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