Version 3 – 11th April 2016
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Version 1 : February 2 0 1 6
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Contents
Page No.
Plan on a Page
2
Chair’s Foreword
4
1
Introduction and Context
5
2
What will the future look like? A new relationship with patients and communities
8
3
The Nine ‘Must Dos’
21
4
The Ten National Programmes
134
5
Governance
192
6
Business Development, Planning and Resilience
199
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Birmingham South Central Chair Foreword
“As we look forward to 2016-17 there is no doubt that we face considerable challenge as a health and social care system. I would particularly highlight significant budget
reductions in the Local Authority’s Public Health and Social Care expenditure in the context of obesity, physical inactivity and the increasing numbers and complexity of
vulnerable children and adults. I heard significant concerns about mental health services at our AGM in September and this debate, rightly, continues in the national media.
On top of this there is still record underfunding in General Practice in the context of rising demand and real concerns about its future viability. Many acute providers are in
deficit and it might be that any transformational monies evaporate simply in attempting to meet demand in the context of the how system is currently set up.
I like this quote from Buckminster Fuller, “When I am working on a problem, I never think about beauty but when I have finished, if the solution is not beautiful, I know it is
wrong.” As a CCG we have started on a number of transformational programmes taking on the above challenge with a combination of realism and optimism with courage
and compassion. I reflect on our work in diabetes prevention, safeguarding, 0-25 CAMHS redesign and 7 day access to date. We see this as a great start but we need an
outstanding middle and a brilliant finish.
The “Sustainability and Transformational Plan” (STP) mandated by NHSE brings together commissioners and providers over Birmingham and Solihull and this will create a
dialogue that will bring us closer to solutions. We will focus with laser like intensity on maintaining the promises in the NHS Constitution which includes A and E and
ambulance waits and numerous cancer standards. I would like to stress the need for much greater capacity in diagnostics and we will perform a system wide review to
facilitate improved cancer waits. I would highlight, too, our Macmillan funded cancer survivorship programme- well done to all involved so far! Other priorities at the level
include non- emergency patient transport and a dementia strategy
There is much to be done in mental health and our investment will increase as we mobilise FTB, integrate our wellbeing hub into this service and drive forward the “New
Dawn” review. We must build services that are sensitive to the trauma experienced through “Adverse Childhood Experiences”
General Practice will continue as a key focus for us and we will plan to improve the estate, develop and fund a workforce strategy and support the establishment of a GP
Federation. Building on the Challenge fund will enable us to potentially offer 7 day access 8-8 365 days a year to all our patients. Integrating this into 111, OOH and Urgent
Care Centres could be the single most important transformational element to reducing non- elective admissions in hospitals.
Although none of this might appear “beautiful” in the solution phase I strongly believe that, if we can mobilise all our plans, we will look back in years to come and say that
this move to a” more preventative socialised model “did indeed fulfil Fuller’s criterion.
I would like to end this foreword, again, on a note of celebration and with thanks to all our fantastic providers whether our member practices, community services and
voluntary sector or acute trusts.
We have achieved a lot together and we need to press on with new models of care to meet the challenge this generation is uniquely placed to answer- and these plans are
a significant part of that solution and I commend them to you.”.
Dr Andrew Coward – Chair, Birmingham South Central
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1.1
Introduction and Context
Introduction, Context and Background
The healthcare system is facing the challenge of significant and enduring financial pressures. People’s need for services continue to grow faster than
funding, meaning that we have to innovate and transform the way we deliver high quality services, within the resources available, to ensure that patients,
and their needs, are always put first.
This Operational Plan sets out how Birmingham South Central (BSC) CCG intends to respond to this challenge during 2016/17, to deliver improvements in
the health and health services of the Birmingham South Central population and how we will ensure that local services are transformed through partnership
working with patients, the public, neighbouring CCGs, Local Authority, provider organisations and NHS England.
BSC recognises the scale of the current and future financial challenge. The CCG has a
central role in delivering savings and cost-effectiveness to ensure continuing financial
balance on a recurrent basis. We also have a responsibility to ensure we invest to
support service transformation, which will secure both health gains and improved
outcomes and efficiencies.
The CCG has grown by approximately 20% following 10 practices joining in April 2015,
taking the overall population of the CCG from 253,000 to 298,500 in our latest
constitution.
BSC has maintained and built upon the strong existing local knowledge, joint working
and governance arrangements. Active engagement and delivery is occurring at a
network level. There are 5 mature Networks with developed localised areas of interest,
each Network comprising of 6 - 23 practices (40,000-105,000 patient population). The
Networks are based on groups of likeminded GPs across geographical catchment areas.
Clinical commissioning through this structure provides us with the best opportunity to
ensure that we maximise clinical engagement in the challenges we face, steer clinical
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understanding into the commissioning process and embed a local focus in our plans. Our continuous work to engage and consult with local communities
and partners over the last year has shown us that we are moving in the right direction. We are ambitious and determined to ensure that through this Plan
we will deliver the improvements to health and wellbeing that our population needs and deserves.
The BSC patient “PPLEA” is borne out of these needs as follows:
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1.2
Prevention – Take a proactive rather than reactive stance on health with preventative measures at the top of the commissioning agenda.
Partnership Working – with each other (GP Practices, networks and other CCGs); the 3rd Sector; Providers; wider stakeholders (LA, Schools,
Community groups)
Localism – a ‘grass roots’ approach to commissioning with local priorities taking precedence
Education – in supporting prevention, education is key to improving the health of the community
Access and Quality of Primary Care – transparent quality frameworks across BSC to ensure consistency in access to and the quality of services
being delivered. This will inevitably lead to the expansion of primary care with associated resource.
Five Year Forward View
The NHS Five Year Forward View was published on 23 October 2014 and set out a vision for the future of the NHS. It was developed by the partner
organisations that deliver and oversee health and care services including NHS England, Public Health England, Monitor, Health Education England, the Care
Quality Commission and the NHS Trust Development Authority. Patient groups, clinicians and independent experts have also provided their advice to create
a collective view of how the health service needs to change over the next five years if it is to close the widening gaps in the health of the population, quality
of care and the funding of services.
The purpose of the Five Year Forward View is to articulate why change is needed, what that change might look like and how we can achieve it. It describes
various models of care which could be provided in the future, defining the actions required at local and national level to support delivery. Everyone will
need to play their part – system leaders, NHS staff, patients and the public – to realise the potential benefits for us all. It covers areas such as disease
prevention; new, flexible models of service delivery tailored to local populations and needs; integration between services; and consistent leadership across
the health and care system. The 2016/17 Shared Planning Guidance builds on this, Delivering the Forward View: NHS Planning Guidance 2016/17 – 2020/21
requires NHS bodies to produce two separate but connected plans:
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a five year Sustainability and Transformation Plan (STP), place-based and driving the Five Year Forward View; and
a one year Operational Plan for 2016/17, organisation-based but consistent with the emerging STP.
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Place-based planning
Planning by individual institutions will increasingly be supplemented with planning by place for local populations. For many years now, the NHS has
emphasised an organisational separation and autonomy that doesn’t make sense to staff or the patients and communities they serve.
1.3
BSC Mission and Values
From its inception BSC has invested time and effort in to ensuring that all members are actively engaged with
the work of the CCG and that all Practices have the power and opportunity to influence how the CCG works
and what it stands for. Put simply, the CCG wants to develop with its members an identity and integrity which
forms a vital element of how we do business.
BSC has agreed a vision and a set of values and behaviours which are enshrined in the BSC Constitution. The
BSC public and stakeholders were fully consulted on the mission and values.
The CCG has matured greatly in the last 24 months and is well known for its principles and culture. As part of
the refresh of the Constitution we have revisited our values and behaviours, alongside our members, staff,
partners and our patients. Our ambition is to ensure we maintain a clear solution focus on improving quality,
delivery and outcomes through strong partnerships and best use of resources.
Mission
Best Care, Best Place, Best Time…
‘Aspiring to work together with our partners and communities to improve long-term health and wellbeing of
our citizens, through clinical excellence, innovation, and person-centred leadership’.
Values
The values that lie at the heart of BSC’s work are set out in the adjacent diagram.
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2
What will the future look like? - A new relationship with
patients and communities
2.1
Improvements for Patients
We have used the NHS England produced RightCare pack and other information including the
locally CSU produced QIPP Opportunities tool to analyse our position and priorities against the
Delivering the Forward View ‘Must Do’s ‘ and National Programmes. We have also directly
engaged with Stakeholders and Member Practices to agree and review priorities with a clear
focus on the NHS Constitution under the banner of ‘Improvements for Patients’.
Our engagement programme for this year’s commissioning intentions consultation
“Improvements for Patients: Tell us how you want us to spend your money”, commenced in October 2015. The programme set out a number of
opportunities for the public, our patients, service providers and wider partners to test, challenge and shape the future commissioning directions of
Birmingham South Central Clinical Commissioning Group (BSC CCG).
It also provided an opportunity to confirm our current direction of travel, local mandate and the relevance of our PPLEA (Prevention, Partnership Working,
Localism, Education, Access & Quality of primary care) commitment as mentioned in the introduction to this document.
In line with our revised engagement approach we have worked hard to ensure that our activities were accessible, relevant and
responsive. They included our recently launched ‘Ideas Café’ drop-in activities, allowing people to explore issues in a social,
informal, but structured way at a variety of venues, as well as a public question & answer session in partnership with ‘Different
Anglez of Society’ and New Style Radio 98.7FM.
Themes, Questions & Feedback
This year’s programme focused on the following key themes:
1. Primary Care & Access
2. Mental Health and Wellbeing
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3.
4.
5.
6.
Urgent Care
Children’s & Maternity
Integration
Safeguarding
It also considered wider context issues such as:
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Care for vulnerable people
Ensuring Quality & Safety
The NHS Constitution & Patient Promises (including Cancer services)
NHS England Directives
Medicines- Access & Safety
Child Sexual Exploitation (CSE)
Female Genital Mutilation (FGM)
Domestic Violence (DV).
For each of the key themes we created a simple feedback sheet that described the service (or issue) and posed two key questions. People were then asked
to respond at an Ideas café, online or by post. This feedback was used to inform the final workshop activity and public questions and answer session.
Member Council Engagement
As part of the development process a session was held with BSC CCG’s Members Council on the 11th November, the member practices worked through the
themes and questions for feedback to ensure they were as clear and supportive as possible.
Stakeholder and Member Practice Commissioning Priorities Development Session
Our main engagement workshop was held on the 2nd December at The Saffron Centre, Balsall Heath. The event was attended by over 50 delegates and
allowed for a facilitated exploration of the key themes. The session allowed delegates to consider aspects of each theme through structured discussions and
provided a rotation of table groups to ensure an opportunity to input into each. The session was convened and concluded by our chair, Dr Andrew Coward,
with the feedback collated in the following section.
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2.1.1
Priorities Identified by Stakeholders
Primary Care
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Integrated Care
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Urgent Care
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Safeguarding
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Mental Health
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Maternity & Children
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2.2
Relationship with our Stakeholders
The Public Sector’s conversation with those it serves is changing. We believe that over time the process of consultation and involvement has become too
formal and is often too remote from the day to day lives of our citizens. Effective partnerships are crucial to adapting public services to rapidly changing
need and to underpinning our dialogue with the citizens we serve across the city.
Our partnerships approach is based on three key engagement principles:
1. Our activity must be accessible- How do I get to it? We must ensure that citizens can understand, explore and identify with our services openly in a
way that is social, informal, yet structured.
2. Our activity must be relevant- How will it affect me? We must clearly relate our services to the day to day lives of our citizens based on local
context and lead by our membership.
3. Our activity must be action-orientated- What difference does it make? This means an approach that operates in real-time, demonstrates an open
capture of feedback and promotes dialogue through a variety of means.
Our new partnerships framework builds on BSC CCGs ‘communications and engagement strategy 2012-14’ and outlines the organisation's approach to
developing, embedding and sustaining effective partnerships across our membership, with local citizens and organisations.
For BSC CCG, communications and engagement are key elements of our partnership work, driven by a community development focus and the notion of the
NHS as a social movement. Building on our ‘Big Social Conversation’ we have revised our engagement approach to ensure that our activities are more
relevant and responsive. We have recently launched:
A new Citizens Group to initiate projects around key themes and topics. The Citizens Group is a citizen-led group within BSC, which is tasked with
strengthening the relationship between commissioner and community. It seeks to put people and patients at the heart of the CCG’s decision-making
through real time projects and accessible activities.
The Citizen’s Group seeks to:
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Listen to and act upon patient voice
Ensure an ‘experts by experience’ approach
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Check and inform local delivery and the personal impact of commissioned services
Act as a focus for collaborative project work through community research
Challenge commissioning decisions and the engagement approach of the CCG
Provide evidence and assurance through creative engagement
Collect community intelligence over time and identify trends
Citizens Group Model
The citizens group and our mixed engagement model is being developed
with support from Birmingham Voluntary Sector Council (BVSC), University
of Birmingham, Newman University, Aston University, Birmingham City
Council, St. Basil's, Gateway Family Services through their expertise, advice,
networks and the recruitment of volunteers.
For further details: Stakeholder Council Review Summary paper
Ideas Café drop-in activities at a variety of venues to explore issues in a
social, informal, but structured way. We are committed to running at least
one activity per month and making closer alignment to our commissioning
intentions work across the year.
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Community Radio projects including a
quarterly public question & answer session
with our CCG chair and a guest panel in
partnership with the ‘Different Anglez of
Society’ programme and New Style Radio
98.7FM presenter Charmaine Burton. We are
also developing a ‘positive partnerships’
initiative through a regular monthly show on
the station.
We are facilitating a bi-monthly Patient Participation Group (PPG) forum to bring
together lead representatives from across our networks and to consider their
role, better communications and outline mutual expectations.
We have consciously moved to a more community and place-based focus,
allowing for wider engagement and conversations beyond GP practices and care
settings. We are also building links to the national NHS Citizen project as a local
demonstrator site.
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To cater for targeted consultation on specific
topics, issues and policies we are developing an
ad-hoc series of focus groups. Snapshot
activities will also help us to refine, develop and
co-design our engagement approaches more
effectively. Attendees will be invited from a
recruited pool of volunteers and we will work to
build an active membership that is updated
monthly and participates in simple monthly
opinion polls.
We will continue to build our Annual General
Meeting (AGM) as a flagship event for BSC CCG
and as an opportunity to celebrate our
achievements with our GP membership,
partners, stakeholders, providers, third sector,
the public, service users and staff. In 2016 we
will use this event to encourage healthy lifestyle
choices, explore our community impact and to
improve the health and wellbeing of our
citizens. The AGM will also incorporate our BSC
Awards 2016.
For further details:
AGM report
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Annual Report
On-line - Last year our website achieved over 155,000 hits, with a growing audience on
mobile and tablet devices. We are looking at ways in which we can improve our digital
dialogue to complement our wider citizen engagement within the locality. This work will
include a brand new website for 2016.
Twitter Statistics
@BSC_CCG
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BSC
joined Twitter
September 2009
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BSC has
over 6,400 followers
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BSC
follow over 2,640 accounts
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BSC has tweeted over 7,600 messages since 2009
We will build on our established blog to create a regular narrative about the life of the
CCG and the challenges it faces. Content will be drawn from across our staff roles, local
geography and clinical areas.
We will also facilitate a Linked-iN group to engage colleagues from partner agencies across the city, a monthly podcast with our chair and host Twitter days
to improve our on-line presence, linked to the launch of our new website.
Healthwatch
We will continue to work actively with colleagues in our local Healthwatchs (Birmingham and
Worcestershire respectively) to complement our public involvement activities and to strengthen
patient feedback & experience data. We will support Healthwatch as it refocuses in relation to
revised remit under the CQC.
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its
3
The Nine “Must Dos”
3.1
Sustainability and Transformation Plan
Planning by individual institutions will increasingly be supplemented with planning by place for local populations. Delivering the Forward View: NHS
Planning Guidance 2016/17 – 2020/21’ set out the steps to help local organisations deliver a sustainable, transformed health service and improve the
quality of care, wellbeing and NHS finances. The Five Year Forward View identified these three ‘gaps’ as where improvements were necessary to create a
sustainable and transformed NHS by 2020/21.
Birmingham South Central CCG is committed to supporting
the Health System to deliver this Triple Aim, a framework
that describes an approach to optimising health system
performance through the simultaneous pursuit of three
dimensions:
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•
improving the quality of healthcare
improving the health of the population, and
achieving value and financial sustainability.
It highlights the importance of working on all three
components in parallel and recognises the
interconnections; a change in one component can affect
the other two, either positively or negatively.
Every health and care system is asked to come together to
create its own ambitious local blueprint for accelerating its
implementation of the Forward View. Commissioners and
providers in localities need to agree a transformation
planning footprint (unit of planning) to deliver a
Sustainability and Transformation Plan (STP), as part of the
journey towards place-based planning – this will require
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national and local organisations to work and behave differently to deliver. STPs will cover the period between October 2016 and March 2021, and need to
be submitted for consideration in June 2016. The Plan needs to show how local services will evolve and become sustainable over five years – providing
clarity about how the locality will close all three gaps and deliver on national priorities between now and 2020/21.
THE Key features of an STP include:
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Integrated approach to cross boundary and specialised care
Population and patient flow
Commissioning partnerships
Provider clinical networks
Layers that allow focus at right level
New Models – can be implemented within this footprint
The agreed STP footprint BSC falls in covers Birmingham and Solihull.
3.1.1
Birmingham and Solihull Sustainability and Transformation Plan
The STP for Birmingham and Solihull encompasses the following key stakeholders:
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Birmingham Cross City, Birmingham South Central and Solihull CCGs
Birmingham City Council and Solihull MBC
UHB/HEFT, BCH/BWH, BCHC, BSMHT and ROH providers
Vanguards involving ROH and BSMHT
Boundary issues – Key interfaces will need to be made with the following associates:
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South Staffordshire
Worcestershire
Sandwell and West Birmingham
Within the STP most of the providers have a wider tertiary footprint making specialised commissioning particularly important to the STP document.
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The draft governance framework for the STP is articulated in section 5.2 of this document.
3.1.2 RightCare
Section 4.1 of this document discusses RightCare in more detail. We are committed to using the RightCare approach to support the Sustainability and
Transformation Plan Programme; Birmingham Cross City CCG is part of the Wave One of the RightCare delivery support. As a group of CCGs we will work
together to review our Commissioning for Value packs and agree common areas we need to focus on. By June we will have agreed “where to look” but
already understand the following actions have taken place:
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Solihull has reviewed their CfV pack and are targeting MSK – MSK pathways have been or are in the process of being designed
BXC has met their development partner and discussed MSK with a view to having further meetings
BSC has reviewed our CfV pack and highlighted respiratory, trauma and injuries, MSK, cancer and common mental health pathways
At the recent RightCare Regional Launch we agreed there are some common themes across all CCGs such as respiratory, Mental Health and MSK that we
should work on together. There are already programmes of development in mental health (primary care mental health and New Dawn in Birmingham) and
the spinal pathfinder through the planned care SRG leading to a more in depth development of an MSK pathway which an MSK triage service would front.
As part of the “Where to look”, before we decide what to change ( via a clinically led group receiving deep dives, undertaking service review and building
the case for change) we will map current developments and do a gap analysis.
In addition we understand further work is required in terms of:
•
•
•
3.1.3
Need to get the balance right between local CCG issues and STP issues
How the current CCG QIPP plans relate to the findings contained within CFV packs and expected Focus packs
Be clear via the Programme what the priorities are within the STP and how these are taken forward
Better Care Fund
We are part of a system which is committed to transformation of all its part to deliver sustainability moving forwards. With our Local Government and
wider partners we are building a vision that recognises the importance of economic success for our citizens and the key roles of work and education in
future health and wellbeing. In the shorter term we are developing a programme of work which systematically aims to remove avoidable demand from the
whole system and drives productivity through eliminating unwarranted variation, improving efficiency and implementing new ways of working including
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new models of care. We have made a start through our Better Care Programme which has supported improved relationships and greater understanding
between partners and also delivered improvements in some key metrics, but we now aim to move at scale and pace together to deliver radical change in
primary care, hospital and social care systems for both mental and physical health.
The system operational plans form the basis of year 1 of this plan and will be subject to refinement as our planning progresses to consider the three NHS
England challenges of closing the health and wellbeing gap, the care and quality gap and finance and efficiency gap.
Better Care Fund Plans 2016/17
A summary of the existing BCF schemes and the scheme actions planned for 2016/17 are outlined below.
Scheme 3: Place Based Integration & Accountable Community Professional
Scheme Aim: : Joining up the system in relation to the interface between statutory and non-statutory services by establishing the role of volunteer based
Wellbeing coordinators, based on best practice, ensuring the third/voluntary sector can take an active role in supporting prevention. Delivering an NHS
facing commitment to carers which supports BCC activities. Developing Primary Care MDT to support proactive and anticipatory care planning for people to
support them to stay well for longer in their normal place of residence.
Scheme Actions planned for 2016/17:
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•
•
•
•
•
Full implementation of the wellbeing coordinator pilot
Development of Birmingham Route2Wellbeingbringing together information on voluntary sector services into one place, also linking to the existing
BCC website
Working with Primary Care to further develop the approach to anticipatory/proactive care planning and MDT single assessment
Revised service specifications for Rapid Response and IMT’s within the BCHC contract with an associated service development improvement plan
Introduction of frailty CQUIN at BCHC to further develop the approach to anticipatory/proactive care planning and MDT single assessment
Evaluating all Care Homes Projects
Establishing deliverables across Carers work stream
Scheme 4: Equipment & Technology
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Scheme Aim: Setting the strategic direction to support future plans for equipment & technology, manage the transition from the current system to reduce
fragmentation. Providing a robust mechanism and pathway for a fully integrated and coordinated approach, implementing an information and Technology
Hub for both social and healthcare. Developing access to retail provision of equipment and services to enable the self-funded and enhance/promote selfcare ensuring through the programme that equipment and assistive technology are considered within new service delivery models.
Scheme Actions planned for 2016/17:
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AT Home communication packages to improve awareness of assistive technology
Future vision of assistive technology to be developed. What is available; who will benefit and what can we achieve?
Scheme 5: Care in a Crisis- Intermediate Care
Scheme Aim: Implementation of a Clinical Utilisation Tool (CUR) across the city. Evaluate and develop outcome based service specifications for provision of
any new delivery models required to support transformational change, if applicable, across a city wide intermediate care provision. Develop integrated
primary / secondary / social care interface and care pathways / protocols to support care in a crisis, avoidable hospital admissions and earlier discharge
across Birmingham.
Scheme Actions planned for 2016/17:
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CUR CQUIN within all provider contracts for 2016/17
Rapid Response and Enablement teams – move to a single recovery through revised service specifications and SDIPs
Revised Core Bed specification for BCHCT for 2016/17 and associated service development improvement plan
Virtual beds pilot continuation until March 2017
Implementation of changes to Dementia Beds
Length of stay reductions across BCHC/EAB/D2A/Dementia beds through increased efficiency, the use of CUR and increased enablement support
Review of Birmingham Bed Brokerage
Scheme 6: Instigate 7 day health and social care services
Scheme Aim: Deliver the 2016/17 requirements for 7 day services across the system. Implement the 10 Clinical standards across acute trusts. Develop 7
days service standards across community, mental health and primary care including and where appropriate across social care. Provide status overview of 10
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Clinical/Community standards to aid local gap analysis. Oversight of Service development Improvement plan (SDIP) across organisation relating to clinical
standards working alongside CCG contracting teams.
Scheme Actions planned for 2016/17:
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7 Day services SDIP included within provider contracts
SRG operational plan for system wide 7 day services in 2016/17
STP plans for 7 day services
Scheme 8: Data Sharing and integration
Scheme Aim: To improve data sharing between health and social care partners as part of the Birmingham Better Care programme, efficiently and
effectively for the benefit of its citizens and within the law and in line with robust information governance guidelines. Including but not exclusively to the
data protection act and Caldicott Guardian principles.
Scheme Actions planned for 2016/17:
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Digital SDIP included within provider contracts for 2016/17
System wide data sharing agreements put in place for 2016/17
Scheme 9: Dementia
Scheme Aim: Support the delivery of the pan-Birmingham Dementia Strategy, ensuring the needs of people with dementia are incorporated in the
developing work of the Better Care Programme.
Ensure that commissioning for dementia adopts whole systems approach between health and social care commissioners and providers. To develop robust
action plans that reflect where dementia fits with operational planning (including any KPI’s) this will underpin the delivery of the dementia strategy.
Scheme Actions planned for 2016/17:
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Development of the memory assessment pathways and options appraisal of post-diagnostic clinical pathways for people with dementia with
Primary Care.
Delivery of Birmingham’s Dementia Strategy
3.1.4
National Maternity Review
A major review of maternity services across the local health economy in Birmingham (including Sandwell and Solihull) is planned during 2016 in order to
address the recommendations of the National Maternity Review. The expected outcomes are aimed to also address the pressures on capacity, workforce,
promoting choice of place of birth (including at home or in midwifery-led units) and ensuring improved safe birth for the most complex presentations. To
support the improvement in maternity services, a number of specific developments will be implemented in-year including improved patient experience,
greater choice of place of birth, support to vulnerable women and addressing issues to improve perinatal mortality.
Children’s Services
3.1.5
Children’s Community Services - We will continue to improve community therapy services to children during 2016/17 which includes targeting
improvements to those most at risk. This will include:
•
•
•
•
•
•
•
reviewing and implementing a revised Looked After Children’s Nursing Service
Implement a palliative care strategy to include children
review and revise community paediatric services
review children’s Community / Acute Nursing Pathway for complex cases
Review and revise children’s continence services in Birmingham
Review provision of school age eye screening across range of providers in Birmingham
Special Educational Needs and Disabilities, continue to develop and implement requirements outlined in the Children’s Act (2014)for children in
Birmingham
Acute Paediatric Services – During 2016/17 the intention is to reinvigorate the local paediatric forum developing a provider/commissioner work plan to
improve none elective pathways, surgical pathways and link to community prevention of respiratory disease at the earliest point.
This will include addressing:
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1. The health and wellbeing gap – how through prevention and support in primary care we can reduce the demand on hospital A&E and admissions of
under 18 year olds
2. The care and quality gap – how working with primary, community and acute care we can join up pathways in order to provide care sooner and
more effectively
3. The funding and efficiency gap – consider more efficient and cost-effective ways of delivering care to children for example addressing variation in
provision in our area.
3.1.6
Strategic Review Of Care Of People With Chronic Pain In Birmingham, Sandwell And Solihull
Currently, the care for patients with chronic pain can vary across Birmingham and waiting times for patients to be seen within these services can sometimes
be quite long. Adult pathways of care are not always clear and this can result in unjustifiable duplication, gaps, inefficiencies and variation in access to
these services. In the longer term, this can result in a poor patient experience and sub-optimal outcomes for patients. The position in relation to children
and young people with chronic pain is that no service is currently commissioned in the West Midlands and children and young people are often referred out
of the region. Waiting times for some services are long.
As a direct result of these issues, regional commissioners and providers have agreed that a Strategic Review of the care of all both adults and children
suffering with chronic pain should take place. This review will form part of the West Midlands Quality Review Service (WMQRS) 2015/16 work programme
for these health economies and will commence in April 2016
Aims and Objectives
The aim of the strategic review is to make progress towards equitable access for children, young people and adults with chronic pain to high quality,
effective services which meet their needs and make efficient use of NHS resources.
The review’s objectives are:




To identify the strengths and weaknesses of current services for people of all ages with chronic pain in Birmingham.
To identify areas of unmet need for care of people with chronic pain.
To develop a vision for care of people of all ages with chronic pain based on evidence of good practice and effective outcomes.
To develop proposals for clear, consistent, equitable pathways of care for people of all ages with chronic pain which are:
o Easy to understand and use by GPs and patients / carers
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
o Clinically agreed, including by GPs, and supported by commissioners
o Have clear goals and outcome measures
o Provide care by appropriate staff in appropriate settings (primary / secondary care, community / hospital)
o Identify the multi-disciplinary input required
o Include appropriate links with mental health, muscular-skeletal and other relevant services
o Have clear exit points
o Make good use of resources
To identify the actions required by commissioners and providers to achieve implementation of the agreed vision and pathways of care.
Scope
The Strategic Review will cover the care of adults with chronic pain in Birmingham, Sandwell and Solihull and children and young people with chronic pain
from across the West Midlands. Transition of young people to adult services will be included.
The review will cover all types of chronic pain and all children, young people and adults, including those with neurological disabilities or learning disabilities.
3.1.7
Digital Road Map
The local digital roadmap comprises 4 CCG’s, 6 Acute Hospitals, 1 Community Trust and the Ambulance service. With an intention in the first quarter of
2016 to integrate the ‘Better Care Fund’, to provide a more robust vertical integration of digital services. The steering group is led by the CIO and CCIO’s of
the respective organisations to ensure that clinical needs are matched by technical knowledge.
The early stages of the LDR process, has resulted in a standardisation in the form of Service Development Improvement Plans (SDIP) that tackle digital
equality of key requirements throughout the footprint. These include the electronic transfer of referrals and discharge letters to ensure the transition of
patients in and out of shared care environments are paperless. A second theme revolves around the full implementation of a local health record spanning
all of the organisations and allowing an informed transition of care that is facilitated digitally. The third piece of work being currently undertaken is a
unification of strategies to tackle the overarching regional strategy; this is currently awaiting supply of the overarching Digital Maturity Indices from NHS
England in order to progress further.
3.1.8
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Palliative and End of Life Care
Adult Palliative Care and End of Life Commissioning Strategy for Birmingham
Following the development of the ‘Integrated Palliative and End of Life Care Commissioning Strategy for Birmingham 2014/15 – 2017/18’, Birmingham
Cross City CCG and Birmingham South Central CCG have developed an implementation plan to support the delivery of the strategy. This plan sets out a
range of actions which will be delivered over the next twelve months commencing in January 2016.
The care that people receive at the end of their lives has a profound impact not only upon them but also upon their families and carers. At the most
difficult of times, their experience will be made worse if they encounter poor communication and planning or inadequate professional expertise.
Objectives
There were three strategic objectives identified as part of the Integrated Palliative Care and End Commissioning Strategy for Birmingham, these are set out
below:
•
•
•
Identification of patients: We will ensure that the number of patients who are identified as having palliative care needs increases, and
that these patients have access to, and receive appropriate high quality palliative and end of life care
Care planning: We will ensure that patients and their carers receive the information and support to manage care according to their
choice and needs.
Delivering choice: Improved care planning and the provision of choice will result in a reduction of the number of avoidable emergency
admissions to hospital for patients receiving palliative or end of life care.
Workstreams
A review of these workstreams has recommended that there should be three workstreams going forward which will form the framework to deliver against
the strategy as follows:
1. Primary Care – GPs and out of hours services.
2. Secondary Care Services – hospitals.
3. Community Services – hospice, other voluntary sector, district nursing and care homes.
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Whilst it is recognised that workforce and training is critical to provision of palliative and end of life services, this should be a core part of each of the above
themes and not undertaken as a separate work-stream.
IT systems to improve information sharing and care coordination is also a central part of all three above themes however, this work should be undertaken
under the primary care workstream to explore the opportunities to develop a palliative care and end of life shared records function within Your Care
Connected.
The strategy described much of the proposed workstreams as ‘service redesign’, however it is recommended that the focus for 2016 should be on gathering
comprehensive information that will inform future commissioning of palliative care and end of life services rather than redesign. Therefore, the proposed
focus will be on:





Developing better intelligence about current services.
Understand service gaps and challenges to delivering integrated 24/7 care.
Understand the CCGs current financial envelope and how to meet future demands.
Explore opportunities for innovation and to improve quality of services (e.g. using new technology).
Compassionate cities approach to build community capacity and resilience
The provision of palliative and end of life care for our patients represents one of the most challenging areas of clinical practice, but also one of the most
rewarding. No two patients are the same, and we are privileged to be able to support and care for patients and their carers at this unique time in their
lives. But we only have one chance to get it right.
Paediatric Palliative Care Strategy for Birmingham
Following the development of the ‘Integrated Palliative and End of Life Care Commissioning Strategy for Birmingham 2014/15 – 2017/18’, the CCG is now
leading on the development of an Integrated Palliative and End of Life Care for Children and Young People Commissioning Strategy for Birmingham 2015/16–2017/18. The strategy is being developed in collaboration with Birmingham Cross City CCG and Sandwell West Birmingham CCG.
Children and young people with life-limiting illness represent a growing challenge for health and social care services. Their diagnoses are diverse and with
advances in paediatric medicine, improved survival and greater use of medical technology, their needs are becoming increasingly long-term and complex.
Currently, most children and young people who die have long-term life-limiting conditions. They mostly die in hospital, frequently in an intensive care
environment, where the most common mode of death is withdrawal or limitation of life-sustaining treatments, with all the clinical, ethical and emotional
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dilemmas that this situation presents. There is also evidence to suggest that the length of stay in the paediatric intensive care unit before death is
increasing.
The death of a child is a profound, unique and devastating event for a family. Evidence suggests that families facing the death of a child wish for well-coordinated healthcare, with the option of this care being delivered in the home environment.
In view of this our vision is for all patients and their carers, including children and young people, across Birmingham to have 24/7 equitable access to high
quality, consistent palliative and end of life care when they need it, with accurate identification and proactive management of all of their palliative care
needs: physical, social, psychological, spiritual and cultural.
At the moment current palliative and end of life care services:




Vary across the city, is inconsistent, and does not meet the needs of the growing number of children and young people who need this type of
care.
Do not meet national guidelines and recommendations.
Lack consultants in some providers.
Do not meet the cultural needs of all patients and their families.
We want a service that is:







Available to all Birmingham patients, whenever they need it; 24 hours a day, seven days a week.
Consistent across the city.
Of high quality.
Adequately staffed, robust and sustainable for the future.
Co-ordinated across health and social care providers.
Sensitive to the needs of all cultures and ethnicities.
Catering for all physical, social, psychological, spiritual and holistic needs.
We think this can be achieved by:

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Ensuring patients are aware of the services to support them.






Involving patients and their families in decisions about their care.
Identifying where services vary and making them consistent.
Ensuring the service meets national guidelines and recommendations.
Supporting staff to provide the best possible care by working with colleagues across organisations where necessary.
Putting efficient and effective processes and systems in place, such as IT systems, to help staff deliver an excellent service.
Listening to the views of patients, their families, health care professionals and local communities to help design the service.
A steering group consisting of key stakeholders was established in August 2014 and during 2015 ‘The Draft Palliative and End of Life Care for Children and
Young People: A Strategy for Birmingham’ was developed. A formal consultation process was undertaken between 23rd November 2015 to 7th February
2016 to further engage with stakeholders on the key components of the draft strategy. Following the end of the consultation period the findings will be
collated and included within the final version of the strategy which will be presented to the Birmingham CCGs in spring 2016 for approval.
3.1.9
Non-emergency patient transport
On the 1st April, 2013, Clinical Commissioning Groups (CCGs) assumed responsibility for funding all non-emergency patient transport (NEPT) services.
Shortly after this responsibility was transferred to CCGs, it was agreed by commissioners across Birmingham and Solihull to undertake a review of all local
NEPT services. In the summer of 2014, the outcome of this review indicated that there appeared to be a significant variation in the delivery of these services
between NHS hospital trusts across Birmingham and Solihull. The review also evidenced that there appeared to be limited information available to
commissioners regarding the quality of the NEPT services being provided and the extent to which these services were meeting the needs of patients.
On this basis, CCGs in Birmingham, Sandwell and Solihull agreed to work collaboratively to develop an overarching strategic approach for the
commissioning of NEPT patient transport. The purpose of doing this was for CCGs to develop and procure a universal NEPT service that would help to
ensure equity of provision and overarching improvements in quality, productivity and efficiency across the local health economy.
The project is being led by Birmingham Cross City CCG, in partnership with Birmingham South Central CCG, Sandwell and West Birmingham CCG and Solihull
CCGs. It also involves other CCGs and populations within the wider West Midlands area, who use NEPT services.
Phase one of this process has included a detailed review of the commissioning of all NEPT services and has resulted in local CCGs going out to procurement
on the 8th January 2016 to directly commission a new universal service CCGs for the NHS trusts listed below;

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Birmingham Women’s Hospital NHS Foundation Trust;






Birmingham Community Healthcare NHS Trust;
Heart of England NHS Foundation Trust;
Royal Orthopaedic NHS Foundation Trust;
University Hospital Birmingham NHS Foundation Trust;
Worcestershire Acute NHS Trust (Birmingham, Sandwell & West Birmingham CCGs only);
Or other primary, secondary or community NHS services as defined by the Commissioners including hospices.
It is proposed that the new service will commence in May 2017.
As part of the agreed plan to procure NEPT services at the above NHS trusts, each of the four Birmingham, Sandwell and Solihull CCGs also agreed through
their Governing Bodies that a second NEPT project will be undertaken in 2016 to review patient transport at the following NHS trusts:



Birmingham Children’s Hospital NHS Trust
Birmingham and Solihull Mental Health Foundation Trust
Sandwell & West Birmingham NHS Trust
In addition to the above, the project will also review;



Secure mental health transport at all NHS trusts in Birmingham, Sandwell and Solihull
Healthcare Travel Costs Scheme (HTCS)
Out of area NEPT for repatriations back to home area or Individual Funding Requests (IFR)
One of the themes that emerged from the 2015 NEPT consultation was around access to health care services for patients that may not be eligible for NEPT.
Therefore, a review of the Healthcare Travel Costs Scheme (HTCS) for patients on low incomes will enable CCGs to look at wider issues of access and how
these may be addressed.
This project will be led by Birmingham Cross City CCG and delivered jointly by the NEPT Project Team which is made up of representatives from all four
CCGs. This project team is already well established.
The aim of the project will be to review all the above services to develop a detailed case for change to set out a commissioning plan for CCGs by June 2016.
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3.2
The Health and Well Being Gap
3.2.1
Birmingham and Solihull
Closing the Health and Wellbeing Gap (PHE Health Profiles)
Initial Analysis of the Birmingham and Solihull Footprint as set out in the following tables shows we have considerable challenges in closing the gap against
the England metrics, particularly for Birmingham.
For example, the gaps in Life Expectancy, infant mortality and smoking related deaths along with < 75 mortality rates for CVD and cancer remain. This
similar to the other Urban Centres.
Solihull, on the other hand, has a different profile with higher melanoma rates and higher rates of diabetes recording (6.9% QoF register) - but not as high
as Birmingham (8.3 % QoF register).
Compared to the other Urban Centers Birmingham seems to do better on hospital stays for self-harm but is similarly challenged in relation to alcohol
related admissions, substance misuse, STIs and TB rates.
These metrics will need to be validated against the most up to date data available with trend analysis in collaboration with our public health colleagues. This
should then be triangulated with our current public health and CCG commissioned programmes to ensure we are closing the health and wellbeing gap.
Birmingham in comparison to England and other centers of education and business
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Life Expectancy and causes of death
Disease and Poor Health
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Adult’s health and Lifestyle
Children and Young People’s Health
Solihull in comparison to the rest of the West Mildands Region
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Life Expectancy and causes of death
Disease and Poor Health
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Adult’s health and Lifestyle
Children and Young People’s Health
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3.2.2
Birmingham South Central
Alignment of operational plans with the Birmingham JSNA
The Joint Strategic Needs Assessment (JSNA) in Birmingham is being taken forward as a process with an annual summary. The JSNA process has developed
a number of specific pieces of work that have direct relevance to the CCG operational and strategic plans. These include:
•
•
•
The Birmingham Health & Wellbeing Strategy
Excess years of life lost by CCG
Overview of the Public Health, Adult Social Care, NHS and CCG outcomes frameworks and indicator sets
Health and Wellbeing Strategy
The Health & Wellbeing Strategy has been agreed by all the partners of the Health and Wellbeing Partnership. It has been developed with three aims:
•
•
•
Improve the health and wellbeing of our most vulnerable adults and children in need
Improve the resilience of our health and care system
Improve the health and wellbeing of our children (BSC provides a leadership role on this strand, focussing on; child safeguarding, childhood
obesity prevention and infant mortality reduction)
The current strategy identifies ten strategic outcomes that cover the broad areas identified as city-wide priorities. It has also been recognised by the HWBB
that specific areas, such as the low uptake of a large number of vaccination programmes across the city should be taken into consideration in the action
plans supporting the strategy.
The agreed outcomes and actions are:
Vulnerable People
Make children in need safer
 Implementation of the Early Help Strategy to increase family support for children at risk of coming into care
Improve the wellbeing of vulnerable children




Increase the independence of people with a
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Systematic implementation of evidence based interventions relating to behaviour change
Pooling our resources to develop holistic services
Transformation of approach to life-time care for those with a learning disability
Transformation of approach to life-time care for those with mental health problems
learning disability or severe mental health problem
Reduce the number of people and families who are
statutory homeless
 Implement the domestic violence action plan
 Implement the homelessness action plan
Support older people to remain independent
 Systematic personal and environmental advice to all aged 75 and over
 Focused early intervention to those at risk, including falls and isolation
Child Health
Reduce childhood obesity
Reduce infant mortality
 Implement systematic behavioural change interventions, based on evidence, at scale, for healthy eating and
physical activity
 Review the intelligence related to infant mortality and severe morbidity
System Resilience
Health and care system in financial balance
 Develop a budget that mitigates unintended consequences amongst partners
Common NHS and Local Authority approaches




Improve primary care management of common and
chronic conditions
Mapping organisations, priorities and groups
Identify opportunities for common work areas
Establish common approaches
Systematic approach to managing and treating common health problems
 Implementation of a dynamic care record to reduce unplanned emergency activity
Excess years of life lost
The main causes of excess years of life lost in Birmingham, when compared to England have been identified as:
•
•
•
•
•
•
•
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Infant Mortality
Coronary heart disease
Lung cancer
Alcoholic liver disease
Stroke
COPD
Pneumonia
•
Malignant neoplasms of lip, oral cavity and pharynx
We will further explore the occurrences of these conditions as part of our ‘deep dive’ process and compare them with the ‘Commissioning for Value
Insights’ pack and coordinate them against our ambitions to ensure improvement.
Improving Health
Birmingham overall is a relatively young and diverse city. Sixty six per cent of the population under 45 years old, with 17% being in the 20-29 age group and
13% over 65 years old. It has the highest proportion of residents aged 18 and under out of all 8 core cities. Twenty two percent (238,313) of Birmingham
residents were born outside UK and 103,682 of these arrived in the UK since 2001. Almost 40% of Bordesley Green, (38.3%), Sparkbrook (38.1%) and
Washwood Heath (36%) ward residents reported a main language other than English. This compares with the Birmingham average of 15%.
Birmingham is ranked the 9th deprived Local Authority in the UK. Over three quarters of the city is in the most deprived 40% of areas nationally. The level
of child poverty in Birmingham is worse than the national average; based on accepted indicators 29.9% of children under 16 years in the city live in poverty.
Almost one in five households in Birmingham suffer fuel poverty compared to and England average of around 10%. The impact of an impoverished
childhood upon the emotional health and wellbeing, resilience, and illness of children and young people is significant.
These levels of deprivation are reflected in the health outcomes for Birmingham relative to England, with life expectancy in Birmingham for men 77.6 years
and women 82.2 years compare to national figures of 79.4 and 83.1 years respectively. Healthy life expectancy is also lower than the national average at
58.8 years for men and 60.5 years for women compared to 63.3 and 63.9 years.
The Birmingham Health and Wellbeing Board (BHWBB) has developed its Strategy to deliver better health and wellbeing for residents, focussing on the
most vulnerable. The strategy was developed with the involvement of a wide range of partners acknowledging the influence on health and wellbeing that
extends well beyond those services provided by Birmingham City Council and the NHS.
The process for developing the strategy has included a detailed examination of what is known about health and social care need in Birmingham. Since 2008,
Birmingham has developed a comprehensive Joints Strategic Needs Assessment (JSNA) that has explored a range of factors that affect health and wellbeing.
This JSNA process has produced over forty reports that include issues as varied as cancer, mental health and substance misuse. The JSNA also sets out
pictures of each of the wards in the City. In November 2015 an update of current performance has shown that against the priorities there are concerns
around the ability to achieve the agreed targets for:
•
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Adults with a learning disability who live in stable and appropriate accommodation Adults with a learning disability who are in employment
•
•
Emergency Hospital Admissions
Infant mortality,
And, there is a need to review the indicators and targets for:
•
•
•
•
Children
Adults in contact with secondary mental health services who are in employment
Adults in contact with secondary mental health services who live in stable and appropriate accommodation fuel poverty, and
Fuel poverty
An update of local performance across as measure by the Public Health Outcomes Framework presented to the Health & Wellbeing Board Operations
Group has highlighted a number of indicators where we are performing particularly poorly:
•
•
•
•
•
•
•
•
•
•
Vaccination uptake
Access to non-cancer screening programmes - diabetic retinopathy
Cancer screening coverage - cervical cancer
Fuel poverty
Excess weight in children
Hip fractures
Incidence of TB
Infant mortality
Low birth weight of term babies
Social Isolation: of adult carers
Overall the update reaffirmed that the existing aims and the ten strategic outcomes cover the broad areas identified as strategic priorities. Specific areas,
such as the low uptake of a large number of vaccination programmes across the city should be taken into consideration in the action plans supporting the
strategy.
The CCG plays an active role in both the BHWBB and the BHWB officer group and has ensured that this plan builds on the BHWB Strategy. In addition a
Director of the BHWBB attends our Governing Body. The figure below summarises the BHWB strategy on a page.
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As part of the strategy refresh process the importance of the above priorities were re-emphasised across the range of partners at the Health & Wellbeing
Board meeting in January 2016. However, it was also agreed to prioritise the efforts of the Board on fewer priority areas where collective action would
have the greatest benefit. The main areas were agreed as:
Vision:
Birmingham is a City that sets the health and wellbeing of its most vulnerable citizens as its most important priority.In order to improve
the health and wellbeing of all residents, Birmingham has built services that are both resilient and sustainable.
Aims:
Improve the scale, effectiveness and coordination of system working
Improve the health and wellbeing of our most vulnerable adults and children in need
Improve the resilience of our population
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Priority
We will have integrated/coordinated services
that are resilient and sustainable




Sharing information
Common assessments
Multidisciplinary working
7 day services at scale across our city
Enabling adults to remain/be more
independent





Better Care Fund
Reduced isolation
Building personal capacity
Facilitating participation
Safeguarding
Improving the outcomes for families & children





Better Care Fund
Reduced isolation
Building personal capacity
Facilitating participation
Safeguarding
Work is now underway to map the contribution of partners across the health & social care economy to enable the Board to focus on specific areas where
improvements can be delivered collectively.
Prevention – Quantifiable levels of ambition - The Plan on a Page sets out a number of quantifiable levels of ambition to reduce local health and healthcare
inequalities and improve outcomes for health and wellbeing.
Guiding the focus of the BHWB Strategy are a set of common themes from local consultation, namely,
•
•
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The strategy needs to target the most vulnerable individuals and communities
Prevention needs to be stressed as does early intervention
•
•
•
•
Early identification and optimal treatment of disease is important
Independence and personal responsibility needs to be encouraged in all communities
People need to be able to choose health lifestyles and in environments that support these choices
Services need to be joining up resources to deliver tangible results.
Working with H&WB partners, our planned outcomes from taking the 5 steps recommended in the “commissioning for prevention” report are set out
below.
Step 1. Analyse key health problems
As mentioned in section 4.2.1, priorities from the JSNA, the key conditions that account for the gap in life expectancy in Birmingham, compared to England,
have been identified and the impact of these on the BSC population quantified.
These, along with the earlier JSNA and consideration of wider Public Health, Adult Social Care, NHS and CCG outcomes frameworks and indicator sets,
comparing both Birmingham and BSC CCG performance against national and peer data have been used to agreed priorities across the city (see below).
Step 2. Prioritise and set common goals
A number of common goals across the health economy have been prioritised and set through development of the Health & Wellbeing Strategy. This has
been agreed by all the partners of the Health and Wellbeing Partnership. It has been developed with three aims:
•
•
•
Improve the health and wellbeing of our most vulnerable adults and children in need
Improve the resilience of our health and care system
Improve the health and wellbeing of our children
Within these are a number of groups who have been identified as being in particular risk of poor health and social care outcomes, including:
•
•
•
•
•
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Looked after children
People with a learning disability
People with a severe mental health problem
People who are homeless
Victims of domestic violence
•
Older people
However, it is also recognised that other factors such as ethnicity and deprivation are also linked to poor outcomes and exacerbate inequalities in these
groups. Underneath these aims are a series of agreed outcomes as outlined in the attached strategy on a page. These are reinforced through BSC’s local
priorities as outlined on the BSC plan on a page.
Step 3. Identify high-impact programmes
A number of key actions have been identified in the Health and Wellbeing Strategy to address the priorities outlined in the strategy. Each of the three
themes has senior leadership from across the health and social care economy; the Child Health theme being led by the BSC CCGs Chair.
Step 4. Plan resources
The resources required to support the programmes are developed as part of the supporting governance process.
Step 5. Measure and experiment
Clear outcome measures and quantified targets have been agreed by all partners for the Birmingham Health and Wellbeing Strategy (these are highlighted
on the BHWB strategy on a page). A recent review of progress against the original targets by the Health & Wellbeing Board has highlighted the need for a
number of the targets to be reviewed. This process is now underway.
Reducing Health Inequalities
The Birmingham Health and Wellbeing Strategy has made improving the health and wellbeing of the most vulnerable adults and children a priority.
Vulnerable children, people with a learning disability or severe mental heal problem, the homeless and older people have all been identified as groups for
whom health and social care outcomes need to be improved.
Additionally, infant mortality has been identified as a key area for improvement. Infant mortality is linked closely to deprivation and ethnicity. It is also the
single greatest contributor to gap in life expectancy in both the CCG and Birmingham as a whole.
Locally as we host the Safeguarding Team and lead the CCGs in terms of Children and Young People we are
•
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Working with the BCHC LAC medical lead
•
•
•
Championing the prevention of violence against vulnerable people (PVVP) initiative
Promoting safeguarding issues for children, young people and adults
Promoting the health issues of young people including mental health issues
Implementation of the 5 most cost effective high impact interventions recommended by the NAO report on health inequalities:
•
•
•
Increased prescribing of drugs to control blood pressure; Hypertension was one of our three local quality premium priorities in 13/14 and we
are currently achieving our target to increase identified prevalence. Increasing prescribing drugs to control blood pressure is included in the
CCG’s Cardiovascular Local Improvement Scheme (LIS). Guidance notes have been developed for the management of a range of cardiovascular
conditions which help to support this approach. This includes the initial screening, review and management of patients who are have, or at risk
of hypertension to confirm that their medication is both optimised and regularly reviewed.
Increased prescribing of drugs to reduce cholesterol; This work remains a focused priority for the CCG and is included within the required
outcome of the Cardiovascular LIS that will be launched at the beginning of April 2014. Practices signing up to this service will be measured
against their ability to achieve 90% of all patients on their Coronary Heart Disease (CHD) register being offered a statin, if not otherwise contraindicated.
Increase smoking cessation services; Smoking Cessation services are commissioned by Public Health, based in the Local Authority and remain a
key priority. Smoking prevalence in Birmingham (18.4%) is currently similar to the national National average of 18.0%, thought there are
significant variations in smoking rates within the population.
This service is delivered via three providers that include a core service (BCHC), Pharmacies and GP’s. The service has undertaken a review and
has been re-commissioned as a ‘Payment By Results’ model that prioritises populations that demonstrate higher smoking prevalence; this is to
encourage improved quality outcomes and quit success. The service now encourages longer term quit success that reflects the need to provide
greater level of support over a longer period to address the issues around patients re-accessing the service several times as a result of
returning to smoking. The service remains available for all patients that work, reside or are registered with a Birmingham GP but now provides
a 4 and 12 week quit payment. The tariff structure also recognises the need to target those populations with higher smoking prevalence and in
whom it is difficult to encourage positive behavioural change; this includes young people, Routine and Manual Workers, deprived communities
and pregnant women. The service continues to prescribe pharmacotherapy in combination with support from a trained smoking advisor.
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The contracts enforce minimum standards that ensure Primary Care supports the city to achieve the national directed local quit target. The
service continues to be available on the front line at the point at which a patient raises the need to access a local service. Further information
about these services is available via www.birminghampublichealth.co.uk
Birmingham Public Health is currently reviewing all its commissioned services as part of a broader Lifestyle Review with the intention to
introduce a simplified prevention and treatment system that seeks to support patients to access a range of Lifestyle services as necessary via a
single care plan; this will also address the interrelationship between different lifestyle risk factors e.g. smoking and weight gain. The intention is
to introduce a single point of access (Lifestyle Hub) for all referrals, whilst re-procuring a range of services that takes account of the latest
evidence and guidelines to deliver the most effective lifestyles programme, addressing specific Birmingham needs. Design and consultation is
ongoing. Primary care plays a critical role within this and therefore Public Health will work closely with CCG colleagues through the
development and implementation phases.
•
•
Increased anticoagulant therapy in atrial fibrillation; The Long Term Conditions LIS scheme will encourage atrial fibrillation case finding and the
implementation of the atrial fibrillation pathway and the AQP for anti-coagulation supports high quality and safe management of this
condition.
Improved blood sugar control in diabetes; Member practices are supporting this through implementation of the Long Term Conditions Local
Improvement Scheme which includes:
o
Pre-diabetes – aim to identify and support patients who are at risk of developing diabetes. Initially through lifestyle and behaviour
change. However, where Metformin is to be considered – assure optimal therapies are prescribed and the patient is compliant with
the treatment. Monitor the patient’s HbA1c.
o
Patients with type 2 diabetes on oral therapies - assure optimal therapies are prescribed and the patient is compliant with the
treatment. Monitor the patient’s HbA1c.
o
Patients with type 2 diabetes on insulin therapies - assure optimal therapies are prescribed and the patient is compliant with the
treatment. Monitor the patient’s HbA1c.
Tackling the gap in life expectancy
The main causes of the gap in life expectancy across the city have been identified. Work to address the causes of this inequality will also include
understanding of the variation in outcomes for vulnerable groups and where necessary implementation of targeted initiatives. Specific actions to address
issues relating to priority groups identified in the Health and Wellbeing Strategy Include:
51 | P a g e
Make children in need safer
 Implementation of the Early Help Strategy to increase family support for children at risk of coming into care
Improve the wellbeing of vulnerable children






Increase the independence of people with a
learning disability or severe mental health problem
Reduce the number of people and families who are
statutory homeless
Support older people to remain independent
Systematic implementation of evidence based interventions relating to behaviour change
Pooling our resources to develop holistic services
Transformation of approach to life-time care for those with a learning disability
Transformation of approach to life-time care for those with mental health problems
Implement the domestic violence action plan
Implement the homelessness action plan
 Systematic personal and environmental advice to all aged 75 and over
 Focused early intervention to those at risk, including falls and isolation
In encouraging our members to tackle health inequalities the CCG is keen to support practices to build relationships across their communities to connect
and develop collaborations and partnerships that maximise the “assets” within communities to tackle inequalities. This will include both the narrow and
wider determinants of health and operate at the individual, family and Practice population level.
To address wider health inequalities there is a need for more preventative interventions aimed at lifestyle choices. Public Health data indicates that:
•
•
•
•
Smoking prevalence in Birmingham is similar to the England average of 18.0%. Smoking is also a key driver of health inequalities and continues
to be more prevalent in the most deprived areas, with a prevalence of 28.1% in routine and manual groups.
Compared to England, the Birmingham population eats less healthily. Estimates suggest that 44.1% of our population eat healthily (at least 5
portions of fruit and veg per day) compared to 53.5% across England.
24.2% of children in Year 6 (aged 10-11) are obese and a further 15.2% are overweight. Of children in Reception (aged 4-5), 11.3% are obese
and another 12.1% are overweight. This means over a third of 10-11 year olds and nearly a quarter of 4-5 year olds were overweight or obese.
Across Birmingham 31.8% of adults are inactive, doing less than 30min physical activity per week; with only 54.1% of adults meeting the
recommended minimum activity levels.
A review is currently addressing the way in which lifestyle services are serving groups who suffer health inequalities across the city. For example, although
the current smoking cessation service is targeted predominantly around deprivation, it does not have a specific remit regarding priority groups as identified
within the Birmingham Health and Well Being Strategy. As such pathways and resources are not currently established to respond to the multiple needs
(mental, physical and social) experienced by such groups as the homeless. Without a focus on both the social and health inequalities that are faced by such
individuals, it is unlikely that the service will be successful in responding to their lifestyle needs. These groups are subject to the highest level of risk in
relation to both prevalence and outcome but correspondingly have the highest level of gain to be made from contact with a service. In addition, services
52 | P a g e
currently perform poorly regarding overall uptake by BME groups, which does not reflect the diversity in the city and potentially suggests that the services
are not adapting to cultural differences in tobacco use, although this would need to be investigated further.
Whilst the above sets out the city wide approach to tackling health inequalities we have a local proactive approach to facilitate prevention through our
business and work programmes:
•
•
•
•
•
•
•
•
•
•
•
•
•
Increasing engagement with Birmingham City Council District Health and Wellbeing priorities
Engagement and empowerment – skills up young people through engagement : St Basil’s led Young People’s Charter, Experts by Experience
component of the Children and Young Person’s Mental Health Consultation
Community engagement with the Roma and Somali communities in partnership with CAB and Gateway in the Washwood Heath Locality
Primary Care LTC LIS – specifically includes diabetes prevention and proactive management of LTCs
Partnership approach to improving the physical health of those with Severe and Enduring Mental Illness
Delivering a programme that involves developing 7000 Education, Health and Care plans as part of the SEND initiative
Primary care LISs that focus on the key drivers of inequalities in health outcomes such as cardiovascular disease & respiratory illnesses
Better Care Fund and Healthy villages- will allow place based commissioning to develop
Safeguarding CQUIN – ensuring our Trusts take a proactive approach to learning from safeguarding cases
Early Help Offer- early intervention for families and children identified as needing support
0-25 years Mental Health Service procurement – will support early intervention for children and young people with mental health problems
Childhood obesity : city wide strategy - works across schools, Leisure Services the Environment to reduce the obesogenic environment
Corporate Social Responsibility - contributing to a Food Bank
The changes to the commissioning arrangements for lifestyle services have now ‘bedded in’ and are the responsibility of the Public Health function within
Birmingham City Council. They currently commission a wide range of lifestyle services including:
•
•
•
•
•
Stop Smoking services
NHS Health Checks
Healthy Eating/Weight Management (Both Children and Adults)
Physical Activity
Health Trainers
We expect that there will similar levels of service provision by our Practices as there were in 2014/15.
53 | P a g e
3.3
Returning the system to aggregate financial balance
The Planning guidance sets out the requirement to return the system to aggregate financial balance. This includes secondary care providers delivering
efficiency savings through actively engaging with the Lord Carter Provider Productivity Work Programme and complying with the maximum total agency
spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand
through implementing the ‘RightCare’ programme in every locality.
3.3.1
Closing the Funding and Efficiency Gap
The operational plan for 2016/17 begins to lay the foundations for the Sustainability & Transformation Plan being developed in the first half of 2016. In
terms of closing the funding and efficiency gap, one of the first tasks will be to update work to confirm the size of the challenge. Previous work undertaken
across the Unit of Planning, which included Sandwell & West Birmingham at that stage, identified a gap of £0.7bn over the 5 year planning period, which
correlated closely to the national position. High level estimates of the national challenge of £22bn places the local challenge at around £0.5bn for the new
planning footprint.
In addition to this sum, Birmingham City Council faces further significant reductions to its budgets, with consequent reductions in essential services
including adult social care and third sector services. The impact of these reductions is not reflected in the £22bn calculation, and will add to the challenge.
In approaching this challenge, the operational plan starts to address the following areas that will be further developed in the STP:


Control of demand – including demand management and self-care.
Key local initiatives include the CCG’s primary care demand management scheme, the Prime Minister’s Challenge Fund, Local
Improvement Scheme for over 75s. Of course, in some areas there is a need to increase demand, a prime example being in terms of early
detection & diagnosis of cancer. The CCG’s LIS focussing on patient promises is having an impact in increasing referrals, and the
transformation plan will need to address such changes over the five year period.
Efficiency – including savings from the agency cap and implementation of Carter productivity savings, in addition to efficiency savings
driven via the tariff.
The potential savings from these initiatives are set out at a high level in the table below, individual Trust figures are due to be published
shortly.
54 | P a g e

Prevention – local examples include the National Diabetes Prevention Programme and Vaccine preventable programme. In addition, the
impact of the CCGs long term conditions LIS and Respiratory scheme appear to be beginning to feed through into
Attempting a broad brush high level estimate of the potential gap and mitigations:
Cost Reduction
Estimated Planning Gap
Carter Savings
Agency cap
Tariff Efficiency 2%
Remaining Gap
National
£m
£22,000
BSOL
£m
£494
BSC
£m
£112
£5,000
£333
£112
£7
£113
£25
£2
£20
£16,667
£261
£65
NHS Planning guidance makes it clear that providers need to be addressing deficits by cost reduction, not by income growth. It is clear that these cost
efficiency savings alone, whilst significant, will be insufficient to close the longer term gap. This highlights the need for schemes of a transformational
nature that can help deliver the required savings.
The STP will develop transformation plans supported by the Transformation Funding included in the NHS Mandate.

Funding £8.4 billion investment & new care models to close the financial gap
Transformation funds potentially available to the local footprint, again based on a pro rata share of the national sum, are:
Transformation Fund
Transformation Fund
National
£m
£2,900
BSOL
£m
£65
BSC
£m
£15
Therefore, it is clear that the implementation of transformation schemes and new models of care need to leverage significant savings to ensure the long
term sustainability and financial balance across the planning footprint.
55 | P a g e
2016/17 – The System in Aggregate Balance
3.3.2
An absolutely key priority for the NHS in 2016/17 is to return the system as a whole to financial balance. For the CCGs within the Birmingham & Solihull
footprint, the focus is on Solihull CCG returning to financial surplus, with BSC and Cross City maintaining their strong financial position, albeit in the face of
significant QIPP challenges. The QIPP challenge for BSC CCG in 16/17 is £9m (2.4%).
Provider organisations face a significant financial challenge. Based on the latest aggregate reported provider deficit in 15/16 within the planning footprint is
in excess of £70m, the underlying position is likely to be worse. Organisations with strong financial track records are in difficulties.
Estimated Forecast Outturn 15-16
Heart of England FT
University Hospitals Birmingham FT
Birmingham Childrens Hospital FT
Birmingham Womens Hospital FT
Royal Orthopaedic Hospital FT
Birmingham Community Healthcare NHST
Birmingham & Solihull Mental Health FT
Overall total 15-16
£m
-58
-7
0
-3
-4
3
-2
-71
In 16-17 providers have been allocated non recurrent transitional support from the Sustainability Fund by NHS Improvement, although individual amounts
have yet to be published. A “fair share” of the £1.8bn available nationally would indicate that £40m may be available locally. The basis of distribution and
individual Trust awards have yet to be published, so this figure could well vary.
Sustainability Fund (NR)
Sustainability
National
£m
£1,800
BSOL
£m
£40.4
BSC
£m
£9.2
Providers have been issued challenging targets for 2016/17 to achieve either greater surpluses or reduced deficits, taking account of sustainability support.

Finance & activity plan for 16/17 - The CCG has submitted its initial financial plan for 2016/17 which delivers NHS England business rules. As
noted above, the QIPP challenge to deliver the business rules is £9.9m, which is in excess of sums required in the past two years. The reduced
tariff efficiency requirement of 2% will aid providers in their move towards financial stability, however impacts on the CCGs financial position,
56 | P a g e
with a tariff inflator applying for the first time in a number of years. In addition, anticipated changes to the NHS contract are expected to
reduce the level of fines & sanctions.
Activity plans will be submitted and reconciled with provider plans during February.

Carter productivity - As noted above, Carter Efficiency savings demonstrate the potential for providers to make savings towards their targets
in 2016/17. Initial discussions with providers indicate a degree of scepticism in terms of deliverability, and this will be tested in the
development of the STP. In a full year this could deliver savings of £112m across the planning footprint if delivered in full. In 16/17 the impact is
likely to be somewhat less as opportunities are implemented over a period of time.

Agency Spend - The Agency Cap appears to be contributing to reduced costs for providers. The full cap will be in place in 16/17 and can be
expected to contribute £7m across the footprint.

Right care programme implementation - Opportunities highlighted in the Right Care programme, and QIPP opportunities information
available to the CCG highlight areas of potential savings used to inform the QIPP programme. In 2016/17, BSC is not in the initial wave of Right
Care pilots, and in many areas is towards the lower end of savings opportunities where individual CCG opportunities are identified. However,
the Right Care commissioning for value pack for the CCG has highlighted trauma, musko- skeletal and mental health services as the key areas of
opportunity. Good progress has been made in mental health, so focus will be on the first tow areas in 16/17.
3.3.3
Financial Plan Summary
The CCG financial plan reflects the CCG allocations announced in January 2016. Work is underway in connection with developing a Sustainability &
Transformation Plan (STP) to address longer term planning requirements. The plan for 2016/17 meets all NHS England planning / business rules NHS
England has set out its “business rules” that the CCG is required to follow, and which the current 2015/16 financial plan meets in full including:
1) Delivery of a 1% Surplus: The CCG is planning for a 1% (£4.4m) surplus in 2016/17 which includes 1% of primary care budgets. This implies a drawdown
of prior year surplus of £0.9m. Delivery of a 1% surplus on delegated primary care budgets is subject to receipt of the 1% prior year surplus.
o Surplus 2015/16
£4.4m
o Drawdown 2016/17
(£0.9m)
o Primary Care b/fwd surplus
£0.4m
o Agreed increase in 16/17 surplus £0.5m (due to 2015/16 recurrent allocations)
o Planned Surplus 2016/17
£4.4m
57 | P a g e
2) Contingency: The plan includes a contingency of 0.5% (£1.9m) across all commissioning streams.
3) Non Recurrent Reserve: The plan includes non-recurrent expenditure plans for 1% of overall commissioning spend, including delegated primary care.
The summary table detailing the application of the 1% non-recurrent reserve is detailed below:
Non Recurrent Reserve
Risk Reserve 0.5%
Devolved Network Budgets
Winter Planning
Other Reserves
Total Non-Recurrent Reserve
3.3.4
Value £
£1.9m
£1.0m
£0.3m
£0.2m
£3.4m
Commissioning Allocation
The national spending review provided an additional £5.8bn for NHS in 2016-17 (5.5% uplift). This included three year firm plus 2 year indicative CCG
allocations released 8th January 2016. Growth funds allocated to CCGs on a relatively complicated basis that:




Moves CCGs that are over 5% from target closer to target
Takes account of overall “Place” allocations – CCG / Primary Care / Specialised Services
Provides a basic uplift of 3.05%
Specialised Services receive 7% uplift
The CCG Commissioning Allocation is 3.1% below target in 2015/16 which falls to 2.2% in 2017/18, then 2.1%. The CCG is 3.6% below target at end of
2018/19:
Allocation
growth
CCG Baseline
Growth £
% growth
58 | P a g e
2015-16 2016-17 2017-18 2018-19 2019-20 2020-21
£000s
£000s
£000s
£000s
£000s
£000s
330,417 341,043 348,377 355,620 363,070 377,469
10,626
7,334
7,243
7,450
14,399
3.2%
2.2%
2.1%
2.1%
4.0%
The CCG commissioning allocation uplift in 2016/17 is 3.2% (£10.6m) which includes a number of pre announced funds that are already included within the
baseline:






Inflation 1.7% = £5.6m as previously anticipated
GPIT = £0.8m which is uplifted to reflect the new BSC practices
CAMHs = £0.6m CYP transformational plan monies are already included within the recurrent baseline
ETO/DTR = £0.6m which is BSC’s capitation share of the £150m made available to fund the tariff uplift in 2015/16 recurrently
Real growth 0.95% = £3m is the real growth that the CCG has been allocated
Better care fund assumptions are based on roll over of 15-16 agreements
3.3.5 Primary Care Allocations
In 2015/16 the CCG is 0.7% above target for primary care funding, the uplift for 2016/17 is 3.6% (£1.3m), and this reduces to 2% per annum for next two
years (£0.8m). The CCG is 1.8% below target at end of 18/19. Treatment of primary care 1% surplus is still to be confirmed by NHS England.
Allocation growth
Primary Care
Growth £
% growth
3.3.6
2015-16 2016-17 2017-18 2018-19 2019-20 2020-21
£000s
£000s
£000s
£000s
£000s
£000s
38036
39392
40173
40984
42247
44103
1356
781
811
1263
1856
3.6%
2.0%
2.0%
3.1%
4.4%
Place Based Allocation
A summary of the BSCCCG placed based allocation is detailed below:
59 | P a g e
Place Based
Allocations
CCG Commissioning
Primary Care
Specilaised
2016/17
£m
341
39
90
2016/17
DFT
-3.6%
0.5%
3.7%
£ per pt
1155
133
306
470
-2.0%
1594
Total Place Allocation
A summary of the wider Birmingham & Solihull footprint placed based allocation is detailed below:
Total Place Allocations 2016/17
BSC
BXC
SOL
Total
£m
471
1221
381
2073
The Birmingham City Council financial position has led to the publication of a 2016+ budget consultation assuming £60m savings from joint working with
the NHS which includes a potential procurement of early years services (0-5 years), Residential dementia beds and enablement services alongside cessation
of smoking and weight management services.
3.3.7
Planning Assumptions
Planning assumptions are summarised in the table below, inflation (updated as per the latest Tariff Consultation) and deflation rates are consistent with
those published by NHS England. Growth rates have been determined through trend analysis of the prior 3 years spend.
60 | P a g e
SUMMARY OF CCG ASSUMPTIONS
Assumptions
2016/17
%
Allocation growth - programme
Allocation growth - running costs
3.22%
0.00%
Demographic growth
Activity growth - acute
Activity growth - mental health
Activity growth - community
0.70%
1.70%
1.70%
1.70%
BCF growth
CHC (inflation and growth)
Prescribing (inflation and growth)
0.10%
7.30%
3.30%
Inflation
Efficiency
Net Tariff Deflator
3.3.8
2016/17
3.10%
-2.00%
1.10%
Financial Plan Detail 2016/17
A breakdown of the key expenditure areas is set out below, more detail is provided in the accompanying template and narrative. The financial position is
shown after the application of planned QIPP initiatives.
61 | P a g e
Financial Position
Revenue Resource Limit
£ 000
Recurrent
Non-Recurrent
Total
Income and Expenditure
Acute
Mental Health
Community
Continuing Care
Primary Care
Other Programme
Primary Care Co-Commissioning
Total Programme Costs
Running Costs
Contingency
Total Costs
£ 000
Surplus/(Deficit) In-Year Movement
Surplus/(Deficit) Cumulative
Surplus/(Deficit) %
Surplus (RAG)
62 | P a g e
2015/16 blank1
2016/17
374,892
387,024
5,429
4,900
380,321
391,924
168,064
41,463
46,554
23,969
49,929
1,105
37,924
369,008
167,680
44,871
46,487
25,389
47,546
8,719
38,803
379,495
5,898
6,049
515
1,960
375,421
387,504
2015/16
1,761
4,900
1.4%
GREEN
2016/17
(480)
4,420
1.3%
GREEN
Note:
1) Expenditure in relation to the 3 practices transferring from BXC to BSC and one practice transferring from BSC to BXC is currently excluded from the
analysis.
2) Running costs are as per the notified 2016/17 running cost allocation.
3.3.9
The resources you are allocating to mental health to achieve parity of esteem
The CCG has reflected an increase in Mental Health Services budgets over and above the growth received into the CCG of 3.2%. The increase in Mental
Health expenditure from 2015/16 to 2016/17 is detailed in the tables below:
Programme
Growth in
Growth
2015/16 FOT 16/17 Plan MH Spend
%
£k
£k
%
3.0%
64,438
67,716
5.1%
Parity of Esteem
Parity of
Esteem
Acheived?
YES
Mental Health Parity of Esteem
Improved access to psychological therapies (adult)
Children and young people's (CYP) mental health - excluding LD
A and E and Ward Liaison mental health services (adult)
Early intervention in psychosis ‘EIP’ team (14 - 65)
Learning Disabilities
Eating Disorders (CYP only)
Dementia
Crisis resolution home treatment team (adult)
Primary care prescribing on mental health drugs
Other adult mental health
TOTAL
3.3.10
Core Mental Health Spend
2015/16 FOT
2016/17 Plan
Rec
Non-Rec
Rec
Non-Rec
1,625
90
1,682
638
637
6,891
132
1,497
1,549
7,643
(153)
7,775
121
130
125
546
565
28,446
40,516
111
947
26,284
44,871
- -
Spend on Mental Health in Other Areas
2015/16 FOT
2016/17 Plan
Rec
Non-Rec
Rec
Non-Rec
42
42
248
121
120
120
80
80
102
100
22,485
21,816
464
22,975
22,281
564
Total Mental Health Spend
2015/16
2016/17
Rec
Non-Rec
Rec
Non-Rec
1,667
90
1,724
886
637
7,012
132
1,617
1,669
7,723
(153)
7,855
121
130
125
546
667
100
50,931
111
48,100
464
63,491
947
67,152
564
Better Care Fund Impact 2016/17
The plan includes sums in excess of the identified CCG minimum contribution to the Better Care Fund in 2016/17. All sums are currently funding existing
services. There is no growth funding available to contribute further to the transfer made to the Local Authority as part of the Fund in 2015/16.
63 | P a g e
Health and Well Being Board - Birmingham
Figures in £'000s
2015/16
Blank2
Mandated Transfer
from CCG Baseline
BLANK1
BCF Allocation
Additional BCF Allocation
Transfer from Existing CCG Allocations to the BCF
Minimum 2015/16 CCG Contribtion to BCF
2016/17
Additional CCG
Contribution to BCF
1516
Additional 2016/17
BCF Allocation
2016/17 Mandated
Transfer from CCG
Baseline
Additional CCG
Contribution to BCF
1617
11,624.9
11,624.9
-
16,411.9
3,183.8
3,183.8
3,183.8
19,595.7
Total
4,787.0
4,787.0
Additional CCG contribution to BCF
4,776.0
Total CCG contribution to BCF
4,776.0
3.3.11
Blank3
4,787.0
11,624.9
Activity Assumptions 2016/17
The table below details the expected changes in activity based on demographic growth 0.8%, other activity growth of 1.7%, totalling 2.44% less QIPP
scheme reductions. The impact of the practice transfer activity (circa +3.6%) has also been included within the activity assumptions. Activity plans have
been uploaded into the IHAM (indicative Hospital Activity Modelling) tool to establish the activity impact by national policy scheme.
Unify activity template:
64 | P a g e
Code
Activity Line
E.M.1 Total Referrals (All Specialties)
15/16 YTD Actuals
CCG 15/16 Forecast outturn
16/17 Annual Plan
Forecast Growth in
16/17 on FOT 15/16
15/16 YTD from
QAR (Q1 & Q2)
57,584
To be entered by
CCG
115168
121875
5.8%
E.M.2
Consultant Led First Outpatient
Attendances (Total Activity)
15/16 Month 1-6
from SUS
38,399
NHS England
Produced
76,975
81587
6.0%
E.M.3
Consultant Led Follow-Up Outpatient
Attendances (Total Activity)
15/16 Month 1-6
from SUS
87,427
NHS England
Produced
175,838
185971
5.8%
E.M.4
Total Elective Admissions (Spells) (Total
Activity) [Ordinary Electives + Daycases]
15/16 Month 1-6
from SUS
11,356
NHS England
Produced
22,960
24086
4.9%
E.M.5
Total Non-Elective Admissions (Spells) (Total 15/16 Month 1-6
Activity)
from SUS
14,984
NHS England
Produced
30,156
32365
7.3%
15/16 Month 1-6
from SUS
40,740
NHS England
Produced
80,461
85044
5.7%
16/17 Annual Plan
Forecast Growth in
16/17 on FOT 15/16
E.M.6 Total A&E Attendances
Code
Activity Line
E.M.7 Total Referrals (G&A)
15/16 YTD Actuals
CCG 15/16 Forecast outturn
15/16 YTD from
MAR
(Month 1-6)
39,746
To be entered by
CCG
77566
82,210
6.0%
E.M.8
Consultant Led First Outpatient
Attendances (Specific Acute)
15/16 Month 1-6
from SUS
32,013
NHS England
Produced
64,138
68,184
6.3%
E.M.9
Consultant Led Follow-Up Outpatient
Attendances (Specific Acute)
15/16 Month 1-6
from SUS
68,014
NHS England
Produced
136,887
145,102
6.0%
E.M.10
Total Elective Admissions (Spells) (Specific
Acute) [Ordinary Electives + Daycases ]
15/16 Month 1-6
from SUS
11,338
NHS England
Produced
22,936
24,084
5.0%
E.M.11
Total Non-Elective Admissions (Spells)
(Specific Acute)
15/16 Month 1-6
from SUS
11,994
NHS England
Produced
24,324
25,983
6.8%
E.M.12
Total A&E Attendances excluding planned
follow ups
15/16 Month 1-6
from SUS
40,424
NHS England
Produced
79,853
84,403
5.7%
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Activity changes as per IHAM model categories:
2016-17 Outpatient Attendances: Change from Baseline
2016-17 Elective Admissions: Change from Baseline
0
-200
Final Position
-100
Clinical Thresholds
Right Care
Final Position
-4,000
New Care Models
-2,000
Prevention
Clinical Thresholds
Self Care
0
-300
-6,000
-400
-8,000
-500
-10,000
-600
-12,000
-700
2016-17 A&E Attendances: Change from Baseline
2016-17 Non Elective Admissions: Change from Baseline
-2,000
-2,500
-1,500
-3,000
-3,500
-2,000
-4,000
-4,500
-2,500
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-5,000
Final Position
7 Day Services
New Care Models
-1,500
Prevention
-1,000
UEC Models
Final Position
7 Day Services
Cancer
New Care Models
-1,000
Prevention
Right Care
-500
-500
Right Care
0
0
3.3.12
QIPP 2016/17
The CCG’s QIPP plan builds on the CCG’s successful track record of QIPP delivery, the table below summarises the 2016/17 QIPP which is described in the
format of the IHAM tool categories:
2016/17 QIPP finance & activity assumptions
IHAM category
Prevention
New Care
Models/Extra GP's/7
Day services
New Care Models
New Care Models
Right Care
New Care Models
Self Care Guidance
Prevention
Cancer
Clinical Thresholds
Guidance
Clinical Thresholds
Guidance
Prevention
Prevention
Prevention
UEC Models
UEC Models
Non IHAM
Non IHAM
Non IHAM
Non IHAM
Non IHAM
Non IHAM
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Scheme Description
Vaccine Preventable
Prime Ministers Challenge Fund:
Element of Multi-specialty provider
Over 75's
Better Care Fund (Schemes Detailed below)
Working with BCC
Right Care Savings:
MSK/Falls/Alcohol
Enhanced Care in Care Homes
MDT service spec (Self Care)
Clinical Utilisation Tool
Falls/Fracture admission reductions
Reduction in NEL Cancer Gastro/Bowel
PLCV
Prescribing (Community and Primary Care)
RQIP: COPD/Asthma
Primary Care Demand Management
Diabetes Prevention and CVD LIS
WMAS Frequent Flyers
Discharge to Assess Pathways and CHC
Estates Strategy
AQP Audiology
CHC List Cleansing/functional MH health
CSU Procurement
15/16 Carry Forward Surplus
Acute Contract Performance Management
Totals
Total QIPP Value
QIPP Reductions by Activity POD
QIPP Scheme
Value £'000 (Rec)
150
QIPP Scheme
Value £'000 (Non
Rec)
500
350
1,546
First
Follow Up
NEL
Daycase Elective Outpatients Outpatients
150
247
173
1204
A&E
724
507
900
765
180
100
50
49
17
306
245
61
920
145
245
61
658
200
600
100
70
760
400
140
1,035
94
306
612
1333
1473
269
2666
3321
874
1677
696
615
644
8,468
1,515
9,983
2,020
490
122
3,381
7,473
4,669
In year mitigation plans:
The CCG has been working with the CSU to analyse further QIPP opportunities highlighted within the various support packs provided by NHS England, e.g.
commissioning for value and Right Care, and from the CSU’s own detailed analysis. The latter benchmarking and data analysis have highlighted a number of
key QIPP opportunities that are currently the subject of deep dive analysis and will form the basis of the longer term QIPP plans included in the
Sustainability and Transformation Plan. Successful delivery of these plans will be crucial to the longer term sustainability of the local health system.
The CCG is scoping options around delegating budgets to primary care with CCG member practices during 2016/17 alongside the implementation of a
federation of GP practices within BSC, with a view to providing more resources to Primary Care to manage areas such as prescribing and to build upon the
capacity within Primary Care to manage integrated patient pathways.
3.3.13
Risk
The CCG faces a number of risks and these are set out in the template and plan narrative. Whilst a number of risks are significant, they are covered by
identified mitigations. The CCG participates in a risk share pool arrangement with three other CCGs in order to provide a greater degree of risk cover than
that which could be achieved through the CCG acting alone.
3.3.14
Investment
The CCG’s current financial plans including QIPP are planning to release circa £3.4m to fund the CCG’s non-recurrent reserve which includes investment into
the CCG’s key priorities including devolved budgets to practices. The QIPP is also required to fund the Mental Health Parity of Esteem investment as
described above. There are a number of further key priorities of the CCG that require additional investment e.g. increased Diagnostics, Primary Care
Commissioning and future integrated models of care which are being developed as part of the Sustainability and Transformation Plans. There are a number
of risks that may impact the level of available invest in year such as a) delivery against planned QIPP targets, b) the financial impact of the BCF and c) further
acute activity growth and increases in spend above the planned growth levels.
The CCG also continues to invest into primary care through increasing funding available for Primary Care LIS schemes and seeks to reinvest any funding
released through PMS reviews back into Primary Care.
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3.3.15
Statement of financial position – Cash - Capital
Balance sheet and cash flow statements are set out in the separate financial plan submission tables. The CCG does not anticipate any capital spend at
present (GP IT being part of NHS England capital expenditure).
3.3.16
Quality Premium - 2016/17
The 2016/17 Quality premium guidance indicates that the quality premium will only be paid if the CCG meets is statutory financial duties which is
incorporated into the delivery of the CCG’s 2016/17 operational plan. The premium will be reduced where the key constitutional requirements are not
met; the CCG is planning for full achievement against the key constitutional requirements. The quality premium local targets are agreed in line with the
right care KPIs selected for reducing emergency admissions, increasing access to psychological therapies and % of patients returning to usual residence
following a fractured femur.
3.3.17
Contract values - 2016/17
Contract values set out in the separate financial plan and contract tracker submission tables reflect agreed contract values with Birmingham Children’s
Hospital, Birmingham Women’s Hospital and The Royal Orthopaedic and are the latest estimates for all other contracts. Final values for 2016/17 are
expected to be available following expected signature by the 22nd April 2016. The activity assumptions underpinning the majority of the acute offers have
been agreed with final growth/QIPP numbers being negotiated into contracts. All local CQUINs/SDIPs and KPI changes have been agreed with providers.
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3.4
Ensuring the sustainability and quality of general practice
We must develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues.
NHS England view - The NHS Mandate is expecting the following to be delivered in 16/17 towards the goals for 2020 with respect to new models of care
and general practice:
•
•
•
New models of care covering the 20 percent of the population designated as being in a transformation area to:
o provide access to enhanced GP services, including evening and weekend access and same-day GP appointments for all over 75s who need
them; and
o make progress on integration of health and social care, integrated urgent and emergency care, and electronic record sharing.
Publish practice-level metrics on quality of and access to GP
services and, with the Health and Social Care Information
Centre, provide GPs with benchmarking information for
named patient lists.
Develop new voluntary contract for GPs (Multidisciplinary
Community Provider contract) ready for implementation in
2017-18.
3.4.1
CCG Governance of Primary Care
In order to improve our progress towards these expectations we
have recently reviewed our governance processes and leadership
for primary care development. The new arrangements will facilitate
the CCG in delivery against particular themes. In the following
section we deal with our approach to use of the Primary Care
Transformation Fund, the development of a primary care workforce
strategy, supporting the GP Federation, local improvement
schemes and how primary care can support ‘seasonal pressures’.
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3.4.2
Estates Strategy and the CCG Approach to the Primary Care Transformation Fund
In December 2014, NHS England announced the Primary Care Transformation Fund (PCTF), funding support of £1bn over four years to , improve access and
the range of services available in primary care, through investment in premises, technology, the workforce and support for working at scale across
practices. The first tranche of this fund is being deployed in 2015/16 to support a range of initiatives, including hundreds of schemes from individual
practices to improve their estate.
In 2015/16 NHS England, with BSC support, approved four premises development schemes for completion in 2015/16. These will deliver 11 additional
clinical rooms, with an overall capital investment of £1.5m. These schemes demonstrate that the PCTF is able to deliver additional clinical accommodation
in areas of need, offering VfM and the ability to improve on functional and statutory problems within the primary care estate.
To support the use of this fund in 2016/17 CCGs were asked to produce an initial estates strategy by December 2015 which set out an approach to the use
of the fund and initial priorities. Any schemes put forward need to demonstrate that they meet one or more of the criteria set out below:
•
•
•
•
•
increased capacity for primary care services out of hospital;
commitment to a wider range of services as set out in your commissioning
intentions to reduce unplanned admissions to hospital;
improving seven day access to effective care;
increased training capacity.
Submissions should request financial support for investment in premises or technology which will increase the capacity of general practice and out-ofhospital care, linking to local estates strategies and digital roadmaps.
Within the Estates strategy a number of key short term priorities were identified including:
•
•
To obtain a firm baseline on condition and capacity –The local LIFT company undertook an analysis of General Practice Surgeries in 2013, but to
provide an up to date baseline, the CCG has secured funding for a new survey to be undertaken in Dec 2015 and Jan 2016 of all Primary Care
buildings to give an abridged 6 facet summary of condition and capacity
To explore options to increase utilisation of void and bookable space -In Birmingham there are a number of buildings that are not fully utilised and
have large areas reserved for bookable rooms. The CCG bears the rental costs of void properties and of bookable rooms not used. Improved
utilisation of these buildings must be a priority in the short and medium term
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•
•
•
•
•
•
•
To support urgent care delivery -A new Urgent Care Centre in the Selly Oak area of the city is a key priority to assist in keeping people out of
hospital and providing extended hours access to Primary Care services. This development has stalled because the investment regulations are
restricted in terms of how PCTF monies can be used to invest in new properties not owned by the NHS. New regulations are in the process of being
developed that will facilitate these types of development, with the NHS securing recurrent benefits from rent abatement following similar principles
to that already applying to Improvement Grants.
To agree appropriate Hub locations for The Prime Minister’s Challenge Fund –the ‘My Healthcare’ project has identified three hubs to offer
convenient extended hours Primary Care Services, and we need to ensure the Estate facilities associated with those hubs are of a sufficient quality
and capacity to enable achievement of those objectives.
To identify opportunities under the Transformation Fund -4 practices have had Surgery developments funded through the Primary Care
Transformation Fund in 2015/16 and the CCG will be looking to develop more surgeries, that have the potential to offer increased access to clinical
services, through the remaining 3 years of this fund.
To agree criteria for assessment and prioritisation of PCTF funds –and the process for managing applications for 2016/17 funds. It is noted that
there are plans to make regulations more flexible in a way that will give opportunities for more ambitious projects than simply Improvement Grants
through this fund. And the CCG will assess the current and optimum estate in each locality to explore what developments could be considered that
provide real transformation in Primary Care provision.
Agree a process with Birmingham Community Healthcare to develop a joint Estate strategy that enables savings to be explored for the NHS as a
whole, rather than for one organisation at the expense of another. It is the case that the Trust have excess capacity and are looking at Estate
rationalisation as part of their strategy.
Consider a subsidy policy to be applied in respect of CHP accommodation, to ensure equity and to facilitate best use of available space and to
attract new tenants. This includes GP accommodation, including an approach to service charges.
Resolve issues relating to property cost charges and reimbursement relating to GP practices in NHSPS and CHP premises. There is currently a lack
of clarity around the charges that the CCG is bearing.
3.4.3
Primary Care IT Strategy
In addition to the work we have articulated in section 3.1.6 with regard to the local digital road map we have set out an agreed programme and priorities
plan for primary care IT.
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Local programmes
GP Clinical Systems - To date we have successfully migrated 54 practices to Emis Web over the past three years with 2 practices on Vision and 1 practice on
TPP. Our long term strategy would be to offer all practices the opportunity to migrate to Emis Web to better enable delivery of services through one GP
clinical system.
EMIS Enterprise search and reports - Across our 54 practices we have established pseudonymised data sharing which enables critical centralised reporting
of numerous enhanced services to help support practices and BSC CCG.
Prime Minister’s GP Access Fund - My Healthcare were successful in bidding for a wave 2 which launched in July 2015 connecting 23 practices to 4 hubs to
enable extended 7 day services. This was unpinned by local data sharing via Emis Web to share full records with patient consent and enable cross site
appointment booking. This has been highly successful and is being rolled out to other practices in the CCG as part of winter pressure measures.
Windows 7 hardware refresh - By the summer of 2015 all practices have completed migrations to Windows 7 through a hardware refresh programme.
Primary Care Servers - Ongoing infrastructure programme is underway to upgrade old clinical and docman servers along with ensuring domain profiles and
security levels are in place.
N3 NGA Upgrade - By the summer of 2015 all applicable practices have received the N3 NGA upgrade.
Branch Practice Links - Private networks are being installed to help support all our 5 branch practices due to limitations of docman.
Wi-Fi - Surveys have been completed for all practice sites within BSC CCG and options are being considered as to how best provide Wi-Fi ideally in
collaboration with neighbouring stakeholders at scale.
SMS text messaging - One way text messaging has been funded to enable appointment reminders, blood test results and the potential to launch health
SMS campaigns. Two way SMS has been optional for practices to procure.
Business continuity - Help and support for practices has been provided to ensure plans are in place, vigilance for cyber security and IT help desk services
times have been extended.
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Regional programmes
Electronic Document Management - 82% of practices are live with receiving electronic letters via docman from providers such UHB, HEFT, ROH, BSMHFT
and BWH. Collaborative working needed to reduce costs of adding additional providers.
Child Protection Information Sharing (CPIS) - BSC CCG have been supporting the role out of CPIS to share child protection information with hospital
providers. Birmingham City Council is currently waiting for a go live date from HSCIC.
Your Care Connected (YCC) - After a successful pilot progress is being made to roll out YCC with a patient mail out following completion of a data sharing
agreement and data quality programme.
National programmes
Summary Care Record - All practices are live but with limited uptake by hospital providers other than hospital pharmacists.
E-Referral Service - Ongoing support and training is being provided for practices to help increase uptake.
Electronic Prescription Service - 79% of practices are live or have planned go live.
Patient Online (appointments, prescriptions, record) - All practices have enabled basic services with new requirements to enable detailed sharing of coded
data by 31st March 2016.
GP2GP - All practices have GP2GP enabled with 89% making good use of this.
3.4.4
Development of a Primary Care Workforce Strategy
The GP workforce capacity in England is declining reflected in increasing rates of early retirement and intentions to reduce hours of working. Coupled with
an increase in demand for primary care, there is clear recognition that a plan is needed to protect, sustain and future proof the delivery of quality primary
care.
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GP per head of population has declined since 2009, with major problems of recruitment and
retention. Nursing is another area of serious concern, with an ageing workforce in general practice
nursing and similar problems of recruitment and retention.
The CCG has responded to Building the Workforce- the New Deal for General Practice and The
future of primary care creating teams for tomorrow Report by the Primary Care Workforce
Commission by establishing a Primary Care Workforce Strategy Group. BSC CCG recognises the
importance of giving general practice workforce more prominence and acting now, and ensuring
high quality care is best delivered with the correct MDT staffing level; GP, Nurse, HCA, AHP, etc.
within general practice.
A survey launched by the CCG in January 2016 aims to establish a baseline of current staffing levels
within general practice, with the view to addressing potential shortfalls. Information gathered
from our survey will also guide the development of a workforce strategy for the CCG to support
general practice.
3.4.5
Local Improvement in Primary Care
In supporting the sustainability and quality of primary care we constantly review and develop local improvement to support primary care. Our key aims are
to enable general practice, community pharmacy and other primary care services to play a much stronger role, at the heart of a more integrated system of
community-based services, in improving health outcomes. Primary care needs to play a stronger role in preventing ill-health, involving patients and carers
more fully in managing their health and ensure consistently high quality of care. We have developed a business model to integrate primary care
commissioning and contracting within our existing integrated model of commissioning.
For the CCG this means supporting our Practices to develop their ideas such as the Prime Minister’s GP Access Fund (My Healthcare), continuation of our
long term conditions local improvement scheme, the development of a local improvement scheme to support the NHS Constitution, undertaking any
qualified provider (AQP) procurements for primary and community based services where these make sense and the continued support of the Edgbaston
Well-being Hub and the Springfield project as pathfinders prior to full rollout across Birmingham (see table below).
As part of local improvement in primary care we have implemented the schemes as shown:
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Local Improvement in Primary Care Schemes
Scheme
Stakeholders
Aims
Stage of Development
Prime Minister’s Access
Fund
GPs, BCHC, 111, OOHs,
WiCs and BSC CCG
Develop an Integrated Networked Primary and Community
Care System
Operational across 23 practices in the CCG and CCG wide in
support of primary care winter pressures
Over 75s
BSC Practices, Members of
PHCT, BSC CCG, BCHC,
Medicines Optimisation
To deliver a model of care that is aimed at reducing
avoidable admissions for the over 75s whilst also improving
their experiences of the services offered and the care that
they receive.
Launched 1st December 2014, network led model of support
for over 75s, will be reviewed and redesigned in early 2016.
LTC LIS
BSC Practices, Members of
PHCT, BSC CCG
To improve the outcomes for patients in the CCG with CVD
LTCs – this scheme includes the following conditions;
Diabetes, CKD, Stroke and TIA, Heart Failure, AF, CHD
Launched 1st April 2014 reviewed and refreshed by Quality
Improvement in Primary Care Group (QIPC) Feb/March 2015,
further review and refresh will take place Feb/March 2016.
Anticoagulation AQP
BSC CCG and Providers
To improve access and choice in relation to local
anticoagulation services
AQP contracting process complete providers in place.
RQIP
BSC Practices
To improve the outcomes for patients in the CCG with
asthma and COPD
Scheme being reviewed in March 2016, CPB agreeing
programme for 16/17
Primary Care Demand
Management
BSC Practices
To develop practice-based interventions aimed at improving
clinical quality and avoidance of unnecessary use of
outpatient and urgent services.
15/16 Scheme will be reviewed by QIPC Group in early 2016
Primary Care Diagnostics
BSC Practices, Relevant
Provider Organisations
To implement a Primary Care recording and interpreting
service by April 2016.
ECG service currently going through the gateway process for
agreement. 24hr BP monitoring outline business case in
development. DVT service being developed by My
Healthcare. My Healthcare are taking forward a CRP pilot
To develop a 24 hour BP monitoring service in primary care.
To develop a primary care DVT service.
CRP Testing to ensure appropriate antimicrobial prescribing.
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NHS Constitution / Patient
Promises
BSC Practices
Support the delivery of the NHS Constitution measures,
particular focus on cancer support, IAPT and vaccine uptake
Scheme commenced October 2015, 15 month scheme
agreed.
Springfield Project
CCG’s Central Network,
Voluntary Sector
The project will run over a two-year pilot to look at
supporting local citizens to work together providing a
network of sponsorship to individuals who require social and
emotional support. The aim will be to promote wellbeing
amongst our citizens, and provide interventions that are not
accessible via GP surgeries.
Approved in July 2015 started in November 2015 as a two
year pilot
Primary Care
Safeguarding
BSC Practices, BCHC,
Birmingham LA
To hold a practice-based multi-agency children and young
person’s safeguarding meetings
Included as a local quality premium priority in 14/15, 15/16
will be reviewed and further dialogue following release of
Quality Premium guidance.
Edgbaston Wellbeing Hub
CCG’s Edgbaston Network,
BSHMT, Voluntary sector
To pilot a holistic approach to mental health issues in one
locality
Pilot extended until March 2017 evaluation commencing
April 16.
Value Based Standards
BSC Practices, Macmillan,
The overall aim of the service will be to look at how the
Standards can be used as an indicator of service quality, in
order to effect a positive change in patient and staff
relationships. Drive up performance in primary care
especially in patient experience, satisfaction and outcomes.

MUS Pilot
CCG’s Edgbaston Network,
BSHMT, Local Acute Trust
To develop a multiagency cost-effective approach to dealing
with medically unexplained symptoms
Diabetes Prevention
BSC Practices, Voluntary
sector
GP Practices have mailshotted patients on their High Risk of
Diabetes Registers (HbA1c of 42 – 47mmol/mol) who are
between 18 years and 75 years and have a Body Mass Index
(BMI) of 25 or more – inviting them to attend the lifestyle
intervention
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Cohort in phase 1 of 3, establishing practices for pilot
with a view to scoping their current position against the
8 behavioural values.
 Cohort in Phase 2 engaging and enabling to include the
wider BSC group.
 Phase 3 evaluation and embedding of VBS across
providers/other CCGs – June 16.
Pilot in place.
Scheme commenced October 2015
Religious and Cultural
Circumcision AQP
Primary Care Providers
Develop service to support religious and cultural circumcision
for BSC patients
AQP contracting process complete providers in place.
Prescribing support
BSC Practices, medicines
optimisation
Prescribing development scheme for all practices.
Review of over 75s medication
Prescribing development scheme to be reviewed for 16/17.
Review of over 75’s medication will be reviewed as part of
Over 75s scheme, evaluation to date has proved successful.
Repeat prescribing support for Edgbaston Network pilot
Business case under development
Reinvestment of PMS
monies
BSC Practices
Reinvestment of any retained PMS monies following review
back into primary care.
To be reviewed by QIPC group early 2016.
Pershore Happy Hub
Pershore Network, BCC,
Voluntary sector
Wellbeing hub providing non clinical support services such as
gardening, walking, massage therapy, dietary advice.
Business case in development pilot plans to start by June
2016.
Rewards statement/
Practice engagement
BSC Practices
To develop an approach that promotes practice inclusion and
increased communication with the CCG, enabling practices to
understand membership benefits. Support member practice
involvement and engagement in CCG business.
Rewards statement in development in early 16 alongside GP
online reporting information tool (GPORT).
3.4.6
Primary Care Seasonal Pressures
As part of a co-ordinated seasonal pressures (winter 15/16 through to Easter 2016) plan across the Birmingham SRG we have sort to improve our primary
care response to Seasonal Pressures in order to more appropriately meet patient need by:
•
•
•
Adding capacity to the existing My Healthcare Hubs in order to take urgent ‘on the day’/111 GP disposal bookings
Extending the hours available at the Katie Road WiC to 10pm and exploring the same arrangement with The Hill Urgent Care Centre
Establishing My Healthcare mini-Hubs for the Edgbaston Network and Small Heath area of the Central Network
The primary care winter pressures plans were built on the following principle:
•
Extend period of extra capacity/extended opening to match period of pressure
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•
•
•
•
•
•
Make best use of the opportunity provided by My Healthcare and Hub and Spoke model
Link into 111 as part of DOS
Ensure equality of access between My Healthcare service and non-challenge fund Practices
Ensure links to SRG plan and strengthen relationships with other Providers (acutes, ambulance, mental health)
Where possible allow for increased data sharing for patients attending Hubs
Assure VFM and keep objectives in mind
Strategic Fit
BSC’s Urgent Care vision was developed by a Task and Finish Group during the early part of 2015. This included the development of a hub and spoke
arrangement aligned to a 24/7 urgent care centre that could deal with urgent care type presentations. Since July 2015 My Healthcare, a wave 2, Prime
Minister’s Challenge Fund award (see section 4.3.2) has allowed the development of a Hub and Spoke arrangement for extended primary care access across
23 Practices within the CCG. This arrangement has been set up to provide for additional GMS bookable type capacity with extended hours including 8 am to
8 pm and weekend opening.
April’s guidance on the 8 high impact changes for SRGs in relation to urgent care included the following:
•
•
•
•
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No patient should have to attend A&E as a walk in because they have been unable to secure an urgent appointment with a GP. This means
having robust services from GP surgeries in hours, in conjunction with comprehensive out of hours services.
Calls categorised as Green calls to the ambulance 999 service and NHS 111 should have the opportunity to undergo clinical triage before an
ambulance or A&E disposition is made. A common clinical advice hub between NHS 111, ambulance services and out-of-hours GPs should be
considered.
The local Directory of Services supporting NHS 111 and ambulance services should be complete, accurate and continuously updated so that a
wider range of agreed dispositions can be made.
SRGs should ensure the use of See and Treat in local ambulance services is maximised. This will require better access to clinical decision support
and responsive community services.
The new model of care for an integrated urgent care system
This primary care winter pressures plan therefore allows the CCG to meet the
above guidance and aligns with the vision for a local primary care urgent care
service as envisaged by the CCG’s urgent care task and finish group. It also
provides a stepping stone to vision outlined in the recent guidance –
Commissioning Standards Integrated Urgent Care
Primary Care Winter Pressures Plan
The following programme of services were agreed:
•
•
•
•
Urgent care bookable on the day/111 disposals at PMCF Hub across all 55
Practices of the CCG (subject to data sharing agreements) ; requiring
+1GP wte 3pm-7pm weekdays & 10am to 4pm weekends for 16 weeks
with administration support and hub co-ordination,
Extra 2 Hours opening at the Katie Road Walk in Centre (WiC) 8-10pm
(access open to all), requiring +2GPs wte between 8-11pm daily for 16
weeks, and exploring extended access with the Hill Urgent Care Centre
for same
Establishment of an in hours My Healthcare mini-hub for the Edgbaston
Network launched January 17th.
Establishment of an in hours My Healthcare mini-hub in the Small Heath area of Central Network launched February 2nd.
This was chosen because:
•
•
In terms of healthcare seeking behaviour
o it reinforces the use of the WiC during the busiest times
o it opens up a new disposal route for 111 calls as part of the DOS
o it reinforces a GP first approach to urgent but not emergency/critical type health problems
In terms of ‘switching off’ such services
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•
•
•
o The Katie Road WiC and the Hill Urgent Care Centre service can easily be scaled back
o The mini-hubs could be closed and patients referred to one of the bigger current three Hubs
o The urgent care bookable on the day 111 type attendances could be also be redirected after changing the DOS
In terms of the CCG’s approach to urgent primary care
o The vision includes a 24/7 WiC and urgent care centre at the centre of the local network of services (see diagram above)
o It allows the addition of an urgent care aspect to the My Healthcare arrangements as requested by clinicians in the Commissioning
Programme Board
o It supports the achievement of one of the Urgent Care High Impact Changes i.e. no patient should have to attend A&E as a walk in because
they been unable to secure an urgent appointment with a GP
In terms of staffing
o It is realised that securing enough clinical time to staff any particular permutation is key and the rate limiting step
In terms of adding value to the urgent care system, all the schemes listed would have added value but this particular permutation allows us to
extend the My Healthcare concept to more CCG Practices in a managed way (bookable/111 disposals) and improved inter-practice working in the
areas of Edgbaston and Small Heath. It also prepares the ground for any forthcoming GP seven day access contract offer.
We will evaluate the viability of this approach as part of our seasonal pressures planning for 16/17 to ensure we learn from these innovative ways of
expanding capacity.
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3.5
Access Standards for A&E and ambulance waits
One of the 9 ‘must do’s’ for 2016/17 is to get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients
wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through
making progress in implementing the urgent and emergency care review and associated ambulance standard pilots.
The current structure for managing unplanned care is set out below to show how the individual trust performance feeds up into the Birmingham & Solihull
System Resilience Group which is part of the West Midlands Urgent Emergency Care Network.
West Midlands Urgent Emergency Care Network
(Region wide)
BSOL SRG: Unplanned Care (Birmingham and
Solihull) and Birmingham Children’s Hospital SRG
Individual Provider Trust Contract Quality and Performance
Review Meetings (Host CCG arrangements)
West Midlands Urgent Emergency Care Network (UECN)
Following publication of the Keogh Urgent & Emergency Care Review, West Midlands UECN has been established to provide strategic oversight of urgent
and emergency care over the Birmingham, Black Country, Hereford and Worcester major trauma network area covering the following System Resilience
Group areas:



Birmingham and Solihull SRG
Birmingham Children’s SRG
Dudley SRG
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




Herefordshire SRG
Sandwell & West Birmingham SRG
Walsall SRG
Wolverhampton SRG
Worcestershire SRG
Member Systems Resilience Groups (SRGs) maintain responsibility for the operational leadership and coordination of those local services, coming together
with partners in West Midlands UECN in order to ensure coordination of the overall urgent and emergency care strategy to:







Create and agree an overarching, [medium to long term] plan to deliver the objectives of the Keogh Urgent & Emergency Care Review;
Designate urgent care facilities within the network, setting and monitoring standards, and defining consistent pathways of care and equitable
access to diagnostics and services for both physical and mental health;
Make arrangements to ensure effective patient flow through the whole urgent care system (including access to specialist facilities and repatriation
to local hospitals);
Maintain oversight and enable benchmarking of outcomes across the whole urgent care system, including primary, community, social, mental
health and hospital services, the interfaces between these services and at network boundaries;
Achieve resilience and efficiency in the urgent care system through coordination, consistency and economies of scale (e.g. agreeing common
pathways and services across SRG boundaries);
Coordinate workforce and training needs: establishing adequate workforce provision and sharing of resources across the network;
Ensure the building of trust and collaboration throughout the network; spreading good and best practice and demonstrating positive impact and
value, with a focus on relationships rather than structures.
The oversight and governance of system resilience plans will continue to sit with the Systems Resilience Groups (SRGs) as part of Urgent and Emergency
Care Network structure.
Birmingham & Solihull System Resilience Group (BSOL SRG): Unplanned Care
The BSOL System Resilience Group (BSOL SRG) brings together acute, community, mental health and ambulance service providers with social care, to work
collaboratively on the development of strategies and plans that ensure system-wide resilience.
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The review of performance against activity levels and quality standards occurs through a variety of forums with SRG taking an oversight to enable effective
planning. The objectives of all are to reduce unplanned attendances and emergency admissions, provide effective alternative care within the community, in
line with the Better Care Fund plans for Birmingham to ensure patients are treated in a timely manner.
Analysis of 2013/14 winter initiatives identified community capacity as a significant factor restricting patient flows within the urgent care system. This was
supported by the ECIST report undertaken in March 13, which recognised the considerable issues with intermediate care and rehabilitation at home
provision. This was supported by ward based audits undertaken jointly by commissioners and providers and confirmed a large number of patients, above
40% on some wards, no longer required an acute bed but did need on-going step down care (this is also supported by the Better Care Fund Intermediate
Care analysis undertaken in 2014). The Birmingham & Solihull System Resilience Plan 2015/16 includes investment which continues into 2016/17 for a
number of areas:
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Out of hospital provision community services
Improving discharge; including adoption of a robust discharge to assess pathway, the provision of enhanced assessment beds, ensuring those
patients who no longer require acute care are transferred to a more appropriate, community setting for further assessment
Supporting the management of mental health patients in crisis – Rapid Assessment Interface and Discharge (RAID), assessment of patients out of
A&E and increasing access to talking therapies
Promoting 7 day working – working towards delivery of the national requirements, increasing capacity in all providers including social workers
Continuing development of ambulatory emergency care
Expanding acute medical clinics in the trusts
Establishing specialist facilities e.g. Community Medical Assessment Unit (CMAU) dedicated geriatric input at Birmingham Community Healthcare
Trust
Psychiatric Decision Unit (PDU) providing an alternative to A&E for those patients experiencing a mental health crisis at BSMHFT
Mental health services for 0-25 years through Forward Thinking Birmingham
All enabling short term input and timely movement to a community setting for on-going care and support.
The demand and capacity within primary care is a key component on the unplanned care dashboard which impacts on the level of A&E attendances seen
through acute providers. The CCG is working with member practices, GP OOH providers, WIC providers and NHS 111 to develop the urgent care offer for
the CCG’s population. The SRG plan also includes the utilisation of the skills of the commissioning support unit to develop a comprehensive winter
communications plan for 2016 to ensure patients are able to access the services they require in the right setting.
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The expanded opening hours of practices via the CCG’s Prime Ministers Challenge Fund model alongside the utilisation of primary care skills and knowledge
at the front door will enable acute providers to focus on the major A&E attendances and those patients requiring admission and on-going acute care. This
will reduce ambulance hand over delays and the number of patients waiting longer than 4 hours.
Ensuring more than 95 percent of patients wait no more than four hours in A&E:
Heart of England Foundation Trust (HEFT):
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HEFT has consistently failed to deliver the A&E 4 hour standard overall since April 2013 and has only delivered against it for 4 months since then.
The last month it was met was in April 2014, following which there was a decline to 85%. Although performance has improved since that time, it is
yet to meet the 95% standard.
The number of A&E attendances has increased by 4.4% between 2013/14 and 2014/15 and by a further 4.9% against the 2015/16 forecasted
outturn.
Emergency admissions increased by 6.9% from 2013/14 to 2014/15 and by 0.4% from 2014/15 to 2015/16 forecasted outturn.
Around 80% of discharges for emergency admissions take place during weekdays and 20% over the weekend. This position has not changed
materially since 2013/14.
The average length of stay reduced by around half a day during 2014/15 and has increased slightly in 2015/16 to date.
The rate of delayed transfers of care has increased significantly since 2013/14 and correlates with the increasing number of attendances, increase in
emergency admissions, and the decline in 4 hour performance.
The HEFT improvement plan for Urgent Care includes a number of initiatives that the trust are focussing on, these include:
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Emergency (A&E) and Ambulatory Emergency Care (AEC) Departments:
o Expanded Majors and Minors areas at Heartlands Hospital to support increased demand
o New AEC departments to manage the ambulatory patients more efficiently
o New medical rotas to better match patient demand profiles
o Extended opening hours to support demand profiles
o New escalation processes to communicate site status pro-actively
Dedicated Clinical Site Management (CSM) teams introduced to manage flow and capacity.
Introduction of the Safer Patient Placement process, to aid flow through the Hospital.
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Increased focus and emphasis on the morning Jonah Board/Ward Rounds:o Length of Stay Reduction
o Daily Discharge Targets
o Earlier Discharge before 1pm
University Hospital Birmingham (UHB):
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Historically, UHB has demonstrated stronger performance against the A&E 4 hour standard, with one or 2 months not meeting the target. However
since July 2015, the Trust has struggled to meet the target.
The number of A&E attendances has increased by 6.0% between 2013/14 and 2014/15 and by 4.1% against 2015/16 forecasted outturn.
The number of emergency admissions has increased by 3.6% from 2013/14 to 2014/15, and 5.6% from 2014/15 to 2015/16 forecasted outturn.
Around 80% of discharges for emergency admissions take place during weekdays and 20% over the weekend. This position has not changed
materially since 2013/14.
The average length of stay reduced during 2014/15 by 0.35 days and again in 2015/16 by a quarter of a day.
The Trust has carried out a significant amount of work in to address discharge delays for medically fit for discharge patients and this is
demonstrated in a reduction in the delayed transfers of care rate to 2.7% in 2015/16 to date.
The data shows that there has been a slight increase in the emergency readmission rate.
Whilst UHB have historically delivered against the 4 hour standard. Over the last 12 months, as a result of the increased activity and acuity of
patients, the trust has found it increasingly difficult to maintain performance.
UHB has a remedial action plan in place which contains the following:
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Resolution of staffing issues at middle grade level through cross cover by specialty doctors, increasing Emergency Nurse Practitioner cover, and
exploring the possibility of a substantive contract with a GP who is experienced at working in ED.
Improving flow through the department by reviewing OPAL usage in ED and reinforcing the specialty referral policy in ED.
Assess the impact of the Community Medical Assessment Unit on ED activity and flow.
Assess the impact of the Psychiatric Decision Unit on ED activity and flow.
Improve site management processes.
Further development of the Integrated Complex Discharge Team to reduce length of stay and release bed capacity
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Improve capacity and flow internally through opening up tidal flow beds, ensuring consistent use of the Discharge Lounge, full implementation of
3pm MDT Board Rounds, reducing the time/number of patients waiting in ED for transport, and reviewing the criteria for internal escalation.
Implementation of an annualised hours rota to provide a third consultant in the evenings
Trial Rapid Assessment and Treatment model in ED.
Birmingham Children’s Hospital (BCH)
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Birmingham Children’s Hospital is a separate SRG to BSOL SRG as the issues pertinent to children’s services are very different to adult services.
Historically, BCH has been a very strong performer in delivering on average 97% within 4 hours each month in A&E until winter 2014 and winter
2015 where October, November and December were below 95%.
BCH delivered the A&E 4 hour 95% target in 2014/15 and is expected to deliver 95% for the 2015/16 full year.
Overall A&E activity has increased by circa 3% year on year but on peak days during winter 2015 the increase it upto 20% higher than attendances
seen at the same time the previous year
BCH A&E department can maintain upto 170 A&E attendances per day although during winter 2015 attendances peaked at 228.
Emergency admissions reduced in 2014/15 compared to 2013/14 due to the introduction of the Clinical Decision Unit (CDU which is equivalent to
an AMU). In 2015/16 the average growth in non-elective admissions was 2%.
Main pressures on the delivery of the 95% of A&E attendances seen within 4 hours are:
o Spikes in demand for primary care type attendances
o Specialised/trauma patients reducing the overall capacity available for ‘general acute’ paediatrics
o Delayed discharges due to children awaiting complex care package placements
o Delays in accessing NHSE CAMHs Tier 4 beds
BCH has a remedial action plan in place which contains the following:
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Implement an interim complex care discharge solution by increasing BCH out of hospital services to reduce delayed discharges from PICU/Ward
Increased capacity within primary care out of hours and weekends
Communications plan for Winter 2016 to ensure ‘primary care’ type attendances are directed to primary care facilities where appropriate
Joint review with NHSE around access to Tier 4 CAMHs beds and PICU beds
Review of options for relocating the Clinical Decision Unit outside of A&E to create more physical capacity within A&E
Review of recurrent workforce model to cover Winter 2016
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Review of NHS111 DOS for children’s services
Review Paediatric EMS triggers across all local Paediatric providers
16/17 SDIP milestones to increase 7 day working against the 4 key standards
16/17 CQUIN to implement a clinical utilisation tool which aids clinical decision making when determining whether a patient requires or should
remain in an acute bed
Improved response rates for mental health assessments and improved psychiatric liaison
Improved access to patient information through the digital SDIP
16/17 CQUIN to improve monitoring of PEWS for children
Review of children’s place of safety arrangements (currently A&E)
Review potential for separate primary care stream
BSC takes a formal but collaborative approach to the management of performance issues with the acute trusts. Contractual levers have been utilised and
relevant financial penalties have been applied to ensure focus on improvement. However, funding accumulated through fines has been reinvested back into
the trusts in the first instance, or, when relevant and agreed, invested into the wider system if that investment results in further support to the trust in
moving towards improvement.
Ambulance trusts respond to 75 percent of Category A calls within eight minutes
Ambulance services commissioned through West Midlands Ambulance Service have gone through a service development improvement process during
2013-15 where staff hours and breaks were redesigned to enable the trust to respond to the required response times more efficiently.
Ambulance turnaround times within the acute trusts is intrinsically linked to the delivery of the 8 minute target as the flow through A&E departments is
critical to the release of ambulances to respond within 8 minutes to Red 2 calls. Where ambulance turnaround times do not meet the required standard
WMAS deploy HALO’s (Hospital Ambulance Liaison Officers) to assist with enabling patient flow. Through the application of developed pathways and
processes, the HALO’s ensure that ambulances are cleared to return to duty following the handover of patients.
In 2015/16 WMAS forecast indicated that 75% of Cat A calls were responded to within 8 minutes, compared to non-delivery against this key target for
2013/14 and 2014/15. In 2016/17 the maintenance of this target will require system partnership working to ensure that patients are disposed to
alternative community settings, including primary care. Pilots carried out in 2015/16 will be expanded into 2016/17 following evaluation; this also includes
amendments to the NHS111 DOS to include access to GP bypass numbers.
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Unplanned care resilience/Winter Resilience
There were 3 key components to the 2015/16
Birmingham & Solihull System Resilience Plan
(BSOL SRP). The priorities for 2015/16 will be
based on the implementation and expansion of
existing good practice – i.e. creating capacity
through the application of evidence based
interventions. It also contains plans to develop
longer term capacity through the development of
new models of primary care, for example. In
addition, it includes plans which are aimed
specifically at supporting existing service
capability and capacity during periods of surge or
sudden increased demand, for example during a
cold weather spell or in the context of a flu
pandemic.
The SRP will be dynamic and reactive. Whilst the SRG believes the focus and interventions agreed will deliver improvements in care and performance, the
plan will be regularly reviewed and monitored and where relevant, initiatives will be stopped and investment moved to a more appropriate intervention.
Work will continue to assess the plan against the national standards, including 8 high impact interventions and Safer, better, faster. Areas identified as
requiring further work will form part of the contingency planning.
Winter resilience for 2016 will build on the learning taken from the system resilience plans developed through 2015/16 and will also incorporate key
elements of the safer, faster, better: good practice for developing urgent and emergency care including:
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Preventing crowding in A&E
Getting patients into the right ward first time reduces mortality, harm and length of stay
Patients on the urgent and emergency care pathway should be seen by a senior clinical decision maker (this is linked to 7 day services
requirements)
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Daily senior review of every patient, in every bed, every day, reduces length of stay and costs of care through the clinical utilisation tool
Frail and vulnerable patients, including those with disabilities and mental health problems of all ages, should be managed assertively but
holistically: this is incorporated through the Frailty CQUIN that the CCG has built into the community trust contract for 2016/17
Acute assessment units enhance patient safety, improve outcomes and reduce length of stay
Managing mental health problems within the 4 hour window through PDU/RAID and CAMHs ERA services
Continuity of care is a fundamental principle of safe and effective practice within, and between, all settings through the use of electronic handover
tools
Properly resourced intermediate care, linked to general practice and hospital consultants, can prevent admissions, reduce length of stay and enable
home based care and assessment: through the Better Care Fund plans this strategy will be progressed through 2016/17 aligned to the wider
Sustainability and Transformational Plan.
Workforce planning across the SRG/UECN footprint to enable variations in emergency care across care settings and providers to be managed more
effectively
Development of the urgent care pathway to include integration of NHS111 and GP Out of Hours services and the use of Walk In centres and urgent
care centres
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3.6
Referral to treatment
The CCG, alongside the System Resilience Group partners, have implemented a number of interventions to deliver one of the national ‘must do’s’ for
2016/17 to deliver improvements against and maintenance of the NHS Constitution standards so that more than 92 percent of patients on non-emergency
pathways wait no more than 18 weeks from referral to treatment, including offering patient choice which includes:
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An annual review of optimum waiting list size by provider in line with IMAS standards in line with expected demand and capacity modelling by trust
An annual review of trust patient access policies incorporating the treatment of patient choice
The inclusion of an information requirement included within the 2016/17 contracts to include submission of monthly patient tracker lists which will
enable monitoring of overall waiting list size and waiting time profiles by trust, by specialty and by month
CCG investment in additional activity (growth) to sustain growth and reduce waiting list backlogs
Monthly monitoring and performance management undertaken though contract performance review meetings with trusts
System wide escalation of RTT performance issues via the Planned Care SRG dashboard
System wide elective demand and capacity review (including diagnostics) through the Birmingham & Solihull Sustainability and Transformation Plan
The following actions were agreed by the Birmingham & Solihull System Resilience Group as defined within the 2015/16 SRG plan which will continue into
2016/17:
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Specialised commissioning investment in Paediatric Intensive Care and High Dependency Care to provide additional capacity and flow through levels of
paediatric intensive care.
Specialised commissioning investment in acute based rehabilitation service to support improvement in patient recovery, reablement and rehabilitation
goals, increasing the number of patients who can be discharged to home and community care settings.
Provider investment, reconfiguration and streamlining of pathways and operational processes, the impact of which is increased efficiency that enables
increased capacity and improved flow through the care pathway.
Commencement of elective flow work streams to tackle challenged specialities:
o
o
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Neurosurgery: implementation of national pathfinder, treat and triage and clinical policies and protocols to reduce demand and ensure patients access
appropriate treatments at the right time and right setting.
General Surgery: use of local and national PMO to access support from Independent Sector or other NHS providers as an extended choice scheme; review
of access and discharge protocols - review and refresh of existing referral, treatment and discharge protocols, to ensure that partners are implementing
these and patients are being referred and discharged in line with these to reduce outpatient activity.
3.7
Cancer - 62 day cancer waiting standard - improving one-year survival rates
3.7.1
Cancer Task Force Report
The report of the Independent Cancer Taskforce - ACHIEVING WORLD-CLASS CANCER OUTCOMES A STRATEGY FOR ENGLAND 2015-2020 sets out over the
next five years, how the NHS can improve radically the outcomes that the NHS delivers for people affected by cancer. The report proposes a strategy for
achieving this. It includes a series of initiatives across the patient pathway. These emphasise the importance of earlier diagnosis and of living with and
beyond cancer in delivering outcomes that matter to patients. The report recognises that no two patients are the same, either in their cancer or their
health and care needs. At its heart, it sets out a vision for what cancer patients should expect from the health service: effective prevention (so that people
do not get cancer at all if possible); prompt and accurate diagnosis; informed choice and convenient care; access to the best effective treatments with
minimal side effects; always knowing what is going on and why; holistic support; and the best possible quality of life, including at the end of life.
The strategy seeks also to harness the energy of patients and communities and encompass their responsibilities to the health service. This means taking
personal ownership for preventing illness and managing health; getting involved in the design and optimisation of services; and providing knowledge as
experts through experience. This section sets out how we intend to deliver the vision.
3.7.2
Diagnostics
A diagnostics review was carried out on behalf of the 4 CCGs in the Birmingham, Sandwell and Solihull (BSS) Unit of Planning Commissioning Group and
formed part of the High Level High Level review of Diagnostics current activity and estimate future demand.
The demand and capacity gap
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During the past decade, activity in imaging and diagnostic examinations or tests has risen by 40%.
National strategies (e.g. Cancer Taskforce and Personalised Medicine) are going to have a significant impact on demand.
Public awareness campaigns and national screening programmes increase referrals for diagnostic tests and examinations.
7 day working will have an impact on workforce planning and capital equipment.
There are significant risks surrounding workforce with shortages present across all staffing groups.
Continuing learning and development is vital to keep up with emerging technologies.
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The quality and efficiency gap
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Several accreditation standards have been developed and are helping to improve quality.
Commissioners can incentivise quality by commissioning only -accredited providers, using incentives such as the Best Practice Tariff and the use of
specifications detailing quality standards.
Research points to patient experience-specifically confidence in the care provider and perceived quality of care-correlated negatively with longer
wait times.
The UK has a lower number of CT scanners and MRI machines per population than other OCED countries and more than 10% of CT equipment is
more than ten years old.
It is clear from the review that there are opportunities for improvement across diagnostic services, particularly around patient-centred service design and
delivery. New ways of working may help to address current and predicted workforce shortages and new models of care, such as the East Midlands
Radiology Consortium (EMRAD) Vanguard, based in Nottinghamshire, will offer useful insights. New technologies are emerging all the time, which will
impact on efficiency and effectiveness; however, it could be argued that an approach focused on “getting the basics right” first could pave the way for more
robust adoption of innovations in the future.
This review has produced a baseline review of where the CCG is at the end of 2015/16, and has modelled the volume of diagnostics the CCG would need in
2020 to keep up with the national screening programmes and demographic change.
In summary the current position as the CCG enters 2016/17 is that demand growth of around 7% is exceeding activity growth which averages 2% across
Birmingham & Solihull, which is resulting in performance breaches against the 6 week diagnostic waiting time target.
This particularly affects endoscopy (of all kinds) urodynamics and paediatric MRI. Demand growth is driven by national screening and awareness
campaigns, demographics and a small amount by technological change.
In urodynamics the activity is very volatile which suggests a service organisation component to the current issues.
Overall the CCG will need to see a 52% growth in diagnostics activity by 2020 to meet all current standards and targets and the requirements of the cancer
waiting times.
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The Sustainability and Transformation plans across Birmingham and Solihull will include a transformational plan to increase diagnostics capacity in line with
required demand by 2020. The expected outcomes are closing the gap on cancer diagnosis, improving treatment times and increasing survival rates
between the Birmingham and Solihull STP and England as a whole.
3.7.3
Birmingham and Solihull Cancer SRG
Locally, The Birmingham and Solihull System Resilience Group (BSSRG) has established a Cancer SRG Subgroup to undertake a systematic approach to this
important work programme. In order to reflect the pathways flows across the NHS system for cancer services, the subgroup has been established on the
previous Pan Birmingham Cancer Network footprint.
The Pan Birmingham Cancer SRG Sub-group has responsibility for ensuring the effective delivery of Birmingham, Black Country and Solihull cancer services,
including associated performance targets in their area. In addition, The Pan Birmingham Cancer SRG Sub-group will be the forum where all partners across
the health and social care system come together to undertake regular planning of service delivery. The group will be responsible for the planning and coordination of the capacity required to enable delivery of integrated, effective, high quality and accessible cancer services for local patients.
The group will work together to ensure that the local health economy has sufficient year round capacity and resilience to ensure that all national standards
are consistently achieved, taking an oversight on planning and implementation of national strategy, guidelines or policy directives as to understand the
impact on the wider system flow and to ensure consistency of implementation across the system.
The detailed Cancer SRG workplan schemes are detailed below:
•
•
•
•
WS1 Development of a commissioning proposal for the implementation of New NICE Guidelines
WS2 Refresh of Pan Birmingham wide clinical tumour site pathways
WS3 Development of Pan Birmingham access processes, policies and protocols
WS4 Communication and Engagement Plan
Thus, the work programme of the Pan Birmingham and Solihull Cancer SRG coupled with specific CCG cancer projects (see below) will deliver the
expectations of the cancer task force report and ensure that the system meets the demand and capacity requirements to deliver the Cancer NHS
constitutional targets 2 weeks, 31 and 62 days.
.
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3.7.4
BSC CCG Cancer Specific Projects
CCG Cancer Survivorship Programme
BSC CCG successfully bid for a 3-year Macmillan Primary Care Nurse Facilitator post in 2014. Two nurses have been recruited to this post on a job share
basis. The Macmillan Primary Care Nurse Facilitators have been working with the Macmillan GP Facilitator, our Chief Nurse and one the CCG’s
Commissioning Managers. Their work programme supports the local implementation of the national Cancer Reform Strategy: early awareness and
diagnosis of cancer, primary and secondary care interface, cancer survivorship and quality of end of life care. The service will be an integral part of the
CCG’s cancer action plan, addressing the identified needs of the Birmingham population.
Practice Nurse Course
The CCG has established a Practice Nurse Cancer Survivorship course comprising 30 hours participatory learning plus approximately 10 hours of online
learning. The course covers the following modules:
Module 1 - The changing story of Cancer and Cancer care
Module 2 - Introduction to Cancer
Module 3 - Effect of treatment and recurrence
Module 4 - Communicating with people affected by cancer
Module 5 - The Recovery Package
Module 6 - The Impact of Cancer
Module 7 – Diversity
Nine nurses in total have completed the course which finished in January 2016 and has been very well evaluated by the course attendees. This cohort of
nurses are the first in Birmingham to complete this course which has given them the knowledge, skills and confidence to care for cancer patients in Primary
care. While the nurses are in post, these nurses will receive mentorship and support to develop their skills. A follow-up study half-day is being arranged for
them for July 2016.
As a result of the recruitment drive a number of other nurses have expressed an interest in doing the course but due to various constraints were not able to
commit to the first course. Consideration is being given to an additional course in the Spring of 2016. We have applied to Macmillan for funding for a
second course and at the moment we are awaiting their response. We have no guarantee that funding will be available from Macmillan as the money that
they have set aside for Practice Nurse education has to be allocated fairly across the whole of England.
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We are working closely with Dr Veronica Nanton who is leading the Prostate Cancer Research Project, which includes an element of Practice Nurse
education. The hope is that some of the nurses who have completed our course will then go on to be part of the research project. If we can secure funding
for a second cohort of nurses this will help the research team with recruitment into their project.
Awareness Raising and Early Detection Project
With the publication of the new NICE guidelines and the cancer plan for 2015-20, early diagnosis of cancer is being promoted as a high priority. The CCG is
ranked in the bottom quartile for early diagnosis of cancer in the West Midlands, and have developed various projects to improve this situation.
Promoting cancer awareness is an ongoing activity, for example December 2015 was Bowel cancer awareness month and as a consequence the CCG
distributed Macmillan resources to practices and prepared public information to go out on social media about bowel screening and early diagnosis. We will
continue to take the opportunity to raise awareness across the year starting with World Cancer day on February 4th and the Be Clear on Cancer campaign
that is running from February to April 2016.
The Practice Nurses who have completed the cancer course are well placed to educate their patients about the importance of taking part in the cancer
screening programmes and giving advice about the cancer risks associated with lifestyle.
Our Macmillan GP Facilitator started a programme of visiting GP practices in summer 2015 to look at their cancer profiles and explain the early diagnosis
toolkit and Macmillan support resources available. In addition the West Midlands Strategic Clinical Network (SCN) obtained resources for the CCG from
Cancer Research UK (CRUK) in the form of a CRUK Facilitator to support the Macmillan GP Facilitator and help improve cancer prevention, early diagnosis
and cancer outcomes across the CCG. Both the SCN and CRUK are very keen to ensure that the projects objectives are adapted to take into account local
need, priorities and to complement prior and existing activity.
The project is delivered through trained CRUK Health Professional Engagement Facilitators who visit GP practices and:
•
•
•
•
•
•
provide practices with their cancer data, presented in an easy to understand format
encourage reflection on referral patterns, current practice, screening uptake, safety netting procedures and ways to improve
introduce practices to various early diagnosis tools and interventions, such as audits and Cancer Decision Support Tools
share best practice and innovative solutions trialled by another practice
provide training to clinical and non-clinical staff
provide evidence, information and resources to help practices with specific issues.
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Facilitators provide follow–up, practical support to help busy practices to implement activities and embed changes. They are catalysts for change.
We are also influencing GP education within our CCG by ensuring cancer topics are included in their training, ie. we provided educational sessions on cancer
survivorship and palliative and end of life care on 21st October. We will be promoting as we have done over the last 18 months any Macmillan/ CRUK and
other relevant study days.
In addition, links have been made with cancer screening team at Public Health England. Over 16/17 we intend to build on this very local work to improve
our early detection and hence increase survival within the CCG population.
Living With and Beyond Cancer - Health and Wellbeing Events
Health and wellbeing events are part of the recovery package. Ideally they are aimed at patients who have reached the end of their treatment and there
are education events that are aimed at keeping them as well as possible for as long as possible by promoting healthy life style, supporting emotional
resilience and informing patients of symptoms to be aware of. Some of our colleagues in secondary care have been piloting different models of providing
these events and have aimed them at specific tumour sites.
Discussions are being held regarding further health and well-being events. Although the different models that have been trialled have been well received
by patients there is no clear strategy to deliver any more. For health and well-being clinics to be most effective, they need to be integrated into the patient
pathway and part of the stratified follow up for appropriate patients. Our colleagues in secondary care are focused at the moment with improving their
cancer waiting times, so health and well-being clinics are not a priority at present. It is hoped that the commissioning of the recovery package will include
the provision of health and wellbeing events as part of the patient pathway.
In the meantime, education of the Primary Care work force will continue and the value of health and wellbeing will be promoted within our area. Again our
Practice Nurses who have completed the course have a good understanding of the needs of cancer survivors and know where to signpost patients to who
would benefit from 3rd sector providers (e.g. Penny Brohn, Sutton Cancer Support, Help Harry Help Others Support centre, etc.).
To supplement this work the CCG organised two events aimed at all cancer types. The aim of the events was to inform and educate cancer patients about
strategies they can use to stay as well as possible for as long as possible. We asked the cancer charity Penny Brohn to facilitate this for us as they have a
long history and tried and tested methods of delivering this type of patient education. The Cancer taskforce report also emphases the importance of
patient experience and wants to develop the quality of life measures for cancer patients.
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These types of events are highly valued by the patients who access them with the first event being attended by 35 patients plus their families/friends/carers
(see below for attendees comments). The intention is to hold further events in spring 2016.
What are the main messages or ideas that you are taking away from today’s session?
Selected quotes:
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•
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“Keep well, try activity, keep a varied diet and talk to people”
“Amount of support available”
“Feel more positive”
”To look after yourself inside and out”
“Relax and de-stress more”
”Reducing stress levels, eating healthily. Thank you, nice day”
“Cancer awareness, that I should be aware now on things that will keep me stay healthy and live longer cancer free”
“Lead a more healthy lifestyle”
CCG Primary Care End of Life Local Improvement Scheme
In November 2014 the CCG developed a Primary Care Palliative and End of Life Local Improvement Scheme that included improved outcomes for cancer
patients:
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•
•
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Cancer patient MDT using key worker to promote H&WB incorporating third sector providers
Appointment of cancer key worker for cancer care plan
Cancer patient experience improvements measured
Health and wellbeing events/sessions
RCA to be carried out following every death.
At the end of the scheme each practice should have a protocol in place
outlining how they manage patients at the end of life.
CCG - NHS Constitution General Practice Local Improvement Scheme
In November 2015 the CCG developed a “Patient Promises” Local
Improvement Scheme that included the facility for Practices to choose one of
three cancer related projects:
•
•
•
Tracking of the cancer pathway (48 out of 55 practices)
Root cause analysis of patients diagnosed with cancer in A&E (42
out of 55 practices)
Promotion of colorectal screening in low take-up groups (19 out
of 55 practices)
The LIS extends until 31 December 2016 and we will be monitoring the action
plans via our on-line reporting system that includes specific actions as
required and capturing evidence of new processes that have been developed
and implemented as a result of the LIS. For example below is a screen shot of
a Practice level tracking tool and a newly devised Practice based algorithm.
Example of a Practice Developed Cancer Referral Tracking System – algorithm
and tracker (Source: Cofton Medical Centre, West Heath Medical Centre)
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Macmillan Values Based Standard update
There is increasing evidence of a link between high quality patient experience and improved health outcomes. The Macmillan Values Based Standard is a
framework for improving patients’ experience of healthcare, based on human rights principles. It identifies 8 specific behaviours – practical things that staff
can do on a day-to-day basis to ensure that people’s rights, including dignity and respect, are protected. It also sets out the role patients can play and what
they can expect. It focuses on the ‘moments that matter’ to people and their carers affected by cancer. Although the Standard has been developed for
cancer care, the CCG is using it to improve the experience of any patient in primary care. The CCG successfully bid for a 3-year Macmillan Values Based
Standard Project Lead post in 2013. At that time the CCG’s patient experience was variable and it was felt that the Standard would support a consistent
approach to improving patient experience across the CCG. The project outcomes include:
•
•
•
•
•
Improved co-production between staff and patients – increased focus in service design on ‘what matters most’ to patients and professionals.
Patients supported to make decisions about their care in partnership with health care professionals.
Improved relationships between staff and patients/carers – leading to more opportunities for disclosure to identify problems earlier.
Improvement in performance on key patient experience outcomes, e.g. communication; information; respect and dignity; emotional support, etc.
Increased knowledge, confidence and expertise in primary care in delivering patient-centred services that protect and promote human rights.
To date ten practices have been recruited for the pilot, which cover all of the CCG’s five networks. All of these practices have delivered simple, yet effective
changes to the way they offer services to their patients, as a result of continued dialogue between frontline staff and patient participation groups (PPGs).
For example, the reconfiguration of a foyer layout has resulted in more throughput and a reduction in complaints regarding confidentiality at reception.
The co-design approach in Values Based Standard has uncovered gaps in frontline staff skills and two areas of focus were common to several practices.
Those were, dealing effectively with difficult patients and how to deliver better customer service. Training courses have been developed to address these
shortcomings, with the aim of further fulfilling the Macmillan and CCG ethos of, all patients being treated with dignity and respect. Future targets include:
•
•
•
Recruiting additional practices to Values Based Standard from across the CCG.
Working with practices requiring improvement following Care Quality Commission inspection.
Investigating how best to ensure the overall findings are embedded and continues as part of the CCG’s commissioning plans going forward.
The eight behavioural elements of the Values Based Standard have been recognised by the Care Quality Commission as key examples of how staff can go
that ‘extra mile’ to help achieve the best possible outcomes for all their patients. This has led to a local agreement that Values Based Standard evidence
can be included in GP inspection presentations, as evidence of what the practice and its workforce is doing to improve those areas that are not so good.
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3.8
New Mental Health Access Standards and Dementia Diagnosis
3.8.1
New Mental Health Access Standards
Parity of esteem will be further strengthened in 2016/17 with the introduction of two new access standards in mental health.

More than 50% of people experiencing a first episode psychosis will commence treatment with a NICE approved package of care within two weeks
of referral. This will be achieved by supporting clinicians, including those in primary care, to recognise the signs and symptoms of first onset
psychosis. Commissioners are working with secondary care providers (Birmingham and Solihull Mental Health Foundation Trust and Forward
Thinking Birmingham) to ensure that they have the appropriate systems and mechanisms in place to receive referrals with appropriate red flags and
expedite service users on a NICE compliant treatment pathway within the timeframe.

Ensuring that 75% of people with common mental health conditions referred to the Improving Access to Psychological Therapies (IAPT) programme
will be treated within 6 weeks of referral with 95% treated within 18 weeks. This will build upon the work commissioners have undertaken with
Providers in 2015/16 to reduce waiting times into treatment.
Achieve and maintain the two new mental health access standards
More than 50% of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral
More than 50% of people (circa 19 patients per month for BSCCCG) experiencing a first episode psychosis will commence treatment with a NICE approved
package of care within two weeks of referral. This will be achieved by supporting clinicians, including those in primary care, to recognise the signs and
symptoms of first onset psychosis. Commissioners are working with secondary care providers (Birmingham and Solihull Mental Health Foundation Trust
and Forward Thinking Birmingham) to ensure that they have the appropriate systems and mechanisms in place to receive referrals with appropriate red
flags and expedite service users on a NICE compliant treatment pathway within the timeframe.
Both B&SMHFT and Forward Thinking Birmingham have undertaken the following review prior to the implementation of the new standards/mobilisation of
the new service (FTB) in April 2016:

Understanding demand – local incidence rates and profiles
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


Workforce development – understanding the baseline position and gaps in respect of staffing, skill mix and competency to deliver the full range of
NICE concordant interventions.
Optimisation of RTT pathways - engaging all potential referral sources, many of which will be internal in secondary care and which will include
CAMHS and acute services.
Preparation for the new data collection requirements – this will include development to provider systems and training for service and information
leads.
75 % of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within
six weeks of referral with 95% treated within 18 weeks
IAPT services are now commissioned across a number of providers for BSCCCG:



Birmingham & Solihull Mental Health Trust (Over 25’s namely but provision for 18-25 if patients opt for B&SMHFT through exercising patient
choice)
Forward Thinking Birmingham (Consortium of providers with Birmingham Children’s Hospital as the lead provide alongside Worcester Health and
Social Care, Priory Group and a number of Voluntary sector organisations) for 0-25 year old patients
Mental Health Consortium (all ages) which is a consortium of non nhs providers which takes referrals mainly from non GP sources therefore
reducing health inequalities
The 2015/16 standard for commencing IAPT treatment was 28 days, therefore current performance against the 6 week target is already circa 80% and
above 95% for 18 weeks. With the addition of new IAPT providers in 2015/16 IAPT waiting times are as low as 2 weeks in some cases. 2016/17 contracts
with the above providers include the national KPI targets with associated contractual performance clauses for non-delivery and monthly information
reports to enable monthly monitoring to ensure current performance does not reduce.
3.8.2
Dementia Diagnosis
Between now and 2030 the number of people with dementia in the UK will double to 1.1 million. This will have a profound effect on health and social care,
as well as carers, Government and business. The Secretary of State has said, “Dementia is one of the biggest challenges we face. Our ambition is to
become one of the best countries in the world for dementia care”.
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Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia.
The CCG has been working hard to improve its dementia diagnosis rate, which was 64.9% in November 2014. GP practices and CCGs are measured by the
numbers of people they diagnose with dementia against what would be expected for their area, given population size, age and other factors. The national
ambition is for 67% of people with dementia to have a diagnosis and access to post-diagnostic support. The average dementia diagnosis rate across
England is 67.1%, in the West Midlands it is 65% and for BSC CCG it is 99.1%. (HSCIC data as at the end of November 2015). For a population of 300,000 it
means that 1,748 people aged over 65 have been diagnosed with dementia, leaving a gap of 50 people including those under 65.
How has this been achieved:











Adopting the Birmingham and Solihull Dementia Strategy 2014-17 in May 2014.
Developing practice ‘Dementia Packs’, e.g. how to diagnose dementia/Alzheimer’s, information on local services, Read codes to use, information for
patients/carers on the Memory Assessment Service and national guidance/toolkit for GPs.
Including ‘dementia screening’ in the CCG’s Neurological Conditions Local Improvement Scheme
Including an ‘assessment of dementia and cognitive concerns’ in the CCG’s Over 75s Local Improvement Scheme.
Including regular reviews of patients in Nursing Homes where severe cognitive impairment with challenging behaviours as a result of dementia
are significantly higher. The CCG’s Nursing Homes Local Improvement Scheme also contributes towards the reduction in the use of long term anti
psychotics in people with dementia.
Targeted support by Clinical Lead for Mental Health and Lead Nurse/Dementia Champion for practices where diagnosis rates were low.
Recording information consistently by checking that GP practice dementia registers were accurate and issuing practices with a guide to the
codes/searches required
Providing training and education sessions for clinicians in diagnosing dementia.
Additional recurrent funding to provide an increased level of dementia adviser/dementia support worker capacity to provide post-diagnostic
support to people diagnosed with dementia in Birmingham South Central CCG, commencing in January 2016.
Dedicated webpages for member practices and the public, which includes a Video Blog by the CCG Lead Nurse/Dementia Champion on “Reasons to
make a timely diagnosis of Dementia”.
Birmingham Better Care have provided oversight of the Birmingham and Solihull Dementia Strategy 2014-17 and dementia moved under the Better
Care Fund Team in 2015 and a Steering Group established in February 2015. They coordinate the Dementia Partnership Forum, which meets
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quarterly and is made up of patients, carers, third sector organisations, health and social care. Birmingham Better Care have also funded additional
Dementia Café’s and provided training for carers in identifying physical deterioration to avoid hospital admission.
The CCG is also a member of the Dementia Action Alliance (DAA) which came about as part of the Prime Minister’s Challenge on Dementia and is working
towards bringing about a society-wide response to dementia. At a national level the DAA has begun to shape policy and attitudes and is looking to do the
same locally through Local Dementia Action Alliances. Membership is a clear indication of organisational ‘sign up’ to becoming ‘dementia friendly’.
The CCG has put a lot of focus on improving its dementia diagnosis rate because of the difference the support available makes to people’s lives. Indeed the
Governing Body has highlighted the need to achieve this target to the Network Clinical Leads.
A diagnosis of dementia means that family carers can be provided with the skills to respond to crisis, and to care for their loved ones in ways which prevent
future crisis. It’s a great credit to our GP practices that they have achieved such a high diagnosis rate.
The Birmingham and Solihull Dementia Strategy 2014-17 gave us a framework to develop our vision – for people with dementia to be helped to live well
with the condition, no matter what the stage of their illness or where they are in the health and social care system, including care homes, hospitals and the
community.
There are particular issues we want to address, including changing attitudes and increasing understanding among both the public and health professionals,
dispelling the fear and stigma associated with dementia. Families affected by dementia should know where to go for advice and support. Timely diagnosis
and treatment should be the rule, not the exception. Getting a definite diagnosis as soon as possible helps people with dementia and their families plan
their lives, make informed choices and get the support they need. In 2016/17 we will build on work to date and our successful delivery against the dementia
diagnosis rate standard of at least two-thirds of the estimated number of people with dementia being diagnosed.
Our priorities for supporting dementia services and planning in 16/17 include:




Implement recommendations of review of pre-diagnostic pathways for people with dementia and improve timely access to assessment and
diagnosis
Implement recommendations of review of post diagnostic secondary care pathways for people with dementia
Implement recommendations of BSC and BXC CCG EOLC strategy for people with dementia
Seek additional resource/ services to support projected growth in numbers of people with a diagnosis of dementia (demographic growth) in all
services and to reduce inequities of access
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






Amendments to specifications (and funding) for older adults services within BSMHFT block contract to manage services to meet needs of older
adults with dementia and other MH problems as part of a staged development plan for post diagnostic pathways for people with dementia and
their carers.
Consolidate reporting requirements from BSMHFT block contract and improve timely access to assessment and diagnosis
Development of section 75 agreement under BCF for dementia related services
Implement performance and quality framework across all dementia services
Commissioning of services for Carers through S 256 funding and a robust strategy for future development
Development of ‘step up/ step down’ beds for people with severe dementia
Education and development for primary care on dementia
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3.9
Transforming Care for People with Learning Disabilities
We recognise the importance of delivering the actions set out in local plans to transform care for people with learning disabilities, including implementing
enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy.
For a minority of people with a learning disability and/or autism, there is too much of a reliance on inpatient care. As good and necessary as this can be,
people are clear they want to be cared for at home and not in hospitals.
Over the last 12 months, BSC CCG has focussed on reducing the number of patients in hospital who live within the BSC geographical area and are registered
to a BSC CCG GP.
Initially, there were 12 such in-patients and all of these patients have had their required statutory CTR (Care and Treatment Reviews) completed in order to
establish their discharge pathway from hospitals.
Planning assumptions
Based on national planning assumptions, it is expected that no area should need more inpatient capacity than is necessary at any time to care for:
•
•
10-15 inpatients in CCG-commissioned beds (such as those in assessment and treatment units) per million population
20-25 inpatients in NHS England-commissioned beds (such as those in low-, medium- or high-secure units) per million population
All partnerships will need, however, to work through the complexities of planning and the scale of the work is considerable.
To progress this, as a health community, a Transforming Care Partnership Board (TCP) has been established with representation from Birmingham City
Council (who are the nominated lead for this work), BCCCCG, BSCCCG, NHSE and the Learning Disability Joint Commissioning Team, the Children’s Service’s
Joint Commissioning Team and the NHSE Specialist Commissioning Team.
The TCP is now in the process of drawing up a joint transformation plan, and this plan will have to be jointly agreed by all partners in the TCP, including
Local Authorities and NHS England specialised commissioning teams and involve people with lived experience of inpatient services and their families/carers.
This plan is due for submission in February 2016 and will remain the focus of progressing this work and regular updates provided.
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The Transformation Plan
NHS Birmingham Cross City CCG and NHS Birmingham South Central CCG are situated within the Birmingham City Council local authority boundary and
together the CCG’s commission healthcare services for a combined total population of 1.014m population, comprising 170 member GP practices. In
addition to these CCG areas, residents living within West Birmingham have their healthcare needs commissioned separately by NHS Sandwell and West
Birmingham CCG but are also within the Birmingham local authority boundary and are therefore included within the Birmingham Transformation Plan.
The Joint Transformation Plan for Birmingham has been developed to continue to build on the work undertaken locally to reduce the number of people in
inpatient facilities and sets out how we will jointly ensure that there is the right workforce, capacity and appropriate support in place to improve people’s
experience and quality of care, improve their quality of life and improve their health outcomes.
The plan aims to:
1.
2.
3.
4.
5.
Improve the quality of care
Improve quality of life
Reduce the reliance on inpatient care
Improve people’s experience
Improve health outcomes
In order to deliver this, services will be focussed around the diverse and individual needs of clients, and there will be a full understanding of their individual
needs through integrated Care & Treatment Reviews (CTRs), development of the provider market based on feedback from CTRs, and the development of
personalised care packages that make the best use of personal health budgets and personal budgets. Packages of care will be spot purchased to ensure that
the individual needs of people are understood and provided but to do this effectively, significant work will be undertaken to develop the provider market to
ensure care is cost effective. The model focuses on:
1. Prevention;
2. Developing suitable post discharge support and community provision to keep people out of hospital;
3. Reducing the reliance on inpatient facilities.
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The new model of care will be comprehensive and will focus on building on the work already undertaken by enhancing community teams and developing
the provider market and housing market further. However there will be some specific services that we would like to further develop, test and evaluate to
understand their effectiveness in enabling clients to be discharged safely from inpatient facilities and live meaningful lives in the community as follows:
1. Developing intensive & crisis support services by a multi-disciplinary health and social care team 7 days per week for children including
behaviour support planning;
2. Further enhancing intensive & crisis support services by a multi-disciplinary health and social care team including social workers, 7 days per
week for adults;
3. Develop effective care, crisis & relapse planning with clients, carers and families including exploring the need for the introduction of an
intensive wrap around service short term ‘place of safety’ linking to the Crisis Concordat and better access to understandable information (a
capital bid will be submitted to support the ‘place of safety’);
4. Explore and scope the development and testing of a Learning Disabilities HUB linking with local third sector developments to provide an
advocacy, training and information HUB.
These initiatives will require support through the Transformation funding available from NHS England
In order to deliver the plan, the following key developments and actions will be undertaken:
1. Ensuring clients and carers/families are at the heart of the Transformation plan – this includes enabling them to be part of the Transformation
journey;
2. Ensuring that all pathways are clinically appropriate, safe and high quality through a Clinical Reference Group;
3. Standardising and integrating CTR processes across Birmingham including design of integrated paperwork and a memorandum of understanding to
make best use of resources;
4. Further development and embedding of Risk Stratification processes and person centred care planning for adults and children;
5. Further work to understand, develop and redesign Children’s pathways and services;
6. Developing the provider market to reflect the complex needs of clients, their carers and families;
7. Integrated partnership working across organisational boundaries including work to develop the personalisation agenda;
8. Understanding the required housing and accommodation provision to reflect clients complex needs;
9. Develop personalised care including processes for joint health and social care funded Personal Budgets, Education Health and Care Plans;
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10. Developing and integrating the workforce to reflect the changing landscape. This includes helping to up-skill clients and carers linking to outreach
teams;
11. Focus on Transition from Inpatient Care to Community Care – swiftly understanding clients complex needs;
12. Transforming Care Partnership - Developing the 5 year Joint Strategy to deliver the model of care from childhood to older adults.
In order to deliver the Birmingham Transformation Plan, a number of enablers are required including:
1. Continuing Communications & Engagement including ‘Making the Plan Happen’ Events;
2. Programme Management & Delivery Support.
The inclusive model will test a number of new ways of working that build on the work already undertaken locally and create a seamless journey for people
with Learning Disabilities and/or autism who display behaviour that challenges from childhood through to older adult services.
The local model will be underpinned by an effective system of:








Ensuring clients receive care of the highest quality;
On-going assessment and review of clients;
On-going and inclusive engagement with clients, carers, families and wider stakeholders;
Effective market management to promote learning disability service capacity and the skills of the learning disability workforce across the City;
Strengthen links with primary care to ensure people’s ongoing healthcare needs are addressed;
On-going engagement to ensure that the needs of people are fully understood and continue to refine and develop the requirements;
Significant work to introduce crisis management, a place of safety and S117 aftercare agreements and relapse prevention plans;
Ensuring the effective use of inpatient beds.
In order to meet the 8th February initial deadline, the Transforming Care Partnership have developed the first iteration of the plan and further work will be
required to refine the plan going forward.
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3.10
Improving Quality
Quality Assurance
Birmingham South Central Clinical Commissioning Group (BSC) will maintain a focus on delivering clinically effective, high quality and safe care, as well as a
positive patient experience across all commissioned services.
To achieve this, the BSC quality team uses a number of overarching assurance functions that span BSC commissioned services, which will continue to be
developed and refined throughout 2016/17.
The team will



Collate, analyse and triangulate a wide range of data across quality, experience and performance to provide meaningful insight into the safety and
sustainability of service provision.
Continue to monitor a range of external data sources including Care Quality Commission (CQC) inspection reports/outlier alerts, NHS Choices data,
PLACE assessment scores, national survey results, Friends and Family Test results and data from Monitor and the Health Safety Executive.
Review provider performance against contractual quality requirements and intelligence gained through the management of Serious Incidents and
Never Events to identify emergent issues, make recommendations and apply appropriate levers to improve quality and safety for patients
To support this approach, the BSC Quality and Safety Committee will continue to review provider dashboards, patient safety and experience reports,
serious incident, infection prevention and workforce assurance reports, including safer staffing, on a monthly basis.
BSC also recognises the continued value of sharing appropriate information on quality across the local health economy. We will continue to build upon the
excellent working relationships with neighbouring CCGs, NHS England, Care Quality Commission and the Local Authority in order to join up and triangulate
information on the quality of provision across a range of providers including secondary care, community, mental health, learning disabilities, primary care,
third sector providers and nursing homes.
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Clinical Quality Review Groups
Over the next year it is also aimed to continually review the functions of provider Clinical Quality Review Groups (CQRG) to ensure continued and targeted
focus on quality. A robust contractual framework will be monitored throughout 2016/17 to ensure data is submitted by the Provider against the following
areas:













Monthly local quality indicator compliance
Patient Experience and Complaints (including Friends and Family Test)
Workforce (including a six monthly safer staffing skill mix analysis)
Incident and Serious Incident report
Infection Prevention data and work plan
Equality and Diversity framework updates
Remedial Action plans in response to CCG Assurance Visits
Closure of remedial actions relating to Serious Incidents and Never Events
Quality priorities
NICE guidance compliance
CCG Medicines Management framework
Quarterly CQUIN evidence
Response/gap analysis against relevant independent/national reports and reviews
The CCG Quality team comprise of a number of clinical and non-clinical specialists. During 2016/17 the Patient Experience & Improvement Project Officer
will continue to review a range of metrics including complaints, concerns/PALS, lessons learnt, FFT, social media and soft intelligence.
The continued identification and utilisation of patient stories that highlight areas of good/poor practice to help shape future commissioning decisions will
be promoted. Such stories will be presented to the Quality and Safety Committee and Governing Body, often by patients and their families or via other
mediums such as video. The Infection Prevention Lead will continue to work closely with counterparts in provider trusts to support them in their roles, and
to provide assurance to the CCG of the quality of service provision.
This will involve regular meetings with provider leads and attendance at internal Infection Control Committees, outbreak and investigation meetings.
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The team plan to continue with the visit programme implemented in the latter half of
2015/16 and conduct assurance visits to providers once a quarter as a minimum. The
visit programme will include a mixture of announced and unannounced visits that will
be focused and intelligence led. Prior to assurance visits the CCG Quality team will
ensure thorough preparation is undertaken and that the area of greatest concern is
targeted.
This will include an analysis of the most recent Provider quality and safety data and
soft intelligence, ensuring that each assurance visit has a specific focus on identified
and relevant issues. We will continue to develop joint assurance visits with NHS
England and Birmingham Cross City (BCC) CCG, ensuring a collaborative approach is in
place. This will enable the team to access areas covered by Specialised Commissioning
and providers where BCC CCG is the lead commissioner.
The monthly serious incident closure panel was established in 2015/16. This provides
an opportunity for the CCG quality team to work collaboratively with the CCG Chief
Nurse, Clinical and Quality Leads to review the more complex serious incidents and
Never Events. Joint recommendations on further actions or closure are made which
are taken forward by the team. During 2016/17 this process will continue and it is
anticipated that this will be widened to include review of higher level serious incidents
arising in primary care and the third sector.
3.10.1
Provider Assurance
Birmingham Children’s Hospital (BCH)
The quality team will implement a planned bi-monthly quality assurance visit
programme to commence April 2016, working collaboratively with NHSE to look at
commissioned and specialised commissioned areas. Quality issues will inform key lines
of enquiry within specialisms with an initial focus on surgery. The impact of cancelled
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operations on patient and parent experience has been a key factor throughout 2015/16, relating in particular to extended fasting times and psychological
trauma. The trust is planning to complete an audit of patient experience in relation to cancelled operations before the end of 2015/16. In view of this focus,
feedback on individual experiences will be sought throughout the 2016/17 assurance visit programme. The quality team will also move forward with this
robust process of checking action plans for satisfactory closure by due dates.
Specific local quality indicators will be implemented in April 2016, focusing on treating and caring for people in a safe environment and protecting them
from harm. These will address paediatric sepsis, staff training and escalation of learning from incidents related to sepsis.
CQUINs for 2016/17 have been developed to incentivise quality effectiveness and safety in specific areas including escalation of the deteriorating child and
use of the Paediatric Early Warning Score. Harm reduction through monitoring compliance with surgical best practice and standardisation during hospital
transfers and discharge will be a key focus in the coming year. The Transfer of Care Plan and Nutrition and Hydration CQUINs will require staff engagement
to develop and improve current practice.
Planned CQUINs for 2016/17 will focus on the following areas:




Children’s Safeguarding
Transfer of Care Plan
Care of the Deteriorating Child
Nutrition & Hydration
Infection Prevention practices will continue to be reviewed, including the root cause analysis process when an issue occurs. In view of environmental issues
relating to the age of the building, effective maintenance and improvement works will be evaluated on an on-going basis. Particular attention will be given
to ward environments including flooring and drainage. The Infection Prevention Lead will work collaboratively with BCH throughout 2016/17 to ensure that
required standards are met and maintained.
Forward Thinking Birmingham (FTB)
The quality team will focus on the safe transition of services as FTB mobilisation plan is to go ‘live’ April 2016. Quality issues will be monitored during the
transitional period in relation to workforce and patient experience regarding service provision. Monthly CQRG meetings have been established and the
principles developed by the Clinical Forum are being considered. Discussions on future requirements including a quality dashboard are now underway and
will be developed over the first year.
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Planned CQUINs for 2016/17 will focus on the following areas:



Resilience
Early Intervention
Physical Health
The current quality indicators and CQUINs were established as part of the procurement process. The team plan to use 2016/17 to develop meaningful
quality metrics in preparation for 2017/18.
Birmingham Women’s Hospital (BWH)
Following the themed review of serious incidents and the subsequent assurance visits the CCG Quality team will continue to gain assurance on the progress
made against the key issues that have been identified including maternity triage systems (including telephony software), antenatal demand management
and ensuring lessons learned as a result of serious incidents are embedded across the organisation.
BWH will continue to deliver against the two year CQUIN implemented in 2015/16 which requires dedicated and specialised analysis of perinatal mortality
with an agreed action plan between CCG and provider on areas of focus for improvement.
Planned CQUINs for BWH in 2016/17 will focus on the following areas:






The management of complex pregnancies (specific focus on diabetic mothers)
Antenatal clinic demand management
Implementing a learning culture from best practice
Safeguarding
Patient Experience – Always Events
Analysis of possible reduction in perinatal mortality
It is planned that specific contractual indicators will be included in the 2016/17 contract which will ensure that assurance is gained against Intrauterine
growth restriction, maintaining ‘fresh eyes’ approach to reviewing cardiotocography (CTG’s) and that a place of birth (including homebirth) discussion takes
place with every woman at the initial booking appointment.
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Following the implementation of the maternity safety thermometer the CCG Quality team will ensure regular and robust monitoring of the BWH data is
continued and triangulated with all other local and national information.
The CCG Quality team will continue to provide support to the ‘Home birth pilot’. Specific focus will be given to ensuring that all women have the
opportunity to explore their individual preference.
Environmental cleanliness and cleaning programmes in maternity have been reviewed through an Infection Prevention assurance visit undertaken in 2015.
Further assurance on the effectiveness of actions taken to address cleaning issues including the equipment replacement programme will be a focus for the
coming year.
Birmingham Community Healthcare Trust (BCHC)
The CCG Quality team will continue to work collaboratively with the Better Care Fund to build on relationships developed throughout the past year. The
2015/16 CQUIN focusing on multi-disciplinary team (MDT) working within primary care has been taken forward into a new two year CQUIN planned for
2016/17 which has been extended to cover frailty. This will enable the development of person centred supportive care pathway that has a focus on
prevention and MDT working to recognise and assess frailty
Planned CQUINs for BCHC 2016/17 will focus on the following areas:





Adult Nutrition and Hydration Care Bundle for in-patient services
Adult Safeguarding
Children’s Safeguarding
Implementation of the national Clinical Utilisation Review Framework
Multidisciplinary Team working in Primary care and Dementia Services with a focus on Frailty
It is anticipated that the nutrition and hydration CQUIN will be span 2 years to enable the development of processes, staff training, recruitment of specific
leads and a sub-acute ward pilot. This will be followed by a roll out across the trust in year 2.
New quality indicators in the 2016/17 contract will address issues highlighted in 2015/16. In response to an incident relating to sepsis involving a grade 4
pressure ulcer, an indicator to ensure tissue viability review within 5 days of referral by a District Nurse in relation to the assessment of grade 3 or 4
pressure ulcers has been introduced. Others include referral to treatment times of less than 18 weeks for paediatric Physiotherapy, Occupational Therapy
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and Speech Therapy. The current indicators covering falls, medicines management and pressure ulcers will be strengthened to ensure they are sufficiently
robust.
The assurance visit programme has previously focused on in-patient services. During 2016/17 we plan to widen the programme to cover community
services. This will commence with a rolling programme of visits to District Nurse teams and Tissue Viability Nurses will be developed to gain a better
understanding of the services with a focus on pressure ulcer management.
Environmental issues relating to the older wards at Moseley Hall Hospital have been assessed during 2015/16 by the Infection Prevention Lead. The
upgrade and modernisation programme with a particular focus on Ward 6 which has poor sluice facilities, will be reviewed throughout 2016/17.
Primary Care
Throughout 2016/17 the quality team will be developing their role in gaining assurance of quality in primary care. This will include developing a process for
the management and review of incidents and serious incidents.
Through the latter part of 2015/16, BSC CCG and Midlands and Lancashire CSU jointly developed the DATIX system. The system replaces the manual ‘yellow
card scheme’ which GPs have used to report their concerns in relation to secondary care.
In addition to enabling GP practices to report concerns related to secondary care the new system will allow GPs to report their Patient Safety Incidents to
the CCG Quality team. There is also an option for each incident to be linked to the ‘National Reporting Learning System’ (NRLS). This facility will ensure that
all practices can use DATIX to meet the NHS England requirement as set out in NHS England document ‘Guide for General Practice staff on reporting patient
safety incidents to NRLS’ published in February 2015.
The DATIX system was piloted from Oct 15 – Jan 16 and has since been launched across BSC CCG member practices. Throughout 2016/17 the Quality team
will provide a resource to train and assist BSC CCG member practices on how to use DATIX. A systematic and robust process will be implemented which will
ensure that Providers are contacted when feedback has not been responded to.
The quality team will review each primary care safety incident and piece of primary care feedback so that any incident where there is possible severe harm
can be acted upon in accordance with the CCG Serious Incident policy. During 2016/17 as the use of DATIX becomes more widespread across BSC CCG
practices the Quality team will use data submitted by practices to inform the wider quality assurance agenda.
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A specific login for recording serious incidents on the national STEIS system is already established. The quality team will support practices to undertake
robust investigations, and will be responsible for closing incidents on STEIS once sufficient assurance has been gained. The team will ensure that lessons
learnt are disseminated across the CCG through locality meetings and that remedial actions are completed by due dates.
The team will participate in and provide infection prevention and clinical input into the CCG programme of contractual visits. It is anticipated that practices
will be risk assessed using a range of quality assurance metrics including CQC ratings which will inform the visit schedule.
Repeat visits will depend on the visit outcome. Practices demonstrating sound governance processes who meet contractual requirements will be visited
every 3 to 5 years and will be required to complete an annual self-assessment. The team will utilise clinical skills to support the CCG to review these reports
and make appropriate recommendations for further improvement where required. Practices requiring additional support will be visited more frequently. As
part of the governance process practices are required to investigate a number of incidents that may not meet the criteria for serious incidents. Practices will
be supported to undertake these where nursing or infection prevention issues have arisen.
Throughout 2016/17 infection prevention processes will be strengthened across primary care. In line with national guidance, all cases of C.difficile and
MRSA attributable to the CCG are investigated and potential care lapses and lessons learnt identified. The Infection Prevention Lead will support practices
to undertake such investigations and will work collaboratively with the CCG Head of Medicines and Prescribing to ensure a robust process is followed.
This will enable the ‘avoidability’ of each case to be assessed and agreed by all stakeholders. Robust action plans will be developed and lessons learnt
disseminated across the CCG through locality meetings. It is anticipated that this process will be reviewed to ensure it remains fit for purpose. Investigation
toolkits will be developed in conjunction with GPs which will facilitate practice engagement. The Infection Prevention Lead will work with teams from other
CCGs to share learning and good practice relating to C.difficile and MRSA cases across the health economy.
Over the next year practices will be further encouraged and supported to complete the annual self-assessment Infection Prevention audit. The self-scoring
audit tool automatically generates an action plan and provides evidence of meeting statutory Infection Prevention requirements. All staff in primary care
are required to attend annual mandatory infection prevention training and a programme will be developed to support staff to meet this requirement.
The quality team are committed to improving patient experience across primary care. The Patient Experience & Improvement Project Officer will continue
to support the CCG to promote the GP Friends and family Test and increase the commitment of practices to participate and meet their contractual
requirements. To date it has not been possible to undertake an in-depth analysis of the scores due to the high number of practices that have not submitted
the data on one or more occasions.
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Throughout 2016/17 an action plan will be developed to address low response rates and will include:





Promoting the test in practices
Working with practices to include additional questions in order to make the test more relevant
PPG involvement
Encouraging practices to display “You Said, We Did” information to encourage more patients to take part
Ensure that practices comply with their contractual requirements to submit FFT returns
The Patient Experience & Improvement Project Officer will build on the analysis undertaken of the national GP survey results from January 2013 to July
2015, incorporating the results from the January and July 2016 survey. An action plan is being developed throughout the year to support the CCG in its aim
to further improve its rating within its peer group. This will include strategies to assist practices to achieve increased scores in future surveys as a measure
of improved patient satisfaction. Areas of focus will include:






To provide support to individual practices to understand the analysis of the GP survey results and to develop strategies to improve scores.
To increase uptake of the Friends and Family Test and responsiveness of practices, as highlighted above, to ensure that issues are dealt with in as
real time as is possible thus impacting on the scores of the less frequent GP survey.
Support practices to promote the use of social media, such as NHS Choices, to receive feedback and increase responsiveness of practices.
Develop PPGs to assist practices in the gathering of patient experience feedback.
Out of hours services – support practices to improve patient experience of OHH services
Access to GP services – Support practices to develop plans to improve non urgent access to GP services
Third Sector and Private Providers
During 2015/16 all third sector and private provider contracts have been risk assessed by the CCG. Highest risk contracts are those providing a significant
volume of specialist clinical care to a range of client groups. During 2016/17 the quality team will focus initially on the following providers:


Health Harmonie
The Acorns Children’s Hospice
A robust quality assurance process will be developed and refined to meet the requirements of each provider. This will carried out through collaborative
working and through attendance at Contract Review Meetings. A reporting framework for quality will be established and will define both frequency and
content.
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A specific login for recording serious incidents that occur in third sector organisations on the national STEIS system is already in place. The quality team will
log incidents on STEIS and the local incident management system (DATIX) and support the providers to undertake robust root cause analysis investigations
of serious incidents. We will be responsible for closing incidents on STEIS once sufficient assurance has been gained. In addition we will ensure that lessons
learnt are disseminated across the CCG through locality meetings and that remedial actions are completed by due dates.
3.10.2
Closing the Quality Gap
BSC CCG is committed to ensuring patient safety is a priority for all services we commission, in both primary and secondary care. The CQUIN and quality
indicators for 2016/17 have been utilised to measure safety and are based on tangible quality gaps in service provision. The Safeguarding indicators have
been reviewed by the team and strengthened through increasing thresholds, ensuring a renewed focus in this area. Throughout the coming year provider
performance against contractual measures will be measured through Clinical Quality Review Groups and further assurance sought where required.
Demonstrable quality improvement will be sought from providers through supporting evidence provided for quarterly CQUIN milestones. In addition to
CQRG, the quality team will aim to attend additional provider meetings including Contract Review Meetings, System Resilience Meetings and Joint Clinical
Commissioning Groups to increase awareness of organisational operational issues which may have an impact on the quality of services provided.
BSC CCG safety improvement leadership is a priority for the team and ensures the quality of care and safety in provider organisations. Within the serious
incident reporting and management process we continue to challenge providers with robust scrutiny processes such as review of severe incidents which do
not meet the serious incident criteria. Throughout the coming year we will embed the new process of monitoring and closure of serious incident
improvement action plans and where appropriate, post action plan impact analysis to ensure efficacy of improvement actions and confirmation of
embedding change within clinical practice.
Patient Experience will continue to be strengthened throughout 2016/17 and opportunities for joint working will be developed. The provider Patient
Experience Lead Forum was established in the latter half of 2015/16 and has provided an opportunity for learning and information sharing. The success of
this group will be built on through the coming year and opportunities to extend the remit and membership will be developed.
The template used to measure patient experience during announced and unannounced visits is evolving so that it is adaptable to a variety of settings such
as outpatient clinics, intermediate care facilities, children’s services, etc. The CCG also plan to pilot alternative methods of gaining patient feedback, for
example Focus Groups and the concept of the ‘Ideas Café).
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The CCG will continue to work with providers to produce joint patient stories. The subject of the story may be suggested by the Provider as a result of an
internal themed analysis. The theme may be driven by the CCG as a result of findings from an announced or unannounced visit, a ‘deep dive’ review or
trend in serious incidents.
Patient Story examples

A 100 year old patient, who lived alone with multiple health conditions, requested a home visit from her GP. During the visit it became apparent
that the patient was isolated, very lonely and not at all happy with her situation. One of the statements the patient made to the GP was ‘you might
as well give me an injection and end it all’ as she had no quality of life.
In recognition, that there are many elderly people in Birmingham in the same position as this patient, elderly with no family or friends living locally,
the committee requested for a resource pack to be developed containing details of organisations that provide a befriending / companionship
service. GPs will be able to use the resource pack when treating patients in a similar situation.

A parent described a two year old child’s experience when admitted for day surgery at Birmingham Children’s Hospital. The story was produced as a
result a trend in patient experience data. The parent described the lack of information and miscommunication about the timing of surgery, delays
throughout the day which led to increased anxiety and prolonging period of fasting before finally going to theatre. The Trust has since put a number
of measures is place to improve the management of theatre lists and to improve communication with patients/families/guardians.

A patient and his wife described their experience following cancer surgery and the positive impact the continence service had made to his life. The
story also highlighted issues around referrals into the service from secondary care. His wife was also a carer to her elderly father who had
dementia. A number of actions are currently being worked through.

A woman described her experience of being in an abusive relationship for 13 years. She explained that she couldn’t put into words what was
happening to her and hoped that professionals would ‘notice’. As a result, her injuries were misdiagnosed and she received unnecessary treatment,
e.g. received treatment for grinding her teeth when she had been kicked in the jaw. She tried to leave her husband on several occasions but always
found it easier to go back to him as support mechanisms were difficult to access. The situation had a detrimental effect on her children and one
child ultimately died from solvent abuse. This was the turning point in the patient’s life as her husband let her attend a training course. T gave her a
break from her situation and confidence to leave him. She decided she wanted to help other women in her situation by putting in place the support
that would have helped her. She went on to become the Domestic Violence Co-ordinator and Programmes Co-ordinator/Facilitator for the Allens
Croft Project.
GPs now receive training on recognising the signs of domestic abuse through the Iris Project. A resource pack including details of support
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organisations is being developed that can be accessed by health professionals. There was commitment from the Governing Body that domestic
violence would be included in the CCG’s commissioning intentions for 2016/17.
The CCG will continue to work with providers to increase response rates of the Friends and Family. Response rates are lower than the national rate in some
specialities, with providers introducing a number of initiatives to increase uptake. The CCG will continue to monitor the activity and support providers to
increase Friends and Family Test Activity.
The continued development by providers of “real time” feedback using social media is supporting providers to develop a proactive approach to responding
to patient feedback. BCH, BWH and BCHC have each developed Apps that enable feedback via the Friends and Family Test. BCH and BWH have the facility
for patients to seek immediate assistance and real time responses. The CCG will continue to work with these providers to review the effectiveness of these
tools, the data produced and the sharing of good practice via the Patient Experience Leads Forum.
We will build on the Duty of Candour assurance visits undertaken in 2015/16 ensuring that compliance with the contractual Duty of Candour requirements
are being met. These involved conducting audits of all incidents meeting the National Patient Safety Agencies grading of harm of moderate or above and
making appropriate recommendations to address shortfalls. For 2016/17 it is proposed to develop a process of provider self- assessment audit and quality
review. Follow up visits will be undertaken to address any concerns arising from audits or other sources, where required remedial action plans will be
developed and monitored for compliance.
The CCG are a beacon site for the ‘Sign up to Safety’ campaign and have developed a Safety Implementation Plan with seven areas of focus:
No
Objective
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1
2
Further development of Patient Safety related CQUINs for 2016/17 –
•
Management of complex pregnancies
•
Learning from positive incidents
•
Hydration and Nutrition
•
Children’s and Adults Safeguarding
Increase the level of Primary care feedback (yellow card) reporting and ensure a robust system is in
place, ensuring provider feedback and effective change is evident
3
Increase the level of GP incident reporting so that on average at least one incident is reported per
practice per month
4
Improve the amount of unnecessary repeat medications that are prescribed
5
To increase awareness of Sign up to Safety campaign and increase the number of BSC CCG staff and
member practice staff who have signed up to the campaign
6
To increase ‘patient activation’ and patient ownership of patient safety
7
Safeguarding
The Safety implementation Plan includes a driver diagram outlining what components need to be considered to deliver the national objective of reducing
avoidable harm by 50% and saving 6000 lives.
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Whilst the Safety Implementation Plan has specific areas of focus and the driver diagram has allowed the Quality team to ensure all different components
are covered as part of the on-going work to improve patient safety, it is imperative that significant momentum is achieved in terms of raising awareness of
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the campaign and sharing resource/best practice with relevant colleagues and stakeholders. During 2016/17 the CCG Quality and CCG Partnerships team
will ensure that dedicated resource is provided to




Promote and share Sign up to Safety information using the BSC CCG social media accounts
Explore how Instagram may be used to increase awareness of the Sign up to Safety
Hold awareness sessions and ‘launch’ the campaign to wider BSC CCG members
Establish links with other NHS Organisations Sign up to Safety leads to help share best practice and promote the
campaign
A fundamental part of the Sign up to Safety campaign is to remove blame and foster a culture of learning across the NHS. To
this end the CCG Quality team have organised serious incident root cause analysis training for not only CCG staff but also for
staff from services it commissions. The Team will continue to attend table top root cause analysis meetings hosted by providers
investigating serious incidents to support and assist in the development of a healthy, learning and positive culture.
In addition to the Sign up to Safety campaign the CCG will build upon the progress made to date regarding the West Midlands patient safety collaborative.
The CCG are included as stakeholders in the following two areas identified by the collaborative:


Paediatric sepsis
Pressure ulcers in care homes
Initial scoping meetings have taken place and the CCG will ensure that the Quality team will provide on-going commissioner input into the safety
collaborative.
The CCG Quality team have previously highlighted the lack of an appropriate paediatric mortality measurement and are committed to ensuring that the
planned measure of ‘avoidable mortality’ baseline is due to be released in 2016 . All three providers where BSC CCG are the co-ordinating commissioner
have provided assurance regarding their mortality review process and the CCG Quality team will ensure that the avoidable mortality measurement
becomes an integral part of the wider quality assurance process used by the CCG.
During 2015/16, BCH have embedded the paediatric safety thermometer in line with national guidance. The latest data is shown in the graphs below. The
Quality team will review the data throughout 2016/17 as part of the wider assurance programme and ensure that regular updates are provided by BCH at
the monthly CQRG meetings.
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Throughout 2016/17, the Quality team will continue to review the national maternity safety thermometer data as part of the wider assurance programme,
and ensure that regular updates are provided by BWH at the monthly CQRG meetings.
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3.10.3
Horizon Scanning
The quality team are committed to anticipating and reacting to changes in national priorities/policies that are likely to occur. We are signed up to a number
of national bodies that send out regular bulletins, including Sign up to Safety – SignUPdate and NHS England – CCG Bulletin. Over the next twelve months
we plan to expand and develop our horizon scanning processes.
We will continue to work with providers on new national initiatives. For BWH this will include consideration of the implications of the national maternity
review, which has been undertaken to assess current maternity care and consider how services should be developed to meet the changing needs of women
and babies. It is anticipated that proposals will be made to shape future services to ensure that they are personalised, family friendly, safe, kind and
professional.
We plan to continue working with the CCG to review progress made on the BCHC District Nursing Dependency Tool and Inpatient Acuity Tool
implementation and roll out during 2016/17. Summary reports have been submitted and there are joint BSC/BCHC plans to benchmark with other
community District Nursing and in-patient providers. This will expand our understanding of the impact of patient dependency within District Nursing
services and the elements impacting on patient acuity within community inpatient beds.
In our provider organisations we plan to develop systems to review NICE guidance. BCH, BWH and BCHC have a contractual information requirement to
submit updates against NICE guidance and quality standards. Where they are not compliant they must submit an exception report including actions to
address. During 2016/17 this will be strengthened to ensure reports go through CQRG meetings to increase the focus and enable wider discussion.
We are keen to work with the CCG on managing the quality impact of new models of care including the multispecialty community provider model and 7 day
working. We will be working with and supporting providers through the proposed changes in provider partnerships such as the anticipated BCH/BWH
merger.
3.10.4
Governance
The CCG Quality Team work to a defined governance framework, which will be subject to continual review throughout 2016/17. Provider performance will
be measured against contractual quality requirements, intelligence gained through the management of serious incidents and Never Events, a rigorous
programme of assurance-visits, a range of provider assurance reports and soft intelligence. The team have revised the CCG serious incident policy to ensure
it aligns to current guidance. This includes a scrutiny process that will be applied to provider Root Cause Analysis investigation reports, highlighting potential
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triggers for further assurance to be requested. Where sufficient assurance is not forthcoming, or if the incident is of sufficiently high level, escalation will be
made to the monthly CCG serious incident panel.
Provider data is reviewed, triangulated and discussed at monthly provider CQRG meetings which operate as a sub group to the Contract Review Meeting
(CRM). CQRG provides the opportunity to discuss issues with providers, to seek further assurance and to manage local resolution informally. On-going
delivery by providers is actively monitored through CQRG. If there is a failure to meet contractual quality performance trajectories over a number of
months, or if issues are not resolved, the team
will follow an agreed escalation process
whereby concerns are referred to the CRM.
The CCG will be advised of issues through the
CCG Chief Nurse and/or the CCG Lead for
Governance, Quality and Safety. Serious risks
to patient safety are referred to the CCG Senior
management Team through this route. The
CCG quality team will work in partnership with
the CCG Contract Team to agree corrective
actions and financial sanctions that may need
to be applied. Formal contract performance
notices are served and providers are required
to submit a remedial action plan with
timescales in response.
The Quality team have oversight of the CCG
action plan detailing all the actions required by
the CCG to meet the requirements of the
Francis Report. We are responsible for
ensuring that CCG staff update and refresh
their actions quarterly. A RAG rated report is
submitted to the CCG Quality and Safety
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Committee, highlighting the areas that remain red and amber. Actions to address these areas are agreed and reported onwards to the CCG Governing Body.
Data and intelligence from a number of sources, including feedback from CQRG and CRM are used to populate monthly integrated quality reports. These
will escalate both good practice and concerns and include measures taken to drive improvements and recommendations for further action. Routine reports
on Serious Incidents and Lessons Learned, Infection Prevention, Workforce, Equality & Diversity, Patient Experience and assurance visit outcomes are
produced by the team at agreed intervals. The quality team have established monthly meetings with quality leads in Birmingham Cross City (BCC) CCG.
These will continue throughout 2016/17 and provide a useful forum for joint working and sharing of intelligence on a range of providers across the city.
Reports, including the quality report from BCC CCG, will be submitted to the monthly CCG Quality and Safety (Q&S) Committee to ensure that CCG
governance structures and clinical leads have appropriate oversight of clinical risk within provider organisations. Following discussion at the CCG Q&S
Committee, the integrated quality report is submitted for discussion at the CCG Governing Body. Both the CCG Q&S Committee and the CCG Governing
Body have the opportunity to approve or instigate actions taken to mitigate poor performance. These may include immediate unannounced visits or
themed reviews, deep dives or risk summits. High profile concerns are escalated to NHS England via the Quality Surveillance Group.
3.10.5
NHS Continuing Healthcare
The CCG will work to develop excellent working relationships with the new provider of NHS Continuing Healthcare services (Arden and GEM Commissioning
Support Unit). Development work that has already commenced will continue and includes:
Quality Assurance – Further develop the quality assurance process for nursing homes and home care provision, including the implementation of incident
and serious incident reporting processes in line with the newly developed “CHC Serious Incident Policy”. The CCG will continue to work collaboratively with
neighbouring CCGs, CQC and Local Authority to improve the quality of provision across CHC providers.
Infection Prevention – The CCGs Infection Prevention nurse will support nursing homes with all areas of infection prevention, including annual audits and
provider action plan monitoring.
Audit Recommendations – The CCG will seek assurance from the CSU that progress towards delivering the audit recommendations is maintained. The main
vehicle for this assurance will be review of the action plan on a monthly basis at the CHC Performance Group.
Market Development and Management – In order to provide patients with a range of services to meet their needs the CCG recognises the need for targeted
provider market development and during the course of 2016/2017 will develop, in partnership with neighbouring CCG and the CSU, a strategy for this area.
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Personal Health Budgets – The CCG will continue to proactively support the development and roll out of personal health budgets for individuals assessed as
meeting the eligibility criteria for NHS Continuing Healthcare
Outstanding Reviews – The CCG will work with their new commissioning support provider to resolve, in a timely manner, the outstanding 3 month and
annual review of patients in line with the national framework
Nursing Home Forum – The CCG will develop a local Nursing Home Forum that will provide nursing homes the opportunity to share good practice, agree
standards as well as training and development opportunities e.g. pressure ulcer care, dementia awareness, trips and falls prevention, management of
serious incident reporting etc.
3.10.6
Previously Unassessed Periods of Care (PUPoC)
The CCG will work closely with Midlands and Lancashire CSU to ensure that national deadlines are achieved with regard to the delivery of PUPOC. Monthly
reporting mechanisms will continue to be developed and refined in line with both local CCG reporting requirements and wider NHS England requirements.
3.10.7
Practice Nurse Forum
Building on the success of last years Practice Nurse Forum the CCG are committed to continued development of this important forum, supporting the
sharing of best practice, revalidation, development of a core set of practice standards and well as supporting the primary care workforce work stream.
Safeguarding
3.10.8
Protecting Vulnerable People
•
The new Safeguarding CQUIN that was negotiated into contracts for 2015/16 has been successful in raising the profile of Safeguarding within
Trusts. This has been refined and will be maintained within the contract for 2016/17. A Did Not Attend (DNA)/Was Not Brought (WNB) CQUIN has
been negotiated into contracts for 2016/7The 2015/16 CQUIN has also been taken up for use by a number of Commissioning Organisations across
the UK. The Safeguarding Team will continue to promote the CQUIN in 2016/17.
•
A CQC Action Group, attended by NHS Provider Safeguarding Leads was set up following the inspection of Children Looked After and Safeguarding
held in October 2014. This work has been progressing and all actions contained within the original Action Plan have been completed. The group will
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continue to meet to provide support, direction and a means of progressing consistency of approach in ensuring the protection of vulnerable
children, adults and families in the City.
•
The Safeguarding Team is committed to the delivery of safeguarding priorities and the service Business Plan. In the 2016/17 we intend to work
closely and collaboratively with all our partners in all agencies to deliver a high quality safeguarding service that is focused on the prevention
agenda and assist in the protection of vulnerable children , adults and families in the City.
•
The Safeguarding Team continues to work closely with all partners including those in Commissioner and Provider health services, Birmingham City
Council, Education providers, the third sector and West Midlands Police.
•
The Team participated in a Section 11 Audit Peer Review in 2015/16 and an Action Plan has been developed. Another Peer Challenge event will be
held in 2016/17 and Action Plans will be further reviewed.
•
The Safeguarding Team continue to monitor the Safeguarding Dashboard (KPIs) including new indicators on Female Genital Mutilation (FGM) in
provider contracts.
•
The Named GPs have held a series of Safeguarding Master Classes for Safeguarding Practice Leads, and focus on training within Primary Care
Services will remain a priority. These will continue into 2016/7.
3.10.9



Child Sexual Exploitation (CSE)
The Safeguarding Team are working closely with the Regional Strategic CSE Coordinator along with CSE representatives from West Midlands Police and
other partners to progress the CSE agenda. This includes looking at how best to capture data on CSE, working with health providers to identify those at
risk. This work is being done in conjunction with the CSE Strategic sub group of the Birmingham Safeguarding Children’s Board (BSCB).
A CSE Health link group is held bi- monthly and is chaired by the Safeguarding Team with representatives from provider organisations. The aim of the
group is to share good practice within the health economy and to gain assurance that provider organisations are making progress on their CSE action plans.
NHS England is undertaking an analysis of CSE cases identified in providers through a survey. This data will be analysed and action plans developed with
the health economy and partners for 2016/17.
3.10.10

Mental Capacity Act (MCA)
BSC established the Mental Capacity Act project in order to improve awareness in different agencies and with the general public across the whole
of Birmingham. This project, hosted by BSC has been very successful in raising awareness in MCA and training front end staff in its application. A six
month extension of the funding of this project has been agreed to progress this further.
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

Various resources including tool kits and videos have been developed by the project team in order to help relate the Act to practice issues and they
have also engaged with a wide range of different communities and organisations. This enabled BSC to provide an in-depth response to the Law
Commission consultation.
Training links and information has been disseminated to all GP practices and there is a case study which relates to the MCA in the scenario training
which is being delivered by the safeguarding team.
3.10.11

The Birmingham Safeguarding Team continues to work with Birmingham City Council where there are large scale concerns around nursing and care
homes. The continuing health care team deal with quality issues within nursing homes and provide the health input for any individual safeguarding
investigations. Work is being carried out in partnership with neighbouring CCGs to improve incident reporting and processes around this.
3.10.12



Care Homes
Care Act 2014
The Care Act has been in place for almost a year and BSC CCG has been heavily involved in bringing about changes in the structure of the local
safeguarding adults board to bring it in line with the new legislation. One of the main principles within the Act is ‘making safeguarding personal’
which puts the person at the centre of the safeguarding process. It is outcome based rather than process driven. This message has been
disseminated to all GP practices via various methods such as the specific training and support, the safeguarding bulletin, twitter and safeguarding
forums. Case scenario based training run by the safeguarding team has now been rolled out across the whole of Birmingham and will reinforce the
message in the adult cases discussed.
Our contracted providers are expected to ensure that the Care Act is embedded in practice and assurance of this has been gained via our one to
one provider lead meetings and information requests written into the contracts. The reflective practice CQUIN was successful and all providers
submitted evidence that safeguarding issues in practice were dealt with in line with this important piece of legislation. The Safeguarding CQUIN
proposed for 2016/17 has an adult safeguarding part which requires the trusts to provide evidence that they are engaging directly with people who
have experienced abuse to obtain their feedback.
One of the priorities on the safeguarding team business plan is engagement with the local community. Resources will be developed for the general
public and plans are being developed to obtain feedback from patients using GP practices
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3.10.13


The research project carried out by the CSU highlighted that there was some variation in people’s understanding of safeguarding. As part of the
engagement work being carried out by the safeguarding team, carers will be offered resources to ensure they understand how to report abuse and
what to expect when there is a safeguarding concern raised.
Work is also progressing with the Birmingham Better Care Fund to provide support the people with Dementia and specifically carers.
3.10.14

o
o
o
3.10.15

Female Genital Mutilation
The Safeguarding Team have set up a Task and Finish Group that is looking at a number of work streams for 2016/17 and has included the following
in the Work Plan:
o

Carers
Care Pathways: Including developing a Service Specification for FGM services - including maternity, children, Urology, gynaecology and mental
health issues.
Care pathways for Child Protection Medicals: Including the development of a sustainable service.
Data Collection: Data collected and reporting is now mandatory. Data is collected on a Clinical Audit Platform. The Team will continue to
monitor this data.
Community Education and Engagement: Linking with the work of the Birmingham Against FGM Sub Group of the BSCB.
PREVENT
The Prevent strategy is now embedded in the standard NHS contract and in legislation. The Birmingham Safeguarding team, safeguarding adults
lead continues as the CCG prevent lead and the lead nurse is named as the executive lead. All staff are offered wrap training which is higher than
the standard expected within the NHS England prevent competency framework for Prevent.
KPIs for wrap training have been included in all contracts and are monitored for progress. Wrap train the trainer sessions are being planned to help
third sector organisations to deliver prevent. Where there is resource available these sessions will also be offered to GP practices
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3.10.16

Domestic Abuse
Funding has been secured to pilot of the Implementation, Referral, and Identification & Safety (IRIS) Programme across the city. This programme is
now active in 25 practices across the city. Training for these practices will be completed to by March 2016 and GP responses to the programme
have been very favourable. Work on the project will continue into 2016/17.
3.10.17
Child Death

In 2015 (Jan-Dec) the Birmingham Child Death Overview Panel (CDOP) – a subgroup of the Birmingham Children’s Safeguarding Board (BSCB)
reviewed a total of 216 deaths (146 Neonatal Deaths, 177 Expected and 39 Sudden Unexpected Deaths in Infants – SUDI). As a result of the review
of these deaths a number of themes were identified and a local Safer Sleep Campaign is planned for 2016/17. The ‘Keep Me Safe While I Sleep’
campaign aims to educate and support parents in reducing the risk of cot death by raising awareness of the dangers of co-sleeping and the steps
that can be taken to reduce the risk of it happening to their baby. The campaign will be launched on 14th March 2016. The campaign aims at
encouraging parents to use safe sleep practices provide first time parents with a resource pack containing a Room Thermometer, BSCB Safety
Booklet and other supported evidence based family friendly information to reduce SIDS within the city of Birmingham.

For this coming year the Birmingham CDOP will be providing quarterly briefing letters to be shared will all stakeholders in order to highlight any
identified themes, in addition to any lessons learnt from child deaths reviews.

BSC CCG will continue with its statutory responsibility to review and investigate and child deaths as well as support the work of BSCB and the Child
Death Overview Panel.
3.10.18

CP-IS
CP-IS provides health professionals with prompt and easy access to key social care information that can help them to assess whether a child is at
risk. The process of identifying children who have been maltreated, or are at risk of significant harm from abuse or neglect, during a single
attendance remains difficult for even the most experienced clinician. This project continues, so that information can be appropriately shared where
children are on a protection plan, are classed as looked after/Children in Care and (i.e. children with full and interim care orders or voluntary care
agreements) and any pregnant woman whose unborn child has a pre-birth protection plan.
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3.10.19

The Birmingham MASH
The Birmingham MASH is a multi-agency team for Child Protection, Domestic Abuse, Sexual Exploitation and Early Help referrals, and since its
inception, has improved the quality and timeliness of screening, information sharing, and decision making by partner agencies, resulting in
interventions which are appropriate to the needs of the child, and which keep the child at the heart of everything we do. BSC CCG commission the
Health component of MASH will continue to work in partnership with health, social care and the police to ensure the MASH is further developed
and provides a proportionate, timely and co-ordinated approach to child safeguarding across the city.
3.10.20
Early Help

Early Help is a multi-agency approach to meet the needs of children and their families whenever needs arise that cannot be met solely by universal
services. The multi-agency Early Help strategy has agreed the definition and principles to be adopted across the partnership. Early Help is provided
to children and families by consent and seeks to involve the family in finding solutions to meet the needs identified. Universal plus Early Help (level
2) is provided by all agencies alone or working together to work with the family to address identified needs. Additional (targeted and more
intensive) Early Help (level 3) are a range of family focused services provided more intensively, usually on a key/family worker basis to support
families make positive changes. In Birmingham this includes the Troubled Families programme (Think Family) and the family support teams.

The Partnership will build on the success of Think Family and MASH in bringing agencies together to meet children’s needs, by broadening this
partnership approach to Early Help, children in need and child protection in the hubs and Areas across the City.
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4
Addressing the Ten National Programmes
4.1
RightCare
RightCare, together with the New
Care Models, support the vision set
out in the Five Year Forward with its
focus on the transformation of
healthcare services to drive
improvements in quality and
efficiency. We acknowledge that
RightCare and Commissioning for
Value support the new NHS shared
planning guidance for 2016/17 which
emphasises the importance of
improving outcomes: better health for
the whole population, reduced
inequalities, increased quality of care
for all patients, and better value for
the taxpayer.
Commissioning for Value is a
partnership between NHS England,
Public Health England and NHS
RightCare. It provides the first phase
of the RightCare approach – where to
look. The approach begins with a
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review of indicative data to highlight the top priorities or opportunities for
transformation and improvement. Value opportunities exist where a health
economy is an outlier and will most likely yield the greatest improvement to
clinical pathways and policies. Phases two and three then move on to explore
What to Change and How to Change.
In 2015/16 we specifically used the lower gastrointestinal cancer pathway on a
page to highlight the relatively high rate of presentation of colorectal cancer as
an emergency. Subsequently we designed a GP Local Improvement Scheme,
part of which supported practices to improve the take up of bowel screening
and the undertaking of root cause analysis of emergency presentation of
colorectal cancer in their patients. See Cancer section 3.6.4.
In addition we have worked in partnership with Birmingham Cross City CCG’s
Urgent Care Team to implement a 999 frequent callers initiative based on the
Blackpool Case Study and evidence contained on the RightCare Website.
We have reviewed the Commissioning for Value Pack released in January
2016 https://www.england.nhs.uk/wp-content/uploads/2016/01/birmghmsth-cntrl-ccg-16.pdf and have identified the following areas for focus and
action i.e. Phase 1.
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We will use this information to review existing services and improvement
schemes for example the Respiratory Quality and Improvement Scheme to
understand why we are an outlier and what action could be taken and the
population size that might be affected.
We understand there are potential savings on cancer and musculoskeletal elective admissions; this will need further analysis to
understand how this breaks down. Work is in place to support cancer
identification as highlighted above. The System Resilience Plan includes
a review of musculo-skeletal services.
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From the Pathways on a Page information we recognise the need to undertake a deep dive into a number of specialties.
Common mental health disorder pathway highlights the need to understand the impact of our additional investment in the IAPT pathway on performance,
we will need to understand the timeframe for the data and match this against the increased capacity we have commissioned.
We intend to take the pack to our Commissioning Programme Board for more detailed discussion and evaluation. In developing our priorities we will
triangulate the findings of the deep dives with our commissioning intentions events.
4.1.1
Collaborative Approach across STP
The CCGs within the Birmingham and Solihull STP footprint are committed to following the Right Care model in partnership; progress to date includes:
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







Attended recent RC Regional Launch
locality workshop
Reviewed Commissioning for Value
packs
Agreed three common themes
o Respiratory
o Mental Health
o MSK
Agreed to either plug into existing
delivery vehicles System Resilience
Groups/Joint Commissioning Teams
or create new group
Advice from Right Care team within
STP “ let the fastest make progress”
Likely to have a layered approach
Co-ordinating through CCG
Commissioning leads meeting
Agreement via STP Delivery Group
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4.2
Addressing Urgent Care and the Urgent and Emergency Care Models
Urgent and emergency care (UEC) is one of the new models of care described in the Five Year Forward View. The UEC review proposes a fundamental shift
in provision of UEC, the Five Year Forward View and subsequent UCE Review guidance has identified eight 'high impact interventions' that it expects every
System Resilience Group to address –








No patient should have to attend A&E as a walk in because they have been unable to secure an urgent appointment with a GP. This means having
robust services from GP surgeries in hours, in conjunction with comprehensive out of hours’ services.
Calls categorised as Green calls to the ambulance 999 service and NHS 111 should have the opportunity to undergo clinical triage before an
ambulance or A&E disposition is made. A common clinical advice hub between NHS 111, ambulance services and out-of-hours GPs should be
considered.
The local Directory of Services supporting NHS 111 and ambulance services should be complete, accurate and continuously updated so that a wider
range of agreed dispositions can be made.
SRGs should ensure the use of See and Treat in local ambulance services is maximised. This will require better access to clinical decision support and
responsive community services.
Around 20-30% of ambulance calls are due to falls in the elderly, many of which occur in care homes. Each care home should have arrangements
with primary care, pharmacy and falls services for prevention and response training, to support management falls without conveyance to hospital
where appropriate.
Rapid Assessment and Treatment should be in place, to support patients in A&E and Acute Medical Units to receive safer and more appropriate
care as they are reviewed by senior doctors early on.
Daily review of in-patients through morning ward or board rounds, led by a consultant/senior doctor, should take place seven days a week so that
hospital discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the
week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient
discharges over the weekend.
Many hospital beds are occupied by patients who could be safely cared for in other settings or could be discharged. SRGs will need to ensure that
sufficient discharge management and alternative capacity such as discharge-to-assess models are in place to reduce the DTOC rate to 2.5%. This will
form a stretch target beyond the 3.5% standard set in the planning guidance.
The SRGs continue to strive to deliver and priorities these interventions which include some of the work areas highlighted below.
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4.2.1
Re-procurement of NHS 111 and GP Out of Hours services:
Following direction from NHS England in July 2015 to ensure that we commission an integrated urgent care system we are undertaking a collaborative reprocurement of NHS 111 services and our GP Out of Hours service.
The re-procurement will take place Between March and July 2016 with the intention that services go live in October 2015.
The intention of the re-procurement is to ensure that there is reduced confusion for both patients and professionals, providing a single point of access for
advice, consultation and care and ensuring that transitions of care between providers are seamless.
The revised service will be coherent with the functionality to transfer patients to the right place for treatment directly or more effectively. Patient
experience should be enhanced with greater access to a wider range of clinical expertise and better integration between urgent and emergency care
services and other service providers within the system.
The quality of care will also be improved with the service ensuring that there is significant clinical resource to manage complex and challenging cases with
clinicians having appropriate access to clinical records to make well informed decisions.
This will support our goals of achieving a managed urgent care system with the patient directed to the right place efficiently for treatment whilst providing
a safe and quality service which will ‘deflect’ patients turning up at local A&E departments when the service they require is delivered within another part of
the system.
No investment will be required as an annual budget is already in place; however, we want to use that money more effectively.
4.2.2
Walk in/Urgent Care Centres:
Due to changes in the procurement process for NHS 111 and GP Out of Hours services the re-procurement of walk in and urgent care centres has been
delayed. The CCG completed a collaborative consultation with key stakeholders alongside Birmingham Cross City CCG during 2015 in order to inform the
development of the model for these services.
The collaborative review of service provision re-commenced in January 2016 with a city-wide strategy for development of these centres expected shortly.
Locally we will review current urgent care centre provision with a view to commissioning primary care led urgent care centres. The review will include the
two existing centres namely The Hill and Katie Rd.
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Following this the CCG will undertake a procurement exercise to re-tender these services and as part of this we will re-engage with all stakeholders to
ensure that the service model is appropriate and meets the identified needs of the population.
In addition to this the CCG will be maximising the potential to integrate this service with the revised NHS 111 and Out of Hours service and the development
of 7 day services from primary care.
This supports the CCG’s ambition to reduce duplication, confusion and access issues in the current system and ensure that patients are easily able to
navigate these services and receive timely, effective and appropriate care at a time of need and vulnerability.
The timetable for changes to this system is under review but any service changes are not likely to take effect until Spring / Summer 2017.
4.2.3
WMQRS - Designation of Birmingham, Sandwell & Solihull Urgent Care Services
Prior to the establishment of the West Midlands Urgent and Emergency Care Network, the Birmingham, Sandwell and Solihull (BSS) Strategic Urgent Care
Network Board had agreed an approach to standards and designation. Providers in the BSS have nominated leads for this project to work with West
Midlands Quality Review Service (WMQRS). Representatives from all relevant services and commissioners are being invited by WMQRS to discuss and agree
the standards for the designation process. The nationally-defined standards will be used but the expectation is that consideration will be given to whether
(i) additional detail is needed to ensure consistent interpretation and/or (ii) additional standards are needed to ensure a robust designation process and (iii)
what evidence (if any) should be submitted in support of self-assessments. In particular, the work will look at whether the care of people with mental
health problems is adequately reflected in the national standards. The meetings will also consider the criteria for recommending either designation or a site
visit.
Process of Design of Standards and Designation of Tiers 1-3 in Emergency and Urgent Care
1
Confirmation of services (Tiers 1,2&3) to be involved in the designation process
2
Agreement of Standards for all services
3
Self-assessment by Tier 1 & 2 services and peer assurance of self-assessments
4
If required, site visits to Tier 1&2 services
5
Self-assessment Tier 3 services and peer assurance of self-assessments
6
If required, site visits to Tier 1&2 services
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4.3
New Clinical Models
The Five Year Forward View highlights the traditional divide between primary care, community services and hospitals is increasingly a barrier to the
personalised and coordinated health services patients need. This has led to demarcation between GPs, hospitals social care and mental health services
these boundaries need to be broken down. Caring for people with long term conditions has become the central duty of the NHS, this requires a partnership
with patients and system that underpins and supports patients across their entire episode of care. BSC is committed to supporting our population and
patients with this shift in direction and has therefore welcomed the new models of care discussed within the five year forward view alongside the enablers
such as primary care co-commissioning.
As stated in section 3.3 the NHS England view - The NHS Mandate is expecting the following to be delivered in 16/17 towards the goals for 2020 with
respect to new models of care and general practice:
•
•
•
4.3.1
New models of care covering the 20 percent of the population designated as being in a transformation area to:
o provide access to enhanced GP services, including evening and weekend access and same-day GP appointments for all over 75s who need
them; and
o make progress on integration of health and social care, integrated urgent and emergency care, and electronic record sharing.
Publish practice-level metrics on quality of and access to GP services and, with the Health and Social Care Information Centre, provide GPs with
benchmarking information for named patient lists.
Develop new voluntary contract for GPs (Multidisciplinary Community Provider contract) ready for implementation in 2017-18.
‘My Healthcare’:
BSC has worked closely with our membership to implement a successful
provider bid (My Healthcare) for Wave 2 of the Prime Minister’s GP
Access Fund. 23 of BSC’s practices have come together under the
umbrella of South Doc Services (a GP co-operative) to deliver an
innovative programme working across three geographic hubs.
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The Programme
The intention was to extend GP opening hours and
redesign the interface between primary care, community
based services and urgent care providers so that patients
are able to access a range of services via a single point of
contact. Service provision has been enhanced so that
patients have access to a full range of GMS and enhanced
clinical services complimented by pharmacy and nursing
support, health, wellbeing and lifestyle services. Services
are delivered using both physical and virtual platforms via
a ‘Hub and Spoke model’. Patients access services using
traditional methods and in the near future it is hoped
digital technologies giving a wider range of options
available to meet their varying needs.
The service currently operates between 8:00am-8:00pm,
6 days a week (with Sunday opening responding to local
demand) with a vision to integrate with out-of-hours services thus enabling 24/7 provision of consistently high quality, integrated wrap-around services in
which patient flows are managed in the most appropriate setting. Each element of the service reduces the waste of clinical time and inappropriate
demands on urgent care services. This creates a systematic approach to alleviate access issues and service pressures by introducing extended hours and
increasing the range of services available, with the aim being to convince patients that there is a viable OOH’s alternative to A&E.
Extended Access
As referenced above, the programme is based on a Hub and Spoke model with the 23 participating practices being grouped around 3 Hubs. Practices
continue to provide GMS/PMS and Enhanced services during contracted opening hours. Patients’ first point of contact continues to be their registered GP
who retain overall responsibility for their care. Within normal surgery hours practices are expected to manage their patients as they had previously
although there is the opportunity to transfer telephone, walk-in queries and repeat prescription request to one of the Hubs if it is felt that they can be
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managed more effectively. In exceptional circumstances, such as periods of unusually high demand, staff absenteeism, or an unexpected event which
renders surgery premises unusable, the Hubs and surrounding practices are able to take patient overflows until normal service is resumed.
The Main Hub houses call handling, clinical, pharmacy and administrative staff and back office functions. The two satellite Hubs meet the GMS and
Enhanced Services needs of their surrounding practices. The model has the flexibility to scale-up or down to meet the ongoing demand and has been used
to this effect to support winter pressures.
The 3 Hubs operate between 8.00am and 8.00pm, 7 days per week. Physical and virtual patient flows into the Hubs during weekend opening hours are
monitored and, if necessary, adjusted to ensure that patients receive the maximum benefit from the extended access. The overall aim is to deliver
increased access and choice for patients. The GMS Contract specifies that GP surgeries must provide services for a minimum of 52.5 hours per week (minus
contracted half days). Patients registered with My Healthcare are able to access services for 84 hours per week including Bank Holidays giving a total of 31.5
additional hours of access per general practice each week.
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Next Steps
Birmingham South Central CCG hopes to build on the success of My Healthcare, we
hope, subject to positive evaluation, to expand the model across the remaining CCG
practices. We plan to use tools such as the new voluntary contract for GPs
(Multidisciplinary Community Provider contract) to support this aim.
In the short term My HealthCare has the following service plans as set out in the
adjacent image:
4.3.2
GP Federation Development:
The development of a vibrant GP Federation as an option for our membership to join has become a priority for our CCG. In order to support this
development, “at pace”, it was agreed through the CCG Governance structure to commit CCG funding and project development/management expertise.
This would be proportionate to the need to ensure a GP Federation launch by April 2016.
The enhanced CCG support is for a phase 1 development phase only leading up to the launch of the GP Federation formally. However as part of this phase
the interim Federation Board will have to agree an approach to sustainability without such support (particularly direct financial) once launched.
The CCG support provides funding for dedicated management assistance in the form of a project manager, administration and increased support from the
Senior Management Team for a fixed period of time. In addition, we are also supporting dedicated clinical time, practice manager time and organisation
development (OD) facilitation.
Rationale
The rationale to support the development of a viable GP Federation for our membership is driven by a number of factors. Firstly, there is now a clear
national expectation conveyed via meetings with NHS England that this organisation form is the preferred format for how primary care provision organises
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itself in the near future. Secondly, locally we already have at least three formed or rapidly forming GP Federations. Thirdly, the development of viable and
effective GP Federation allows us to take advantage of national initiatives that support primary care such as the GP Access Fund, the expected GP plus
contract and our own workforce development plans.
Strategic Fit - National
Improving General Practice – A Call to Action published in 2013 stated that’ although there is no single blueprint for effective provider models, an increasing
number of practices and CCGs are independently coming to the view that they won’t be able to improve care and access for patients unless’:
•
•
•
•
General practice operates at greater scale, for instance through networks, federations or practice mergers …
…but scales up in a way that preserves the greater relationship continuity that comes from individual practice units
General practice is at the heart of a wider system of integrated out-of-hospital care, working on a more systematic, collaborative basis with
community health services, social care, voluntary/charitable organisations, community pharmacy and other partners
There is a shift of resources from acute to out-of-hospital care, but with need for local flexibility as to how far this flows into general practice and
how far into wider community services that ‘wrap around’ general practice.
The strategy document a Five Year Forward View (October 2014) set out a new deal for general practice and in relation to new care models commented
that “smaller independent GP practices will continue in their current form where patients and GPs want that. However, as the Royal College of General
Practitioners has pointed out, in many areas primary care is entering the next stage of its evolution. As GP practices are increasingly employing salaried and
sessional doctors, and as women now comprise half of GPs, the traditional model has been evolving. Primary care of the future will build on the traditional
strengths of ‘expert generalists’, proactively targeting services at registered patients with complex ongoing needs such as the frail elderly or those with
chronic conditions, and working much more intensively with these patients. Future models will expand the leadership of primary care to include nurses,
therapists and other community based professionals. It could also offer some care in fundamentally different ways, making fuller use of digital technologies,
new skills and roles, and offering greater convenience for patients. To offer this wider scope of services, and enable new ways of delivering care, we will
make it possible for extended group practices to form – either as federations, networks or single organisations”.
Building on this, the Five Year Forward View New Models of Care explained how a multispecialty community provider (MCP) can play into the reinvention of
out of hospital care with MCPs organising care for the whole population. MCPs will deliver an expanded version of core and enhanced general practice,
based on larger, more resilient multi-disciplinary teams and bringing a broader range of specialist and generalist care closer to all patients and citizens in
the diverse community.
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From a GP Profession point of view the RCGP has set its vision for General Practice 2022. Their vision is that the GP practice team in 2022 is likely to:
•
•
•
•
•
•
work as a community-led, multidisciplinary, flexible, integrated team with an appropriate mix of skills and roles
work in federated organisations, with interconnected clusters of practices and other care providers, spanning traditional primary, secondary and
social care boundaries
be contracted under a range of different flexible arrangements according to need, including independent contractor and salaried arrangements
work in purpose-built premises able to deliver the range of clinical and diagnostic services required in the community, as well as community-based
education and training
monitor, understand and manage inappropriate variability in the quality of health care
work closely with specialists and third-sector, private and NHS providers to deliver care in a more integrated and coordinated manner l include a
range of community-based generalist professionals who will work both within and outside acute and intermediate care facilities and admit patients
to these as needed
Strategic Fit - Birmingham South Central CCG
At a local level the development of a CCG wide GP Federation builds on the successful federated working of GP Practices within the My Healthcare Prime
Minister’s GP Access fund project as set out in section 4.3.1 and acts as a step on our road map to developing a Multispecialty Community Provider as
described in section 4.3.3.
Federation OD Outputs
Three local GP Federation development sessions have been held on September 9th 2015, October 22nd 2015 and January 28th 2016. In the first meeting Working together to design the future of our local general practice and dispelling myths, we discussed the ambitions for general practice, the implications
of federating including themed benefits and opportunities from the participants as well as themed challenges and negatives about federating.
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Word Cloud summarising benefits/opportunities of federated working
Threats/challenges of federated working
The second workshop- Working together to explore options for ‘federated’ working, explored the potential menu of federated services and the potential
approach in terms of the structure of the Federation. There was overwhelming support for a single Federation to cover all Practices as can be seen below.
Before undertaking the third development session in January 2016, a range of critical success factors were identified including:
•
•
•
•
•
Networks to agree on a network GP and Practice Manger representative
Clinical leads can commit to the time needed over the next 3 – 4months
The interim Federation Board can agree ways of working at a speed commensurate with the requirements of project
The OD process can keep the high level of engagement already experienced with the membership given the expectation of pace
The content experts of the CCG and its CSU (governance, HR, finance etc) can prioritise the OD project
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•
Interim Board to review ToR and the OD project PID including key tasks and
milestones.
In addition to this a set of high level milestones were agreed based on the RCGP toolkit
and the Primary Care Commissioning 10 stage process for the development of a
federation.
The third workshop summarised progress from the first two development sessions. It gave member practices the opportunity to here and learn from the
success of two federation/alliances of member practices within BSC namely, My Healthcare and Smartcare a federation of practices within the Central
Network of BSC. The workshop then focussed on the potential legal structure options for the federation; these were developed prior to the session by the
steering group with the assistance of DR Solicitors. Finally the session gave the opportunity for member practices to consider the work programme for the
federation in Year One.
At the end of the session member practices were encouraged to discuss federating further within their practices and networks with a view to making an
expression of interest in February.
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4.3.3
Multispecialty Community Provider:
BSC recognises that primary care of the future will build on the traditional strengths of expert generalists, proactively targeting services at registered
patients with complex ongoing needs such as the frail elderly or those with chronic conditions, and working much more intensively with these patients.
Future models will expand the leadership of primary care to include nurses, therapists and other community based professionals. It could also offer some
care in fundamentally different ways, making fuller use of digital technologies, new skills and roles, and offering greater convenience for patients.
BSC and Birmingham Community Healthcare NHS Trust (BCHC) have reached an agreement in principal for the formation of an Integrated Care Partnership
based on the multispecialty community provider model (MCP)as articulated through the Five Year Forward View to serve the population of South and
Central Birmingham.
Our Vision
Our vision will improve the health and well-being of all our population in South
and Central Birmingham (circa 300k people) and ensure access to high quality,
fully integrated out-of-hospital care and support delivered within the local
community, appropriate to the needs and lifestyle of the individual and their
families. Birmingham offers a vibrant diversity of localities with different cultures,
demographics, and some of the greatest disparity in health outcomes of any city in
Britain. One size will not fit all and our challenge is to address all of these diverse needs.
A key vehicle for the realisation of this vision is the design and delivery of SCBMCP
with a road map through to becoming an accountable care organisation.
The underpinning philosophy of the new provider organisation is to shift the
emphasis from a traditional medicalised model to a more proactive social model
where individuals, their families and carers are encouraged to take ownership of
their own health and well-being choices and behaviours, at the same time as
being partners in decision-making when care is required.
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The main objectives are:
i.
ii.
iii.
iv.
v.
vi.
vii.
Enabling over 75s to stay at home, living independently as long as possible, by providing a comprehensive service of appropriate support, advice
and care which is delivered by fully integrated locality based teams within their own home via a proven Hub and Spoke model designed around
existing GP practice networks.
Improving the health and well-being of our children including addressing health inequalities and reducing the incidence of mental health in our
children and younger adults (28% of population of Birmingham are under 20 and 62.9% of school children are from black and ethnic minority
groups).
Providing enhanced community based mental health management and treatment services to speed recovery, improve user outcomes and
experience and reduce admission to acute services.
Improving patient outcomes and maximising use of resources by targeting our services at the most appropriate patients using risk stratification and
designing patient services around levels of need rather than diagnosis using cluster analysis
Developing a coherent urgent and emergency care system within the community that is responsive and proportionate and complements the wider
system.
Developing a culture of consumer directed care.
BSC will review the capacity and capability within local LD community teams in order to successfully support more people with Learning Disabilities
to live the least restrictive, most inclusive lives within the community. This will enable the development of a specific plan to ensure implement this
aim.
The principle changes to the delivery of care include:
1) Improving Patient Outcomes:
Redesign services into network based integrated community teams using learning from our experience of developing the Complete Care model. Our
integrated team of staff in each network includes GPs, primary and community nurses, therapists, social care, third sector and voluntary organisations.
Networks have access to consultant geriatricians who provide the type of proactive and co-ordinated service our users are demanding. We will build on our
experience to supporting our most vulnerable patients while also providing a greater emphasis on maintaining health and well-being and supporting carers
and engaging the community.
Provide a more comprehensive mental health service offer in the local community including assessment, advice, treatment and support. Changes will
include learning from and roll out of our established model of Well-being Hubs and implementing the new 0-25 Community Mental Health Service
Specification.
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Provide Nursing Home Clinical Support, in line with arrangements already in place across Birmingham providing additional clinical cover to patients living in
care homes and registered with participating practices. The MCP will learn from the evaluation of the two year programme and support recommended
improvements.
2) Acting on what our citizens tell us:
Extend GP opening hours to 8am-8pm 7 days a week by forming a hub and spoke model in each network and having a fully integrated community team
providing services for these extended hours.
Guarantee the use of a single joined-up electronic care record across our services. We are in a strong position with 95% of all our practices use EMIS Web.
Ensuring all appropriate staff have timely access to care information is one of the key drivers in our model. It will also provide improved data sharing,
monitoring and measurement of outcomes.
Provide a greater variety of service delivery options including digital technologies will be offered using different platforms e.g. web-based tools and apps,
tailored to the expressed preferences of the populations we serve.
3) Improve health and well-being outcomes
Recruit Health and Social Care Navigators to provide information on lifestyle and Health Promotion Services, Local Authority Services, Citizens Advice and
Third Sector Services and support. The service will be tailored to meet the needs of groups that are seldom heard who do not historically access health
services (e.g. Young Peoples Services, Homeless and some minority ethnic communities).
Develop Children’s Services –the MCP will bring together GPs and a skilled BCHC workforce improving children’s health and wellbeing through the building
of a comprehensive integrated Early Help offer including; an extensive team of Health Visitors, School Nurses and GPs working in partnership with families in
their local environment. Paediatricians, specialist nurses and therapists will work closely with GPs to support families of children with additional health needs
and disabilities.
The local community will:


Enjoy significantly improved access to services at a time and location convenient to their lifestyle and circumstances and using a variety of channels.
The services will be based round their GP network and users will have to travel no more than 3 miles from their own GP practice to access services
Receive a more responsive and co-ordinated service delivered by a fully integrated team sharing a common electronic record leading to a reduction
in assessments, tests, appointments and improved outcomes
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


Have greater support to manage their own health and well-being and to access the most appropriate support, information and services
Improved access to and reduced waiting times for community based mental health services particularly for children and young adults
Have alternative community based emergency and urgent care services via a single point of access
The design of our MCP is driven by the many in-depth consultation events and engagement work with our population and with our staff (many of whom are
in both categories) and our priorities, objectives and outcomes echo their concerns about the current system and their aspirations for the future.
Working towards the new model
In December 2014 a Joint Statement of Working was signed between BSC CCG Governing Body and BCHC Board to confirm the principles that underpin the
design and development of SCBMCP including the creation of the Partnership Board. BSC CCG’s Member Council representing all member practices have
agreed this.
We applied for Vanguard status for the MCP new model of care and although unsuccessful we were shortlisted; a delegation presented to the Vanguard
Site Worksop Event on the 3rd March 2015.
Progress during 15/16
As outlined previously in this plan the focus during 15/16 has been on steps one and two of the MCP Road Map, the implementation and development of
the My Healthcare model and the creation and establishment of an effective GP Federation. BCHC representatives sit on the My Healthcare Delivery Board
as does the Local Authority. BSC is supportive of BCHC’s Foundation Trust Application.
Plans for 16/17
During 16/17 we plan to continue to develop the ‘My Healthcare’ model and the GP Federation whilst recognising the need to then move to step three.
The key vehicle for successful delivery of our vision and objectives for step three is the existing dynamic and equal partnership between BSC CCG and BCHC
which is already delivering measurable improvements for our population. The Partnership Board will need to be established providing strategic direction
from population, provider and commissioner perspectives while recognising the importance of robust governance.
The Partnership Board will provide the overarching framework for the creation of the new delivery structure encompassing a Commissioning Board and a
Provider Board. The 5 Provider Networks/ Federations of GP practices feed into the Provider Board with BCHC. SCBMCP places GP practices at the heart of
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service delivery via the five existing primary care networks and emergent Federations which each provide services based on a ‘hub and spoke’ model. Each
network is made up of a population of between 30-100k.
Local evidence-base of successfully delivering new models of care
The local healthcare economy benefits from strong Clinical leadership at all levels and a specific mandate from the population we serve. Examples of this
include:
Complete Care - The Complete Care model has been piloting ‘place based’ integration in Birmingham based on a model developed in a medical-socialcommunity-academic partnership lead by BCHC. This model’s uniqueness lies in the patient navigation model, which brings to life the aspiration outlined in
the 5 Year Forward View of engaging the whole community, including voluntary sector and informal carers.
The accelerated learning from our MCP will further demonstrate the individual empowerment, improved health and wellbeing and effective use of the
healthcare economy’s resources as this radical departure from the past hospital dependent medical model becomes effective at scale.
Primary Care Well-being Hub - The Hub, designed and delivered by a local GP network, provides GPs and 55,000 patients access through the Health
Exchange, a well-established Birmingham third sector organisation providing health support to local residents. Members of a triage team made up of
Birmingham Healthy Minds, CAMHS, Big Community, Chaplains, Health Exchange and My Time therapists make initial telephone contact within 1-3 days.
Service users are supported to access various other services (or spokes of the Hub) to help them to address their mental health issues.
My Healthcare - As stated in earlier one of our GP Co-operatives, covering a population of 123,289 and 23 practices, have implemented a Prime Minister’s
GP Access Fund Project which is based on a detailed model which fully integrates with the MCP plans and is step one on the road map.
The partnership between BSC GP Practice networks and federations, BCHC and BSC CCG has already invested in both the development of the new models
of care described above and the creation of strong foundations described below. The partners have invested in excess of £6m to the development of
the integrated partnership to date.
Building blocks in place
Building block
Evidence
Service specifications being grounded in service user
Innovative 0 – 25 Community Mental Health Services based on ‘You said – We did’
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experience
Service commissioning and delivery based on best available
evidence and including payment by outcomes
Improvement schemes aimed at improving quality of life and
reducing avoidable mortality
Long term conditions Local Improvement Scheme (LIS), Cardiovascular LIS and Respiratory
Quality Improvement LIS
Common IT platform used across all practices in CCG
EMIS web is used by over 95% practices in South Birmingham. This allows sharing of clinical
records, reporting and benchmarking on CCG wide basis
Data sharing: a safe electronic system that allows doctors and
the wider care team to view important, relevant information
from GP records and social care data
South Central CCG, as part of a joint Birmingham, Sandwell and Solihull CCG collaborative
has developed Your Care Connected, to make care safer.
Innovative integrated matched cohort health and social care
analysis
Pan-Birmingham analysis of combined NHS and Social Care data on costs for older people
demonstrated 95% overlap between health and social care services and potential for
service and productivity improvement.
A risk stratification tool is embedded in all GP practices
Identifies 6000 patients with highest level of unplanned admissions. Unplanned
admissions DES in place
High level of GP engagement that is increasing
(IPSOS MORI national 360) and the CCG continues to grow seeing a recent increase in size
by 25%.
Financially stable
The CCG has maintained financial stability during 2013/14, 2014/15 and continues this in
2015/16
Experience of developing workforce models
Development of workforce modelling toolkit based on workforce development and
planning for integrated teams to deliver effective MCP model (Complete Care pilot)
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Data sharing agreement in place across My Healthcare practices enabling the GP Patient
Record to be viewed and utilised during Hub appointments to support patient care.
Experience in developing tools to support safer staffing
There are no national/validated tooIs available to support the roll out of the safer staffing
agenda across community services. The ‘Dependency’ tool has been developed in
partnership between GEL Data Solutions Ltd and BCHC NHS Trust and roll out to all District
Nurse teams. Interest from NICE and regional NHS organisations has also been received.
Innovative analysis of community services data including data
based on patient postcode and use of resources to inform
development of new models of care
(Birmingham Intermediate Care Programme, Better Care Fund Modelling Group)
4.3.4
Forward Thinking Birmingham:
Birmingham CCG’s have commissioned a ground breaking 0 to 25 mental health service which aims to deliver the vision set out in the Future in Mind report.
The provider, Forward Thinking Birmingham (FTB) is a new consortium formed of five partners; Worcestershire Health and Care NHS Trust, Birmingham
Children’s Hospital NHS Foundation Trust (BCHFT), The Children’s Society, The Priory Group and Beacon UK.
This new service is due to ‘go live’ in its entirety from 1 April 2016. Fundamentally, the contract is designed to provide a fully integrated and early
intervention mental health service for children, young people and young adults. BCHFT is the prime contractor and the partners are managed through a
sub-contractor relationship. The service will provide flexible and timely access to services at the earliest onset of problems, in locations suitable for families
and young people including providing a drop-in centre at the heart of Birmingham.
The development means there will no longer be a transition for young people between 16 to 18 years old when they are at their most vulnerable, and we
expect to see a long term reduction in ongoing mental health problems for those over 25. The diagram below depicts the pathways of care that will be in
place from this April.
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4.4
Variable Interventions
4.4.1
Procedures of Lower Clinical Value
Procedures of Lower Clinical Value (PLCV) are procedures that have been identified as being either marginally effective or ineffective with limited clinical
value in the vast majority of cases. The main objective for having PLCV policies is to ensure:
•
•
•
Patients receive appropriate health treatment, in the right place and at the right time.
Treatments with no, or a very limited, evidence base are not used.
Treatments with minimal benefits to health are restricted.
Currently, the criterion for these treatments can vary between areas. In 2013, at the time of the transition from Primary Care Trusts to Clinical
Commissioning Groups (CCGs), it was agreed that previously existing legacy policies should continue to be used to ensure patients maintained access to
essential clinical services. However, to avoid a longer term potential post code lottery access to services, it was also agreed that a Birmingham, Solihull and
the Black Country wide project group should be established to review the existing working arrangements for these policies. The remit for the project group
was to work collaboratively to agree and develop a single, consistent core set of policies for a range of PLCV procedures to make sure that patients have the
same opportunity to access the same treatments regardless of where they live.
In 2014, 6 CCGs across Birmingham, Solihull and the Black Country met together to form a project group to commence this process. The working group
included clinicians and commissioning managers from all of the CCGs involved, along with colleagues from local authorities and public health. The working
group reviewed 45 procedures highlighted within 21 policies in accordance with current clinical evidence and national guidance, such as NICE and Royal
Colleges.
On January 18th, Birmingham Cross City CCG, Birmingham South Central CCG and Solihull CCG commenced a 6 week engagement process to seek the views
of patients, the general public and wider stakeholders regarding the proposed changes and recommendations that have been made by the project group to
the existing PLCV policies. As part of this process, an online questionnaire has been developed and a number of drop in sessions arranged for stakeholders
to input their views into this process. Letters have also been sent to the Health Overview and Scrutiny Committee Chairs in Birmingham and Solihull to
inform them of the proposals and help them actively engage with the process.
It is intended that this engagement phase will conclude on Monday 29th February. All comments and views received during this process will help inform the
final versions of each of the 21 policies being harmonised across all 6 CCGs. The final versions of these harmonised policies will then be included into all
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2016/17 contracts of local service providers. This will make sure that all Birmingham, Solihull and Black Country patients then have the same opportunity to
access the same treatments regardless of where they live.
A comprehensive Equality Impact Analysis (EIA) has also been undertaken for each of the policies affected by this process. This has helped to identify the
people who are most likely to be impacted by these changes so that they can be engaged with specifically during this consultation process.
All of the procedures in the 21 policies will still be available. However, the clinical access criteria for a procedure may have changed. If a patient doesn’t
meet the criteria in the policy, but the GP believes their circumstances are exceptional, the GP can still submit an Individual Funding Request (IFR)
application for consideration by each CCG’s IFR Panel process.
Across the STP footprint we will continue to review and harmonise commissioning policies.
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4.4.2
Medicines Optimisation
Medicines optimisation is a system of processes and behaviours that determines how medicines are best used by patients and by the NHS. Effective
medicines optimisation places the patient as the primary focus, therefore delivering better targeted care and better outcomes for individuals, through close
and effective working relationships with BSC Practices. Effective medicines optimisation can improve patient outcomes, reduce risk and improve patient
safety with regards to medicines, help achievement of local and national targets, allow appropriate use of resources and obtain value for money, contribute
to service redesign and clinical pathway development.
Headline Medicines Management Issues for 2016-17:
Outcome Domain(s)*
QIPP Target
CCG MM Priority Action
Domain 1
Prescribing efficiencies including:
Prevention
Reducing premature mortality
from the major causes of death
[1.1] under 75 mortality rate
from cv disease
[1.2] under 75 mortality rate
from respiratory disease




Use of most cost-efficient medicines
and brands in agreement with local
health economy.
Scrutiny of provider charges to
ensure correct allocation
Appropriate use of rebate schemes
and prescribing decision support
systems
Primary care long term conditions scheme
Use of EMIS WEB and to identify patients requiring interventions to
optimise prescribed treatment and reduce risk (PINCER intervention
approach)
Use of Aristotle to identify high risk patients with multiple hospital
attendances
Use of dedicated medication review to prevent medication associated
adverse events and hospital admissions (over 75 scheme and extension)
Targeted prescribing efficiency
improvement in areas of significant
variation.
Domain 2
Enhancing quality of life for
people with long term
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Contribute to area wide review of interface
formularies via the Area Prescribing
Partnership
Participation in Area Prescribing Committee in collaboration with
conditions*
2.6 Enhancing quality of life for
people with dementia
Committee:
1. Introduction and implementation of
guideline for the rational use of
newer anti-diabetic agents
2. Review of blood glucose testing
meter formulary
3. Harmonisation of three local
interface formularies
4. Collaborative work across local
Healthcare economy to ensure
rational introduction of updated
NICE clinical guideline for treatment
of diabetes mellitus.
5. Review of patients on high dose ICS
with a view to stepping down dose
and using a more cost-efficient
brand in line with local formulary.
6. Review of analgesic prescribing (in
particular use of opioid patches
where local area prescribing is a
significant national outlier)
Domain 5
Reducing Medicines Related Risk scheme in
production for 2016-17:
i) MRSA
Entry qualification for scheme will require a
reduction in:
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Work with local provider trusts to reduce pharmaceutical risk associated
with medicines through improved communication on discharge and
increased reporting of medication related errors. Introduction of Medicines
Assurance Framework.
Localism
Explore areas for joint initiatives with neighbouring CCGs and local
pharmacy contractors.
Education
Training package for practice reception staff to enable them to manage
repeat prescription services more effectively – extension and roll out of
learning from pilot practices.
Repeat ordering slip project – declaration to be signed by third parties
ordering on behalf of patients.
[5.2] Reducing the incidence of
healthcare associated infection
(HCAI)
ii) c.difficile
neighbouring CCGs and local provider trusts to agree and oversee the
introduction of new drugs and treatments and harmonise current interface
formularies to remove geographical inequity.

cephalosporins, quinolones
Training for GPs on appropriate nutritional support and use of MUST
scoring.
Workshop for GPs in innovations in medication review and principles for
appropriate reductions in prescribed medicines.
Support increased incident reporting in primary care allowing identification
and co-amoxiclav as % of total antibiotics.

overall antibiotic prescribing rate
Other requirements:

Review of all patients receiving
nutritional supplementation to
improve adherence to local
guidelines, use of MUST scoring,
weight objective setting and reduce
waste
and dissemination of key learning points to reduce future risk – support for
Quality Team in introducing and embedding incident reporting within CCG
GP practices. Introduction of a medicines safety newsletter for circulation to
all primary care clinicians.
Access and quality of primary care

[5.4]
Reducing incidence of
medication errors causing
serious harm
In depth review of repeat
Improve identification and registration of LTCs in general practice
prescribing systems, discontinuation
Use of EMIS WEB and PINCER methodology to identify patients requiring
of third party prescribing
dose modification, drug monitoring, READ coding.
Additional areas
Ensure effective management of repeat prescribing systems to improve
Reduction in use of high dose PPIs
accuracy of patient clinical record data
Safer insulin prescribing
Support improvements in incident reporting
in primary care.
Identification and dissemination of key
learning points from incident review.
Review of care home patients –
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Introduction of protocols to rationalise supply of home-delivered items e.g.
incontinence, stoma, nutritional items
Explore potential for better use of clinical pharmacists to manage care of
patients with LTC
Rationalisation of prescribing and supply of unlicensed pharmaceutical
specials – repatriation of paediatric specials prescriptions to BCH.
optimisation of care, review of therapy in
patients with dementia and waste
minimisation.
Over-75 project to provide individual
medication review for high risk patients.
Improving Antibiotic Prescribing
Primary Care
Practices and networks receive monthly bench-marking data to show performance against two key national targets associated with antimicrobial
prescribing.
Audits have been carried out at practice level with feedback at practice meetings and discussion of different management approaches. Support materials
for practices to use with patients instead of issuing prescriptions have also been provided.
The Prescribing Scheme for 2015-16 will have reducing medicines related risk as its main theme. Appropriate reductions in overall antimicrobial prescribing
and percentage of broad-spectrum antibiotics will be an initial qualification requirement for practices to achieve any rewards under the scheme.
Secondary Care
Antimicrobial stewardship is included in the Medicines Assurance Framework for all three providers where BSC is lead commissioner.
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4.5
Self-Care
National Guidance
Delivering the Forward View expects a step-change in patient activation and self-care as part of our delivery as well as involving and supporting carers. Such
a step-change will help to close the health and wellbeing gap and features both in our own operational plan and the forthcoming Sustainability and
Transformation Plan for our ‘footprint’.
BSCs Approach to Self-care
BSC builds self-care principles with the aim of empowering patients and their carers into as many of our programmes as possible. This includes amending
existing contracts as well as commissioning, testing or working in Partnership to develop innovative approaches to the promotion of self-care. For example
in terms of contracts for this coming year, in relation to the Birmingham Community Healthcare Trust we are from 1st April 2016 to including the following
in the contract:


A patient experience outcome measure ‘Am I able to self-manage my condition’.
People receiving home based treatment though multidisciplinary teams will receive education and training (and their families and informal carers)
to enable self -care

Providing people and carers with information that will enhance their understanding of their care and promote self-care and independence
People receiving home based treatment though multidisciplinary teams will be signposting people/carers at the earliest opportunities to other
services/organisations to enable optimum support and self -care

On the other hand we have acted as a demonstrator site for the National Diabetes Prevention Programme and as of 04/02/16 have through our Providers
enrolled 338 people at high risk of developing diabetes (as defined by having an HbA1c of between 42mmol/mol – 47 mmol/mol) which exemplifies a high
degree of innovation in wanting to test new ways of supporting self-care in particular groups. Whereas the last example has been commissioned as part of
a national programme, we have also worked in Partnership with MacMillan to promote self-care as part of a cancer survivorship programme (see section
3.7.4).
Every year we plan extensively for the surge in demand experienced during the winter and early spring seasons. This includes taking part in the local SRG
surge planning and working locally in our CCG with our Communications and Engagement team on promoting the appropriate messages over the winter
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months. This last year we have had to communicate extended Walk-in Centre opening hours and additional capacity in the My Healthcare hubs (section
3.4.6).
In addition there are examples with further details in sections such as FTB – New Models of Care; LD – Transforming Care; Dementia – Mental Health and
Dementia; Children with complex needs – NHS Continuing Care; Over 75s and RQIP Local Improvement Schemes – Local Improvement in Primary Care.
Other examples are shown below in table below:
National Driver
Health and Wellbeing Gap
Example
My Healthcare Apps
Detail
Development of a digital platform for e-communications with
patients who are registered with My Healthcare including selfcare apps for particular conditions (in development)
Early Years Re-procurement
Consultation and re-procurement of the BCC Early Years Services
to create new integrated Health and Wellbeing offer
Care and Quality Gap
Test beds – digital access –
mental health
Funding and Efficiency Gap
Self- care for Long Term
Conditions
Ensuring the sustainability and
quality of general practice
Over 75s Local Improvement
scheme
Respiratory Quality
Improvement Scheme
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Mental health patients will be able to use technology and apps
to manage their condition, linked to a hub which can despatch
specialist staff if a crisis looks likely.
The CCG has a comprehensive CVD LIS and shared care
arrangements that support self-care. Examples include - CKD 3b
register and self-management plan; Stroke and selfmanagement plan ; Heart Failure and de-compensation plan and
CHD and lifestyle counselling
A LIS designed to support those over 75 years by dedicated
medicines management reviews (two localities), and building
upon the existing work of the Unplanned Admissions DES by
enhancing the care offered to this population group by providing
safe, proactive, personalised care for those who need it most
Working with patients who suffer from Asthma (>8 yrs) and
COPD so that are written self-management plans in relation to
both conditions and that Practices follow up those hospitalized
for these conditions to offer further advice within 2-4wks of
discharge
We have also developed several approaches to Social Prescribing. These include direct services to patients via the Edgbaston Wellbeing Hub and more
latterly the Springfield Project (section 3.4.5). In terms of the wider determinants of health we intend to continue the work initiated with Birmingham City
Council’s Northfield District following our recent ‘Joint Working in Housing and Health Workshop’. This work is seeking to review ways in which we can work
better in partnership to promote early intervention, improve crisis management, develop more supportive pathways, explore opportunities for social
prescribing and the use of community assets, and build cohesion within neighbourhoods. This work is supported by Midland Heart Housing Association and
Bromford Housing Association, hosted at The Factory youth centre.
BCF Carers Approach - Carers are a core focus of the national Better Care Fund Policy and our local work stream sits within the Better Care Fund
arrangements. There is a Carers Strategy group which is co-chaired between our Quality & Governance lead and Better Care Transformation lead and
includes membership of 3 CCG’s, Birmingham City Council and Healthwatch Birmingham, with co-opted representatives as required e.g. RCGP Regional
Clinical lead, Forward Carers.
Across Birmingham there has been a specific focus on ensuring that the NHS responds positively to the needs of carers and in discussion with Birmingham
City Council the strategy group has sought to understand the quality, capacity and potential gaps in the provision of services which support carers.
With the establishment of the Care Act 2014 which took effect in April 2015 the Local Authority has a specific responsibility to treat carers in the same way
as those who are cared for. This shifts the rights of family carers from those carers who provided ‘regular’ and ‘substantial’ care meeting criteria for an
assessment to anyone who may benefit from carer’s support being entitled to an assessment.
For this coming year we intend to deliver the following actions to improve the Health and Wellbeing of Carers:


Dementia
o Improve access to respite care
o Extend ‘Step Up’service across Birmingham
Safeguarding
o Raising the awareness levels of carers with regard to safeguarding procedures
o To incorporate the learning from the “Carers and Safeguarding Project” with training material to professionals
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Under consideration is an initiative to develop an enhanced service for community pharmacy with medicines management teams and NHSE Area Team and
to develop a Carers corner/ wellbeing offer within practices with support from Forward Carers service providers to work with practices providing “drop in”
sessions focused on supporting carers.
Personal Health Budgets - Personal Health Budgets are one way of giving people more choice and control over the care they receive from the NHS.
Personal Health Budgets can help people find the care and support that best suits their personal circumstances and achieve the things that are most
important to them. The CCG is mainly working with Birmingham City Council and NHS Arden and GEM Commissioning Support Unit in the delivery of
Personal Health Budgets. The CCG also works with local NHS Trusts to help identify people who can benefit from a Personal Health Budget and support or
signpost people through the process.
The approach is to support existing transformational/service development programmes and commissioning teams to offer and implement PHBs whilst
developing a common supporting infrastructure to help people choose and manage a PHB. This will be achieved through local engagement,
communication, project management and governance structures as well as on-going participation in NHS England’s national support programme
‘Developing a Local Offer’.
Aims and objectives include:


expand the offer of Personal Health Budgets (PHBs) to those groups of individuals where evidence has shown there are benefits, where possible
offering integrated Personal Budgets.
increase the ‘take up’ of PHBs in Continuing Healthcare (CHC) and children’s continuing care where there is a ‘right to have’ a PHB.
In addition to increasing the offer of PHBs in CHC and children’s continuing care, the project will initially focus on offering PHBs to;








Adults with a learning disability and/or autism;
Children with SEND who have an Education, Health and Care plan;
People currently receiving joint NHS/LA packages of care to support their mental health needs;
People who are high users of mental health crisis services;
People who have palliative care and end of life care needs;
People with multiple long term conditions; and
Hard to reach groups (Travelers, homeless people).
And also Personal Maternity Care Budgets in 2017/18.
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Key milestones;
-
Project infrastructure established April 2016;
Consultation/ engagement on priorities for extended offer June 2016;
Commissioning intentions issued to support extended offer Sept 2016;
Strengthened PHB infrastructure in place December 2016.
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4.6
Getting serious about prevention
BSC CCG recognises that the sustainability of the NHS is dependent on a radical upgrade in prevention and public health. We understand the need to
support different approaches to improving health and wellbeing during 2016/17. The sooner we identify people at risk of developing serious health
problems, the more we can do to either prevent the condition or provide them with the best possible treatment to live well with it.
4.6.1
Ambition to reduce inequalities and improve outcomes through behavioural interventions for HWB – Smoking, Alcohol,
Obesity
Work has progressed with Birmingham City Council (BCC) Districts to develop local health & wellbeing priorities. These will be coordinated with CCG
Networks to harmonise actions at a local level.
BCC is re-commissioning lifestyle services including targeting smoking cessation services at priority population groups. This process will include CCGs and
their local ambitions.
CCGs have already set smoking in pregnancy targets and are monitoring these. These have been shared and agreed with BCC.
Safeguarding and early help are priorities of the Birmingham Health & Wellbeing Strategy. These are significant features of the FTB 0-25 service.
4.6.2
National Action on Prevention – National Prevention Board – tackling risks – alcohol, fast food, tobacco and other
NHS England, Public Health England and the Local Government Association are to develop and publish proposals for actions that local areas can take to go
further in risks from lifestyle factors. Notwithstanding these proposals, within Birmingham we are currently undertaking the following in key areas as
follows:
Alcohol
Public Health in Birmingham City Council have re commissioned both alcohol and drug services with a single system and a lead provider approach. The new
provider - Crime Reductions Initiatives (CRI), commenced delivery from the 1st March 2015.
The new system includes acute sector, primary care, community based and criminal justice service responses. There is also a greater emphasis on family
focussed interventions, addressing child safeguarding risks and developing outreach responses with respect to BME engagement. The different levels of
service response will be a feature, dependent upon need. This includes the delivery of brief interventions, extended interventions, structured treatment
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and residential services where required. The aspiration for service users will be in line with the recovery agenda i.e. improving employment, housing,
health, family-functioning, criminal justice and Blood Borne Viruses outcomes.
Fast food and Childhood Obesity
Birmingham is performing favourably against the Core Cities, who have shown an average increase in obesity rates since 2010. Some successes on the
childhood obesity work stream include:







Childhood obesity rates have started to decline in Birmingham since the implementation of the Childhood obesity strategy: Fit for the Future 20132018, meaning that we are making progress to reduce the proportion of children with excess weight in Reception and Year Six.
Birmingham has been recognised nationally via the media for the progress made towards limiting fast food outlets. There are 73 Local Centres within
Birmingham; these are covered by the Local Centres Supplementary Planning Document (SPD). The SPD contains the planning policy relating to Hot
Food Takeaways (A5s). Public Health was the driver for developing and getting the policy adopted to regulate the proliferation of A5s, this was in 2012.
The crux of the policy is a 10% cap on all A5s within all local centres in Birmingham – 31 of the 73 Local Centres were at the 10% cap when we
introduced the policy, this has now increased to 33. Since the policy was introduced, 28 A5s have been refused within Local Centres, and 40 A5s that fall
outside of the Local Centres boundary have also been refused.
The part of the SPD that contains the A5/10% policy is being lifted from the policy and embedded into the emerging Birmingham Development Plan –
this means that the policy will now be firmly fixed into the Core Planning Strategy for the city.
A series of events and workshops have taken place to engage potential partners, e.g. Planning and Health workshop, district workshops and citywide
clinicians’ workshop
9/10 districts have chosen childhood obesity as one of their top 3 priorities
The STARTWELL programme has been expanded and re-designed to ensure universal delivery of both nutrition and physical entitlement in early years
settings across the city
Food Dudes Ltd has been awarded the contract to deliver a motivational behaviour change programme to support staff in Primary Schools.
We continue to commission a number of school and community based obesity programmes to address healthy eating and obesity. Additionally there are
two Children’s weight management services specifically targeting those children with excess weight; this includes a under 11’s.
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Lifestyles: Obesity, exercise, smoking cessation
Birmingham Public Health continues to commission a range of lifestyle services that address obesity, smoking and sedentary behaviour. All three areas are
current priorities and are reflective of the Public Health Outcomes Framework, Birmingham Health and Wellbeing Strategy and the Birmingham City Council
Leaders Policy Statement.
A range of providers are commissioned to deliver a variety of free services that are reflective of local needs; these include:
•
•
•
•
•
•
•
•
Adult Obesity (BMI >30) – Two online weight management programmes specifically for Men (Commit2bFit) and Women (Choose2bSlim) that
provide a 12 weeks support programme. Additionally the Lighten Up programme triages those that are not deemed appropriate for the online
programme to commercial programmes including Slimming World and Weight Watchers, where a patient is offered 12 weeks of free support. This
is available through a health professional or self-referral.
The Lighten Up programme is expanded to address maternal obesity and again provides triage into support programmes that includes BirthFit,
Slimming World and Health Trainers. This service is accessed via a Midwife referral usually following the ‘Booking Appointment’ or self-referral.
Physical Activity – The Health and Wellbeing Service (formally Be Active) is commissioned by Public Health and provides a multitude of free physical
activity interventions that utilises leisure centres, community facilities, and green space to increase access to physical activity. In addition a 12 week
GP exercise referral programme (Be active+) provides a tailored physical activity programme specifically for sedentary patients that have a long
term chronic condition that can be managed (solely or in part) through a structured physical activity intervention.
Health Trainers – The Health Trainer Service provides more general lifestyles related behavioural change support across healthy eating, physical
activity, smoking and alcohol. The service can be accessed via health professional referral or self-referral.
Smoking Cessation is delivered via three providers that include a core service (BCHC), Pharmacies and GP’s. This includes the prescribing of
pharmacotherapy in combination with support from a trained smoking advisor (one of the providers). Those GP’s and Pharmacy providers sign up
to a Local Enhanced Primary Care Contract issued by Public Health.
Introduction of voluntary smoke free zones – first is council owned children’s playgrounds. If this becomes established then it is hoped we can look
further at voluntary smoke free zones around other council run buildings such as outside sports facilities, café’s etc.
Litter fixed penalty notices for smoking related litter. These are litter enforcement patrols undertaken by Regulation and Enforcement, working
towards - where the litter is smoking related - education material being given out with fixed penalty notices. The hope is to progress into incentives
for getting money back should individuals successfully quit through smoking cessation services.
Shisha – multi agency working group looking at compliance of shisha premises and working on an educational package to delivery of harm
reduction messages to young people.
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•
Cessation services within the existing council services – starting with smoking cessation in Birmingham’s markets, helping traders and customers
give up smoking.
Project on availability of tobacco in retail areas – a short project looking at discrete retail areas of Birmingham to evaluate the availability of tobacco
within areas and relating this information to smoking prevalence and uptake.
•
4.6.3
National Diabetes Prevention Programme
We wish to support NHS England’s desire to take action to become the first country to implement at scale a national evidence-based diabetes prevention
programme. In 2014 we developed a new cardiovascular disease local improvement scheme with a particular focus on the two stages of diabetes –
identifying people at risk of developing it, and managing patients who have been diagnosed with type 2 diabetes who are on insulin therapies and
monitoring how often they need hospital care. Our approach has already made a big difference. We identified nearly 9,000 patients (3 per cent of the
registered population) likely to develop diabetes. Targeting them with the right advice and support means around 600 of these patients are no longer at
risk.
NDPP Demonstrator (See section 4.5)
During 15/16 we were selected as one of seven ‘demonstrator’ sites as part of a national programme to help people most at risk to change their lifestyle
and reduce the chance of developing type 2 diabetes. Undiagnosed diabetes is a potentially big problem for Birmingham. Figures show a higher than
average proportion of the local population either have the condition or are likely to develop it – 74,000 in 2015, expected to rise to over 90,000 in 2025,
unless we address the issue. The demonstrator site status enabled us to test a blended programme which included the enhancement of our existing CVD LIS
Diabetes Scheme and built on the way current Lifestyle Change Support Services are commissioned in Birmingham by the local authority.
Components of the scheme include:
a. Community Engagement – community engagement work focussing on BME communities with support from the South Asian Health Foundation
b. Motivational Interviewing - Training in motivational interviewing for front line clinical staff and brief intervention techniques for lifestyle change.
c. LIS Development - Enhanced CVD Local Improvement Scheme that provides for case finding and referral through primary care and BSC General
Practices.
d. Core Intervention - Commissioning a pilot local six week structured programme for people at risk of diabetes from existing providers - to include
nutrition and exercise.
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e. Feedback – designing enhanced feedback and tracking for those on structured programmes.
f. Local evaluation - to support the wider local authority led lifestyle services re-procurement process. Including preferences and barriers to accessing
services from BME groups.
The CCG received £350,000 to support the delivery of the programme with the bulk of this funding supporting the delivery of the core intervention. To
deliver this intervention we have worked closely with two local third sector providers Gateway Family Services and Health Exchange, these organisations
are well established providers of lifestyle intervention support within Birmingham and the surrounding area.
The intervention was aligned to closely mirror the National
Programme specification; it is a 13 session programme that
runs for a period of 9-12 months. The first 6 sessions are
intensive weekly sessions with the final 7 sessions stretched
over the remainder of the 9-12 months to provide ongoing
support and reinforcement of the intervention messages.
The demonstrator programme plans to see 1,500 patients in
15/16; progress to date is strong with over 1,000 patients
referred for lifestyle intervention by the end of January 2016.
Providers are collected a range of data including:
•
•
•
•
•
•
•
•
Blood Pressure
Dietary change assessment tool
HbA1c (indicating average blood sugar levels over 3
months)
Other anthropometric measures (e.g., waist
circumference)
Weight/BMI
Perceived importance of and confidence in achieving healthy levels of activity and a healthy diet
Quality of life (EQ5D);
Self-reported physical activity (GPPAQ)
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Case finding has been led by Primary Care, GP Practices
have mailshotted patients on their High Risk of Diabetes
Registers (HbA1c of 42 – 47mmol/mol) who are between
18 years and 75 years and have a Body Mass Index (BMI)
of 25 or more – inviting them to attend the lifestyle
intervention. In addition GP practices have been
opportunistically referring patients to the providers as
and when they are identified.
First Wave Implementer
On behalf of Birmingham, Solihull and Sandwell CCGs
and Local Authorities, Birmingham South Central led on
an expression of interest to be a first wave implementer
of the National Diabetes Prevention Programme; we
received confirmation in December 2015 that we had
been successful. As a result we will form part of the
National Procurement process and following a local mini
competition will be able call off activity from one of
these providers. The cost of the intervention will be met
centrally however case finding is to be funded locally and
initially we plan to use the local authority commissioned
Health Checks to support this.
We are planning to be part of the second call off against
the procurement with the intervention and provider in
place by the start of June.
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4.6.4
Latent Tuberculosis Infection
Background
Tuberculosis (TB) is the leading cause of death from an infectious disease, with 1.5 million dying from TB every year(1). In May 2014 the World Health
Organisation approved a new post-2015 Global TB Strategy aiming to end the global TB epidemic, with targets to reduce TB deaths and new cases and
ensure that no family is burdened with catastrophic expenses due to the disease. The global strategy reinforced a focus on serving populations highly
vulnerable to infection and poor health care access, such as migrants. The Global Plan to End TB affirms that TB has always been associated with poverty
and has persisted throughout history because its roots are deeply intertwined with economic and social inequalities. The Global Plan suggests that the way
the disease is managed is a measure of a country’s commitment to social equality and health for all. There is a compelling economic case for ending TB; on
average, effective treatment may give an individual in the middle of his or her productive life about 20 additional years of life, resulting in substantial
economic and health returns.
The incidence of TB in England steadily increased from the 1980s to 2005 and has remained at relatively high levels ever since (>20/100,000 population).
England now has one of the highest TB rates in Western Europe and rates more than four times higher than in the United States. A high incidence of TB is
associated with significant morbidity, mortality and costs.
TB can be difficult to detect and late diagnosis is associated with poorer outcomes and a risk of transmission to the public. The majority of TB cases in
England are the result of ‘reactivation’ of latent tuberculosis infection (LTBI) an asymptomatic phase of TB which can last for years. LTBI can be diagnosed
by a single, validated blood test (interferon gamma release assay (IGRA)) and is usually treated with antibiotics.
In January 2015 Nation Health Service England (NHSE) and Public Health England (PHE) launched The Collaborative Tuberculosis Strategy (2015)(2) setting
out an approach to bring together best practice in clinical care, social support and public health with an aim to achieve a year-on-year decrease in the
incidence of TB and a reduction in health inequalities. The strategy advised the establishment of TB Control Boards to bring together key stakeholders to
plan, oversee, support and monitor all aspects of local TB control. The West Midlands TB Control Board was established in 2015 and includes
representation from local service providers, commissioners, GPs and PHE.
In 2015 NHSE invited bids from CCGs to support local delivery of the Collaborative TB Strategy. BSC, BCC and SWB CCGs successfully submitted a joint plan
for new migrant LTBI testing and treatment.
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Birmingham and Sandwell CCGs Joint Plans for Latent Tuberculosis Infection (LTBI) Screening
Local TB Epidemiology data indicated that there are a significant number of GP Practices across Birmingham and Sandwell with a higher than the national
average burden of TB disease; confirming the need for identification and prevention through the systematic implementation of LTBI screening.
CCG
TB Number average 201113
TB Rate average 2011-2013
per 100,000 population
% of England TB Numbers
SWB
240
50.5
3.05
BSC
78
39.1
0.99
BCC
208
28.1
2.64
TB Epidemiology of the CCG areas covered by the plan and evidence of need for LTBI testing and treatment
BSC, BCC and SWB CCGs successfully submitted a joint plan for funding to NHSE to support new migrant testing for LTBI screening in Birmingham and
Sandwell. In November 2015 NHSE confirmed funding allocations for a five month period covering November 2015 to March 2016. The joint CCG plans
propose implementation of the LTBI screening project through the adoption of an agreed Local Improvement Scheme (LIS) within primary care. The LIS
aims to ensure that processes are embedded within GP Practices for the systematic identification and screening of new entrants to the UK from countries
with a high TB incidence (>150/100,000 population).
The LTBI Screening project will be implemented in two phases: Phase 1 (commencing in April 2016) will involve initially identifying new eligible patients
when they register with a GP practice. Phase 2, will involve retrospective identification of patients already registered with a GP who meet the key eligibility
determinants and offering them the opportunity to be screened for LTBI. The project will include awareness-raising communications and materials for GPs,
practice staff and patients.
Target Population for LTBI Testing
Across BSC, BCC and SWB CCGs the LIS will determine that individuals who meet the eligibility criteria below will be prospectively offered LTBI screening as
they register with GP Practices.
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Where a new registrant meets the eligibility criteria a single IGRA test will be offered in primary care. A blood sample will be taken and sent to the
laboratory as per agreed pathway. If the new registrant has symptoms of active TB, immediate referral to TB services will be required.
Following successful implementation of LTBI new migrant screening, a retrospective data trawl of GP registers will be undertaken to identify eligible
patients who are already registered with a practice to offer them the opportunity for LTBI screening.
Project Outcomes
•
•
•
1.
2.
4.6.5
The number of GP Practices that have a systematic new entrant LTBI screening LIS in place
Proportion of eligible new entrants covered by LTBI screening and treatment programmes who accept the offer of LTBI testing
Proportion of individuals who complete LTBI treatment (of those who commenced treatment)
The Stop TB Partnership (2015) The Global Plan to End TB: The Paradigm Shift 2016-2020
The WHO: Global Strategy to End TB (2014) accessible http://www.who.int/tb/post2015_strategy/en/
Vaccine Preventable Admissions
We are aware from reviewing the Rightcare information and our own local QIPP Planning packs that vaccine preventable admissions are an area we should
plan to manage and improve.
Disease prevention is the key to maintaining public health. It is always better to prevent a disease than treat it. Vaccines prevent disease in the people who
receive them and protect those who come into contact with
unvaccinated individuals. Immunisation is therefore a proven tool for
controlling and eliminating life-threatening infectious diseases and is
estimated to avert between 2 and 3 million deaths each year.
Delivering a robust vaccination programme and helping to ensure
targets are met is one of the most cost-effective health investments,
with proven strategies that make it accessible to even the most hardto-reach and vulnerable populations. It has clearly defined target
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groups; it can be delivered effectively through outreach activities; and vaccination does not require any major lifestyle change (WHO, 2015).
In November 2015 the CCG developed a “Patient Promises” Local Improvement Scheme that included the facility for Practices to choose a vaccine and
immunisations uptake project:
The LIS extends until 31 December 2016 and we will be monitoring the action plans via our on-line reporting system that includes specific actions as
required and capturing evidence of new processes that have been developed and implemented as a result of the LIS.
4.6.6
Familial Hypercholesterolaemia
Familial hypercholesterolaemia (FH) is a genetic condition that causes high cholesterol and coronary heart disease, often resulting in premature coronary
heart disease (CHD) myocardial infarction (MI) and reduced life expectancy. FH is a relatively common genetic disorder, estimated to affect 120,000
individuals in Britain, but is under diagnosed with only 15-17% of cases identified in the UK. Unlike many genetic conditions, FH can be diagnosed relatively
easily and, with inexpensive treatment, people with FH can lead normal, healthy lives.
The British Heart Foundation has agreed to provide over £1m of funding nationally to support the employment of specialist FH nurses or other key staff.
The West Midlands Strategic Clinical Network, in collaboration with clinical colleagues, including BSC CCG, was successful in securing £375,000.00 from
British Heart Foundation to support the introduction of a West Midlands regional FH service. The funding will cover the cost of 5 specialist FH nurses for a
period of 18 months. In addition, patients who meet the referral criteria as being at risk of FH will require genetic screening and family cascade testing.
BSC CCG is supporting the model of care and providing a proportion of funding to the cost of specialist FH nurses. In addition the CCG is funding genetic
and cascade testing to support the model of care.
4.6.7
Healthy workplaces
Birmingham South Central CCG has always held the belief that Staff wellbeing is central to great organisational performance. From the point of deciding to
develop the CCG this has been a key factor in our culture, our beliefs and our values.
We have a BSC Wellbeing Strategy explains our ongoing plans to ensure that our CCG is a great place to work; a workplace that provides an environment
that is safe, supportive and innovative to help us create ways to improve quality and patient experience.
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The new NICE Guidance, ‘Workplace Policy and Management Practices to Improve the Health and Wellbeing of Employees’, June 2015, supports the BSC
view that the physical and mental health of employees is of critically importance and it states the expectation that leaders ensure that the organisational
culture not only reflects this as a key priority but encourages continuous opportunities for health improvements for its staff groups.
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4.7
Cancer
The report of the Independent Cancer Taskforce - ACHIEVING WORLD-CLASS CANCER OUTCOMES A STRATEGY FOR ENGLAND 2015-2020 sets out over the
next five years, how the NHS can improve radically the outcomes that the NHS delivers for people affected by cancer. The report proposes a strategy for
achieving this. It includes a series of initiatives across the patient pathway. These emphasise the importance of earlier diagnosis and of living with and
beyond cancer in delivering outcomes that matter to patients. The report recognises that no two patients are the same, either in their cancer or their health
and care needs. At its heart, it sets out a vision for what cancer patients should expect from the health service: effective prevention (so that people do not
get cancer at all if possible); prompt and accurate diagnosis; informed choice and convenient care; access to the best effective treatments with minimal side
effects; always knowing what is going on and why; holistic support; and the best possible quality of life, including at the end of life.
The strategy seeks also to harness the energy of patients and communities and encompass their responsibilities to the health service. This means taking
personal ownership for preventing illness and managing health; getting involved in the design and optimisation of services; and providing knowledge as
experts through experience.
Section 3.6 sets out in more detail how we plan to respond to delivering standards for cancer care and support patients and outcomes further.
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4.8
Seven Day Services
The 7 day services work stream is one of the work streams within the Birmingham Better Care Fund programme which reports to the Birmingham Health
and Wellbeing Board.
In 2015/16 all provider trust contracts included a service development improvement plan which collated the baseline assessment and gap analysis and
actions required to ensure compliance against the 10 national standards. This work has informed the 2016/17 SDIPs within provider contracts to ensure
delivery of the 2016/17 requirements to ensure that as a minimum 25% of the England population has access to the following 4 standards 7 days a week by
March 2017 with 100% coverage by March 2020:




Access to consultant review within 14 hours
Access to diagnostics
Access to consultant interventions
On-going review by a senior clinician
Access to a consultant review within 14 hours
The baseline assessments undertaken by providers during 2015/16 indicate that more than 25% of patients have access to a consultant review within 14
hours across 7 days but there are gaps at the weekend dependent upon time of admission, 2016/17 SDIP across all providers will target:
All patients to have ‘National/Paediatric Early Warning Score’ (NEWS/PEWS) established at the time of admission from April 2016
Consultant involvement for all patients considered ‘high risk’ from April 2016
Workforce modelling including job planning/ rota’s/scheduling across day/night and weekends by Quarter 2.
Workforce and system process changes required to deliver 100% compliance by 2020 by Quarter 3.
Access to Diagnostics
The baseline assessments undertaken by providers during 2015/16 indicates that more than 25% of patients have access to diagnostics over 7 days but
again there are gaps at the weekend dependent upon time of admission/attendance. The 2016/17 SDIP across all providers will target:
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




Demand and capacity review of diagnostics over 7 days in line with the findings of the Birmingham & Solihull Diagnostics Rapid Review and agreed
action plan for 2016/17 (Quarter 1).
Provider engagement in the development of a Diagnostics plan as part of the Sustainability and Transformation Plan for Birmingham & Solihull to be
submitted by June 2016. (Quarter 1).
Implementation of agreed actions for 2016/17 (Quarter 2, 3 and 4)
Development of detailed action plan for 2017/18 (Quarter 2)
Additional capacity (based on demand projections) requirements for each year up to 2020 to be defined and agreed by Quarter 3.
Access to consultant interventions
The baseline assessments undertaken by providers during 2015/16 indicates that more than 25% of patients have access to consultant interventions over 7
days but again there are gaps at the weekend with access to urgent non trauma urgent surgery and the delivery of a consistent 7 day emergency access
model. The 2016/17 SDIP across all providers will target:





Increasing emergency surgical lists carried out a weekends. Plan to be agreed by the end of Quarter 1 and implementation by Quarter 2.
Use of the CUR tool within the inpatient setting to aid clinical decision making around consultant interventions by the end of Quarter 1.
Workforce modelling including job planning/ rota’s/scheduling across day/night and weekends by Quarter 2.
Summary report required to identify, through CUR, the resource gap in consultant interventions to inform the action plan for reviewing consultant
resources by the end of Quarter 2 (dependent upon CUR roll out plan).
Option appraisal on proposed consultant resource solutions (including sharing resources across provider networks) to reach 100% compliance by
the end of Quarter 3.
On-going review by a senior clinician
The baseline assessments undertaken by providers during 2015/16 indicates that more than 25% of patients have access to an on-going review by a senior
clinician over 7 days but again there is variability across wards/specialties across 7 days. The 2016/17 SDIP across all providers will target:


Use of the CUR tool within the inpatient setting to aid clinical decision making around consultant interventions by the end of Quarter 1.
Workforce modelling including job planning/ rota’s/scheduling across day/night and weekends by Quarter 2.
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

Summary report required to identify, through CUR, the resource gap in senior clinician review to inform the action plan for senior clinician review
resource by the end of Quarter 2 (dependent upon CUR roll out plan).
Option appraisal on proposed senior clinician review solutions (including sharing resources across provider networks) to reach 100% compliance by
the end of Quarter 3.
Continued progress against the other 6 standards
Mental Health: A 7 day a week 24 hour service is commissioned for 2016/17 through Forward Thinking Birmingham CAMHs ERA/Home treatment teams
and B&SMHFT’s Raid and Psychiatric Decision Unit services.
Patient Experience: Is measured through all existing contract routes through the Family and Friends Test and specific patient experience key performance
indicators and monitored through information requirements.
Multi-Disciplinary Team Review: Improvement plans will be agreed within individual providers.
Shift Handovers: A number of providers have already implemented electronic handover tools, where providers have not invested into an electronic
handover system this will be a required improvement for 2016/17.
Quality Improvement: In 2016/17 providers will need to deliver and maintain the actions detailed within improvement plans, remedial action plans,
CQUIN’s and KPI’s in relation to urgent care patient flow. Quality improvements required over and above these work programmes will be included as part
of the 2016/17 CQUIN’s to address local quality issues specific to each trust.
Transfer to community/primary/social care: In 2016/17 the key SDIP requirements are:





The implementation of the CUR tool as a key enabler to identifying bottlenecks in the system where patients discharge is delayed, by the end of
Quarter 1/2.
Sharing of best practice when reviewing the utilisation of social care assessments within the acute and community settings across Birmingham and
Solihull.
Submit changes to service provision across 7 days to WMAS for update on the DOS
Expand the CMAU (Community Medical Assessment Unit) to 7 days from 5 days from April 2016 (BCHC)
Acute/Community providers to submit monthly information on reasons for delayed discharges/delayed transfer of care
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
A commitment to review the ‘shared assessment’ model across Health and Social Care
As indicated under the ensuring “95% of patients are accessing A&E within 4 hours section” this demonstrates that only 20% of patients are discharged on
weekend compared to 80% on a weekday.
Baseline assessments carried out across a range of community services show that the core services to enable patient flow: community, nursing home, social
care and primary care services are available over 7 days. The Sustainability and Transformation Plans will review the demand and capacity across each
sector and will outline the system approach to addressing the balance of acute discharges across 7 days through the transformation of primary care and
community care.
The national planning expectations for 2016/17 for 7 day services will be met in full by BSC through:



Delivering access to the 4 key 7 day services standards for 25% of the CCG’s population
Increasing access to primary care appointments across 7 days (see Primary Care)
Procurement of an integrated NHS111 and GP Out of Hours service (see Urgent Care)
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4.9
Mental Health
Section 3.7 explained our approach to the new mental health standards and dementia diagnosis, this section further develops our mental health
commissioning priorities and plans.
New Dawn Commissioning Statement Adult (25 plus) Services
This commissioning statement sets out the intentions of commissioners in respect of planned changes to adult mental health services for those service
users who are aged 25 years and over that are being implemented through Birmingham and Solihull Mental Health Foundation Trust’s New Dawn
Programme.
What did commissioners set out to achieve?
Birmingham South Central CCG believes strongly in the importance that good mental health and wellbeing has in peoples’ lives. We know that this view is
shared by our members, staff across health and social care and the public at large.
Where people have poor mental health their physical health can suffer too. Social factors, like poverty and poor housing, can damage peoples’ mental
health. Conversely, people with poor mental health can find themselves worse off as a result. The CCG is committed not only to improving the way in which
peoples’ mental health needs are supported within the NHS but also to working with stakeholders across the local authority and Third Sector to help
promote good mental health.
In spite of the financial pressures on the NHS and wider public sector, commissioners remain focused on improving the experience of, and outcomes for,
people who need the support of mental health services to lead fulfilling lives.
The aspirations of commissioners are set out below:
-
A better experience of support and treatment for people who use services and their carers
A reduction in the stigma associated with mental health issues and accessing mental health services
People are supported as close to home as possible and are admitted to and remain in in-patient beds only when it is absolutely necessary
Services work collaboratively with the people who use them and involve them and their carers to the greatest extent possible.
Achieving recovery and minimising the impact of illness on people is the central focus of services. This also means supporting people to achieve
social not just clinical outcomes.
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-
The physical health needs of people with mental health issues are treated with equal importance
Approach to achieving this change
Change is most effective where it is owned by the people who it affects most and those who will be making the changes. With this in mind commissioners
wanted the aims to be achieved through a process of dialogue and collaboration with Birmingham and Solihull Mental Health Foundation Trust, people with
experience of mental health issues and wider partners like the 3rd Sector and Local Authority.
Primary care mental health and wellbeing developments
Investment into primary care mental health has been paltry over the last few decades. In south Birmingham we have a vision for the development of a
matrix of triaged ageless wellbeing services, linking existing statutory and voluntary agencies together with community resources and volunteers in order to
facilitate the development of increasing resilience in individuals and communities, and to maximise the available skill and resources in a time of public
spending cutbacks. IAPT and non-IAPT services for mild moderate and severe mental health conditions should be linked with coordinated social prescribing
with more focussed psychological support (in primary and secondary care)for people who have suffered psychological trauma. This should be part of an
overall prevention strategy which takes into account the population burden of adverse childhood experiences which can lead to the consumption of greater
health care resources, earlier co-morbidities , and reduce the productivity and ability to thrive and contribute. Achieving these ends will require
considerable cooperation and co-funding between various organisations, and the support and leadership of the clinical commissioning process.
Secondary care developments
‘New Dawn’ is the name given to the programme of work that has been undertaken to develop, plan and implementation changes to achieve these aims
within specialist mental health services, and in the interface between primary and secondary care . What changes will be made to achieve the aims?
The New Dawn Programme will make a number of changes to the way that services are delivered to achieve the aims:
Putting the person at the centre
- Service users will develop recovery and crisis plans with their care coordinator based on their own needs, requirements and preferences
- Crisis assessments will take place in the setting of choice
Access
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-
Assessment within 1 hour when people access A&E/RAID
Assessment within 4 hours for people in CDU and MDU settings
2 weeks from referral to treatment for people with a first episode of psychosis
Faster access to treatment for psychological therapies
Recovery hubs accessible 7 days a week
Direct access to psychology from primary care rather than via CMHT
Pathways
- Proactive discharge planning and access to recovery hubs, home treatment and respite to reduce length of stay
- Transitions to adult services at age 25 rather than age 18
- Integrated hubs enable people to get specialist support whilst benefitting from a full MDT approach
- A menu of options for integrated community mental health care
Workforce
- First line assessments are undertaken by the most experienced clinical staff
- Introduction of peer workers
- Integrated discharge facilitators
- 7 day working
- Wards overseen by a single dedicated consultant
- More Advanced Nurse Prescribers in primary care
Partnership
- Extension of liaison with care homes
- More services provided in primary care and more shared care arrangements
- More collaborative working with the 3rd Sector
New Dawn is an ambitious programme of change that will be developed and delivered over an 18 month timeframe commencing April 2016.
Commissioners, representing CCGs, will continue to work alongside BSMHFT to firstly assure the management of change process and also ensure that the
aspirations are delivered to improve outcomes for service users.
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Crisis Care Concordat
The Concordat describes a multi-agency approach to ensuring a system response to crisis is managed within the framework of the Crisis Care Concordat.
On behalf of the CCG the joint commissioning team commissions a range of responsive services for crisis in mental health, and dementia, in conjunction
with urgent care colleagues. These incorporate Street Triage, RAID, Place of Safety, and the 24/7 Psychiatric Decision Unit (PDU), as well as the urgent same
day response from Home Treatment.
The CCG aims to consolidate the proven successes within this urgent care pathway by securing longer term commissioning arrangements and working with
BSMHFT around newer services such as the PDU which requires continued evaluation. We were instrumental in initiating the mental health pilot of
embedded psychiatric nurses for 111 and will support urgent care colleagues in future modelling and specification to build upon this.
However, the Care Concordat is not just intended as a reactionary vehicle and should encompass preventative approaches. The CCG intends to develop
thinking around non clinical crisis support, ensure that people from BME groups can access support and services at the earliest points possible, and work
with BSMHFT to improve the response and culture of approach for people with Personality Disorder.
Mental Health Access Standards
The revision of mental health services in Birmingham includes the establishment of a ground breaking 0 to 25 service to address challenges in transition and
the development of a new model for the over 25’s. As part of this development, access standards for people experiencing a first episode of psychosis and
eating disorders will be fully implemented.
Children and Young Peoples CAMHS Transformation Plan
Children and Young Peoples CAMHS Transformation Plan – Birmingham has put in place an assured transformation plan in collaboration with service
users/parents and the Local Authority which builds on our innovative 0 to 25 Children and Young Adults Mental Health Service being provided by Forward
Thinking Birmingham (FTB). This new service builds on existing provision which includes a dedicated home treatment service which has shown major
reductions in under 18 inpatient activity, alongside a place of safety (currently up to 16 but will be 18) and complements recommendations of the national
taskforce report published in March 2015 - Future in Mind. The new service becomes fully operational from the 1st April 2016. During its first year of
operation it will be extensively evaluated by independent researchers to review the implementation and service delivery that will provide an opportunity to
learn lessons as well as to improve the service in future years. The Transformation Plan itself is overseen by the multi-stakeholder Transformation Board
which will monitor its delivery including ensuring the resources allocated are appropriately and fully used on delivering the transformation of CAMHS
services in Birmingham. The outcomes of the plan are to:
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
Reduce demand on specialist mental health provision through increasing preventative interventions

Develop perinatal mental health services that support mothers pre-birth and after including those who would be deemed as ‘worried well’ who
would not otherwise receive any support
Develop a community based eating disorder service that is aligned to the guidance issued in August 2015


FTB are part of wave 3 of the Oxford and Reading Learning Collaborative for CYPIAPT. They are committed to the principles and delivery of CYP
IAPT. Routine monitoring has become embedded in the approach for those who have undergone the training. Birmingham is planning to invest in
more staff to access additional curriculum and improve coordination of services across the whole pathway.

Our CAMHS Transformation plan recognises the challenges to workforce across the system and has a range of actioned aimed at building capacity
and capability in this area.
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4.10 Extra GPs
BSC’s approach to supporting primary care sustainability, developing the GP workforce and creating extra GPs is outlined throughout this document. In
particular, section 3.3 sets out how we will support sustainability and quality of general practice. Specifically in section 3.4.3 we describe how we are
supporting the development of a local primary care workforce strategy.
In section 4.3 we have identified our programme supporting new models of care and in particular section 4.3.2 details our programme to support provider
development within primary care through the creation of a GP Federation. This will have significant role in supporting sustainability and developing the
primary care work force of the future.
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5
Governance
5.1
BSC Governance Structure/Board and Committees
An effective and robust governance structure is critical to BSC and provides a system of oversight and assurance to the Governing Body on delivery of the
CCGs statutory duties and responsibilities. The CCG is currently in the process of reviewing the structure and process; this is due to be completed by March
2016.
All the committees of the Governing Body have varying degrees of delegated
authority from the Governing Body and all are chaired by a Governing Body
member as well as having representatives from across Networks.
Audit Committee – The Committee provides the Governing Body with an
independent and objective review on its financial systems, financial
information and compliance with laws, guidance and regulations governing
the NHS. The Committee assure the Governing Body that the CCGs systems
of internal control are robust.
Remuneration Committee – The purpose of this Committee is to advise the
Governing Body in all matters relating to remuneration and employment
terms for the CCG.
Quality and Safety Committee– The primary function of this Committee is to
monitor all aspects of quality and ensure that all commissioned services are
being delivered in a high quality and safe manner. The Committee provides
reports and assurance to the Governing Body.
Fit For Purpose Committee – The main function of this Committee is to oversee all aspects of organisational development, including workforce
development, aspects of primary care development as well as overseeing the risk management and board assurance framework and communication and
engagement.
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Finance and Performance Committee – The primary function of this Committee is to monitor all aspects of finance and performance delivery ensuring that
BSC achieves financial balance and delivers against key performance targets.
Commissioning Programme Board – The primary function of this Committee is to oversee the development and delivery of the commissioning programmes
as set out in the operational plan and delivery plan.
Primary Care Committee – The primary function of this Committee is to carry out functions relating to the commissioning of primary medical services,
including GMS, PMS and APMS contracts and associated services. The Primary Care Committee is a decision making body in respect of primary medical
services.
Stakeholder Council – The Stakeholder Council is a citizen led council within BSC, tasked with strengthening the relationship between commissioner and
community. We want to put people and patients at the heart of every decision we make. The Stakeholder Council helps to ensure this.
Member Council – The Member Council is established to represent members’ interests and hold the Governing Body to account for the performance of the
CCG, including ensuring that the Governing Body acts so that the CCG delivers on its statutory functions and agreed bespoke measurements that support
overall organisational development. The Members Council work with the Governing Body to develop and agree the long term vision and strategic plans of
the CCG and act as a critical friend and guardian of the CCGs values.
Each practice nominates a named individual to represent their practice on the Member Council. The role of a Practice Representative is to represent their
practice’s views and act on behalf of the practice in matters relating to the CCG.
5.1.1
Gateway Process
BSC has a well-established approvals gateway process, the gateway process seeks to prioritise, validate, and assure viability of commissioning and service
development initiatives, and to assess quality impact prior to approval and entry into the delivery programme. As a result of the review the key change to
the existing gateway process was the introduction of an initial sense check at the early stages of commissioning proposal development.
The revised gateway process provides a one-stop resource for project initiators and those working on business cases to have a standard format and links to
relevant local/national guidance and documentation. It also provides a standardised process ensuring good governance and an equitable process as it
enables consistent, evidence-based decision making with open and transparent criteria at each stage. The process is clinically led with networks and the
proposed sense check group (Network and Clinical Leads Group) having decision-making roles at key stages.
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The revised process ensures resources (both financial and human) are targeted at working up and implementing ideas which help deliver CCG priorities and
are most likely to succeed.
BSC Gateway Process
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5.1.2
Managing Conflicts of Interest
The CCG has structures, processes and checks in place to ensure that it is aware of potential or actual conflicts of interest and that they are managed
correctly and appropriately. During 2015/16 the CCG was criticised and questioned on how it had managed potential conflicts of interest in relation to a
primary care provider organisation. The CCG investigated this complaint as part of an overarching review of all governance systems and processes. This
investigation showed that the conflicts had been managed but improvements in how we do this and how it is recorded were identified and implemented. A
recent Internal Audit review provided significant assurance on our arrangements for managing COI within Primary Care, the majority of which apply across
all providers and work areas.
Arrangements include:
Identifying and including key risks relating to conflicts of interest are included in our risk register and Assurance Framework




Maintaining a publicly available register of interests
Maintaining a publicly available register of procurement decisions which includes details of conflicts of interest and how they are managed.
Having a clear process for dispute resolution and for managing ongoing conflicts of interest
Ensuring Governing Body members and staff are trained and actively following all policies and procedures relating to the identification and
management of conflicts of interest.
5.2
Sustainability and Transformation Plans Governance Framework
Partnership Context and Ambition
As stated in section 3.1, the requirement to produce a STP forms part of the planning guidance for the NHS in 2016/17, a draft governance framework is
under consideration, this will need to be ratified by the BSC Governing Body.
There is already a commitment between partners that this is an opportunity to achieve a number of ambitions which support the NHS, Local Government
and wider business and education agendas, namely to:


completely change the way health and social care at all levels is delivered
place a focus on prevention and influencing the determinants of health at front centre rather than just managing the consequences
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





place a focus on communities and their resilience with the state’s first offer being support not services
create a partnership which works together and is an entity that is greater than the individual parts (need to review current partnerships)
use available data and intelligence from all partners and central support to inform the place problems and solutions including economic data
establish effective metrics of success for our ambitions and measure them consistently and collectively
put in place ‘place wide’ strategies and plans for key enablers – workforce, IT, estates, enabling technologies
demonstrate value for money and bring transformation monies into the system (business support, philanthropic, NHS)
Partners
The partnership initially includes:













Birmingham City Council
Solihull Metropolitan Borough Council
Birmingham Cross City CCG
Birmingham South Central CCG
Solihull CCG
Birmingham Children’s Hospital Foundation Trust
Birmingham Community Healthcare Trust
Birmingham and Solihull Mental Health Foundation Trust
Heart of England Foundation Trust
Royal Orthopaedic Hospital Foundation Trust
University Hospitals Birmingham Foundation Trust
Women’s Hospital Foundation Trust
Primary care representatives
Associate Members:


Sandwell and West Birmingham CCG
Sandwell and West Birmingham Hospitals Trust
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However, given the scale of the ambition it is recognised that other members are likely to be co-opted as the plan development progresses.
The status of associate membership is in a non-voting capacity to support the parties in developing and implementing the STP, where there are impacts for
associate member’s patients/populations.
Collective challenges
The following collective challenges have been identified in early stages of working together. We need to:






Align organisational visions
Develop a partnership which works collectively for our citizens, where the entity is greater than the sum of its individual parts
Create and implement ‘place based’ strategies and plans including key enablers – workforce, IT, estates, technology
Use available data and intelligence from all partners and central support to inform the scale of our ‘gap’
Establish effective metrics of success for our ambitions and measure them consistently and collectively
Demonstrate value for money and bring transformation monies into the system (business support, philanthropic, NHS)
System Leader
Central policy guidance from NHS England identifies that a single individual should be identified ‘who will be responsible for overseeing and co-ordinating
the STP process.’ This individual must be able to ‘command the trust and confidence of the system’ and can come from any background – provider,
commissioner or local authority. A process to identify this leader needs to be agreed by partners and completed by 11th April 2016.
5.2.1
Draft Governance Framework
Overview
We are committed to work collaboratively to improve the health and wellbeing of all our citizens and developing a sustainable health and care system for
both Birmingham and Solihull.
We will work with the public, provider and commissioning partners within the Local Authority boundaries on the development of our Sustainability and
Transformation Plan which will identify the gap within the system triple aims and a describe how to close that gap .
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We have agreed governance arrangements under the leadership of
Mark Rogers, Birmingham City Council CEO, which reflect an inclusive
leadership approach headed by a Chair and Leaders Group.
Health and Wellbeing
Boards
This group and the System Board will own the plan and commit our
organisation to delivering our identified and agreed contribution.
Partnership Governing
Bodies
Leaders and Chairs Group
Members: Local authority political
leads & provider & commissioner
chairs
BSol System Board
Members: Independent chair, system
leader, chief executives, or accountable
officers from local authority,
commissioners and providers
STP / STP Plus Programme Board
Members: Programme director and
representatives from relevant levels
within organisations
STP
Triple aims:
wellbeing,
quality,
finance &
sustainability
 Enablers
a) Workforce
b) IT & Data
c) Estates
 Work related to
transforming
healthcare at STP
level
 Tackling health
inequalities

a)
b)
c)
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STP Delivery Group
Members: PMO, Work stream groups


Clinical and Citizen Reference Groups
and the Third Sector

STP Plus
Birmingham’s
commitment to
building a more
functional system
Exploring wider
transformation
opportunities
Work streams relating
to wider aims; tackling
poverty and inequality,
productivity and
transforming
healthcare (to be
developed further)
6
Business Development, Planning and Resilience
6.1
Clinical Leadership
BSC is a clinically led organisation with a third of its management costs invested in clinical leadership. The Governing Body has a majority of front line
practitioners and all committees are chaired by clinical leads with the exception of finance and audit committees which are chaired by Governing Body lay
members. The development and delivery of the Operational Plan is overseen by the Commissioning Programme Board and a RAG rated report is provided
to the Governing Body for assurance each month. The financial plan development and delivery is overseen by the Finance and Performance Committee and
a finance and performance report provided to the Governing Body for assurance monthly. The Fitness for Purpose committee oversees the development of
the CCG's capacity and capability to deliver the operational plan and the development and delivery of the CCG business plan. A RAG rated report is provided
to the Governing Body for assurance each month.
Each work stream within the operational plan is led by a clinician. The clinical lead roles are being reconfigured to match the CCG priorities for the period of
the plan including mental health, maternity care, children and young people, long term conditions management. Quality priorities include primary care
quality development, Safeguarding adults and children and provider quality assurance for the Trusts for whom we are lead commissioner; Birmingham
Children's Hospital FT, Birmingham Women's Hospital FT and Birmingham Community Health Care NHS Trust.
BSC is formed of 5 clinical networks each with an elected clinical lead who sits on the Governing Body of the CCG. The networks ensure each practice is
involved in the development and delivery of the plan and that the front line primary care clinical perspective both informs the development and are
reflected in the delivery of the plan.
BSC also has a Members Council with a representative of each practice which ensures member engagement and ownership of the plan, and holds the
governing body to account for delivery. The Members Council are developing local member generated metrics for measuring CCG performance against
plan.
BSC has a Talent Management Strategy that includes developing our clinical leaders, spotting and supporting new talent and succession planning.
A review was carried out in 2015 that has provided further opportunities for us to enhance CCG development and support for clinical leaders.
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6.2
Business Plan
The BSC Business Plan is written to plan for and ensure that we have the capacity and capability to meet all of our ambitions, objectives and targets within
the Operational Plan. It is written with staff and clinical leaders and is monitored quarterly through the Governing Body.
6.3
Business Resilience
BSC has a Business Resilience Plan that is seen as best practice by the Area Team. It is closely monitored by our Governance Team to ensure it remains true
to current risks and is regularly monitored to ensure it is fit for purpose.
6.4
Organisational Development
Organisational development continues to have a key role in the success of the CCG so far and remains a hugely important focus. Our OD activity is based on
the ambitions of BSC as reflected in our Business Plan. We have a Talent Management Strategy that was developed with our staff team and portrays our
intentions to develop individuals and to succession planning to ensure we have the capacity and capability to meet our future challenges. We also work
very closely with Health Education West midlands as a leading CCG in the field of organisational development. Our model of collaborative leadership
underpins all of our OD work.
6.5
Corporate Social Responsibility
BSC CCG continues to meet its corporate social responsibility (CSR)
through a variety of projects and linkages to its local community and
environment. We believe that the NHS is well placed to influence and
unlock local resources to ensure benefit for the social, economic, and
environmental wellbeing of our citizens.
We will continue our partnership with:
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The Freedom Project, which provides awareness, empowerment and creative projects for women who have been the victims of domestic violence.
Local food banks through the Northfield Town Centre Partnership, benefiting people across the city.
The Bethel Doula Service which provides emotional support to vulnerable, isolated and asylum seeking women in Birmingham who are pregnant.
We are working with Thrive to develop an engagement project for people with learning disabilities, which will include structured work experience and work
shadowing within the CCG. We have also established a regular advice and sales stall within our offices.
We will continue to hold regular fund-raising activities for local charities.
In 2015 we agreed to support staff who wish to undertake voluntary work on a regular basis for local community projects and charities. In 2016 we will
work to further develop the range of roles taken on by our staff through volunteering and to encourage mutual skills development. We have committed to
release colleagues for volunteering for half a day every month.
Apprentices
The national apprenticeships scheme helps us employ more local young people to learn on the job and gain qualifications. We purposely focused on people
from within our operating area as we felt it was important to demonstrate that we want to be a community CCG and aim to offer development
opportunities to local people wherever possible.
In December 2014 we recruited a Creative & Digital Media Apprentice through Bournville College who works within the partnerships function for duration
of 18 months.
In September 2014 we recruited a Business Administration Apprentice through Bournville College who works within the partnerships function and supports
our Admin and Quality teams for duration of 14 months.
In 2016 we are seeking to create a number of student placements that can support the project work of the Citizens Group and our wider engagement.
These placements are being developed through active partnerships with University of Birmingham, Aston University and Newman University.
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Regional NHS Graduate Management Training Scheme
We are now in the fourth year of supporting the NHS Graduate Management Training Scheme by providing placements to second year students. The first
three graduate students have moved on successfully to employment within the NHS and the fourth person is currently working with us. We aim to continue
to attract more graduates from the Birmingham area to help improve the healthcare services offered to the local community.
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