Welcome
NHS North West Surrey
Public Annual General
Meeting
1 July 2015
Today’s agenda
● Welcome – Dr Liz Lawn
● Our year in review – Dr Liz Lawn
● Patient and public engagement – Charles Stewart, Chair, ‘Friends of Pirbright Surgery’
● Targeted communities – Dr Eva Van Velzen
● Locality Hubs – Dr Henriette Coetzer
● CoSI – Dr Chrissie Clayton
● Musculoskeletal services – Dr Amer Sheikh
● Diabetes – Dr Asha Pillai
● Quality – Clare Stone, Chief Nurse / Associate Director for Quality
● Finance review – Neil Ferrelly, Director of Finance
● Looking forward – Julia Ross, Chief Executive
● Close + Q&A – Dr Liz Lawn
Our year in review
Dr Liz Lawn
Clinical Chair
North West Surrey serves a population of 350,00 people,
with 42 practices working in three localities across four
boroughs
SASSE
13SASSE
practices
(Spelthorne BC)
Thames Medical
14 practices
Thames Medical
(West of Elmbridge
Locality
& Runnymede BCs)
Weybridge Community
Cobham Community
Hospital
Hospital
• Day surgery
Woking Community
Hospital
Woking
15Woking
practices
(Woking BC)
Clinical leadership is at the heart of our CCG
Clinical Chair
Council of Members/Practice Leads
Clinical Executive
Clinical
Director
(SASSE)
Clinical
Director
(Thames
Medical)
Clinical Programme Directors
Clinical
Director
(Woking)
Clinical Chief
Contracts &
Performance
Clinical Chief
Innovation &
Quality
Clinical Chief
Leadership &
Development
Clinical Contract Leads
Clinical Workstream Leads
QUALITY & PERFORMANCE COMMITTEE
PROGRAMME BOARDS
LOCALITY GROUPS
CLINICAL
COMMNG
NETWORK
Our vision is to enable all North West Surrey
people to enjoy the best possible health
● With clinical leaders and managers working in
partnership we will empower member practices,
GPs and our residents to determine how spending
on health is decided by together:
•
Considering the needs of patients and the local population
•
Deciding on how and where to invest to ensure effective
services and treatments
•
Leading the local health economy to ensure health and other
care providers work effectively together to deliver safe,
seamless, high quality services in the best interests of
patients
Commissioning high quality, safe healthcare
services that meet your needs
● This year we measurably improved healthcare
services and clinical outcomes for local people
● Working in partnership across the wider Surrey and
regional system
● Next year’s challenges are very real:
● An ageing population with increasingly complex health and
social care needs
● Annual requirement to reduce costs, particularly hospital
based care
● Continually improving local healthcare services and patient
outcomes
Leading the local health system
We’ll continue to lead the local health system by
understanding your needs and providing you with the
right care in the right place at the right time
Matching healthcare service capacity to patient
demand is challenging
Your needs
Clinical
commissioning
Service
provision
Clinical
outcomes
Finances
This year’s highlights
Diabetes
Medicines
management
Dementia
Urgent
care
Locality
Hubs
Mental health
CoSI
MSK
Targeted
communities
Primary care
Finances
Sepsis
pathway
Hypoglycaemia
CAMHS
Care homes
Patient and Public Engagement
Charles Stewart
Chair, ‘Friends of Pirbright
Surgery’
Targeted communities –
Prevention plan
Dr Eva Van Velzen
Targeted communities / prevention
We work with the Public Health team at Surrey
County Council on our prevention programme
Prevention
Individual,
environmental
Partnership
working
Targeted communities
● Our targeted communities prevention plan aims to
improve health and reduce inequalities in people
living in North West Surrey
● Key actions
● Smoking cessation
● Early identification of COPD in practices
● Alcohol risk reduction programmes
● Winter preparedness
● NHS health checks
● Physical activity / diet interventions
Targeted communities
● Early identification of Chronic Obstructive
Pulmonary Disease (COPD)
● We know that many patients with COPD have not been
diagnosed yet
● This puts their health at risk and they are at higher risk of
hospital admission
● Diagnosis  right treatment  better health
● In the first practice, almost 50% of the patients reviewed
were newly diagnosed with COPD
● Aim: identify 600 new patients with COPD by 1 November
Locality Hubs
Dr Henriette Coetzer
Integrated Care – Locality Hubs
Our ambition is to ensure that no one becomes frail – or more frail – if
they can be helped to stay well, and that no one is in an acute bed simply
because they are frail
Locality Hubs will
• Deliver an integrated GP-led service across health and social care that
meets the holistic needs of frail and elderly patients
• Encompass a comprehensive MDT across acute, community, mental health,
pharmacy, social care and voluntary sector services
• Work to a consistent set of evidence based pathways and protocols
• Have the operational infrastructure to support excellent clinical care - rapid
access diagnostics, shared care records, care navigators
• Provide a portfolio of services in one location that can keep people healthy
and independent for longer and provide timely response to avoid
exacerbation and/or to manage it effectively when it happens
Locality Hubs
A physical building next to a community hospital providing an integrated frailty
service for people & their carers with all locality GP practices and services operating in
a network
Locality Hub
Place of residence
e.g.
• Home
• Nursing Home
• Residential Home
• Extra Care Housing
Self Care
Care packages
People are referred to the Hub
from local services based on
flags for high risk & formal
screening at GP surgeries
Transport
Hub out-reach
Assessment, Care Coordination & Care Planning
u
v
w
x
y
z
{
Adherence & Persistence
Adaptive Environment & Assistive Tech.
Hospital
Medical Monitoring & Testing
Medication Management
Carers, Family, Friends & Community Support
Emotional Resilience
Transitions
Support services
Diagnostics
Pharmacy
Hub out-reach into
hospital to proactively
pull people through the
urgent care system
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
Locality Hubs: key 2015/16 activities
Key Activities
Indicative 2015/16 Timescale
Clinical Design
• Clinical pathways developed and signed off in Q1 for:
 Advanced Cardiac Disease
 Chronic Respiratory Illness
 Incontinence Conditions
 Social Care
 Dementia, Cognition and mood
•
•
•
•
Target Cohort
Case Mix & needs
Hub Pathways
Workforce reqs
Operational Planning
• Job descriptions
• Ops protocols
• Staffing Structure
Integrated IT Solution
• Solution Design
• Solution Build
Estates
• Estate appraisal
• Design phase
• Build phase
•
•
•
•
•
First phase, first hub staffing model developed in April/May 2015
Medical Director & Operational Director recruited March 2015
Operational protocols developed and adopted May 2015
Development of final state staffing model for fully operational hub by Q2
Recruitment and mobilisation of staff throughout the year in line with hub ramp-up
• Solution Design Signed Off March 2015
• Hub EMIS Live July 2015
• Full Interoperability Portal Live Feb 2016
•
•
•
•
Full option appraisal of estates completed April 2015
Architects and Quantity Surveyors inquiries/tenders for the Woking site issued June 2015
Refurbishment of the Woking site September 2015
Ashford development due for implementation 2016
CoSI
Dr Chrissie Clayton
Co-ordinated, Safe, Integrated Service
● End of life care is a national priority
● We began a pilot of our Co-ordinated, Safe,
Integrated Service (CoSI) in June 2014
● This community service supports people in the last
six to eight weeks of life by
● Providing high quality care
● Helping people to be discharged more quickly from hospital
● Providing care in their preferred place before their death
● Supporting family members and main carers
Co-ordinated, Safe, Integrated Service
● Outstanding clinical service
● Over 80% of local people are receiving care in their
preferred place and over 85% of people are dying in
their preferred place of death, compared to a
national average of around 50%
● Feedback
● Privacy and dignity respected
● Confidence and trust in the team
● Absolutely brilliant – involved as much as we wished to be
with the care that was given
Musculoskeletal Service
Improvement
Dr Amer Sheikh
Musculoskeletal service improvement
● Our ambition is to improve mobility, quality of life
and reduce the levels of chronic pain
● We are achieving this by fixing issues such as poor
coordination between services, limited access to
conservative treatments and a confusing pathway
for patients and professionals
● We will be procuring a new integrated service which
will start next year
23
Musculoskeletal service improvement
● Our one year MSK pilot has improved patient
experiences and outcomes through the Referral
Support Service
● 95% of GPs use the service
● 200 fewer referrals to secondary care every month
● More patient choice, better coordination of treatment
approaches and quicker investigations and treatment
● Good GP and patient feedback
● Saving approximately £60k per month
24
Musculoskeletal service improvement
New MSK service procurement
Integrated
patient
pathway
Quicker
response
times
Greater
Holistic
range of
focus
conservative
treatments mind + body
25
Diabetes
Dr Asha Pillai
Our Diabetes challenge
15,430 patients in North West Surrey
21% undiagnosed locally?
Life expectancy
Heart attack
Stroke
Blindness
Hospital admissions
Diabetes: achievements
Foot Care Team
Ramadan Project
Award winning Hypo
Pathway
Improved Diabetes
Pathway
X-PERT programme
Diabetes: our future aspirations
● We will achieve better outcomes for our patients by:
● Understanding the current North West Surrey diabetes
pathway and delivering care closer to home
● Developing a North West Surrey Diabetes Prevention
Programme
● Tackle obesity that leads to Type 2 Diabetes
Quality
Clare Stone, Chief Nurse &
Associate Director for Quality
Quality
Will I have a good
experience?
Ensuring safe, high
quality services for the
people of North West
Surrey is at the heart
of everything we do
Am I safe?
Will I get the best care available?
What matters most to me?
21
Quality
● 2014/15 achievements:
● Management of serious incidents and sharing learning
across all providers
● Reducing the severity of harm from pressure ulcers through
early identification
● Maintaining low levels of avoidable healthcare acquired
infections
● Working with social care and CQC to support quality
improvements in care homes
Safe, committed, compassionate care
Quality
● 2015/16 focus:
● Using more patient feedback and experiences to improve
care
● Improving patient information sharing to support seamless
care provision
● Supporting effective antibiotic prescribing to reduce
resistance and infection rates
Ensuring the right people, with the right skills, are in the right
place at the right time
Finance review
Neil Ferrelly, Director of Finance
ur achievements: keeping within our budget
2014/15
ional Health
vice Act Section Duty
Maximum
£’000
Performance
£’000 Duty Achieve
411,389
406,415
Y
350
315
Y
407,960
402,986
Y
Capital resource use on specified matter(s) does not exceed the amount
specified in Directions
0
0
J(2)
Revenue resource use on specified matter(s) does not exceed the amount
specified in Directions
0
0
J(3)
Revenue administration resource use does not exceed the amount specified
in Directions
9,154
7,273
H(1)
Expenditure not to exceed income
I(2)
Capital resource use does not exceed the amount specified in Directions
I(3)
Revenue resource use does not exceed the amount specified in Directions
J(1)
ancial Statements in our 2014/15 Annual Report and Accounts, available on our website. Page 139 Note 35
Y
Y
Y
In 2015/16 NW Surrey is allocated £415.452m to
commission services for its population of 361,485 people
In 2014/15 NW Surrey is allocated £415.452m to
commission services for its population of 361,485 people
Looking forward
Julia Ross
Chief Executive
Working with stakeholders we have set out a
vision for the next 3 to 5 years
Acute Sector
‘Right sized’ – doing
the work that
only it can do
Integrated
pathways
Phone First
Clinical Triage
Single Point of Access for
patients & professionals
Locality Hubs
Extended access to integrated planned
and urgent care ‘out of hospital’ with
strong medical (GP) leadership
Integrated Frailty Service
All community health & social
care, led by primary care
Delivering our vision for the people of North West Surrey
through our annual operating plan
MSK
Hospitals
Surrey
Stroke
Review
Quality
ASPHFT
Strategy
Integrated
Community
Health and
Social Care
Integrated Planned Care
Locality
Hubs
CAMHS
Phone First
Urgent Care
Pathway
Personal
Health
Budgets
Urgent
Care
Centres
Better Care
Fund
Extended
Primary
Care
We have a large procurement programme
Major procurement programmes in progress
Child and Adolescent
Mental Health
Patient Transport
Services
Procurement programmes in preparation
Primary
Community
Care Out
Services
Of Hours
Ashford
Walk In
Centre
NHS 111
We’re improving service quality
Cancer
A&E
Recovery
IAPT
Patient
outcomes
Dementia
Stroke
We’re developing Primary Care
Meet growing
local demand
Develop services
at locality level
Practice Development
Premises
GP IT
Access
Encouraging cross practice working
Investing to support changes in service design
Shared healthcare
records
How you can get involved
● Join your GP practice’s Patient Participation Group
● Join a Patient Advisory Group supporting our major
commissioning programmes
● Send your thoughts to:
Contactus2@nwsurreyccg.nhs.uk
● View our website for other opportunities
● Write to us: North West Surrey Clinical
Commissioning Group, 58 Church Street,
Weybridge, Surrey, KT13 8DP
Achieving our vision
We are committed to enabling all North West
Surrey people to enjoy the best possible
health
2015/16 will be challenging
We will continue to work closely with local
stakeholders and partners as we evolve our
plans to achieve significant positive changes
in healthcare services that really meet local
people’s needs
Thank you
Close + Q&A
Dr Liz Lawn
Clinical Chair