Cumbria Cluster
and
Cumbria CCG
Integrated Strategic and Operational Plan
2012/13 TO 2014/15
April 2012
v 5.2
1
CONTENTS
Pages
Executive Summary
3–4
1
Strategic Vision
5–9
2
Transformation Programme
10 – 17
3
Programme Delivery
18 – 19
4
Resources
20 – 24
5
QIPP
25 – 37
6
Engagement
38 – 39
7
Performance and Quality
40 – 63
8
Workforce
64 – 66
9
Informatics
67 – 69
10
Transition and Reform
70 – 79
APPENDICES
Pages
A
Integrated Performance Measures – Cumbria trajectories
80 – 82
B
Locality Service Initiatives
83 – 89
2
EXECUTIVE SUMMARY
During 2012/13 the health economy in Cumbria must keep a grip on finance and performance and improve quality and outcomes against a backdrop of transition
to a new commissioning architecture.
The 2012/13 Integrated Strategic and Operational Plan (ISOP) for Cumbria
has three main objective:
•
To keep a grip on performance and finance during a year of
significant changes required by the Health Bill;
•
To deliver improved quality and patient outcomes; and
•
To facilitate transition to the new commissioning
architecture.
The CCG and NHS North have been working with UHMBFT to develop an
action plan to eliminate clinically unjustified MSA. The plan has yet to
identify timescales and outcome measures however these will all be
agreed and embedded into the Programme Office at UHMBFT. The plan
will be signed off by the end of March 2012 and weekly monitoring will be
in place between UHMBFT and the CCG.
FINANCE
PERFORMANCE
Performance has improved in Cumbria over recent years alongside
demand management and reductions in unplanned care.
NCUHT has been clearing a backlog in Ophthalmology and Gynaecology
cases since January 2012. A recovery plan has been agreed with the Trust
and is being performance managed weekly by the CCG. From June 2012
the Trust will achieve all RTT indicators. NCUHT has improved in year
against the stroke performance indicator and will be fully compliant by
April 2012.
UHMBFT
UHMBFT has consistently failed the A&E and MSA indicators since late
2011. A series of operational changes have been implemented from 12th
March 2012 and these will improve the emergency flow through the
system. Early analysis shows improved performance and a trajectory will
be agreed with the Trust to achieve the 95% target by early 2012/13. It is
expected that EMSA will be compliant by April 2012. A fundamental
overhaul of Stroke services at UHMBFT may mean that this indicator
continues to be variable during 2012/13.
However, there is a significant challenge in terms of non recurrent
funding due to:
•
The ambitious transformational plan for primary care and
long term conditions management being developed by the
CCG. The GPs have agreed that their main development
priority will be improving primary care, particularly
increasing capacity and reorganising urgent day time care in
Barrow to improve health outcomes and reduce health
inequalities;
•
The need for funding to support acquisition of NCUHT by
Northumbria Healthcare NHS Foundation Trust;
•
The need to fund stabilisation of UHMBFT as part of the
improvement response to recent quality issues and support
the development of a clinical strategy for South Cumbria;
and
•
Investment in health improvement initiatives (linked to
primary care and long term conditions strategies) to tackle
the health inequalities that are prevalent in Barrow, Carlisle
and parts of West Cumbria.
EXECUTIVE SUMMARY
However there are a number of performance issues still to be addressed
and these include:
•
Stroke and RTT at NCUHT; and
•
A&E, Stroke and MSA at UHMBFT.
Commissioners have moved to a position of recurrent balance following
problems in 2010/11. The CCG has also agreed realistic activity plans with
acute providers which should minimise risk during the year. Contracts
were agreed in March, which is a significant step forward from previous
years.
3
EXECUTIVE SUMMARY (cont.)
QIPP & TRANSFORMATIONAL CHANGE
Commissioners have a QIPP gap of £58m, which is in line with other
similar health economies. Half of this will be met through
transformational change, with 6 key programmes of change
identified by the CCG:
• Planned care
• Unplanned care
• Children and Young People
• Long Term Condition Management
• Primary care
• Secondary care transformation & reconfiguration
BUILDING ON SUCCESS
Delivery of this plan builds upon the success of recent years. Good
progress has been made during 2011/12 in delivering reductions in
elective referrals through the Evidence Based Referral programme.
The initial focus was on 10 procedures of limited clinical value and
implemented through a robust referral management system. For
2012/13 the programme has been expanded to 60 procedures.
Use of the national contract has driven down Continuing Care costs
and this will continue into 2012/12.
Each locality has been developing its Community Services base with
CPFT to deliver the new clinical pathways for people with long term
conditions and these will now be expanded to include the new
paediatric pathways.
There has been a 9% reduction in unscheduled admissions since the
first phase of the Closer to Home plan started in 2007. For this final
phase the CCG will focus its efforts for adult admissions on the
localities with most to achieve and the delivery of the targets
include paediatric admissions across all localities.
TRANSITION
Plans are in place to ensure effective transition to the new
commissioning architecture. There is a strong CCG with good clinical
leadership and involvement. The CCG has been instrumental in the
planning process for this ISOP. The CCG is actively managing 100%
of the delegated budget and has agreed the year end financial
position with providers as well as leading the negotiation of the
12/13 contracts. The CCG is also instrumental in the reconfiguration
work in both North and South Cumbria.
There has always been close working relationships between the PCT
and local authority which has facilitated speedy development of
health and wellbeing shadow board and will ensure smooth
transition of the public health function to Cumbria County Council.
EXECUTIVE SUMMARY
The first 4 of these programmes have clear milestones and
outcomes and reflect the activity plans set out in the plan and
2012/13 contracts. Primary care and reconfiguration at UHMBFT
are in the planning stage and will result in further transformational
change. The detailed outcome measures for these programmes are
currently being determined. The QIPP gap for Cumbria as a whole is
£105m but in addition there is a non recurrent issue associated
with the NCUHT underlying deficit which will be addressed through
the acquisition process.
Prescribing costs have been reduced through QOF Medicine
Management targets, QOF QP indicators, Specials Order Products,
Scriptswitch and focusing on clinical systems and processes.
Localities will continue to focus on practice outliers to further
reduce prescribing costs and achieve the cost avoidance targets.
4
SECTION 1: STRATEGIC VISION - OVERVIEW
xxx
This Integrated Strategic and Operational Plan for Cumbria PCT Cluster builds on the progress to date in transforming the NHS
in Cumbria.
It sets out a delivery plan for the key initiatives that will be required to meet the Quality, Innovation, Productivity and Prevention (QIPP)
challenge over a four year period. It identifies how the financial, performance and activity priorities will be met in 2012/13. It identifies
the key milestones for the delivery of the transformational change which will free resources in the system to address the health
inequalities that exist across Cumbria.
This Integrated Strategic and Operational plan sets out a vision and
delivery plan to transform the NHS in Cumbria in line with national
requirements and local need. It will deliver a fully functioning
Clinical Commissioning Group (CCG) prepared and ready for
authorisation and accreditation. The Plan has been developed
jointly between the PCT Cluster and Cumbria CCG.
This will result in:
•
Improved health outcomes and reduced health
inequalities across Cumbria as outlined in the CCG 5
Year Strategic Plan and Clear and Credible Plan for
2012/13;
•
A financially resilient health economy that provides real
choice to patients; and
•
A high performing health economy that consistently
achieves the national performance requirements and
reflects what is important to patients.
This updated integrated plan outlines the key activities that will
build on the achievements made in 2011/12 and deliver the vision
through to 2014/15 and beyond.
Planning for this year has been adjusted to reflect the achievement
of the strategic objectives for Cumbria Cluster in 2011/12.
Achievements in meeting the QIPP challenge during 2011/12 have
focused on transactional delivery. However, ongoing delivery of a
clinical strategy and associated key initiatives will create the
building blocks to underpin the transformational change in 2012/13
and beyond.
1. STRATEGIC VISION
The CCG will be:
•
Engaging locally with populations and communities;
•
Undertaking effective commissioning and redesign of
services to meet local need as identified in the Joint
Strategic Needs Assessment (JSNA);
•
Working effectively in partnership with the local
authority partners; and
•
Maintaining good relationships with local providers.
Patients will see a different kind of national health service that:
•
Builds on the principles of Closer to Home (C2H) set out
in earlier Strategic and Operational Plans;
•
Is much more integrated between primary care, acute
hospital care, community services and social care
provision; and
•
Supports them to manage their Long Term Conditions
(LTC) better.
The Cluster has maintained strong oversight of the key strategic
initiatives throughout 2011/12 and will continue to work with the
CCG and local providers during 2012/13 to deliver whole system
transformation.
5
SECTION 1: STRATEGIC VISION – TRANSFORMATION
Clinically led commissioning and better integration between Primary Care, Secondary Care, Community Care, Social Care and the Third Sector has
resulted in a 9% reduction in unscheduled admissions during a period when other health economies have seen significant increases in admissions.
Cumbria has been championing clinically led commissioning for some
years as part of the Closer to Home (C2H) Clinical Strategy. Critical to this
model of care is a joined up approach which sees greater integration
between Primary Care, Secondary Care, Community Services, Social
Services and the third sector. Over the last three years the health
economy we has gone some way to transforming Community Services
and reduced overreliance on secondary care. Clinicians across Cumbria
have been involved in the development of this Clinical Strategy and
reconfiguration plans to transform how services are delivered.
As a result of this over the last 3 years non elective admissions have fallen
by 9% as shown opposite.
Delivery of this model of care will require whole system transformation to
Primary Care, Community Services and Secondary Care.
Pathways are being redesigned and some of the clinical care currently
delivered to patients in a hospital bed or outpatient department will be
delivered in a different way in a community setting. Staff will be equipped
with the appropriate skills and competencies to deliver high quality
healthcare services. Our clinical services will always be driven by clinical
outcomes.
Thirty per cent of the population in Cumbria live with a LTC. Modern health
services are still organised around a medical model with clinicians taking
control away from the individual. Individuals living with a LTC meet with a
clinician on only a few occasions within a year however they live with their
condition every day of their lives. The new service model will ensure that
individuals are equipped to manage their condition every day of their lives.
Primary Care will be the coordinator of services for individuals in their
practice populations. Each practice will risk stratify its population,
coordinate integrated clinical teams based on clinical need and develop the
infrastructure to support self management.
Unscheduled Admissions
9%
9% reduction
reduction in
in the
the last
last three
three years,
years, contra
contra to
to the
the
national
national and
and regional
regional trend
trend of
of year
year on
on year
year increases
increases
1. STRATEGIC VISION
The CCG wants to deliver the remaining elements of the Clinical Strategy
systematically across Cumbria through a service model whereby:

Individuals are supported to take responsibility for their own
health;

Local health services are responsive to local need;

Local communities support the health needs of their local
population;

Admission to acute secondary care only happens when it is in
the best interest of the patient; and

Services are safe and of the quality they would wish for
themselves and their families.
This approach requires systematic and consistent information and
education programmes for individuals living with a long term condition as
well as programmes for professionals to ensure they have the skills to
deliver services that are more responsive to individual patient need.
6
SECTION 1: STRATEGIC VISION – TRANSFORMATION (cont.)
The CCG has a clear evidence base behind its decision making through the
Joint Strategic Needs Assessment (JSNA) and real time patient experience
and quality information.
The CCG five year strategic commissioning plan sets out key priorities to
address these needs. Delivery against the priorities are supported by six
initiatives.
The six initiatives are outlined in pages 11 to 17 and include:
•
•
•
•
•
•
Planned care
Unplanned care
Children and Young People
Long Term Condition Management
Primary care
Reconfiguring Secondary Care in North Cumbria and South
Cumbria
Initiative
Improving care to respond to the
challenges of an ageing population
 LTC Management
Improving the health of children and
young people and the quality and
integration of care services
 Children and Young People
Improving mental wellbeing and reducing
alcohol misuse
 Primary Care, LTC Management
Reducing health inequalities and
premature mortality from cancer and
cardiovascular disease
 Primary Care, Children and Young
People, LTC Management
Reconfiguring and modernising health
services to provide more sustainable and
higher quality care
 Planned Care
 Unplanned Care
 Primary Care
In addition to the initiatives are cross cutting themes which are key
enablers to delivery of the strategy and these include:
•
•
•
•
•
A refreshed approach to commissioning for quality;
A new approach to improving patient engagement and
experience;
Aligning the workforce;
Developing the availability and use of patient
information; and
Modernising the estate.
1. STRATEGIC VISION
The JSNA draws attention to the higher than average proportion of older
residents resulting in more people living with a LTC such as diabetes and
dementia. There are also significant inequalities for health outcomes for
children alongside a higher than national average rate for suicides. The
main causes of premature mortality in Cumbria are cancer and circulatory
disease with significant variation in life expectancy across the county.
Equally the health economy has the challenges of clinical and financial
sustainability caused in part by geography but also by how primary and
secondary care services are configured. Over the next three years the
QIPP gap for Cumbria amounts to £105 million therefore whole system
transformation is required to address these challenges.
Priority
7
SECTION 1: STRATEGIC VISION – TRANSFORMATION (cont)
In line with the strategic vision and the JSNA priorities the health and
social care system in Cumbria in five years time will have the following
characteristics:









In five years time there will be a higher level of engaged patients and
engaged communities, with more patients taking responsibility for
their own health and wellbeing. There will be better education for
patients to help them co produce their care plan and manage their
long term conditions.
There will be integrated working with the local authority public health
team to help improve lifestyles and stay healthier for longer and
actively mobilising the many community assets.
There will be greater consistency in the quality of Primary Care with
an expansion of capacity in Barrow to address the health inequalities.
There will be better management of long term conditions and frail
older people to improve quality of life, keep people healthier for
longer and reduce unnecessary admissions. Delivery of the strategy
will result in shifting activity and the diagram below sets out how
services will be configured.
Clinical pathways
Cardiology
Cardiology
Paediatrics
Paediatrics
Palliative
Palliativecare
care
Elderly
Elderlycare
care
Respiratory
Respiratory
T&O
T&O
Surgery
Surgery
Etc,
Etc,etc
etc
Most interventions will be
delivered by multi disciplinary
teams in practices or
community based teams
Specific clinical pathways
require specific clinical
interventions
Clinical interventions
Primary
Primaryand
andcommunity
communitycare
care
Specialist
Specialistsupport
support
Secondary
Secondarycare
care
Disease
Diseaseregisters
registers
Case
Casefinding
finding
Care
Careplanning
planning
Annual
Annualreview
review(YoC)
(YoC)
Diagnosis
Diagnosis
Bio
medical
Bio medicaltreatment
treatment
Education
Educationprogrammes
programmes
Support
Supportfor
forself
selfmanagement
management
Minor
Minorelective
electivesurgery
surgery
Minor
Minorinjuries
injuries
End
of
life
care
End of life care
Identifies
Identifiesbest
bestclinical
clinicalpractice
practicefor
for
care
carepathways
pathways
Complex
Complexemergency
emergencyclinical
clinical
interventions
interventions
Identifies
Identifiesskills
skillsgaps
gapsfor
forprimary
primary
care
care
Complex
Complexelective
electiveclinical
clinical
interventions
interventions
Delivers
Deliversprogrammes
programmesto
toaddress
address
skills
skillsgaps
gaps
Complex
Complexdiagnostic
diagnosticinterventions
interventions
For primary care to have overall
responsibility for health outcomes of practice
populations and integrated services they will
secure some enhanced skills
1. STRATEGIC VISION

Improved outcomes and performance;
Improved safety and quality;
Greater integration of care across pathways breaking
down traditional barriers between primary, community,
secondary and social care;
Clinical leadership at all levels;
Financial stability for all organisations;
Individuals supported to take responsibility for their own
health care;
Meaningful engagement of patients and communities in
decision making and active use of patient experience to
improve care;
Greater innovation and use of technology to drive
improved outcomes and transformation;
Earlier intervention through better identification of
patients at risk and targeted support; and
Innovative forms of contracting which incentivise
integration and joint delivery of better outcomes and
quality.
There will also be greater support through decision aid tools to enable
patients to take informed decisions on secondary care procedures,
such as orthopaedic operations. Patients will have access to their care
records and summary information will be available to all clinicians to
provide better care.
Delivers
Deliverscomplex
complexclinical
clinicaladvice
advice
and
andguidance
guidance
Specialist support will enable
primary care to deliver enhanced
integrated services
Secondary care case mix becomes more
complex and specialised as primary and
community care practitioners become
more skilled
8
SECTION 1: STRATEGIC VISION - TRANSFORMATION (cont)
A significant shift will take place across the health and social care
system based on clinical pathways. Primary Care and Community
Services will focus on case finding, care planning, education
programmes, minor surgery and end of life care. Cumbria Partnership
Foundation Trust will be a key player will be a key player in delivering
community services to support LTC management and providing more
community alternatives to acute secondary care. They will also
provide an improved interface with North Cumbria University
Hospitals Trust and University Hospital of Morecambe Bay
Foundation Trust to speed up and ensure appropriate admissions and
discharge. These will be co ordinated through a Single Point of Access
and supported by integrated health and social care teams.
Over the next five years there will be continued move to higher
quality acute units with mortality rates in line with national averages.
Provision will be from larger, more sustainable Foundation Trusts with
financial stability and provision within tariff.
Acute hospital services will deliver care which cannot be delivered in
Primary Care or community settings and there will be more effective
networking across the north of England to improve skills in Cumbria
and provide specialist skills where they cannot be sustained within
Cumbria.
There will be full integration between Primary and Secondary Care to
deliver the Emergency Floor Model and for consultant support for
better long term condition management and care for frail older
people in community settings.
Reductions in elective procedures of limited clinical value will create
capacity in acute hospitals to repatriate routine procedures that are
currently carried out outside Cumbria alongside the development of
new services such as PCI which will be available during 2012/13.
Integration with Social Care will focus on priority areas such as
dementia and frail older people)and children and young people. There
will be more integrated nursing and social care to support discharge
from hospital and reduce delayed transfers of care.
There will be more joint commissioning to ensure value for money
and more joint deployment of technology such as telehealth.
1. STRATEGIC VISION
There will be enhanced integration between Community Services,
Mental Health Services and Social Care particularly for dementia.
There will be an increased move to more community mental health
services rather than inpatient care and more effective drug and
alcohol services.
Non elective admission rates per 1,000 population will be maintained
despite demographic change although there will be a particular focus
on reducing the high levels of unnecessary emergency admissions in
Barrow. Paediatric emergency admissions will be reduced through the
implementation of a Short Stay Paediatric Assessment Unit linked to
the Emergency Floor.
9
SECTION 2:TRANSFORMATION PROGRAMME
•
Excess
cancer &
CVD deaths
Improve care to
respond to the
challenges of an
ageing population
•
•
•
•
Health
inequalities
Improve the health of
children and young
people and the quality
and integration of care
services
•
•
•
•
•
•
Ageing
population
Reduce health
inequalities and
premature mortality
from cancer and
cardiovascular disease
•
•
•
•
•
•
•
Limited
resources
Reconfigure and
modernising health
services to provide
more sustainable and
higher quality care
•
•
•
•
35% reduction in the overall number of paediatric
non elective admissions across three years
Reduction in unplanned hospitalisation for under
19s for asthma, diabetes, and epilepsy*
13.5% of people with depression receiving
psychological therapy
48.5% of people who complete psychological
therapy moving to recovery
95% of people under adult mental illness
specialties on CPA followed up within 7 days of
discharge from psychiatric inpatient care
Reduction in number of alcohol related hospital
admissions**
Reduction under 75 mortality rate from cancer**
Reduction under 75 mortality rate from CVD**
Reduction in mortality within 30 days of hospital
admission for stroke**
85% of patients receive first treatment for cancer
within 62 days of an urgent GP referral
98% of patients receive subsequent treatment for
cancer within 31 days for surgery, anti-cancer drug
regime or radiotherapy treatment course (94%)
3,807 four week smoking quitters
20% of people aged 40-74 have been offered an
NHS health check
95% of patients seen in A&E in 4 hours or less
90% of patients referred for treatment admitted
within 18 weeks
95% ambulances respond to category A calls within
19 minutes
Reduce hospital acquired infections etc.
Long term conditions management
•
•
Deliver C2H Pathways for diabetes, respiratory, heart
failure and service models for older people in care homes
and end of life care
Develop a holistic strategy for long term conditions and
integrated primary and community delivery models
Children and young people
•
•
•
•
Implement short stay paediatric assessment services
integrated with Emergency Floor model
Improve outcomes across 6 key pathways
Improve access to and quality of CAMHS
Improve quality of maternity and paediatrics (see
Morecambe Bay programme)
Unplanned care
•
•
•
Implement integrated emergency floor
Implement single point of access for urgent care
Implement new care pathways
Planned care
•
•
•
Implement referral protocols and guidelines for clinically
agreed EBR procedures and increase repatriation of out of
county activity
Transfer ophthalmology & MSK into community setting
Repatriate out of county activity
Primary Care
•
•
•
•
•
•
Reduce unacceptable variation
Implement long term conditions strategy
Deliver more focused health improvement work such as
health checks and smoking cessation
Increase primary care capacity in Barrow, and reconfigure
urgent day time primary care
Provide more straight forward planned care
Develop a strategy for managing the changing age and skill
profile of the general practice workforce
Secondary care transformation & reconfiguration
•
•
Deliver the North Cumbria Clinical Strategy in line with the
recent NCAT review and support the acquisition of NCUHT
by Northumbria Healthcare
Develop and deliver a clinical strategy for the Morecambe
Bay area and ensure rapid improvement in the quality of
services for: maternity; paediatrics; A&E; stroke; and
outpatients
*New indicator – awaiting guidance on target setting ** Targets for these indicators are currently being developed with Public Health as part of transition planning to ensure future clarity on responsibilities for delivery.
2. TRANSFORMATION PROGRAMME
Premature
mortality
Improve mental
wellbeing and reduce
alcohol misuse
83% of people with a long term condition to feel
independent and in control of their own condition
Reduction in unplanned hospitalisation for adults
with chronic ambulatory care sensitive conditions*
15% reduction in patients using anti-psychotics (on
primary care dementia registers)
10% reduction in unscheduled admissions
from residential care homes to acute trusts
Net 2.3% reduction in adult non elective admissions
Net 5% reduction in number of elective admissions
Cross Cutting Initiatives
Information Technology
Increase capability and capacity to produce information and integrated systems to support better patient care
•
QIPP Programmes & deliverables
Engagement
Improve patient and community engagement arrangements and arrangements for assessing patient experience
Outcomes/outputs
Priorities
Quality
Commission for quality and improve quality management information
Context
10
SECTION 2: TRANSFORMATION PROGRAMME – PLANNED CARE
OBJECTIVE
Target
PERFORMANCE INDICATOR
To improve planned care quality, efficiency and access and repatriate care back to
Cumbria.
Reduction in admissions (incl EBR)
2012/13
2013/14
2014/15
-1,431
-1,964
-1,964
Reduction in out of area activity
WHY IS CHANGE NEEDED?
Levels of planned care have not reduced in Cumbria in the same way unplanned
admissions have. NHS Cumbria has agreed a strategy with NCUHT to reconfigure
acute services internally and address its underlying deficit in year. This requires a
reduction in the cost of service delivery, achieving efficiency in service utilisation and
creating opportunities to refocus activity towards repatriation of out of area activity.
DESCRIPTION
1.
2.
4.
5.
KEY MILESTONES FOR 2012/13
Q1
Q2
Q3
RISKS
Ability to identify additional capacity in
NCUHT for repatriation
NCUHT elective flow programme in
place and identified this action
Current Tariff payment stifles change
System wide discussions underway to
review a financial model and
unbundled tariffs
Engagement of GPs in utilising the IT
solutions to aid good referral
Integration into core system processes.
Validation of content and proactive
‘marketing’ of benefits.
Lack of capacity in community and
primary care to support early discharge
Business case to assess cost benefit of
any required investment
WORKFORCE IMPLICATIONS
None expected.
Q4
RESOURCE IMPLICATIONS
Implementation of EBR protocol & IT referral tool
for first 15 procedures
Implementation of EBR protocol & IT referral tool
for next 15 procedures
Additional acute capacity available for repatriation
Marketing of services & slot availability by NCUHT
Ophthalmology & MSK transferred to community
Discharge procedures aligned across CPFT/NCUHT
MITIGATING ACTIONS
Investment
£’000
Savings
£’000
2012/13
1,052
2013/14
2,897
2014/15
2,898
Total
6,847
2. TRANSFORMATION PROGRAMME
3.
Reduce activity in areas of service with limited clinical value (evidence based
referrals-EBR) by implementing referral protocols and guidelines for clinically
agreed EBR procedures, supported by ICT tools for procedures to be online on
GP desk tops;
Increase internal efficiency to repatriate activity (Orthopaedics and PCI)
currently undertaken out of Cumbria; implement theatre efficiency
programme in NCUHT to increase capacity to repatriate out of area activity;
and improve access to services using the Choose and Book system;
Reduce out patient activity in line with clinical models and agreed good
practice targets;
Reduce length of stay and improve early discharge in Orthopaedics;
Transfer services as appropriate into community settings – Ophthalmology in
North Cumbria and MSK in South Cumbria.
Number of community
Ophthalmology procedures
11
SECTION 2:TRANSFORMATION PROGRAMME – UNPLANNED CARE
OBJECTIVE
Target
PERFORMANCE INDICATOR
To redesign integrated urgent care services to reduce hospital attendances &
manage care more effectively in community settings
Reduction in unplanned adult hospital
admissions
2012/13
2013/1
4
2014/
15
-2,282
WHY IS CHANGE NEEDED?
National and regional trends for urgent care admissions are rising; in Cumbria
admissions were down by 8% in the last two years but concerns remain over
continued high levels of urgent care admissions, particularly in Barrow. Acute trusts
In Cumbria have substantial resource and demand management challenges resulting
in a need for alternative solutions to hospital based care.
DESCRIPTION
KEY MILESTONES FOR 2012/13
Operational and workforce model for Integrated
Emergency floor
Co-location of urgent care services commenced
Integrated emergency floor fully operational in
north Cumbria
Single point of access fully operational in north
Q1
Q2
Q3
MITIGATING ACTIONS
Achieving an integrated model whilst
challenged with medical recruitment in
NCUHT
•
•
Recruitment underway for medical
consultants
Alternate clinical roles being
explored
Option appraisal and system wide
financial model developing
WORKFORCE IMPLICATIONS
Detailed workforce plans for Integrated emergency floor in production- expected
April 2012
RESOURCE IMPLICATIONS
Investment
£’000
Q4
Savings
£’000
2012/13
2,245
2013/14
245
2014/15
245
Total
2,735
2. TRANSFORMATION PROGRAMME
Implement the new integrated model for unplanned care (as agreed in North
Cumbria at the Systems Board), with the following key components:
•
Implement the integrated emergency floor, with an improved medical
assessment & observation model in urgent care services and colocation of urgent care services (A&E and PCAS) on acute sites;
•
Implement single point of access into urgent care;
•
Implement new pathways of care – see long term condition
management and paediatric programs;
•
Provide specialist clinical out-reach support into communities;
•
Maximise ‘step up & down’ care in community hospital beds and
ensure effective discharge/admission liaison arrangements with acute
beds; and
•
Increase care in community settings, particularly capacity for
community based short term intervention services.
RISKS
12
SECTION 2:TRANSFORMATION PROGRAMME - CHILDREN AND YOUNG PEOPLE
OBJECTIVE
PERFORMANCE INDICATOR
To improve the health of and care services for children and young people.
Target
2012/13
Reduction in paediatric emergency
admissions
WHY IS CHANGE NEEDED?
2013/14
2014/15
-1,604
-1,604
Reduction in length of stay
Cumbria’s acute hospitals have a high rate of admission for paediatric care and there
is a focus towards ‘admission to assess’ which results in a longer length of stay and
unnecessary admission for the child. An expert review undertaken in 2010
recommended services become more integrated, with more care delivered in the
community and the overall delivery model for children integrated across
organisational boundaries. There are concerns around maternity and paediatrics in
the South of the County. There is also concern around access to CAMHS.
RISKS
DESCRIPTION
1.
3.
4.
5.
KEY MILESTONES FOR 2012/13
Q1
Q2
Q3
Workforce will need adjusting and
recruitment of skills challenging
•
•
Develop innovative/integrated
roles to support better recruitment
Phase implementation to meet staff
capacity
WORKFORCE IMPLICATIONS
•
•
•
•
•
Workforce modelling underway as part of redesign of urgent care services
Integration and co-location of staff expected in a phased approach
Staff skills training will be required and as yet unknown
Recruitment expected for some specialist clinical skills
Resource implication to be identified
RESOURCE IMPLICATIONS
Q4
Investment
£’000
Operational & workforce models for Short stay
paediatric assessment unit
Savings
£’000
Co-location of urgent care services commenced
2012/13
0
Implementation of short stay paediatric
assessment unit (link to emergency floor A2)
2013/14
1,326
2014/15
1,326
Total
2,652
Pathways developed and commissioned
Pathway delivery (1 pathway in at least 1 locality)
Review of CAMHS
2. TRANSFORMATION PROGRAMME
2.
Improved pathways for Children, young people and families and promote
greater range and use of community based and self managed care: key
pathways include: Constipation; Fever; Acute respiratory; Emotional
Wellbeing; Attention Deficit Hyperactivity Disorder (ADHD); Autistic
Spectrum Disorder (ASD)
Deliver an integrated response to urgent care needs including development
of short stay assessment services and integration of care within an
Emergency Floor model and maximise range of clinical skills
Review of CAMHS service
Design a new model for working collaboratively across organisations and to
deliver seamless services through the Health Builders partnership.
Improve quality of maternity and paediatrics (see Appendix 6 Morecambe
Bay programme)
MITIGATING ACTIONS
13
SECTION 2: TRANSFORMATION PROGRAMME – LONG TERM CONDITIONS MANAGEMENT
OBJECTIVE
To build on previous long term condition pathways and the work of Cumbria diabetes
to develop a holistic Long Term Conditions Strategy which encompasses a preventative,
anticipatory and whole person approach to managing care, based on self-management
by confident patients.
WHY IS CHANGE NEEDED?
The number of people, in Cumbria, with one or more Long Term Condition (LTC) is set
to increase significantly over the next 20 years in line with a rapidly ageing population.
Premature mortality and morbidity from LTCs and Cancer are the main drivers of
health inequalities across Cumbria and LTCs currently account for 70% of overall health
and social care spend with a projected increase. The current system for managing LTCs
will not meet this challenge and does not equip individuals to make informed decisions
about their own health needs or to be confident about managing their own health
(only one third of diabetes patients currently feel very confident about managing their
own health).
Whilst we have developed individual LTC pathways (eg for diabetes, COPD and heart
failure) there is currently no overall strategy for managing LTCs and reconfiguring the
relevant services in Cumbria.
common menu of services from which to create packages of care for patients; a
common approach to care planning and clinical teams with the right skills. These are
all underpinned by a common set of outcome measures.
In order to deliver appropriate care to people with complex physical and mental
health care needs and also for people who have reached the end of their lives, it is
necessary to deliver care through integrated practice, community and social care,
across a population base of 15,000 - 40,000, in a natural community wherever
possible – i.e. bigger than most general practices. These groupings would be known
as Accountable Care Partnerships (ACPs).
KEY MILESTONES FOR 2012/13
Q1
Q2
Q3
Q4
Continued delivery of phase 1 pathways/models
Overall LTC strategy developed
Continued roll out patient education programmes
PERFORMANCE INDICATORS:
PHASE 1
Target
2012/13
2013/14
2014/15
This programme is in two phases:
Phase 1: this is based on continued delivery of existing Closer to Home Pathways for
diabetes, COPD/respiratory, heart failure and the service models for care for older
people in care homes and end of life care. We have already provided resources for
additional community capacity during 2011/12 which will ensure delivery of non
elective admissions avoidance targets.
Phase 2: We are developing a holistic strategy for long term conditions which will
continue in 2012/13 to ensure CCG member practices and other partners are involved
in design and delivery. The service model starts by identifying what common resources
are required across Cumbria to support practices in delivering care to their registered
population. This will be care directed both at those at risk of developing a long term
condition as well as those with established problems.
The core principles underpinning the model are: Know your population; Know your
team; Know your community’s resources; Know how to help people become
confident self-managers; Know how you are doing.
There will also be a ‘common platform’ approach (drawn from the modern
production line found in car manufacturing) to ensure consistency of service delivery
across Cumbria, based on a common infrastructure with: integrated electronic records;
PERFORMANCE INDICATORS PHASE 2
The outcomes for the Phase 2 Strategy will be determined in detail as part of the of
the strategy development, but the broad outcomes are to:
•Reduce premature mortality and health inequalities;
•Reduce the rate of increase in the number of people developing a long term
condition (we know rates will increase given the aging population; but we want this
rate of increase to be significantly reduced compared to ‘doing nothing’);
•Improve the number of patients feeling in control of their own self management;
•Further reduce the number of unnecessary acute admissions through more
effective care planning; and
•Increase value for money by better integration of health and social care and more
patients being confident self managers.
RESOURCE IMPLICATIONS
Resources for phase 1 were put in place in 2011/12.
Resource implications for phase 2 will be determined as part of the Strategy
development process.
2. TRANSFORMATION PROGRAMME
Reduction in emergency admissions
DESCRIPTION
14
SECTION 2: TRANSFORMATION PROGRAMME – PRIMARY CARE
OBJECTIVE
Develop and deliver a strategy for transforming primary care to move from a group
of individual practices and community services, into community-aligned federations
within an integrated system necessary to deliver sustainable health care
WHY IS CHANGE NEEDED?
The quality of primary care in Cumbria is generally good but this masks variation, with
unacceptably low standards of care in some practices (often caused by capacity, poor
infrastructure or a need for improved skills) leading to unacceptable variation. There
is a need to support other strategic change areas such as long term condition
management and unplanned care and the age profile and increasing demand on
practices means we need a new strategy to attract, retain and skill-up new entrants
within the approach outlined above; and consider the skill mix of primary care .
We are developing a strategy to address these issues and this work will continue in
2012/13 to ensure CCG member practices are involved in design and delivery. Hence
this plan is indicative of the issues and outcomes the Strategy is likely to address.
The emerging Primary Care Strategy is likely to focus on:
1.
Reducing unacceptable variation (e.g. in referrals, prescribing, the level of
exceptions etc.) caused by capacity, poor infrastructure or a need for
improved skills;
2.
Implementation of the Long Term Conditions Strategy (appendix B4) in
primary care, with greater integration with community and secondary
services;
3.
More focused health improvement work such as increasing delivery of CVD
health checks, smoking cessation and brief interventions on alcohol and
exercise: there will be increased targeting in deprived areas such as Barrow,
Carlisle and the West Coast to help reduce health inequalities;
4.
Increasing primary care capacity in Barrow, and the reconfiguration of
urgent day time primary care to reduce unnecessary admissions, provide a
greater focus on the management of long term conditions targeted to
improve health outcomes and reduce health inequalities;
5.
Providing local service alternatives in straight forward planned care; and
6.
Producing a strategy for managing the changing age and skill profile of the
general practice workforce.
Q1
Q2
Q3
Q4
Cumbria Primary care strategy developed
Primary care education and workforce plan
developed
Additional capacity input to Barrow alongside
delivery of day time urgent care initiative
Ongoing peer review and improvement of
performance and delivery health checks
Business cases developed for planned care (in
line with Strategy)
PERFORMANCE INDICATORS
Performance indicators will be developed in detail as part of the Strategy
development, but will focus on improving the following outcomes and outputs,
many of which link to other programmes:
•Reductions in premature mortality and health inequality rates
•Reduction in unnecessary non elective admissions, especially in Barrow
• Increased levels of smoking cessation and health checks
• Improvements in the quality of prescribing, with further reductions in outliers for
prescribing per 1,000 population and BCBV PIs (both high and low)
•Maintenance of high levels of patients satisfaction with primary care
• Increase in the percentage of LTC patients feeling confidently managing condition
RESOURCE IMPLICATIONS
Investment
£’000
Savings
£’000
2012/13
4,800
Incl in other programmes
2013/14
3,000
e.g. Long Term Conditions
2014/15
2,000
& urgent care
Total
9,800
2. TRANSFORMATION PROGRAMME
DESCRIPTION
KEY MILESTONES FOR 2012/13
15
SECTION 2: TRANSFORMATION PROGRAMME – SECONDARY CARE TRANSFORMATION & RECONFIGURATION
DELIVERY OF THE CLINCIAL STRATEGY AND TRUST ACQUISITION IN NORTH CUMBRIA
OBJECTIVE
To develop and deliver a clinical strategy for North Cumbria alongside
an acquisition process which:
• Improves health outcomes and reduces health inequalities; and
• Ensures the provision of safe, high quality and clinically and
financially sustainable services.
Milestones and perfromance indicators are included in the
Unplanned and Childrens’ Transformational Workstreams.
A System Board has been established in North Cumbria to support
delivery of these key building blocks. The diagram below outlines
the relationships between the System Board and stakeholders in
North Cumbria.
DESCRIPTION
The Strategic Vision for North Cumbria was first set out in the Closer to
Home (C2H) Public Consultation in early 2008. C2H was embraced
within all six localities in Cumbria and underpinned their
commissioning intentions year on year.
Rapid response nursing and social care teams have been created to
help people get the care and support they need in their own homes
and GPs are working with hospital consultants in emergency
departments.
A refreshed Clinical Strategy for North Cumbria was agreed by the PCT
and NCUHT in 2011, building on C2H Strategy. As part of the
implementation of the Clinical Strategy, a number of key building
blocks have been identified, including delivery of an Emergency Floor,
Short Stay Paediatric Assessment Unit and Single Point of Access in
addition to community based specialist teams.
Other
Other
providers
providers
CCG
Operational and Clinical
Delivery Group
CPFT
West
West
CAG
CAG
NCUHT
Clinical
Leaders
Forum
Operational
Delivery
Group
East
EastCAG
CAG
Workstream Groups
PCT Cluster
Unplanned
care
Planned care
Paediatrics
Workforce
LTC
IT
The other important element of secondary care improvement in
North Cumbria is the acquisition of NCUHT by Northumbria
Healthcare FT. This will facilitate and accelerate secondary care
reconfiguration and ensure greater clinical and financial
sustainability of services in the north of the County and better
patient outcomes and experience (e.g. through more service
delivery within the area). The milestone plan for the acquisition
process is set out in Section 10 on Transition and Reform.
5. Governance arrangements
A Locality Board exists in each locality and has representation from
each GP practice and other local stakeholders. Each Locality Board is
responsible for ensuring their commissioning intentions reflect the
needs of their local populations.
Integrated System Board
CHoC
CHoC
3. PROGRAMME DELIVERY
A series of care streams developed clinical pathways for Planned Care,
Unplanned Care, Long Term Conditions, Children’s Services and Mental
Health. The membership of each care stream included clinicians from
both secondary and primary care and Social Services.
Primary
Primarycare
care
16
SECTION 2: TRANSFORMATION PROGRAMME – SECONDARY CARE TRANSFORMATION & RECONFIGURATION
DEVELOPMENT OF A CLINICAL STRATEGY FOR THE MORECAMBE BAY AREA
OBJECTIVE
To develop and deliver a clinical strategy for the Morecambe Bay area
which:
• Improves health outcomes and reduces health inequalities; and
• Ensures the provision of safe, high quality and clinically and
financially sustainable services.
DESCRIPTION
There have been a number of quality issues at UHMBFT over the last 6
months, some of which have been highlighted through major reports
from regulators, covering maternity, paediatric, outpatients, A&E and
stroke care. These quality issues link directly to poor performance on
the Operating Framework indicators in Section 7.
The Cumbria CCG, supported by the Cluster and NHS North of England,
are beginning the process to develop a strategy to address these issues
in partnership with the Lancashire Cluster, UHMBFT and CPFT.
Emerging principles include:
•Having a clear approach to health improvement, tackling inequalities
and using a needs assessment, data driven plan; and
•Being driven by quality including Clinical Effectiveness, Patient Safety
and Patient experience.
Patients and communities will be reassured that much of this isn’t
new; however, there are some “big issues” to tackle and articulate a
better vision for services such as maternity services at Barrow.
Performance indicators will be developed as part of the Strategy
formulation and will focus on the following :
•Reductions in premature mortality and health inequality rates;
•Reduction in unnecessary non elective admissions, especially in
Barrow;
•Improvements in the quality of care and achievement of core
standards in services such as stroke, paediatrics and maternity; and
•Improvements in the level of confidence of the local communities
and stakeholders in health services and improvements in patient
experience.
Effective programme management and arrangements for operational
delivery will be put in place across the health and social care system.
Whole system governance arrangements will be put in place with
similar arrangements to the System Board in North Cumbria.
3. PROGRAMME DELIVERY
At the same time there is an emerging strategy for improving primary
care that will increase capacity in Barrow and improve the quality of
care for people living with a Long Term Condition.
Work to develop the Strategy will continue in 2012/13. The key next
steps are to:
•Bring partners together to recognise the issues, challenges and
opportunities and create a consistent and owned impetus for change;
•Develop an integrated Clinical Strategy for the Morecambe Bay area
(which links to other transformational programmes such as Primary
Care and Long Term Conditions) bringing in experts and good practice
to address stroke care, paediatrics, maternity etc.;
•Engage communities, patients and stakeholders in the process to
understand and champion the need for change and consult if
appropriate, on new models of care; and
•Develop effective programme management and operational
arrangements to ensure effective and timely delivery of the strategy
across the health and social care system.
17
SECTION 3: PROGRAMME DELIVERY – MANAGING RISK
The approach to programme delivery is based on a cycle of planning
and implementation followed by benefits realisation.
During 2011/12 each of the six localities in Cumbria has implemented
a series of community based initiatives that will deliver the planned
reductions for 2012/13. Appendix B contains the detail by locality
however a summary is contained on the next page. Alongside this
planning has been underway to deliver an Emergency Floor Model
and SSPAU both of which will be fully implemented by late 2012. The
key aim of the Emergency Floor and SSPAU is to direct patients to the
appropriate service through a Single Point of Access and to provide
senior clinical assessment to prevent admission. There will be some
in-year benefit from the models during 2012/13 however the full year
benefits will be realised during 2013/14.
For 2012/13 the PCT Cluster is assured that there is a sound and
realistic plan through conservative activity reductions and increased
community based activity. The emerging plan for 2013/14 will focus
on the localities in Cumbria with the furthest to travel in achieving top
quartile admission rates.
NCUHT has yet to achieve financial balance and this will only be
achieved through the impending acquisition by Northumbria
Healthcare NHS Trust and subsequent reconfiguration of clinical
services. This will be a two or three year programme of work and will
require significant resources to support the acquisition.
UHMBFT has until recently had recurrent financial balance however
significant quality issues means that the CIP programmes may not be
achieved. In addition significant stabilisation resources will be needed
to reconfigure service models and improve quality.
The PCT Cluster and CCG can therefore expect non recurring resource
pressures from four key areas:
•
The need to pump prime transformation in Primary Care;
•
The need to invest in Public Health initiatives that will
address the health inequalities challenge;
•
The need for resources to support the acquisition of
NCUHT; and
•
The need to support service reconfiguration at UHMBFT.
The resource impacts in each of these four areas are currently being
determined but in total are likely to be in excess of the resources
available from the 2% top slice. This issue is currently being
considered with NHS North of England and a resolution to the funding
issue is expected early in 2012/13.
3. PROGRAMME DELIVERY
Also during 2012/13 the CCG will focus on developing a Primary Care
Strategy to deliver the infrastructure to support risk stratification,
integrated clinical teams and self management using a Year of Care
approach. This programme is less well developed however during
2012/13 the CCG will be working though a programme of
engagement with Primary Care, Secondary Care and Community
Services to identify outcome measures and implementation timelines
for 2013/14 and beyond. In addition the PCT Cluster and CCG will be
working with secondary care clinicians to implement the Clinical
Strategy in North Cumbria and develop a Clinical Strategy in South
Cumbria.
Cumbria has had some serious financial and quality issues although
through Closer to Home the Cluster and CCG collectively are in
financial balance. CPFT which provides Mental Health and
Community Services is also in financial balance.
18
SECTION 3: PROGRAMME DELIVERY – MANAGING RISK (cont)
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
Reduction
£’000
Summary of Service Initiatives Across Cumbria
Respiratory
182
283
•
•
•
•
•
•
•
Increase in number of pulmonary rehabilitation patients
LES for case finding, coding severity, assessment, ensuring appropriate pathway and medication
Re-evaluation of patients using oxygen therapy to optimise treatment
Increase in pulmonary rehabilitation services
Skilled respiratory nurses linking with community based services
Local version of Met office Scheme
Asthma reviews linked to community pharmacist, roll out of asthma prescribing pathway
Cardiac
626
509
•
•
•
•
•
•
•
•
•
Specialist heart failure service, improved education for primary care teams
LES for identification and management of heart failure patients, optimisation of medication and heart failure scoring
Increase in pulmonary rehabilitation services
24 hour access to ECHO and ECG diagnostics
Protected learning time for upskilling in primary care
Use of Qrisk tool
Psychological therapies for patients with multiple chronic disease
Exercise on Referral service (lower acuity patients)
Post discharge support for heart failure
Diabetes
49
51
•
•
Practice nurses engaged in diabetes care training courses
Year of care initiative
Elderly Care
478
555
•
•
Established Integrated Care Services for Older People (nursing, physio and pharmacy) improving continuity of care and
management of LTCs for residential and nursing homes and extra care housing
Care plans for all care home residents lodged with CHOC
Availability of interim care home beds for frail elderly and EMI patients including district nurse and GP admission
rights
Geriatrician of the week
•
•
Alcohol and Drugs
100
65
•
•
Provision of liaison psychiatry services to support people with mental health issues in A&E and on hospital wards.
Brief interventions LES in primary care for patients with harmful drinking
Infrastructure
872
782
•
•
•
Redesign of community based STINT team to provide rapid response services
Primary Care Medical Assessment Service managing GP referrals for diagnostics and intermediate care services
Joint working with NCUHT to deliver Single Point of Access (Gateway into Services) and Emergency Floor projects
1,430
1,052
•
•
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic procedures, MSK (traigerd through physiotherapy), minor
skin lesions, varicose veins, grommets and tonsillectomies
Expected reduction in day case activity resulting from achievement of 18 week target during 2011/12
Elective
•
TOTAL
3. PROGRAMME DELIVERY
Reduction
No.
3,297
19
SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN
xxx
The NHS Cumbria financial plan is consistent with the NHS North financial planning guidance. A planned surplus is delivered in each year of the plan.
Contracts have been agreed and signed for 2012/13. A limited amount of additional resources are being provided to build capacity in primary and
community care settings to support the delivery of the CCG commissioning intentions. The funding requirements and funding sources to support
transformation change in NCUHT and UHMBFT are still being considered with NHS North of England.
KEY RESOURCE ISSUES AND ASSUMPTIONS
The NHS Cumbria plan is based upon maintaining the 2011/12
planned surplus of £4.1 million as identified in NHS North financial
planning guidance. In addition, the plan reflects the requirement to
utilise 2% of the recurring revenue resource limit non-recurrently
each year.
At this stage no specific assumptions are included in respect of the
costs relating to the planned acquisition of NCUHT or any longterm transitional requirements of the on-going major incident at
UHMBFT. Discussions on resource requirements in these two
Trusts during the plan period are being held with NHS North of
England. The next discussions on funding requirements and the
availablility of resources within NHS Cumbria is set for mid April.
Local investment priorities include the expansion of breast
screening, the further expansion of PCI in Cumbria along with
the re-instatement of deferred investments from 2011/12 (e.g.
EMIS web).
The financial plans include, for each year, a contingency for
demographic growth to cover secondary care activity, non-PBR
drug costs and continuing care.
Details of the planned cost improvements across the three years
of the plan are shown in Section 4.
4. RESOURCES
The secondary care activity plans reflect NHS Cumbria CCG’s
commissioning intentions to secure further reductions in
secondary care activity. These plans are phased realistically across
the plan period, reflecting the need to implement new service
models at a time when major reform is taking place in the local
acute sector. Similarly transformation is required in primary and
community care (notably in the Furness locality) to ensure
appropriate capacity and capability is in place to deliver the
expansion in local, community based services.
The Operating Framework investments planned reflect the need
to address key target areas such as dementia, health visiting,
health checks and implementation of the summary care record,
along with specific investment in re-ablement.
The PCT currently has a significant number of equal value claims
outstanding for which it is not possible to make a reliable
estimate of the costs, although should this change then
provision would have to be made.
A key assumption is that the transfer of resources relating to
changes in organisational responsibilities for managing resources
(i.e. public health & specialist commissioning) will be revenue
neutral.
20
SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN (cont.)
The
xxx resource plan includes resources for the assessed impacts of demographic change, the requirements of the Operating Framework and new service
investments. These investments are essential for securing the delivery of agreed clinical strategies and for tackling health inequality. The allocation of
the £17 million non recurring resource in each year is being reviewed.
SUMMARY 3 YEAR KEY RESOURCE CHANGES FOR NHS CUMBRIA
2012/13
£’000
B/fwd recurring position
2013/14
£’000
USE OF 2% TOP SLICE
2014/15
£’000
-32,384
-36,632
Surplus returned
-4,146
-4,080
-4,088
Less 2% top slice
17,080
17,080
17,421
Growth funding
-24,684
-17,080
-8,711
Social Care Funding
-6,934
0
0
FUNDS AVAILABLE
-33,240
-36,464
-32,010
Demographic change
9,189
9,749
11,240
Inflation
5,302
4,457
4,541
15,342
15,495
16,095
Full year effect 2011/12 investments
3,518
0
0
Operating Framework
1,600
6,000
4,000
Social Care Funding
6,677
6,000
0
0
1,813
1,813
New service investments
3,117
2,850
4,750
TOTAL NEW SPENDING
44,745
46,364
42,439
RESOURCE GAP
11,505
9,900
10,429
Tariff savings
-8,091
-5,500
-5,505
Planned CIPs
-4,197
-3,406
-3,923
Commissioning Intentions
-3,297
-5,083
-5,083
-15,585
-13,988
-14,511
-4,080
-4,088
-4,082
CQUIN (2.5%)
Planned Commissioner Intentions
TOTAL SAVINGS AVAILABLE
SURPLUS
The use of the 2% top slice non recurrent allocation across the plan
period is currently being considered. The key demands for funding
from this source are:
•
•
•
•
Pump priming service transformation in Primary Care
across Cumbria particularly in Barrow;
Investing in Public Health initiatives that will help to
address health inequalities;
Underpinning transitional resources for the NCUHT
acquisition; and
Service reconfiguration at UHMBFT.
4. RESOURCES
-14,555
21
£17.9m
£19.1m
£12.7m
£25.6m
£16.1m
£11.6m
£13.5m
£11.5m
4. RESOURCES
COST IMPROVEMENT
COMMISSIONER REDUCTIONS
TARIFF REDUCTION
SOCIAL CARE FUNDING
OTHER INVESTMENTS
OPERATING FRAMEWORK INVESTMENTS
CQUIN
DEMOGRAPHIC CHANGE
NON RECURRENT SPENDING (ANNUALISED)
£50.5m
INFLATION
NEW GROWTH FUNDING
SURPLUS
2011/12
£4.1M
B/FWD UNALLOCATED FUNDS 2012/13
SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN (cont.)
RESOURCE MOVEMENTS BETWEEN 2012/13 AND 2014/15
£14.3m
£17.4m
£30.2m
SURPLUS
2014/15
£4.1M
22
SECTION 4: RESOURCES: NHS TRUST FINANCIAL PLANS
All
xxx three provider Trusts are expected to have a minimum 4% cost improvement programme in place in each of the plan years. CPFT is expected to
retain its annual surplus position. NCUHT is taking action to remove its underlying deficit position and will require further external financial support
during the plan period as identified within the Trust acquisition process. UHMBFT is now the subject of a transformation project to deliver improved
service quality and stability and it is anticipated that it will similarly require external financial support during the three year plan period.
CUMBRIA PARTNERSHIP FOUNDATION TRUST
NORTH CUMBRIA UNIVERSITY HOSPITALS TRUST
In 2011/12 Cumbria Partnership FT successfully took over the
management of the PCT’s provider arm under TCS without any adverse
impact on the Monitor Financial risk rating of 5.
In 2011/12 NCUHT received strategic support funding of £28 million to
address an identified underlying deficit, slippage in its in-year cost
improvement programme and the excess costs of its PFI Hospital.
The expectation is that CPFT will continue to deliver the nationally
mandated efficiency targets over the planning period.
NCUHT has developed a Long Term Financial Model to demonstrate
how the historic recurring deficit and future mandated efficiency targets
can be addressed. This information has been provided to bidders as part
of the acquisition process.
The contract for 2012/13 has been agreed and signed with the Trust.
UHMBFT currently has a financial risk rating of 3 and in 2011/12
received agreed financial support from both NHS Cumbria and NHS
North Lancashire to ensure the short-term financial consequences of
the major incident while maintaining the current financial risk rating.
The expectation is that UHMBFT will continue to deliver the nationally
mandated efficiency targets over the planning period but it will require
external financial support during the three year plan period. The extent
of this support is currently being determined.
The Trust, and its preferred bidder, have both identified that further
underpinning transitional financial support will be required and this is
being considered with NHS North as part of the Trust acquisition
process.
4. RESOURCES
UNIVERSITY HOSPITALS OF MORECAMBE BAY FOUNDATION TRUST
In conjunction with this NCUHT has produced hospital based trading
accounts (which again demonstrate how the Trust anticipates getting
back into financial balance) and these have been used to support the
decision to progress with the redevelopment of the West Cumberland
Hospital in Whitehaven.
The contract for 2012/13 has been agreed and signed with the Trust.
23
SECTION 4: RESOURCES: NHS CUMBRIA CAPITAL PLAN
xxx
A £40 million Capital Programme has been identified across the 3 year planning period, which includes the Cockermouth and Cleator Moor projects.
NHS Cumbria cluster is working with the Cumbria Partnership FT to identify the
priorities for estate renewal. The programme below includes funding of a rolling
programme to maintain existing infrastructure and the two projects for which the
Cluster has now received Stage2 Business Case approval – the Cockermouth Hospital
and GP practices project and the Cleator Moor Health Centre.
The programme also includes provisional funding to address the infrastructure
requirements for the modernisation of primary care premises in Barrow.
3 YEAR CAPITAL PLAN FOR NHS CUMBRIA
The Capital Resource Limit for NHS Cumbria is set out below.
2012/13
£’000
2013/14
£’000
2014/15
£’000
3,000
4,000
15,352
20,500
The associated Capital Programme across the plan period is as follows:
Capital to maintain existing
infrastructure
2011/12
£’000
2012/13
£’000
2013/14
£’000
2014/15
£’000
3,000
3,000
3,000
3,000
Refurbishment of UHMBFT
premises for relocation of GP
services
 Negotiations are currently in place with UHMBFT to refurbish
redundant premises on the Furness General Hospital site in Barrow to
provide GP premises, with an outline cost estimate of £1 million;
 A provisional sum of £17.5 million has been included as the necessary
capital investment to address the infrastructure requirements for the
modernisation and optimisation of primary care premises in Barrow.
Currently feasibility work is being undertaken in conjunction with eLC
and it is anticipated that the final scheme will be ‘on balance sheet’;
 The capital expenditure profile has been shown based on the current
asset base of NHS Cumbria, and therefore for planning purposes
potential asset transfers have been excluded;
12,352
New Primary Care
Development in Barrow
Total Plan
 The ‘on balance sheet’ treatment of the Cockermouth & Cleator Moor
projects is shown when the buildings become operational in 2013/14
based on the Stage 2 business case approval and financial close during
March 2012. These schemes are developed by ELIFT Cumbria (eLC),
NHS Cumbria’s LIFT partner;
 In addition to the above projects the financial plans include the
recurring revenue costs of new Primary Care premises developments in
Kendal (Captain French), Grange and Carlisle (Stanwix).
1,000
Cockermouth & Cleator Moor
 An annual commitment of £3 million is assumed to maintain the
existing estate in line with current underlying expenditure patterns;
4. RESOURCES
Anticipated Capital Resources
2011/12
£’000
KEY PROJECTS
17,500
3,000
4,000
15,352
20,500
24
SECTION 5: QIPP: OVERALL APPROACH
NHS Cumbria has a confirmed plan to achieve change and increased efficiency across all clinical services. However there are four key demands on non
recurring resources and these are likely to outstrip the level of non-recurring resources available within the community during the next three years.
PROGRAMME CONTENT
RESOURCE PRESSURES
The short term QIPP Plan centres on the completion of the Closer to Home
initiatives, including providing a single point of access to emergency services,
implementing integrated emergency floors and providing improved short stay
paediatric assessment services. These key initiatives will improve clinical quality
and sustainability, integrate care for better patient experience and help to
secure reductions in admission rates.
We have had serious financial and quality issues in Cumbria. However, through
implementing the Closer to Home programme, which was consulted on in 2007,
commissioners have achieved recurrent financial balance and have begun to
change the way patients are managed across Cumbria.
The three year strategy is to maintain non elective admission rates in most
localities, despite the increases in demand which we are expecting from an
ageing population, but look for significant improvement in Furness. The CCG will
seek to reduce paediatric non elective admission rates across all of Cumbria by
providing more accessible and child friendly, community based services. There
will also be a reduction in elective referral rates which will be achieved through
addressing procedures of limited clinical value and making available to GPs more
effective decision tools and providing referral management support.
It is highly likely, given the substantial change agenda experienced by the two
main providers, that the service changes outlined will only be implemented and
embedded during the course of 2012/13. For this reason the CCG has planned
to achieve its key activity changes across the full three years of the plan period.
An overall 4% efficiency target has also been built into contracts with all
providers.
Approximately 58% of the QIPP programme across the three years can be
classified as transformational.
In addition to these plans there are transactional QIPP initiatives, such as
continuing changes in GP prescribing practices which will deliver cost savings and
management cost reductions.
NCUHT has a significant deficit which requires a large and sustained cost
reduction programme and will need significant underpinning resources to
support the acquisition of the Trust.
UHMBFT has until recently had recurrent balance but significant quality
problems means there is a risk that CIP programmes will not be achieved and
that significant stabilisation resources will be needed to help deliver new service
models to secure quality improvement and reconfiguration across sites to deliver
long term clinical sustainability.
5. QIPP
Delivery of Phase 1 of the long term condition strategy, which delivers pathway
improvements in diabetes, respiratory and cardiac care, will also allow the CCG
to achieve improved admission rates.
The Cumbria-wide community and mental health provider, the Cumbria
Partnership FT, is in recurrent financial balance and has a significant agenda for
service change across community and mental health services.
Commissioners can therefore expect to have a significant call on non recurrent
resources from four key areas:
• The need for non recurrent investment to pump prime change in the
transformation of primary care;
• The need to find resources to address the significant challenges of
health inequalities across Cumbria;
• The need for resources to support the acquisition and
transformation of NCUHT by Northumbria Healthcare FT; and
• The need for transformation and stabilisation funding for service
change to improve service quality in UHMBFT.
The source of funding which is available to deal with these four key areas is the
2% top slice which is to be applied for non-recurring purposes.
25
SECTION 5: QIPP: THE COMBINED GAP ACROSS CUMBRIA
xxx
The combined commissioner and provider gap amounts to £105 million for the three year period 2012/13 to 2014/15. Of this, £9.5 million relates to
service providers outside of Cumbria. In addition there is a £28 million underlying deficit at NCUHT which will be managed through the Trust
acquisition process.
OVERALL QIPP GAP
PROVIDER QIPP GAPS
The overall QIPP gap for NHS Cumbria is identified at £105 million.
In addition there is a £28 million underlying deficit at NCUHT which
Is being managed as part of the Trust acquisition process.
The QIPP gaps which have been estimated for the three Cumbria provider
Trusts, based on the 4% efficiency requirement, are as follows:
2012/13
£’000
2013/14
£’000
2014/15
£’000
NCUHT (Cluster estimate)
6,549
6,383
6,478
19,410
UHMBFT (Cluster estimate)
4,693
4,543
4,570
13,806
6,183
6,247
6,463
18,893
This is set out in the table below.
2012/13
£’000
2013/14
£’000
2014/15
£’000
TOTAL
£’000
TOTAL
£’000
13,988
14,511
44,084
CPFT (Cluster estimate)
4,669
4,702
4,833
14,204
17,425
17,173
17,511
52,109
20,254
18,690
19,344
58,288
CUMBRIA PROVIDER QIPP
GAP
Cumbria provider efficiency
target*
11,197
12,814
13,149
37,160
Less tariff deflator
-6,228
-4,359
-4,362
-14,949
11,197
12,814
13,149
37,160
Cumbria QIPP gap
31,451
31,504
32,493
95,448
2,716
3,345
3,414
9,475
Total QIPP Gap (FIMS QIPP)
34,167
34,849
35,907
104,923
Add NCUHT underlying deficit
28,000
0
0
28,000
62,167
34,849
35,907
132,923
Cost avoidance target
Other providers efficiency target*
• The provider efficiency targets exclude the value of the tariff deflator
which is included in the figures for the Commissioning QIPP gap.
5. QIPP
15,585
Commissioning QIPP gap
The expectation is that the QIPP gaps identified for UHMBFT and CPFT will be
delivered through the internal CIP programmes in those Foundation Trusts.
As a result of the acquisition process, NCUHT is expected to deliver a
significant CIP programme as a contribution to the gap identified. However,
closure of the gap will require external support during the plan period.
26
SECTION 5: QIPP GAP: COMMISSIONER GAP
xxx
A commissioner QIPP gap of £58 million (including the targets for cost avoidance) has been identified across the three year plan. NHS Cumbria Cluster
and CCG has identified a robust plan to close this gap so that the required revenue surplus can be delivered in each year.
IDENTIFICATION OF THE QIPP COMMISSIONING GAP
NHS Cumbria has a QIPP gap of £58 million across the three years of the plan.
This is constructed as follows:
2013/14
£’000
2014/15
£’000
Changes in Income
33,240
36,464
32,010
101,714
Changes in Expenditure
44,745
46,364
42,439
133,548
Resource Gap
11,505
9,900
10,429
31,834
4,080
4,088
4,082
12,250
15,585
13,988
14,511
44,084
4,669
4,702
4,833
14,204
20,254
18,690
19,344
58,288
Surplus Required
QIPP RESOURCES GAP
Cost avoidance
QIPP TOTAL GAP
TOTAL
£’000
The QIPP resources gap (which excludes the cost avoidance targets) can be
compared to the four year QIPP gap which was identified in May 2011, as
shown in the table below.
Identified QIPP Gap
2011/12
Submission
£m*
2012/13
Plan
£m
2011/12
28.1
28.1
2012/13
23.3
15.6
2013/14
9.3
14.0
2014/15
5.1
14.5
65.8
72.2
TOTAL
• Per QIPP plan dated May 2011 as submitted to NWSHA
and which forms the baseline for monitoring in 2011/12
•
•
•
•
Amended PCT funding levels;
The CCG decision to rephase the commissioner plan following
discussions with NHS North, where 2012/13 becomes a year
for consolidation and a lower level of commissioner savings;
Reconsideration of service investment requirements; and
Reassessment of committed funding requirements.
PLAN TO DELIVER THE NHS CUMBRIA QIPP RESOURCES TARGET
The savings plan which has been identified is set out in summary below.
Delivery of this programme will ensure the closure of the identified £44 million
QIPP resources gap.
2012/13
£’000
2013/14
£’000
2014/15
£’000
Unplanned Care
2,245
2,157
2,158
6,560
Planned Care
1,052
2,897
2,898
6,847
378
750
750
1,878
Primary care
1,560
1,560
1,560
4,680
Provider tariff deflator
8,091
5,500
5,505
19,096
699
508
1,025
2,232
Other transactional projects
1,907
529
490
2,926
TOTAL QIPP PROGRAMME
15,932
13,901
14,386
44,219
Mental health
Other local services
Total
£’000
5. QIPP
2012/13
£’000
The key issues which have been taken into account in this
reassessment are:
The PCT has completed the triangulation analysis utilising the SHA template.
27
SECTION 5: QIPP (cont.)
TRANSFORMATIONAL CHANGE
Approximately 58% of the QIPP target will be delivered through
transformational change (see table opposite).
NCUHT has a dual challenge of delivering the 4% efficiency target,
amounting to £19.4 million across the three years of the plan and
eradicating the £28 million underlying recurring deficit. This will require
transformational change to provide sustainable clinical services. This will be
achieved through delivery of the clinical strategy for north Cumbria and the
acquisition process with Northumbria Healthcare FT. The North Cumbria
System Board will oversee delivery of the transformational change. The
QIPP efficiency gap will be delivered through a combination of transactional
and transformational change.
The three year QIPP efficiency target for CPFT is £18.9 million. In line with
the clinical strategies for both North and South Cumbria, CPFT is planning
to deliver more activity for less income. This will result in better integration
and more effective services. There are two key priorities. The first is the
further integration of community and mental health services following the
TCS transfer in April 2011 alongside the integration. The second is securing
integration between primary and secondary care in the delivery of a
transformed emergency flow pathway including Single Point of Access,
Integrated Emergency Floor and Short Stay Paediatric Assessment Service.
HEADROOM IN THE NHS CUMBRIA QIPP PLAN
Significant headroom exists in the 2012/13 plan with over £9 million
allocated for demographic growth (i.e. activity over and above 2011/12
levels). In some instance this has been encapsulated in contracts with
specific providers, and in other areas retained as a generic contingency
to manage costs. The prescribing budget also contains a CCG
contingency of £900,000 (1%) over and above planned growth.
•It is expected that funding for transition/stabilisation with NCUHT and UHMB
will be conditional on this being used as the first call on any additional activity;
•A risk sharing arrangement for controlling the cost of high cost mental health
patients and incentivising repatriating patients to lower cost local alternatives
has been established with CPFT;
•The NWAS contract provides marginal relief for over activity; and
•NHS Cumbria supports the proposal of collective risk sharing for specialised
commissioning.
In addition:
•The net impact of growth/tariff deflator identified in 2012/13 is quantified at
approximately £33 million (circa 3.5% of total RRL); considerably more prudent
assumptions have been used for 2013/14 (2.5%) and 2014/15 (1.55%); and
•In addition to the prudent assumptions on growth further planning
contingencies have been established of circa £15 million for both 2013/14 and
2014/15.
Transformationa
l
£’m (est)
5. QIPP
The Cumbria three year QIPP efficiency target for UHMBFT is £13.8 million.
In view of the deep rooted clinical quality issues there is a need to consider
reconfiguration of services across the three hospital sites into primary,
secondary and tertiary services. This transformation will be achieved
through the emerging system wide Clinical strategy.
In addition, the following can also be cited as further contractual mechanisms
to mitigate risk:
Transactional
£’m (est)
NCUHT underlying deficit
28.0
NCUHT efficiency target
9.7
9.7
UHMBFT efficiency target
6.9
6.9
CPFT efficiency target
9.4
9.5
Commissioning savings
15.3
9.8
0
14.2
TOTAL £m
69.3
50.1
TOTAL %
58%
42%
Cost avoidance
28
SECTION 5: QIPP SAVINGS ANALYSED BY PROGRAMME AREA
ANALYSIS OF SAVINGS BY PROGRAMME AREA
The £105 million savings plan across Cumbria has been analysed by service
area and this is shown in the table below. This analysis is consistent with the
content of the FIMS QIPP return for 2012/13.
2012/13
£’000
2013/14
£’000
2014/15
£’000
TOTAL
£’000
4,301
6,212
6,245
16,758
Acute non-elective
8,465
7,729
7,882
24,076
Acute outpatients
2,057
2,562
2,636
7,255
607
598
622
1,827
Acute other
2,336
1,996
2,234
6,566
Mental health and learning difficulties
2,593
3,336
2,658
8,587
Community services
3,590
3,660
3,805
11,055
Ambulance services
953
906
932
2,791
Specialist commissioning
1,577
1,592
1,637
4,806
Non-NHS contracts
1,075
0
750
1,825
0
508
508
1,016
3,926
3,980
4,085
11,991
Excluded drugs and devices
866
922
1,065
2,853
Primary care, dental, pharmacy, ophthalmology
823
848
848
2,519
1,000
0
0
1,000
34,169
34,849
35,907
104,925
Acute direct access
Continuing healthcare
Primary care prescribing
PCT running costs
TOTAL
5. QIPP
Acute elective
29
SECTION 5: QIPP: PLANS TO CLOSE THE QIPP GAP
NHS Cumbria has well developed plans to deliver the cost reduction measures necessary to close the £58 million QIPP gap. These are a combination of
transformational and transactional changes.
The £28.1 million commissioning QIPP gap for 2011/12 and the reductions
to contracts for provider efficiency targets have been delivered, reducing
the NHS Cumbria cost base by £50.1 million.
The majority of the gap for the next three years will be managed by
Cumbria CCG. The CCG has cost reduction and cost avoidance plans which
are fully developed for delivery in 2012/13.
Plans to close the gap in the following two years are currently being
reviewed. These plans are a combination of:
•
•
•
•
The activity reduction plans were set out in a Commissioning Framework
which was produced in November 2011. These cover unscheduled and
elective activity for both adult and children’s services.
Overall, Cumbria has the lowest rate of unscheduled admissions in either
the North West or North East and therefore the opportunities to secure
further reductions need to take this into account. However, the position
varies across the six localities and the strategy therefore is to deliver the
agreed patient pathways and to set target admission rates for each locality
which reflect the opportunities available to secure reductions in hospital
admissions.
Paediatric admission rates are high for all localities and action will be taken
to reduce these through the Children and Young People work programmes.
The detail for each of these three programmes for reducing hospital
admissions and referrals is set out later in this section. The CCG will seek to
ensure provider commitment to achieving the target activity shifts in the
interest of our patients as a condition of stabilisation support.
ASSURANCE PROCESSES FOR DELIVERY
The cash releasing QIPP savings have been embedded into the PCT budget
that is approved by the Board with formal delegation to the CCG through
an accountability agreement. The financial reporting systems of the PCT
have been developed to provide information at PCT, CCG and, where
appropriate locality level. Financial performance is monitored through the
following formal mechanisms:
•The PCT Board, through the Resources Committee, monitors in-year
financial performance of the whole NHS Cumbria resources; this process
includes scrutiny of year-to-date position (and hence progress on targets),
forecast position and the impact of any recovery measures required and
implemented to manage variances from plan;
•The CCG is in addition monitored on financial performance through
monthly performance meeting on delivering its financial targets; and
•The CCG has implemented a formal system of “peer review” to review
financial performance and corrective action at a locality level.
In addition, this approach is supplemented by weekly reporting of key
“informal” activity indicators to highlight trends in localities and with
individual providers to identify potential risks (e.g. out-patient referrals,
admission rates, OOH activity) in advance of receiving formal contractual
information. This information, coupled with use of benchmarking tools, is
also used to provide assurance of “costs avoided” in addition to planned
cash releasing savings.
5. QIPP
•
Reductions in hospital based activity in line with the CCG’s
clinical and commissioning strategies;
The impact in each year of the PbR tariff deflator;
Continuous improvements in efficiency which lead to cost
reduction, for example in primary care prescribing;
Securing the benefits from the national contract for
continuing care; and
Standard housekeeping projects.
Four of the six localities are at or below the national average rate for
elective admissions, although there is scope for improvement to upper
quartile rates. The Audit Commission benchmark tool for procedures of
limited clinical value confirms that there is scope for significant
improvement.
30
SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – ADULT EMERGENCY ADMISSIONS
xxx
Cumbria has a good track record of reducing hospital based activity over the last three years, particularly in non elective patient care. However, the
track record on delivering against plan has not always been consistent and a more rigorous approach is being taken to the activity plans for 2012/13
which reflects the relative position of each of the Cumbria localities.
Source: NHS Comparators
Cumbria
NW & NE SHA PCT
Other PCTs
Allerdale
Carlisle
Copeland
Eden
Furness
South Lakes
National Average
160
140
Maintain top
quartile position
Target for
Furness
Target for
Copeland &
Carlisle
120
100
80
60
40
20
0
Prim ary Care Trust
Policy across the three year period
Reduction in
admissions
No.*
Reduction in
commissioning
cost
£’000*
Allerdale
Maintain current position within top
quartile
0
0
Carlisle
Move to top quartile position
33
129
Copeland
Move to top quartile position
413
1,004
Eden
Maintain current position within top
quartile
0
0
Furness
Move half way between current
position and top quartile
508
1,600
South Lakes
Maintain current position within top
quartile
0
0
953
2,733
Locality
*NB Overall emergency reductions are the net
position excluding paediatric reductions (shown on
the next page) to avoid double count.
TOTAL
5. QIPP
Considerable investment in Furness will be
necessary to achieve admissions reduction.
There is a particular need to address primary
care capacity which impacts on the ability to
manage urgent day time patient care
effectively. This is in line with the CCG
primary care strategy.
Emergency Admissions; Q3 2010/11 Annual Rate;
Standarised Rate per 1000 pop
Overall, Cumbria has the lowest rate of
admissions in either the North West or North
East. Three out of the six localities are at or
below upper quartile levels; two are at or
below national average. Only one, Furness,
has high levels of admissions. The strategy,
therefore, is to maintain rates in South
Lakes, Eden and Allerdale; work to improve
rates in Carlisle and Copeland (accepting the
relatively high levels of deprivation there);
and to significantly improve rates in Furness.
31
SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – PAEDIATRIC EMERGENCY ADMISSIONS
Paediatric admission rates remain high across Cumbria and the strategy is to reduce the level of admissions in each locality by providing more
accessible community based assessment facilities.
Source: NHS Comparators
Cumbria
NW & NE SHA PCT
Other PCTs
Allerdale
Carlisle
Copeland
Eden
Furness
South Lakes
National Average
25
20
Target for Eden and
South Lakes
Target for
Allerdale
Target for Carlisle,
Copeland & Furness
15
10
5
5. QIPP
During the plan period, three of the six
localities will move to the current national
average position, Allerdale will move to the
mid point between the average and top
quartile position and the Eden and South
Lakes localities have an opportunity to
deliver top quartile performance.
Paediatric Emergency Admissions; Q3 2010/11 Annual Rate;
Standarised Rate per 1000 pop
Paediatric admission rates are high for all
localities and action will be taken to reduce
these through the Children and Young
People work programmes, particularly
implementation of the paediatric assessment
unit in each of our main hospitals linked to
the emergency floor and single point of
access; alongside implementation of new
children’s pathways (e.g. for the acutely ill
child).
0
Prim ary Care Trust
Locality
Policy for three year period
Reduction in
admissions
No.
Reduction in
commissioning
cost
£’000
Allerdale
Move to mid point between the
average and top quartile position
574
475
Carlisle
Move to national average position
492
407
Copeland
Move to national average position
364
301
Eden
Move to top quartile position
358
296
Furness
Move to national average position
873
722
South Lakes
Move to top quartile position
547
452
3,208
2,653
TOTAL
32
SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – ALL ELECTIVE ACTIVITY
There is scope to improve referral practices in each locality and during the next three years the focus will be on reducing referrals for procedures of
limited clinical value.
Comparisons through the Audit Commission
benchmark tool for procedures of limited clinical
value indicate there is scope for significant
improvement.
Source: NHS Comparators
180
160
Cumbria
NW & NE SHA PCT
Other PCT
Allerdale
Carlisle
Copeland
Eden
Furness
South Lakes
National Average
Target for Allerdale, Carlisle,
Eden, and South Lakes
Target for Copeland &
Furness
140
120
100
80
60
40
20
0
Prim ary Care Trust
Locality
Policy across the three year period
Reduction in
admissions
No.
Reduction in
commissioning
cost
£’000
Allerdale
Move to top quartile position
1,080
1,178
Carlisle
Move to top quartile position
1,322
1,442
Copeland
Move to current Allerdale position
811
885
Eden
Move to top quartile position
375
409
Furness
Move to current Allerdale position
1,054
1,149
South Lakes
Move to top quartile position
717
783
5,359
5,846
TOTAL
5. QIPP
The strategy for elective admissions is to move
four of the six localities to the current top
quartile position and to target performance
improvement in Copeland and Furness localities
to the level currently achieved in the Allerdale
locality.
Elective (Day Case & Ordinary) Admissions; Q3 2010/11 Annual Rate;
Standarised Rate per 1000 pop
Four out of the six localities (South Lakes, Eden,
Allerdale and Carlisle) are at or below the
national average rate for elective admissions,
although there is scope for improvement to
upper quartile rates. Copeland and Furness are
above average (3rd quartile).
33
SECTION 5: QIPP: SUMMARY OF COMMISSIONING PLANS
SUMMARY OF THE COMMISSIONING PLANS
The commissioning plans are brought together in the next two pages to
demonstrate the impact of the commissioning policies on overall hospital
activity and PbR payments.
These tables also show the anticipated impact on hospital activity of
demographic change over the three years of the plan. The CCG has
reviewed the way in which it assesses the impact which its ageing
population will have on clinical services. This will ensure there is a more
accurate assessment of the likely impact of demographic change on
elective and non elective admissions.
The summary table below shows the net activity changes that are
anticipated over the next three years in the level of hospital based activity.
2011/12
2012/13
2013/14
2014/15
2012/13
2013/14
2014/15
No.
No.
No.
No.
%
%
%
Unscheduled
53,469
50,154
49,611
49,222
-6.2%
-1.1%
-0.8%
Elective
65,835
65,014
63,692
62,531
-1.2%
-2.0%
-1.8%
Excess Beddays
30,755
30,725
29,226
27,994
-0.1%
-4.9%
-4.2%
All outpatients
445,573
399,245
400,513
400,812
-10.4%
+0.3%
+0.1%
A&E
109,821
110,129
109,458
108,973
+0.2%
-0.6%
-0.4%
5. QIPP
Change on previous year
34
SECTION 5: QIPP: CHANGES IN PATIENT ACTIVITY LEVELS
Plan
2011/12
No.
Outturn
2011/12
No.
Plan
2012/13
No.
Plan
2013/14
No.
Outturn
2011/12
No.
Plan
2012/13
No.
Plan
2013/14
No.
Plan
2014/15
No.
120,135
120,725
118,630
-3,020
-3,020
925
704
120,725
118,630
116,314
249,261
201,627
204,397
2,770
2,152
201,627
204,397
206,549
76,177
76,907
77,486
579
463
76,907
77,486
77,949
109,821
110,129
109,458
-903
-903
308
232
418
110,129
109,458
108,973
Outpatients - First
Unscheduled
Baseline
53,320
53,469
50,154
49,611
Commissioning intentions
-2,378
-2,282
-927
-927
114
524
384
538
Other net changes
-1,293
-1,557
Total
49,763
Demographic impact
Plan
2011/12
No.
Plan
2014/15
No.
53,469
50,154
Baseline
Commissioning intentions
119,011
-2,818
Demographic impact
Other net changes
49,611
49,222
Total
590
116,193
120,135
Outpatients- Follow up
Elective
Baseline
65,835
65,014
63,692
-934
-1,431
-1,964
-1,964
Demographic impact
340
642
803
Other net changes
270
63,692
62,531
Commissioning intentions
Total
65,093
65,835
65,014
33,939
Commissioning intentions
-2,718
30,755
Demographic impact
Other net changes
Total
30,755
30,725
Commissioning intentions
-53,950
Demographic impact
Other net changes
-47,634
203,198
249,261
Outpatients - Procedures
Baseline
62,213
-1,299
30,725
29,226
Commissioning intentions
-2,119
-2,119
Demographic impact
474
620
887
Other net changes
256
Total
-30
31,221
257,148
Total
Excess Beddays
Baseline
Baseline
29,226
27,994
60,915
76,177
A&E
Baseline
110,055
Commissioning intentions
The figures shown for outturn 2011/12 and 2012/13 are consistent with
contracts for 2012/13
5. QIPP
66,027
Demographic impact
Total
110,055
109,821
35
SECTION 5: QIPP: CHANGES IN PATIENT ACTIVITY LEVELS – RESOURCE IMPLICATIONS
Plan
2011/12
£’000
Outturn
2011/12
£’000
Plan
2012/13
£’000
Plan
2013/14
£’000
Plan
2011/12
£’000
Plan
2012/13
£’000
Plan
2013/14
£’000
Plan
2014/15
£’000
20,125
20,211
19,870
-500
-501
159
120
20,211
19,870
19,489
18,961
14,796
15,050
254
194
14,796
15,050
15,244
11,733
11,821
11,911
Demographic impact
70
90
73
Other net changes
18
Plan
2014/15
£’000
Outpatients - First
Unscheduled
Baseline
95,651
95,114
90,929
90,584
Baseline
Commissioning intentions
-3,725
-2,245
-1,571
-1,571
Commissioning intentions
155
1,142
1,226
1,645
Other net changes
-2,831
-3,082
Total
89,250
Demographic impact
Outturn
2011/12
£’000
95,114
90,929
19,654
-449
Demographic impact
Other net changes
90,584
90,658
Total
86
19,205
20,125
Outpatients- Follow up
Elective
Baseline
81,683
81,220
79,683
-924
-1,052
-2,397
-2,397
Demographic impact
400
860
1,020
Other net changes
189
79,683
78,306
Commissioning intentions
Total
75,054
81,683
81,220
Commissioning intentions
Commissioning intentions
-5,092
Demographic impact
Other net changes
7,900
7,129
-660
Other net changes
7,135
6,757
-514
-514
136
195
7,240
7,129
7,135
Commissioning intentions
Total
6
6,757
6,438
-4165
18,084
18,961
Outpatients - Procedures
Baseline
Demographic impact
Total
23,176
Total
Excess Beddays
Baseline
Baseline
9,559
-179
9,380
11,733
11,821
11,911
11,984
10,062
10,201
10,201
10,333
10,291
-72
-73
30
51
10,291
10,269
A&E
Baseline
Commissioning intentions
The figures shown for outturn 2011/12 and 2012/13 are consistent with
contracts for 2012/13
5. QIPP
75,978
Demographic impact
32
Other net changes
Total
100
10,062
10,201
10,333
36
SECTION 5: QIPP: ESTATES
NHS Cumbria and its associated provider services are working on a number of estates projects which will assist in closing the QIPP efficiency gap. The
eight key projects are listed below.
DRIVING EFFICIENCY FROM ESTATES RATIONALISATION
NHS Cumbria is working with its associated provider organisations to
secure efficiencies from new capital projects or through the rationalisation
of the existing Cumbria estate. The eight key initiatives are listed below.
NHS Cumbria is working with UHMBFT to investigate the feasibility of
relocating staff from the Tenterfield site in Kendal to the Westmorland
General Hospital site.
NHS Cumbria has signalled its support for the new West Cumberland
Hospital. This will deliver an operating surplus of £3 million per annum
through more efficient buildings infrastructure and space layout, improved
clinical adjacencies and new ways of working facilitated by the new
hospital.
The 111 proposals are likely to consolidate the infrastructure in Cumbria,
improving utilisation of space & technology.
5. QIPP
The DoH has identified the Cumberland Infirmary, Carlisle as one of a small
number of first stage PFI hospitals where excess operating costs can be
identified as a result of the contractual conditions which exist. A national
funding stream has been identified from which these excess costs will be
met. NCUHT anticipates that this will make a significant contribution to its
underlying deficit position.
NHS Cumbria is working jointly with NCUHT and CPFT to review the scope
for vacating peripheral buildings on hospital sites to improve the space
utilisation of the main buildings and release costs.
The new estate projects in Cockermouth and Cleator Moor will deliver
annual savings of £528,000 per annum (of which £226,000 has been
identified from estates services). Both these projects consolidate four
existing buildings into one location in each town.
NHS Cumbria is considering the refurbishment of a building on the Furness
General hospital site (owned by UHMBFT) to provide new GMS
accommodation. This will be a cost effective solution when compared to a
new building on an acquired site.
The new GMS development in Stanwix is being built on land owned by
Cumbria County Council at less than open market value. This avoids
potential costs estimated at around £25,000 per annum.
37
SECTION 6: ENGAGEMENT : Patients and Communities
xxx
The CCG has always set great store on the engagement of patients in decision making and service re-design and will introduce a ‘Listening to Cumbria’
campaign and other initiatives as an early priority.
Clinicians in Cumbria have always set great store on the engagement of
patients in decision making and service re-design. For example, engagement of
patients is at the heart of the diabetes pathway re-design, with a focus on
patient education and co-production of the care plan.
In line with the ‘promise to patients and communities’ the CCG is keen to make
a quantum leap in the development of its engagement arrangements, and like
quality, embed them at the heart of all the commissioning arrangements.
Members of CCG will work with the emerging Healthwatch organisation to
ensure efforts are joined up and there is no duplication.
There will also be programmed meetings with key stakeholders such as the
Overview and Scrutiny Committee, emergent Health and Wellbeing Board,
MPs, League of Friends, LMC and social care and local authority
representatives. We will also actively seek patient views about how they can
be more closely involved with decision-making on both individual and
collective levels.
This ‘multi-channel’ methodology will focus include:
1. Near time, post treatment, out-bound telephone follow-up interviews;
2.On-line opportunities to comment on-line with moderated feedback and
publication;
3.Structured attitudinal surveys;
4.Patient experience sampling across service lines and provider geography;
5.Proactive mobilisation of community and voluntary groups to monitor;
6.Primary care satisfaction surveys;
7.Comments and notes boxes in every GP surgery;
8.Requirements of providers to carry out satisfaction surveys in situ;
9.Deliberative patient groups in every locality; and
10.Feedback loops to patients to demonstrate how their experience has been
taken into organisational and contractual learning to make service changes.
It is expected that the CCG will commission these services from an external agency
to provide a regular and systematic monitoring of patient experience. This data will
be reviewed by clinicians at monthly locality and CCG Executive Boards as a core
metric in the quality dashboard and for contract monitoring and service
development.
Key Milestone Plan for 2012/13
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
6. ENGAGEMENT
An early priority for the CCG will be to carry out an extensive ‘Listening to
Cumbria’ campaign throughout the spring of 2012. This will involve health
roadshows, ‘meet your GP’ surgeries and other public facing events in every
locality in the county. It will be led by the elected GPs from each locality and
seek the views, aspirations and needs of patients. It will also be an introduction
to the new world of GP commissioning.
The outcome of the listening campaign will be an evaluation which will lead to a
new and dynamic ‘multi-channel’ methodology for capturing and acting upon
patient experience on an ‘industrial scale’.
Mar
Listening exercise
Patient experience metrics dashboard
developed/targets included 2013/14 contracts
Systematic approach to engaging patient
representation
Third party contract to gather, analyse, report
experience metrics: specification & contract
38
SECTION 6: ENGAGEMENT : Public Sector Equality Duty
xxx
The PCT Cluster has met the first part of the PSED and is engaging across the whole system to develop equality objectives. The Cluster and CCG are
working together to develop an implementation plan.
The PCT Cluster met the 1st part of the PSED by publishing
information of the effects of policies on people protected by the Act
on 31st Jan 2012.
In addition the Cluster is reviewing EDS evidence with self
assessment due mid March 2012 alongside providing training to
enable grading of self assessment by wider Stakeholders 6th March.
A Joint accreditation event where wider stakeholders will verify self
assessments leading to a Cumbria wide assessment proving a
baseline for EDS will be held on 26 March 2012.
The Cluster and CCG will work together to develop performance
measures to show how Equality Objectives will be met over the
next 4 years.
6. ENGAGEMENT
From the event Equality Objectives will be drafted for verification by
the Board and publication by 6th April.
39
SECTION 7: PERFORMANCE AND QUALITY – KEY PERFORMANCE INDICATORS
Good progress has been made in achieving the 2010/11 Operating Framework performance however there are still some key issues that
need to be resolved.
Good progress has been made in achieving the 2011/12 Operating
Framework performance however there are still some key issues that
need to be resolved. The table below sets out the most recent position
alongside the year end forecast.
UHMBT
NCUHT
RAG - Forecast
Cumbria
UHMBFT
NCUHT
Cumbria
RAG - YTD
In summary NCUHT will achieve 5 of the 6 key performance indicators from
April 2012 and all 6 indicators from June 2012.
Referral to Treatment
A&E 4 hour wait
Stroke
Mixed Sex Accommodation
HCAI
Ambulance Cat A
NCUHT
NCUHT has been clearing a backlog of Ophthalmology and Gynaecology
cases since January 2012. The anticipated additional capacity was not fully
realised in early 2012 therefore the backlog will not be cleared until May
2012. A recovery plan has been agreed with the Trust and is being
performance managed weekly. From June 2012 the Trust will achieve all
RTT indicators. NCUHT has improved in year against the stroke performance
indicator and will be fully compliant by April 2012.
UHMBFT
UHMBFT has consistently been failing the A&E and Mixed Sex
Accommodation (MSA) indicators since late 2011. A series of operational
changes have been implemented from 12th March 2012 and these will
improve the emergency flow through the system. Early analysis shows
improved performance and a trajectory will be agreed with the Trust to
achieve the 95% target early in 2012/13. A weekly review meeting takes
place between UHMBFT, the Cluster, the CCG and the Cluster and CCG in
Lancashire.
The CCG and NHS North have been working with the Trust to develop an
action plan to eliminate clinically unjustified MSA. The plan has yet to
identify timescales and outcome measures however it is expected that MSA
will be eliminated from April 2012. The plan will be signed off by the end of
March 2012 and weekly monitoring will be in place between UHMBFT and
the CCG.
A fundamental overhaul of Stroke Services at UHMBFT may mean that this
indicator continues to be variable during 2012/13. In summary, UHMBFT
will achieve 4 of the 6 indicators by end March 2012 and will have agreed
plans in place to achieve all 6 indicators early in 2012/13.
7. PERFORMANCE & QUALITY
Cancer - 62 day
However NCUHT remains an outlier in relation to Delayed Transfers of Care
(DToC). A series of operational changes have recently been implemented
and a whole system event is to take place early May. This will result in a
whole system action plan and trajectory and will be performance managed
through the current System Board arrangements.
40
SECTION 7: PERFORMANCE AND QUALITY: CLUSTER APPROACH
Every effort is made to ensure quality and safety is firmly embedded in all commissioned services. This function has remained the responsibility of the
Cluster for 2011/12 however the CCG constructed and performance managed the CQIN contracts. During 2012/13 CCG will have full accountability for
the quality agenda.
CLUSTER APPROACH
Whole system
innovation
We aspire to deliver high quality safe services whilst improving
efficiency, performance and productivity. This vision will be
supported by clear leadership for quality in the new NHS
arrangement with patients at the heart of what we do and robust
methods for delivering innovative solutions.
Pathways redesign
Clinical Strategies
Energising for
Excellence
High Impact Actions
Safety Express and
Safety Thermometer
Patient and public experience is a key driver and will help shape
commissioning and service provision. New techniques will be used
to understand and act of patient wishes.
Integrated governance arrangements will be in place and will
underpin good quality outcomes.
Workforce changes will be made explicit to ensure that individual
clinicians have the right skills and competencies to deliver care
outside hospital as well as supporting individuals to manage their
LTC.
Systems will be in place to prevent harm, learn lessons and ensure
clear board reporting. The Cluster is developing an assurance
framework taking a 360 view. This allows safety programmes to be
viewed alongside increasing efficiency by “scaling up” areas of
innovation.
External regulation
PC performance
CQIN/Contracting
Management of SUIs
Gold Command
Safeguarding
5 Outcome measures
1.
2.
3.
4.
5.
“Scaling up” and “spread” techniques will be promoted and
facilitated where necessary.
Primary Care/CHOC
CPFT
NCUHT
UHMB
NHS Funded Care
Performance
Management
Helping people recover from episodes of ill health and injury;
Preventing people dying prematurely;
Enhancing the quality of life for people with Long Term Conditions;
Treating and caring for people in a safe environment and protecting from
avoidable harm;
Ensuring people have a positive experience.
A proposal is currently being developed to support Cumbria Health
Watch to become a strong body for surveillance of our health and
care facilities. This work is complemented by ‘deep dives’ in to
specific areas such as the care of older people.
The Quality Framework will focus on the five NHS outcomes and the
CCG will embed this approach into their commissioning
arrangements. Organisations will be held to account through robust
contracts and performance measures for quality, safety and
outcomes and financial incentives or penalties will be applied
through CQIN.
7. PERFORMANCE & QUALITY
A whole system approach will be taken to make quality everyone’s
business and there will be a “Quality Alliance” for Cumbria. Clear
expectations will be outlines for al providers of healthcare.
Service Delivery
41
SECTION 7: PERFORMANCE AND QUALITY: THE APPROACH OF THE CLINICAL COMMISSIONING GROUP
The Clinical Commissioning Group is developing its approach to delivering quality with a key focus on clinical leadership, embedding quality in the
commissioning and contracting process and the integration of care between providers across the primary, community and secondary care sectors.
The CCG recognises the importance of ensuring quality and is developing its
approach to quality, with a focus on clinical leadership and embedding quality in
the commissioning and contracting process.
The CCG has committed to ensuring that its approach to contracting and quality
concentrates on the following major areas:


The approach will centre on:
Patient experience: both more effectively acting upon what
patients tell them and strengthening their voice in service
improvement and in targeting specific aspects of patients
experience, such as personal dignity and communication;
Safety of clinical services: targeting areas of concern raised by
external or local intelligence including proactive assurance of
performance against national standards and ensuring that action
from lessons learnt is taken effectively;
Good clinical practice: Ensuring that clinicians and services are
systematically working to accepted good practice guidelines, and
that there are good systems of clinical communication that are
timely, accurate, relevant and systematic;

Agreed pathways of care: ensuring the effective adoption by
primary, community and secondary care services of agreed care
pathways in Cumbria, with care indicators that measure the quality
of a whole pathway of care;
Commissioning intentions and implementing new models of service
delivery.
In each area there will be a strong emphasis on integration of care between
providers, primary, community and secondary, with the CCG recognising its
responsibility as a partner to ensure that primary care works effectively as part of
the health system. The CCG understands integration to mean the effective
management of care for a patient between providers, requiring collaboration and
communication.

Incorporating common indicators across individual Trusts, to support
integrated working and improved communication;

Being actively led by clinicians;

Motivating staff and focusing on direct patient care, at team or ward level;

Including specific quality measures for children’s services in all contracts.
During the next few years the CCG will develop alternative approaches to contracting that
better support integrated working between primary, community and secondary care and
place quality at the heart of the contracting process. In agreeing contracts for 2012/13 the
CCG will to anticipate those developments by laying foundations for this changed approach.
It will maximise the potential in existing contracting arrangements towards supporting its
aims for quality.
The CCG regards contracting as a major lever, for both commissioners and providers, in
driving attention to and improved performance in the quality of health and health care in
Cumbria. It will use contracting as an integrated part of its commissioning processes to
support the focus on quality.
CQIN will be agreed in 2012/13 and beyond as an incentive to improve performance. This
may be performance beyond that nationally mandated or in areas of specific local concern.
CQIN will not be used to incentivise practice or performance which would normally be
expected to be delivered as part of the national NHS contract. In line with national
guidance, targets previously incorporated within local CQIN schemes will be incorporated
within the main contract, with CQIN focusing on new areas of improvement or higher levels
of performance in areas that remain a priority.
7. PERFORMANCE & QUALITY


From the patients perspective the CCG will ensure that the service they receive is coherent
and of high quality across the health system. That requires individual NHS providers to
provide good quality care, but it also requires collaboration between organisations and
clinicians to make sure that the patient is the focus of how care is provided. Promoting and
supporting that collaboration will be a key feature of the contracts with providers.
42
SECTION 7: PERFORMANCE AND QUALITY: THE APPROACH OF THE CLINICAL COMMISSIONING GROUP (cont.)
The CCG will work supportively with its NHS provider partners to ensure that
they have a small number of high priority areas that remain at the top of their
agenda, and drive the overall approach to quality care. These will be common to
all contracts.
Service Reviews:
• Each Trust will be required to undertake two service reviews per
year. These reviews will be in areas highlighted through shared
understanding of Hospital Mortality data (SHMI) and the NHS Atlas
of Variation. The reviews will be against NICE or best practice
guidelines with the review scope jointly agreed with Commissioners.
Improvement plans, where required, will be jointly agreed between
commissioners and providers and progress monitored through the
Quality Contract Meetings.
• Each Trust will participate, with primary care, in two shared clinical
audits per annum. These will be across jointly agreed patient
pathways and have jointly agreed development plans monitored
through implementation.
• Each Trust will demonstrate effective collaboration across provider
Trusts for the implementation of agreed models of care for
Children’s Services.
In addition the contract is being used to incentivise the CCG’s commissioning
intentions, as set out in the following section on developing services, by ensuring
that performance measures and incentives are used effectively in each contract.
• Not pay a Trust for care carried out that is agreed locally or
nationally as a ‘never’ event;
• Reduce the total contract payment to a Trust should the Trust be in
receipt of an improvement notice from the CQC.
Clear expectations for performance and quality are embedded in the CCG’s
relationship with its providers, with all quality and performance standards
mapped against the NHS Outcome Framework, developed in collaboration wit
the Cluster.
The CCG is developing its governance arrangements and its intelligence systems
with clinical leadership, through forums such as Clinical Advisory Groups where
clinical leaders from all Trusts address outcome, service quality and development
issues in open discussion and work projects across Trusts.
The CCG’s six localities ensure clinician and patient feedback are as close to the
patient as possible, with delegated authority to address local issues. This local
intelligence, is brought together with information from a broad range of data
sources ( lessons learnt, public health mortality and trend data, etc) to
proactively identify quality issues for action at local, or countywide level.
Quality contracting meetings will be appropriately supported at Director level
with clear communication between and within organisations.
Each quality component of the contract, individual targets and major areas of
focus, will have a named clinical lead from the CCG and from the NHS Provider
Trust. It is expected that this lead will be a Consultant, GP or Senior Clinical
Professional at an equivalent level
7. PERFORMANCE & QUALITY
• Each Trust will be required to report regularly on the outcome of
lessons learnt from complaints, serious incidents and external
service reviews, providing evidence of the effective implementation
of lessons learnt or agreed action plans.
The CCG will ensure that the care that it pays for through its contracts is of good
quality. Therefore the CCG will:
43
SECTION 7: PERFORMANCE AND QUALITY – CQIN TARGETS
CONTRACTING FOR QUALITY IMPROVEMENT IN 2012/13
There are a significant number of improvement areas in the CQIN and
other contract schedules which will drive quality improvements in our
providers. Examples linked to other elements of the Plan are shown in
the tables below. These cover delivery of transformational initiatives,
targets for improving quality in under performing areas and delivery of
operating framework priorities.
Transformational Priority
Reduction of 15% (609) patients
in use of anti-pyschotics by
patients on primary care dementia
registers
Dementia
Dementia screening for all
patients aged 75 and over- all
inpatient services ( acute, mental
health, community)
Care of the elderly
During 2012/13 there will be no
more than 365 falls which cause
harm in community settings
across Cumbria. (This is a further
stretch of 15% against 2011/12)
Frail older people model for
elderly care
10% reduction in unscheduled admissions
from residential care homes to acute trusts
during the day, Monday to Friday
Compliance with evidence based referrals
thresholds and clinical criteria (assessed
through clinical audit)
Performance and quality issues
Target
Clinical communication:
discharge letters
Discharge Letters to be sent 24
hours post discharge & of
appropriate quality The provider
will be penalised £50k Q1, £100k
Q2, £250k Q3&4 if the quality of
the discharge letters is not up to
standard
Quality issues in UHMBFT
CQIN payments dependant upon
detailed improvement and action
plans implemented and CQC
assurance achieved as per agreed
programme plans
HCAIs
Stretch targets for MRSA/CdIff
7. PERFORMANCE & QUALITY
Q1 integrated governance systems in place; Q2:
improved performance in LOS, length of stay,
A&E lodging; Q3.&4 reduction of admissions,
targeted against individual pathways against
11/12 performance (as set out in detailed
business case)
Target
Reduce anti-psychotic
prescribing
Target
Delivery of emergency floor
model
Evidence based referrals
Operating Framework area
44
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES
CANCER SERVICES
LONG TERM CONDITIONS
Cancer is the second greatest cause of death in Cumbria and although
overall incidence rates are lower than the national average, mortality
rates are higher. The five-year survival rate is 46.9%, which is
considerably lower than the regional and national average.
The number of people, in Cumbria, with one or more Long Term
Conditions (LTC) is set to increase rapidly over the next 20 years in line
with a rapidly ageing population. The current system for managing LTCs
does not equip individuals to make informed decisions about their own
health needs and be in control of their lives.
The Cumbria Cancer strategy, produced in 2010 aims to reduce the
number of deaths from cancer, the number of premature deaths and
the variation in death rates across the county.
The emerging model describes multi-disciplinary teams that will be
organised to reflect local needs and local characteristics. The multidisciplinary teams will be organised to deliver care based on the needs
of those patients who can walk in to receive their care and those who
can’t. Care will be supported by specialist teams mapped to areas of
need. Use of telehealth and telecare will be considered to enhance the
model.
NHS Cumbria recognises that whilst Primary Care and Community
Services have a key role to play in the delivery of an effective system all
providers, including Social Care and the 3rd sector, will need to work in
a different way. We are therefore working with partners to develop a
framework and model that makes things better for both patients and
staff who deliver care to everyone with a LTC. When agreed, the
implementation of the model and performance monitoring will be
overseen by the existing North and imminent South Cumbria Integrated
Systems Boards.
7. PERFORMANCE & QUALITY
In 2011, an external review of cancer services was undertaken, which
built on the strategy and enabled the identification of key priority areas
for Cumbria:
•
Improve early presentation with cancer symptoms, by
educating the public, public health campaigns, exploration
of incentives in primary care and engaging GPs in the early
diagnosis agenda;
•
Improve early diagnosis by improved GP response and
consistent access across the county to diagnostics to
exclude possibility of cancer e.g. ultrasound, CT, MRI;
•
Improved screening, increased ownership in primary care
of the take up of breast & bowel screening, follow up of
patients who do not attend and use of incentives e.g.
through a LES;
•
Primary care education e.g. by practices undertaking the
RCGP audit, develop education programme with
secondary care colleagues;
•
Information and data at practice level e.g. on screening
targets, use of 2 week waits, routes to cancer diagnosis;
•
Appoint clinical leads in each locality;
•
Develop world class oncology for Furness; and
•
Follow up support with community/practice nurse for
cancer survivors and palliative care patients.
The Cluster can confirm that there is sufficient capacity available to
manage the anticipated increased demand resulting from the national
Bowel Screening Programme.
The CCG is refreshing the strategy for 2012/13 to ensure it is focused
on the right areas and to invigorate these services for patients.
The vision for LTCs in Cumbria is of a whole system approach that
improves the lives of people with one or more long term condition. The
patient will be the key decision maker and will be equipped to take
control of their own healthcare. The vision addresses the health care
needs of the population alongside the individual needs of all patients
living with or at risk of a LTC. Service delivery will be centred on GP led
care that is wrapped around the needs of individual patients and
population.
45
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
MENTAL WELLBEING SERVICES
In line with England’s Mental Health Strategy, No Health without Mental
Health, Cumbria launched in October 2011 its own Strategic Framework,
Working Together for Wellbeing and Mental health 2011-14. Informed by
the national strategy and a mental health joint strategic needs assessment
(JSNA), and co-produced through a programme of engagement, it sets out
both to improve mental health and wellbeing of people in Cumbria and to
improve outcomes for people with mental health problems through high
quality, community oriented, services that are equally accessible for all.
It identifies the following key outcomes to ensure more people recover
sooner from mental health problems:
•
•
•
The JSNA has highlighted concerns about the high levels of alcohol related
hospital admissions and suicides in Cumbria, and about the quality and
capacity of the CAMHS service.
A multi agency Cumbria Mental Health Partnership Board, co chaired by
adult social care and a person who has personal experience of mental
illness, has been set up to assure delivery of the Strategic Framework. This
Board reports to the Mental Health Commissioning Steering Group and the
Cumbria Joint Commissioning Group, then through these into the Health
and Wellbeing Board.
• Continued focus on improving access to psychological therapies,
particularly for people with long term conditions;
• Continued improvements in physical healthcare of people with
mental health problems, supported through CQUIN targets;
• Development of mental health PbR in a shadow year, for
implementation in 2013/14, linked to domains and improved
pathways of care; this will also allow the development of more
and better community service alternatives alongside
preventative models of care;
• Whole system reviews of:
o Rehabilitation and recovery pathway;
o The effective use of the Psychiatric Intensive Care Unit
to ensure all PICU activity is managed within county;
o Child and Adolescent Mental Health Services, to
include review of targeted support for children and
young people at particular risk of developing mental
health problems, such as looked after children;
• Continued repatriation of out of county placements for
treatment in Cumbria;
• Improved substance and alcohol misuse services through a
market testing exercise undertaken in collaboration with the
Cumbria DAAT; and
• Support to deliver the Cumbria suicide prevention strategy.
7. PERFORMANCE & QUALITY
•
More mental health problems are identified and treated early
in the community;
People with mental health problems have better physical
health and live longer;
High quality, recovery focused specialist services are available
to all when needed; and
Citizens, service users and carers are fully engaged and
empowered and more people have a positive experience of
care and support.
Within this context, priorities for 2012-13 for NHS Cumbria are:
46
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
ELECTIVE CARE
EMERGENCY CARE
NHS Cumbria has delivered significant change in recent years in the
commissioning of planned care and is now in the top quartile of
performance in the North. However the CCG believes that there are further
opportunities both to deliver care in non secondary care settings and to
ensure the appropriateness of referrals.
The CCG is commissioning a new model of emergency care in north Cumbria which
is outcomes focused and performs against a set of measurable service aims. All
providers of health care are integrating emergency and urgent care services to
improve the experience for patients whilst achieving greater efficiency and use of
resources.
Service Transfers
Following a procurement process, optometrist-led ophthalmic follow ups
will be available, together with Low Vision triage services. Both of these
will contribute to easing the significant capacity issues in this specialty in
the north of the County.
Repatriation of Services
Commissioners will be working with providers to ensure that patient choice
is available locally for all secondary care services which can be safely and
appropriately provided in local hospitals and that these are correctly
applied through Choose and Book and associated service directories.
Earlier Discharge
Commissioners and providers are developing business cases to determine
the viability of earlier discharge into the community for selected
procedures (e.g. Joints).
Any Qualified Provider
NHS Cumbria is committed to offering three services to AQP from the
national directory. These will be community continence, community
diagnostics and primary care psychological therapies.
The new ‘Integrated Emergency Floor’ based on each acute hospital site will:
•
Be clinically led and collaborative;
•
Deliver a single point of access into urgent care services, including
‘out of hours’ services;
•
Clinically triage patients into a primary care & community minor
illness/injury pathway and a more serious acute pathway of care;
•
Case manage patients through emergency care and improve
discharge; and
•
Divert inappropriate admissions from secondary care.
Whilst the model for emergency and urgent care changes, ambulatory pathways of
care are being implemented for a range of conditions with the intention to manage
patients with chronic conditions or acute exacerbation in a more efficient and
effective way.
A systematic high quality Integrated Emergency care service will be in place by April
2013 with the aim of reducing admission to hospital for some conditions, focussing
resources on the most effective treatment for patients and removing organisational
boundaries that cause patients to experience a higher rate of admission than may be
acceptable.
7. PERFORMANCE & QUALITY
Evidence Based Referrals
Although NHS Cumbria already has an EBR policy in place, this is being
extended and strengthened for 2012/13 with IT led decision support
through GP clinical systems to aid effective referral management. In
addition compliance with EBR protocols is being negotiated into acute
contracts.
Adopting a whole systems approach to managing urgent care demand has become a
priority as the trend for urgent care is rising at national level and within Cumbria
there are pockets of patients who are more likely to experience an admission to
hospital than others.
47
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
NHS 111
The CCG has played an active part in the development of the 111
project in the North West and is committed to the regional
procurement process.
The CCG has elected to seek a ‘sub-regional’ footprint for provision of
111 telephony as it believes local knowledge and content are vital to
the success of the project. A full and functioning directory of services
has been compiled for the county.
The CCG has made clear that 111 is an integral part of improving
primary care and community services. The CCG’s expressed wish is to
create a single point of access (SPoA) for Cumbria with 111 as the
front end public number for a range of non urgent clinical services.
This list is not exclusive and the CCG will be seeking partners who can
add the greatest value to enriching primary care and community
services.
This service will be fully functional by the start of the 2013/14
financial year.
Cumbria is below trajectory for both MRSA Bacteraemias and
Clostridium difficile infections. There is a Cumbria wide approach
to dealing with these infections with close cooperation between
primary care, secondary care and commissioners. We have
worked with providers and the Health Protection Agency to
comply with the mandatory reporting for meticillin sensitive
staphylococcus aureus (MSSA) and E.coIi bloodstream infections.
Preventive activity will continue to focus on high impact
interventions of known efficacy, such as hygiene and appropriate
use and care of lines and catheters. We will be assured of
sustained, reduced rates of Clostridium Difficile associated
diarrhoea and MRSA bacteraemias across the health economy via
the Provider Assurance Framework.
Specific initiatives that we plan to progress in the Cluster this year
include:
• Ribotype initiative;
• Clostridium difficile testing flowchart; and
• Root cause analysis review
The above initiatives will be progressed through the Cumbria
Infection Prevention Steering Group. There are already effective
County wide networks which will be used to implement the
protection and prevention initiatives outlined above. MRSA
targets will be included in contracts and the framework outline
above will deal with underperformance.
We will continue to use the HCAI assurance frameworks as
evidence that all relevant actions are being taken and that
compliance with the Health and Social Care Act and national
guidance is delivering significant improvements for patients.
7. PERFORMANCE & QUALITY
A specification is being drawn up to supplement the regional
procurement process. This specification will require providers to
demonstrate that they will deliver not only non urgent call handling
but also develop services such as:
• Out of Hours services;
• Long term condition advice;
• Specialist nurse services;
• Social services advice and contact; and
• Booking services for patient transport, dentistry etc.
HEALTHCARE ASSOCIATED INFECTIONS
48
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
STROKE SERVICES
The Cluster has highlighted difficulties associated with the delivery of stroke
targets in 2011/12 predominantly as a result of the issues faced by UHMBFT.
Whilst performance at NCUHT is close to achieving the 80% on a
consistent basis, the variable performance at UHMBFT means that the Cluster
will struggle to attain the target across Cumbria by 31st March 2012. This is
despite recent improvement in Q3 where the 80% target was achieved by
UHMBFT in two months out of the three.
Recommendations from the review:
Thrombolysis: The Coronary Care Unit does not have the
facets required for hyper acute stroke care. A process
mapping exercise needs to be undertaken once again. In the
interim the organisation needs to decide on where to locate
circa 6 beds where it will be possible to deliver appropriate
hyper-acute stroke care on a 24/7 basis. For thrombolysed
patients there will be a requirement for monitoring; other
patients with more severe strokes will be sicker and need to
be properly and safely managed and this would help to
reduce current mortality rates.
To address the current issues, the Royal College of Physicians was invited by
the Lancashire Stroke and Cardiac Network to undertake a peer review.
•
Early Supported Discharge: pursue plans to develop this.
The informal outcome of the peer review highlights significant concerns:
•
Commit to engage positively with the Cardiac & Stroke
Network.
Overall, there is still concern about the ability of UHMBFT to achieve longer
term sustainable performance. This is a view shared by North Lancashire
Cluster.
•
•
•
•
•
•
•
Lack of ownership across the whole pathway;
Lack of responsibility across the organisation at all levels;
Key relationships are not working;
Pathways are haphazard and fragmented;
Lack of co-ordinated approach;
No proper setting of targets or effective action planning; and
Multiple disconnections in the layers of the organisation.
The review concluded that current stroke unit cannot provide safe and
effective care for neurological emergencies and is probably 15-20 years
behind current best practice for Stroke care. There needs to be:
•
•
•
•
•
Rigorous, robust ownership and accountability at all levels;
Review of Clinical leadership with support for development of
key roles;
A full review of what can be delivered on the RLI site;
Revision of the whole pathway - thinking about the whole
service differently; and
A Stroke champion at Board level.
The above recommendations will be built into the 2012/13 contract with
the Trust, along with a requirement for a recovery plan that addresses
the Peer Review concerns.
It is apparent that there is a need for a fundamental overhaul of stroke
services, which may mean that achievement of performance targets
continues to be variable in the south of Cumbria in the coming year.
7. PERFORMANCE & QUALITY
•
49
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
SMOKING QUITTERS
HEALTH CHECKS
The Stop Smoking Service (SSS) was transferred to the Cumbria
Partnership NHS Foundation Trust in April 2011. Important developments
have resulted in improved patient experience:
•
The introduction of a central telephone booking system has enable
patients to be offered immediate appointments;
•
Patients can access immediate support via a telephone consultation
called ‘Direct Quit’; and
•
The development of an online database via EMIS web, which allows
for immediate access to patient notes and also paperless working.
Between 2010 and 2012 NHS Cumbria piloted a primary care based
Health Check programme within one locality in Cumbria. This targeted hard
to reach individuals. Clinical audit within one participating practice
suggested that the programme has been successful in identifying and
engaging patients with previously undiagnosed vascular conditions.
Some difficulties have been experienced in producing documentation for
the Department of Health return, which is being addressed.
There is growing support amongst Authorities in Cumbria to introduce a voluntary
ban on smoking in children’s play areas.
Women who smoke during pregnancy are being rewarded for not smoking as part
of a North West program to reduce the Smoking at Time of Delivery (SATOD)
target. Evaluation by Stirling Universityshows that the program results in fewer
women smoking throughout their pregnancy.
A program to identify those at risk of undiagnosed COPD targets customers at two
pharmacies and the local Stop Smoking Services. Customers are offered the
chance to be tested, with results being forwarded to their GP.
Practices will be encouraged to prioritise hard to reach and high risk
individuals and will be supported by the Department of Public
Health and primary care information systems to enable them to do
this.
Once the primary care programme is established, the Department
of Public Health will also commission social marketing activity to
promote further uptake in more deprived communities. This
will build upon the lessons learned from the recent successful
‘cough, cough’ Lung Cancer campaign which utilised a mix of
professional engagement, media and community partnership
approaches to increase patient ‘push’ factors as well as service
‘pull’ factors.
The department of Public Health is also currently developing a
Health at Work programme with major employers in the county
and will be exploring the potential for implementing NHS Health
Checks in workplace settings.
7. PERFORMANCE & QUALITY
Advocacy work and campaigns have been delivered addressing the accessibility
and visibility of tobacco products by children:
•
The removal of vending machines and point of sale displays;
•
Smoke free environments for children – in homes and cars; and
•
Raising awareness of illicit tobacco.
A specification for a primary care Local Enhanced Serviced (LES) has been
developed which will roll out within all localities
during 2012/13. The specification meets the full requirements of the
NHS Health Check programme and will use the national dataset
to record findings.
50
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
FRAIL ELDERLY SERVICES
The CCG is developing a new service model for frail older people. Frailty is
difficult to define with specificity, and is experienced by different people
at different ages.
Key features of the service model include:
•
Clinical leadership from a lead Consultant Geriatrician;
•
Assessment and Care Planning around the individual and
their family, rather than around a presenting condition; and
•
Integrated Care, across physical and mental health needs,
across Primary and Secondary Care, and as far as possible
across health, social care and the third sector.
The model will enable improved outcomes including:
•
Reduce avoidable hospital admissions, including from
residential/nursing homes and from patients at high risk of
admission;
•
Reduce hospital LOS, including a reduction in LOS for patients
with a dementia co-morbidity;
•
Reduce inappropriate medication; and
•
Reduce morbidity (specific metrics, e.g. reduction in
fractured neck of femur).
The patient stories collected by each of Cumbria’s three NHS Trusts will
heavily inform the development of the service.
NHS Cumbria is working with Cumbria County Council Adult and Community
Services and other partners to deliver the Cumbria Dementia Strategy.
Implementation of the dementia strategy and improvement of care
environments have been identified as priorities for the investment of
resources transferred to the local authority.
NHS Cumbria is leading the following work streams of the action plan:
• Prevention and public health;
• Integrated care pathways, including early diagnosis, reducing
prescribing of antipsychotics, end of life care, and care in care
homes; and
• Inpatient care.
Antipsychotic prescribing has been audited in primary care and in specialist
dementia services. Findings of the primary care audit and advice and
information on alternatives to prescribing have been sent to all Cumbria
practices. Findings of the specialist audit are also being implemented.
Repeat audits are to take place later in 2012. A CQUIN target for reduced
antipsychotic prescribing has been set.
The Acute Trusts in Cumbria are implementing the findings of the national
audit of dementia care in hospitals and will be compliant with relevant NICE
quality standards, with information published in quality accounts. The new
mental health liaison service will support delivery of the national CQUIN to
improve diagnosis of dementia in hospitals. A specification for dementia
advisors has been developed jointly by health and social care, and is to be
piloted across Cumbria.
Cumbria CCG is reviewing care pathways and service specifications for
dementia with a strong locality focus.
Cumbria CC will invest £1.9 million in the dementia strategy over the next 2
years from NHS funds, with the CCG investing a further £0.6m in 2012/13 in
dementia services. The CCG funding of £0.9 million for demographic issues
in 2011/12 in CPFT has been mainly focused on dementia services.
7. PERFORMANCE & QUALITY
The model will:
•
Support the pro-active management of the frail elderly
including those resident in nursing and residential homes;
•
Provide rapid assessment for those experiencing acute illness
or deterioration;
•
Radically change hospital discharge and continuity of care;
•
Improve the end of life pathway, using GSF / Liverpool care
standards; and
•
Provide a specific focus on dementia co-morbidities.
DEMENTIA SERVICES
51
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
CHILDREN’S SERVICES
We aim to commission integrated (acute, community and mental health)
children’s services fit for purpose in the 21st century in partnership with
Cumbria County Council’s children’s services. The strategy is aligned to
Cumbria Children’s Trust Board’s vision:
•
No avoidable child deaths;
•
No children living in poverty;
•
All children to be ready for school at five years of age; and
•
Young people ready to be proactive and productive citizens.
To deliver this, we have embarked on a programme of change in
conjunction with our service providers. This includes an integrated pathway
development for key conditions in childhood e.g. urgent care, constipation,
fever, acute respiratory, emotional wellbeing, ADHD, ASD and reflects
services being delivered Closer to Home for children and their families. This
will also address and improve the health outcomes for children and young
people in Cumbria. At present, these outcomes are described as ‘average’
but they hide large inequalities which exist across the county.
In the West, in conjunction with the plans for a new West Cumberland
Hospital, the implementation of the urgent care pathway provides an
opportunity to ensure that an appropriate model of care will be developed
to meet the needs of children and to avoid unnecessary admissions to the
hospital. We have agreed with our providers the principle of an integrated
emergency floor model with paediatrics which will provide timely senior
paediatric assessment and opinion. This will undoubtedly improve the
safety and the quality of service including safeguarding. This approach will
streamline resources which would be more appropriately used in the
community.
Health Builders for Children and Young People- an approach to delivering
innovative healthcare- was formed in 2010 as a consortium of health care
providers in Cumbria, led by a senior paediatrician. This in initiative is
supported by a group called The Village Elders, which includes parents,
members of the Children’s Trust Board, the Local Authority,
representatives from the voluntary sector, General Practice, Lancaster
University, a Public Engagement Lead and our four Health Trusts (NHS
Cumbria PCT, UHMBFT, NCUHT, CPFT. This has paved the way for the
development of a new children and young people’s service in Cumbria.
This approach will support families and their communities to become the
healthiest children, adults and parents of the future. This initiative is a
response to concerns and feedback from the users and the staff about
current services (and confirmed in Dr Andy Mitchell’s report, Review of
Children’s Services, Cumbria PCT, Feb 2009 and the publication of the
National Child Health Strategy- Healthier Lives, Brighter Futures).
The National Strategy outlines a vision of continuous improvement in the
quality of children’s services and an ambition of making England the best
place for children to grow up.
The Health Builder foundation stones- equity, access, prevention (includes
early intervention and prevention and health promotion) and experience of
service form the basis of their pathway development.
7. PERFORMANCE & QUALITY
The urgent care pathway will streamline care for children so the right care
is available to children at the right time and in the right place by a
workforce with the right skills. This should reduce the number of children
admitted to hospital and facilitate children being treated Closer to Home.
The constipation pathway which was implemented in August 2011 in
Furness has had an impact on reducing admissions to hospital and is now
being implemented in all Localities with support from the Locality Boards.
In addition, the paediatric consultant workforce will undertake more
outreach clinical work and will also provide education, training, and
support to primary care and multidisciplinary teams.
52
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
CARERS
During 2011/12 NHS Cumbria agreed recurrent funding for carer
organisations in each local authority area, in consultation with Cumbria
County Council. Carer organisations submitted plans for how the money
would be used in each area in line with the Carers Strategy. The
recurrent funding levels which will be provided are set out below.
Performance is led by localities via their contracts with the carers
organisation. Quarterly reports to the localities include:
The detail of services that are being developed are:
•
Carer support workers being funded with a focus on
supporting primary care to identify carers and refer for
assessment of needs;
•
Increase in services available to support carers through the
carer organisations; and
•
Funds in each locality to support short break opportunities.
Some localities have supported this work with a LES for Primary Care to
encourage GPs to identify carers and assess health needs in light of their
caring roles. Further money has been requested through the transfer of
money to ASC to support awareness raising training to be delivered in
each practice across the county. A decision about these funds is awaited.
Roll out of Personal Health Budget work has begun already in
conjunction with Adult Social Care to support those moving from joint
packages of care to fully funded healthcare to continue in packages they
have established. Where direct payments have been used from ASC,
brokerage arrangements are put in place to ensure continuity of
packages. These have been in place for some time.
Learning from the ASC In Control programme is being shared and a
funded post to support development of personalisation in healthcare is
in place through the ASC money for health outcomes. This post will focus
on all health funded packages including CHC, mental health and
children’s packages.
Locally we are linking with work across the North West to share learning
and develop systems to support personalisation.
Developments in South Lakeland, which operates the same broad
agreement as in the rest of the county, include an additional 500
individual short breaks per year for carers, including up to 5 relaxation
treatments for 80 different carers and up to 4 sits for 50 different
carers; a sitting service to provide a volunteer for up to 3 hours; a
requirement to complete 100 carers’ assessments per year; moving and
handling training for 50 carers on a one to one basis. Carers will have
access to flexible grants which will allow them to spend up to £300 on a
break.
Budget
2011/12
£’000
Recurrent
Budget
£’000
North Cumbria
214
305
South Cumbria
136
195
TOTAL
350
500
7. PERFORMANCE & QUALITY
• Overall number of new referrals during the month from a
Primary care source;
• Breakdown of number of referrals in the three months from
individual GP Practices; and
• Number of:
o referrals that have led to a full carers assessment;
o support groups provided for young carers across the
range of intervention;
o young Carers receiving trips and number of Young
Carers attending support groups;
o carers receiving relaxation treatments and number
of treatments delivered;
o carers receiving a sit and number of sits delivered;
o carers receiving domestic support or other break
and number delivered;
o moving and handling training sessions delivered.
53
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
END OF LIFE SERVICES
HEALTH VISITORS AND FAMILY NURSE PARTNERSHIPS
The population of older people in Cumbria is predicted to rise significantly
over the next 20 years and by 2029 over 28% of the population will be over
65. By 2031 it is estimated that over 5% will be aged 85 or over, therefore the
CCG is is cognisant of the impact this will have on end of life care services.
The Cumbria target for Health Visitor establishment is 98 and the Cluster
is on track to deliver against the trajectory.
The vision for end of life care in Cumbria is one that supports people with
advanced or progressive incurable illness to live as well as possible until they
die. This means providing people and their carers with an opportunity to make
choices about their priorities for care and ensure that as far as possible they
are treated with dignity, respect and the appropriate levels of care in all care
settings.
This will deliver greater quality for patients and carers as well as improved
performance for all providers. To achieve this we need to complete the
programmes of county wide DNA CPR; achieve electronic connectivity across
all palliative care settings; design an education framework to identify the core
competencies required across health and social care settings and manage
providers to make the change.
The target for 2012/13 is an additional 7.8 Health Visitors. There are
currently 8 Health Visitors undergoing training with a total of 41 by
2014. It is expected that the target will be met for 2012/13.
The Health Visiting Project Board oversees and monitors the
implementation of the new service model, quality of provision and
future workforce configuration. Members of the group include NHS
Cumbria Cluster and CCG, Public Health, Safeguarding, Workforce
Development, GP provider and commissioner.
Health Visitor Trajectories
Establishment target
Additional posts needed in year
11/12
12/13
13/14
14/15
15/16
76.1
78.4
86.2
92.9
98.5
2.3
7.8
6.7
5.6
0
7. PERFORMANCE & QUALITY
The Cumbria End of life multi-agency workstream is developing the ‘Cumbria
Deciding Right’whole system approach to the delivery of end of life care that
supports:
•
Early identification of patients and coding in line with the North
West End of Life care model;
•
Advanced Care Planning using the end of life planning tools –
Gold Standards Framework Preferred Priorities of Care and
Liverpool Care Pathway;
•
Delivery of information to support the patient and their
family/carers;
•
Timely and appropriate use of ‘Do Not Attempt Cardio
Pulmonary Resuscitation’ (DNA CPR); and
•
Support through bereavement.
The 2011/12 target is to have 78 Health Visitors in post by 31 March 12.
The actual position in January 2012 is 74 Health Visitors in post. The
projected year end position is 76.
54
SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)
PRIMARY CARE SERVICES
IMPLEMENTING THE INNOVATION REVIEW
Primary Care services have significant importance in ensuring that the
Cumbria health system achieves its commissioning intentions. Its
development as an integral and integrated part of the health system in
Cumbria is regarded as a key enabler to achieve the performance and
quality objectives of the CCG.
The Cluster is currently working towards implementation of the
Innovation Review and the six High Impact Innovations. Many
innovations have already been adopted across Cumbria through delivery
of evidence based clinical pathways.
A strategy is being put together which covers how primary care will
continue to develop as part of the healthcare system and this will address
health improvement, patient experience and new models of care
delivery. That strategy will need to address capacity issues, in particular
in the urban areas and west coast localities, particularly in Barrow. These
are the communities which have the poorest health of all Cumbrians.
During 2012/13 the CCG will focus on the following key issues:
• Increasing primary care capacity in Barrow;
• Supporting the primary care workforce: increase in capacity,
skills development and mentoring;
• A primary care led approach to CVD healthchecks;
• Increasing efficiency and developing shared support systems
across GP practices through the Productive Primary Care
programme;
• Development of the Year of Care model for Long Term
Conditions; and
• Locality based primary and community care teams, with local
area services e.g. for frail elderly care, and care of the elderly
physicians working as part of multi disciplinary teams with
primary care practitioners.
Safer care programmes have been implemented in all provider
organisations.
The Year of Care Programme is about to be launched by the CCG and
builds on the national pilots.
We want to ensure all patients receive the best possible clinical care and
aim to systematically ensure that all providers deliver care in line with
the Right Care Atlas of Variation.
7. PERFORMANCE & QUALITY
The development of the strategy is an important objective for the CCG
during the first quarter of 2012/13. It is important that primary care
increases its effective capacity, works consistently to high standards,
ensures the efficient use of resources and develops new models of
integrated working across the primary, community and secondary care
sectors.
GPs have been using Map of Medicine to ensure referrals are made at
the right time and to the right clinician.
55
SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Preventing people from dying prematurely
xxx
In January the Cluster underachieved on one cancer target however there has been overall performance improvement and full compliance should be
xxx
achieved by year end with ongoing delivery against targets during 2012/13.
Measure
PHQ 01
PHQ 02
Ambulance quality Cat A response within 8 mins
- Cat A response
times
Cat A response within 19 mins
PHQ 03
PHQ 04
Cancer 62 day
waits
PHQ 06
PHQ 07
PHQ 09
Cancer 31 day
waits
Percentage of patients receiving first
definitive treatment for cancer within 62days of an urgent GP referral for
suspected cancer
Percentage of patients receiving first
definitive treatment for cancer within 62days of referral from an NHS Cancer
Screening Service
Percentage of patients receiving first
definitive treatment for cancer within 62days of a consultant decision to upgrade
their priority status
Percentage of patients receiving first
definitive treatment within one month of a
cancer diagnosis
Percentage of patients receiving
subsequent treatment for cancer within
31-days where that treatment is Surgery
Percentage of patients receiving
subsequent treatment for cancer within
31-days where that treatment is an AntiCancer Drug Regime
Percentage of patients receiving
subsequent treatment for cancer within
31-days where that treatment is a
Radiotherapy Treatment Course
12/13
T’hold
Jan 11
(YTD)
11/12
Year End
April
2012
12/13
Year end
75%
76.5%
>75%
>75%
>75%
95%
95.8%
>95%
>95%
>95%
85%
84.7%
>85%
>85%
>85%
90%
96.7%
>90%
>90%
>90%
85%
93.8%
>85%
>85%
>85%
96%
96.7%
>96%
>96%
>96%
94%
96.8%
>94%
>94%
>94%
98%
98.6%
>98%
>98%
>98%
94%
95.6%
>94%
>94%
>94%
Operational Plans to secure performance
Improved performance and anticipate full
achievement by year end
Improved performance and anticipate full
achievement by year end
7. PERFORMANCE & QUALITY
PHQ 05
PHQ 08
Definition
56
SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Enhancing quality of life for people with long-term conditions
Measure
Definition
12/13
T’hold
Dec 11
(YTD)
11/12
Year End
12/13
Year End
Mental health measures - EI
The number of new cases of psychosis
served by early intervention teams year to
date
-
95
126
(target:
195)
195
PHQ 11
Mental health measures CR/HT
Commissioner measure is number of
episodes, provider measure is % of
inpatient admissions that have been gate
kept by CR/HT
-
165
169
169
PHQ 12
The proportion of people under adult
mental illness specialties on CPA who were
Mental health measures - CPA followed up within 7 days of discharge
from psychiatric in-patient care during the
quarter (QA).
95%
96.1%
>95%
>95%
-
10.8%
13.5%
13.5%
-
43.4%
45%
48.5%
PHQ 13
Mental health measures IAPT
Proportion of people with depression who
receive psychological therapy
Proportion of people who complete
therapy who are moving to recovery
PHQ 14
People with Long Term
% of people with LTCs who said they had
Conditions feeling
had enough support from local
independent and in control of
services/orgs
their condition
PHQ 15
Unplanned hospitalisation for Proportion of unplanned hospitalisation
chronic ambulatory care
for chronic ambulatory care sensitive
sensitive conditions (adults) conditions (adults) per 100,000 population
PHQ 16
Unplanned hospitalisation for Proportion of unplanned hospitalisation
asthma, diabetes and
for asthma, diabetes and epilepsy in under
epilepsy in under 19s
19s per 100,000 population
* Sep 11 data only
-
-
-
87.4%*
TBC
TBC
>82%
TBC
TBC
>82.7%
TBC
It is expected that there should be a reduction
in admission rates. This is a new indicator for
12/13 and no guidance on specific targets has
yet been issued.
TBC
It is expected that there should be a reduction
in admission rates. This is a new indicator for
12/13 and no guidance on specific targets has
yet been issued.
7. PERFORMANCE & QUALITY
PHQ 10
Operational Plans to secure performance
57
SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Helping people to recover from episodes of ill health or following injury
There has been a year on year reduction in acute emergency admissions. Although the trajectory has yet to be defined delivery of the indicators is
aligned with commissioning intentions.
Measure
PHQ 17 Emergency Admissions
Definition
Emergency admissions for acute
conditions that should not usually
require hospital admission
T’hold
Latest
data
Mar
2012
April
2012
Mar
2013
TBC
TBC
TBC
TBC
Operational Plans to secure performance
This target is aligned with commissioning
intentions and contract values. It is expected
that there should be a reduction in admission
rates. This is a new indicator for 12/13 and no
guidance on specific targets has yet been issued.
7. PERFORMANCE & QUALITY
58
SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Ensuring that people have a positive experience of care
There will be a dip in RTT performance during Q4 2011/12 however full compliance will be achieved from April 2012 onwards.
Measure
PHQ 18
Definition
T’hold
Jan 11
YTD
11/12
Year End
April
2012
12/13
Year End
Outliers identified using NHS PF
Patient experience
approach + narrative & results of
survey
local surveys
RTT - admitted % within 18 weeks
90%
87.5%
<90%
>90%
>90%
PHQ 20 RTT waits
RTT - non-admitted % within 18
weeks
95%
96.3%
<95%
>95%
>95%
PHQ 21
RTT - incomplete % within 18 weeks
92%
89.8%
<92%
>92%
>92%
PHQ 22 Diagnostic Waits
% waiting 6 weeks or more
<1%
0%*
<1%
<1%
<1%
PHQ 23 A&E
% of patients who spent 4 hours or
less in A&E
95%
96.7%*
>95%
>95%
>95%
93%
94.7%
>93%
>93%
>93%
93%
93.9%
>93%
>93%
>93%
minimal
74*
99
Minimal
Minimal
PHQ 24
PHQ 26
Cancer 2 week
waits
MSA breaches
Percentage of patients seen within
two weeks of an urgent GP referral
for suspected cancer
Percentage of patients seen within
two weeks of an urgent referral for
breast symptoms where cancer is not
initially suspected
Numbers of unjustified breaches
Resolution of incomplete pathways will
result in underachievement of admitted
pathway at NCUHT until May 2012.
However there will be full compliance
from June 2012.
7. PERFORMANCE & QUALITY
PHQ 19
PHQ 25
Operational Plans to secure performance
59
SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Treating and caring for people in a safe environment and protecting
them from avoidable harm
Measure
PHQ 27
PHQ 28
PHQ 29
HCAI measure
(MRSA & CDI)
VTE Risk assessment
Definition
T’hold
MRSA bacteraemia
Jan 11
YTD
11/12
Year End
12/13
Year
End
8
<12
7
200
<243
190
Operational Plans to secure performance
CDI
% of all adult inpatients who have
had a VTE risk assessment
-
92.5*%
>90%
TBC
Although no plans are required and no
specific standards have been set nationally, it
is expected that performance against this
indicator improves.
7. PERFORMANCE & QUALITY
60
SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Public Health
Measure
PHQ 30 Smoking Quitters
PHQ 31
Definition
T’hold
Dec 11
YTD
11/12
Year End
12/13
Year End
Number of 4 week smoking quitters that
have attended NHS Stop Smoking Services
-
2083*
3520
3807
% people ages 40-74 who have been
offered an NHS health check
-
0.34%
0.5%
20%
-
0.34%
0.5%
13%
Coverage of NHS
Health Checks
% people ages 40-74 who have received an
NHS health check
Operational Plans to secure performance
Resource constraints has precluded delivery in
2011/12. Resources are in place for 2012/13
and commissioning arrangements with
primary care for the following two years are
being finalised.
7. PERFORMANCE & QUALITY
61
SECTION 7: PERFORMANCE AND QUALITY: INEQUALITIES AND MORTALITY
Life expectancy varies across Cumbria., and on average is slightly below the national average rate. Mortality rates in Cumbria are high and action is
being taken to improve health outcomes across a range of high prevalence clinical conditions.
Cumbria is a county of contrasts with major differences in health
outcomes across the county. As a whole, Cumbria outcomes are similar to
the national average across a range of health measures. However, there
are marked differences between good health outcomes in South Lakeland,
Eden and much of Allerdale compared to poor health outcomes across the
board in Barrow, Copeland and Carlisle.
Causes of deaths in major disease categories in Cumbria,
January 2010 to December 2010
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
The main causes of mortality in Cumbria are cancer and circulatory
disease, with 34.7% all of deaths being associated with cancer and 22.4%
with circulatory disease.
30.0%
Overall, average life expectancy in Cumbria for both males and females is
slightly less than the national figure. But the average raises issues in
particular areas and four out of the six districts in Cumbria have a lower
life expectancy than the England and Wales average, with only Eden and
South Lakeland having a higher life expectancy. The most recent life
expectancy data shows that female life expectancy has decreased in
Cumbria, acting to widen the gap between Cumbria and the national
average, but the average masks issues in particular areas.
10.0%
Circulatory
Disease,
22.4%
Accidents,
8.5%
Diseases of the Digestive System, 7.3%
Circulatory Disease, 5.6%
20.0%
Suicides, 5.4%
Other,
16.1%
0.0%
Male life expectancy varies by 2.4 years between people living in Barrowin-Furness (77.1) and Eden (79.5). This contrast is even starker at ward
level where there is nearly a 20-year gap in life expectancy between
people living in Moss Bay in Workington and Greystoke in Eden.
7. PERFORMANCE & QUALITY
Health inequalities is linked to deprivation. There are significant levels of
deprivation in Barrow (which is the second most deprived shire district in
England), parts of Carlisle and West Cumbria, as well as pockets of
deprivation in rural parts of the County (Carlisle and Barrow were
designated Spearhead areas i.e. in the fifth of areas nationally with the
worst health and deprivation indicators). Around 16% of our population
(95,000 people) live in the bottom fifth of the most deprived wards in
England. Around 55,000 people in Cumbria live in wards which are ranked
amongst the most affluent 20% of wards nationally.
Cancer,
34.7%
62
SECTION 7: PERFORMANCE AND QUALITY: INEQUALITIES AND MORTALITY (cont.)
Life expectancy at birth gap between the England and Wales average
and local authorities in Cumbria. (2007-2009)
Males
Females
84
The mortality data will form an important part of the
discussions within the commissioning and contracting
processes, especially around 'contracting for quality', both
through the CQUIN process and in shaping the commissioning
intentions of the CCG. It will also be a fundamental feature of
the development of a clinical strategy for Morecambe Bay (P17)
82
80
78
76
74
72
70
Stroke care in north Cumbria has improved but changes are
necessary in south Cumbria to establish an effective stroke unit.
This work is underway.
England
Allerdale
Barrow
Carlisle
Copeland
Eden
South L
Cumbria
The CCG and Cluster is actively working with both Trusts to improve
performance. Examples are enabling service redesign to ensure
consultant led acute services 7 days a week to counter the increased
risk at weekends and overnight. Improved clinical pathways will ensure
prompt assessment of acute illness within Trusts and the community.
SHMI
HSMR
Deaths in
Low-Risk
Conditions
Deaths
after
Surgery
UHMBFT
114
124
1.01
127
NCUHT
112
118
0.53
163
IMPACT ON HEALTH INEQUALITIES FROM THIS PLAN
There are a number of areas in this plan which will have a direct
impact on reducing health inequalities, such as:
• Delivery of health checks and smoking cessation targets (page 50);
• Delivery of the Cumbria Cancer Strategy (page 45) and the cancer
access to treatment targets (page 56);
• Action in response to SHMI/HSMR data (as described on this
page);
• The new approach to long term conditions management (page
14);
• The transformation of primary care programme (page 15);
7. PERFORMANCE & QUALITY
The standardised mortality figures demonstrate high mortality rates in
both UHMBFT and NCUHT. The areas of concern reside in the high
prevalence conditions including stroke, ischaemic heart disease, upper
gastrointestinal bleed, and respiratory conditions. Cancer survivals are
also poor, especially for respiratory and colorectal tumours.
Particular emphasis will be placed on the necessary expertise
being in the right place at the right time, so that experienced
clinicians are positioned to effect the best outcomes. Both
trusts will need to reduce their reliance on locum clinicians and
junior medical staff.
• Delivery of the Cumbria Suicide Prevention Strategy (page 46); and
• Improvements in the quality of Stroke services (page 49).
63
SECTION 8: WORKFORCE
xxx
Delivery of the Strategic Vision alongside the system reform requires workforce planning across the whole system. A joint venture is in
place with Lancashire Cluster to develop and deliver a whole system workforce strategy.
All healthcare organisations across Cumbria aspire to provide high
quality, safe and integrated services and improve productivity and
performance. A well trained, committed and flexible workforce who
feel empowered to initiate change is an essential element in achieving
this overall objective.
NHS Cumbria Cluster has sought assurance from Providers around the
Key Lines of Enquiry and narrative questions in the Planning guidance
and the themes in the safety and quality assurance framework. It is
evident from the QIPP programme that the integration of health and
social care staff alongside redesigned care pathways and the
realignment of staff in line with service change will underpin the future
success of the Cumbrian health economy.
For the past three years there has been an increase in staff costs and
numbers across the health economy however this trend is reducing
with a 1% reduction in FTE against a 0.22% increase in cost during
2011/12. Work is underway to reassess the numbers and skills of staff
to ensure that services are affordable yet deliver high quality and safe
patient care.
Competency based workforce planning is driving workforce changes
by putting multi professional teams at the heart of the service
improvement and redesign. This is enabling rapid change and
transformation within community services resulting in better
management and reduced hospital admissions. In addition to
reshaping the workforce around care pathways there has also been a
focus on building sustainable capacity across the six localities in
Cumbria. New service models with increased workforce numbers and
skills and competencies are required on the west coast particularly in
Furness. Workforce strategies have required a reduction in the
workforce in some localities with increases in others. In order to
increase Health Visitor provision commissioners have agreed targeted
budget increases to localities such as Furness. Clinicians and
workforce teams have held roadshows and recruitment events to
attract candidates for the current and future workforce models and
expect to be amber for the March 2012 target, although further
recruitment is taking place. The target for March 2012 is 78.4 FTE,
currently the shortfall is 2.8 FTE.
8. WORKFORCE
Delivery of the Clinical Strategy requires an integrated approach with
relatively fewer staff providing care for more people with more complex
needs in changing healthcare settings. Community and primary care
staff will be more skilled in the management of long term conditions
and the prevention of ill health. Elements of the workforce strategy
have already been implemented with the development of community
provider teams and it is not expected that further investment will be
required. Ongoing priority includes the reshaping of the workforce
across care pathways and the education and development of the
workforce.
New ways of working has resulted in an increase in the number of
highly competent support staff and more efficient use of expert
clinical staff. Cumbria has received recognition within the northwest
for having successfully introduced the roles of cadets, apprentices and
assistant practitioners across a range of care pathways. The
introduction of these new support roles has had an impact on service
models and has led to change in the way student numbers are
commissioned for pre and postgraduate education programmes. The
changes in workforce configuration in Allerdale locality last year
resulted in a decrease in acute admissions and lengths of stay across
acute and community in-patient services. The positive outcomes
resulted in community teams winning seven national awards.
64
SECTION 8: WORKFORCE (cont)
The key workstreams supporting the changing workforce include:
•
•
•
•
The collaboration between Human Resources Directors will be extended
to include:
•
•
•
Benchmarking of workforce metrics including sickness
absence, turnover and workforce numbers alongside staff
surveys and staff forums;
Working across the North West to explore how eWin
functionality can be improved to interrogate data and
enable planning and performance management discussions
across pathways;
Working with Directors of Nursing in relation to working
with care homes, education strategy groups and
competency based education programmes for long term
conditions;
•
Training needs analysis and identification of workforce
competencies across care pathways and the
establishment of local education networks that can
deliver tailored and flexible programmes to the health
care workforce in Cumbria; and
Review of learning and Development activities to
promote eLearning and developmental toolkits,
generate reduced costs through more effective
procurement and greater portability of pre-existing
learning between organisations. The assurance work
undertaken indicates a need to improve participation
in appraisal and mandatory training to sustain staff
morale and the overall safety and quality of services.
Succession planning and talent management to retain and develop
the most talented staff is underway. This is a piece of collaborative
working across Cumbria and Lancashire which seeks to retain a
highly skilled and inspirational set of clinicians and managers to
drive and sustain service reconfiguration and redesign. It is even
more important to retain and develop these staff at a time of
change and the assurance work demonstrates the need for a more
systematic approach to leadership development at all levels.
8. WORKFORCE
•
Completion of the transition of PCT staff to new
organisations complemented by a programme of voluntary
redundancy to achieve necessary reductions in workforce
numbers;
Regular dialogue and planning with HEIs to ensure that
education and development programmes keep pace with
changing skill mix requirements;
Collaborative workforce planning and deployment to ensure
that staff are retained within the NHS wherever possible
thereby retaining skills and minimising the effect on local
communities of job losses;
Closer integration between CPFT Community Staff and
Adult Social Care; and
Integrated back office functions with Lancashire through a
joint venture Commissioning Support Service.
•
Health care organisations in Cumbria are seeking to maximise
opportunities for staff. This has included a review of the use of
agency staff, locums and overtime. All organisations have agreed a
target to reduce costs through the development of flexible
employment contracts and flexible staffing models.
65
SECTION 8: WORKFORCE (cont)
It is recognised that more development work needs to take place
to plan more accurately and at an earlier stage for the workforce
implications arising from pathway redesign and a methodology
for examining the workforce plans of local providers needs to be
developed. There is evidence of clinical involvement at all levels
in workforce planning (including Nurse and Medical Directors)
arising from service redesign but this needs to be more strongly
integrated with performance management systems generally and
for regular audits of actions to be undertaken.
Whole system reform across Cumbria means changes and
uncertainty for all staff.
A joint Transition Team has been established with NHS Lancashire
to ensure a smooth transition of all PCT functions and staff to
successor organisations during 2012/13. Work programmes
supporting transition are in place and staff are actively engaged in
managing themselves through this process positively and
constructively.
8. WORKFORCE
The major incident at UHMBFT has highlighted the need for a
more robust approach to examining workforce metrics against
quality and safety considerations and for identifying more robust
mechanisms to provide ‘early warning’ of workforce difficulties
impacting on service quality and safety. These pieces of work are
underway.
Where service reconfiguration or major clinical changes are
proposed the Communications and Engagement teams across
Cumbria and Lancashire are increasingly working together to
ensure that a robust strategy for Stakeholder and staff engagement
compliment the service redesign proposals. Existing
communication systems work well but the assurance work
indicates the need to improve the engagement and involvement of
staff representatives in services changes particularly in the PCT.
Key Milestone Plan for 2012/13
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
HR Strategy Forums established
Education and workforce plans agreed
Cohort 1 HV trainees commenced
Education and workforce strategy in place
66
SECTION 9: INFORMATICS
Cumbria has recognised that ICT can be a key enabler for improved patient care. To this end we embarked 12 months ago on an ambitious programme
of interoperability and electronic patient record deployment. Directed by good clinical leadership, this is already improving outcomes for patients and
care delivery as well as delivering efficiencies. The CCG plan is to build on this strong foundation of local interoperability and blend this with national
strategic initiatives, such as the summary care record (SCR), in order to further enhance patient care.
CAPABILITY AND CAPACITY
The Cluster and CCG are working with Cumbria Partnership Foundation
Trust (CPFT) to implement a deeper collaborative approach to informatics
delivery. Building on existing jointly delivered ePR and network projects, it
makes sense for us to define a common set of requirements for informatics
provision in Cumbria. Future informatics service provision will be shaped by
these requirements.
The Information Strategy for the NHS, defined in the operating framework
2012/13 outlines the need for improved patient access, better information
on outcomes to inform patient choice and supported by information
sharing across organisations to ensure the right information is provided at
the right time to improve patient care. In Cumbria we are already on this
journey and now have 75% of our community services fully operating in a
ePR, a growing programme of information sharing across primary,
secondary and community settings as well as innovative interoperability
work underway to join up information provision with non NHS providers to
support care pathways.
Recognising the common objective of moving this programme forward, we
have already agreed to establish a jointly funded Programme Office in
2012/13 to drive delivery and achieve the outcomes defined below.
Key Milestone Plan for 2012/13
Deployment of Summary Care Records
Deployment of Community Electronic Care
Records (ePR)
Deployment of Children & Young People Service
ePR
Telemonitoring/Telehealth
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
9. INFORMATICS
Apr
Patient Access to electronic records
Pilot Intelligence led choice for patients
(outcome led)
Information Sharing/Interoperability Programme
across organisations
Majority of Primary Care on hosted application
Business Intelligence to support commissioning
Review of Informatics Service
67
SECTION 9: INFORMATICS (cont.)
SUMMARY CARE RECORD
INFORMATION SHARING & INTEROPERABILITY
NHS Cumbria will be deploying the Summary Care Record (SCR) in
conjunction with the existing local detailed care record development
underway. We will have fully implemented the SCR by March 2013.
There is an ever increasing need for interoperability – the ability to share
information between multiple systems and service providers - to facilitate
and enable new and improved patient pathways. In addition, the need to
achieve more efficient working practices through the QIPP agenda is driving
healthcare providers to look for opportunities to improve processes, reduce
administration and the ‘paper chase’.
COMMUNITY & MENTAL HEALTH ELECTRONIC PATIENT RECORDS
(ePR)
In the next 7 months we will have completed the deployment of a
community based ePR. We will also be establishing a ePR for Children
and Young People services, including Child Health, by March 2013 in
conjunction with Cumbria Partnership Foundation Trust (CPFT) as
provider. We already have over 1600 community users operating in
clinically rich electronic patient records with information sharing
supporting clinical care across services as appropriate.
PATIENT ACCESS
.
We already have the technical capability to provide direct access for
patients electronically (EMIS) within primary care with our other major
primary care supplier (INPS) undertaking to provide the same
functionality in the next 12 months. However, there is still a programme
of work to ensure this is being universally activated and promoted to
patients so that it isproperly utilised. Wider access to records outwith
primary care will be supported by the implementation of electronic
patient records elsewhere in the programme.
We have a continuing programme of work to further enable information
sharing across care settings including:
• Sharing of clinical views between primary care and community services;
• Sharing of clinical views and discharge summaries between acute and
primary care services;
9. INFORMATICS
In parallel, we are working with CPFT to define and explore the
requirements for a Mental Health ePR and a deployment plan thereafter.
With this in mind, NHS Cumbria has embarked on a dynamic
interoperability programme that is already having far reaching benefits for
patients and the wider health economy in Cumbria. Through the sharing of
clinical views from detailed care records and associated clinical
documentation via a secure data exchange, clinicians have ready access to
accurate, timely information that supports patient care and joins up health
provision in an unprecedented way. Indeed, NHS Cumbria is leading the
way in the utilisation of the Medical Interoperability Gateway (MIG), a joint
system development by INPS and EMIS clinical systems.
• Sharing of electronic discharge summaries between Acute(s) and Mental
health trusts through to primary care; and
• Sharing notifications and support plans from adult social care to primary
and community services.
68
SECTION 9: INFORMATICS (cont.)
INFORMATION GOVERNANCE
SUPPORTING PATIENT CHOICE
One element of the CCG commissioning plan is to require that more ‘slots’
are published through Choose and Book to enable improved referral
processes, greater choice for the patient. We will also be deploying
mediated (system to system) referrals locally to enhance choice and
improve the quality of referral information supported by detailed care
record sharing.
The CCG is pushing CfH to enable Choose and Book compliance testing from
our Community EPR.
Planned enhancements to our ePR to support electronic care planning will
enable the capture and recording of outcomes for current patients. This in
turn will enable new patients to have better information of outcomes by
service in Cumbria. We intend to pilot outcome based choice following the
successful deployment of care planning in our ePR.
Business intelligence is a by product of high quality clinical data capture as
well as good administrative practices. Our ePR programme has allowed us
to design, build and implement a full data extract which, when blended with
other administrative information, supports more effective analysis of this
aggregated information.
In addition, CPFT is currently (March 2012) completing the roll-out of
additional functionality in the community ePR system to support the data
capture for RTT and CIDS datasets with our support. High quality
information is crucial to support patient choice and intelligent
commissioning.
Realistic plans are in place for all Provider organisations, including GPs and
the GP Out of Hours provider, to have achieved IG Toolkit compliance in
year.
TELEHEALTH AND TELECARE
With the geography of Cumbria the CCG recognises that telehealth and
telecare would bring significant patient and service benefits. The CCG is in a
pilot phase with Cumbria County Council to deploy assistive and monitoring
technology across the Allerdale locality led by a locality GP. Subject to
suitable justifications the CCG will assess further roll out.
The CCG has commissioned Wide Area Network upgrades which will be able
to support many to many High Definition video consultation and case
conferencing.
NHS NUMBER COMPLIANCE AND USEAGE
In the NHS Spine compliant systems in Cumbria NHS Number compliance is
complete. Some systems in Cumbria are not compliant but these are in the
process of being decommissioned as a result of our ePR programme. Any
new systems are required to be NHS number compliant.
9. INFORMATICS
BUSINESS INTELLIGENCE TO SUPPORT COMMISSIONING
Information governance is seen as a key enabler for pragmatic sharing of
clinical information with informed patient consent and legitimate
relationships. We have embedded IG support within our informatics
programme to ensure we have the best advice and guidance in all aspects
of our delivery.
PRIMARY CARE HOSTED APPLICATIONS
We have an on-going programme of migration of primary care systems to
hosted environments. This is to improve business resilience and continuity
as well as supporting information sharing at the detailed care record level.
As a by product this will also achieve efficiency savings in the longer term
through improved support arrangements and the decommissioning of on
site clinical servers.
69
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: TRANSITION PROGRAMME , CONTRACTS & NCB LOCAL OFFICE
A comprehensive Transition Programme and programme control process has been established , covering all aspects of transition to the new
commissioning landscape. The programme encompasses links to joint programmes with other agencies, including receiving bodies.
TRANSITION PLANNING
NHS COMMISSIONING BOARD
A comprehensive Transition Programme has been established within
the Cluster to plan and oversee the activities needed to ensure
effective transition to the new Commissioning architecture . It includes
workstreams covering routes to all receiving organisations/functions:
Following release of the design guidance for NCB there has been initial
scoping of the work required for transition to NCB local office
arrangements. Further discussions are required regarding the shape
and scope of a local office to cover Cumbria. However, planning and
activities for transition of Primary Care , Specialist Commissioning,
Prison & Military Health commissioning are well developed (see Direct
Commissioning section).
CCG; Commissioning Support Services; NHS Commissioning Board
(NCB) local office; & national scale services; NCB Primary Care; NCB
Specialised Commissioning; NCB Prison/Military; Public Health; Health
& Wellbeing Boards, PropCo; CT dissolution.
It also includes workstreams for cross-cutting functions that enable the
receiving routes:
Programmes incorporate all relevant national and NHS North of
England milestones and every programme workstream has an
identified executive level lead.
The Programme Steering Group regularly reports to the Cluster Board
and Management Executive. Progress reporting includes risk
management and linkage between workstreams.
A joint Transition Team has been established with NHS Lancashire to
ensure a smooth transition of all PCT functions and staff to successor
organisations during 2012/13. Work programmes supporting transition
are in place and staff are actively engaged in managing themselves
through this process positively and constructively.
CONTRACTS TRANSITION
The Cluster is fully engaged in the ongoing DH exercise to support the
transition of healthcare contracts.
The stocktake phase detailing all existing NHS and non-NHS healthcare
contracts will be completed and submitted to NHS NoE by end March
2012. The stocktake phase will provide two valuable outcomes:
•
A list detailing every existing healthcare contract held by
the PCT, which will support the mapping of all existing
services to successor bodie;s and
•
Any clinical, legal, contractual or financial risks related to
existing healthcare contracts will be identified.
The PCT will then embark on a period of stabilisation in which
measures will be taken to mitigate and eliminate those risks identified
in the stocktake phase. By 1 October 2012 the PCT will be in a position
to start the shift of healthcare contracts to future contracting
authorities, including NCB.
10. TRANSITION & REFORM
Estates management; Emergency Planning & resilience; managing
performance; Quality/Governance/Legacy; Contracts transition;
Finance; Information management /IT/Information Governance;
Communications & Engagement ; HR/Workforce transition; workforce
development.
STAFF TRANSITION PLANNING
70
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: CLINICAL COMMISSIONING GROUPS
Cumbria has always had a high level of clinical involvement, especially GPs and the past 12 months have been characterised by GPs taking further
leadership and responsibility for 100% of CCG resources. They have made good progress in establishing the CCG, with an interim structure and
decisions on ‘do’, ‘share’, buy. They also have a clear development for the organisation and are producing a ‘clear and credible’ strategic
commissioning plan, key elements of which are reflected in this operating plan, both in terms of strategic vision and operational plan delivery.
There is a strong CCG emerging which has been established in the
interim as a sub-committee of the PCT Board. It has 100% of relevant
CCG budget delegated through a formal Accountability Agreement and
the CCG is exercising responsibility, agreeing recovery plans, year end
closure and so forth.
The lead GPs in the CCG led the 2011/12 contract negotiation in South
Cumbria with UHMBFT and supported the negotiation of the other two
major contracts with CPFT and NCUHT. They have also lead in-year
contract monitoring and management .
The CCG are heavily involved in system transformation, such as the
commissioning input to the acquisition process for NCUHT, the approval
process for the West Cumberland Hospital Full Business Case and
support to the UHMBFT Gold Response.
There is an interim structure in place to get the CCG under way, with
resources seconded to the CCG localities (for commissioning, service
redesign and relationship management) and corporate functions
(strategic, finance and contract support). Work on decisions for
‘do/share/buy’ and organisational development (using the self
assessment tool) has been undertaken with support from the Cluster and
the Region through external consulting.
Although there are generally good primary care results (e.g. low
prescribing costs; high patient satisfaction) the CCG is developing a
primary care transformation strategy, which will focus on long term
condition management & year of care, improved education and
training and greater primary care capacity in Barrow particularly for
day time urgent primary care.
The CCG is also setting out its vision for putting quality at the heart of
the contracting process, with a focus on doing the right things for
patients, with robust and measurable metrics, including an increased
emphasis on patient experience and engagement.
The CCG is leading service change, particularly through the System
Board in North Cumbria – specifying the models for emergency floor,
Single Point of Access, paediatric assessment units and so forth. There
is also an ambition to develop new forms of contracting (eg Alliance
and AQC) once the key providers are in a more stable position
following quality improvement in the South and Trust acquisition in the
North.
10. TRANSITION & REFORM
The CCG developed commissioning intentions documents for acute,
mental health, community and childrens’ services and are actively
leading the negotiation of all relevant contracts for the 2012/13 contract
round in line with these intentions.
The CCG Executive is developing the strategic narrative for the CCG –
focused on a ‘closer to patients’ theme and illustrating the added value
of clinical commissioning. Alongside a clear view on the shape of the
health economy over the next 5 years, this will be embedded at the
heart the CCG’s clear and credible Strategic Commissioning Plan. This is
currently being developed in parallel with this Operating Plan to ensure
CCG leadership. The CCG is also working with Cumbria CC to produce
the new JSNA so that there is a firm evidence base to the key priorities
in the Plan.
71
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: CLINICAL COMMISSIONING GROUPS (cont.)
Aspect
Milestone
Progress
Position
Configuration
✔
All Cumbrian practices signed up to a single viable CCG
Phase 1 Risk Assessment
✔
Assessed green except amber for LA Boundary (Bentham membership)
CCG Budget allocation
✔
100% of approved budgets have been delegated
✔
Engagement & leadership in key areas: planning & service development; strategic planning; response to Operating
Framework; formulation of commissioning intentions & contract negotiation; quality issues across all domains; QIPP
workstream including System Board and all clinical relationships across organisations; HAWB interaction increasing.
Build a track record
✔
Diagnostic undertaken jointly by CCG and Cluster including clinician inputs; development areas identified for joint
development planning. External OD expertise enlisted. Locality offices established & phase 1 assignment of support staff
completed; MD and senior staff in place. CCG internal functions/operating model established & draft structure developing.
Authorisation
✔
Regular joint CCG Authorisation/Development group; evidence bank established; Cluster management resource provided to
support DCD and CCG leadership.
CCG User Requirements
✔
Do/share/buy considerations undertaken and affordability tested; CSU specification being developed.
Commissioner Support
Business Process
✔
Initial stocktake completed and function/people mappings submitted; working to create robust ‘client’ specification of
requirements to support development of Cumbria/Lancashire joint venture CSS.
Key Milestone Plan for 2012/13
Apr
Do/share/buy decisions and CSS agreement in place
2012/13 Contracts negotiated by CCG
Development Plan and Clear & Credible Commissioning
Plan approved
Budgets agreed (100% delegation) and staff in place to
manage and continue to develop CCG
Lead the local health system, actively reviewing finance,
performance, quality and activity
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM
Organisational Development
Confirm senior leadership
Prepare authorisation application & complete process
Be operating and prepared full statutory responsibilities
with contracts & SLAs for 2013/14 in place
72
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: COMMISSIONING SUPPORT
xxx
Significant progress is being made by Cumbria Cluster and CCG in determining and implementing the model for commissioning support, including the
delivery of a stand-alone integrated Cumbria and Lancashire Commissioning Support Service (CLaSS).
Cumbria Cluster has entered into a joint venture with Lancashire Cluster
to develop an integrated Commissioning Support Service (CSS) and to
manage workforce into the new commissioning architecture.
The shadow year 2012/13, will be a transition year for both CLaSS and CCGs,
whilst new ways of working and business like relationships are established.
Significant steps have been taken to fully integrate the Lancashire and
Cumbria dimensions into a unified model , Cumbria and Lancashire Support
Service (CLaSS) , to be taken forward at arms-length from the Clusters from
April 2012. An interim Managing Director and dedicated interim senior team
have been appointed March 2012, mirroring a more substantive leadership
structure for the shadow year 12/13 and a future externalised service.
Governance arrangements have been put in place to provide accountability to
both Clusters during the shadow year.
Since then the CSS has undertaken significant 1:1 work with all of the
Cumbria and Lancashire CCGs, jointly exploring CCG do/share/buy
perspectives and CSS responses. As a result the CSS has developed its
planning on a flexible & tailored service offer that will meet customer
needs and wants, and further defined its pricing and organisational
design. Cumbria CCG, supported by the Cluster with external facilitation,
developed , in February, a detailed specification for the service elements
and approach it requires from a CSS. A high level memorandum of
agreement has been signed off, to be followed by a fuller HOA in April
and a contract in July – following iterative co-production of the service
offer with CCGs and agreement on running cost implications.
CLaSS is progressing a wide-ranging programme to develop as a customer
focussed, commercially viable service. This includes active consideration of
partnerships (with LAs, other NHS agencies, independent sector) and
outsourcing/brokerage, based on an assessment of where services could be
practicably sourced externally or in partnership to provide better quality or
value for money. Appropriate scale of provision is being considered as the
organisational structure is developed further , including appropriate linkages
with national at scale services. An Outline Business Plan, describing progress so
far, has been submitted for checkpoint 2 and a Full Business Case will be
developed by September 2012. Early in 12/13 CLASS will undertake an options
appraisal of exit route options, followed by staff consultation.
Key Milestone Plan for 2012/13
Apr
Set up & design phase & Checkpoints 1 & 2 - Prospectus
and OBC submitted
CCG do/share/buy requirements/specification clarified,
CSS response agreed , HoAs for 12-13 agreed with CCGs
Interim Managing Director & leadership team in place
Exit option appraisal completed, exit strategy developed,
staff consultation in progress, FBC produced, NHSCB
hosting approved
CLaSS operating at arms length (prior to NHS CB
hosting), 13/14 CCG contracts agreed, exit route agreed
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM
The CSS has successfully undertaken the set up and design phase of the
national CS review process and passed checkpoint 1 with the production
of a service offer prospectus and technical appendix. The offer arose from
early planning and development work, and provided early assurance that
a viable, appropriately focussed service could be developed as well as an
initial discussion document for much more in depth engagement with
CCGs.
73
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: DIRECT COMMISSIONING, PRIMARY CARE
A
primary care development plan has been developed between NHS Cumbria Cluster and CCG and the baseline assessment of primary care contracts
xxx
has been completed.
Following publication of the draft operating model for primary care a draft
primary care development plan has been discussed with the CCG. It will be
agreed by 30th June to enable implementation to commence 1st July
2012. An implementation lead for primary care commissioning has been
appointed to oversee the transition period and the field force
configuration.
The baseline assessment of the primary care contracts that will need to
pass to the NHS Commissioning Board was completed at the end of
January 2012. That stocktake has informed the contract transition
programme which is progressing, to ensure effective handover. All general
medical contracts to be re-issued to ensure all providers have complete
signed documentation by June 2012. Standard PMS contracts will be issued
and agreed with PMS providers by June 2012. There are no PCTMS
contracts in Cumbria.
Apr
Primary Care development plan agreed with CCG
Contract transition baseline assessment completed
LPNs for dentistry & pharmacy established
Practice review framework agreed & standard
performance review completed with all practices
May
An implementation lead for primary care commissioning has been
appointed to oversee the transition period and the field force
configuration.
Scoping is underway to map out the field force configuration. This work
will be informed by national guidance as it becomes available. We await
the publication of “Towards Excellence in Primary Care” (Spring 2012)
which will set out the vision for the single operating model and provide
clarity around configuration and functions.
Key Milestone Plan for 2012/13
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM
Dental and optometrical contracts will be reissued by exception only.
Discussions with all LRCs are taking place in relation to contract
stabilisation and these will be completed by April 2012.
Contracts will be available in electronic format by December 2012.
Work to facilitate standardised payment system will be taken forward
pending further guidance.
Local professional network pilots for Dentistry and Pharmacy have been
established. The Dental LPN met and agreed terms of reference in
December 2011. A dental Clinical Engagement event is planned for March
2012 and the agenda for next year, to include refresh of Oral Health
Strategy, will be agreed in April 2012. A meeting planned with LOC April
2012 to begin scoping exercise around Optometry. Further work is
required in next months to align LPNs with the aims and objectives of the
HWBB.
A discussion with Cumbria LMC is planned for April 2012 to agree the
process for review of general medical practice lists. This process will be
undertaken with LaSCA and Registration team during summer 2012 with
an aim to complete by December 2012.
Initial scoping re capacity & capability, and plans
developed to map field force configuration
Standard Operating model in operation
Primary care commissioning staff transferred
74
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: DIRECT COMMISSIONING, SPECIALISED SERVICES
xxx
The stepped implementation of the transfer of specialised service commissioning is well underway and transitional governance arrangements were
agreed in December 2011.
NHS Cumbria is working closely with the North West and North East
Specialised Commissioning teams and service providers on the stepped
implementation of the transfer of specialised service commissioning.
In Cumbria’s case, the minimum take for 2012/13 includes a number
of services previously commissioned by NHS Cumbria:
The PCT Board agreed to transitional governance arrangements in
December 2011, following the clustering of the existing Specialised
Commissioning Groups.
The first phase of transfer, a minimum take of services to be
commissioned by all Specialised Commissioning Groups (SCGs) for
2012/13, is progressing to completion. This involves providers
identifying and splitting out activity and prices from existing contracts
and validation by commissioners in preparation for revised contract
sign off for 2012/13.

Some services which are provided locally such as
radiotherapy, vascular surgery and interventional
radiology; and

A number of services which are provided outside of
Cumbria e.g. Cardiac electrophysiology, major trauma, HIV
inpatient services at identified centres, specialised mental
health services including disorders, Tier 4 CAMHs.
Key Milestone Plan for 2012/13
Apr
Formally agree transitional governance arrangements
Facilitate the contract activity & price work needed for
minimum take service contract transfer to SCG for
2012/13
Agree the support arrangements at CCG/CSS level to
facilitate the operation of direct commissioning
functions for specialised commissioning
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM
The operation of direct commissioning functions inline with
agreed operating model is being considered as part of
transition planning and the CCG/Commissioning Support
Service do/share/buy analysis.
Operate the shared operating model
Facilitate the transition of the full specialised services
commissioning list
75
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: DIRECT COMMISSIONING, PRISON & MILITARY HEALTH SERVICES
Progress is being made in the delivery against the key milestones for the commissioning of Prison and Military health services.
xxx
Aspect
Milestone
Progress
Position
Prison HNA completed
Possible provider identified and working with NE PCT to establish appropriate methodology
Prison Health Service Specifications
Service specifications being updated and KPIs and quality monitoring put in place for 2012/13
contract year
Prison secondary care activity and costs
Currently identifying activity and costs associated with prisoners accessing local health services
(elective and emergency – acute and MH)
✔
Lead identified – to attend regional military health network meetings; lead GP and Non Exec
lead also identified; HWBB work due to start in April
Military Health - SHAs should maintain
and develop their Armed Forces
networks
✔
Cluster has place on SHA AF Network and regular correspondence and quarterly meetings.
The MOD NHS Transition protocol for
those who have been seriously injured in
the course of duty to be implemented
✔
SHA has links with Military PRU to manage the transition of the seriously injured on a case by
case basis. Procedures for referral for accessing care and prosthetic devices to be understood
locally and will depend on nature of needs and location
Key Milestone Plan for 2012/13
Apr
Cluster lead identified
Cumbria mental health mapping JSNA (July) and
AQ event with key stakeholders (April)
Engagement with Disability Service Centre in
relation to meeting needs of veteran amputees
NSC completed to ensure reservists released for
service as required
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM
Cluster lead for military health identified
Service specs, KPIs and quality monitoring
agreed
Engagement with Shadow HWBB
76
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: HEALTH & WELLBEING BOARDS
xxx
The shadow Health and Well Being Board will be operational from April 2012 and will contain all of the statutory partners.
Cumbria is part of the National Early Implementers Network for the
Health and Wellbeing Board.
An interim Health and Wellbeing Board (HWB) was established in
June 2011 and has met regularly supported by senior managers
from Cumbria Cluster and Cumbria County Council.
The shadow Health and Wellbeing Board will be operational from
April 2012 and will contain all the statutory partners. Previous
work has meant that there will also be agreed representation
from the district councils and one member representing parish
councils.
Officers from the PCT Cluster and from the local authority are
supporting the development of Healthwatch focusing on wide
stakeholder involvement.
The CCG has had a member on the board for some months with a
mandate to represent the CCG and the localities.
The CCG is supporting the JSNA refresh and will be involved in the
development of the Health & Well Being Strategy, which will be
reflected in its commissioning intentions.
A programme to support the H&WB members has been agreed
and commissioned.
A JSNA will be published in April 2012 and will result in a Health
and Wellbeing Strategy which will be published in June 2012.
Key Milestone Plan for 2012/13
Apr
Shadow HWB operational
JSNA published
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM
The shadow board will offer a place to the Director of
Commissioning as an interim position as links with NHSCB are
considered.
Health and Wellbeing Strategy Published
77
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: PUBLIC HEALTH
xxx
Delivery of the JSNA has already facilitated the establishment of close working relationships between stakeholder organisations and Cumbria County
Council. Building on these relationships the reconstituted Health and Wellbeing Board will ensure delivery of the Public Health agenda.
An overarching action plan has been developed with workstreams to
include:
Public Health Transition Executive and Operational Groups have been
established to ensure that all national and local milestones are met.
A transition programme board co-chaired by the DASS and the PCT CE
has been established to oversee the transfer, maintain performance
and mitigate against any risks. The board is accountable to the loc auth
CE.
A senior member from the public health team has been identified to
manage the programme, with support from both the PCT and the
council.
Each work-stream will have a project plan which will be monitored by
the board.
HR and workforce;

Embedding the health responsibilities into the local
authority.

Commissioning, contracting and finance;

Delivery of Public Health functions prior to transition;

Milestones against migration;

Core offer of Public Health support to CCG;

Governance, risk, infrastructure and quality assurance;

Access to shared functions; and

Communications and engagement.
Key Milestone Plan for 2012/13
Apr
Business plan and Workforce Plan agreed
Scheme of delegation in place
Integrated Plan submitted to DH
Most Public Health duties transferred to CCC
All Public Health duties transferred to CCC
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM

Complete formal handover to CCC
78
SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: NCUHT ACQUISITION
xxx
The Tripartite Formal Agreement identified that NCUHT would achieve Foundation Trust status through a merger or acquisition with another
Foundation Trust. This process is well advanced with the identification of a preferred bidder and the expectation is that new Trust status will be
achieved by October 2012.
The Cluster and CCG key objectives for working with a new enlarged
Foundation Trust are:
The acquisition process is being conducted by NCUHT with support from
NHS North. NHS Cumbria Cluster and CCG are engaged in providing
Commissioner support to the negotiation process following the identification
of the preferred bidder.


At the end of January 2012 Northumbria Healthcare Foundation Trust
was identified as the preferred bidder. It is expected that a Management
Contract will be in place by April 2012.



It is anticipated that, subject to due diligence process and confirmation by
Monitor and the Co-operation and Competition Panel, a new Trust will be
formed and operating in October 2012.
Key Milestone Plan for 2012/13
Apr
Preferred bidder identified
Management contract agreed
Due diligence completed
Monitor and CCP approvals received
Business Case construction and approval
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
10. TRANSITION & REFORM

Delivery of the agreed clinical strategy for north Cumbria;
Securing the opportunities that exist to repatriate patient
activity and enhance the portfolio of services available
within Cumbria;
Implementation of a robust plan to deliver financial
stability in north Cumbria within the period of this plan;
Implementation of enhanced management processes;
Delivery of economies of scale across a larger
organisation including improved efficiency in back office
and support functions; and
Confirmation of support for the West Cumberland
Hospital development.
Secretary of State approval
New Trust in place and fully operational
Engage in delivery of key objectives
79
APPENDIX A
INTEGRATED PERFORMANCE MEASURES –
CUMBRIA TRAJECTORIES
APPENDIX A
80
APPENDIX A: INTEGRATED PERFORMANCE MEASURES – CUMBRIA TRAJECTORIES
1 YEAR TRAJECTORIES
PHQ13_06 The proportion of people who
complete treatment who are moving to
recovery
PHQ13_06 The proportion of people who
complete treatment who are moving to
recovery
PHQ27 Number of MRSA bacteraemia
PHQ30 Number of 4-week smoking
quitters that have attended NHS Stop
Smoking Services
PHQ31_04 Percentage of eligible people
who have been offered an NHS Health
Check in 2012/13
PHQ31_05 Percentage of eligible people
that have received an NHS Health Check
in 2012/13
Q2
Q3
ACTUALS - 2011/12
3.3%
3.8%
2012/13 Trajectories
3.3%
3.3%
3.4%
ACTUALS - 2011/12
3.5%
3.3%
3.8%
2012/13 Trajectories
47.0%
48.0%
48.9%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
ACTUALS - 2011/12
2
1
0
1
1
0
1
1
0
1
2012/13 Trajectories
1
1
0
1
1
0
1
1
0
1
ACTUALS - 2011/12
19
23
31
17
18
19
11
25
16
21
2012/13 Trajectories
18
18
17
17
16
16
16
15
15
14
Q1
Q2
Q3
ACTUALS - 2011/12
768
687
590
2012/13 Trajectories
842
898
710
ACTUALS - 2011/12
0.1%
0.2%
0.3%
2%
4%
6%
ACTUALS - 2011/12
0.1%
0.2%
0.3%
2012/13 Trajectories
1.6%
3.0%
4.1%
2012/13 Trajectories
0
Q4
2012/13
3.5%
13.5%
50.0%
48.5%
Feb
Mar
2012/13
0
0
7
14
14
190
Q4
2012/13
1357
3,807
8%
20%
4.3%
13%
APPENDIX A
PHQ28 Number of C. Difficile infections
Q1
3.5%
81
APPENDIX A: INTEGRATED PERFORMANCE MEASURES – CUMBRIA TRAJECTORIES
3 YEAR TRAJECTORIES
PHS06 - Non-elective FFCEs
ACTUALS - 11/12
12/13 Trajectories
PHS07 - No of GP written
referrals
ACTUALS - 11/12
PHS08 - No of other (nonGP) referrals
ACTUALS - 11/12
12/13 Trajectories
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
4399
4389
4448
4352
4395
4385
4560
4353
4621
4471
4286
12/13
13/14
14/15
4246.9 4332.3 4159.5 4203.2 3886.7 4073.8 4267.9 4143.3 4500.9 4201.4 3836.3 4348.7 50201
49666
49269
8845
9915
10061
9700
9714
9549
9406
9607
7750
8982
Mar
9492
8690.7 10063 8690.7 10063 10063 9148.1 10520 10063 8690.7 10063 9148.1 9148.1 114351 113036 111556
2804
3306
3177
3078
3099
3144
3100
3135
2896
3317
3151
37687
37025
36280
12/13 Trajectories
7390.6 8557.6 7390.6 8557.6 8557.6 7779.6 8946.6 8557.6 7390.6 8557.6 7779.6 7779.6 97245
95930
94451
PHS10 - No of first
outpatient attendances
ACTUALS - 11/12
10728 11841 12566 11939 11730 12642 12091 12622 10777 12118 11736
12/13 Trajectories
11112 12866 11112 12866 12866 11697 13451 12866 11112 12866 11697 11697 146208 144230 142006
PHS11 - No of elective
FFCEs - Ordinary adms
ACTUALS - 11/12
1392
PHS11 - No of elective
FFCEs - Daycase Adms
ACTUALS - 11/12
PHS11 - No of elective
FFCEs - Total
ACTUALS - 11/12
PHS09 - No 1st outpatient
attendances after GP
referral
12/13 Trajectories
ACTUALS - 11/12
12/13 Trajectories
12/13 Trajectories
PHS14 - Diagnostic Activity - ACTUALS - 11/12
Endoscopy based tests
12/13 Trajectories
PHS15 - Diagnostic Activity - ACTUALS - 11/12
non-Endoscopy based tests 12/13 Trajectories
PHS16 - Total numbers
ACTUALS - 11/12
waiting on an incomplete
12/13 Trajectories
RTT pathway
6968
7832
1423
8299
1542
8099
1520
7873
1422
8656
1625
8006
1542
8438
1620
7147
1444
7775
1494
3015
7501
1582
1389.1 1606.9 1388.9 1607.7 1603.9 1461.3 1678.7 1606.4 1389.2 1603.8 1459.7 1462.2 18258
4415
4776
5161
4884
4684
5032
4873
5164
4565
5261
6199
6703
6404
6106
6657
6415
6784
6009
6755
1542
1528
1451
1398
1482
1366
1558
1303
1493
57210
56312
75165
74006
17417
17417
6464
5814.4 6731 5814.2 6731.7 6728 6119.6 7035.6 6730.4 5814.5 6727.9 6118 6120.5 76486
1440
17694
4882
4425.3 5124.1 4425.3 5124.1 5124.1 4658.2 5357 5124.1 4425.3 5124.1 4658.2 4658.2 58228
5807
17955
APPENDIX A
12/13 Trajectories
2864.2 3316.5 2864.2 3316.5 3316.5 3015 3467.2 3316.5 2864.2 3316.5 3015
1449
1391.3 1489.9 1476.4 1401.9 1350.7 1431.9 1319.7 1505.4 1545 1543.1 1554.7 1406.8 17417
11524 12688 13266 12939 13549 13266 12671 13743 12601 13586 13513
11749 12935 13525 13191 13814 13525 12918 14011 12631 12354 12695 11209 154555 154555 154555
23031 25099 24058 25400 25486 24903 24849 24785 24749 23845 25279
25000 24900 24800 24700 24700 24700 24700 24700 24700 24700 24700 24700
24700
24700
24700
82
APPENDIX B
Locality Service Initiatives
APPENDIX B
83
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
Allerdale Locality
Respiratory
Reduction
No.
Reduction
£’000
60
94
Service Initiatives
Timeframe
LES for identifying , coding severity, assessment, ensuring appropriate
pathway and medication of all patients with respiratory disease
Fully skilled respiratory nurse in each of the five sub localities linking with
the community based services
All patients using oxygen therapy re-evaluated to optimise treatment
Increase in pulmonary rehabilitation services
In place
Expanded from April
2012
In place
In place
49
41
Direct access to ECHO diagnostics and 24 hour access to ECG.
Heart failure nurses managed by CHOC to improve focus and direction
In place
In place
Diabetes
17
19
Practice nurses engaged in diabetes care training courses
In place
Elderly Care
39
52
Elderly care team recruited to ensure basic levels of care and end of life
care in place in care homes
Care plans for all care home residents lodged with CHOC
In place
Alcohol and
Drugs
In place
0
0
Infrastructure
131
121
Joint working with NCUHT to deliver the Single Point of Access (Gateway
into Services) and Emergency Floor projects
Partial
implementation from
September 2012
Elective
268
215
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic procedures
and minor skin lesions
From June 2012
Continuing from
2011/12
TOTAL
APPENDIX B
Cardiac
542
84
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
Carlisle Locality
Respiratory
Cardiac
Reduction
No.
Reduction
£’000
Service Initiatives
50
80
Chronic Disease Management Network reviewing COPD services
Expansion to COPD specialist team (includes expansion of pulmonary
rehabilitation services)
Local version of Met Office scheme
Asthma patient reviews linked to community pharmacist, roll out of asthma
prescribing pathway
131
107
Community cardiology service
Heart failure team
Protected learning time used for upskilling in primary care
Psychological therapies for patients with multiple chronic disease
Use of Qrisk tool
0
0
Elderly Care
80
98
Development of Integrated Care Model
In place
In place
In place
In place, referrals
expanding
In place
In place
In place
In place
Warmer Home and flu vaccines projects
Care homes work (medication reviews, falls, pressure sores, nutrition) long
established and being extended to house bound patients
Increasing impact
during 2012/13
In place
In place and being
extended
Alcohol and
Drugs
41
25
Mental health liaison support within CIC
Support to DAAT to support those people most at risk of admission
April 2012
April 2012
Infrastructure
46
41
Joint working with NCUHT to deliver the Single Point of Access (Gateway
into Services) and emergency Floor projects
Partial
implementation from
September 2012
Elective
254
204
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic procedures
and minor skin lesions
From June 2012
Continuing from
2011/12
TOTAL
555
APPENDIX B
Diabetes
Timeframe
85
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
Copeland Locality
Reduction
£’000
Respiratory
54
81
New breathlessness pathway, CPFT deliver new breathlessness service
Drug reviews and case management for asthma and COPD patients
Increase in uptake of pulmonary rehabilitation service
Q2 2012/13
In place
In place
Cardiac
36
28
CPFT deliver new breathlessness service
Heart failure management workshops for practice nurses, community staff
Relaunch of Exercise on Referral service (lower acuity patients)
Enhanced case management, part of LES
Extended hours for community based service
Review of oxygen service
Q2 2012/13
In place
In place
In place
In place
Diabetes
32
32
Upskilling community service staff to raise the level of clinical support
In place
Elderly Care
32
37
Implementation of Care Home 6 Steps Programme – full sign up
Availability of interim care home beds for frail elderly and EMI patients
including district nurse and GP admission rights
Geriatrician of the week
In place
In place
Alcohol and
Drugs
0
0
Infrastructure
271
239
Joint working with NCUHT to deliver the Single Point of Access (Gateway
into Services) and emergency Floor projects
Partial
implementation from
September 2012
Elective
166
133
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic procedures
and minor skin lesions
From June 2012
Continuing from
2011/12
TOTAL
Service Initiatives
Timeframe
APPENDIX B
Reduction
No.
550
86
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
Eden Locality
Reduction
£’000
Service Initiatives
Respiratory
2
3
Increased referrals to community support services
Implement ambulatory care pathways for children with respiratory disease
Implementation of adult pathways for COPD and asthma
In place
In place
Fully developed by
July 2012
Cardiac
28
24
CHOC led community cardiology services
Increased referrals to pulmonary rehabilitation services
Review of oxygen therapy services
On call stroke physician out of hour cover
In place
In place
April 2012
In place
Diabetes
0
0
Elderly Care
98
116
LES for Care Home engagement and production of assessment and care
plans, prescription reviews
April 2012
Alcohol and
Drugs
0
0
Infrastructure
47
45
Joint working with NCUHT to deliver the Single Point of Access (Gateway
into Services) and emergency Floor projects
Partial
implementation from
September 2012
Elective
127
102
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic and MSK
procedures (triaged through physiotherapy) and minor skin lesions
From June 2012
Continuing from
2011/12
TOTAL
Timeframe
APPENDIX B
Reduction
No.
290
87
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
Furness Locality
Respiratory
Cardiac
Diabetes
Reduction
No.
Reduction
£’000
Service Initiatives
Timeframe
0
0
Systematic review of COPD pathway undertaken with increase in number of
pulmonary rehabilitation patients
In place
187
150
Increasing caseload for specialist heart failure service, improved education
for primary care teams
LES in place to improve identification and management of heart failure
patients, optimisation of medication and heart failure scoring
In place
April 2012
0
Elderly Care
112
127
Established Integrated Care Services for Older People (nursing, physio and
pharmacy) improving continuity of care and management of LTCs for
residential and nursing homes and extra care housing
In place and increasing
care home coverage
Alcohol and
Drugs
0
0
Provision of liaison psychiatry services within Furness Gh to support people
with mental health issues in A&E and on wards.
Brief interventions LES in primary care for patients with harmful drinking
June/July 2012
Infrastructure
370
330
Redesign of community based STINT team to provide rapid response
services
Primary Care Medical Assessment Service managing GP referrals for
diagnostics and intermediate care services
April 2012, fully
function Q3 2012/13
April 2012/13
Elective
297
192
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic procedures
and minor skin lesions
From June 2012
Continuing from
2011/12
TOTAL
APPENDIX B
0
799
88
Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions
South Lakes Locality
Reduction
No.
Reduction
£’000
Service Initiatives
Respiratory
16
25
Specialist respiratory nursing service for patient diagnosis, case finding and
identification of sub optimal drug regime
In place
Cardiac
195
159
Specialist heart failure nursing service with consultant oversight and
prescribing support
Education programme for primary care
Post discharge follow up for heart failure
LES for primary care upskilling
Case finding for patients with atrial fibrillation, improved prescribing
In place
Recruitment of elderly care physician
Care Home engagement of district nurses and dietitians and production of
assessment and care plans, prescription reviews
Primary and community care programme for patients with co-morbid
dementia
October 2012
In place
Improve extended brief interventions in primary care for patients with
harmful drinking
Build psychiatric liaison service to provide A&E and ward support at WGH
and RLI
In place
Use of 30 new referral templates and embedded decision tools
Focus on reduction in unnecessary referrals for orthopaedic procedures
minor skin lesions, varicose veins and grommets and tonsillectomies
Expected reduction in day case activity resulting from achievement of 18
week target in 2011/12
From June 2012
Continuing from
2011/12
Anticipated in
2012/13
Diabetes
Elderly Care
0
0
117
125
59
40
Infrastructure
7
6
318
206
Elective
TOTAL
561
In place
In place
In place
In place
In place
APPENDIX B
Alcohol and
Drugs
Timeframe
89
APPENDIX C
Public Health Transition Plan
APPENDIX C
90