Agenda reference B/13/319 - Nottingham North · 2013. 5. 17. · (SFH) (11,361 )7,137 (8,514) 4,536 Mental Health and LD 2,682 2,095 2,165 944 3,000 509 Community 325 332 683 950

Report to:

Joint Board

Date of meeting:

Tuesday 28 March 2013

Title of paper:

Quality, Innovation, Productivity, Prevention (QIPP) Legacy – The Nottinghamshire Story

Executive Summary: The QIPP Legacy document has been produced to record and recognise the significant progress that Nottinghamshire County PCT and Nottinghamshire City PCT has made in the delivery of QIPP from 2011-11 – 2012/13. The document maps the service change and financial savings achieved across key service and corporate areas. Details of some of the schemes that have contributed to the overall achievement are provided under each of the service and corporate areas. Key learning from the PCTs experience over the past three years has been captured as the lessons learned are critical to ensure delivery continues under the leadership of CCGs.

Have All Relevant Implications Been Considered?

Further Information (If there is an implication, briefly explain what it is or refer to the appropriate section of the paper)

Strategy Not applicable

Finance Not applicable

Governance Not applicable

Quality, Innovation, Productivity and Prevention

Not applicable

Transformation Programme

Not applicable

Agenda reference

B/13/319

Equality Duty Not applicable

Key Risk Implications: (please explain briefly)

Risk Assessment

Likelihood Impact Score

Person presenting paper:

Helen Pledger, Director of Finance

Originator of paper:

Stefanie Rutherford, QIPP Programme Manager

The Joint Board is recommended to:

NOTE this report.

QIPP: The Nottinghamshire Story…

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Quality Innovation

Productivity Prevention

(QIPP)

The Nottinghamshire Story…


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Contents

Executive Summary……………………………………….3

Acute Sector………………………………………………..5

Community………………………………………………….8

Mental Health & LD………………………………………..9

Continuing Care…………………………………………...10

Prescribing………………………………………………….10

Primary Care……………………………………………….11

Corporate Schemes……………………………………….11

Key Learning……………………………………………….12

Author: Stefanie Rutherford, QIPP Programme Manager NHS Nottinghamshire County


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Executive Summary

“The NHS is facing a massive financial challenge. There will be a „gap‟

between what we need to spend to keep up with demand, and the money we have, of £20 billion by 2015 – unless we start to do things differently”

Within Nottinghamshire there has been a strong focus on the Quality, Innovation, Productivity and Prevention (QIPP) agenda over the past three years. QIPP was launched in 2010 with the aim of supporting clinical teams and NHS organisations to improve the quality of care they deliver while making efficiency savings to meet demand and where possible to be reinvested into the NHS. It aimed to ensure that each pound spent by the NHS was used to bring maximum benefit and quality of care to patients, whilst encouraging the spread of innovation and prevention of ill health. In 2010 the NHS was tasked with delivering £20bn savings of which NHS Nottinghamshire County had an individual challenge of £106.6m.

Nottinghamshire County‟s health community has risen to the QIPP challenge over the past three years, delivering a considerable amount of savings against its annual targets as shown in the table below.

Although QIPP delivery was slightly below target in 2010/11 and 2011/12, the savings delivered represents a significant achievement and has relied on a huge amount of effort and innovative thinking from clinicians, providers and commissioners across Nottinghamshire. QIPP has been an integrated process from the outset with commissioners and providers working collaboratively together to scope, plan and implement schemes. The development of the QIPP programme for 2012/13 has been led by CCGs and is structured around the four key provider contracts NUH, SFHFT, Mental Health and Community and a series of corporate schemes as outlined below:

Workstreams 2010-11 2011-12 2012-13

Plan (£)

Actual (£)

Plan (£)

Actual (£)

Plan (£)

Actual M8 (£)

Acute Care 13,815 8,968 30,196 13,194 19,614 8,214

(Planned Care) (9,494) (7,509)

(Urgent Care) (4,321) (1,459)

(NUH) (18,835) (6,057) (11,100) (3,679)

(SFH) (11,361) (7,137) (8,514) (4,536)

Mental Health and LD 2,682 2,095 2,165 944 3,000 509

Community 325 332 683 950 3,386 2,060

Prescribing 3,003 3,158 3,518 4,812 1,000 5,842

Year QIPP Challenge

Savings Achieved

% Delivered

2010-11 £28.8m

£25.0m 87%

2011-12

£46.4m £37.6m 81%

2012-13

£31.4m £35.8m (forecast)

114%


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Primary Care 1,910 1,911 2,759 3,496 500 1,113

Continuing Care 2,109 2,711 3,238 3,617 3,100 2,392

Specialised Commissioning 317 1,011 0 142

Management & Admin. 4,918 5,857 2,284 8,308 0 1,035

Other. 1,243 1,302 800 776

28,762 25,033 46,403 37,634 31,400 22,083

As can be seen in the summary above Prescribing, Primary Care, Continuing Care and the Corporate Schemes have consistently over-delivered against their target whilst the provider workstreams have been the most challenging areas. Delivering QIPP is part of managing the overall financial position and where in-year shortfalls have occurred, these have been managed to ensure that the PCT continues to forecast delivery of its financial duties. Over-delivery across the outlined workstreams has supported under-delivery across the provider workstreams, whilst the under-delivery has also been managed through other budgets including the previously identified Contingency Reserve. Over the past three years transactional efficiencies through the commissioning process have been maximised across the QIPP workstreams, whilst progress has been made to improve the quality and efficiency of patient care. The 2% non-recurrent Transformational Funding has been used to support transformational change across health and social care. However, further opportunities for significant service transformation need to be harnessed across the health economy in order to deliver sustainable change. Throughout 2011/12 and 2012/13, QIPP delivery has been reported at CCG level to CCG Boards, Finance Recovery Group and Finance and Performance Committee. The PCT Cluster Board has held CCGs to account for the implementation and delivery of the QIPP Programme through the Cluster PMO. In addition to providing an assurance function, the Cluster PMO has supported the scoping and development of QIPP plans across CCGs, encouraging the adoption of best practice and the spread of innovation. The Cluster PMO has reviewed QIPP plans from other health communities nationally to identify successful schemes that could be implemented locally. Furthermore the Cluster PMO has reported the PCT‟s QIPP position on a monthly basis to the Strategic Health Authority and Department of Health via the Milestone Tracker. This report will reflect upon the achievements of Nottinghamshire‟s QIPP programme to date as well as the challenges and lessons learned in preparation for transition to the new system from 1st April 2013 onwards. It is hoped this report will support CCGs to build upon the work already started to ensure that we continue to innovate and transform the healthcare system to meet the needs of local people in years to come.


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Acute Sector

2010/11 - £9.0m 2011/12 - £13.2m 2012/13 - £8.2m Over the past three years the acute QIPP programmes have predominantly focused on reducing inappropriate acute admissions, length of stay and excess bed days. Overall the acute sector has been the most challenging area of QIPP delivery mainly due to rising activity in particular non elective activity and internal cost pressures. Even though lots of initiatives have been implemented which have reduced non elective activity, the overall trend of rising activity nationally has meant financial savings have not been fully realised. CCGs have supported the delivery of acute QIPP targets by working with Primary Care Teams to develop initiatives to manage demand including developing alternative pathways to acute admission. Primary Care Demand Management

Commissioners have collaborated with GPs to reduce referrals for both electives and non-electives. In order to improve primary care demand management:

PAAR (Patients at Risk of Re-hospitalisation) has been implemented, which is a software tool that uses inpatient data to identify patients at risk of re-hospitalisation within a year and Newark & Sherwood are currently implementing the Devon Model risk stratification tool which systematically profiles the whole population.

CCGs have developed detailed practice packs for GP practices which benchmark their referrals and activity, thereby supporting demand management.

However, reducing acute activity has always been challenging and continues to be a key risk of under-delivery in the 2012-13 QIPP plan due to rising activity nationally. The breadth and pace of primary care demand management needs to be increased and transformational change is required to underpin this.

Case Management for High Volume Services Users

A number of initiatives have been implemented across Nottinghamshire to proactively manage patients who frequently attend A&E without clinical need on a case management basis:

NHCT have implemented county-wide nurse specialist reviews where substance misuse and mental health issues are identified and have provided alternatives to emergency care. While there have been positive outcomes from these schemes, it has had little impact on the overall rising activity trend.

Moving forward there needs be improved processes for monitoring high volume service users from the primary care GP setting to ensure they are referred onto an appropriate pathway of care so that all patients are accounted for within the system.


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Primary Care Co-location with ED and Clinical Navigator (“Single Front Door”)

A series of schemes have been implemented across NUH and SFHT to reduce acute admissions. These initiatives have been successful in re-directing activity at both Trusts to primary care where clinically appropriate. These have included

Co-locating primary care within ED so that patients not appropriate for acute admission are streamed into primary care.

Opening Clinical Decision‟s Units and introducing Clinical Navigators to stream patients.

Development of Services in the Community Setting

There is a national drive to treat more patients closer to home in the community setting where this is clinically appropriate. Commissioners and providers have developed pathways within the community setting over the past three years including:

Acupuncture

ENT Pathways

Diabetes, Dermatology and Rheumatology

Cataracts

COPD Pathway

Gynaecology Pathway

Gastroenterology Pathway

Hepatobilliary Pathway

Not all programmes have delivered QIPP savings but have resulted in quality improvements for patients.

Appropriate management of Outpatients

The acute sector has been tasked with reducing outpatient new to follow up ratios in line with national standards. The following projects have been implemented

Diabetes pathway

Back Pain Injections

Reduction of Duplicate Outpatient Appointments

Although progress has been made across acute pathways, this remains a challenging task operationally and work is on-going at both Trusts to implement further reductions. Furthermore, it has been recognised that there needs to be a more cohesive, joined up approach between primary care, community care and acute care to provide alternatives to the acute setting where clinically appropriate.

Acute Pathway Redesign


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Savings have been realised over the past three years through the redesign of the following acute pathways:

Ophthalmology

Heart Failure Integrated Care Pathway

Implementation of DVT / UTIs and IV Antibiotic Pathways

Minor Oral Surgery

End of Life Pathway

Alcohol Pathway

Maternity Pathway

Contract Efficiencies

Contracting teams have supported the delivery of QIPP savings by:

Transacting pricing changes in accordance with PbR guidance

Negotiating local tariffs

Validating acute invoices

Supporting the maintenance of appropriate clinical thresholds through monitoring compliance with Low Priority Procedure and Cosmetic Procedure policies

Re-tendering of contracts under AQP More innovation is required around local pricing structures to enable further contract efficiencies. Regional QIPP Workstreams

Over the past three years, Nottinghamshire has delivered a series of regional QIPP milestones as outlined below.

All acute trusts with an obstetric unit to have a midwifery led birthing unit: Nottingham University Hospitals and Sherwood Forest Hospitals both provide a midwifery led service.

100% of organisations within each trauma network have implemented integrated trauma systems with formally adopted policies, procedures and protocols Nottingham University Hospitals and Sherwood Forest Hospitals comply with these standards

100% of major trauma patients receive tranexamic acid within 3 hours (excl isolated head injury) Nottingham University Hospitals and Sherwood Forest Hospitals both meet this standard.

All providers to have implemented Enhanced Recovery for the 4 clinical specialties identified by the national programme (part of Right Care work stream) - Nottingham University Hospitals NHS Trust has implemented Enhanced Recovery in the following four specialties: Colorectal, Gynaecology, Urology and Orthopaedics – hips and knees. Sherwood Forest Hospitals NHS Foundation Trust has enacted Enhanced Recovery via the 12/13 contracting process.


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95% patients requiring access to carotid enderarterectomy surgery receive access within 14 days of referral Nottingham University Hospitals consistently meets this standard.

Oesophageal Doppler Monitoring (ODM) - In 2011 Innovation Health and Wealth recommended full adoption of ODM which is used by anaesthetists during surgery to assess the fluid status of patients and guide the safe administration of fluids and drugs. Nottingham University Hospitals is using a Cardio Q monitor which provides the same information as ODM and is used in Gastro Surgery and on the trauma lists.

Community 2010/11 - £0.3m 2011/12 - £1m 2012/13 - £2.1m

There is a drive within the NHS to move more services from the acute sector to the community setting where this is clinically appropriate. It is recognised that this can only be achieved through large scale transformational change. Whilst progress is being made in the areas outlined below to transform the system and deliver QIPP savings, further transformation is required in order to ensure the sustainability of the healthcare system.

Frail Older People - Frail elderly was identified by clinicians as being a critical issue that Nottinghamshire needs to address as part of the QIPP agenda and one which requires a transformational approach. „Appropriate care of the frail older person‟ was approved by the Nottinghamshire Executive Team as a Productive Notts workstream in February 2012. The workstream brings together the Community Programme in the South of the County and Sherwood Forest Hospital‟s Geriatric Pathway Programme in the North of the County. Both programmes aim to drive transformational improvement in service delivery to improve quality of care and reduce costs through reduced acute admissions, readmissions and length of stay. Both programmes are currently being implemented and are expected to realise financial savings in 2013/14 onwards.

Integrated Health and Social Care Programmes (NNE and N&S) - The overall aim of the Integrated Health and Social Care Programmes is to establish new ways of working and to co-ordinate care by transforming the capacity, capability and processes of the community health workforce to provide an extended and highly competent service to patients/users with long term conditions in the community. Services will be based on effective and integrated partnerships across primary, community and secondary care and the programmes aim to reduce inappropriate admissions, excess bed days and readmissions, and improve care in the community. Positive progress has been made in implementing these transformational change programmes which are expected to realise financial savings from 2013-14 onwards.

Lings Bar Hospital Pathway Development - The 2010 Utilisation Review of Community Hospitals identified opportunities for reducing patients‟ length of stay at Lings Bar Hospital and managing a greater number of patients outside the hospital environment through improving capacity and access to alternative community based services. Resultantly a Pathway Development Group was established to develop local approaches to early discharge and has succeeded in achieving the following to date: a 20% reduction in the hospital‟s length of stay, a reduction in the number of delays attributable to social care resulting in a monthly average reduction from 300 to less than 50 days, a recurrent QIPP saving of £1.2m for decommissioned beds and improved partnership working. Work is continuing at Lings Bar Hospital to reduce length of stay and improve quality of care through integrated partnership working.


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Assistive Technologies: Telehealth and Telecare - In January 2012 a Productive Notts Assistive Technology workstream was set up with the aim of establishing a strategy and programme for the delivery and spread of telehealth/telecare across Nottinghamshire in line with national policy. One of the key achievements has been the implementation of “Flo”, a telehealth system which supports self-care management in over 150 clinical protocols including COPD, heart failure, hypertension and diabetes. The programme is on track to have 250 patients enrolled onto Flo by March 2013 and has a range of benefits including improved patient experience, quality of care and productivity by reducing admissions and travel costs. There are further opportunities to maximise the benefits of assistive technologies across the County.

One Care Home One Practice - A new locally enhanced service to care homes (nursing and residential) to align one practice to one care home was piloted in six care homes and two of NNE‟s largest GP practices in 2012-13 in order to provide a more proactive approach to care. Each care home involved was aligned with a named practice and identified lead GP and the service included a weekly ward round with each home, annual care plan for every resident, advanced care planning, bi-annual medication review for every resident, care to meet individual needs and regular reviews of all admissions with the home. The review of the pilot has demonstrated a greater reduction in non-elective admissions from care homes involved in the pilot than non-pilot homes with significantly less admissions from GPs, improved quality of care, improved relationships between practices and care homes with better information sharing and improved end of life care and prescribing.

Mental Health and LD 2010/11 - £2.1m 2011/12 - £0.9m 2012/13 - £0.5m

The Mental Health and LD QIPP workstream has encountered challenges in delivering its QIPP targets over the past three years. One of the key issues has been a lack of resource to coordinate the QIPP schemes which have multiple stakeholders. Activity management has been a key priority and one of the few areas to deliver QIPP savings.

Rehabilitation Review - A comprehensive utilisation review of mental health rehabilitation services was undertaken in 2011. The review identified that a number of mental health rehabilitation in-patients could be supported in community placements which would enhance their overall recovery and that care could be delivered closer to home. The priority was to redesign the clinical pathway into and out of the service; revisit how the service model is delivered in and outside of the hospital setting to avoid increasing readmissions and to ensure a high quality and safe service is delivered to patients. To date this scheme has delivered no savings and one of the key issues has been its complexity and lack of project resource to drive the service change.

Delayed Transfers of Care (DTOC) - It was identified that Nottinghamshire Healthcare Trust had a high rate of DTOC compared to other trusts. Systems and Processes have been introduced to review all DTOC cases to determine why delays occur and take action to remove the delays to improve patient pathway and minimise the number of delayed transfers in the Trust. To date this workstream has delivered little savings and again this has been due to its complexity and lack of project resource to drive the service change.

EMSCG - The aim of this programme has been to ensure that patients are not retained in low secure care any longer than necessary. Nottinghamshire has been challenged to reduce the number of inpatients by 31% to bring it in line with other similar providers. A


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step down provision is being developed to expedite appropriate transfers, although financial savings are yet to be realised.

Continuing Care 2010/11 - £2.7m 2011/12 - £3.6m 2012/13 - £2.4m

Continuing Healthcare is care that is funded by the NHS for people with long-term, on-going complex and intense health needs. This workstream has consistently achieved its planned savings over the past three years predominantly through close management of a range of care packages as outlined below. It has also been achieved by ensuring that out of area patients are charged to the correct PCT, through close management of transport charges, equipment requests and consumables and reducing funded nursing care spend.

Fast Track packages - This scheme has ensured that fast track packages are reviewed in a timely manner and has increased the number of reviews carried out each month. Activity is closely monitored and finance is regularly updated of changes in packages following reviews at the weekly Panel.

High Cost packages - This scheme has ensured that high cost packages are reviewed according to framework requirements. A monitoring system for Staying in Control packages has been implemented in addition to a local policy to cap costs and a Staying in Control Contract. The team regularly liaise with providers who have contracts for complex packages of care to negotiate and reduce their costs.

Small packages (under £2K packages excluding LD) - This scheme has ensured that all under £2K packages are reviewed in accordance with framework requirements. Furthermore, it has been agreed that the Panel will only full fund packages where there is a Primary Health need.

Primary Care Prescribing

2010/11 - £3.2m 2011/12 - £4.8m 2012/13 - £5.8m Over the past three years the Prescribing workstream has consistently over-delivered against its targets. Prescribing teams have worked closely with practices across Nottinghamshire to ensure prescribing is cost effective in line with local and national targets. Schemes have included:

Better Care Better Value Indicators (BCBV) - This workstream has delivered significant savings by ensuring local compliance with the BCBV prescribing indicators for drugs such as statins, PPIs and ACE-Is.

Use of Cost Effective Medicines and Preparations - This workstream has delivered significant savings through the use of cost effective, generic medicines including indapamide and triptans.

Oral Nutrition &SIP Feeds - A review of Oral Nutrition and Sip Feeds was undertaken in 2010 to ensure that oral nutritional supplements were being used, prescribed and reviewed appropriately across the Nottinghamshire health community. This led to the publication of the Nottinghamshire Oral Nutritional Supplement (SIP Feed) Guidelines and compliance with these guidelines continues to deliver savings.

Scriptswitch - Scriptswitch is a decision support tool for primary care clinicians which delivers national guidelines, local initiatives and formulary choices instantly at the point


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when a drug is prescribed by GPs. It automatically makes a recommendation in support of clinical decision making. Over the past two years it has consistently over-delivered against plan whilst enhancing patient safety.

Review of Wound Management Formula

Review of Unlicensed Specials

Medication Reviews

Primary Care 2010/11 - £1.9m 2011/12 - £3.5m 2012/13 - £1.1m The primary care workstream has consistently achieved its financial targets. Savings have been delivered through:

A review of underperforming dental contracts

List size cleansing exercises

NEMs and CNCS efficiencies

Funding Cap for PMS/APMS practices

Primary care services are currently being reviewed as part of the national and local strategy including GP contracts. The outcomes will impact upon the QIPP programme and targets going forward.

Corporate Workstreams and Other.

2010/11 - £5.9 m 2011/12 - £8.6m 2012/13 - £1.8m The Management and Admin workstream has consistently over-delivered against its target and thereby supported under-delivery in other areas. Savings have been generated through estates rationalisation, restructures and a series of non-pay schemes as outlined below.

Roll out of Audio Web Conferencing - During 2011/12 a project was developed to enhance the use of audio web conferencing across the Hub, Cluster and CCGs. Meeting point software has been developed that enables users to video conference from their desktops and share documents during live audio / video conferences. Implementation is on-going and it is estimated that a 40% reduction in mileage could be achieved.

QIPP Communications Campaign - During 2010/11 a targeted communications campaign was undertaken to encourage staff to make savings within their areas. These messages were designed to enact small changes to staff behaviour to bring about cost savings and resulted in savings in the following areas: disposable linen, books, journals and subscriptions, training expenses, furniture and office equipment, hospitality, stationary, travel and subsistence and computer maintenance.

Key Learning Whilst QIPP delivery over the past three years represents a significant achievement, there are lessons that can and need to be learned to ensure that the delivery continues, particularly as the savings going forward will become more challenging to deliver.


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Planning

QIPP planning should focus on the medium and long term as well as the short term, recognising the significant time necessary to plan and implement transformational change

There should be a systems approach to transformation

It is recognised as best practice to identify schemes to the value of 140% of the QIPP target in order to minimise the risk of under-delivery

It is important to review QIPP schemes in other health economies in order to generate new ideas and to share lessons learned. Implementing changes are more successful when based on a sound evidence base

SLAs and Programmes should be cross checked to ensure no duplication and to share good practice and lessons learned

QIPP planning should ensure there is a balance between opportunities to save and benchmarked areas of high spend

Schemes should not be planned in isolation without thinking of whole patient pathway or moving cost pressures to other areas of the programme

There is a need to avoid re-visiting areas which have not delivered and salami slicing rather than planning major transformation

The breadth and pace of primary care demand management needs to be increased and transformational change is required to support this.

There remains some potential for contract efficiencies where tariffs can be unbundled and local prices can be negotiated.

All QIPP schemes should have a robust evidence base with a strong case for change. Where appropriate, benchmarking should inform service change.

The Prevention agenda needs to feature more strongly in the QIPP programme moving forward.

Quality and Equality

It is essential to ensure there is no diminution in the quality of services and that health inequalities are not worsened as a result of QIPP schemes. All schemes should have quality impact assessments and equality impact assessments

Quality and Equality should be considered at both an individual project and overall programme level

Systems and Processes

CCGs should ensure that a framework is established to ensure reporting and accountability lines for cross CCG schemes remain robust, with a documented process in place to demonstrate how progress will be monitored.

QIPP information presented to the Governing Bodies should be exception based and RAG rated, highlighting the highest risk schemes and areas of focus to enable sufficient challenge. Forecasting of QIPP performance should be enhanced, particularly where schemes are under-performing.

All key stakeholders should be engaged with QIPP planning, implementation and delivery. Risk sharing arrangements should be in place to encourage shared ownership.

Clear outcomes and measures are required for all schemes including activity indicators. More innovation is required around indicators to demonstrate delivery.

Resources

QIPP schemes require sufficient resourcing to implement particularly staffing including project management support

It is essential to harness the clinical expertise and resource within primary care to support QIPP delivery


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Implementation

All schemes should identify and demonstrate outcomes to establish the impact of changes made

Ownership and clear accountability is essential for successful delivery

It is essential to maintain focus on QIPP delivery amidst competing priorities

Change is often complex and its essential to recognise this and adopt realistic timescales

There is a need for strong communication between providers and commissioners in order to facilitate collaborative working and maximise benefits

There is a need for ownership of milestones. If milestones slip, there should be a risk assessment of the impact upon financial delivery

B-13-319 FS QIPP Legacy.pdfB-13-319 QIPP Legacy FINAL VERSION.pdf

Documents

Agenda reference B/13/319 - Nottingham North · 2013. 5. 17. · (SFH) (11,361 )7,137 (8,514) 4,536 Mental Health and LD 2,682 2,095 2,165 944 3,000 509 Community 325 332 683 950