Bracknell & Ascot
Strategic plan
2014/15 – 2015/16
BACCG QIPP Triangle
Programme One: Prevention and self care
The focus will be on prevention in line with
the priorities in the JSNA(s) and Supported
Self-management for people with long terms
conditions such as COPD, diabetes and
dementia following diagnosis and
throughout the course of their condition.
Targeted and evidence based programme
with an emphasis on reducing NELs and A&E
attendances
Current year enabling projects
• 2013/14 Additional resource for joint
work with Local Authorities for delivering
Call to Action and self-care priorities
2014/15 enabling projects
• Establish the preferred methods of
communication for local people
• Alignment with primary care vision
• How technology would support
2014/15 Investment through a joint
integrated plan with partners
Intended projects 2014/15 include:
• Smoking cessation prior to elective
surgery
• Reduction of years lost through
identifying opportunities to target specific
groups of patient from benchmarking
national indicators
• Healthy Lifestyle education clinics in
primary care as part of whole system
programme
• Talking Health programme
• Signposting to services and support
• Extensive campaign to promote
appropriate use of new UCC and
education centre
Programme One: Prevention and self care
Theme
13/14 enabling
projects utilising 2%
non recurring funds
14/15 QIPP projects
15/16 vision
Self Care
Awareness campaigns:
• Keep Calm
• Self care week
• Innovations projects
•
Targeted joint campaign
to deliver JHWS
priorities
Sign posting and
Education on the use of
UCC, including young
people
•
Supported
selfmanagement
Review existing services:
• Expert patient
programme/Talking
Health
• Purchase healthy
lifestyle tools (Pufell)
•
Extended coverage and
integration of self
management, reviewed
support pathways for
COPD, Diabetes and
Dementia
•
All people diagnosed
with a long term
conditions are
enabled to selfmanage
Prevention
and health
improvement
•
•
•
•
•
New falls pathway
Targeted campaigns
Smoking cessation for
surgical patients
•
Risks that local people
face are identified and
mitigated
•
Flu campaign
Increase capacity at
falls clinic
Condition specific
campaigns i.e. male
cancers/heart disease
•
•
Reduced years of life
lost
Children and Young
People support,
specifically reducing
obesity levels
Programme Two: Long Term Conditions
This programme will achieve the a QIPP
target of 66 (per 1,000 population) for
unplanned admissions with a view to
reducing to 64 in 15/16.
Current year enabling projects:
• Long Term Conditions: resources
required £40k recurring funds
2014/15 to ensure delivery of
benefits
• Review of COPD pathway to establish
equity of access and outcomes
• Review of Diabetes pathway to
establish high quality services across
primary care
• Delivering the joint Dementia
Strategy including increasing
diagnosis rates
• Cancer opportunity being scoped by
clinical lead for screening and
improve Breast Cancer pathway
Intended projects 2014/16:
• Investment in community Mental
Health: including medically
unexplained symptoms service
• Implementation of the Better
Care Fund vision, agreed with
our partners, with supporting
programme of work
• Sustainable and effective
Integrated Care Teams as part of
Better Care Fund and building on
evidence and experience to grow
caseloads
• Review of IT requirements to
further integration of key medical
information
Programme Two: Long Term Conditions
Theme
13/14 enabling
projects utilising 2%
14/15 QIPP projects
Mental health • Review existing
• Talking Health
gaps in services i.e. • Dementia
CAMHs
• Reviewing liaison
psychiatry
provision
15/16 vision
• Effective community
based services
available to all
Diabetes
• Review foot health • Education project • Best practice
provision
• Review of pathway
pathways for all
• Elimination of
unnecessary
diabetes related
admissions
COPD
• Review existing
pathways and
identify gaps
• Equitable
pathways
commissioned
from best practice
sites
• Reducing inhaler
waste
• Reduction of
unplanned
respiratory related
admissions
Programme Two: Urgent Care
This programme will support the QIPP for
unplanned admissions, provide
appropriate urgent services for our
population and to manage the increasing
pressures on accident and emergency
services.
Current year enabling projects
• Urgent Care Centre: resources
required £40k recurring funds 2014/15
to ensure delivery of benefits
• Scoping of pathways during 2013/14:
– End of Life care planning
– Develop the primary care discharge
decision tree
– Reducing variation in primary care in
NEL and A&E activity with project
support to general practice
– Winter pressures projects including 7
day in-reach nursing to Frimley Park
Intended projects 2014/16:
• Deliver the primary care led Bracknell
urgent care centre and drive out
business case benefits
• Integrated frail elderly pathway, with
‘real time’ information across agencies,
support through patient journey around
Frimley system
• Falls Clinic capacity, then redesign local
pathway to incorporate prevention and
adequate capacity, and aspire to local
RACC model
• Expand Integrated Care Teams and work
with clinicians to achieve more effective
patient outcomes
• Cellulitis pathway linking to Urgent Care
• Nursing and residential homes project
delivered jointly with UA
Programme Two: Urgent Care
Theme
13/14 enabling projects
utilising 2%
14/15 QIPP projects
15/16 vision
Bracknell UCC
•
Completion of
procurement and
mobilisation
•
Successful
implementation of
the new service for
April 2014
•
Realisation of full
UCC benefits
Integrated frail
elderly pathway
•
Pathway and best practice
review and gap analysis
Clear falls clinic backlog
•
Integrated pathway
as part of BCF,
including falls
prevention
•
Fully integrated
services
incorporating new
Bridgewell and UCC
Social worker and mental
health input to ICTs
Introduce secondary care
clinicians into ICTs
Review the pilots around
sharing essential patient
information to improve
outcomes
•
Support to practices
for case
identification
Sustainable cluster
teams that meet
identified needs
Review IT needs
•
All people with
complex needs
anticipated and
supported by ICTs
•
Integrated care
teams
•
•
•
•
•
Programme Three: Recovering from Ill Health
This programme includes projects in
planned care pathways/services which will
maintain the 115 (per 1,000 population) GP
referral target, and benchmarked levels of
elective care whilst commissioning services
closer to home. Current year enabling
projects:
• Scoping and benchmarking of
Gastroenterology pathways
• ENT extended scope in the community
• Community Cardiology service closer to
the patients and acute FPH services
• Reduce variation in the use of Pathology
and Radiology
• Scoping neuro-rehab pathway
• Generic rehabilitation pathway scoping
linking the stoke reablement
Intended projects 2014/16:
• Dermatology commissioning
including low risk BCCs in the
community
• Implementation of MSk service and
the new community physiotherapy
service
• Ophthalmology pathway review with
FPH system
• Addressing clinical variation via
Performance review group – Referral
Management, medicines
management, pathology etc.
• Tongue Ties provision into primary
care minor operations service with
Area Team
• Smoking cessation service prior to
surgery
• Limiting access to Procedures of
Limited Clinical Value
Programme Three: Recovering from Ill Health
Theme
13/14 enabling
projects utilising 2%
14/15 QIPP projects
MSk and direct • Procurement of new • Service
access
service
implementation in
physiotherapy
Qtr. 1 2014/15
• Improved outcomes
for physio patients
Clinical
variation in
referrals
• PRG escalation
• Additional support to
framework
practices to identify
• Tier two refresh
and reduce variation
through referral
• Include secondary
management
care conversion rate
• Review local strategy
comparison
on C&B/e-referrals
Benchmarked
variation in
elective
procedures
• Opportunity locator
analysis
• Work within unit of
planning to identify
opportunities to
improve outcomes
15/16 vision
• Achievement of
top decile
performance in
MSk elective
• Top decile
performance =
115 target
• Develop service
• Top decile
redesign projects and
performance
commissioning
intentions, or contract
challenge
Programme Four: Patient Experience &Engagement
This programme is a cross-cutting
theme to the strategic plan
emphasising the importance of
patient and public engagement in all
that we do
Current year enabling projects:
• Patient Participation – support
and develop the PRG Assembly in
conjunction with Healthwatch
• Consult and engage around the
CCG Communications and
Engagement Strategy
• Call to Action responses
• Response to poor perception of
GP access
Intended projects 2014/16:
• Work in partnership with
Healthwatch to ensure broad
engagement across the CCG
population
• Launch the Communications and
Engagement Strategy
• Public launch of the CCG
website/s and social media
(requires recurring investment in
post holder)
• Gain understanding of the impact
of the Personalised Health
Budgets
• Improve effective public and
patient involvement in service
redesign
Programme Four: Patient Experience &Engagement
Theme
13/14 enabling
projects utilising 2%
PRG
engagement
• Development work • Programme of
via Healthwatch
engagement
Communication • Consultation on
and Engagement
C&E strategy
Strategy (C&E)
• Call to Action
Public and
patient
engagement in
service redesign
• UCC, MSk and
Physio
14/15 QIPP projects
15/16 vision
• Fully integrated
network with
Healthwatch at hub
• Implementation of
C&E strategy
• Review impact from
strategy with
partners
• Continuation
throughout
• Fully integrated
Programme Five: Quality and Safety
This programme includes quality
improvement areas and commissioning
intentions for existing provider contracts.
All projects have a relationship with
quality and safety and with that in mind
this programme spans all the three QIPP
programmes for the CCG.
2013/14 intentions for contracts:
• Review of the Community Service
specifications to reflect
commissioning intentions and
integration
• Ensure robust quality schedules and
monitoring for all new and revised
services
• Working collaboratively across the
Unit of Planning and Frimley System
• Support joined up provision of
safeguarding across our population in
line with Winterbourne
• Continual review all provider
contracts and service
specifications including unit of
planning and Frimley System
• Develop further the collaborative
and integrated approach to
commissioning with all our
partners
• Continue to support our
providers to deliver the best high
quality services, including CQC,
Monitor and assurance around
Francis report and Keogh
principles
• Maintaining the high quality in
general practice
Programme Five: Quality and Safety
Theme
13/14 enabling projects
utilising 2%
14/15 QIPP projects
15/16 vision
CQUIN
•
•
•
Appropriate
management of
unplanned care
•
Working across all
provider on the
shared CQUIN
7 day working
implementation
Joint (Health)
Commissioning
•
Ensure robust quality
schedules and
monitoring for all
new and revised
services
•
Establish robust unit •
of planning with clear
strategic objectives
Ensuring high
quality standards
•
Continue to reflect
on CQC
Respond to Clinical
Concerns, patient
and user feedback to
improve quality and
outcomes
•
Service specification
review with best
practice from
Networks
Deliver quality
outcomes indicators
i.e. C-diff and MRSA
•
•
•
Extension on 13/14
unplanned care CQUIN
(three year
programme)
Ensure through best
practice of
commissioning,
procurement and
contracting we obtain
value for money
Continue the focus on
patient safety
throughout all services
in line with the Berwick
review and the Francis
report