
Milestone 8
Savings projected
£88,436
Initial savings as calculated on attached spreadsheet. Estimate 641 scans fewer than 14/15 outturn for AVCCG in 15/16
just by reflecting the longer term average, which at the price of a basic MRI is £88,436
Milestone 9
Target Date
Radiology - MRI
reduction calculation.x
Expected bottlenecks and roadblocks
Completing the data analysis is expected to cause a delay to being able to develop a project and take savings further
than the initial plan. CSU Informatics team has been asked to timetable this work around the wider planning round
requirements placed upon them.
Milestone 10
Reviewed and approved by Operations and Performance
Sign and date
Reviewed and approved by Finance
Sign and date
Target Date
Target Date
Target Date
Appendix 4 – 151603 Advice & Guidance
JET
Project name
Outline of project
Right Care
Choose & Book Advice & Guidance
Clinical Lead
Project lead
Key Resource requirements
Christine Campling
Name of project manager
Utilisation of the Advice & Guidance functionality within Choose & Book can reduce the
Project lead to engage with provider and GPs, and to monitor progress.
number of outpatient first attendances. Projects in a number of places across the country
have seen significant savings generated as cases where GPs need some additional advice and
support, but a patient does not ultimately require referral to secondary care, can continue to
safely be managed in primary care.
Expected impact
See attached business case. Pilot running to January 2015. Following that, expected to be
expanded at BHT, potentially with an amount to compensate BHT for its clinician’s time in
dealing with requests for Advice & Guidance. Assuming pilot works, and taking lower
estimate of £15.5k/month potential savings for AVCCG, this would be £186k. Also consider
current low utilisation of C&B, and national target to increase this to 80% may increase
opportunity. However, a replacement system for C&B is due to be launched nationally in
2015/16, which may delay traction being gained in this project, so the overall opportunity
has been halved to £93k.
Milestone 1
Target Date
Describe each milestone in turn, and insert the expected date of completion of the milestone in the relevant
‘Date’ box. Milestones should be significant points in the project’s life-cycle, rather than basic monthly progress
updates.
Milestone 2
Target Date
Milestone 3
Target Date
Milestone 4
Target Date
Milestone 5
Target Date
Milestone 6
Target Date
Milestone 7
Target Date
Milestone 8
Target Date
Milestone 9
Target Date
Milestone 10
Target Date
Advice & Guidance
Business Case.docx
Investment Required
£25,812
Investment is the potential cost of reimbursing BHT for Clinical input into Advice & Guidance
requests at £23 per request. This is based on identified amounts paid to providers elsewhere
where the scheme has been successful.
Savings projected
£212,064
Based on opening advice and guidance across all specialties at 25% C&B utilisation. There is a
national target to increase C&B utilisation to 80% through 2015/16, supported by elements of
the GMS contract, so this is considered to be a conservative estimate.
Expected bottlenecks and roadblocks
Current utilisation of C&B in AVCCG is around 20%. National target to increase to 80% may
provide some impetus in this area, however a new C&B system is due to be launched nationally
in spring 2015. Until this is in place and operational, a significant push on C&B may not
generate long term increases in utilisation.
Reviewed and approved by Operations and Performance
Sign and date
Reviewed and approved by Finance
Sign and date
Appendix 5 – 151604 PLCVs
JET
Project name
Outline of project
Right Care
Procedures of Low Clinical Value (PLCVs)
The CCG’s in Buckinghamshire have a suite of policies relating to Procedures of Low Clinical Value (PLCVs). Some
are ‘Threshold Dependent Procedures’ where providers are expected to document how patients and their
conditions meet specified criteria in order to qualify for funding; and some are ‘Individual Funding Requests’ which
need referral to the IFR panel for approval before treatment commences. Where activity is not conducted in
accordance with policies, payment should not be made to providers. An audit in December 2014 of PLCV activity at
BHT has indicated approximately £1m of recurrent activity which should not be undertaken or paid for. Further
recommendations to refine the wording of some policies and also to refine the SUS data challenge script are
expected to lead to a further £0.5m savings. Finally, it is known that a notable amount of PLCV activity is
undertaken at BMI, which is also subject to the same policies and should be enforced.
Clinical Lead
Project lead
Key Resource requirements
Dr Christine Campling
Paul Hutt
A workshop is planned with BHT on 9 March to discuss the audit findings and how the
commissioner and provider can work together to ensure maximum compliance with the
policies, as this will be of benefit to both parties. An audit of BMI is being arranged as of early
Feb 2015, and is hoped to be completed by 31 March 2015. Once completed, the resource
requirements do not stretch beyond the standard IFR management and contract management
processes which already exist.
Expected impact
Milestone 1
Target Date 09 March 2015
By reducing the volume of PLCV activity undertaken at BHT, capacity will be released which will (a) reduce the need Workshop to be held between commissioners and BHT
to outsource activity to IS providers and (b) help to ensure the sustainability of the Trust’s 18 week performance. It
Milestone 2
Target Date 31 March 2015
is not expected that a significant reduction in activity overall will arise at BHT, as the capacity released will be filled
Audit of PLCV activity at BMI to be completed
with other patients who would otherwise be on waiting lists.
Milestone 3
Target Date 31 March 2015
By reducing the volume of PLCV activity at BMI, it is expected that the contract value will be able to be reduced by
£1-£1.3m for Bucks – approx. £0.5m for AVCCG. This will be through a combination of PLCV work at BMI not being
carried out any longer, and also of a reduction in the patients transferred from BHT to BMII (much of which was
through a variation to the CCG contract in 14/15).
BMI 2015/16 contract to be negotiated with an AVCCG activity plan of £0.5m less than
2014/15 (£1-£1.3m for Bucks as a whole).
Milestone 4
Target Date
Milestone 5
Investment Required
£Audit work at BHT was conducted in Dec 2014. BMI is expected to be audited before 31/3 2015. As such, costs in the
2015/16 year will be limited to utilisation of existing resources and capacity to manage PLCVs through the contract
Milestone 6
and IFR processes already in place.
Target Date
Milestone 7
Target Date
Milestone 8
Savings projected
£500,000
Savings are expected to materialise through negotiation of a lower contract value with BMI, which will be monitored
on a monthly basis through SLAM returns. The normal challenge processes around PLCV activity at all providers
Milestone 9
should also continue as in previous years, and may derive further savings as a more refined challenge script should be
operating from 1 April 2015.
Milestone 10
Target Date
Target Date
Target Date
Target Date
Expected bottlenecks and roadblocks
Reviewed and approved by Operations and Performance
Negotiation of the contract with a significantly lower indicative activity plan may be challenging. However, the plan is Sign and date
only indicative, and under a PBR contract if the activity arises then it should be paid for (unless it does not meet the
Reviewed and approved by Finance
requirements of PLCV policies).
Sign and date
Appendix 6 – 151605 Excess bed days - OUH
JET
Project name
Outline of project
Right Care
151605- Excess Bed Days – OUH
Clinical Lead
Project lead
Key Resource requirements
Dr Christine Campling
Name of project manager
In 14/15 a successful project has been run to reduce excess bed days for AVCCG patients at
Milton Keynes FT. It has been identified that there is an excessive level of excess bed days at
OUH (approx. 3% of contract value). Following a similar model to that in Milton Keynes,
AVCCG proposes to pay for a discharge co-ordinator to work at OUH.
One band 6 nurse to act as the discharge coordinator for AVCCG.
Expected impact
If the success at Milton Keynes can be replicated at OUH, a reduction of 45-50% in excess bed
days can be expected. This equates to approximately £130k. This should see patients able to
leave hospital much closer to the point at which they become clinically fit for discharge,
improving patient experience and freeing up beds at OUH.
Milestone 1
Target Date 1 April 2015
Band 6 Nurse in post to act as discharge coordinator for AVCCG at OUH.
OUH Discharge
Co-ordinator Service S
Investment Required
£50,000
AVCCG will fund one band 6 nurse at a cost of approximately £50k to act as a discharge
coordinator for AVCCG patients.
Milestone 2
Target Date 31 March 2015
Negotiation of contract value, including maximum £130k planned value for excess bed days.
Milestone 3
Target Date
Milestone 4
Target Date
Milestone 5
Target Date
Milestone 6
Target Date
Milestone 7
Target Date
Milestone 8
Savings projected
£130,000
A reduction of 45-50% in Excess Bed Days at OUH for AVCCG. This equates to approximately half
of the forecast £258,950 expenditure on excess bed days at OUH in 2014/15. The 2014/15
Milestone 9
contract included a planned £307k excess bed day costs. The 2015/16 contract should include a
maximum planned £130k excess bed days.
Milestone 10
Expected bottlenecks and roadblocks
Recruitment of a nurse by 1 April 2015; negotiation of the reduced contract value.
Target Date
Target Date
Target Date
Reviewed and approved by Operations and Performance
Sign and date
Reviewed and approved by Finance
Sign and date
Appendix 7 – 151606 Anti-coagulation
JET
Project name
Outline of project
LTC & Meds Management
Anticoagulation AQP
Clinical Lead
Project lead
Key Resource requirements
Stuart Logan
Through 2013/14 and 2014/15 a project was worked through to re-procure community
The project is close to completion, with new AQP contracts in place having gone through a procurement
anticoagulation services on an AQP basis. 2015/16 is expected to begin to see the savings that process. Ongoing resource requirements around monitoring the implementation phase are dealt with.
this project was designed to generate
Monitoring through the year will need to include stroke cases to identify any associated savings.
Stage 2 Full Business
Case - Anticoagulation
Expected impact
Milestone 1
Target Date 31 March 2015
The embedded spreadsheet outlines the estimated impact on the activity and costs of
Conclude BHT negotiations with £1,326k removed from contract value. Value of Stroke savings will be
secondary care at BHT for AVCCG and CCCG. For AVCCG BHT needs £1,326k removed from the monitored through activity as it happens through the year.
main NHS contract, across £997k OPFUs, £16.7k pathology, £208k non face to face contacts,
Milestone 2
Target Date
and £104k NOACs clinics. In addition, it is expected that there will be 63 fewer strokes, saving
a further £238k. This will only be delivered if through the AQP contracts the targeted level of
Milestone 3
Target Date
patients receive AC therapy, with the outcomes as detailed in the business case.
Milestone 4
Target Date
Milestone 5
Investment Required
This is the expected cost through the AQP contracts of the AVCCG population which should
access anticoagulation services, at £225 per patient per year. The contracts have been let, so this Milestone 6
cost is going to arise. This investment totals £730k is reflected in financial plans as an increase in
LES contracts, so is reflected outside of QIPP as contracts are in place and costs expected to be
incurred to that level in 15/16. The savings element in the QIPP plan is the amount which should Milestone 7
come out of the acute contract for the year.
Target Date
Milestone 8
Target Date
Milestone 9
Target Date
Milestone 10
Target Date
FBC_Anticoag_optio
ns_costings_v7 June
Savings projected
£1,563,624
Total savings estimated as a combination of reduced outpatient follow ups, reduced number of
anticoag monitoring tests, non face to face contacts, NOAC clinics, and avoided strokes. See
embedded spreadsheet in expected impact section.
Target Date
Target Date
Expected bottlenecks and roadblocks
Reviewed and approved by Operations and Performance
New contracts are in place and operational. The key issue now is identifying all anti-coag activity Sign and date
under t14/15 BHT contract, and removing from the 15/16 contract value and activity plan –
Reviewed and approved by Finance
particularly any non-activity based elements.
Sign and date
Appendix 8 – 151608 Over 75s
JET
Project name
Outline of project
N/A – Localities led
Over 75s Fund
Clinical Lead
Project lead
Key Resource requirements
A significant amount of work is ongoing across the three localities in AVCCG in relation to over
75s, aimed at reducing non-elective admissions, A&E attendances and ambulance
conveyances. A suite of documentation supporting these projects and reporting of outcomes
exists, with modelling at ..\..\..\..\..\Localities\Investment Proposals\Over 75s
Fund\Implementation\Reporting\Over 75s Report vs2.xlsx
Over 75s project documentation and reporting contains this information.
Expected impact
Currently planned investments of £715,898, with approx. additional £300,000 investment
earmarked in the financial plans. Expect minimum of £1 for £1 reduction in non-elective and
urgent activity, so QIPP plan reflects £1m projected savings. These will be realised through
reduced non-elective admissions for over 75s, as well as reduced A&E attendances and
ambulance conveyances. These are all being monitored and reported on for Over 75’s
monitoring purposes, and the QIPP reporting will reflect project reporting.
Milestone 1
Target Date
All milestones and project monitoring is through Over 75s project reporting.
Milestone 2
Target Date
Milestone 3
Target Date
Milestone 4
Target Date
Milestone 5
Target Date
Milestone 6
Target Date
Milestone 7
Target Date
Milestone 8
Savings projected
£500,000
Minimum expectation is £1 for £1 return on investment, however MRET impact means that only
50% reduction will be felt in the contract (marginal rate for emergency activity above a threshold Milestone 9
level is 50% under proposed 15/16 contract).
Target Date
Investment Required
£1,000,000
Approx £716k planned, with an additional approx. £300k earmarked in financial plans. The
investment figures are reflected independently in financial plans as already committed, and
therefore the QIPP plan only reflects the projected savings.
Milestone 10
Expected bottlenecks and roadblocks
Target Date
Target Date
Reviewed and approved by Operations and Performance
Sign and date
Reviewed and approved by Finance
Sign and date
Appendix 9 – Coding challenges
JET
Project name
Outline of project
Right Care / Urgent Care
Coding challenges
Clinical Lead
Project lead
Key Resource requirements
Dr Christine Campling / Dr Kevin Suddes
Name of project manager
There are a significant number of elements of acute contracting where data analysis can
identify elements of concern, and can point to areas where technical challenges may be
successfully made. This will require work over and above the robust implementation of the
standard contract challenge set – detailed analysis and enquiry into SUS and SLAM data, and
external benchmarking sources, through the year to identify potential issues and raise them
through formal contractual routes are necessary. It is known that BHT has budgeted £0.5m for
this.
Expected impact
The impact will depend on the nature of the challenge. One to follow up is that BHT
benchmarks comparatively high for the proportion of admissions through A&E where in A&E
there has been either no investigation with no significant treatment, or just category 1
investigation with category 1-2 treatment. These admissions potentially arise when providers
attempt to meet the 4 hour A&E standard, and some may be inappropriate. Challenging the
clinical validity of these is appropriate. Other examples will exist.
Milestone 1
Target Date
Describe each milestone in turn, and insert the expected date of completion of the milestone in the relevant
‘Date’ box. Milestones should be significant points in the project’s life-cycle, rather than basic monthly progress
updates.
Milestone 2
Target Date
Milestone 3
Target Date
Milestone 4
Target Date
Milestone 5
Investment Required
£
The CSU informatics and contracting teams will need to dedicate time and resources to reviewing
and probing data on a routine basis every month in order to identify opportunities to pursue.
Milestone 6
This should be a part of the core service provided by the CSU.
Target Date
Milestone 7
Target Date
Milestone 8
Target Date
Milestone 9
Target Date
Milestone 10
Target Date
Admissions through
A&E.pptx
Savings projected
£200,000
BHT is known to budget approximately £0.5m for coding challenges per year. AVCCG’s share of
this is approximately £200,000.
Expected bottlenecks and roadblocks
Resourcing and capacity at the CSU is likely to be a sticking point in terms of ability to scrutinise
and probe data adequately to identify potential challenges.
Target Date
Reviewed and approved by Operations and Performance
Sign and date
Reviewed and approved by Finance
Sign and date
Agenda Item: X
GOVERNING BODY MEETING
MARCH 2015
FINANCIAL PLANNING UPDATE
Purpose of Paper
The attached report provides an update from the Chief Finance Officer on the
Financial Planning 2015/16.
Executive Summary
The report provides the Governing Body with an update of the Financial Plan
2015/16 which has been discussed at Executive meetings in previous months.
As at the date of this paper the Financial plan is subject to change in relation to:
•
•
Ongoing contract negotiations and the impact of the late planning changes
which covers the provider’s decision as to which tariff they wish to use.
The CCG has not yet received any feedback from the NHSE on the
February submission which may change the plan.
Any decisions that maybe required can be made by the Accountable Officer and
Chief Finance Officer and any changes will be reported to the Governing body at
future meetings.
The report highlights:
•
The business rules being applied to cover Surplus, Headroom and Contingency
and identifying the Winter Resilience and Better Care Fund pass through.
•
The outturn position, investments and cost pressures that the CCG has
established through the planning process.
•
Deflation and growth applied to contract envelopes.
•
Qipp and risks
Aylesbury Vale CCG: Finance Report – MARCH 2015 GOVERNING BODY
1|Pag e
Within the plan there are certain areas that have investments that are subject to
business case approval e.g. detailed use of drawdown, support to transformational
programmes and Parity of Esteem.
Actions Required
• The Governing Body is requested to note the progress on the
Financial Plan 2015/16.
• Approve the 2015/16 Budgets.
Objectives supported by this Paper (Please Tick)
Improve people's health and reduce inequalities
Enhance quality, safety and experience of patient services
Ensure local people have greater influence and management of own care
Deliver financial sustainability with headroom to invest
Perform well as a CCG
X
X
ROBERT MAJILTON – CHIEF FINANCE OFFICER
Appendices
A Financial Plan 2015/16 Report,
Aylesbury Vale CCG: Finance Report – MARCH 2015 GOVERNING BODY
2|Pag e
AYLESBURY VALE CCG
UPDATE ON 2015/16 FINANCIAL PLANNING
1.0 Introduction
This paper provides an update of the development of the 2015/16 financial plan and the
assumptions that were presented to the Executive meetings in January and February 2015.
The plan continues to be reviewed both in light of feedback from the area team, internal discussions
and the triangulation with the continuing contract negotiations. Contract negotiations have been
further confused by the consultation on tariff which has resulted in providers making a choice on
accepting one of two options by 4th March 2015. The two options being:
Default Tariff Rollover (DTR), 2014/15 prices and rules will remain in force, with no adjustment for
efficiency requirements or cost uplifts, until such time as Monitor publish a new tariff. However,
providers opting for the DTR will not be eligible for CQUIN for the entirety of 2015/16 in recognition
of the lower efficiency implied in the DTR and the statutory need for the commissioning sector to
live within the funding Parliament has allocated.
Enhanced Tariff Option (ETO), this would in effect be a ‘local variation’ to the 2014/15 National Tariff
Payment System, agreed by the provider and commissioner. Opting for the ETO will entail adoption
of the 2015/16 prices and rules published on 26 November 2014, with amendments made to the
gross tariff deflator, the marginal rate for emergency admissions and the specialised services risk
share arrangements. Providers opting for the ETO will continue to have access to CQUIN up to 2.5%.
Whilst contract negotiations are on-going the plan may change further within the general planning
assumptions agreed by the Executive at the November and January meetings.
The build-up of the Financial Plan is shown in Appendix A.
2.0 Compliance with Business Rules
The plan continues to adhere to the overall planning assumptions advised by NHS England and
agreed at the November and January executive as shown in the following table:
Table 1 – Compliance with business rules
Area
Surplus of at least 1%
Surplus drawdown (included in
headroom shown below)
Headroom of 1% to be used nonrecurrently
Contingency of 0.5%
1|Page
Current
Financial
Value
£’m
2.2
0.4
2.5
1.1
Comment
Plan at 1%
Business case for drawdown of
2014/15 surplus
£0.4m for 5YFV
£1.3m for CHC legacy (1)
£0.8m balance
Held as a contingency
Investment in Mental Health
1.0
The investment must equate to the
same increase in CCG funding
The CCG is currently planning to utilise headroom to cover the CHC legacy risk contribution which is
doubling in 2015/16. The area team would prefer we planned on the basis of legacy risk contribution
coming from general allocation and 1% headroom on top however this would add a further £1.3m of
pressure/QIPP. It is recommended we continue to plan on the basis of utilising headroom for the risk
contribution, recognising this significantly limits the amount of headroom available to invest or for
risk mitigation.
3.0 Outturn
Adjustments for 2014/15 outturn positions represent investment from growth. In 2015/16 the
requirement for non-recurrent headroom has reduced from 2.5% (£5.1m) to 1% (£2.1m) releasing
£3m into the recurrent position. Of this £3m, £1m has been used to make the over 75 fund recurrent
and funded at the full £1m and £2m has remained in the acute baseline as a pre-commitment (£2m
has been utilised to support the acute baseline since 2013/14).
The forecast position in the Month 10 finance report is £0.6m underspent before carry-forward
surplus but £4.2m has been included in the outturn position in the plan. A summary reconciliation
between these two positions is shown below.
Table 3 – Build up of Outturn position
Area
Month 10
forecast
£’m
Acute & Comm.
Joint & CHC
Prescribing
Running Costs
Reserves
Non-Rec Programmes
Sub-total
(3,291)
(258)
310
548
2,176
1,100
585
Non-recurrent
(gains) / Costs in
2014/15
£’m
(1,362) 1
155 2
(67) 4
(2,176)
(1,100)
(4,350)
Other
movements
£’m
Funded in
2015/16 Plan
£’m
(3)5
96 3
(481) 5
(4,653)
(261)
561
-
(388)
(4,153)
4.0 Investments & Cost Pressures
£6.9m has been identified to cover specific pressures and investments and in some cases are subject
to further business cases / development and therefore there will be further executive oversight,
however they have been identified and recognised in the plan.
1
Mainly Fines, MRET treated as non-recurrent in 2015/16 planning and Non-recurrent benefits used to cover
pressures and QIPP – Total £1.7m less £0.3m of assumed non-recurrent costs/activity
2
Quality Incentive Scheme – Month 10 position is net, gross outturn is in plan.
3
Movement in forecast outturn between month 9 and 10
4
Non-recurrent underspends
5
Reduction in Running Cost allocation in 2015/16
2|Page
There are more specified reserves or funding areas than normal principally due to delay in tariff, as
noted above and therefore financial aspects of acute plus areas subject to further business cases and
decisions. Any slippage on these will be reported through the normal process to the Executive.
A summary is shown below:
Table 4 – Summary of Cost pressures & investments
Area
Amount identified
£’m
Acute & Community
Impact of 2014/15 Arbitration
1.2
with BHT
Activity relating to additional
0.5
emergency beds
Comment
Items to be charged from 2015/16 –
part of contract negotiation with BHT
Recognises pick up of additional
bed base at BHT – part of contract
negotiation
MRET – Tariff change to 50%
0.5
Cost pressure from recurrent
reduction in relation to
specialist commissioning
MRET re-investment
0.5
18-week reserve
0.6
QIPP Contingency
0.9
Joint & CHC
Parity of esteem
1.0
Other
Over 75 Fund
Investment above growth to
match POE guarantee – actual
use subject to further business
cases and delivery of Mental
health improvement & targets
1.0
TOTAL
6.9
Make Over 75 funding
recurrent at full value – c £0.6m
current full-year spend. Overall
fund subject to evaluation and
business cases for any
additional spend
0.6
Subject to outcome of tariff
negotiation
Cost pressure relating to
2014/15 reduction in allocation
Reserve for re-investment of
MRET into admissions
avoidance – subject to SRG &
Urgent Care JET approval
Held for elective activity
position – to be agreed via
contracting process
Mitigate between QIPP stretch
and required delivery
There are some areas with no specific investment e.g. continued progress on 7 day working and the
total areas developed as part of 2014/15 resilience planning and are linked to the ETO proposal
decision. Therefore it continues to be important that all investment areas (including outturn and
growth) are triangulated to maximise delivery of the CCGs plans whilst still delivering financial
performance.
3|Page
The above list will need to reviewed in light of the providers choice on the tariff option which
represents over £1m additional acute costs to the CCG.
5.0 Deflation
Deflation has been included in relevant contract envelopes based on the tariff consultation before
Christmas and amounts to £1.1m in total (note that in Joint & CHC there is a net inflation due to a
majority of non-NHS contracts and placements which are normally subject to inflationary pressure).
Whilst the tariff for 2015/16 is not agreed this represents a risks to the overall financial plan and will
not be included in current contract offers. There is no specific mitigation in the plan for deflation
being less than £1.1m.
6.0 Growth
Growth of £4.8m has been included in the plan. This is broadly based on 1.1% demographic growth
across programme budgets plus:
• 0.9% for Acute & Community
• 0.3% for CHC – additional growth has been built into investments through the POE
• 4.7% for Prescribing
In overall terms the table below shows the increase, by programme area compared to the recurrent
2014/15 baseline (ie excluding outturn position) and against outturn.
Table 5 – Summary of programme growth
Acute & Community
Joint & CHC
Prescribing
Uplift
on
Outturn
Uplift
(preon
Uplift on
baseline
QIPP)
Outturn
%
%
%
6.6%
4.8%
3.0%
5.4%
4.7%
4.7%
2.6%
5.0%
5.0%
All areas are c 5% up on outturn with Acute reduced due to the application of QIPP. Parity of Esteem
means Mental Health spend need to grow by 5.1% against 2014/15 outturn but taking into account
non-mental health spend within Joint & CHC the overall growth level is 4.7% on outturn. Further
work is on-going to allocate the growth related to Parity of Esteem against the need to delivery
mental health targets and specific areas of investment and will be subject to further business cases
to the Executive.
7.0 QIPP
The QIPP target is 1.5% of allocation. Of the £3.4m the minimum required delivery if £2.5m (73%)
and the currently most likely is £2m so there exists a QIPP gap of between £1.4m and £0.9m. The
4|Page
Area Team were looking for a QIPP ambition of 3% (£6m) however the generally benchmarking
information does not identify significant opportunities. The work through the P&L process identified
potentially £12m of opportunities if the CCG was in the best decile across Prescribing and All acute
spend. Therefore the QIPP target for 2015/16 is c 30% of the total and builds on a forecast delivery
of £2.5m in 2014/15. Therefore it is extremely risky to plan for significantly higher QIPP schemes
that are not identified at this stage.
Our overall strategy over the last couple of years has to reduce the planned QIPP to improve
deliverability and also maintain contract integrity as most QIPP translates into reduction in provider
contracts.
The QIPP schemes have been identified through the planning process and have included assessment
of Best case, most likely and worst case. QIPP remains a triangulation of identified schemes with the
need to balance financial risks and growth. At the January executive the QIPP target was agreed at
£2.5m with a stretch target of £3.5m to cover risk. The best case of the current version of QIPP is
£3.4m and contract envelopes have been based on the delivery of the best case scenario. To deliver
the required £2.5m requires an overall delivery of 73%, a summary is shown below:
Table 6 – QIPP Summary
Area
Target
£’m
1.2
0.5
1.3
0.2
0.2
3.4
In contract envelopes
£’m
1.1
0.3
1.3
0.2
2.9
Outside envelopes
£’m
0.1
0.2
0.2
0.4
QIPP Target
Required delivery
3.4
2.5
73%
Current most likely
2.0
59%
£0.9m has been budgeted
as QIPP mitigation
£0.5m not mitigated and
remains an unfunded risk
Right Care
Urgent Care
Long Term Conditions
Contract Challenges
Better Care Fund
TOTAL
10.0 Risks & Contracts
Some risks have been highlighted in the report and further work on mitigation will continue through
contract negotiation as some of the unspecified areas are firmed up however current significant risks
to the plan include:
•
•
•
QIPP - £0.4m of identified risk rising to £1.2m based on worst case
Contracts – potentially between £1.5m - £2.5m
Deflation – between £0.5m - £1.5m
Risks in the range £2.5m - £5m
Against this there is a formal contingency of £1.1m plus any uncommitted headroom (£0.8m) plus
any in-year mitigation or slippage.
5|Page
11.0 Budgets
The financial plan translates into budgets which the CCG then performance manages itself during the
year through the Finance report to executive and Governing Body. The budgets are a result of the
planning assumptions, investments and cost pressures shown in annex A and are shown in summary
level in Appendix B and detailed level in Appendix C.
The Governing Body is requested to approve the budgets as shown in appendix B and C with the
caveat that they will be subject to change due to the continuing contract negotiations, decisions
relating to tariff options and feedback from the NHSE on the February Plan submission.
6|Page
Appendix A – Build-up of financial plan
Acute & Community
Joint & CHC
Prescribing
Other
Reserves
Surplus
Headroom
Contingency
Total Programme
Running Costs
CCG Total
2014/15
Budget
M8
£'000
139,704
37,717
24,870
1,312
46
2,093
0
1,100
206,842
2014/15
Recurring
Other NonBaseline
Recurrent
£'000
£'000
-2,613
137,091
37,717
24,870
-512
800
101
147
-1,992
-101
0
0
1,100
-1,992
-3,125
201,725
2014/15
C/fwd
£'000
4,906
211,748
Funded
Growth
£'000
2014/15
C/Fwd
£'000
Running
Cost
Move
Reserves Reduction
£'000
£'000
-3,479
-778
-800
5,057
10,736
2,577
10,736
2,577
0
10,736
2,577
0
0
4,906
-1,992
-3,125
2015/16
Revenue
Allocation
£'000
133,612
36,939
24,870
0
3,012
18,952
2,577
0
1,100
3,012
218,050
Better
Care
Fund
£'000
4,425
-481
206,631
-481
3,012
222,475
2015/16
Better
2015/16
Revenue
Care
Revenue
Surplus
Contingency
Allocation drawdown Headroom 1%
Fund Allocation
0.5%
Resilience
£'000
£'000
£'000
£'000
£'000
£'000
£'000
Acute & Community
133,612
133,612
Joint & CHC
36,939
36,939
Prescribing
24,870
24,870
Other
0
0
Reserves
18,952
-2,125
-13
-1,099
-3,012
12,703
Resilience
1,099
1,099
Surplus
2,577
-356
2,221
Headroom
0
356
2,125
2,481
Contingency
1,100
13
1,113
Better Care Fund
3,012
3,012
Total Programme
218,050
0
0
0
0
0
218,050
Sub Total
£'000
Acute & Community
133,612
Joint & CHC
36,939
Prescribing
24,870
Other
0
Reserves
12,703
Resilience
1,099
Surplus
2,221
Headroom
2,481
Contingency
1,113
Better Care Fund
3,012
Total Programme
218,050
Cost Pressures
Outturn / Investments
£'000
£'000
4,653
4,958
261
955
-561
1,000
-4,353
-6,913
0
0
Net
Deflation
£'000
-1,007
247
-361
Growth
£'000
2,663
529
1,575
1,121
-4,767
0
0
2015/16
Revenue
Allocation
QIPP
£'000
£'000
-2,463
142,416
38,931
25,523
1,000
2,463
254
1,099
2,221
2,481
1,113
3,012
0
218,050
Running Costs
4,425
222,475
7|Page
Appendix B – Summary budgets for 2015/16
Budget Area
Planned & Unscheduled Care
Prescribing
Joint & Continuing Care CC
Joint & Continuing Care MH
Other services
Depreciation
Reserves
Contingency
Running Costs
Surplus
Total Resource Limit
M10 2014/15 Budget
140,016
24,870
16,726
20,991
1,312
0
0
1,144
4,906
2,093
212,058
2015/16 Budget
143,515
25,524
16,673
22,258
1,000
108
5,638
1,113
4,425
2,221
222,475
Appendix C – Detailed budgets for 2015/16
Budget Area
Planned & Unscheduled Care
ACUTE COMMISSIONING
AMBULANCE SERVICES
COMMUNITY SERVICES
EXCEPTIONS & PRIOR APPROVALS
INTERMEDIATE CARE
LOCAL ENHANCED SERVICES
NCAS/OATS
NHS 111
OUT OF HOURS
PATIENT TRANSPORT
PLANNED CARE
URGENT CARE
Winter Resilience
Planned & Unscheduled Care Total
Prescribing
PRESCRIBING
Prescribing Total
Joint and Continuing Care
Joint & Continuing Care CC
CHC ADULT FULLY FUNDED
CHC ADULT JOINT FUNDED
FUNDED NURSING CARE
LEARNING DIFFICULTIES
Joint & Continuing Care CC Total
Joint & Continuing Care MH
CARERS
CHC CHILDREN
CHILD AND ADOLESCENT MENTAL HEALTH
COMMISSIONING - NON ACUTE
CONTINUING HEALTHCARE ASSESSMENT & SUPPORT
END OF LIFE
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES
MENTAL HEALTH CONTRACTS
MENTAL HEALTH SERVICES - ADVOCACY
MENTAL HEALTH SERVICES - NOT CONTRACTED ACTIVITY
MENTAL HEALTH SERVICES - OTHER
REABLEMENT
Joint & Continuing Care MH Total
Other services
NON RECURRENT PROGRAMMES
Other services Total
Contingency
Depreciation
Reserves
BETTER CARE FUND
COMMISSIONING RESERVE
HEADROOM
Reserves Total
Running Costs
Running Costs
Running Costs Total
Surplus
Surplus
Surplus Total
Grand Total
8|Page
M10 2014/15 Budget
2015/16 Budget
6,222
6,150
17,797
364
1,527
880
2,318
641
1,717
1,206
61,327
38,482
1,385
140,016
4,569
6,458
17,816
352
1,452
1,621
1,952
784
1,710
1,214
63,453
41,036
1,099
143,515
24,870
24,870
25,524
25,524
10,009
898
3,988
1,831
16,726
9,989
922
3,919
1,842
16,673
309
541
1,593
625
626
521
53
14,360
19
84
1,788
472
20,991
322
562
1,644
638
650
537
53
14,388
20
145
2,921
378
22,258
1,312
1,312
1,000
1,000
1,144
0
1,113
108
0
0
0
0
3,012
145
2,481
5,638
4,906
4,906
4,425
4,425
2,093
2,093
212,058
2,221
2,221
222,475
Agenda Item: X
GOVERNING BODY MEETING
MARCH 2015
FINANCE REPORT
Purpose of Paper
The attached report provides an update from the Chief Finance Officer on the
financial position to the end of January 2015.
Executive Summary
To the end of January the CCG is reporting an in-year surplus of £84k against a
budgeted spend of £175,945k (0.05%). This is in line with plan. The CCG has
increased the forecast surplus to £2,577k as directed by NHSE in light of the
return of £484k due to the underspend on the CHC Legacy Risk Pool.
The report highlights:
•
The year-to-date (10 months) surplus is £84k with an in year forecast of £101k.
•
Actual spend within Planned and Unscheduled Care is based on the available
month 9 Contract Reports and estimated for month 10. The adverse variance of
£2,486k is mainly on OUH and BHT as a result of movements in reported spend
from Trusts and include a release of £2,500k from Reserves.
•
The favourable variance of £237k includes the CHC Risk share refund of £484k
which when removed shows an adverse variance of £247k (£249k the previous
month) in Joint and Continuing Care which mainly reflects current monthly activity
within continuing care, which is now showing an increase in spend as anticipated.
•
£84k has been released from the commissioning reserves in month to cover acute
overspend on programme.
•
Other services show a favourable variance of £1,100k due to slippages in projects
and the release of legacy accruals.
•
Running costs favorable variance of £352k is a result of staff vacancies and
slippage on non-pay.
At this stage the forecast position is on plan.
Main risks are highlighted in the report.
Aylesbury Vale CCG: Finance Report – MARCH
1|Pag e
Actions Required
Note the financial position and small planned surplus for 2014/15
Review risks to the financial position
Objectives supported by this Paper (Please Tick)
Improve people's health and reduce inequalities
Enhance quality, safety and experience of patient services
Ensure local people have greater influence and management of own care
Deliver financial sustainability with headroom to invest
Perform well as a CCG
X
X
ROBERT MAJILTON – CHIEF FINANCE OFFICER
Appendices
A Finance Report,
Aylesbury Vale CCG: Finance Report – MARCH
2|Pag e
Aylesbury Vale
Clinical Commissioning Group
FINANCIAL PERFORMANCE TO January 2015
MONTH 10 2014/ 15
Section A1 - Finance Dashboard:
Indicator
Target
Financial Position in month
Planned monthly surplus
Financial Position year to date
Financial position forecast outturn
Actual Actual %
Rating this
month
% DFT Explanation of target measure
323
√
0.00% Achievement of Plan target
Planned YTD Surplus
2,229
√
0.00% Achievement of Plan target
Planned Annual Surplus
2,577
√
0.00% Achievement of Plan target
QIPP year to date
(355)
X
(45.00%) Achievement of Plan target
QIPP forecast outturn
(520)
X
0.00% Achievement of Plan target
Creditors - Better Payment Practice Code
Target of 95%
89.00%
!
Monthly Cash Drawings
1.75% bank balance
15.00%
X
Key
On Plan
(6.00%) Target number of Non NHS invoices paid in 30 days
(13.25%) Balance in bank at end of month compared to cash draw down
Note:
√
+ive £ = positive performance (underspend against budget),
Take Note
!
-(ive) £ = negative performance (overspend against budget)
Action Required
X
(this convention applies to all but the specific QIPP tables)
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 1 of 19
Aylesbury Vale
Clinical Commissioning Group
Section A2 – Key Issues and Actions in Financial Position:
Actions for:
Issue:
Key Drivers:
Financial
Impact YTD:
Action:
Owner:
Timeline:
Acute FOT
TBC
Review current levels of spend to
establish how much relates to RTT
initiatives
CSU Finance and
HIIA
Jan-15
CCG to work with QIPP lead
CCG
Ongoing
Further
Detail:
CSU
CCG/CSU Increase in forecast overspend on
Joint Actions Independent Sector Providers
CCG
QIPPs
Delivery and
monitoring
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 2 of 19
Aylesbury Vale
Clinical Commissioning Group
Section B – Contents
Performance Against Plan
This Month
£84k surplus Vs plan spend £173.7m
£6k surplus Vs plan spend £17m
£1.494m surplus Vs plan of £1.494m
£2.577m surplus includes c/fwd surplus of £1.992m from 13/14
Last Month
£76k surplus Vs plan spend £155.8m
£6k surplus Vs plan spend £16.1m
£1.494m surplus Vs plan of £1.494m
£2.577m surplus includes c/fwd surplus of £1.992m from 13/14
In month
Year to date
Forecast
Plan
QIPP
£470k achieved with the use of headroom reserves Vs plan £547k
£3.3m achieved with the use of headroom reserves Vs plan £3.7m
£4.2m (89%) achievement Vs plan £4.76m
£4.76m
£555k achieved with the use of headroom reserves Vs plan £447k
£2.65m achieved with the use of headroom reserves Vs plan £2.6m
£4.4m (92%) achievement Vs plan £4.76m
£4.76m
Planned and unscheduled care
Ambulance
Prescribing
Joint & continuing care
Reserves
£2.1m adverse variance Vs plan spend £90.8m
£255k adverse variance Vs plan spend £5.1m
£253k favourable variance Vs plan spend £20.7m
£237k favourable variance Vs plan spend £31.6m
£1.2m released year to date
Running costs
£352k favourable variance Vs plan spend £3.7m
Year to date
In month
Historic surplus
Forecast 14/15
Risks to forecast
Page Number
4
4
4
7
5-6
5-6
5-6
5-6
Commissioning
£1.9m adverse variance Vs plan spend £81.9m
£168k adverse variance Vs plan spend £4.6m
£260k favourable variance Vs plan spend £18.7m
£249k adverse variance Vs plan spend £28.5m
£787k released year to date
8
8
9
10
£431k favourable variance Vs plan spend £3.3m
12
Running Costs
Commissioning
Locality budgets
Changes to plan
Contracting monitoring
Treasury management
Glossary
Recurrent allocation of £65k Specialist Services funding
Non recurrent allocation of £245k quality premium funding
Table of abbreviations
Table of abbreviations
Financial Performance to January 2015 (Month 10 2014/ 15)
13
14 - 16
17
20
Page 3 of 19
Aylesbury Vale
Clinical Commissioning Group
Section C – Financial Performance:
Key Points
Financial Performance to January 2015 (Month 10 2014/ 15)

The year-to-date (10 months) surplus for the year is £84k, plus
c/fwd. surplus of £1,660k. The year to date surplus has been
increased by £484k reflecting the underspend on the CHC risk
pool, resulting in a total surplus of £2,229k.

The YTD adverse variance on planned and unscheduled care of
£2.5m is mainly related to BHT, OUH and Independent
Providers based on reported activity.

QIPP –The reported YTD under-delivery is mainly arising from
overspends reported against Contract Plans and expected
slippage on delivery, which has been partly mitigated through
use of the CCG headroom reserve.

The adverse variance of £237k in Joint and Continuing Care
includes the return of £484k Legacy CHC Risk Share, which
when adjusted for results in an overspend of £247k, similar to
the previous month.

The favourable variance for Other Services of £1,174k relates
to slippage on projects and the release of legacy accruals not
being utilised in 2014/15.

Running costs favourable variance of £352k is a result of staff
vacancies and slippage on non-pay.
Page 4 of 19
Aylesbury Vale
Clinical Commissioning Group
Section D – QIPP Overview and Forecast Performance
Key Points

All QIPP will be reported through the QIPP & Performance report.

The table above shows the QIPP plan and delivery to January 2015.
In month: Actual reported was £313k against a plan of £547k (57% achievement).
YTD: Actual reported was £2,049k against a plan of £3,671k (56% achievement).

CCG reserves have been played in to mitigate YTD underachievement.
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 5 of 19
Aylesbury Vale
Clinical Commissioning Group
QIPP Planned Savings Vs Actual Savings £'000
£'000
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Plan
280
280
280 280
280
280
447
447
547
547
547
545
Actual
137
137
137 153 276
380
816
448
435
470
Variation
-143
-143 -143 -127
-4
100
369
1 -112
-77
Var %
49%
49% 49% 55%
98%
36% 82%
0% -21% -14%
RAG
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 6 of 19
Aylesbury Vale
Clinical Commissioning Group
Section E – Forecasts, Risks and Mitigation
Key Points:
Financial Performance to January 2015 (Month 10 2014/ 15)

The first table shows the potential range of risks for the 12 months to
March 2015. The current range, before c/fwd., is from a £1.2m surplus
(the “best case”) to a £2.6m deficit (the “worst case”).

The most likely forecast surplus was increased last month to £2,577k, an
additional £484k in excess of the planned surplus of £2,093k. The £484k
relates to the return of the unspent element of the CHC Risk Share Pool.

Whilst we have reflected this there is a risk that the forecast does not
fully take into account of the financial pressure as a result of the recent
system escalation level and on-going pressures to maintain system flow
for the remaining of the winter. The SLAM data from the Trust was
reviewed for M9 and no significant increase in activity reported.

Planned and Unscheduled Care forecast is net of £4.1m Acute reserves
and gains for fines and MRET assumed not to be reinvested of £1.13m.

Major issues include:
o
Additional pressures from increasing activity in the acute sector
through the Winter Months
o
Additional RTT initiative not fully funded by NHS England
o
Increasing activity in Adult CHC
Page 7 of 19
Aylesbury Vale
Clinical Commissioning Group
Section F - Commissioning
F1/ F2 –Planned and Unplanned Care Summary
Key Points
Financial Performance to January 2015 (Month 10 2014/ 15)

There is a £2.5m adverse variance on Planned and Unscheduled
care against plan at the end of the 10 months to January 2015.

Planned and Unscheduled care – YTD adverse variance mainly
relates to overspends at BHT, £2.1m, in the areas of Outpatient
activity and Emergency admissions. OUH, £563k adverse variance,
mainly due to PbR Devices, Maternity, Critical Care and
Outpatients activity. Independent providers’ £1.2m adverse
variance due to 18 weeks activity which is netted off in the YTD
position by monies received from NHSE for RTT.

Ambulance services, adverse variance of £255k, relating to Delayed
Transfers at hospitals and increased activity.

NHS 111 is over performing by £109k against plan resulting from
additional activity.

Patient transport service is over performing by £30k as a result of
increase in patient journeys over the last quarter.

Out of hours adverse variance is resulting from higher SLA charges.
Page 8 of 19
Aylesbury Vale
Clinical Commissioning Group
F3 –Prescribing
Key Points
Financial Performance to January 2015 (Month 10 2014/ 15)

The 2 month delay in the provision of the Prescribing figures
nationally means the CCG has only received M8 data.

The PPA has adjusted the phasing of expenditure in its forecast
outturn to reflect the impact of Category M drugs.

This means that the PPA forecast is more meaningful, therefore the
CCG has utilised this estimate within its forecast outturn figures.

The increased spend in October reflects this adjustment, alongside
influenza claims. As anticipated the in-month spend for November
has decreased.

The current forecast from the PPA suggests a forecast outturn
position of a favourable variance of £309K.
Page 9 of 19
Aylesbury Vale
Clinical Commissioning Group
F4 – Mental Health, Joint & Continuing Care
Key Points
Financial Performance to January 2015 (Month 10 2014/ 15)

Overall the Mental Health, Joint & Continuing Care budgets are
£237K underspent.

Adult fully funded continuing care budget has moved in month due
to the fact that the 2014/15 CHC Legacy Provisions being incurred
are currently lower than anticipated as a result the NHSE has
returned the underspend back to CCGs. This surplus is an additional
£484k. This gain cannot be utilised by the CCG but must be used to
improve the bottom line surplus.

After adjusting for the £484k mentioned above the budgets are over
spent by £247k.

The current overspend on fully funded CHC cases is offset
somewhat by reduced expenditure on the historic joint funded
cases and Children’s CHC, as the number of these individuals has
reduced and by a reduced call on Funded Nursing Care.

The Continuing Care Team is showing an adverse variance due to
increased usage of agency staff and the budget being lower than
the funded establishment. Work is on-going to identify costs
incurred by the CHC Team of Legacy cases, as these costs can be
reclaimed from the Provision with NHS England.
Page 10 of 19
Aylesbury Vale
Clinical Commissioning Group
Section G – Running Costs
Key Points
Financial Performance to January 2015 (Month 10 2014/ 15)

There is an overall £352k favourable variance against the running cost
allocation due to staff vacancies and non-pay slippage.

The running cost allowance is set nationally at £25 per head of
population. Against this allowance the CCG is running at £20.53 per
head for the year to date.

Based on current levels of spend, the forecast underspend for the year
remains at c£548k.
Page 11 of 19
Aylesbury Vale
Clinical Commissioning Group
Section H – Changes to Plan:
Key Points
The changes in the budget this month:

Financial Performance to January 2015 (Month 10 2014/ 15)
Recurrent allocation of £65k received in respect of funding for
the transfer of specialised services from Wessex Area Team
relating to Oxford University Hospital. The allocation provided
was less than anticipated as due to an error and an additional
transfer will be enacted in month 11.
Page 12 of 19
Aylesbury Vale
Clinical Commissioning Group
Section I –Contract Update, Month 10
Buckinghamshire Healthcare NHS Trust;
Key Points:




The position reported by the Trust to month 9 is an over spend against Plan of £2,136k, 3% over plan (which is line with last month). This
position will be amended for outstanding challenges still to be resolved and the confirmation of estimated values e.g. Best Practice
Tariff, CQUIN achievement.
There is continuing significant overspend against Outpatient Procedures £820k which is 46% over plan in line with pressures shown in
previous months.
The other areas of over performance fall within Follow up Outpatient attendances at 17% over plan, A&E at 7% and Non-Elective spells
at 7%. Critical Care has been showing an increased pressure in the last few months, but has now fallen back to 11% over plan.
Unbundled Radiology has a pressure of £340k, which is currently risk shared with the Trust under the application of national rules. Risk
sharing of this area was not mandated nationally in the 2015/16 draft rules. As the rules are now under review it is unclear whether
there is still a further risk in this area next year.
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 13 of 19
Aylesbury Vale
Clinical Commissioning Group
Oxfordshire University Healthcare;
Key Points:


The position reported by the Trust to month 9 is an over spend against Plan of £546k at 8%. This represents a small
improvement over last month, due to a reduction in elective work in December
The main areas of over-performance continue to fall within Maternity of 29%, ITU beds 14%, A&E attendances – 21%,
Outpatient procedures at 23% and Excluded Drugs and Devices at 17%.
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 14 of 19
Aylesbury Vale
Clinical Commissioning Group
Milton Keynes Healthcare Foundation Trust;
Key Points:



The position reported by the Trust to month 9 shows an over spend against Plan of £275k, an increase of £136k over last month. The
year to date movement relates to the increase in Critical Care in December, which has been running below plan all year.
The over performance mainly relates to Maternity Pathway 71%, PbR excluded drugs 26%, Outpatient first attendances of 8% and
Elective Spells 28%.
The significant underspend is within Non-Elective Spells 5%.
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 15 of 19
Aylesbury Vale
Clinical Commissioning Group
Section J – Treasury Management
Aylesbury CCG
Statement of Financial Position as at:
11 Statement of Financial Position
31 January 2015
As at
31 Mar 14
As at
31 Dec 14
Movement
As at
31 Jan 15
£'000
£'000
£'000
£'000
Non Current Assets
-
-
-
-
Key Points:
Total Non Current Assets
-
-
-
-
NHS Receivables - Revenue
2,426
763
306
1,069

NHS Prepayments and Accrued Income
499
499
(4)
495
Current trade receivables and other assets have increased
by £1.2m in January to £2.4m. This is due mainly to increase
in Non NHS prepayments and accrued income of £0.8m.
Non-NHS Receivables - Revenue
23
3
65
68
-
(2)
786
784
7
3
(1)
2
2,955
1,266
1,152
2,418
165
3,594
(1,303)
2,291
Total Current Assets
3,120
4,860
(151)
4,709
NHS Payables - Revenue
(3,084)
(2,636)
(2,821)
(5,457)
NHS Accruals and Deferred Income
(1,706)
(4,270)
6,620
2,350
(126)
(1,398)
424
(974)
(8,017)
(8,551)
(5,178)
(13,729)
(407)
(155)
(7)
(162)
(16)
(16)
(37)
(53)
(13,356)
(17,026)
(999)
(18,025)
(184)
(184)
-
(184)
(10,420)
(12,350)
(1,150)
(13,500)
(10,420)
(12,350)
(1,150)
(13,500)
(10,420)
(12,350)
(1,150)
(13,500)
Non-NHS Prepayments and Accrued Income
Other Receivables


st
Cash balance at 31 January stands at £2.3m, a reduction of
£1.3m on previous month.
Total current liabilities have increased by £1m to £18m. This
is due to increase in NHS payables of £2.8m, increase in Non
NHS accruals and deferred income of £5.2m offset by
reduction in NHS accruals and deferred income of £6.6m.
Total Trade and Other
Cash
Non-NHS payables - Revenue
Non-NHS Accruals and Deferred Income
Other Payables
Provisions
Total Current Liabilities
Total non Current Liabilities
Total Assets Employed
General Fund
Total Taxpayers Equity
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 16 of 19
Aylesbury Vale
Clinical Commissioning Group
12 Receivables
Aged Debtors
Less than 31 days (not due)
NHS Debtors
Value
(£000)
No
Non NHS Debtors
Value
(£000)
No
Total
Value
(£000)
No
241
5
65
1
306
6
-
-
-
-
-
-
Between 0 - 30 days
Between 31 - 60 days
(44)
1
-
-
(44)
Between 61 - 90 days
585
3
-
-
585
3
Greater than 90 days
70
8
3
3
73
11
852
17
68
4
920
21
Total
There is a small level of debt over 90 days actively being
pursued for payment.
13 Cash
Main Cash
Drawdown To Date
Prescribing Total Cash
Cash Charge Drawings
To Date
To Date
£'000
£'000
154,946
15,690
£'000
170,636
Current
Allocation
Drawings to
Date as a %
of
Allocation
£'000
£'000
207,324
82%
Key Points:

The cash balance at 31st January is £2.3m which represents
15% of cash drawn in month plus opening balance at start of
month.

This compares to 25% previous month and 5% target which
is considered good practice.

NHS Cash Management Team has allocated a current cash
limit of £207.3m to the CCG for 2014-15. The total actual
drawdown to date including prescribing represents 82% of
this cash limit, which is close to the level expected at month
10 of 83%.
1
Key Points:
 Debtors at 31st January stand at £0.9m an increase of £0.2m
on previous month, £0.3m of which is not yet due.


The CCG processed a cash draw down of £15.6m in January,
£154.9m in total for the year including CHC risk pool
contribution of £0.3m.
Financial Performance to January 2015 (Month 10 2014/ 15)
14 Payables
Not Due
Aged Creditors - value
Overdue
1-30 days
£'000
579
Overdue
31-60
£'000
770
Overdue
Overdue
61-90
90+ days
£'000
£'000
67
1,215
Total
At 30 Nov
£'000
11,078
At 31 Dec
10,964
644
285
591
1,222
13,706
At 31 Jan
10,811
1,104
769
86
1,813
14,583
Nos
Nos
Nos
Nos
Nos
Aged Creditors - volume
£'000
13,709
At 30 Nov
245
68
47
32
121
513
At 31 Dec
171
106
59
34
127
497
At 31 Jan
183
121
66
44
149
563
Note
Creditors’ balances have been adjusted for invoices relating
to future months.
Page 17 of 19
Aylesbury Vale
Clinical Commissioning Group

Key Points:


Creditors (unpaid invoices on the system) stand at £14.6m
at 31st January £10.8m of which are not yet due for
payment.
The total number of invoices outstanding has increased
slightly from 497 in December to 563 in January, 183 of
which are not yet due for payment.
BPPC
Overall the BPPC performance on invoices for the year is
100% in value terms, and 90% in terms of number of
invoices.
The graph below shows BPPC performance over the last twelve
months:
%
BPPC Performance 12 months to 31st January 2015
125
NHS Invoices
Better Payment Practice Code - payment
within 30 days (cumulative YTD)
Total invoices paid
Total invoices paid within 30 days
% Paid within 30 days
Value of
invoice
(YTD)
£'000
126,103
126,489
100%
Number
(YTD)
1861
1701
91%
Non NHS Invoices
Value of
invoices
(YTD)
£'000
12,592
11,822
94%
Number
(YTD)
1429
1265
89%
Total
Value of
invoice
(YTD)
£'000
138,695
138,311
100%
115
Number
(YTD)
3290
2966
90%
* 95% or more Green - 75% to 95% Amber - Less than 75% Red
105
95
85
75
The above table gives the percentage of invoices paid within a 30
day period for year to date month 6, compared to the DoH target of
paying 95% of supplier invoices within 30 days.
Key Points:


NHS invoices paid continue to maintain at a level of 100% in
value and 91% in terms of number of invoices.
Non NHS invoices have remained at similar level to previous
month at 94% and Non NHS numbers at 89%.
Financial Performance to January 2015 (Month 10 2014/ 15)
65
NHS Invoices - Value
NHS Invoices - Number
Non NHS Invoices - number
Target
Non NHS Invoices - Value
Overall the payment performance has remained at a fairly
consistent level over the last twelve months with the exception of a
dip in Non NHS invoice numbers in October 14 but recovered to 90%
in November and January.
Page 18 of 19
Aylesbury Vale
Clinical Commissioning Group
Abbreviations and acronyms used:
2014/15
Financial Year from 1 April 2014 – 31 March 2015
NHSE
NHS England
A&E
Accident and Emergency
PBR
Payment By Results – payment system (based on
Healthcare Resource Groups) used mainly in acute
contracts
AT
Area Team
POD
Point of Delivery – area of acute care activity of similar
type (e.g. Inpatient or Outpatient)
BPPC
Better Payment Practice Code- target (currently 95% of
invoices to be paid within 30 days of receipt of invoice
or goods/service.
QIPP
Quality, Innovation, Prevention and Productivity – plans
and associated savings / changes in financial costs
Break-even
Position where actual costs are same as planned i.e. not
in deficit or surplus
Reserves
Monies set aside for a specific purpose eg Contingency
reserves for unforeseen spend in year.
Budget
A sum of money allocated for a specific purpose
RTT
Referral to Treatment is the definition by which patients
waiting to be treated are measured
CCG
Clinical Commissioning Group
Revenue Resource Limit (RRL)
Total funding allocated for the year set by the
Department of Health
CHC
Continuing Health Care
RBH
Royal Berkshire Hospital
CQUIN
Commissioning Quality & Innovation
SCAS
South Central Ambulance Service
Deficit
Financial variance where overall net costs are more
than planned
SLAM
Service Level Agreement Monitoring – i.e. contract
monitoring information
Excess Bed Days
Term used in acute contracts to describe days
chargeable under PBR in excess of the standard tariff
(for example a tariff might set 5 days as standard stay
and days above this are charged to the CCG)
Surplus
Financial variance where overall net costs are less than
planned
FPH
Frimley Park Hospitals NHS Foundation Trust.
Variance (Adverse)
Difference against plan (overspend)
FOT
Forecast Outturn
Variance (Favourable)
Difference against plan (underspend)
HWPH
Heatherwood & Wexham Park Hospitals NHS
Foundation Trust
YTD
Year-to-date (from 1 April to the end of the reported
month)
k
Thousand
m
Million
Financial Performance to January 2015 (Month 10 2014/ 15)
Page 19 of 19
Agenda Item: X
Document reference: X
GOVERNING BODY MEETING
MARCH 2015
PROCESS FOR APPROVAL OF ANNUAL
ACCOUNTS AND ANNUAL REPORT 2014-15
Purpose of Paper
To ask the Governing Body to agree delegated authority to approve the draft
accounts and annual report to the Audit Committee at their meeting on the 21 May
2015 and for final approval of any changes post Audit Committee to the Chair, Chair
of the Audit Committee, Chief Officer and Chief Finance Officer on behalf of the
Governing Body.
Executive Summary
Under the CCG’s Scheme of Reservation & Delegation approval of the annual
report and accounts is delegated to the audit committee. Under the audit
committee terms of reference the audit committee will review the annual report
and financial statements before submission to the governing body. The National
Annual Reporting guidance requires Governing Bodies to approve the final
Annual Report and Accounts. This paper clarifies the process for approval of the
annual accounts and report by 12.00 on the 29 May 2015.
Due to the deadline for the submission of the draft accounts and annual report to
the Department of Health (29 May 2015) and its proximity to the date by which
the preparation and audit of these documents will be completed, it is proposed
that the Governing Body agree to delegate authority to approve the final
accounts and annual report to the Audit Committee at their meeting on the 21
May 2015.
Given the tight timetable for auditing the accounts there may be a requirement for
adjustments post review by the Audit Committee. It is proposed that any such
changes be approved by the Chair, Chair of the Audit Committee, Chief Officer
and Chief Finance Officer on behalf of the Governing Body taking advice from
the Auditors and other members of the Audit Committee. Such approval may be
made virtually.
There are specific Certificates and Statements which are required to be signed
by the Chief Officer (as Accountable Officer) and Chief Finance Officer.
Aylesbury Vale CCG: Process for Approval of Annual Accounts and Annual Report 2013-14
1|Pag e
The Annual Report and Accounts are then published on the CCG website and
presented to an Annual General Meeting to take place in September 2015.
Key dates
By 12.00 Noon, Thursday 23 April 2015
•
Draft Annual report and accounts
•
ISFE consistency statement & supporting data collection templates
•
Head of Internal Audit Opinion
By 12.00 Noon, Friday 29 May 2015
•
Full Audited and signed Annual Report & accounts, approved by the
Governing Body
•
ISFE consistency statement & supporting data collection templates
•
External audit completion report
•
By 17.00 Noon, Friday 5 June 2015
•
Annual report and accounts in full on public website
By 30 September 2015
•
Hold a public meeting at which the Annual report & accounts are submitted
Aylesbury Vale CCG: Process for Approval of Annual Accounts and Annual Report 2013-14
2|Pag e
Actions Required
Delegate authority to approve the draft accounts and annual report to the Audit
Committee at their meeting on the 21 May 2015 and for final approval of any
changes post Audit Committee to the Chair, Chair of the Audit Committee, Chief
Officer and Chief Finance Officer on behalf of the Governing Body.
Objectives supported by this Paper (Please Tick)
Improve people's health and reduce inequalities
Enhance quality, safety and experience of patient services
Ensure local people have greater influence and management of own care
Deliver financial sustainability with headroom to invest
Perform well as a CCG
X
ROBERT MAJILTON – CHIEF FINANCE OFFICER
Aylesbury Vale CCG: Process for Approval of Annual Accounts and Annual Report 2013-14
3|Pag e
Executive Team Meeting Minutes
Thursday 29th January 2015 - 1.00pm- 4.00pm
AVCCG Boardroom, The Gateway, Gatehouse Road, Aylesbury, Bucks
Executive Team Present:
Dr. Rodger Dickson, North Locality Lead (RD) – Chair
Dr. Christine Campling, Elective Care (CC)
Dr. Stuart Logan, Long Term Conditions (SL)
Louise Patten, Chief Officer (LP)
Dr Juliet Sutton, Early Years (JS)
Colin Thompson, Director of Operations and Performance (CTh)
Dr.Charles Todd, Central Locality Lead (CT)
Lesley Munroe-Faure, Practice Manager (LMF)
Dr.Malcolm Jones, South Locality Lead (MJ)
Alison Foster- Director of Quality (AF)
Alan Cadman, Deputy Chief Financial Officer (AC)
Dr. Karen West, Joint Commissioning and Partnership (KW)
Trevor Boyd (TB)
Other Attendees:
Vicki Parker- minute taker (VP)
Apologies:
Robert Majilton, Chief Finance Officer (RM)
Dr. Kevin Suddes, Unplanned Care Lead (KS)
Dr. Graham Jackson, Clinical Leader (GJ)
Page 1 of 15
Item
No.
1
Agenda Item
Lead
Welcome & Apologies
RD
The Chair welcomed members of the Executive Committee
Apologies were noted from: Robert Majilton, Dr Kevin Suddes and Dr Graham Jackson
2
Declarations of Interest
RD
No additional declarations were declared
3
Minutes of the meeting held 27th November 2014 and Action Points
RD
For approval:
Minutes of the 27th November 2014 were approved
Action points update:
Succession planning:
CTh advised we are attempting to secure the resources for a Clinical Chief Information Officer. This will give
additional support to the organisational wide interoperability project. LP will bring a short paper on succession
planning to the February 2015 Exec and time will be allocated for discussion.
The Live Well Business Case will be discussed in the February 2015 Exec.
MK Stroke Pathway: CC attended the Stroke Strategic meetings and noted the following improvements have
been made within the service: Advanced nurse practitioner appointed, 2 empty female and male stroke beds
identified but lost with winter pressures, multi disclipinary team in place, all nurses attended stroke course,
increased physio presence by increasing numbers, awaiting funding for increase to OT, early discharge teams
working closely with MDT, commissioning some long term stroke beds, better rehab model and an exercise
programme for stroke.
IG Training: Action point is closed. Jessica Walsh will be maintaining this record as an on-going exercise.
Updating Outlook diaries to indicate CCG work time: Action point closed:
Page 2 of 15
Action Point
LP to bring a paper
on succession
planning to the
February Exec
Meeting
3a
December decision log
RD
Policy Statements
CC provided clarity on the weight issue for knee replacement patients. We currently will not be aligned on the
weight management policy, however amendments have been made to reduce this gap.
The amendments are:
•
All patients with BMI ≥ 25 to 30 should be strongly encouraged to lose weight.
•
All patients with BMI ≥ 30 should be strongly encouraged and offered to participate in a weight loss
programme.
•
Patients with a BMI>40 may be high risk for surgery and therefore weight loss programme must be
offered prior to surgery.
All comments raised in the December virtual Exec were addressed and the policies authorised.
4
Chief Officers Report
LP
LP provided a verbal update to the Executive Team and confirmed the planned Industrial action has been called
off
LP is the health representative on the Children’s Services Improvement Board and will forward reports to the
Executive.
Office move: LP expressed thanks to Elaine, Vicki, Becky, Jess, Kayli and Alan for organising the office move
and making sure everything went as smoothly as possible.
Re-election of the Chair:
In April 2016 we require the re-election of a GP Clinical Chair. Our constitution states the elected GP chair is
able to do a further term of 3 years but there has to be a re-election. LP will be writing out to members to make
the timetable clear. The new chair has to be in position on 1st April 2016. There will also be two Clinical Locality
Leads up for re-election in July 2016 (MJ and CT).
GP Clinical Leads are employed on a fixed term 3 year contract. A process needs to be put together by which
we review each post at the end of the contractual 3 year post. LP will write a proposal to be reviewed by the
Executive Team before going to the Governing Body for approval. AVCCG has a constitution that came into
effect 1st April 2013 and we interpret this date as the official start of the constitution. Fixed term contracts
commenced from this date.
Page 3 of 15
Action Point
LP to write a
proposal to clarify
the contractual
positions for GP
Clinical leads on
fixed term
contracts
5
Corporate Governance Report and Risk Register
AC
A full review of the Risk Register was carried out in January 2015. All risk leads were asked to review and
update their risks.
We are trying to move to a point where the Risk Registers are covered on the agendas of the various forums.
The Executive Team should only be reviewing the very high risks of 16 and above. A risk of 25 with no controls
identified is a serious issue.
One IMT risk is still 20-25. We believe this is an inheritance from earlier systems. This risk needs to be removed
and reloaded correctly back into the system.
Further updates included:
IMT1: No longer relevant and will be closed off.
IMT2: To be closed.
IMT3: This needs to be reviewed. An information sharing protocol has been put in place and will now be
relevant for new organisations joining.
Two Locality risks need to be reviewed including one on referring incorrectly.
RC10: Needs to be reduced down to amber.
AC asked the Executive Team to consider the recommendations around improving the scoring movement of
certain risks, the approval of removing risks and if anything needs to be escalated to Governing Body.
LP feels some of the risks are too high and should go back to the groups who own the individual registers that
these are still flagging up to high.
The register will come back to the Executive Team on a quarterly basis. It was agreed the Risk Register is still a
work in progress and when it comes to the April Exec we should expect this to be more detailed in its approach.
6
Policies requiring approval
LMF has been through all our outstanding policies with HR. The Executive Team are happy with the approach
to these policies.
The following policies were approved:
HR Policy Update V2, AVCCG Policy Register V1.2 and the Winter Weather Plan
Page 4 of 15
LP
7
Quality Report
AF
AF discussed the Quality Report.
Following an initial workshop in November, there has been some engagement with JETS and Localities to
agree priority areas and ideas for CQUIN. The current list is aimed at having a small number of target priority
areas, focused on making improvements in the community and where we can incentivise bigger impact on
improving outcomes for patients. However the National CQUIN’s are delayed and not due out until the end of
January. They will affect the decision and shape of local CQUINs. The National CQUINs are anticipated to
cover Urgent Care, Mental Health, Dementia, and Acute Kidney Injury. Additionally in areas such as Mental
Health we know there will be some contract metrics we need to consider and build in which have not yet been
released. We are now working with the BHT Team to progress shaping the detail about the draft local CQUINs
and we will need to come back to Clinical Commissioners to ensure the final projects are aligned and
demonstrate stretch. AF would like feedback on any areas that the Executive Team feel have been
missed. JS is delighted to see a focus on maternity and early years.
CTh stressed the importance of the CQUIN contract value (£5.3m). BHT has been invited to the Feb Exec to
discuss their clinical strategy. More support is needed from BHT to help the economy understand the focus and
timetable to deliver the strategy.
Clinical concerns summaryThe feedback loop is going back into BHT and monthly discussions are taking place to address the themes.
There has been a decrease in the number of people using the MAD button and we need to encourage practices
to keep using this system. It is a helpful and valuable tool.
It was suggested we circulate the “Clinical Concerns Summary” to the Locality members to highlight the
outcomes of using this tool.
The Executive Team agreed the new layout of the report was easier to read and provided good feedback.
Page 5 of 15
Action Point
Locality Managers
to send the Clinical
Concerns
Summary” to the
Locality members
8
Corporate Performance Report and Dashboard
CTh
The RTT held through the winter period. NHS England asked the NHS to deliver more on the RTT so there is
pressure to lift another 500 patients off the waiting list, although there is no confirmed funding source for this.
A new mobile MRI Scanner is being delivered to Wycombe hospital next week. This will help clear the
diagnostic backlog and waiting times will be reduced.
Diagnostics waiting times have suffered recently. BHT discovered a large number of audiology patients that had
not been tested inside the ideal stage of treatment. This backlog will clear in the next 4 weeks,
There is significant pressure on the cancer waiting times. The 2 weeks wait dipped to 1.2% below the expected
level. This has been linked to the December pressure period, on annual leave and patient holidays.
We have moved ahead of Chiltern CCG performance recent measurement on IAPT’s in the last quarter. We are
now the best performing CCG in the sub region.
The A&E performance went to the lowest % (82%). The A&E teams have performed tremendously under these
pressures and we have hit one green week at 95% in the last 10 weeks.
All over 75 funds need to be operational by the 1st April 2015.
KW noted there is a large amount of overlap between the quality report and the performance report. How can
we take this forward? CTh advised the same team that produce the quality feeds the information to the
performance report. It was agreed we need to see both reports on a monthly basis but we should review
overlaps.
9
QIPP Report
Preparations are being made for the next financial year. This year has been difficult and has been significantly
helped by mitigation. The different JETS have been looking at their plans for next year. There is a significant
ask on programmes like the over 75’s fund/BCF to deliver by the start of April 2015.
AC advised the internal audit did a review of the QIPP process and outcomes which resulted in the process
being marked as red/amber. The main issues were linking together projects and finance benefits. The next
Audit is in March when hopefully the audit position will upgrade to green.
TB updated the team on the winter pressure funding. The Government opened up a fund for local authorities to
Page 6 of 15
CTh
bid for. BCC appealed the criteria of the funding as they felt it was unfair to local authorities who were not
significantly failing on DTC’s. Due to this the Government opened up a second round of bidding and BCC was
awarded £230k.
10
Chief Finance Officers Report
AC summarised the Finance Report
The M9 financial position shows the CCG has increased its forecasted surplus to £2,577k, an increase of £484k
over the previous month. This increase is due to NHSE returning the unused element of the CHC Legacy Risk
Share which the CCG will be able to submit a business case in 2015/16 for the return and use against Nonrecurrent expenditure. Taking this aside the CCG is still forecasting, as with previous months, to achieve the
year end planned surplus of £2,093k which is represented by the in year surplus of £101k and the historic
brought forward of £1,992k. As noted in previous months, to achieve this position the CCG is utilising all of the
headroom, unutilised accruals and contingencies.
The report highlights:
• The year to date (9 months) surplus is £76k (same as plan) for in year surplus, as shown on page 4 of
the report, with a forecast in year surplus of £101k.
•
Actual spend within Planned and Unscheduled Care is based on the available month 8 Contract
Reports and extrapolated for month 9.
The adverse variance on planned and unscheduled care of £2,242k is mainly relating to OUH, BHT and
Independent providers as a result of over performance mitigated by releasing £3.2m from
Commissioning Reserves of which £1m relates to the RTT.
This overspend is further mitigate by the release of £1,1m held in Non-Recurrent Programmes for
legacy accruals that have not been utilised in 2014/15 and slippage of projects. The BHT over
performance includes the reduction for fines and MRET not re invested of £0.9m.
The over performance is in the areas of:
BHT, Outpatient activity and Emergency admissions - £2,137k, OUH - PbR Devices, Maternity, Critical
Care and Outpatients activity - £689k and Independents, including NCA, £1.9m, due to the additional
activity created by the reducing waiting time initiative which is funded via the RTT funding of £1.3m
received to date.
The ambulance contract is over performing by £168k due to delayed hospital transfers and a general
increase in activity and patient transport services by £26k due to an increase in the number of journeys.
Pressure is also being seen with the NHS 111 service currently over preforming by £113k due to
additional activity.
Page 7 of 15
AC
•
Prescribing is forecasted to achieve a surplus of £355k at the end of M9 and this has been recognised in
our forecasts. This forecast is now aligned to the PPA forecast and includes the reclassification of the
MClass drugs as noted in previous months, shown on page 9.
•
The adverse variance of £249k in Joint and Continuing Care reflects the increase and complexity of Fast
Track and palliative care cases in Adult Continuing Healthcare. Whilst this has maintained the month 8
position, the underspend on End of Life care at Hospices and OATs Learning Disabilities has reduced
resulting in an ytd increase in the overspend of £41k from M8. There is still the outstanding issue of
S117 patients whose finding arrangements are in dispute with the council.
•
Running costs favourable variance of £431k is a result of staff vacancies and slippage on non-pay,
shown on page 11.
•
QIPP schemes shown on page 5 show an achievement of 64% against the YTD budget before
mitigation, mainly due to running costs over achieving. There are a few schemes now not delivering as
shown in the report which are covered at the moment by mitigation and schemes that over performing.
•
Forecast shown on page 7 shows the most likely case of the CCG achieving its planned surplus and is
utilising all headroom and contingency. There are risks to this forecast as follows:
•
Over performance on providers greater than the current forecasted level of underspends in other
budget areas and the amount of reserves and contingency. The worst case forecast would
mean that the surpluses would be utilised.
• Whilst we have reflected this there is a significant risk that the forecast does not fully take into
account of the financial pressure as a result of the recent system escalation level and on-going
pressures to maintain system flow for the remaining of the winter. A full review of the forecast will
be undertaken for month 10 based on the updated position including month 9 SLAMs.
•
Activity through the winter months being higher than that included in forecasts, we have
forecasted an extra 1.5% increase in activity due to weather conditions.
•
Continued increase in Adult CHC activity above forecast of £275k.
•
Page 8 of 15
The most likely forecast surplus has been increased to £2,577k, an additional £484k in excess of
the planned surplus of £2,093k. The additional £484k represents AVCCG element of the
underspend on the CHC Legacy Provision which NHSE are expecting from reduced
commitments in this financial year. CCGs were asked to reflect this in their forecast positions and
expected to increase and carry-forward this.
At this stage the forecast position is on plan.
Contracts – page 13 onwards
These show the performances by POD’s for the major contracts and highlights the areas where over
performance is occurring. This is discussed at the weekly contract and mitigation meetings to identify the issues
and what actions can be taken to bring back on track, headed up by Colin Thompson.
Treasury – page 16 onwards
Balance Sheet – shows a net worth of £12.3m deficit. The movement of £1.2m is represented by a reduction in
Debtors, large invoice outstanding from a CCG has been paid and reduction of the Prepayment from the
previous month that was relating to a pre invoice on creditors and increase in bank balance due to insufficient
invoices being passed for payment.
Debtors
The older invoices relates to invoices raised but disputed with NHSE P/L contributions and some recharge to
practices which are currently being resolved.
Creditors
The ageing analysis shows the volume and value of unpaid supplier invoices by aging bucket. The older
invoices are on hold and relate to NCA activity awaiting further information to validate the invoices.
BPPC is roughly on target for the year in achieving the target of 95%.
Cash
At month 9 the CCG has used £154m of its cash limit which relates to 74% which is in line with expectations.
The Executive Team approved the changes to the Plan (Section H)-the budget adjustments.
11
Financial Plan 2015/16
The plan now reflects the additional increases in the funding, namely £1m for winter resilience funding. We now
have the final planning guidance in terms of the business rules, setting aside 1% surplus, contingency of 0.5%
and headroom of 1%.
The business case has already been submitted due to the deadlines. Within our headroom of £2.6m we need
to set aside £1.2m for the CHC Risk Share. This leaves £700k against over performance. We have also lost the
non-recurrent elements which held up our position.
There is a QIPP gap of approx £2.4m. It has been suggested the Exec considers stretching this from 1% of the
base-line to 1.5.-2% of the base line. The resource map in the report demonstrates where the money is coming
in and going out.
CTh congratulated AC on producing a very informative paper.
Page 9 of 15
AC
Next steps:
We need to work through the contracts and a Financial Plan needs to be submitted on 26th Feb. Final budgets
and plans will come to future Executive meetings.
It was noted the winter resilience money goes into baseline (held in reserve) so we now have the opportunity to
plan for resilience all year round,
Mental Health- we will need to identify what services we will invest into. This will be discussed in February’s
meeting
Agreement was requested on applying the business rules, applying for CHC money and looking further at QIPP
opportunities.
Approved by the Executive Team
12
Integrated Governance Reports Q3
AC summarised the highlights of this report:
-
13
Freedom of information, achieving 100% for 20 day turnaround and 58% on 3 day turnover
PALS- 34 contacts within the period
Complaints: 100% dealt within 25 working days
1 Legal action which related to an IFR.
OOH
LP discussed the attached update on behalf of Ian Cave, Urgent Care Commissioner
AVCCG Exec verbal
briefing for Lou (Dec)
The BUC contract expires October 2015 and a consultation process has been undertaken with patients and
members of the public to establish what sort of service they want. The response has been for better access,
joined up care, access to medical records and better access to local appointments using local GP’s.
The Urgent Care JET feel we need to take our time and be clear on the sort of OOH service we want. It is felt
we are not in a position to go out to tender and that it would be more beneficial to work with existing providers
over the next 12 months to really look at what this service should look like.
Page 10 of 15
The recommendation is to extend the existing contract with the current provider for a further 12 months and
manage the expectations.
Comments from the Executive Team were:
• MJ feels this is a disappointing move and feels we should be able to describe what a good OOH service
should look like.
• KW feels to be innovative we need to give the contract an extra year.
• LP advised there is work going on between BHT and BUC to better integrate.
• LMF questioned at what point will we have enough information to make a decision?
• CT feels we need to be clear on the KPI’s and place indicators that are not currently in the existing
contract.
• There is a need for contractual improvements, performance monitoring and the design of the new
service needs to be worked up by each locality.
• Urgent Care JET members need to attend locality meetings.
LP will take the concerns raised back to the UC JET and ensure a regular progress report from the JET comes
to the Executive meetings. LP to go back with a strong message on clear areas of improvement,
14
AV Respiratory Project Business Case
The policy was approved by the Executive Team and will be placed in the QIPP.
15
Medicine Management Investment Opportunities
a)
Scriptswitch
This medicines management tool has been made available to GPs for the last 6 years. The cost of the software
per annum is £71k for AVCCG and £120k for CCCG. Savings delivered were >£1m in 13/14 and are estimated
to be >£900k in 14/15. GPs have confidence in the tool and Bucks is consistently one of the top performers in
the country. Approved by the Executive Team
b)
Scriptswitch support
In order to maximise the cost savings and quality improvements delivered by Scriptswitch the profile is locally
managed by the MM team. Although we have negotiated additional support from the scriptswitch team there is
still an element that requires input locally that could be provided by less qualified staff than currently used. An
investment of £11.5k (£4.6k for AVCCG and £6.9k for CCCG) would maintain the Scriptswitch savings and allow
increased input into practices from the Practice support pharmacist. Approved by the Executive Team
Page 11 of 15
Action Point
LP will take the
concerns raised
back to the UC JET
and ensure a
regular progress
report from the JET
comes to the
Executive
c)
Care Home Medicines Optimisation Service
Investment of £103k (AV £41.2k, CCCG £61.8k) to recurrently fund a pharmacist and technician to continue to
deliver the service initiated in the Care Homes pilot. Financial savings conservatively estimated at £134k but
significant quality and safety improvements will also be delivered. This service has been achieving results in
terms of medicine wastage and quality and is an important service to the care homes. Discussions took place to
establish alternative funding options.
These included:
1. The JET set a higher prescribing level in their incentive scheme.
2. You add to the list of investments on the QIPP list.
It was agreed that further discussion was needed on this funding request and has not been approved
by the Executive Team. Note- The budget for the AV Care Home LES is currently under spending by £50k
and this could be transferred to fund the requested posts. Further approval for this will be requested in the Feb
2015 Exec.
d)
Nutrition
Investment of £27.5k (AV £11k, CCCG £16.5k) in a nutritional support post to deliver improved nutrition in care
home patients estimated to reduce admission costs by £50k. CTh questioned using the care homes LES? Is
there underspend that can be incorporated into this? CTh feels this piece of work has been evidenced and
should ask the LTC JET to look at possible funding streams through the LES, Care Home Matrons Service or
the Care Homes Quality Team?
It was agreed that further discussion was needed on this funding request and has not been approved
by the Executive Team. Note- The budget for the AV Care Home LES is currently under spending by £50k
and this could be transferred to fund the requested posts. Further approval for this will be requested in the Feb
2015 Exec.
e)
Paediatric EOL
At the moment there is no contract for paediatric EOL care and this is totally reliant on charity funding. The
CCG is at risk of having the service provision pulled if there is a lack of charitable funding available with no
notice period in place. There is no opportunity for the CCGs to ensure that high standards are being delivered
or to design the service to meet our populations needs. There is a recognition at a national and TV level that
there is inequality in access to children’s palliative care and in the sustainability of those charitably –led
services. Helen and Douglas House is requesting 30% funding equating to £69k (CCCG) and £43k (AVCCG).
CTh advised we have got a carers budget and proposes we use this budget and allocate 20% funding in this
coming year. We need to confirm Chiltern CCG will agree to the same level of funding.
Approved by the Executive Team
Page 12 of 15
Action Point
SL to take this
proposal to the LTC
JET and confirm
Chiltern CCG’s
funding proposal
16
Maternity Needs Assessment
Sue Burke joined the meeting via tele-conference and summarised the key findings:
• There are no significant concerns over the main provider (BHT)
• C-Sections were higher than national guidance
• High rate of still births in Aylesbury Vale
• Both CCG’s have a larger % of “older” mums which often presents further medical complications
• AV central is higher than the national average on low birth weights and infant mortality
Recommendations to take forward:
Antenatal
Delivery
Postnatal
Commissioning service user experience and clinical effectiveness
BHT set their C-Section rates at 23% (2% below the national guidance). However they experienced 6 serious
incidents which raised anxiety levels, hence a rise in C-Sections. This peaked at 28% but is gradually coming
down and last month was 24%. This is an on-going piece of work.
CTh asked the group to think about what can be done to address high infant mortality rates in the central
locality. Is it a reflection of social inequality? Aylesbury Vale has similar demographics to areas in High
Wycombe and Chesham but they don’t have rates as high as AV.
Jane O’Grady from BCC Public Health joined the meeting. She advised still birth rates, infant mortality rates
and low birth rates together produce a set of common themes. It’s clear some themes are avoidable i.e.
smoking when pregnant. JS feels the biggest target group needs to be AV Central.
CTh wants the CQUIN to support at least 4 points of quality in antenatal care at BHT which are currently not
meeting standards.
Conclusions:
It was suggested to focus one of the CCG PLT sessions on maternity to gain some primary care input. AF and
CTh will take this through CQUIN and will relook at the business case
JS asked the Exec team if they were happy to approve the paper and the recommendations and then to work
further on the action plan? Approved by the Executive Team
Page 13 of 15
17
Process for ratifying priority statements in Bucks
The policy was approved by the Executive Team
Date of next meeting:
Thursday 26th February 2015. 1pm - 5pm.
Information regarding the February Exec: Aylesbury Vale will hold their Executive meeting from 1 – 3pm to
discuss standard agenda items. We will then move to the Diamond Room to join with Chiltern CCG to discuss
three items of joint business, namely the MSK paper, Better Care fund S75 Update and the BHT Clinical
strategy. This meeting will run until 5pm.
Meeting 2
Jane O Grady- Public Health
Jane O’Grady attended the meeting and discussed the attached presentation
AVCCG Final - 29
January 2015.ppt
Meeting closed at 17:00pm with thanks
Action Log – Executive Team
Open action Points from previous meetings:
URN
2711143.1
2711144.1
Date of
meeting
27/11/14
Agenda
Item No.
3
27/11/14
4
Page 14 of 15
Action:
LMF to discuss Cancer 2 week waits at next PMF
Update needed in the February Exec
AF to provide an update on the MK stroke pathway in March 2015
Assigned
to
LMF
AF
Date opened
Open
27/11/14
CLOSED
26/02/15
Open
27/11/14
Meeting Date: 29th January 2015
New action points
URN
Date of
meeting
Agenda
Item No.
290115.3
29/01/15
3
290115.4
29/01/15
4
290115.13
29/01/15
13
290115.15
29/01/15
15
Page 15 of 15
Action:
Assigned
to
LP to bring a paper on succession planning to the February Exec Meeting
LP to write a proposal on clarify the contractual positions for GP Clinical
leads on fixed term contracts
LP
LP will take the concerns raised over the OOH’s contract extension back to
the UCJET and ensure a regular progress report from the JET comes to
the Executive
SL to take the paediatric EOL care proposal to the LTC JET and confirm
Chiltern CCG’s funding proposal
LP
OPEN
29/01/15
SL
OPEN
29/01/15
LP
Date opened
OPEN
29/01/15
OPEN
29/01/15
Commissioning for Quality Meeting
Venue – Conference Room 1, Aylesbury Vale CCG
17 December 2014
Minutes
Membership
Organisation
Sheran Oke
Secondary Care Specialist Nurse, Chiltern CCG Governing Body
Peta Birch
Interim Director of Quality, Chiltern CCG
Jon Wallis
Lay Member, Chiltern CCG
Annet Gamell
Chief Clinical Officer, Chiltern CCG
Mr. Mike Pittam
Mr. Mike Pittam - Secondary Care Specialist Doctor Chiltern CCG Governing Body
Karen West
GP Member AV CCG
Barbara Poole
Healthwatch
Alison Foster
Director of Quality, AV CCG
Graham Jackson
Chair AV CCG
Attendees
Organisation
Sue Barber
Infection Control Manager, AVCCG & CCCG
Alison Wakeford
Ben Morris
Quality and Transformation Lead
NHS Central Southern Commissioning Support Unit.
Quality Improvement Analyst NHS Central Southern Commissioning Support Unit
Noel Scanlon
Jane McVea
Deputy Chief Nurse, Buckinghamshire Healthcare Trust - for BHT PU presentation
QIP Programme Manager, Buckinghamshire Healthcare Trust – for BHT PU presentation
Julie Sturges
Clinical Nurse Specialist, Buckinghamshire Healthcare Trust - for BHT PU presentation
Apologies
Organisation
Shakiba Habibula
Christine Croft
Public Health Consultant, Bucks County Council
Locality Nurse Lead CCCG
1
3. December Minutes 17/12/2014
Agenda Item 1
Welcome & Apologies
Noted above.
Agenda Item 2
Declarations of Interest
Group
There were no declarations of interest.
Agenda Item 3
Minutes of November meeting
Group
The minutes were agreed as a true record but with amendments.
Action
• Item 4 - Correct capitalised ‘T’ in second paragraph.
• Item 7 - Correct spelling of ‘MRSA’.
• Item 7 – First paragraph - Replace ‘overall’ with ‘HWP and BT’.
• Item 7 – Red practice has improved and is now amber. Making good progress.
• Item 9 – A meeting has been scheduled with Medicines Management.
• Item 12 – AF and PB to discuss risk register outside of the committee (action outstanding).
Key messages for the governing body item to be placed at the top of the minutes.
Agenda Item 4
Matters Arising and Decision Action Log
BM/AW
The committee reviewed actions from the minutes and the decision and action log.
Action
Agenda Item 5
2014/025 – Dates for Quality Assurance visits must be arranged as a priority.
2014/63 – New chief executive with Buckinghamshire Healthwatch is reviewing all reports and formats. The report
will be circulated for the next meeting.
2014/84 – Outstanding action. To include staffing levels and complaints in quarterly SIRI report.
BM/AW
BP
BHT Pressure Ulcer Action Plan
BHT
BM
The BHT Deputy Chief Nurse presented the Pressure Ulcer Action Plan to the group.
The presentation was noted by the committee.
BHT have introduced ‘intentional rounding’ into the Trust, partly in order to reduce the number of hospital acquired pressure ulcers.
Some of the key points (as highlighted on slide 27):
 95% of pressure ulcers are AVOIDABLE.
 Last year we failed to prevent 45 of BHT patients getting avoidable grade 3 or 4 pressure ulcers.
 Documentation - review of BHT serious incidents showed that we were not accurately documenting the care we were giving.
 If it is not recorded it will not be documented as an incident.
 Pressure care is everyone's responsibility.
 Over the next two years we will reduce by 50% avoidable category 3 and 4 pressure ulcers
 Introduction of Care Bundles, Intentional Rounding, Provision of Additional Pressure Relieving Equipment, Enhanced training and a more rigorous
approach to risk management are part of the solutions proposed.
Monitoring of the progress on the delivery of the improvement plan will be through the BHT CQRM.
Action
BM to distribute presentation to committee members
BM
2
December Minutes 17/12/2014
Agenda Item 6
CSU Analysis on Pressure Ulcers
BM
BM presented the Pressure Analysis Report to the group. The group noted the presentation. The group noted the progress which had been made in
the investigation. BM stated that investigation of 2013/14 pressure ulcers will be discussed in the quarterly SIRI report.
Action
A key is to be added to the SIRI report to identify ward area and function.
BM
Agenda Item 7
Frimley Park – HWP (Recovery Plans Presentation)
PB
•
•
•
•
•
•
•
•
There have been several meetings including an overview committee with commissioners.
HWP are currently not technically in special measures.
A detailed action plan for all services has been drawn up. HWP are to have re-launched their core values and beliefs, and there is to be a radical
overhaul of quality assurance processes.
HWP previously had four divisions but this has been changed to ten separate directorates each with a clinical lead. A new management structure
has also been implemented. Risk factors currently include ensuring the man-power to successfully manage structural changes and managing the
necessary cultural changes of the integration with Frimley.
The complaints process has now been centralised.
There are currently issues in obtaining clear RCAs for SIRIs that can be signed off by commissioners.
A new theatre suite is being constructed for day-cases. This is to be completed by January 2015.
HWP are aiming to reduce agency staff by 50% by the summer 2015.
Agenda Item 8
Provider Highlight Reports
BHT
AF met with SEAP and issues were raised about the handling of
complaints by Buckinghamshire Healthcare Trust and the delays in
responding to clients. Report discussed further under agenda item 11.
AG highlighted the current system wide black escalation which was
declared on 16/12/2014. BHT will be holding black status for the next few
days. SCAS has also been struggling and has declared REAP 4 status.
Social services have been engaged throughout and have been very
helpful. There has been spot purchasing of beds within care homes.
There were 12 patients in corridors on Tuesday 16th December.
The key contributing factor to the increase in admissions appears to be
respiratory problems in elderly patients. There is concern that while
discharges are frequent, patients are being re-admitted soon after.
Frimley Park (HEP)
Good engagement between CCCG DoQ and Trust. Stroke Services:
quality notice has been rescinded.
OUH:
• Long term cancer pathway development in progress. FFT response
rate in A/E remains an issue.
• AF will be meeting Oxford CCG Quality team to discuss key issues
and improved mechanisms of communication and assurance.
MK:
• Communication mechanisms in place with AVCCG DoQ.
• There are now staged inquests for child deaths.
• A maternity improvement board is to be set up.
• Transfer to Stroke Unit within 4 hours of admission continues to be an
issue.
Oxford Health Foundation Trust
• Quality assurance visit planned for 19TH December.
Southern Health
• There have been no complaints. This is not necessarily positive and
assurance is required that the appropriate patient engagement is
taking place regarding making complaints.
3
December Minutes 17/12/2014
Agenda Item 9
Quality Dashboard
AW
The group noted the Quality Dashboard.
Action
Review format of the presented version of the dashboard.
BM
Agenda Item 10
AV + Chiltern Quarterly PALS/Complaints Report
AF/PB
The main PALS theme affecting both AV CCG and CCCG relate to GP waiting times and funding concerns.
A quality issue highlighted was a spike in challenges around a policy change effecting wheelchair services at BHT. The challenges concerned:
• Wheelchairs cannot be provided for outdoor use only.
• The wheelchair service is not funded for rehabilitation.
• The wheelchair service is not funded to supply equipment for less than six months use.
PALS are investigating the origination of the policy – whether local to BHT or NHS England.
Action
Add to January BHT CQRM and Update at January C4Q.
Agenda Item 11
Q2 SEAP Report
•
•
•
The group noted the Q2 SEAP report.
The group noted that the patient experience section was not as extensive as in previous reports. PB suggested that the use of case studies is
particularly powerful.
AF suggested that PALS and Complaints reports are linked to and connected with the SEAP reports and also Healthwatch in some way to improve
the triangulation of information where possible.
Action
Discuss quality reporting mechanisms, triangulation of data sources and themes as part of C4Q planning
cycle – Quality team development CS CSU Quality Team, CCG Directors of Quality and committee chair.
Agenda Item 12
IPC Report
•
•
AW/BM
AW/BM/AF/P
B
HCAI status was reported for November. 1 case of MRSA reported for Chiltern CCG. The post infection review concluded that the case was
considered as unavoidable. C.difficile: Aylesbury Vale are currently 1 case below trajectory. Chiltern are 5 cases above trajectory. The reviews do
not show any lapses in care. BHT and HWP are currently in line with their trajectories.
A repeat assurance visit to the spinal injuries centre (St Andrews and & St Patricks wards) was conducted in December 2014. The wards were
assessed as being much improved and currently compliant.
4
December minutes 17/12/2014
Agenda Item 13
Safeguarding
A summary of (adult and children) safeguarding multi-agency reviews and serious incidents ongoing in December 2014 was presented. The format is new
and TA welcomed any comments and suggestions. The lack of designated doctor continues and is monitored through the Safeguarding Steering Group
supported by CCG Clinical leads and Named GP. It was highlighted that there is a Learning Disability Safeguarding Lead gap in BHT- BHT and Southern
Health Foundation Trust are working on options for support and working closely with the Adult Safeguarding Lead.
Action
Send any comments and suggestions on new report format directly to TA.
Agenda Item 14
JET Update
TA
There is work in progress to improve and formalise links and communication between the quality committee and the JETs and localities. Specific
mechanisms for this are being discussed. AF emphasised the need to incorporate more intelligence on patient pathway journeys into the committee,
including engagement with JETs and localities but also with other organisations and associates.
Action
Discuss quality reporting mechanisms, triangulation of data sources and themes as part of C4Q planning cycle –
Quality team development CS CSU Quality Team, CCG Directors of Quality and committee chair.
Agenda Item 15
Multiagency SIRI Review – NHS 111
AW/BM/AF/PB
The group discussed the complexity of the multi-agency SIRI review process. A report on the MAR held in November 2014 including a suggested
framework and process for future reviews will be presented at the January meeting. PB suggested that an option could be that they are managed by the
lead provider rather than commissioners.
Action
Report to be presented in January 2015.
Agenda Item 19
Risk Register
LB
The group noted the current risk register. No changes have been made since the last revision.
Action
PB and AF to review suggested amendments to the risk register.
PB/AF
AOB
It was announced that Jon Wallis will be leaving the committee. The group thanked Jon Wallis for his contribution.
Date and Time of next meeting: 21st January 2015, Large Meeting Room, Chiltern CCG, Amersham.
5
4. Commissioning for Quality Committee – Action Log 21ST January 2015
No
Action
Decision Taken
Who
When
Status
open
2014/025
2014/63
To agree schedule of commissioner
Quality Assurance visits for the
remainder of the year
•
•
Observation visit Report -Community
Mental Health.
Dates for visits to be arranged as a
priority.
HW are undertaking an access/car
parking consultation and the report is
likely to be complete by November
2014. Share report at December C4Q
closed
Delayed
KC
End of
February
2015
Kay Collerton to work
on plan for annual
schedule of visits.
BP/BM
14/11/2014
Open – HW reports are
being reviewed by the
new C/E. Deferred to the
Jan 15 meeting. Remove
on receipt of report
2014/84
Investigate whether there is a
correlation between staffing levels
and complaints – BM
To assess for reporting for C4Q 2015 –
remove following February report
BM
18/02/2015
Open - In progress –
See SIRI report for
staffing analysis
2014/85
Noted in discussion around
complaints - that there were
longstanding issues and themes so what has the learning/action
been. Add this to C4Q standard
process document.
To add to the provider CQRMs 2015.
AW
25/03/2015
For closure
2014/86
There is overlap between HCA1
and the highlight report SB and AW
to work together to clarify reporting
times
Separate reports, Ensure differentiation
between reports against bucks patients –
IPC / providers – Highlight reports.
AW
Closed
AW/SB – Remove
from action log at
January meeting.
2015/87
Review the format of the presented
version of the Quality Scorecard.
A data capture dashboard developed on
Tableau – managed by the analytics team
– with input from Quality.
AW/BM
21/01/2015
Open – Process of
development has
begun between quality
and analytics in
CSCSU
6