DARLINGTON CLINICAL COMMISSIONING GROUPdarlingtonccg.nhs.uk/wp-content/uploads/sites/2/2016/09/Darlington-CCG-Clear...7. Our Strategic Approach 56 7.1 Getting a grip of the system

Darlington Clinical Commissioning Group – Clear and Credible Plan 2012 - 2017 1

DARLINGTON CLINICAL

COMMISSIONING GROUP

CLEAR AND CREDIBLE PLAN 2012 – 2017

Working together to improve the

health and well-being of Darlington

May 2012


Contents

Executive Summary 5

1 Introduction 9

1.1 Who we are 9

1.2 What we are trying to change and why 9

1.3 How we are going to change services 10

1.4 How we will measure that we are making a difference 12

2. Vision 13

3. The Case for Change 19

3.1 Health Need 20

3.2 Disease Prevalence (Quality Outcomes Framework) 20

3.3 Health challenges 21

3.4 Demographic changes 22

3.5 Insight from our patients 23

3.6 What we see as clinicians 24

3.7 Programme Budget Data 27

3.8 Financial considerations 28

3.9 What our key partners are saying to us 30

3.10 The Darlington Formative Health and Wellbeing Board 31

3.11 What our main providers are saying 31

4. ISOP and CCP 33

4.1 Cross-CCG approaches in Year 1 33

4.2 Quality 34

4.3 Driving up quality in primary care 40

4.4 Performance 40

4.5 Delivery of Operating Framework Priorities 42

4.6 Informatics Strategy 43


5. Defining our Strategic Aims 46

5.1 External SWOT analysis 46

5.2 Internal SWOT analysis - capacity and capability 47

6. Our Goals 51

7. Our Strategic Approach 56

7.1 Getting a grip of the system 56

7.2 Making best use of what we’ve got 61

7.3 Investing for improvement 61

7.4 Prioritisation of attention, effort and investment 61

8. Programmes and Initiatives 62

8.1 Track record of delivery 63

8.2 Alignment for PCT Cluster ISOP QIPP Programmes 63

8.3 Demonstrating alignment of activities with our strategic objectives 64

8.4 Working with neighbouring CCGs to share and spread good practice 64

8.5 Exclusions from our plan 65

Strategic Aim 1: Improving the health status of people in Darlington 67

Strategic Aim 2: Addressing the needs of the changing

age profile of the population of Darlington 79

Strategic Aim 3: Taking services closer to home for the

people of Darlington 84

9. Our Financial Strategy 92

9.1 Understanding our commissioning allocation 92

9.2 Risk Sharing 94

9.3 Use of non-recurring funding 94

9.4 Applying 2012/13 business rules 95

9.5 Financial scenarios 96

10. Delivery 97

10.1 Deliver 2013 – The Darlington CCG delivery framework 98


11. Governance 99

11.1 Future arrangements – establishing the governing body,

CCG Board and Executive 100

11.2 Financial Governance 104

11.3 Equality and Diversity 105

12. Risk management and ongoing monitoring 106

Appendices 109

Appendix 1: Overview of Health Needs 110

Appendix 2: Gap analysis 123

Appendix 3: Overview of Programme Budgeting 131

Appendix 4: Commissioning intentions 136

Appendix 5: Communication and Engagement plan 137

Appendix 6: Medium Term Financial Strategy 148

Appendix 7: Governance 170

Appendix 8: Full Risk Assessment 171

Executive Summary


Executive Summary

In developing our five year clear and credible plan Darlington CCG has worked together

with our patients, the public, clinicians, providers, our Local Authority and our many other

community partners in order to ensure all of our stakeholders have had a role to play in

shaping our healthcare services of the future.

In this plan, which is focused on improving the health, healthcare services and healthcare

outcomes of our local population, we aim to capture what will be different in the new

healthcare system and put forward a case for change based on sound clinical evidence,

the thoughts of our patients and the public and our own experiences as clinicians

delivering services.

Our plans now and in the future need to be built up from and reflect the contributions of all

within the local health and social care system, stimulating clinical engagement in order to

improve quality, productivity and health outcomes whilst at the same time reducing

unwanted variation and inequality in the services we offer, all delivered within the finances

available to us.

The development of our plan has been underpinned by the three principles of reform as

set out in the white paper ‘Equity and Excellence: Liberating the NHS’ (DH, July 2010):

An increase in patient choice and control

A focus on healthcare outcomes and quality standards

An increase in the freedom of frontline professionals and the development of strong

leadership roles

Within this plan we have outlined in detail:

Our Vision:

“Working together to improve the health and well-being of Darlington”

For the population of Darlington this means:

health services which are safe and of the highest quality

best possible health outcomes

joined up services which benefit patients and the public and give best value for money

Executive Summary


Our strategic aims:

To improve the health status of the people of Darlington

To address the needs of the changing age profile of the population of Darlington

To take services closer to home for the people of Darlington

Manage our resources effectively and responsibly.

Our strategic goals:

Improving the health status of people from Darlington

Over the 5 years of this plan we will look to:

reduce <75 all-cause mortality by 16%

reduce mortality from causes responsive to health care by 30%

reduce <75 all CVD mortality by 20%

reduce <75 Stroke mortality by 28%

reduce <75 Cancer mortality by 17%

These trajectories will close the gap between Darlington and the National average.

Addressing the needs of the changing age profile of the population


Drive improvement in the management of long term conditions through primary care by

supporting all practices to attain a high level of achievement across a range of QOF

indicators. These indicators relate to the conditions associated within an ageing population

(for example diabetes, CHD and dementia). This improve in primary care will be supported

by targeted commissioning interventions that will reduce admissions for acute

exacerbation of COPD and unnecessary admission to acute care for patients with

dementia.

Executive Summary


Taking services closer to home whilst ensuring current services are

accessible, timely and of a high level of quality


Commission more services from a community or primary care setting where safe and

appropriate to do so. We will monitor this through the number of services commission

through the Any Qualified Provider mechanism and the change in total proportion of spend

in the acute sector over time. We will also measure access and quality targets to ensure

current planned and unplanned services remain responsive to local needs. As well as

improving access in commissioned services, we will support all practices to maintain high

levels of access in primary care as measured through a range of QOF indicators.

Making the best use of public funding

Year on year over the 5 years of this plan we will:

Achieve financial balance and control totals on the commissioning allocation

Secure commissioning support within the running cost allowance

Delivery of CCG QIPP plans including demand management

We have also included a detailed outline of our three stage strategy development and

implementation process:

Stage 1: Getting a grip of the system. This first stage will see us get a better

understanding of our use of secondary care services, prescribing practice and use of

continuing healthcare in order to allow us to manage demand more effectively

Stage 2: Making best use of what we’ve got. Reviewing services for effectiveness,

redesigning priority pathways and disinvesting in poorly performing services to improve

quality, access and value for money

Stage 3: Investing for improvement. Once we have assessed the current services and

redesigned pathways where appropriately, we will invest our uncommitted recurring

resource to improve the health outcomes and reduce health inequalities of our population

for the long term future.

Executive Summary


Over the lifetime of this plan we also face a number of specific health challenges and

opportunities:

We need to focus on addressing the significant public health issues affecting population

of Darlington, cancers, cardiovascular disease, chronic obstructive airways disease,

stroke and dementia

There has not been significant focus on providing care closer to people’s homes

through appropriate clinically led pathway review and development

We have an ageing population with increasing demand on healthcare, particularly

patients with long term conditions, which we cannot sustain given the funding scenarios

over the next five years

We need to improve the quality of care and reduce variation in primary care in order to

improve health outcomes and experience for patients and to contribute to the Quality,

Innovation, Productivity and Prevention (QIPP) agenda.

We believe that by putting in place the appropriate constitutional and governance

arrangements to ensure we have the capacity and capability to fulfil our statutory duties

and by working collaboratively with all of our stakeholders in the development of a plan

which not only has a clear and continuing prioritisation of QIPP and the initiatives set out

in our ISOP, but which also reflects both the required national outcomes and the

objectives set out in our local joint health and wellbeing strategies; that we are in a strong

position to lead the on-going development and delivery of this plan and so make a real

difference to the health outcomes of our local population.

Introduction


1 Introduction

1.1 Who we are

Darlington CCG was established in October 2011 as part of the recent changes to the

NHS outlined in the white paper ‘Equity and Excellence: Liberating the NHS’ (DH, July

2010) and the recent Health and Social Care Bill. This legislation has provided a unique

opportunity for front line clinicians to lead the commissioning and design of local services

to meet the needs of local people.

Darlington CCG is made up of twelve GP member practices and represents a population

of just over 100,000 people. The area covered by DCCG is predominately urban, centred

on the town of Darlington, and is coterminous with Darlington Borough Council (DBC).

Despite the compact nature of the area there are some marked differences in health

between the various wards of the Borough and we do not underestimate the steep

trajectory of development required to enable our organisation to become an intelligent

commissioner with the capacity and capability to meet the health challenges of our

population.

As a new clinical commissioning organisation we recognise that we are at the very

beginning of our journey and it is our intention to not only build upon our past

experiences, gained both as a practice based commissioning (PBC) group and then

subsequently as a pathfinder consortium and GP lead commissioning group, but to also

continue to draw on the skills and expertise currently within NHS County Durham and

Darlington to assist us and ensure we continue to develop the commissioning skills,

knowledge and experience we will need in order to successfully deliver our plan.

1.2 What we are trying to change and why

This plan aims to capture what will be different in the healthcare system going forwards

and puts forward a case for change based on sound clinical evidence, the thoughts of our

patients and the public, and our own experiences as clinicians delivering healthcare

services every day. In addition we have also accessed data from public health, service

performance and financial experts to build up a picture of the challenges and opportunities

that we face as a commissioning organisation.

Introduction


Our Key Challenges:

We know that Darlington has an increasing and an ageing population which will bring an

increased demand on healthcare from cancers, cardiovascular disease, stroke,

dementia and long term conditions such as diabetes and chronic obstructive airways

disease (COPD). Cardiovascular disease and cancers already account for the majority

of early deaths in Darlington.

We need to do more to improve the overall quality of care and reduce clinical variation

in health care in order to optimise health outcomes and overall patient experience for

everyone.

We know that although there are many more services now delivered in the community

and closer to home for patients, this shift needs to be accelerated through

transformational change underpinned by the redesign of pathways of care to give the

best outcomes from the resources available.

This plan clearly sets out our priorities and why our chosen priorities will lead to greatest

health gain taking into account future changes. Our plans now and in the future need to

be built up from and reflect the contributions of all within the local health and social care

system, stimulating clinical engagement and improving quality within the finance

available.

1.3 How we are going to change services

To be an effective commissioning organisation, our strategic aims must not only be

ambitious but, more importantly, underpinned by practical implementation plans developed

with our stakeholders and owned by our member practices and partner organisations.

We will work closely with our current hospital and community services in order to ensure

clinicians from a range of professions and a variety of settings are able to collectively

shape services locally to best reflect our patients’ needs.

As part of our pathfinder programme we are taking forward clinical pathway work for

Musculo-Skeletal Services (MSK) and engaging a range of clinicians with a common

purpose to improve services for the defined patient group. This work extends beyond the

Darlington locality and through learning and evaluation of the programme of work we are

informing a future model for pathway development which can be applied to a range of care

pathways.

Introduction


Equally importantly we will build a true partnership with Darlington Borough Council to

support one another in tackling the common challenges that can only be solved by

adopting a joined up approach across the health and social care pathway. This together

with the coming together of organisations in the Darlington Partnership and its vision for

Darlington expressed within “One Darlington Perfectly Placed” offers an early opportunity

for our CCG to sit alongside our partners in order to develop a shared vision and approach

that defines health and well-being in its widest sense, and so optimises health outcomes.

We will also work in partnership with the two neighbouring clinical commissioning groups

in North Durham and Durham Dales, Easington and Sedgefield, taking advantage of the

benefits of whole health economy working, to ensure we deliver our aims and make best

use of available resources and effectively manage our levels of risk.

As a CCG, and up until our full authorisation, we are supported by NHS County Durham

and Darlington as the umbrella statutory NHS commissioning organisation. It is therefore

essential that our commissioning plan acknowledges and remains consistent with the PCT

Integrated Strategic and Operational Plan (ISOP) 2011/12 - 2014/15 whilst ensuring that

our clear and credible plan captures the opportunities for strengthening clinical leadership

and engagement in the commissioning of health services from this point onward.

The Integrated Strategic and Operational Plan (ISOP) outlines how the PCT (NHS County

Durham and Darlington) will ensure the delivery of national, regional and local priorities

over the defined period, ensuring financial stability and improved levels of service

performance whilst at the same time facilitating the transition towards clinical

commissioning.

We believe our clear and credible plan is consistent with the ISOP themes and will carry

these forward, beyond the lifespan of the ISOP, to the point at which we will be required to

demonstrate alignment to the priorities of the new wider system. This will include

demonstrating strategic alignment with the priorities of the Darlington Health and

Wellbeing Board, the refreshed Local Strategic Partnership at a local level and the

overarching strategic aims of the NHS Commissioning Board.

Our governance arrangements will be reviewed and refreshed as we move along the

trajectory from being a composite part of NHS County Durham and Darlington to a fully

authorised governing body in our own right operating within the NHS.

Introduction


Financial Overview

Our clear and credible plan is based on assumptions around National financial allocations

and any required levels of efficiency we are required to achieve. These assumptions have

allowed us to plan how we will deliver our key priorities whilst ensuring we meet our

statutory financial requirements.

1.4 How we will measure that we are making a difference

Over the next five years we will track our progress against our plans and more importantly

measure the impact they have on the health outcomes we are looking to improve. We will

work closely with stakeholders such as Darlington Local Involvement Network (LINk) and

emerging HealthWatch and other patient groups as well as the new Health and Wellbeing

Board for Darlington to ensure all our stakeholders are informed of our progress to date,

aware of our on-going areas for improvement and involved in celebrating with us in those

areas where we demonstrate success.

Alongside this plan, we have developed a communication and engagement strategy for

Darlington where there is potential for a joined up approach with DBC that will enable our

future work to reflect even more the needs of our local population.

The next five years will be both challenging and exciting, but we are committed to making

a difference to the people of Darlington and we look forward to updating you with our

progress in the future.

Dr Harry Byrne Dr Andrea Jones Dr Richard Harker

Interim Chair Interim Vice Chair Clinical Quality Lead

Darlington CCG Darlington CCG Darlington CCG

Vision


2. Vision

Darlington is a unique place in which to live and work, but not one without health

challenges. Our role as a clinical commissioning group is to understand what our

population both needs and wants, consider the evidence base and quality outcomes and

then act to deliver these improvements within the defined financial framework.

To give ourselves the best chance of success on behalf of our population, our vision

alongside our partner organisations is:

“Working together to improve the health and well-being of Darlington”

For the population of Darlington this means:

health services which are safe and of the highest quality

best possible health outcomes

joined up services which benefit patients and the public and give best value for money

In order to achieve this vision, we have developed strategic aims that cover and define the

challenges facing us. These are:

To improve the health status of the people of Darlington

To address the needs of the changing age profile of the population of Darlington

To take services closer to home for the people of Darlington

As a CCG we will be investing roughly £740m over the five year lifespan of this plan. At

the same time our healthcare providers will have to become more efficient than ever to

respond to the current economic climate. Because of this we recognise that as investors of

public money, we have a fourth strategic aim to: Manage our resources effectively and

responsibly.

Whilst delivering these aims given the current economic climate, we must ensure that we

are making the best use of public money within Darlington.

Vision


Improving the health status of the people of Darlington

The Darlington Single Needs Assessment (SNA) indicates that nearly a quarter of the

residents of Darlington live in the most deprived areas of England. Furthermore, just under

a quarter or residents live in the least deprived areas which signifies a major disparity

across the town of the varying levels of health and deprivation.

Men from the least deprived areas of Darlington live 13.4 years longer than those from the

most deprived areas; with the difference in life expectancy for women between these two

areas is 10.3 years.

By working with partners in social care and public health, we can jointly focus on the

underlying risk factors and wider determinants of ill-health and health inequality so that the

people of Darlington can expect to live longer, healthier lives in the future and the

differences in life expectancy are narrowed.

We will influence and shape this at a strategic level as core members of the Darlington

formative Health and Wellbeing Board as well as those areas of joint priority delivered

through the established Joint Strategic Commissioning Group and including re-ablement

and section 75/256 agreements.

Addressing the needs of the changing age profile of the population of

Darlington

The percentage of the population over 50 years of age in Darlington is increasing and the

majority of older people now live more independently within their own homes. A large rise

is predicted in the number of people diagnosed with dementia and current statistics show

that 19.3% of the Darlington population live with a long-term limiting condition, which is

above the England average.

By working with partners and commissioning a range of new services, we will ensure that

the people of Darlington with long term conditions will be able to live a healthier life that is

less reliant on the NHS in the future.

Vision


Taking services closer to home for the people of Darlington

In recent years several significant changes have taken place in the way the configuration

of healthcare services that the people of Darlington use. In the main these large scale

changes have centred on more specialised services however with the strengthening of

clinically-led commissioning comes the opportunity to re-shape the services to better

reflect the needs of the people of Darlington. Over the next five years we aim to focus

much more on what can be provided locally in Darlington, where it is safe and appropriate

to do so. Our CCG will develop a clinical strategy to inform this future direction and

influence the shape of the provider landscape.

Making the best use of public money within Darlington

Given the financial challenge facing the NHS and the wider economy over the coming

years, we are committed to making the best use of public money in Darlington and

operating within our budget. Our CCG boundary is completely coterminous with Darlington

Borough Council and as such is a recognised strength and opportunity.

The consolidation of close working relationships with Darlington Borough Council

alongside voluntary sector organisations will enable a clear advantage for partner

organisations to optimise the impact of joined up commissioning decisions on patient

outcomes and the overall health and well-being of local people.

Over the five years of this plan, local people will see that we will have considered the

information we have on health and service needs, shared this with them and listened

carefully to their views as we deliver planned changes in services over time services whilst

living within our means and demonstrating real value for money. We will work closely with

our local authority partners to ensure we are making the most of economies of scale and

value for money.

Vision


Values

As a Darlington PBC group, local practices established a series of values that have been

built into a ‘compact’ between the CCG and its member practices and will inform our

approach to clinical commissioning and responsibilities to the local community:

Open, transparent and inclusive relationship between practices, practitioners and with

patients the public and partners

Commitment to improve the care and outcomes for people

Fairness and equity in the use and deployment of resources

Commitment to eliminate unwarranted variation

Focused on transformation with a clear and credible clinical focus

Foster strong clinical relationships as a driver for change

These values will be reviewed and refreshed as Darlington CCG moves towards

authorisation as a statutory body.

The tangible benefits of a compact can readily be demonstrated, for example all practices

have contributed practice data to the SNA and all practices have agreed move to

SystmOne as the preferred clinical system early in the next financial year. The practices

have collectively taken forward a scheme to look at referral management through peer

review at practice and CCG level aimed at reducing variation in practice and improving the

quality of referrals to secondary care.

Vision


Engagement

In developing our vision, purpose and values, we have worked closely with GPs and staff

from our member practices through our management and decision making mechanisms.

Over the course of 2011 we have held a number of engagement workshops with patients

and stakeholders, including provider organisations, local authority and other statutory and

non-statutory organisations to explore opportunities through the new and emerging clinical

commissioning system.

To support on-going delivery of our Clear and Credible Plan, we have developed a

Darlington Communications and Engagement Strategy (see appendix five) which is to be

read alongside the Clear and Credible Plan and the Organisational Development Plan as a

formal strategic document. This overarching strategy includes the following:

Engagement Plan for Darlington;

Engagement Plan for the Darlington Clinical Commissioning Group Clear and Credible

Plan / Vision;

Communications Plan for Darlington;

Stakeholder Map;

Patient and Public Involvement Toolkit

The communications and engagement strategy sets out how Darlington intends to engage

with people at all stages of decision-making about health and healthcare through patient,

carer and public involvement, in the context of existing NHS policy, best practice and

legislation. It states a commitment to achieving effective engagement and communications

and outlines how Darlington will develop engagement and communications functions and

implementation plans to support its vision and priorities. The document also outlines how

the Equality Delivery System (EDS) will be implemented for Darlington.

As the Clear and Credible Plan is an important vehicle for public accountability, we will

develop a public facing version of the plan to provide a focus for discussions on local

health needs and priorities.

The overall aim of the engagement plan for Darlington is to ensure the CCG has a

structured and systematic mechanism for patient, carer and public engagement. Our CCG

aims to give meaningful voices to patients and the public to influence planning and

commissioning decisions. We recognise the new NHS architecture will require a new

approach to engaging with patients and public engagement, particularly given the

emphasis on patient experience in the emerging quality and outcomes frameworks.

Vision


While the Department of Health, the NHS and its constituent bodies have consulted and

engaged with patients and the public in the past, the reforms imply a new set of players

leading those discussions, with key roles for Clinical Commissioning Groups and

HealthWatch.

Our CCG, the PCT communications and engagement team together with the Local

Authority and Public Health colleagues have recently agreed to undertake a joint approach

to patient and public involvement and engagement. This cross-organisation task and

finish group is working on a Joint Public Patient Involvement and Engagement

Implementation Plan to be delivered by October 2012. This joint working group recognises

that we will need to develop innovative ways of engaging with patients and the public as

Darlington’s Single Needs Assessment and Darlington’s Health and Wellbeing Strategy

develop during 2012.

Working collaboratively with our Local Authority and public health partners, we intend to

take a three tiered approach to Public Patient Involvement and Engagement in Darlington:

1) Strategic commissioning level

2) Clinical specific level

3) Practice forum level

Our CCG aims to capture the perspective of patients and the public by talking and listening

carefully to people. In this way we hope to gain a full, robust and complete lay person

perspective. Furthermore the CCG aims to secure lay representation at key levels of the

organisation; clinical board and its sub committees, the governing body and importantly

the pathway/service redesign work streams and task and finish groups.

The CCG clinical board assumes collective responsibility for driving forward its vision and

aims in collaboration with member practices and other key stakeholders.

Our Darlington GP practices have a long established track record of good collaborative

working across the practices as well as with other commissioners, particularly other

localities. The three local CCGs are developing how to work together, including specified

areas for confederated working and risk sharing.

Involvement of stakeholders in the development of Darlington CCG clear and credible plan

and vision has included on-going communications via a series of regular briefings to NHS

and local authority staff, GP practices, the Health and Partnerships Scrutiny Committee,

Darlington Local Involvement Network (LINk), formative Health and Wellbeing Board, local

Foundation Trusts, other providers and MPs.

Case for Change


3. The Case for Change

The starting point for the development of the vision for this plan was to fully understand the

health needs of the local population, the patients’ experience of the services they receive,

insights from the GPs and their teams delivering care to their patients and the financial

environment in which we operate.

This was supplemented by the identification of opportunities to make improvements in

service efficiency and performance. Our awareness of the public health challenges in

Darlington through previous PBC arrangements and learning from our pathfinder projects

further strengthens our case.

Case for Change


3.1 Health Need

Using the Single Needs Assessment, Practice Health Profile and other sources of

epidemiological and demographic data, Darlington CCG has developed a picture of the

health challenges facing our local populations. Darlington is significantly worse than the

England average in the following areas:

Lifestyle (smoking, healthy eating, binge drinking).

Over 65’s “not in good health”

Incapacity benefit for mental illness

Hospital stays for alcohol related harm

Substance misuse

3.2 Disease Prevalence (Quality Outcomes Framework)

Quality Outcomes Framework (QOF) prevalence rates for Darlington can be used as proxy

measures for disease prevalence for the Darlington locality. GP practice registered

disease prevalence in Darlington is 20% higher than the England average for the following

diseases:

Chronic Obstructive Pulmonary Disease (COPD – also the second most common cause

of emergency admissions to hospital)

Coronary Heart Disease (CHD)

It is worth noting that QOF measures may reflect the proactive approach in Darlington to

screening and disease detection by the member practices allowing for intervention and

support at an earlier stage than would otherwise have happened (rather than a simple

measure of high level of disease locally compared to the national picture). This is reflected

in development of community CHD services by the Darlington practices including an

integrated heart failure service comprising a GP with a special interest, specialist heart

failure nurses and consultant cardiologist.

Case for Change


3.3 Health challenges

Darlington stands behind the national average in many of the key headline health

measures:

Men in Darlington are living 1.7 years less than the England average and women are

living 1.5 years less than the England average

Inequalities in life expectancy exist within Darlington with life expectancy for men living

in the most deprived areas over 13.4 years lower than for men living in the least

deprived areas. For women it is 10.3 years lower

Between 2007 and 2009 1,129 people in Darlington died aged less than 75 years

Cardiovascular disease (CVD) and cancer account for around 63% of early or

premature deaths in Darlington.

The underlying risk factors that drive this level of ill health are also stark:

Binge drinking prevalence is estimated to be 31% in Darlington, 18% higher than the

National estimate

Smoking remains the biggest single contributor to the shorter life expectancy

experienced locally

Finally, diseases associated with getting old are also significant locally:

Dementia prevalence is predicted to rise in Darlington to 8.1% by 2030

COPD prevalence is greater in Darlington (2.2%) than England (1.6%).

A full outline of the health need of our CCG area and the gap analysis undertaken against

our commissioning intentions can be found in Appendices One and Two.

Case for Change


3.4 Demographic changes

As shown in the figure below, the population of our CCG will age significantly over and

beyond the life of the plan. An ageing population makes a higher demand on health

services for example there will be an impact on the prevalence of long term conditions as

well as the level of dependency found in Darlington.

Darlington Demographic Shifts

By 2030 it is forecasted that there will be a 51% increase in the over 65 years registered

population. The number of people aged 85 years and over in Darlington is projected to

increase by almost two thirds by 2023. A large rise is predicted in the number of people

diagnosed with dementia (predicted to increase by 61% by 2026) and current statistics

show that 19.3% of the Darlington population live with a long-term limiting condition, which

again is above the England average.

Case for Change


3.5 Insight from our patients

We have well developed links with patients through our member practice forums and the

face to face communication between clinicians and patients. We have developed a robust

patient and engagement involvement strategy and operational plan for the whole of our

community that will link these elements together into a comprehensive approach that puts

patient needs at the centre of what we do.

In September 2011 and in collaboration with Darlington Borough Council we undertook a

joint consultation exercise with attended by patients, carers, third sector organisations as

well as local stakeholders.

The event gave local people the opportunity to have their say about the health services

that are important to them; how they can get involved in how local health services are

commissioned (planned and purchased); and how they wish to be engaged and

communicated with in the future.

The event had the following objectives:

Commence sharing with the community of Darlington the national changes that are

impacting on the clinical commissioning group and the local authority

Highlight changes for Health and Social Care across Local Authority and Health

Outline any key Public Health challenges

Raise awareness of HealthWatch and consult on involvement of the community in

future HealthWatch arrangements.

Raise awareness that the Clinical Commissioning group and the local authority are

working together on this agenda

Highlight local health priorities as identified in Single Needs Assessment and engage

the community in consultation around how we can address these priorities

Commence discussions on how the community can influence the future and what public

and patient involvement needs to look like in Darlington

Those who attended identified the following health priorities in Darlington:

Stopping smoking

Reducing alcohol related deaths

Improving dental health

Tackling obesity

Reducing teenage pregnancies

Improving access and choice to services

Prevention and education

Concerns that there is insufficient funding to maintain existing health and social care

services

Case for Change


Better promotion of health checks

Lack of awareness around commissioning services, and the impact of future changes

Improving communication with people using a range of methods

The need to reduce health inequalities which affect the local population

Building on this successful event and as described earlier we are working jointly with DBC

and Public Health colleagues to develop a Joint Public Patient Involvement and

Engagement Implementation Plan (to be completed by October 2012).

3.6 What we see as clinicians

As a part of the transition to the new system of clinical commissioning we are proactively

informed by our clinicians about service changes that need to happen in order to improve

service safety, quality, access, outcomes or efficiency. The opportunity of face to face

contact with patients and their carers gives clinicians important insights into where we can

direct our efforts to improve what health care services are provided and how they should

be provided.

This plan aims to triangulate the evidence of need and views of patients and the public

with the experience and insights of clinicians delivering services so that any changes

made bring about real improvements in the health outcomes and experiences of our local

population. We believe this will demonstrate the ‘value add’ of clinical commissioning and

underline its difference to those approached that have gone before.

Public Health / Prevention

We see a huge variation in terms of deprivation across Darlington, which is supported

with the data presented within the SNA.

The area that we feel would make the most impact would be the provision of more

integrated obesity pathways of care and interventions to support our population to stay

healthy and reduce the likelihood of developing other long term conditions in future

years. There is a current gap in service provision for the Darlington population.

As we know from our QOF prevalence rates we have a high percentage of our

population diagnosed with coronary heart disease and diabetes-obesity has a direct

impact on these conditions.

Case for Change


Long Term Conditions

We will be recognised for delivering proactive healthcare service where we can jointly

care plan with our patients to help manage their long term conditions (Darlington will

face an increasing elderly population in future years who are likely to be living longer

with potentially more than one long term condition)

We will lead the development of more streamlined and co-ordinated approach to long

term condition care planning along with the pathways that support our patients

throughout their condition.

We are leading the development of care closer to home for patients with long term

conditions to address the current gap in local clinical knowledge and put in place

actions to address the cost pressure associated with secondary care referrals.

Delivering the Right Care, in the Right Place

The North East in general has a high dependency on secondary care services. We want

to ensure our patients are seen at the most appropriate care setting for their condition.

We are initially focussing on specified musculoskeletal pathways to improve not only the

patient experience but also to drive efficiencies that exist within the healthcare system

by reducing the “revolving door” experience that exists for many of our patients. This

area of work is led by our MSK clinical co-ordinators.

We have captured the learning from the pathfinder projects to strengthen our

commissioning approach over time

By streamlining the MSK pathways, we aim to achieve more cost effective pathways

which ensure patients receive the right care at the right time and to develop a

framework for all future pathway developments.

We are reviewing the access to community bed provision in Darlington sin order to offer

patients a facility when they require local access to specialist health interventions but do

not require secondary care level input.

Case for Change


Patients with Mental Health needs

Mental Health is an area of increasing prevalence for Darlington and we will ensure our

patients have a sustained access to appropriate mental health services.

We will focus on areas where current services do not fully support patients or areas we

feel that an improvement in service can be made. This work is led by our clinical leads

for Mental Health.

For Darlington, we believe that further work around the pathway and access to care and

support for patients with personality disorders needs to be undertaken.

We aim to complement our local counselling service to offer more specialist support

services particularly around psychosexual counselling.

Patients needing Emergency Care

We are investigating the reasons behind the high levels of A&E attendances and

emergency admissions. This key area of work is led by our clinical lead for unscheduled

care

We know that we have a high level of paediatric admissions within Darlington in

particular related to respiratory conditions. Our Children’s’ lead clinicians are working

jointly with secondary care to improve the management of children with respiratory

conditions and the poorly child pathway.

We aim to reduce the minor injuries that attend A&E within primary care working hours.

We would like to be able to ensure that our population’s health care needs can be met

by improved access to primary care where ever appropriate to do so in order to reduce

the reliance of A&E attendances for appointments and reduce unnecessary activity

through Darlington urgent care centre in hours.

Resolving service quality issues with our providers

Clinical letters from some of our providers are either late or inaccurate and often a clear

care plan on discharge is not apparent. We are working with our providers to improve

both the quality of the primary care referral letters that providers receive, but equally the

quality of the information that is receive back to the referring clinician. This and other

areas of clinical quality are led by our GP lead for clinical quality.

Case for Change


3.7 Programme Budget Data

Darlington CCG has access to the County Durham and Darlington Annual Value

Population Review – a locally produced guide to the nationally collected programme

budget data that compares spend with outcomes within disease areas. This guide

identifies areas of potential opportunity to re-design services to improve efficiency and

maximise effectiveness of spend. An overview of the Darlington spend profile can be

found in Appendix Three.

In 2009/10 the level of expenditure on the Trauma and Injuries programme in Darlington

was significantly greater relative to other PCTs (there were no programme areas where

expenditure was significantly lower). With respect to outcome, there were no programme

areas that had significantly worse or better outcomes than other PCTs during 2009/10.

There are a number of areas in 2009/10 where there may be more moderate resource or

outcome issues.

Programme areas with

potential overuse of

resources (Higher Spend

and Better Outcomes)


potential misuse of

resources (Higher Spend and

Worse Outcomes)


potential underuse of

resources (Lower Spend and

Worse Outcomes)

Trauma and Injuries* Problems of the Respiratory

system

Cancers and Tumours

Endocrine, Nutritional and

Metabolic (Inc. Diabetes)

Neurological system Conditions of Neonates

Healthy Individuals Problems of circulation

Dental Problems

*significant

The majority of the budget that supports the expenditure on the Healthy Individuals

programme will move to the Local Authority as a part of the Public Health transition

process. Investment in this area also fits in with the strategic direction of the CCG so in

reality would not be considered at this stage an overuse of resources.

Case for Change


3.8 Financial considerations

In order to meet the demands placed on the health system by the increasing demographic

need and increasing patient expectation the NHS was set the ‘QIPP challenge’. This

challenge was to drive up the quality and productivity of the health system to realise the

£20bn saving required to reinvest to meet these financial pressures.

QIPP (Quality, Innovation, Productivity and Prevention) began in 2010 as a set of planning

assumptions that set out to define the potential impact on commissioners and providers

financial allocations/contracted levels of income.

The County Durham and Darlington cluster have an agreed QIPP target of £224m for the

four years from 2011/12 to 2014/15. These figures are set out in the table below.

CDD Cluster Total

2011/12

(£000s)

2012/13

(£000s)

2013/14

(£000s)

2014/15

(£000s)

Total

(£000s)

Provider (technical)

efficiencies 44,726 46,844 47,825 48.827 188,222

PCT/CCG (allocative)

efficiencies 19,497 9,657 6,145 762 36,061

Total QIPP Target 64,223 56,501 53,970 49,589 224,283

Case for Change


A simple apportionment of these cluster-wide totals using weighted capitation provides

indicative QIPP totals for Darlington CCG as shown below:

Darlington CCG

2011/12

(£000s)

2012/13

(£000s)

2013/14

(£000s)

2014/15

(£000s)

Total

(£000s)

Provider (technical)

efficiencies

6,709

(delivered) 7,027 7,174 7,324 28,233

PCT/CCG (allocative)

efficiencies

2,925

(delivered) 1,449 922 114 5,409

Total QIPP Target 9,633 8,475 8,096 7,438 33,642

It must be noted that these figures are based upon a simple apportioned split of the

cluster-wide total and will need to be revisited once firm allocation details are confirmed for

public health, specialised commissioning, and CCG funding.

The savings target for 2011/12 has been delivered ensuring Darlington CCG is entering

2012/13 with a balanced financial position and without legacy debt. We will work

collaboratively with other CCGs in County Durham and Darlington with regard to delivering

QIPP.

Case for Change


3.9 What our key partners are saying to us

The Local Authority have provided their perspective on key drivers and issues which they

feel should be visible and addressed in our clear and credible plan.

Drivers for change:

Delivery of joint strategies through joint commissioning between health and DBC need

to be actively explored. There is a desire and an opportunity for collaborative working

on pathways of care and programmes which prevent poor health and dependence on

social care and those that enable people to better manage long term conditions. Some

examples include:

1) Improve health status through early intervention and prevention programmes in

adults and children

2) Address the needs of the changing age profile- build capacity in the communities to

self-manage; joint commissioning of services to deliver Older Peoples Strategy;

Intermediate Care Plus; Older Peoples Mental Health; Long Term care including

support for people at home; Continuing Health Care

3) Taking services closer to home- commissioning support for people in the community

where appropriate.

Efficient deployment of public resources - Making best use of public money. Align

resources for best outcomes focusing on community premised on prevention,

personalised and person-centred but prioritised care

Opportunities for system wide working on community issues (anti-social behaviour,

poverty, school attendances) that impact on well-being

Financial position of “more for less”, reducing directly funded services for empowerment

of individuals and communities, manage change in voluntary and community sectors-

through “Darlington Together”.

Quality of care and safeguarding for children and vulnerable people or for those in time

of need- for example following planned admission.

Issues to be addressed:

Consider opportunities for closer working with the DBC Strategic Commissioning Team-

develop commissioner led services (rather than provider led)

Transfer of shared line management responsibility for the Head of Strategic

Commissioning & Partnerships from PCT to Darlington CCG

Balance need for Darlington CCG to manage and monitor high proportion of budget for

acute and secondary care with community prevention and provision

Smarter information sharing on which to base commissioning and monitoring

Governance of joint groups and reporting arrangements

Case for Change


Continued support from the CCG for Darlington Joint Commissioning Strategies which

have been developed with the PCT

3.10 The Darlington Formative Health and Wellbeing Board

The health and social care reforms impose a duty on local authorities and clinical

commissioning groups from April 2013 to jointly produce a Health and Wellbeing Strategy

to meet the needs of the population as identified in the SNA. This strategy will be

discharged by the Health and Wellbeing Board.

The Darlington Health and Wellbeing Board is currently in a formative state and has

representation from our CCG where the interim chair as well as senior officers are part of

the core membership. It will be vital that our clear and credible plan aligns to the health

and wellbeing strategy (when developed) however in the transition we believe that our

current plan both acknowledges and aligns to key strategic plans including “One

Darlington Perfectly Placed”, the developing Area Wide Strategy and the identified action

priorities of the Darlington Partnership.

3.11 What our main providers are saying

As the major provider of acute and community services in Darlington, County Durham and

Darlington Foundation Trust (CDDFT) have provided their perspective on key drivers and

describe Darlington CCG, working jointly with the Local Authority and local providers is

perfectly placed to realise the potential to transform health and care services for the

benefits of the residents of Darlington.

Working jointly, utilising the SNA and the emerging Health and Wellbeing strategy will be

key to implementing a local approach. This approach will provide our partners with a jointly

agreed locally determined set of priorities. Decisions about health and care will be made

on the basis of local clinical expertise, evidence from the SNA and input of local people.

The development of relationships and the modelling of the collaborative approach that the

new system is designed to deliver should be “hard wired” into the way of operating.

CDDFT believes a key component of such an approach would be the development of a

Darlington clinical services strategy that would address a whole system approach;

including health improvement services, community services, hospital services and the

social care interface. The overall approach should be captured in an integrated pathway of

care with an emphasis on care closer to home.

Other key aspects of this joint working would need to address the effective management of

demand and capacity as well as the development of the local health economy

infrastructure.

Case for Change


As the main provider for Mental Health and Learning Disabilities, Tees, Esk and Wear

Valleys Foundation Trust (TEWV) are delighted with the way the Darlington CCG has

become an integral part of the local health and social care system, keen to learn, establish

relationships and build on the strong foundations that exist.

A great example of this was the way the CCG helped and played an important role in the

Darlington Dementia Collaborative. TEWV hope that the partnership way of working will

continue so that together we can ensure that people with mental health problems and

people who have a learning disability are able to successfully lead a good, self-determined

lifestyle, receiving the appropriate help they might need from time to time.

Key priorities include working together to:

Develop and implement clinical pathways that are evidence based, in accordance with

best practice – the recent guidelines for dementia are a good example of this.

Improve the physical health of people who have a mental health problem or a learning

disability to substantially reduce the premature death rate.

Improve the mental health of people who have long term health conditions. These are

pre-requisites to enable people to have a good life.

Ensure we have healthy children in Darlington, building resilience and capability - this

will reduce people experiencing mental ill health in adulthood.

Reduce stigma and discrimination that is too often associated with and experienced by

people who have mental ill health or a learning disability

Help keep people well and independent, receiving any help and support people need at

home, thus reducing the need for admission to hospital.

ISOP and CCP


4. ISOP and CCP

2012/13 is a pivotal year in the transition to the new commissioning structure with the PCT

Cluster providing assurance and statutory responsibility for commissioning activities but

having devolved responsibility for this to CCGs using a sub-committee arrangement.

As part of the national assurance arrangements, the Cluster is required to produce an

Integrated Strategic and Operational Plan which details how NHS commissioners within

County Durham and Darlington will:

1) Continue to deliver the commissioning strategy and QIPP efficiencies

2) Maintain and improve performance including delivery of national priorities

3) Ensure safe transition to the “new” NHS.

This plan outlines how the CCG will contribute to the delivery of objective 1 above whilst

the ISOP outlines a series of cross-CCG approaches (signed up to by all CCGs in County

Durham and Darlington) to deliver objective 2. These cross-cutting approaches for

2012/13 allow CCGs to continue to meet national requirements whilst giving us time to

develop local approaches that fully meet the needs of the local populations for

authorisation in October 2012.

4.1 Cross-CCG approaches in Year 1

In Year 1 of this plan, the CCG will adopt cluster-wide approaches to the delivery and

adoption of plans in the following areas:

Ensuring Quality

Maintaining and improving performance

Delivery of Operating Framework priorities

The IMT/Informatics Strategy

As well as signing up to these common approaches in the ISOP in 2012/13, the CCG will

develop locally specific approaches ready for the refresh of this plan in 2013/14.

ISOP and CCP


4.2 Quality

Darlington CCG recognises that quality of care is paramount to patients. During 2012/13

the CCG will work across the PCT cluster to deliver the quality agenda whilst developing a

bespoke approach in Darlington in readiness for authorisation and beyond. Whilst the full

County Durham and Darlington approach to quality can be found in the ISOP, key actions

for the CCG in 2012/13 will be:

Aligning the National Quality Outcomes Framework with the strategic aims in our Clear

and Credible Plan

Making use of the Legacy Document created by the PCT Cluster as part of transition

Using Commissioning Support Unit (CSU) support to continue to deliver workforce

assurance (using the national workforce assurance toolkit) and quality monitoring (e.g.

Patient Reported Outcome Measures and Summary Hospital-level Mortality Indicator

Monitoring)

Identifying a quality lead from the clinical community within Darlington

Taking on the leadership and delivery of the quality actions and risks within the

transition plan

Our approach to ensuring clinical quality

The overall strategic aim is to improve the health and well-being of the population of

Darlington. Clinical quality is viewed as an integral part of achieving this, ensuring that our

patients experience safe and effective care and that their experience is positive across

primary, secondary and tertiary care.

Our primary goals are to:

Immediately safeguard patients;

Ensure continued provision of services to the population;

Secure rapid improvements to the quality of care at failing organisations; and

Drive up quality and foster a culture of safety across primary care

As future commissioners, it is vitally important that we safeguard quality across primary,

secondary and tertiary care. Second to the primary defence of first line staff, the

commissioner’s role as a contract manager is viewed as the next line of defence. In order

to achieve this, we will ensure that the clinical quality, contracts and performance

commissioning support teams, provide us with ‘real time’ intelligence and the most up to

date information in relation to clinical quality and agreed standards of care.

ISOP and CCP


In order that we ‘hit the ground running’, we will ensure that there is a robust system for

handover from the PCT cluster that effectively captures and transfers organisational

memory, and that the current systems and processes are adopted and adapted until our

own clinical quality infrastructure matures. This journey begins with the appointment of an

interim lead nurse, identification of a clinical quality lead, and joint working with the cluster

board nurse and medical director. A key part of this process will be to understand and

make best use of the cluster legacy documents and existing quality risks that are specific

to Darlington and those that relate to the health system as a whole.

Currently, there are separate compliance frameworks for different types of providers, we

will look to utilise the forthcoming quality dashboard to achieve a much closer alignment

and understanding of the health system as a whole. This type of approach will be more

sensitive to quality issues, so that underperformance can be spotted and tackled through

performance management routes and before it becomes a serious failure and requires a

regulatory response. Our lead nurse and clinical quality lead and the named CCG clinical

leads will all have a key role in understanding local and system-wide issues and ensure

that correction action plans are put into place to maintain patient safety and provision of

service.

Whilst a quality experience is what we want to commission for our patients, we will ensure

that the board understands its responsibilities, as set out by the National Quality Board, in

responding to the early warning signs reported against our main providers and

understanding their role in actively seeking assurance, through the quality infrastructure

and processes, that remedial actions are being taken to keep patients safe. This will

involve visiting providers to see that patients are being cared for in a safe and appropriate

environment. The board will also look to see that leadership of our provider organisations

are fully engaged in reviewing the quality of their health system and they are involved in

setting improvement priorities and evaluating their impact as part of their Quality Accounts.

Research and innovation will form part of what we do in the development and

measurement of services both across primary and secondary care. We will make the most

of existing research governance arrangements, but will also look to shape the areas of

research undertaken across our academic and clinical networks to benefit us as

commissioners.

ISOP and CCP


Positioning clinical quality in our everyday commissioning business

Clinical quality is one of the key determinants when establishing the priorities for service

developments. We will ensure that the intelligence gathered from clinical quality informs

what services we choose to review and how any changes in service delivery will impact on

quality and the broader healthcare system.

The development of three clinical commissioning groups across County Durham and

Darlington potentially fragments how quality is managed with our main providers. Whilst

we can influence how patient experience is improved in our own locality, we need to have

a proactive approach to work with our clinical commissioning colleagues across the whole

population and with our neighbouring CCGs when necessary. In response to this and in

partnership with our colleague across County Durham and Darlington, clinical quality will

be governed on three levels:

1) Member practice, in order to drive up patient experience and service delivery, but

also for member practices to consider quality information as a commissioner.

2) Clinical commissioning group, in order to have an overview of patient experience

across member practice, but also to consider quality information as a commissioner

and the impact of poor quality performance and experience on patients. This will

inform future commissioning decisions and areas of escalation.

3) Pan clinical commissioning, to understand and respond to patient experience and

safety issues across the health system. This will involve using the information

gathered via the contract management processes and daily reporting events, as well

as, dealing with national reporting.

It will be the role of the clinical commissioner to balance the matrix of quality (shown

below) and ensure that member practices understand their contribution and the assurance

routes for delivery.

Quality Matrix

Me

mb

er

pra

ctic

es

focus

CC

G

focus

Pa

n C

CG

focus

Contractual management of quality

through performance

Increasing provision in primary care

Primary care development as

commissioners

Improving patient safety &

experience primary care practices

ISOP and CCP


In Darlington, we will have a documented approach to clinical quality, it will deliver both a

framework for assuring the board that there are systems, processes and resources in

place to ensure that clinical quality is managed across commissioned and contracted

services and that we have a continuous improvement approach to drive up quality across

providers and primary care. The approach will also demonstrate how the key elements of

quality, as outlined in the NHS Outcomes Framework as well as in ‘High Quality Care for

All’ – patient safety, patient experience and effectiveness of care, will be governed through

our CCG structure and constitution.

The NHS Outcomes Framework 2011/2012 set out the five national outcome goals. We

know that the NHS Commissioning Board will use these domains, through the emerging

national quality dashboard, to monitor progress and safety of commissioned services.

We will use the domains of quality outcomes to align our strategic leadership (shown

below) and to inform our local improvement programme.

Strategic leadership of the clinical quality domains

Source: NHS Outcomes Framework 2011/2012, DH, 2010

It will be the responsibility of our CCG board to ensure that the delivery of the indicators

above and areas for improvement, within each of the 5 domains, are achieved through the

commissioning of quality healthcare and escalation of poor performance. The monitoring

of such areas will be structured through our quality group, existing information flows,

partnership involvement and contracting performance mechanisms, which we are already

members of.

Preventing people from dying prematurely

Enhancing quality of life for people with long-term conditions

Treating & caring for people in a safe environment and

protecting them from avoidable harm

Ensuring that people have a positive experience of care

Helping people to recover from episodes of ill health or

following injury

Domain 1

Domain 3

Domain 4

Domain 5

Domain 2 Effectiveness – Clinical

quality lead

Patient Experience –

lead nurse

Patient Safety – lead

nurse

ISOP and CCP


In Darlington, clinical quality is already discussed at our commissioning group and our

emerging governing body. Discussion at these forums will help our executive and member

practices become fully appraised of the quality agenda, related areas of concerns and

agreed areas for escalation with providers. The information shared through the

commissioning support team will also be used to inform the decisions we make as

commissioners. The local quality forum will continue to examine the intelligence, national

and local quality standards and oversee the strategic delivery of an effective quality

assurance process across our own clinical commissioning group. When necessary this

forum will take action and make recommendations for areas of improvements, as part of

the commissioning cycle to the commissioning group and emerging governing body. This

will be a joint approach with the clinical quality lead, lead nurse, members of the

commissioning support team and senior commissioning lead.

Locally, the CCG quality lead and lead nurse will understand quality issues and the

potential impact they have on patients so they can keep the Board and member practices

appraised of such matters. The contractual management of quality will continue to be

centrally governed through provider quality review groups and contract performance

meetings. The future leadership of these groups will involve the lead clinical commissioner

and the CCG lead nurse. The CCG lead nurse will have a ‘global’ overview of the health

system and provider performance.

The CCG understands the importance of good collaborative working with other

commissioners, particularly other local and regional CCGs and the emerging NHS

Commissioning Board. In relation to the quality of commissioned services as a whole, we

will strive to maintain an overview of the health system through the emerging clinical

quality infrastructures, but also through a health system-wide forum which will bring

together the lead nurse, CCG clinical quality leads and commissioning support staff to

understand the effectiveness of services, trends of performance and make

recommendations for improvement via the contract management and quality review

forums. The first major piece of work we will prepare to deal with, under the supervision of

the PCT Board nurse and medical director is the second report following the review of Mid

Staffordshire – Francis 2 – due in May/June of this year. The outcomes for improvement

will be monitored through the existing quality review groups.

ISOP and CCP


In order for us to be effective as commissioners we need to continue to actively use the

current reporting system (Safeguard) and tools to foster a culture of reporting patient

concerns, contracting issues and patient safety incidents or near-misses to benefit the

commissioning cycle as a whole. From which, we will be able to undertake a combined

approach to investigating the root causes of issues and communicate the lessons learned

to commissioning staff (as well as providers). We see that the information gained through

the clinical quality system as being key to the decisions we make on commissioning and

decommissioning of services in the future: putting patient safety, patient experience and

clinical effectiveness at the heart of local commissioning process.

ISOP and CCP


4.3 Driving up quality in primary care

One of our primary goals will be to drive up quality in primary care. Not only will this aim to

foster a culture of patient safety, but also to improve the experience of patients through the

reduction of variation in practice. Although the NHS Commissioning Board will be

responsible for the commissioning of primary care services and the performance register,

the CCG will continue to drive innovation in primary care and manage a programme of

continuous improvement to improve the quality of provision in general practice. This work

will be the primary responsibility of the clinical quality lead, but will engage and secure

local leadership from across the GP practices.

4.4 Performance

As part of the transition from PCT to clinical commissioning, Darlington CCG has

undertaken a review of the headline performance metrics that describe how the system is

working for our patients.

This transition will be phased over the life of the clear and credible plan. In the early

months of Year 1 of the plan, we will assume direct accountability for the performance

across a range of key areas. These measures are:

18 Week RTT 95th Percentile

Cancer 62 Day Waits

C. Difficile

A&E 4 Hour Waits

Ambulance Category A response rates

Mixed Sex Accommodation

Stroke patients spending 90% of time on a specialist ward

Choose and Book

ISOP and CCP


Performance in these areas going into the planning period is RAG rated as follows:

C. Difficile

C. Difficile has been a very challenging target in 2011/12. On behalf of the CCG the CSU

has put in place escalation processes and key priorities for action including

Strengthening antibiotic prescribing stewardship in primary care

Targeted work in care homes with an increased incidence (actions such as education

and training to reduce the risk of transmission of C. Difficile between residents)

For 2012/13 the Operating Framework has set a tighter non-negotiable target for C.Difficile

which underlines the essential collaborative working required across the CCGs in Durham

and Darlington to share best practice and review any areas for improvement locally.

Choose and Book

When properly implemented, Choose and Book (C&B) can provide significant benefits not

only for patients, but also for referrers, providers and for the wider NHS, by delivering

choice, certainty, security and reliability.

Although the usage of C&B in Darlington is good, there is some degree of variation

between Practices in the manner in which the system is applied. Darlington CCG will

continue to encourage GPs to utilise C&B when referring patients and will work with the

CSU to successfully implement any recommendations from the County Durham and

Darlington C&B Steering Group.

Hyperacute Stroke

Towards the end of 2011 there was a major change for Darlington residents with respect

to hyperacute stroke service provision. Following a full consultation exercise by NHS

County Durham and Darlington the provision of the immediate acute care phase of a

patient with a stroke was transferred to the University Hospital of North Durham. As the

future commissioners Darlington CCG are eager to understand and monitor any immediate

and longer term quality impacts that the reconfiguration has demonstrated specifically for

the population of Darlington. We will build this into our performance reporting framework

RTT admitted

95th

percentile

62 Day

CancerC-diff

A&E 4

Hour

Mixed

Sex

Accom

Ambulance

Cat AStroke

Choose &

Book

Utilisation

Darlington CCG

ISOP and CCP


alongside any other local service redesign initiatives set out in our plan and which we

implement over time. These requirements over and above that already provided within the

standard reporting framework will be agreed with the CSU and specified as part of our

service agreement.

We believe that involvement of local clinicians in the performance monitoring and reporting

system will ultimately influence sustained improvements in performance. As previously

mentioned as a first step Darlington CCG has identified a lead GP for clinical quality who

will lead clinical quality review meetings with providers to drive up improvements in

performance as part of the contract performance monitoring process.

4.5 Delivery of Operating Framework Priorities

The NHS Operating Framework for 2012/13 outlines the key challenges facing the

healthcare commissioners. Emphasis is given on the requirement nationally to deliver the

QIPP agenda to make up to £20 billion of efficiency savings by 2014/15 in order to

continue meet growing demand and continue improving quality.

Particular areas of national policy focus for 2012/13:

Dementia and care for older people;

Carers;

Heath Visiting and Family Nurse Practitioners;

Military and Veterans’ Health.

Darlington CCG will work collaboratively with other CCGs and partners to deliver the

above. Darlington CCG has taken on the role as the lead CCG for Military and Veterans’

Health for County Durham and Darlington and will ensure delivery of the agreed action

plan.

The Operating Framework also emphasises an outcomes based approach and lays out

the five high level domains that will form the NHS Outcomes Framework which include:

Preventing people from dying prematurely;

Enhancing quality of life for people with long term conditions;

Helping people to recover from episodes of ill health or following injury;

Ensuring that people have a positive experience of care;

Treating and caring for people in a safe environment and protecting them from

avoidable harm.

ISOP and CCP


In the forthcoming year we have identified opportunities to address these areas for

example the Health Visitor and Family Nurse Practitioners expansion programme is being

delivered across three CCGs in one efficient work stream.

The outcome domains within the framework line up to a significant extent to our CCGs

overarching strategic aims:

Improving health of our population would prevent people dying prematurely;

Tackling the challenges of the ageing population provides greater emphasis on those

with long term conditions improving their quality of life;

Making services more responsive and accessible to our communities' needs will have

the effect of increasing their experiences of the care that they receive.

This alignment is presented as “Plan on a Page” (see page 66)

4.6 Informatics Strategy

Darlington CCG recognises that informatics and information technology are key enablers

in delivering improvement in both service quality and outcomes for patients as well as

improving efficiency in for providers and commissioners. Darlington GP practices have a

good track record of working collaboratively for informatics solutions such as the

comprehensive deployment of SystmOne clinical system for all Darlington practices as

well as national programmes such as Summary Care Record, NHS mail, Electronic

prescribing and Choose and Book.

In the commissioning environment Darlington CCG will build on these experiences to

ensure that informatics solutions:

Support the implementation of our strategic initiatives

Provide the information necessary to manage demand on health care services

Deliver the national priorities outlined in the current and previous Operating

Frameworks for England

Supporting implementation of our strategy

For initiatives undergoing implementation in 2012/13, our CCG has fully considered the

IMT implications to ensure successful delivery. Examples of this include:

The development of an e-learning self-management tools for diabetes

The development of the Points tool for COPD patients as a quality indicator of condition

management

ISOP and CCP


Supporting demand management

High quality information is vital to enable clinicians to make informed decisions when

undertaking commissioning to manage demand on the local health service. Our CCG will:

Continue with the interpretation training for CCG members using RAIDR. This training

will support clinical decision making to address unnecessary variation in patient

pathways, outcomes or quality of care.

Trial the use of the LACE module within RAIDR as a predictive modelling tool to identify

patients with a higher risk of admission/re-admission to secondary care using a national

recognised algorithm. We plan to implement the LACE tool in 2012/13 and evaluate its

effectiveness.

Utilise Map of Medicine (MoM) where it is appropriate to do so to support the

introduction of new best practice and evidence based pathways. The learning from the

MSK carpel tunnel pathway will be used to further develop MoM across a range of

pathway redesign initiatives.

In June 2012 Darlington practices will achieve complete deployment of SystmOne as

the preferred clinical system. This will enable information sharing across the CCG and

facilitate numerous initiatives where comparative data and information is required for

quality impact measurement, audit and evaluation.

Darlington CCG has developed and implemented a bespoke GP intranet which is used

to share information, facilitate discussion and information/data transfer between

member practices. The commissioning section of the Darlington GP intranet is to be

further developed to enable storage and retrieval of essential commissioning

information as well as the evidence repository for the CCG authorisation process and

beyond.

ISOP and CCP


Delivering national IM&T priorities

Darlington CCG will support the continued implementation of national programmes such

as:

Summary Care Records (SCRs). SCRs have many benefits for patients and healthcare

staff by providing access to health information that has previously been unavailable and

enabling better informed clinical decision making.

Electronic Prescribing (EPS). This service will allow prescribers to send prescriptions

electronically to a dispenser (such as a pharmacy) of the patient's choice, making the

prescribing and dispensing process safer and more convenient for patients and staff.

Choose and Book. The NHS Constitution sets out choice as a right and the Operating

Framework for the NHS in England 2012/13 states that there should be a presumption

of choice for most services from 2013/14. When properly implemented, Choose and

Book (C&B) can provide significant benefits not only for patients, but also for referrers,

providers and for the wider NHS, by delivering choice, certainty, security and reliability.

Securing informatics and IMT support and further planning

Darlington CCG recognises the need to have an appropriate level of informatics and

technology support to enable our commissioning initiatives as well as support our wider

statutory functions as a clinical commissioning group, in particular information governance

responsibilities.

Our CCG will develop a service level agreement (SLA) with the North East Commissioning

Support Unit for the appropriate level of IMT/Applied Informatics support and

implementation services for both the commissioning functions of the CCG and the

business development needs of primary care as we look to re-shape the health economy.

This will include a review of the potential of telemedicine to support better management of

long term conditions and in moving care closer to patients’ homes. The initial SLA will be in

place by the end of April 2012.

For full details of these approaches, see the NHS County Durham and Darlington Cluster

Integrated Strategic and Operational Plan Year 2 Refresh.

Defining our Strategic Aims


5. Defining our Strategic Aims

Based on the assessment of our populations health need, demographics, financial

considerations, service performance and the insight of clinicians and patients we feel that

the case for change is clear.

To determine our course of action, we have reviewed this evidence with the national policy

direction laid out in the Operating Framework for the NHS in England 2012/13. This review

was then supplemented by two “SWOT” analyses, one of the external environments that

our CCG will be commissioning in and the other internal capabilities of our CCG itself.

5.1 External SWOT analysis

A SWOT analysis was carried out against each of the strategic objectives with a risk

assessment made against each opportunity and threat. The full detail of these drivers and

analysis is as follows.





5.2 Internal SWOT analysis - capacity and capability

In order to assess our internal capabilities we have taken advantage of a range of

organisational development events, diagnostic events and strategic planning events

involving GPs from the Darlington locality as well as practice managers, other clinical staff

and senior commissioning support staff from the PCT.

The diagnostic events used a nationally recognised self-assessment tool to enable

reflection on values, culture and wider organisational health. The tool describes six

domains recognised as authorisation criteria.

The average scores from the self-assessment were as follows:

Domain Average Score Maturity level

1 Clinical Focus and Added Value 32% Getting started

2 Engagement with Patients / Communities 40% In development

3 Clear and Credible Plan 30% Getting started

4 Capacity and Capability 24% Getting started

5 Collaborative Arrangements 40% In development

6 Leadership Capacity and Capability 34% Getting started

The assessment scores were reflective of those expected of a newly formed organisation.

We then assessed our strengths, weaknesses, opportunities and threats at a strategic

planning event in early November 2011. Clinicians and other staff from the Darlington

Practices attended this event alongside the CCG commissioning support staff to have a

collective view on

1) Our current internal capacity and capability to achieve authorisation and beyond

2) Immediate and future development needs to support delivery of the clear and

credible plan



The key areas from the internal analysis are outlined below and have helped to form the

case for change and strategic aims and initiatives of the plan. The analysis takes account

of our current and future organisational capabilities to lead commissioning of health care in

the new system.

Str

en

gth

s

All GP practices engaged

Commitment to a collective approach –

one Darlington practice

Size and Geographic coherence

Single LA-co-terminous

Strong sense of identity

Commissioning experience through

pathfinder projects

Pathfinder working with LA and voluntary

sector

Clinical leadership (need more)

Emerging understanding of needs of the

population

We

akn

es

se

s

Size and lack of finances

Lack of succession planning

Evolving organisation

Large single provider FT

Small pool of staff resource

Data analysis – obtaining relevant data to inform

commissioning decisions

Perceived changes to Dr/patient relationship

Impact on practices to support active engagement

Lack of broader clinical engagement from nursing

and other professions

Op

po

rtu

nit

ies

Do things differently

Joint commissioning

Collaborative working

Strong clinically informed commissioning

– quality, safety and effectiveness

Patient focus on outcomes and

experience

‘One Darlington Practice’ approach

Shape provider landscape

Adoption and spread of good practice

Risk sharing with other CCGs

Th

rea

ts

Ability to manage public/patient expectations

More organisational change (political)

Lack of succession planning

Conflict of interest issues

Cost savings/financial environment

Time and capacity to lead and implement change

Other organisations well established (FT/LA) whilst

CCG is learning

This analysis has helped us to identify the initial priorities of our organisational

development plan which not only ensures successful set up of our new organisation but

also underpins the successful delivery of this clear and credible plan.

The Darlington CCG Organisational Development (OD) Plan 2011/12 describes the full

plans and timeframes for delivery. Full implementation of the OD plan will assist delivery

of our clear and credible plan not only in terms of the capacity and capability to lead

clinical commissioning but also to ensure delivery against priorities. Within our OD plan we

have identified five key themes forming the building blocks for organisational development,

namely:-

Leadership [clinical and non-clinical]

Board development

Team development

Intelligent commissioner

Partnerships and Engagement/relationship management



In summary

We have used the experiences of the pathfinder to further inform our commissioning

approaches and we now believe we have a much greater understanding of the key issues

and challenges for the health needs of population of Darlington. Our strategic aims have

been developed through engagement and feedback from our member practices as well as

key stakeholders, patients and the public. The two SWOT analyses have helped define the

wider context of the strategic aims, the operational activities that will deliver them and the

identification of support and development needs necessary to succeed in achieving our

goals.

Our Goals


6. Our Goals

For each of our strategic aims we have set ourselves realistic yet ambitious goals by which

we can measure our success.

To measure success in improving the health status of people from Darlington we

will use the following indicators:

<75 All cause mortality

Mortality amenable to healthcare

<75 Cardiovascular disease (CVD) mortality

<75 Stroke mortality

<75 Cancer mortality

To measure success in addressing the needs of the changing age profile of the

population we will use the following indicators:

Dementia prevalence

Emergency hospital admissions: diabetic ketoacidosis and coma

Hospital procedures: lower limb amputations in diabetic patients

Bowel Cancer screening coverage

Emergency hospital admissions and timely surgery: fractured proximal femur

Emergency hospital admissions for chronic obstructive pulmonary disease

Emergency hospital admissions for coronary heart disease

Emergency hospital admissions for Long Term Conditions

Hospital procedures: primary/ revision hip and knee replacements

Hospital procedures: Cataract removal

Vaccination: Influenza uptake for those over 65 years

Delayed Transfers of Care

To measure success in taking services closer to home whilst ensuring current

services are accessible, timely and of a high level of quality we will use the

following indicators:

Number of new services commissioned from a primary care or community setting

Cancer waiting times

Referral to treatment waiting times

Accident & Emergency Clinical Quality Indicators

Choose and Book

Ambulance Response Times

Our Goals


To measure success making the best use of public funding we will use the following

indicators:

Financial balance and achievement control totals on the commissioning allocation

Securing commissioning support within the running cost allowance

Delivery of CCG QIPP plans including demand management

The following tables identify some examples of the headline public health measures,

performance metrics and primary care measures that we help demonstrate success. Full

performance monitoring to support the implementation of this plan can be found in the

Deliver 2013 Darlington Delivery Plan.

Our Goals


Our Goals


Our Goals


Our Strategic Approach


7. Our Strategic Approach

Our strategy has three key stages, is delivered through a series of programmes and

initiatives and supported by the strengthening of partnerships, development of primary

care and aligned enabling strategies.

The three stages are:

1) Getting a grip of the system: Management of demand and cost control

2) Making best use of what we’ve got: Reviewing services for effectiveness,

redesigning priority pathways and disinvesting in poorly performing services to

improve quality, access and value for money

3) Investing for improvement: Investing uncommitted growth funding and released

efficiencies for long term health gain

7.1 Getting a grip of the system

Our SWOT analysis and financial risk assessment has highlighted the need for Darlington

CCG to make sure that we are managing the areas of spend with greatest variability in-

year. These areas (secondary care activity paid for under payment by results (PBR) tariff,

prescribing and Continuing Healthcare) are all funded through non-block contracts and

over-performance in any of these areas can threaten the CCGs ability to deliver financial

balance or draw resource identified for other purposes to provide a contingency fund.

Contract Transitions - Stocktake, Stabilise and Shift

Moving from existing PCT contracts to new contract arrangements under the authority of

CCGs will require a significant programme of work by the CSU to securely transfer

contracts and obligations for contract management over to the CCG by 1 April 2013. Each

contract will need to be evidenced by a physical copy of the NHS standard contract. Our

CCG will work closely with the CSU to ensure the contract transitions project is

successfully concluded to minimise risk and satisfy all legal requirements.



Contracting for a realistic level of activity

Darlington CCG has worked with the CSU contracting team to agree a contract mandate

which will determine the negotiation strategy for each of the main contract areas. In

particular, due to the variable nature of the payment mechanism (tariff), our CCG will

continue the approach taken in Year 1 to agree realistic and affordable levels of elective

and non-elective activity from secondary care providers.

Planned Care activity

In 2011/12, Darlington CCG saw a reduction in GP referrals associated first outpatient

attendances but this was offset by an increase in referrals and associated outpatients from

other (non-GP) sources. This overall increase in first outpatients also saw an increased

conversion rate from 2010/11 which led to a significant increase in elective activity (12.7%

increase on G&A specialties using month 9 MAR data).

The CCG intention for planned care activity is to therefore commission a stable level of GP

referral-led demand increased slightly to reflect the impact of extension of the national

bowel cancer screening programmes, changes to the HPV screening pathway and from

the identification of unmet need (e.g. through the Health Checks programme).

Growth in ophthalmology activity (which involves a long term treatment regime) has been

identified in 11/12 and is expected to continue to grow in 12/13. There has also been

increased day case activity linked to new NICE drug approvals for haematology and anti-

TNF utilisation continues to grow. The Cluster also forecast an increase in referrals from

other sources (which make up approximately 40% of all referrals) to reflect demographic

changes and increase in screening services (e.g. retinal screening).

Planned Care activity increases will be mitigated by our approach to demand management

and QIPP transformation schemes outlined later in this plan.



Non-elective activity

In 2011/12 Darlington CCG saw an unprecedented reduction in non-elective activity in the

acute sector. Due to the high level of risk associated with non-elective activity (fewer

contract levers and impact of patient behaviour etc.) we will plan for a similar planned level

of activity as in 2011/12 but look to deliver the actual out-turn again in 2012/13.

This will allow the CCG time to investigate the cause of the reduction in non-elective

activity and to understand any re-classification of activity that may have happened during

this time that will protect the CCG from over-committing itself in year 1 of the plan.

The impact of business rules outlined in the Operating Framework regarding marginal

tariffs and non-payment for a proportion of emergency readmissions has been factored in

to these forecasts.

Demand management

In order to deliver the realistic levels of activity commissioned from the acute sector in

2012/13 we have identified a clear approach to demand management based on:

Analysis of variance and adoption of best practice. Our CCG has now fully

implemented the RAIDR business intelligence system that provides the information

necessary to understand changes in referral patterns and spend across disease areas.

We will direct the CSU via the SLA to supplement the information with analysis that

identifies further opportunity to management demand potentially through the adoption of

pathway changes implemented in neighbouring CCGs where it is appropriate to do so.

Service re-design. Using activity analysis supported by softer intelligence from

practices, pathway innovations will be introduced using non-recurring funding to pump

prime and double run until robust evaluation and impact assessment can be carried out.

Activity management through contract levers. We will direct the CSU via the SLA to

introduce activity management arrangements with providers over-performing against

contracted levels of activity that isn’t caused by increased referrals from general

practitioners. This activity management will bring providers back to contract levels or

secure rebates to CCG budgets where adequate evidence cannot be given for any

over-performance.



Where de-commissioning is necessary, our CCG will direct the CSU via the SLA to

undertake a robust de-commissioning process that meets best practice identified by the

National Audit Office and procurement legislation and involves wider stakeholders when

appropriate.

Prescribing

Our prescribing processes will be as effective as possible to maximise patient safety and

best utilise our prescribing budget.

Darlington CCG in partnership with the CSU medicines management team has reviewed

the National Prescribing Centre working document 2010 “Ensuring the delivery of

prescribing, medicines management and pharmacy functions in primary and community

care” and has agreed how the competencies and key functions will be delivered.

Operational functions will be delivered at a locality level to ensure effective clinical

engagement and the review of local prescribing data to eliminate unnecessary variation

and share best practice. A number of strategic functions will be shared with neighbouring

CCGs and will be delivered at a County Durham and Darlington level and North East

Regional level, supported by the CSU, to ensure effective use of resources.

The prescribing and medicine management agenda will be led by our local clinicians in the

form of GP Prescribing Leads and practice prescribing leads within the CCG. The GP

Prescribing Lead is supported by medicine management advisors employed by the CSU or

by service level agreements to deliver the Prescribing Strategy and annual work plan.

Local clinical engagement is arranged through the Locality Prescribing Sub-Group which is

responsible for the delivery of the strategy and work plan, including QIPP targets, working

within the agreed budgets. The Darlington CCG Prescribing Sub-Group will have clear

governance and reporting arrangements currently under consideration as part of the

overall governing body arrangements.

Darlington CCG will develop a Prescribing Strategy and annual work plan including QIPP

plan by June 2012. This will be based on available national and local guidance, including

the King’s Fund Report ‘The quality of GP prescribing 2011’ and local prescribing data

analysis provided by the CSU, and will be shared and agreed with all local stakeholders.



Continuing Healthcare

Continuing health care (CHC) spend continues to present a very significant challenge and

cost pressure to our CCG, as it has for our PCT predecessors. Our primary goal is to

ensure that we understand the process for allocating resources for packages of care and

that we are assured that the process is consistent and delivers the right outcomes for

patients. This area will continue to be a challenge and cost pressure in light of our aging

population and increase in long tern conditions. We need to continue to work with our

colleagues in the CSU to ensure that the budget takes into account these areas of growth.

We will also work collaboratively across county Durham with our neighbouring CCG and

the local authority to share our knowledge and insights and develop a plan. We have

identified a lead clinician and have the support and expertise of the continuing healthcare

team in the CSU to help us move forward. A working group across County Durham and

Darlington will hold a number of meetings in the first 6 months of 2012/13 and develop

proposals for the CCG to consider and agree. This work needs to include the work of DBC

who also see CHC spend as a key pressure and risk. Given the variable and increasing

costs with this area the CCG has entered into a risk sharing agreement for continuing

healthcare via the Durham and Darlington Confederation to mitigate the potential impact.

This approach combined with the clinical led working group will help us keep a ‘grip’ of this

area as well as plan for future years.

Demand management in Year 2 and onwards

Over the life of the Clear and Credible Plan, more tariff based contracts will appear as

block contracts are replaced. Our CCG will direct the CSU through the SLA to assess the

impact of this particularly for Ambulance and Mental Health Contracts to ensure adequate

demand planning occurs for 2013/14.



7.2 Making best use of what we’ve got

With fair and realistic levels of activity contracted before each year begins and demand

management arrangements in place to mitigate against the pressure of an ageing and

growing population, Darlington CCG will review a range of services each year to

understand if they are delivering improved quality and health outcomes for patients whilst

representing good value for money for commissioners.

These reviews will run alongside the clinical strategy that will be developed in tandem with

clinicians from a range of sectors to inform the re-design and in some cases de-

commissioning of existing services.

7.3 Investing for improvement

Once demand is managed, variable costs controlled, services have been reviewed and

existing pathways redesigned, our CCG will look to invest unallocated growth and released

allocative efficiencies in long term health improvement on a recurring basis. This

investment will be targeted on an evidence based approach and direct towards

interventions and services that will give the greatest return on investment. When doing

this, we will utilise a robust and transparent prioritisation process.

7.4 Prioritisation of attention, effort and investment

We will utilise a robust, open and transparent process for the investment of funding (both

from growth in allocation or release of allocative efficiency).

The first level of prioritisation has already been undertaken as part of the planning round

for 2012/13. This involved:

The use of a robust prioritisation tool with weighted domains to rank initiatives

Facilitated support from the CSU and public health partners

Use of the Single Needs Assessment and other data such as practice health profiles

Engagement from GPs and other clinicians within the CCG

The output of the prioritisation exercise can be found in the financial appendix to this plan

and reflected in the commissioning intentions for 2012/13.

Programmes and Initiatives


8. Programmes and Initiatives

The delivery of the strategic aims and goals through the strategic approach will be

achieved through a broad range of CCG specific and cross-CCG commissioning

intentions, service reviews, contract negotiations and partnership working organised into

programmes.

These programmes and initiatives build on the track record of delivery from the pathfinder

projects and can be aligned to the PCT Cluster QIPP programmes outlined in the ISOP for

2012/13.

8.1 Track record of delivery

The Darlington Pathfinder projects are already providing evidence of local clinical

leadership and engagement underpinned by a better understanding of local population

needs and system wide opportunities to improve patient outcomes and quality of service

provided. This learning must be built upon to ensure that our CCG develops the

knowledge, skills and mind-set to shape care and services that improve outcomes for

Darlington.

The key areas of the Darlington pathfinder which are to be carried forward as integral to

the clear and credible plan are:

Darlington MSK ICATS procurement

MSK pathways- pan CCG lead

Urgent Care integration

COPD acute exacerbation pathway/LTC

Strengthening strategic and operational partnerships with the local authority



8.2 Alignment for PCT Cluster ISOP QIPP Programmes

The CCG will contribute to the delivery of QIPP through the improvement of clinical

pathways as identified in the commissioning intention summaries in the strategic objective

section of this plan. Progress on these initiatives will be reported as part of broad

programmes of work to the cluster as described in the CDD Cluster ISOP.

The Cluster QIPP programmes are:

Transforming Planned Care: By re-designing elective pathways and managing variation

as described in the demand management approach, the CCG will contribute to savings

and cost avoidance for elective and planned care.

Transforming Urgent Care: By reforming the way the urgent care system is delivered

and through improved joint working with social care, the CCG will contribute to savings

and cost avoidance for non-elective and unplanned care.

Transforming care for patients with long term conditions and care for the elderly:

By supporting patients to better their own long term conditions and providing more

services in a community setting, the CCG will contribute to savings and cost avoidance for

non-elective and unplanned care where patients are admitted to secondary care for

exacerbation of their condition and elective and planned care where services are

commissioned more cost effectively from primary care and community rather than acute

settings.

Transforming Mental Health and Learning Disabilities: The CCG will work

collaboratively with other CCG in the cluster to introduce a range of liaison services

between mental health, nursing homes and the acute sector. These evidence-based

systematic reviews show that the use of liaison psychiatry services can help reduce length

of stay, improve clinical outcomes and patient satisfaction in the adult population. In the

elderly, return to independent living can be improved and subsequent health care

utilisation, including emergency care activity and clinic visits, reduced. These services will

also deliver the CCGs commitments to improve care for patients with dementia as outlined

in the Operating Framework for the NHS in England 2012/13.



8.3 Demonstrating alignment of activities with our strategic objectives

In order to deliver our strategic aims we have identified a range of commissioning

intentions. Darlington practices developed intentions based on local health needs and

service priorities utilising available information for Darlington (SNA, practice health profiles)

and the clinical and patient insight they gain through work in general practice.

The intentions were prioritised in a robust and transparent way using a tested prioritisation

methodology with engagement and involvement from practices and clinicians to ensure

maximum impact against priority areas. Many of these intentions built on the lessons

learned and progress made in our pathfinder projects in 2011/12. Some of our intentions

developed at practice level have been likewise identified by other CCGs and strengthened

the case for County Durham and Darlington cluster wide intentions.

The detail of each of the initiatives within these programmes of work will be found in

detailed Case for Change (outline business case) documentation and supported by project

plans for ensuring tracking and management of implementation. The schemes within these

programmes will also benefit from analytical support that will help identify unmet need and

the impact of the demographic changes so that the resulting service changes are reflective

of future needs.

In order to simplify the complex series of commissioning and operational activities the

CCG will lead, direct and work in partnership on, we have produced a Plan on a Page as a

communication tool. This plan can be found on page 67.

8.4 Working with neighbouring CCGs to share and spread good

practice

Darlington CCG fully understands and acknowledges the need for collaborative working

across the cluster and pays equal attention to those cluster wide commissioning intentions

as the sum of the parts for the benefit of the Darlington population. An example includes

the recent community nursing review which is comprehensively looking at community

nursing services across County Durham and Darlington led by the cluster on behalf of all

the CCGs and involving lead clinicians from each of the CCGs. Another example is the

acute exacerbation pathway for COPD- a County Durham and Darlington wide pilot which

is informing commissioning intent for 2012/13.

Where appropriate we will co-ordinate commissioning activities with neighbouring CCGs to

ensure economies of scale, spread cost and maximise impact for specific programme

areas. This may be done at service level (as in the review of community nursing) or across

disease areas e.g. for patients with mental health needs and for those with learning



disabilities. These programmes of work will be co-ordinated through the appropriate

contract support lead with identified clinical leads within each CCG.

Specialist commissioning such as Public Health, Children’s’ commissioning and Mental

Health are noted alongside our local initiatives. Darlington CCG recognises the key role

these commissioning intentions have in filling any gaps identified in the health needs

analysis which are not already covered by the Darlington initiatives.

8.5 Exclusions from our plan

In the new healthcare system and clinical commissioning arrangements, a number of

functions will not transfer from the PCT cluster to our CCG. Commissioning of Primary

care (GMS/PMS, Optometry and Pharmacy), offender health and other specialised

commissioning is likely to transfer to the National Commissioning Board and Public Health

arrangements for Darlington will transfer to the Local Authority. Programmes and initiatives

related to these areas do not therefore feature within this plan.



Darlington CCG – Plan on a Page Cross-cutting

Programmes

Vision Strategic Aim Outcomes Strategic Initiatives

Qu

ality

an

d S

afe

ty

Pe

rform

an

ce

Impro

vem

en

t an

d O

pera

ting

Fra

me

work

De

live

ry

Info

rmatic

s

Working together

to improve the

health and

well-being of

Darlington

1. Improving the health status

of people from Darlington

NHS Outcome framework (domain 1,3 and 5)

1. Preventing people dying prematurely 3. Helping people to recover form episode of ill health or following injury

5. Treating and caring for people in a safe environment and protecting them from avoidable harm

Darlington Specific Public

Health

1. Review of local care pathway for the management of overweight and obese patients

CROSS CCG – PUBLIC HEALTH

1. Re-commission Tier 1 and 4 alcohol services 2. Expand community weight management services 3. Review and expand exercise on referral across County Durham

4. Commission maternal obesity brief intervention training 5. Commission physical activity interventions for pregnant and post-natal women 6. Pilot an enhanced 12-week smoking quitters service

7. Re-commission the Health Checks programme 8. Extend the national bowel cancer screening programme

2. Addressing the needs the

changing age profile of the

population of Darlington

NHS Outcome framework (domain 2 and 3)

2. Enhancing quality of life for people with long term conditions 3. Helping people to recover form episode of ill

health or following injury

Long Term Conditions

1. Develop a patient-home centred acute exacerbation pathway for COPD 2. Review the children’s asthma and wheezing pathway 3. Develop COPD clinics in a primary/community setting

4. Develop e-learning self-management tools for diabetes patients 5. Develop an integrated primary/community setting based diabetes clinic 6. Review intermediate care bed services in Darlington

7. Develop a clinical advisory and training service for nursing homes 8. Develop pulmonary rehabilitations services

CROSS CCG – LTC/JOINT

COMMISSIONING/EOL

1. Review of Community Nursing 2. Develop diabetes services in primary care (including insulin initiation)

3. Establish a gold standard framework for locality registers for those in last year of life 4. Partnership working with the Local Authority on joint priorities

3. Taking services closer to

home for the people of

Darlington

NHS Outcome framework (domain 4) 4. Ensure that people have a positive

experience of care

Urgent Care

1. Contribute towards the review the Darzi centre at Darlington 2. Co-locate Darlington urgent care and accident and emergency facilities

3. Review paediatric pathways from accident and emergency

Planned Care

1. Re-design and implementation of 4 MSK pathways 2. Review Darlington chiropody and podiatry services

3. Develop a cardiology clinic in a primary/community setting 4. Develop an ophthalmology clinic in a primary/community setting 5. Develop a primary/community setting erectile dysfunction clinic

6. Review pathway for paediatric physiotherapy and paediatric audiology 7. Develop an e-mail consultant advice service

Clinical Care 1. Support provider-led developments to improve patient care

CROSS CCG - CHILDRENS 1. Implement the ‘a call for action’ health visitor expansion programme and the expansion of the FNP 2. Review children and young people’s OT, physiotherapy and SALT services

CROSS CCG – MENTAL HEALTH

1. Align mental health staff to general practice 2. Improve equity of autism assessment and diagnosis

3. Deliver the dementia strategy 4. Expand improving access to psychological therapies 5. Re-commission out of area placements

4. Making the best use of

public money within Darlington Financial balance and delivery of QIPP QIPP Programme

1. Improved budget management through use of RAIDR tool

2. Improved use of medicines management service to control prescribing costs 3. Explore opportunities of integrated commissioning with Local Authority



Strategic Aim 1: Improving the health status of people in Darlington

Overview

The key actions that will improve the health status of people in Darlington:

Partnership working with the Local Authority

Establishing the Health and Wellbeing board and developing the Health and Wellbeing

Strategy

Working with the public health function through transition

Improving access to, and use of, public health intelligence

Influencing the behaviour of the public in regards to health and healthy lifestyles

Delivering headline CCG initiatives in 2012/13

Partnership working with the Local Authority

Our CCG understands the importance of, and has a track record of, good collaborative

working with other commissioners and partners. Darlington CCG intends to deepen its

already close working relationship with Darlington Borough Council in regards to their

commissioning functions for local people and work has progressed to establish the

Darlington Partnership in February 2012. Darlington CCG alongside the PCT as the

current statutory NHS body are key partners in this arrangement.

The ambitions and intentions of Darlington CCG demonstrate alignment and consistency

with those strategic aims of “One Darlington Perfectly Placed”. As the two organisations

come together as partners alongside other partners under the umbrella of the Darlington

Partnership and the Health and Wellbeing Board it will allow for the organisations to use

their own foundations and vision to influence and shape the vision and direction and the

shared priorities in the form of a Health and Wellbeing Plan for Darlington.

This will ensure we are best prepared to:

support patients who need both health and social care

engage in the commissioning of services that will move to be the responsibility of local

authorities in 2013/14 (in particular Public Health and Children’s’ Services)

make best use of public resource and avoid “cost-shifting” between the health and

social care sectors

deliver our strategic aims



Alongside the local authority and wider partners as part of the Darlington Local Strategic

Partnership our CCG is taking forward three action priorities which are aligned to the

Darlington Single Needs Assessment and reflected in the strategic aims of this plan. The

three action priorities are:

Alcohol

Vocational Opportunities for Young People

Ageing

Working with the public health function through transition

The CCG has worked through the Director of Public Health for Darlington and the aligned

Public Health Consultant to ensure that local commissioning intentions and those from the

NHS County Durham and Darlington Public Health function address the range of health

challenges, particularly regarding the underlying causes of ill-health such as smoking and

alcohol misuse. These commissioning intentions can be found in the strategic aims

summary table.

Using Public Health intelligence

Darlington CCG will work with Public Health colleagues and the North East Public Health

Observatory to develop specific tools to inform current and future commissioning. This

would involve the use of current population data sets contained within existing strategic

documents such as the Single Needs Assessment and the CCG population profile and the

application of specific tools and techniques to manipulate the data to model future need

and impact of current or potential commissioning intentions on specific population

outcomes.

Techniques such as comparative analysis and trend analysis would show specific deficits

in outcomes and contribute to the analysis of the major contributory factors to early death

and poor life expectancy. Modelling current and future trends of the key population health

indicators would provide linear projections to future end points, and provide commissioners

an insight into potential future outcomes and provide some insight into potential needs and

service demands in Darlington in future years.

The application of Scenario modelling, informed by the latest evidence base, will provide

clinical commissioners with an assessment of the potential the impact of current

interventions on the population outcomes as well as the impact of potential commissioning

decisions. This would also enable the potential impact of other inputs such as economic or

demographic factors to be factored into commissioning decisions and demonstrate some

interdependencies that may exist.



Behavioural change – Public

We will use what we know about our communities to engage with different people and

groups in ways that best meet their needs, and to communicate messages which aim to

improve health.

We will utilise the intelligence gained through our engagement activities to ensure

patients’, carers’ and the public’s experiences, views and opinions are integral to our

planning and commissioning of services. We will also make us of links with demographic

data held locally to support targeted engagement activity.

By developing our relationships with partners and providers and our engagement with

communities, we will be able to better record the information we receive which in turn will

help us to increase the impact we have on shaping local health services and health

outcomes.

We will develop working relationships between the CCG and Commissioning Support

functions to ensure that patient experience data requirements are clearly included in

service specifications and provider contracts; and are linked to performance and quality

improvement.

We will also work in partnership with public health and health prevention professionals to

actively contribute to the health prevention agenda through collaborative social marketing

approaches.



Headline Initiatives for 2012/13

Project Name Implement the ‘a call for action’ health visitor expansion and family nurse partnership

expansion programme

CCG Darlington CCG

Delivered by NE CSU on behalf of Darlington CCG

1. What is the

proposal and

summary

rationale?

This proposal is the delivery of a national priority within the NHS Operating

Framework. The operating framework states, “PCTs should ensure they develop

effective health visiting services, with sufficient capacity to deliver the new service

model to be set out in the Health Visitor Implementation Plan 2011-2015 – A Call to

Action” (p.33). A national increase in health visitors by 4,200 by April 2015, Locally

equating to 39 additional health visitors across County Durham and Darlington.

2. Current Status

and Cost

There are currently 147.5 wte Health Visitors (HV) employed by the County Durham

and Darlington Foundation Trust (as at 31st March 2012). This includes 22 Practice

Teachers (PT) and increased Family Nurses (FNP). The current service is for 0-4

year olds, delivering a historical service model. Patients access the service through

hospital midwives or their general practitioner. Employed by CCDFT community

services arm but some specialist health visitors work on complex cases are in Acute.

The current service costs £15,861,000 on block (£2.296m Darlington; £13.565

County Durham.

3. Consideration

of Options

The capacity of the current provision does not meet the DH guidance in ‘A call to

Action’ p4/7. The current level of Community Practice Trainers meets the learning

needs of the trainee’s throughput necessary to meet the health visitor directive.

4. Proposed

Service Model

and

Implications

The aim of the new expanded service is to meet the requirements of the ‘A call to

Action’ plan to provide additional health visitors in County Durham and Darlington

over the next three years and provide the necessary training infrastructure through

additional community practice teachers. The new service model will deliver the full

scope of the healthy child programme. There is an additional cost to deliver the HV

expansion programme which has been agreed.

The HV definition allows the inclusion (previously excluded in the baseline data

cleanse) of HVs working in Safeguarding (13.5 wte) which will increase the nos. of

HVs to 161.0wte in 2012 and the additional 22 wte posts the PCT agreed to invest

from 1st April 2012 across County Durham & Darlington with CDDFT will bring the

nos. of HVs up to 183.0wte which will exceed ‘A Call to Action’ target in 2012/13 of

179.5wte.

5. Risks 50% of the current health visitor workforce is close to retirement age putting

achieving the requirement at risk should these attrition rates increase suddenly.



6. QIPP

Implications

Quality: A more comprehensive service will be provided

Innovation: An integrated service model of delivery

Productivity: The health visitor will be delivering a better value for money service

Prevention: Supporting the delivery of the public health outcomes framework

(prevention agenda)

7. Key Milestones New Service specification April 2012

Delivery programme to train staff start April 2012

Phase out HV Imms and Vacs September 2012

Delivery programme to train staff end September 2012

New student nurses start October 2012

Project complete October 2012



Summary of activities that will deliver this strategic aim:

Strategic Aim: To improve the health status of the people of Darlington

Link to case for change: Premature Cancer, Stroke and CHD Mortality are greater than the England average. Prevalence of Heart Failure, CHD, Obesity, Hypertension, Diabetes and Cancer are greater than the England average.

Population change Premature mortality rates for the biggest killers (heart disease, cancer and stroke) in Darlington are higher than England. Cardiovascular disease (CVD) and cancer account for 63% of early or premature deaths in Darlington. Life expectancy for men living in the most deprived areas of Darlington is over 13 years lower than for men living in the least deprived areas.

Health need

Patient insight

Clinical insight

Service issue/opportunity

What we’ll be doing to address this in the next five years:

Year 1 (2012/13)

Darlington CCG Specific Commissioning Workstreams

Reviews

Align mental health staff to GP practices- (to be led by mental health commissioning team)

Urgent care provision within primary care and nursing/care homes

Community bed provision including intermediate care beds.

Pathway Re-design Primary/ Community

diabetes pathway

Personality disorder pathway

Asthma and wheezing pathway (under 16)

Pilots Psychosexual

counselling provision

Erectile dysfunction pilot (link to CVD and diabetic prevalence)

Community COPD clinic

Community diabetic clinic

Extend sexual health clinics (Intrahealth proposal)

On-line diabetes education tool.

New Services

Podiatric surgery in a community setting (from Sedgefield pilot)

Diabetic foot care (Grey text intentions dependant on outcomes of review/pilot)

CCG Initiatives Agreeing primary care pre and

post COPD exacerbation pathways

Agreeing primary care pre and post asthma exacerbation pathways for under 16

Continue with embedding best practice via POINTS tool for COPD management



Cluster Working (2012/13) – Working collaboratively with other CGGs across County Durham and Darlington

Public Health: Expansion of Weight Management Services; Review and Expand Exercise on Referral Programme; Pilot a 12 smoking week quitter service; Re-Commission Healthchecks Programme; Full Cost Benefit Review of Public Health Services. The PCT Cluster Children’s Commission Team: Expand the Health Visitor Programme; Commission Maternal Obesity Brief Intervention Training; Commission Physical Activity Interventions for Pregnant and Post Natal Women; Safe at Home Project; Review Maternity Services; Increase Access to Breastfeeding; Commission Childhood Obesity MEND Project. PCT Cluster Mental Health Team: Align Mental Health Staff to General Practice; Improve Access to IAPT; Improve Equity of Autism Assessment and Diagnosis. Contracting intentions: Expansion of the national bowel cancer screening programme National campaigns: Public Awareness campaigns for Bowel Cancer, Throat Cancer and Mouth Cancer (check!)

Contribution from Partners (2012/13) – Working with partners for a common cause

Local Authority: Section 256; etc… Providers: CDDFT; TEWV; 3

rd sector etc..

Darlington CCG will fully engage with partnership working to support the delivery of this strategic objective.

Year 2 (2013/14)

Proposed year 2 Darlington CCG Workstreams

Reviews

Weight management / Integrated obesity pathways

Pathway Re-design Paediatric pathway for

non-elective emergencies

Paediatric pathway to improve access to physiotherapy services and audiology services

Pilots E-mail rapid advice

service

Community ophthalmology service

Community cardiology clinic

Pilot for primary care urgent care provision including nursing and care homes.

New Services

Community bed provision including intermediate care beds

Pulmonary rehabilitation (countywide provision)



Erectile dysfunction clinic

On-line education tool for diabetes

(Grey text intentions dependant on outcomes of review/pilot)



Year 3-5 (2014/15 - 2017/18)

Proposed year 3-5 Darlington CCG Workstreams

Reviews To be determined

Pathway Re-design To be determined

Pilots To be determined

New Services

Community ophthalmology clinic


Primary care support for urgent care provision at nursing and care homes

E-mail rapid advice service. (Grey text intentions dependant on outcomes of review/pilot)

What we’ll measure to see if it’s working:

NHS Outcome framework (domain 1,3 and 5) 1. Preventing people dying prematurely 3. Helping people to recover form episode of ill health or following injury 5. Treating and caring for people in a safe environment and protecting them from avoidable harm A Call for Action Indicators

- <75 All cause mortality - Mortality amenable to healthcare - <75 Cardiovascular disease (CVD) mortality - <75 Stroke mortality - <75 Cancer mortality



Strategic Aim 2: Addressing the needs of the changing age profile of

the population of Darlington

Overview

The key actions that will help address the needs of the changing age profile of the

population of Darlington are:

Strengthened joint commissioning including use of the Joint Fund and re-ablement

funding

Implementation of our headline initiatives for 2012/13

Implementation of Cross-CCG initiatives for 2012/13

Joint Commissioning in Darlington

There are many opportunities for health and social care improvements to be led by jointly

involving health and local authority commissioning. We will look to work closely with our

local authority partners to fully understand the services that are currently jointly

commissioned between health and social care.

There is a well-established Joint Strategic Commissioning Group in place in Darlington

which has focussed on a small number of joint priorities around adult services and

strategies and action plans. The work plan of this group determines the work priorities of

the joint funded strategic commissioning manager who has dual accountability to both the

PCT (CCG) and DBC to deliver agreed outcomes. This arrangement will need to be

refreshed as the commissioning environment changes to ensure the priorities,

responsibilities and governance arrangements are aligned.

A key feature of joint commissioning will be to understand the impact the schemes funded

through the Fund for Joint Working on Health and Social Care that was given to PCTs to

passport to local authorities using a Section 256 agreement. This fund was made on a

two-year non-recurring basis for 2011/12 and 2012/13.

This funding was directed to be used to develop new services and ensure the

maintenance of current services that make an impact on issues identified in the Single

Needs Assessment. The Operating Framework has confirmed that this funding shall be

made available again in 2012/13, 2013/14 and 2014/15 but on a non-recurring basis so an

assessment needs to be made against the schemes evaluated and their quality impacts

and outcomes and also the potential impact of the withdrawal of funding for each of the

services funded by this allocation in 2015/16. Plans will then need to be made to mitigate

the risk of withdrawal of the service or to jointly identify alternative sources of funding

unless new guidance is received.



The focus for the use of the Joint Funding in 2012/13 will be:

Review the provision of community beds in Darlington

Support the Integration of Intermediate care beds

Development of a re-ablement team

Provide supported hospital discharge

Another area of potential joint working is on the re-ablement agenda. National funding has

been made available to support the better re-ablement of patients waiting for discharge for

a hospital setting. We will build on the work already undertaken across Health and Social

Care to make best use of this investment.

The focus for re-ablement in 2012/13 will be:

Year of care tariffs in primary care, where primary care agencies are given an annual

budget to spend on individual patients who are known to make extensive use of health

and social care services. This would build upon the findings of the bespoke patient and

carer engagement exercise commissioned and delivered in 2011/12. Year of care tariffs

in primary care are a proactive approach which harnesses primary care knowledge of

the patients and expertise to provide a patient-centred, joined up approach across all

health and social care provision,

CCG commissioning intentions where these meet the three criteria for re-ablement

funding (ensuring timely discharge from hospital, maximise independent living and

reducing avoidable hospital readmissions)

Project Name Acute Exacerbation Pathway for COPD

CCG Darlington CCG

Delivered by Darlington CCG

1. What is the

proposal and

summary

rationale?

A working group was assigned to look at how to reduce emergency admissions by

20%, reduce LOS and the number of re-admissions. Based on the Easington

pathway, the multi-disciplinary group redesigned a care pathway that could be

rolled out across all the localities. The rationale for this pilot is to understand

whether a rapid response service will reduce the number of emergency admissions

for people exacerbating with COPD and improve the care pathway with improved

outcomes for patients.



2. Current Status

and Cost

This pathway has been established in Easington and from the data we collected 63

patients in Easington were admitted onto the pathway of which 57 (90.5%) had no

admission or A&E attendance recorded after being discharged from the pathway.

Average LOS in Easington in 201-11 for COPD was 6.33 days. Based on this

average LOS and an average cost of admission- these 57 patients who were

treated via this pathway saved 360 bed days and approximately £132,354.

This pathway has the potential to make significant savings from admissions and re-

admissions and will help to reduce the number of beds required in a secondary

care setting. Based on these early indications, a pilot of 6 months is proposed from

1st October – 31st March within existing nursing resources across all localities to

establish a robust data set to evaluate thoroughly the impact both from a

commissioner perspective and a provider one, as this pilot will then give clearer

indication as to the longer term viability of funding this pathway.

Initial short term set up costs for small pieces of equipment have been agreed to

be funded from Darlington’s transformation fund (11.5k)

3. Consideration

of Options

After the pilot has completed, an options appraisal as to the best way forward for

commissioning this service will be documented and assessed

4. Proposed

Service Model

and

Implications

With efficiencies generated we can reduce admissions for patients exacerbating

with COPD, then the proposal would be to go via a contract variation to add a

service specification into the current provider contract

Current Activity and costs at locality level:

The table shows an indication as to the cost of COPD admissions across all

locality areas

COPD led to 2072 emergency admissions in 2010-11, costing £4.7m

Number and cost of emergency COPD admissions by locality 2010/11

5. Risks The risk of not proceeding with the proposal is non-delivery of Darlington Clinical

Commissioning Group and non-delivery of contributing to ISOP QIPP target,

however the risk.

Locality Admissions

Total Bed

Days

Excess

Bed Days

Cost

(£'000)

Cost of

EBDs

(£'000)

Durham Dales 351 2149 92 787.4 16.9

Darlington 330 1872 31 712.5 5.7

Derwentside 321 1633 47 684.9 8.6

DCLS 351 2010 58 811.3 10

Easington 409 2562 71 952.2 13.5

Sedgefield 310 2171 103 710.1 19.3

Co. Durham & Darlington 2072 12397 402 4658.4 74.1



6. QIPP

Implications

Quality: Contribute to care closer to home agenda

Innovation: A more responsive service to meet patients’ needs in times of

crisis.

Productivity: A reduction in COPD related non-elective emergency admissions

Prevention: Enhanced patient experience, shift from secondary care reliance

to a service that is more closer to home for patients

7. Key Milestones A pilot began in December 2011 with the expectation to go live in

October/November 2012 (dependant on project evaluation)

Project Name Dementia Services

CCG Darlington CCG


1. What is the

proposal?

The operating framework 2012/13 makes explicit the requirement to focus on

dementia care with specific reference to improving diagnosis rates, reducing

unnecessary hospital admissions, improving dignity in care for patients, giving staff

appropriate training, reducing inappropriate prescribing of antipsychotic medication

and improving overall quality of life for older people with dementia. Additionally

the national strategy for mental health “No Health Without Mental health” makes

clear the requirement to address the interface between physical and mental health.

2. Consideration

of Options

The proposal has two separate but aligned models of working with associated

costs and KPI’s, a care home liaison proposal which has already been approved

and an acute care liaison project.

1. Care Home Liaison Service Proposal: The philosophy of the service will be to

develop and deliver consistent person-centred mental health care to older people

in Care Homes across County Durham and Darlington.

2. Acute Care Liaison Service Proposal: The service will be a single seamless

service across Adult Mental Health and MHSOP, there will be a number of sub

specialities; A+E, DSH, Chronic Somatisation (MUPS), Ward base liaison,

Dementia, Delirium and Depression. A comprehensive model will include work

related to alcohol associated problems; however the exact nature of this cross

working needs to be developed. LD – the service model will ensure Greenlight

principles are followed. The Liaison role will include links with LD services.

3. Proposed

Service Model

and

Implications

1. Care Home Liaison Service Proposal: The model would offer short term

assessment and interventions for acute inpatients. Depending on the clinical

presentation follow up and further therapeutic interventions will be offered

depending on the level of need. When required the service will facilitate effective



transfer to specialist mental health services, either in secondary care, crisis

services, IAPT, care home liaison, older person CMHTs. The service will also

enable timely discharge by providing intense mental heal support to older people in

their own homes in the immediate post-discharge period.

2. Acute Care Liaison Service Proposal: Agree and establish core data and

baselines required for project outcomes/engagement with acute trust and key

stakeholders re project/recruit project Management/Project Manager to develop

implementation plan – QIS principles to underpin each stage of

implementation/complete workforce development plan

In excess of £4m funding has been identified to fund the programme across

County Durham and Darlington, of which a significant proportion is a re-direction of

technical QIPP efficiencies

4. Risks 1.The project will require partnership approach between TEWV and CDDFT

2. Accommodation required in YHND and on acute wards with networked access

to TEWV IT systems/need to review CQUIN targets to ensure KPIs reflect as

appropriate/engagement with acute trusts and key stakeholders/others to be

identified

5. QIPP

Implications

1.Care Home Liaison Service Proposal:

Quality: Reduction in the levels of prescribing of anti-psychotic medication in

dementia through working collaboratively with primary care colleagues

(Operating Framework 2012 P12 – Section 2.8)

Innovation: Increase the number and range of meaningful activities provided

within care homes and make provision for a programme of education and skills

development to the Care Homes workforce. Help care home staff to develop

the skills needed to manage Behavioural and Psychological symptoms of

dementia

Productivity: Increased rates of detection of dementia and other mental health

problems

Prevention: Reduction in Falls and in turn a subsequent reduction in emergency

admissions, reduce the number of admissions into Acute and Mental Health

Trust beds through working collaboratively with primary care colleagues and

reduce the number of people from Care Homes who are admitted to hospital at

the end of life

2. Acute Care Liaison Service Proposal:

Quality: Reduce length of acute in-patient stay (reduction in Occupied Bed

Days) (Outcomes Framework 2.3), reduce re-admissions to acute hospital

(Outcome Framework 3b)

Innovation: Increase detection of delirium – will contribute to a reduced length



of stay; reduced admissions for DSH; Reduced attendances to acute trust by

top 50 “frequent attenders”

Productivity: One hour response time in A+E do we need another KPI about

effectiveness as well EG reducing admissions to acute hospital from A + E for

those with a mental health disorder

Prevention: Increased detection and treatment of depression, reduced

admissions to Care Homes from hospitals, increased diagnosis of dementia in

hospitals (Operating Framework 2012 CQUIN Target p39 and to Operating

Framework 2012 p12 – section 2.8)

6. Milestones June 2012: Establishing core team and merging of OPMH/ acute by AMH and

MHSOP; Recruitment to key posts; Accommodation and infrastructure; Training

and development for all recruited staff.

September 2012: Begin delivery of service model and key interventions within

UHND/ Shotley. Bridge and Chester le Street; Complete recruitment with required

staff for work within UHND.

Training and development for all staff; Commence data capture, monitoring and

analysis; Implement information sharing with commissioners as agreed.

December 2012: Monitoring and evaluation of outcomes identified to date; Review

via formal mechanism with Commissioners.

March 2013: Scope expansion to DMH / Bishop Auckland; Discuss with

Commissioners further roll out proposals ;Continue monitoring and review of

current service model.

2013/14: Q1 Implement model into DMH and Bishop Auckland. Complete scoping

exercise for other community hospitals Richardson/ Sedgefield/ Weardale/

Peterlee Hospital.

Q3 Discuss and confirm recurrent funding arrangements with Commissioners. Q4

Confirm next steps for service model dependant on outcome of funding

discussions with commissioners.



Summary of activities that will deliver this strategic aim

Strategic Aim: Address the needs of the changing age profile of the population of Darlington

Link to case for change: The population of Darlington is ageing, and with the associated long term conditions of an a more elderly population places a significant growing pressure on the local health economy

Population change “Around 37% of the population is aged 50+. This is projected to rise around 41% by 2020”. Health need

Patient insight

Clinical insight



Year 1 (2012/13)


Reviews

Align mental health staff to GP practices- (to be led by cluster mental health commissioning team)

Urgent care provision within primary care and nursing/care homes

Community bed provision including intermediate care beds.

Community nurses, Matrons and specialist nurses.

Chiropody/podiatry provision

Pathway Re-design Community diabetic

clinic


Osteoporosis pathway- primary and secondary care prevention.

Pilots On-line educational

tool for newly diagnosed diabetics.

Community COPD Clinic

Community diabetes clinic

New Services

Acute exacerbation pathway (COPD)

Psychosexual counselling provision

Urgent care co-location with A&E


CCG Initiatives

Embed Gold Standards Framework (GSF) in nursing homes

Establish education and training packages to be delivered within care and nursing homes.




PCT Cluster Long Term Conditions Team : Commission Home Oxygen Assessment Service; Review End of Life Services; Review Intermediate Care Services; Whole System Development of Services to Deliver LTC Support, Including a Review of Community Nursing; Establish a Gold Standard Framework for Locality Registers for Patients who are in their Last Year of Life due to their Illness and Diagnosis PCT Cluster Mental Health Team: Deliver the National Dementia Strategy .



rd sector etc..


Year 2 (2013/14)


Reviews


Pathway Re-design Not defined


service



Pilot urgent care primary provision/ pro-active primary care management in nursing and care homes.

New Services


Pulmonary rehabilitation

Osteoporosis pathway for primary/ secondary care prevention.

Chiropody/podiatry provision




On-line education tool for newly diagnosed diabetics.




Year 3-5 (2014/15 – 2017/18)





New Services



Urgent care provision and primary care management for nursing and care homes

E-mail rapid advice service (Grey text intentions dependant on outcomes of review/pilot)


NHS Outcome framework (domain 2 and 3)

2. Enhancing quality of life for people with long term conditions 3. Helping people to recover form episode of ill health or following injury Changing Age Profile Indicators

- Dementia prevalence

- Emergency hospital admissions: diabetic ketoacidosis and coma

- Hospital procedures: lower limb amputations in diabetic patients

- Bowel Cancer screening coverage

- Emergency hospital admissions and timely surgery: fractured proximal femur

- Emergency hospital admissions for chronic obstructive pulmonary disease

- Emergency hospital admissions for coronary heart disease

- Emergency hospital admissions for Long Term Conditions

- Hospital procedures: primary/ revision hip and knee replacements

- Hospital procedures: Cataract removal

- Vaccination: Influenza uptake for those over 65 years

- Delayed Transfers of Care

Care Closer to Home Indicators

- Number of new services commissioned from a primary care or community setting

- Cancer waiting times

- Referral to treatment waiting times

- Accident & Emergency Clinical Quality Indicators

- Choose and Book

- Ambulance Response Times



Strategic Aim 3: Taking services closer to home for the people of

Darlington

Overview

The key actions that will enable us to bring services closer to patients’ homes are:

Developing primary care

Extending patient choice

Developing a clinical strategy across Darlington

Implementing our headline initiatives

Working with neighbouring CCGs on cross-cluster initiatives

A Matrix of Clinical Leaders

We are encouraging and enabling clinicians through their specific interests and skill sets to

undertake commissioning improvements through a range of pathfinder schemes from idea

generated through to delivery. In Darlington we have developed a matrix of clinical

leaders, clinical capacity and capability for leading service improvements and shaping

commissioning decisions. All the clinical leads have an agreed set of priorities and

milestones for delivery which are directly linked to our strategic aims and initiatives in this

plan.

In order to support clinicians in commissioning and the behavioural change and ownership

of the delivery of initiatives needed in 2012/13 we plan to:

Ensure all of our initiatives are clinically led and supported by appropriate project

management, service improvement methods, and technical skills.

Ensure the use of data and information is clinically led and directed and that the right

tools are available for clinicians.

Put governance arrangements in place so that clinicians inform and lead decision

making across our organisational structures.

We plan, through our CCG clinical leadership infrastructure to develop effective

relationships with clinicians in provider services. Within these relationships we will seek to

improve the quality and cost effectiveness of services and make the most of our collective

clinical experience and insights by:

Reviewing and developing appropriate pathways for patients that provide quality

outcomes and efficient utilisation of our resources particularly around avoiding

unnecessary admissions to secondary care

Providing appropriate commissioning and management support to clinical leaders and

practices to be able to undertake planned programmes of work



A Clinical Strategy for Darlington

Darlington CCG is committed to working with all stakeholders in order to ensure priorities

are aligned and there is a whole system approach to planning and prioritising health care

in Darlington. The CCG will play a pivotal role in shaping the provider landscape using the

clinical strategy for Darlington as a vehicle for transformational change.

The clinical strategy will be developed by clinicians from a range of sectors, informed by

patients, the public and all partners including the voluntary sector. Over time the strategy

will drive commissioning intentions as well as guide individual decision making and is key

for the long term sustainability of the local health and social care system.

Primary Care and Community Development

Darlington primary care practices are working towards improving the services offered to

the population of Darlington, by adopting a “one big practice” type approach. In essence

this is to develop our approach to sharing best practice and developing more streamlined

pathways.

As part of our established way of working, Practices work collaboratively to improve

pathways of care and reduce the unexplained variation that exists within primary care.

We believe that we can do more locally by improving and enhancing the skill mix offered

within a primary and community care setting to support our population’s needs and prevent

unnecessary secondary care activity.

We will work with all our partners including patients and the public, community staff, social

care staff, nursing and care homes, voluntary sector organisations, to ensure the relevant

people have input into the work we undertake to improve the health and well-being of our

population and we work together in a much more co-ordinated approach to reduce the

duplication of people’s efforts.

Patient Choice

In order to commission more care from a community setting, our CCG will use choice,

contestability and competition as levers for change and drive up quality whilst at the same

time working to further support integration of services where patients will benefit from more

joined up working.



Darlington CCG current usage of secondary care services is as follows:

Provider Outpatients % Elective % Non Elective %

County Durham and Darlington NHS

Foundation Trust

77.2 61.8 85.6

South Tees Hospitals NHS Foundation

Trust

12.8 17.2 7.7

Independent Sector Total 4.1 9.1 0.0

Newcastle upon Tyne Hospitals NHS

Foundation Trust

3.4 7.8 1.9

North Tees and Hartlepool NHS

Foundation Trust

1.4 2.4 0.7

City Hospitals Sunderland NHS

Foundation Trust

0.3 0.6 0.1

Gateshead Health NHS Foundation Trust 0.1 0.0 0.2

Others NHS - PCT 0.0 0.0 2.4

Other NHS Providers 0.7 1.1 1.3

In order to further develop patient choice Darlington CCG will:

Look to utilise the Any Qualified Provider (AQP) mechanism to support the delivery of

our strategic aim to bring care closer to patients’ homes. Using AQP to open up

services allows patients to choose from a wider range of providers (all of whom meet

NHS quality standards).

Continue to support the introduction of Choose and Book

Use quality outcome and performance measures to help inform patients of the range of

potential treatment options open to them.

Whilst looking to working with our main acute provider (County Durham and Darlington

Foundation Trust) to get the most from Darlington Memorial Hospital, we will also look

to identify opportunities to commission secondary care services from other providers in

Teesside (e.g. North Tees and Hartlepool NHS Trust and South Tees NHS Foundation

Trust to reflect population and access) and look to increase the utilisation of the

Independent Sector where appropriate to do so. This will help secure more responsive

and accessible services and drive up quality standards for our patients.



Headline initiatives for 2012/13 relating to Strategic Aim 3

Project Name Implementation of the Urgent Care Strategy - Completion

CCG Darlington CCG


1. What is the

proposal and

summary

rationale?

In 2008 County Durham PCT and Darlington PCT published “Our Strategy

for Urgent Care Services” which sets out the direction of travel to develop

and deliver a model of urgent care services that is effective and ensures

that patients are treated in the right place and at the right time by services

that best meet their needs. The strategy builds upon national, regional and

local policies as well as the outcome of a series of stakeholder events.

The proposal is to ensure that during 12/13 that the full 24/7 Urgent Care

Strategy is implemented. To date 24/7 Single point of access and urgent

care transports have been developed and operationalized. Elements of the

24/7 Clinical Service are in place however integration / co-location of

Accident and Emergency and Urgent Care at Darlington Memorial has not

yet happened.

2. Current Status

and Cost

The current service is part of a block contract which is activity based with a

marginal rate and costs Darlington approximately £2.9m per annum.

3. Consideration

of Options

1. Co-location

The FT have worked with the PCT cluster Estates team to cost up the

capital requirements for integration at DMH with this information being fed

into a full business case (as part of a CDDFT-wide Urgent Care business

case).

The essence of the clinical model for the co-located sites is: a shared

reception facility; an integrated workforce; senior Emergency Care

Practitioner see, assess and treat at the front end of the pathway; separate

streams for majors and minors

2. Move to tariff

Because A&E and UCC activity will become inextricably intertwined in the

new integrated clinical model, it will be difficult to implement fully at the two

Integrated Centres and fund Urgent Care on block and A&E on tariff

therefore we need to explore the best funding model for delivery of an

Unscheduled care service.

3. Options

A number of options have been researched including a status quo option

(which is not agreeable) through to a 24/7 GP-led urgent care service with

a centralised home visiting and telephone consultation service which will be

integrated fully with A&E when on an acute hospital site.



4. Proposed

Service Model

and

Implications

The service option is to operate a 24/7 service at Darlington Memorial

Hospital (DMH) via a co-located / integrated Urgent Care Centre (currently

at Doctor Piper House) and Emergency Department (ED)

5. Risks Increase demand in the in-hours period initially by providing 24/7 Urgent

Care access and less efficient use of primary care. Further financial risks

may arise depending on the funding model agreed.

6. QIPP

Implications

Quality: 24/7 access for patients, improved pathway,

carer closer to home

Innovation: Improved pathway for patients

Productivity: Reduced inappropriate attendances at ED, reduction in

ED attendances

Prevention: n/a

7. Key

Milestones

Discussion paper to Confed in April 2012

Service model decision – June 2012

Service go live Autumn 2012



Summary of activities that will deliver this strategic aim:

Strategic Aim: To take services closer to home for the people of Darlington

Link to case for change: The CCG has a varied demographic profile including small urban populations, small towns and large under populated rural areas. This variety presents significant challenges as regards access to health and other services.

Population change “We send too many of our patients to secondary care facilities when potentially they could be treated in a more cost effective local setting which is more convenient for the patient”

Health need

Patient insight

Clinical insight



Year 1 (2012/13)


Reviews

Community, district and specialist nursing review

Align mental health staff to GP practices.

Pathway Re-design Anterior knee, pain,

mechanical knee pain and OA Knee

Shoulder pain

Lower back pain

Foot pain

Osteoporosis pathway.



Pilots Community bed

provision including intermediate care beds.

Psychosexual counselling

Erectile dysfunction pilot

On-line education tool for diabetes


Community Diabetic clinic.

New Services

Carpal Tunnel pathway

Co-location of Urgent care and A&E with Darlington CCG initiative of ensuring more low level urgent care needs are met by increased primary care provision. Urgent care co-location with A&E

CCG Initiatives

Agreeing primary care pre and post COPD exacerbation pathways

Agreeing primary care pre and post asthma exacerbation pathways for under 16

Continue with embedding best practice via POINTS tool for COPD management.




PCT Cluster Long Term Conditions Team: Whole System Development of Services to Deliver LTC Support, Including a Review of Community Nursing PCT Cluster Mental Health : Align Mental Health Staff to General Practice; Improve Access to IAPT PCT Cluster Urgent Care: Deliver Urgent Care Strategy Including and Satellite by Appointment Service in Rural Areas



rd sector etc..


Year 2 (2013/14)


Reviews


Pathway Re-design Paediatric pathway

(non-elective)

Paediatric pathway to improve access to physiotherapy and audiology services.


service


Community Cardiology Clinic


New Services


Community Pulmonary rehabilitation




On-line educational tool for newly diagnosed diabetics.


Year 3-5 (2014/15 – 2017/18)





New Services

E-mail rapid advice service








NHS Outcome framework (domain 4) 4. Ensure that people have a positive experience of care Urgent Care Indicators

- Financial balance and achievement control totals on the commissioning allocation

- Securing commissioning support within the running cost allowance

- Delivery of CCG QIPP plans including demand management

Our Financial Strategy


9. Our Financial Strategy

In order to deliver our CCG strategic aims there needs to be a clear alignment between

our financial and operational planning. In this section we will outline our approach to

investment of our commissioning allocation, how we have identified our priority areas and

how we will use the financial and contracting tools and mechanism to deliver the

improvements we have outlined earlier.

This financial strategy will describe how we will manage the funding pressures (QIPP) to

both commissioners and providers over the lifespan of our plan.

9.1 Understanding our commissioning allocation

The latest timelines for the national publication of CCG allocations to support this work are as

follows:

1) High level indicative estimates of baseline spending were published on 7th February

2012 to support initial planning by emerging Clinical Commissioning Groups.

2) CCG Allocations for 2013/14 are expected to be published by the end of December

2012.

The information published on the 7th February 2012 is based upon the expenditure returns

submitted in September 2011 for each CCG (excl. red rated CCGs) adjusted for 2012/13

prices. It includes details of the consultation and review process (including a dedicated

email address for feedback).

There have been no further publications of allocation figures for CCG’s, therefore

assumptions using existing published fair shares models from the Department of Health

have been used to estimate anticipated CCG funding. These estimates build upon the

baseline budgets adopted by the CCG in March 2012, and will be subject to a further

refresh once fully coded and costed activity information is available in respect of the

financial year 2011/12, in June 2012.

The allocations for 2013/14 onwards are expected to be published by the end of the

calendar year and are expected to be based upon a revised funding formula (ACRA). It is

expected that any difference between the baseline allocation and the target allocation will

be subject to a pace of change policy. Once published, these figures will enable a further

refresh of financial plans for 2013/14 and onwards.



The table below shows an extract from the financial planning model for Darlington CCG

showing income and expenditure forecasts for 2011/12 to 2016/17 under the most likely

‘base case’ scenario.

The financial model has been built using several key assumptions as listed below:

Starting point is forecast financial outturn for 2011/12 as at 31 January 2012

Estimated investments for 2012/13 have been included

Estimated reductions for public health transfers to the Local Authority and Public Health

England have been included.

Estimated reductions for specialised services transfers to the NHS Commissioning

Board have been included.

It should be noted that these assumptions will be revisited during the planned updates of

the financial model during the financial year 2012/13 as shown in the timeline below:

Baseline Budget

adopted by CCG

(March 2012)

Estimated

investments included

for CCP (April 2012)

Refresh using

11/12 full year

activity

(June 2012)

Refresh using

confirmed CCG

Allocations

(December 2012)

Darlington Clinical Commissioning Group (CCG) Financial Summary

Recurring

Outturn

FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17

£'000 £'000 £'000 £'000 £'000 £'000

COMMISSIONING BUDGETS:

Acute Services 76,557 76,391 77,537 78,700 79,880 81,078

Mental Health / Learning Disability Services 14,788 15,150 15,377 15,608 15,842 16,079

Community / Primary Care Services 13,622 15,571 15,882 16,200 16,524 16,854

Continuing Healthcare / Funded Nursing Care 8,649 8,943 9,122 9,304 9,490 9,680

Childrens Services 353 629 641 654 667 681

Prescribing 17,118 17,157 17,671 18,201 18,747 19,310

TOTAL COMMISSIONING BUDGETS 131,087 133,839 136,230 138,666 141,150 143,682

CORPORATE BUDGETS & RESERVES:

Management & Organisation 158 158 2,844 2,844 2,844 2,844

TOTAL CORPORATE BUDGETS & RESERVES 158 158 2,844 2,844 2,844 2,844

TOTAL CCG BUDGETS 131,245 133,997 139,074 141,510 143,994 146,526

Forecast period



Due to the consistency of boundaries and population between the predecessor

commissioning body Darlington PCT and Darlington CCG, there are no immediate

implications of moving towards the existing fair shares model from the Department of

Health, and practice level budgets in previous financial years have been calculated using

this existing approach.

9.2 Risk Sharing

Currently the CCG risk management arrangements are based entirely on that of the PCT.

A CCG risk register will be completed by end of April 2012.

The CCGs have yet to determine and agree risk sharing of risk pooling arrangements via

the Confederation but will be completed in line with the requirements of the 100%

delegation of budgets to the CCGs.

The CCG is developing a risk-sharing approach for the following areas:

A risk-share arrangement across localities within the CCG for all areas of commissioned

spend to manage the CCG position.

A formal risk-share arrangement across CCGS for high cost patients.

An informal risk-share arrangement across all CCGs within the County Durham and

Darlington Cluster for all areas of commissioned spend.

9.3 Use of non-recurring funding

In discussion with the PCT Cluster in 12/13 pre-authorisation, we will look to direct a

significant element of the CCG allocation held non-recurringly (2% of the CCG allocation)

to stimulate innovation. This funding will be used to:

Pump-prime and double run transformation pilots in line with our QIPP strategy

Support practice level innovation to improve patient pathways

Support providers to introduce pathway changes that support better whole system

working

Support providers where they look to reduce capacity following commissioning

interventions

This non-recurring funding will be deployed in a staged way that ensures that risk of over-

performance on variable contract lines can be covered in-year without the risk of

generating significant back-loaded slippage at year end.



9.4 Applying 2012/13 business rules

In line with CCGs across the North East, we will take a consistent approach to applying the

rules related to the net 1.8% tariff reduction outlined within the Operating Framework (for

the acute secondary care contracts we will apply a 1.5% tariff reduction as 0.3% is already

applied within tariff pricing).

Across all sectors we intend to use the 1.8% tariff saving as a lever for change by re-

investing the released efficiency back into contracts on a non-recurrent basis and steering

providers towards the delivery of services that meet the commissioning intentions of the

CCG.

This will help mitigate against the risk of destabilising providers from the compound impact

of technical efficiencies incurred through payment rules and allocative efficiencies from the

potential loss of activity.

By agreeing the outlined contracted levels of activity and application of business rules we

will ensure a level of stability within providers whilst allowing CCGs to re-design clinical

pathways and deliver QIPP with a lower level of risk.



9.5 Financial scenarios

Darlington CCG has ensured that this plan can be implemented using a range of financial

scenarios through robust prioritisation of investment, realistic contracting of variable

activity (acute tariff, prescribing and continuing healthcare) and delivery of efficiency

through QIPP schemes. The main features of the three scenarios can be described as

follows:

Base Case (Likely) Scenario

In this scenario the CCG will contract for a realistic level of activity over the life of the plan

based on past activity performance and forecast future demand. Unallocated resource

would be invested in the series of prioritised initiatives that will improve health outcomes,

reduce health inequalities identified and bring care closer to peoples’ homes.

Upside Scenario

In this scenario the CCG will again contract for a realistic level of activity over the life of the

plan. The additional unallocated funding will be used to go further, faster on the delivery of

the strategic priorities and to incentivise providers to further improve quality and

experience for our patients who use their services.

Downside Scenario

In this scenario the CCG would shift the focus of activities to the management of demand

and mitigation of cost increases. The CCG would contract for lower than expected levels of

activity and use all the available levers to manage demand. This would include more time

spent on the reduction of variation in referral patterns, introducing elective pathway

changes (funded from the 2% non-recurring element of the allocation) and helping

patients, particularly the elderly and those with long term conditions avoid admission to

secondary care.

The full details of these scenarios and the wider financial strategy of the CCG can be

found in appendix 6.

Delivery


10. Delivery

Our Organisational Development Plan and SWOT analysis identified a wide range of

support needed to be secured in order to successfully deliver the aims and goals in this

plan.

Using our running cost allowance to secure effective support

The 2012/13 NHS Annual Operating Framework indicates a CCG running cost allowance

based on the size of the population for which we have commissioning responsibility.

This allowance of £25 per head of population from 2013/14 means that we have £2.686m

to invest in the management structure that will oversee the statutory responsibilities and

operational delivery of our CCG and also to purchase the technical commissioning support

necessary to do this efficiently and effectively.

Running Costs based on £25 per head (£’000)

CCG Total 2,686

We confirmed a management and operational structure for our CCG at the end of January

2012 (using a phased approach) and will develop a memorandum of understanding (MoU)

with County Durham and Darlington/North East Commissioning Support Unit by end April

2012. A formal business agreement will follow on in line with the checkpoints required for

the CSU and the milestones for our authorisation process.

Darlington CCG subscribes to the collaborative commissioning arrangements with other

CCGs in County Durham and Darlington. Development and formalising of the County

Durham and Darlington Clinical Commissioning Confederation is progressing with the

heads of terms agreed by all three CCGs in April 2012.

The Confederation is a voluntary association with the purpose of securing the co-

ordination of collaborative commissioning arrangements and risk sharing in the following

areas:

Commissioning and co-ordination of contracting arrangements

Continuing Health Care

Management of risk, specifically high cost/low volume and individual funding decisions

Delivery


10.1 Deliver 2013 – The Darlington CCG delivery framework

‘Deliver Darlington 2013’ is the first Delivery Plan published by the Darlington CCG.

Deliver 2013 is a delivery plan for the Darlington Health System. Staff in the CCG and the

CSU will continue to deliver on the commitments set out in the plan as the CCG’s health

commissioning functions and responsibilities continue to develop during this transitional

year.

This plan articulates how Darlington CCG will deliver planning requirements; financial and

operational requirements; quality and safety requirements and transitional requirements.

The plan provides details of the milestones associated with the delivery of these

requirements; in particular the delivery plan articulates within the financial and operational

requirement section how Darlington CCG will deliver key priority areas linked to our four

Strategic Aims.

The key strategic aims reflect the priorities set out in the NHS Operating framework 2012,

NHS County Durham and Darlington ISOP 2012/13, Darlington CCG Clear and Credible

Plan 2012/13 -17/18, the Darlington Single Needs Assessment 2010 - 11 and the

government white paper Equity and Excellence: liberating the NHS (2010).

Programme management expertise and support will be secured via an SLA with the CSU.

Using ASPYRE programme management software delivered through routine reports to the

CCG Board, Executive and/or other subcommittees and fora, progress against the

delivery plan will monitored to ensure risks are identified and mitigated in real-time.

Governance


11. Governance

Darlington CCG has a responsibility for securing high quality services for our local

population, working with partners to commission services which give optimum outcomes

for patients and the population and driving up the quality of primary medical care.

The successful delivery of our clear and credible plan is founded on having the right

governance and constitutional arrangements as well as capacity and capability for

delivery.

Over the course of 2012/13 these arrangements will be developed in stages in readiness

to assume responsibilities devolved by the PCT cluster and key milestones along our

critical path to authorisation. We plan to have appropriate arrangements fully in place that

address the requirements of the Health and Social Care Bill and guidance in the form of

Towards establishment creating responsive and accountable clinical commissioning

groups (DH February 2012).

The success of Darlington CCG is predicated on balancing a number of factors and

principles:

Autonomy at our local CCG level while exploiting economies of scale for tackling

common issues at a cross CCG/Confederation level

Developing a lean organisational structure, while ensuring sufficient resources and

capabilities are in place to deliver the ambitions of the commissioning plan whist

establishing a new organisation and achieving successful authorisation.

Capturing and developing skills with the organisation whilst utilising external expertise

and commissioning support.

During this transition period in 2012/13, prior to Darlington CCG being fully authorised, the

CCG Board is established as a sub-committee of the PCT Cluster Board.

The CCG sub-committee has a membership comprising:

three GP clinical lead representatives from Darlington practices,

an interim chief operating officer (ICOO) who is an executive director of the PCT,

a PCT non-executive director (NED) - as interim chair

a lead nurse,

a senior finance lead,

the director of public health for Darlington,

lay representatives

local authority representative.

Governance


The terms of reference for the CCG sub-committee are agreed and articulate the

responsibilities that have initially been delegated from the PCT cluster to Darlington CCG.

The senior executive team includes the interim chief operating officer (responsible to the

PCT cluster chief executive), interim senior finance officer, interim chair (GP), interim Vice

Chair (GP), interim clinical quality lead (GP), the lead nurse and Deputy ICOO. The main

purpose of the group currently is to oversee the operational management of the CCG in its

commissioning role and ensure, in the short term, that the CCG successfully assumes

commissioning responsibilities from the PCT and achieves full authorisation.

The capacity and capability to deliver the clear and credible plan is provided through two

routes. A number of staff from the PCT cluster are aligned to provide capacity and

capability to support delivery of our plan and undertake functions which will be increasingly

undertaken by the SCGG. These staff will continue to employed by the PCT during this

phase of transition but will have their objectives aligned to those of the CCG to support the

achievement of authorisation. Pragmatically, in the initial phase staff with roles aligned to

the CCG will either “sit” with the CCG or within the developing commissioning support unit

(CSU) within the PCT. Staff within the CSU will continue to provide commissioning support

and back office functions which will be coordinated through a designated relationship

manager.

Work is progressing to understand the critical posts required in the CCG ‘home team’ to

lead, govern and deliver the business of the CCG versus what capacity and capability will

sit in the CSU supporting delivery of the commissioning functions. The backdrop and

challenge for this work is the finite running costs allocation for our CCG as well as the

costs of the CSU.

11.1 Future arrangements – establishing the governing body,

CCG Board and Executive

Governance arrangements for Darlington CCG are still to be finalised and are being

developed in alignment with the timescales for authorisation.

The clinical board has recently been reviewed together with the practice leads and GP

chair roles in order to establish core members (Chair, Vice-chair, member representatives,

Practice nurse lead, and practice manager lead) who have a clear mandate to operate as

member representatives of the governing body for the CCG. The first meeting of the new

governing body was early April 2012.

Governance


From 1 April 2012 our emerging accountability, decision making arrangements and the

way we engage the twelve constituent member practices is shown in the figure below.

Darlington CCG Leadership, Engagement and Decision making

Each CCG is required to have a governing body. The legislation will identify a statutory

core membership although there must be some local flexibility to identify additional

members. The core membership must include:

GP or other health care professionals

Chair of the governing body

Lay member with a lead role in overseeing key elements of governance

Lay member with a lead role in championing patient and public involvement

Clinical member (a doctor who is a secondary care specialist)

Clinical member (a registered nurse)

Accountable officer

Chief finance officer

Governance


The Darlington CCG interim governing body comprises the 12 member practices, each

with a member representative who attends the governing body meetings. The governing

body aims to establish a CCG board which will comprise Chair, Vice chair, Accountable

Officer, Chief Finance Officer, Lead nurse, Secondary Care clinician and two lay members.

Figure on page 103 illustrates the emerging leadership and decision making arrangements

to be agreed with member practices.

Governing body member role descriptions will need to reflect the legislative framework.

The guidance sets out core role outlines supported by specific attributes and

competencies for all members of the governing body, who will be expected to work

together as a team to ensure that CCG exercises its functions effectively, efficiently and

economically in accordance with its constitution as agreed by its member practices.

Our CCG is actively seeking Lay representation for the sub-committee and governing body

in the first instance. We have successfully secured an interim lay representative for patient

and public engagement who joined the CCG subcommittee in April 2012. Appointments of

CCG board members including chair, accountable officer, chief finance officer, nurse and

lay representatives will follow in line with the National timeframes (April-June 2012). The

final governing body constitution and appointments are to be complete by July 2012.

Subject to national milestones and processes

There are number of immediate developments towards the future governance

arrangements that will be taken forward with constituent member practices between April

2012 and October 2012. These are:

Participation and action planning from the board to board development session on 24

April 2012. The learning and action planning will not only prepare the sub-committee

members and senior leadership team for their delegated responsibilities but also set the

trajectory milestones for the authorisation application.

Completion of the scheme of delegation and financial controls at CCG to support

responsibilities delegated by the PCT cluster, subject to a satisfactory performance

review.

Completion of financial and governance training for sub-committee members, governing

body members and senior leadership team.

Arrangements for finalising the CCG constitution and relevant terms of reference

Development of a compact between member practices of the governing body.

Identification of the chair of audit committee and chair of the remuneration committee

Establishing arrangements for the audit committee and remuneration committee

including appointment of chairs for these committees.

Establishing the essential CCG subcommittee arrangements in order to move forward

delivery, demonstrate financial and overall organisation wide governance and grip.

Governance


We are currently working with external providers in a consultancy capacity to support us in

delivery of a development programme for the governing body but

Emerging structure for leadership and decision making

We have adopted the PCT cluster Conflicts of Interest Policy as the CCG Conflicts of

Interest Policy and are currently in the process of establishing Conflicts of Interest

Registers at CCG level.

Governance


11.2 Financial Governance

In line with the CCG strategic aim to manage our finances wisely, we have developed

robust governance framework to oversee this management and prioritisation of our

investment.

The CCG has a robust financial reporting system, building upon the existing system in

place for County Durham PCT. This system ensures that relevant, accurate, timely

financial information is available for decision makers at CCG, Locality and Practice levels.

This financial reporting is underpinned by a suite of governance documents including

Standing Orders, Standing Financial Instructions, Financial Limits, and a comprehensive

Scheme of Delegation. These governance documents were formally adopted by the CCG

in March 2012.in preparation for the expansion of their delegated budget responsibility and

increased accountability.

The Interim Chief Officer (ICO) will identify individual staff members as authorised

signatories for expenditure, and budget management responsibilities linked to the

approved scheme of delegation and financial limits.

Financial accountability within CCG

Ultimate financial accountability for the CCG will be subject to transition during the lifespan of

this plan.

Until 31 March 2012, the ultimate accountability will rest with the PCT Cluster Chief Executive,

although some areas of budgets are currently delegated to the CCG with responsibility

delegated to the ICOO.

In respect of the financial year 2012/13, the CCG will assume responsibility for the full range

of relevant budgets. During this period, the PCT Cluster Chief Executive will continue to

delegate responsibility for these budgets to the ICO. From 1st April 2013, the CCG

Accountable Officer will assume full financial accountability for CCG budgets.

Across this entire period, the Accountable Officer will liaise with both the PCT Cluster Director

of Finance, and Senior Finance Officer for the CCG to provide assurance that all necessary

measures are in place to deliver the control totals agreed at the outset of each year.

Darlington CCG recognises the need for demonstrable grip and financial governance through

close monitoring of financial performance. A proposed subcommittee of the emerging CCG

board will oversee performance and finance. This arrangement will be confirmed by the end

of April 2012 and in discussion with membership of the governing body. The Performance and

finance subcommittee will ensure robust financial management of delegated funds, and

recommend actions to the board to ensure delivery of financial control totals.

Governance


11.3 Equality and Diversity

In order to ensure that no groups or individuals are disadvantaged by our commissioning

activities, we have carried out a full Equality and Diversity Screening assessment of our

plan.

Further screening assessments will be carried out at service level when re-designing or

commissioning pathways of care.

Risk Management and Ongoing Monitoring


12. Risk management and

ongoing monitoring

Our CCG risk management arrangements and processes are based on the PCT cluster’s

existing arrangements. A Darlington CCG risk register is in development with support from

the CSU risk management team (to be populated by end April 2012) to be initially routinely

reported through the CCG subcommittee, CCG executive and when established the risk

and assurance subcommittee of the CCG Board. The ICO will be responsible for the risk

management strategy, policy and processes.

Darlington CCG has carried out a full assessment of this plan using a standard scoring

methodology to understand the key risks to the delivery of the plan, the capacity and

capability of our CCG to implement the plan and the financial resilience of the CCG and

wider health economy.

The top four risks areas are:

1) Strategic delivery - Failure to secure the pathway design, project management,

procurement and transformational skills. Relatively small running cost allowance due

to small population size of Darlington CCG creates a risk in being able to carry and

contract in enough commissioning support and clinical time to deliver the plan. This

will be mitigated through close working with our local authority partner and where

appropriate to do so cross-CCG working via the Confederation.

2) Financial resilience – Increases in continuing health care costs above an affordable

level. Due to the relatively small size, the CCG is more susceptible to variations in

financial performance. This will be mitigated by the risk sharing model outlined below

and specifically managing high risk budget lines such as CHC.

3) Financial resilience – Impact of an aging population contributing to increased costs.

Managing demand on the secondary care system (both planned and unplanned).

This will be mitigated by our demand management approach, use of RAIDR,

targeted commissioning intentions and our clinical strategy.

4) Organisational readiness – establishing unrealistic timescales that don’t recognise

the depth of organisational development needed to assume full responsibilities from

the PCT cluster whilst delivering the business and establishing a new organisation.

Full details of the methodology, risks and mitigations can be found in appendix 8.



On-going monitoring

This Clear and Credible Plan was agreed through the formal CCG governance process

and a wide range of touch points shown on page 93. This approach over the course of the

development of the plan ensured effective engagement with clinicians as well as key

stakeholders.

Performance monitoring of the implementation of the plan, impact of the strategic

initiatives on their stated KPIs and associated health and quality outcomes will be

monitored at both the Darlington CCG governing body level and at the Darlington CCG

sub-committee.



Appendices


Appendices

Appendix 1: Overview of Health Needs

Appendix 2: Gap analysis

Appendix 3: Overview of Programme Budgeting

Appendix 4: Commissioning intentions

Appendix 5: Communication and Engagement plan

Appendix 6: Medium Term Financial Strategy

Appendix 7: Governance

Appendix 8: Full Risk Assessment

Appendix 1


Appendix 1 – Overview of Health Needs

Key cross cutting health related messages from the Darlington Single Needs Assessment:-

Population Growth

Darlington's population is ageing as a result of people living longer

Darlington's aged 50+ population is projected to rise to 40.9% of the total population by

2020. The aged 75+ population is projected to increase to 10% of the total population

Darlington has some of the most deprived areas in England, and is ranked 79th most

deprived local authority out of 324 in England

There are almost 4,200 older people are living in poverty in Darlington (ONS Mid 2008

LSOA population estimates).

Life expectancy

People are living longer however inequalities in life expectancy exist between

Darlington and England. For example, life expectancy for;

Men living in Darlington are living 1.7 years less than the England average (Darlington

Health Profile 2011).

Women living in Darlington are living 1.5 years less than the England average

(Darlington Health Profile 2011). Check wording

Inequalities in life expectancy exist within Darlington. For example:

o Life expectancy for men living in the most deprived areas is over 13.4 years lower

than for men living in the least deprived areas. For women it is 10.3 years lower

(Association of Public Health Observatories 2010,)

Appendix 1


Disease and mortality

Early death rates from cancer and cardio vascular disease have fallen however they are

higher in Darlington than the England average.

Cancer incidence in Darlington:

Is higher for women than men

Is closely correlated with deprivation. The distribution of cancer incidence rates (2004-

2008) in Darlington is not equal, it is higher in the more deprived MSOAs

Cancer mortality in Darlington is:

Significantly higher for men than women

Between 2007 and 2009 1,129 people in Darlington died aged less than 75 years

Premature mortality rates (under 75years) for the ‘biggest killers’ (heart disease, cancer,

stroke) in Darlington are higher than the England average.

o Cardiovascular disease (CVD) and cancer account for around 63% of early or

premature deaths in Darlington.

o Smoking remains the biggest single contributor to the shorter life expectancy

experienced locally

GP practice registered disease prevalence in Darlington is 20% higher than the England

average for the following diseases

Chronic Obstructive Pulmonary Disease (COPD – also the second most common cause

of emergency admissions to hospital)

Coronary Heart Disease (CHD)

Appendix 1


Childhood Obesity

Childhood obesity shows a significant variation in prevalence between reception and

Year 6. Year 6 prevalence is almost double that of reception

Childhood obesity prevalence in reception does not vary within Darlington; however

there is variation in obesity prevalence in Year 6 children.

Poverty is key determinant of what families eat.

Overweight young people have a 50% chance of being overweight adults

Breast feeding is a major contributor to good health in both mother and child

Teenage Conceptions

Teenage conception rates in Darlington are higher than the England average but have

been falling over time

there is a strong relationship between teenage conceptions and deprivation within

Darlington

Prevention of under 18 years conceptions is central to improved outcomes for young

women and men

Alcohol

Darlington has significantly higher rates of hospital admissions for alcohol related harm

for both men and women compared to the England average

Binge drinking prevalence is estimated to be 31% in Darlington, higher than 18%

estimated adults who binge drink nationally

The Social Norms Survey (a large scale drug and alcohol survey carried out in

Darlington Schools) is the basis for development of positive messages to reinforce

healthy choices with young people.

Substance Misuse

Drug misuse is a complex public health issue which also has links with crime and

disorder. The DAAT (Darlington Drug and Alcohol Action Team) commissions

prevention activity and treatment services

Most young people in Darlington do not misuse drugs or alcohol

PDU (Problem Drug User) data suggests the majority of opiates users in Darlington are

known to treatment

Service data indicate people under 25 years are more likely to report cannabis, alcohol or

cocaine use, while over 25 years were more likely to report opiates or amphetamine use

Men are more likely to use drugs and access treatment than women.

Appendix 1


Adult Obesity

The Darlington Health Profile (201) reported that there is higher prevalence of obese

adults in Darlington (26%) than England average (24%)

NHS Health Checks programme has to date screened 5,561 patients between the age

of 40 and 74, this population had an obesity rate of 30%

The Darlington Sport and Physical Activity strategy is broadly based in approach and

engages private and public sector partners.

Dementia

The effect of an ageing population will include an increase in the numbers of people

living with dementia, their health and social care needs and the needs of their carers

Dementia prevalence is predicted to rise in Darlington to 8.1% by 2030 i.e., the

proportion of people aged 65 years and over

Dementia is the main cause of mental health admissions among older people.

Learning Disabilities

The number of people with severe and profound learning disabilities is predicted to

increase by 1% each year due to increasing life expectancy and the growing number of

children with such disabilities

In 2011 370 children attending school in Darlington had Special Educational Needs

statement (2010 figure was 390). There were also 1,526 children receiving School

Action support and 1,125 receiving School Action Plus support

In 2009/10 there were 180 (71.9%) adults with learning disabilities known to Social

Services who were in settled accommodation at the time of their last assessment there

were also 15 (5.9%) adults with learning disabilities known to Social Services who were

in employment

Appendix 1


Inequalities exist both between Darlington, the NE region and England but also within

Darlington with Darlington having some of the most deprived areas in England, and is

ranked 79th most deprived local authority out of 324 in England. Around 39% of

Darlington's lower super output areas (LSOAs) are in the most deprived 30% nationally

with almost 16% of Darlington's LSOAs are in the most deprived 10% in England

% of LSOAs by national deprivation deciles, Darlington. Source: ID2010, DCLG

Inequalities in life expectancy exist within Darlington. For example life expectancy for men

living in the most deprived areas is over 13.4 years lower than for men living in the least

deprived areas. For women it is 10.3 years lower (Association of Public Health

Observatories 2010).

Slope Index of Inequality for Life Expectancy by Deprivation Deciles – 2001-05 to 2005-09.

Darlington. Source: APHO, 2010.

0

2

4

6

8

10

12

14

16

18

1 2 3 4 5 6 7 8 9 10

Deprivation Decile (ID2010)

% o

f LS

OA

s

Deprived Affluent

The size of the gap in LE between rich

and poor has fallen for males, but the

difference is not statistically significant


and poor has increased for females, but

the difference is not statistically significant


and poor is greater for males than

females, but the difference is not

statistically significant.

Appendix 1


What does the Data tell us?

Darlington experiences significantly greater levels of premature deaths than England for

many causes (SMRs figure). Between 2007 and 2009 1,129 people in Darlington died

aged less than 75 years

SMRs which are statistically significantly higher in Darlington than England are:

1. Persons.

COPD

Acute myocardial infarction (AMI)

Lung cancer

All circulatory diseases

All causes

2. Males.

COPD

AMI

All circulatory diseases

All causes

3. Females.

COPD

All causes

Appendix 1


COPD

COPD prevalence is greater in Darlington (2.2%) than England average (1.6%). There are

over 2,200 people registered with COPD in Darlington (QOF, 2009/10). This prevalence

varies by practice by between 1% and 3%.

It is estimated there are over 600 people in Darlington with undiagnosed COPD.

‘Invisible Lives – Chronic Obstructive Pulmonary Disease (COPD) – finding the missing

millions’ (British Lung Foundation, 2007) estimated there are 2.8 million people in the UK

with undiagnosed COPD, which if left untreated could severely restrict their lives and

eventually kill them.

The COPD Prevalence Modeller (based on the Health Survey for England 2001 and a

representative sample of the population of England who had lung function tests and data

collected on relevant risk factors) estimates 600 patients with COPD in Darlington that

have not been recognised by their GP (‘missing’).

The model gives an estimate of the number of patients a practice could expect to have

based on the population characteristics.

Premature COPD mortality rates for the period 2007-09 were significantly higher in

Darlington than England for both males and females. There was no significant difference

between Darlington and the North East. During this period 78 people aged less than 75

died from COPD.

Directly age standardised premature mortality rates per 100,000 for COPD, Darlington,

North East and England, 2007-09 pooled. Source: NCHOD.

Appendix 1


Mental Health

Prevalence modelling in health conditions likely to affect the care needs of those aged 18-

64(2010-2030), Darlington. Source: PANSI, 2010.

Appendix 1


Projecting Adult Needs & Service Information System (PANSI)

% change over time (2010-2030)

Appendix 1


The population projections show an increasing number of elderly people as illustrated in

the graph below. The number of people aged 65 and over in Darlington is projected to

increase from 17,400 in 2008 to 23,800 in 2023 and 29,100 in 2033. The number of people

aged 85 and over is projected to increase from 2,400 in 2008 to 3,800 in 2023 and 6,000

in 2033.

This will have an impact on the prevalence of long term conditions overtime as well as the

levels of dependency found in Darlington. The graph below shows the projected

percentage change over time for significant health conditions for those over 65 years.

Local QOF data (2009/10) indicates a prevalence of 0.6% for dementia for Darlington

against a regional and national average of 0.5%. Dementia prevalence is predicted to

increase in Darlington between 2010 and 2030. The proportion of people aged 65 and

over with dementia in Darlington is predicted to increase from 7.1% in 2010 to 8.1% by

2030, a rise of nearly 1,000 cases.

Nationally, dementia is the main cause of mental health admissions among older people,

accounting for 41% of all mental health admissions (21% unspecified dementia, 14%

vascular dementia and 5% Alzheimer’s Disease) (APHO, 2008).

The national hospital admissions rate for dementia amongst 75- 79 year olds is

approximately 200 per 100,000 rising to around 600 per 100,000 at 85 and over. The

overall admissions rate for over 65’s for dementia nationally (ibid). It is estimated that after

the age of 60 the prevalence of dementia doubles every five years so that about 22% at 85

and 30% of those aged over 95 are affected.

Appendix 1


Appendix 1


Childhood Obesity

Childhood obesity is a key public health issue, posing a major health challenge and risk to

future health and wellbeing and life expectancy in Darlington. Obesity prevalence varies

significantly between reception and year 6 in Darlington, the North East and England

Obesity prevalence in Darlington is not significantly from England or the North East for

reception or year 6. Rates in both reception and year 6 have seen little variation over time

in Darlington, the North East and England

Obesity prevalence 2006/07-2009/10, Reception and Year 6, England, North East and

Darlington. Source: NCMP 2009, National Obesity Observatory (NOO).

Overweight young people have a 50% chance of being overweight adults, and children of

overweight parents have twice the risk of being overweight compared to those with healthy

weight parents. Obese 10 to 14-year olds with at least one obese parent have a 79%

chance of becoming obese adults (Whitaker et al (1997) cited in Kopelman et al (2004,

p4).

Currently there is inequitable access to evidence based material, support to tackle obesity

and specific targeted interventions for children and young people across Darlington.

Appendix 1


Obesity prevalence and deprivation, Reception and Year 6,

Darlington MSOAs. Source: NCMP 2007-09, National Obesity Observatory

Poverty is the key determinant of what families eat. It is suggested that lower income

families spend a much higher proportion of income on food than higher income families.

The link between sustained breast feeding and deferred weaning (to at least six months)

and reduced risk of childhood obesity is increasingly well established. There is now good

evidence of the link between breast feeding and improved emotional attachment between

infant and mother.

Appendix 2


Appendix 2 – Gap Analysis

Through the health care planning process to meet the necessary timelines to both inform

contract negotiations and inform healthcare providers of potential service changes

Darlington CCG developed a set of commissioning intentions. Since this process a more

locally focussed population profile has become available. This document is embedded

below:

The purpose of the gap analysis is to ensure that the derived commissioning intentions

delivers against any local issues identified in the health profile.

Demographic Changes

The ONS residential populations over the past 3 years have been significantly less than

the population that is registered at general practices within Darlington CCG. The table

below illustrated the extent of this difference

Population Health Profile - Darlington.pdf

Appendix 2


In order to plan for services, and address the need for the ageing population it is

necessary to forecast the change in registered practice population. This was done by

applying an error multiplier derived from average difference from previous 4 years applied

to the ONS growth forecasts. Full methodology can be provided under request but due to

the file size it has not been embedded.

Demographic Shifts in GP Registered Population

From the diagram above it can be clearly seen that over the next twenty years Darlington

have registered practice population that are ageing. Ageing population make a higher

demand on health services.

The table below indicates some key issues that the analysis has revealed:

By 2030 it is forecasted that there will by a 51% increase in the over 65 registered

population in the Darlington CCG, with the other age groups remaining relatively stable

(within -/+ 5%).

Age Group 2011/12 Q2 2015 2020 2025 2030

Darlington

0-19 24.71 24.72 25.44 26.3 26.01

20-64 62.87 63.09 63.62 63.46 63.14

65+ 18.39 20.62 22.5 24.9 27.88

Total 105.96 108.44 111.55 114.66 117.03

Directly age standardised premature mortality rates per 100,000 for

COPD, Darlington, North East and England, 2007-09 pooled. Source: NCHOD.

Darlington Demographic Shifts

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

0-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

990

+

Age Groups

Co

un

t o

f A

ge

Gro

up

s (0

00s)

Q2 2011/12

2015

2020

2025

2030

Appendix 2


QOF Prevalence

The tables below provides Darlington CCG level QOF prevalence health data

benchmarked against the North East (SHA) average and England average as included in

the Darlington health profile. Red represents an indicator which is worse than the England

average and the North East average; amber represents where the indicator is than the

England average or the North East average; green represents where the indicator is better

than the England average and the North East average.

Disease Area England North East Darlington

2009/10 2010/11 2009/10 2010/11 2009/10 2010/11

Chronic Obstructive

Pulmonary Disease Register 1.60% 2.50%

2.30%

Heart Failure Prevalence 0.70% 0.80%

0.80%

Coronary Heart Disease

Prevalence 3.40% 4.60%

4.20%

Stroke / Transient Ischaemic

Attacks (TIA) Prevalence 1.70% 2.20%

2.00%

Obesity Prevalence (16+) 10.50% 13.10% 13.70%

Hypertension Prevalence 13.50% 15.30% 14.20%

Diabetes Mellitus (Diabetes)

Prevalence (ages 17+) 5.50% 5.90%

6.30%

Mental Health Prevalence 0.80% 0.80% 0.90%

Asthma Prevalence 5.90% 6.20% 5.80%

Smoking Prevalence n/a n/a n/a

Cancer Prevalence 1.60% 1.70% 1.50%

Epilepsy (18+) 0.80% 0.90% 1.00%

Hypothyroidism 3.00% 3.70% 3.10%

Palliative Care 0.20% 0.20% 0.40%

Dementia 0.50% 0.60% 0.70%

Depression (18+) 11.20% 15.10% 13.20%

Chronic Kidney Disease 4.30% 5.00% 4.40%

Atrial Fibrillation 1.40% 1.60% 1.60%

Learning Disabilities (18+) 0.40% 0.60% 0.50%

Definitions of RAG Ratings

Applies to County Durham and Darlington If worse than England and North East = Red

If worse than England but not the NE = Amber

Applies to DDES, North Durham, Easington,

Sedgefield, Dales, Derwentside and DCLS

If worse than England, NE and CD = Red

If worse than England and NE but not CD = Amber

Appendix 2


APHO derived Locality health indicators

Figure 21 and 22 in the locality Health Profile’s provide information at Middle Super Output

Level on some key health indicators. Unfortunately, this information is not readily available

at the locality level, and due to a complex methodology it is not easy to definitively derive.

However, due to the similar (size and type) populations of a middle super output area

(within the localities) it would be reasonable to estimate a proxy measure using an average

of the locality MSOAs.

Table 1.2 APHO MSOA derived health indicators

Disease Area (09/10) England

2009/10

2010/11

North East

2009/10

2010/11

Darlington

2009/10

2010/11

Obese Children 18.7 20.6 19.4

Obese Adults 24.2 27.8 27.6

Adults who smoke 22.2 27.9 24.4

Binge drinking 20.1 30.1 28.5

Healthy eating (Good) 28.7 21.5 23.5

All Cause premature mortality 100.0 116.2 115.0

Premature cancer mortality 100.0 117.2 108.2

Premature CVD mortality 100.0 115.9 112.4

Premature CHD mortality 100.0 121.3 114.5

All age stroke mortality 100.0 108.7 113.3

All age respiratory mortality 100.0 116.2 101.1

Definitions of RAG Ratings

Applies to Darlington If worse than England and North East = Red

If worse than England but not the NE = Amber

Appendix 2


Summary of Health Needs

From the statistics presented, Darlington CCG has the following health outcome which are

both worse than the England and Northeast average:

Heart Failure Prevalence

Obesity Prevalence

Diabetes Mellitus Prevalence

Mental Health Prevalence

Palliative Care

Epilepsy Prevalence

Dementia Prevalence

Atrial Fibrillation

All Age Stroke Mortality

Ageing Population

Gap Analysis – Is the need addressed by the

interim Commissioning Intentions

Health Issue Commissioning Intentions / Workstreams

That will contribute towards: Prevention, managing demand

(need), better treatment, managing any long term effects

CVD Issues: Heart Failure and

Atrial Fibrillation

Darlington specific:


Intermediate Care Beds

Specialist Nursing Home Care Support Service

Clusterwide:

Re-commission Health Checks Programme;

Review Intermediate Care services;

Whole Systems Development of services that deliver

Long Term Conditions Support, including Community

Nursing;

Gold Standard Framework for Locality end of life

Registers.

Appendix 2





Diabetes Mellitus Prevalence Darlington specific:

Community Nursing

On-line training tool for diabetes

Diabetic Community Clinic

Intermediate Care Beds

Clusterwide:




Nursing

All Age Stroke Mortality: Darlington specific: None

Clusterwide:

Re-commission Health Checks Programme;




Nursing;

Gold Standard Framework for Locality end of life

Registers;

Develop a community stroke rehabilitation team across

County Durham and Darlington

The re-design of the Hyper Acute service will contribute.

The anti-coagulation service currently in procurement

will also contribute.

Obesity: Adult Obesity

Prevalence


Integrated Obesity Pathways

Cluster CIs:

Expand access to community weight management

services

Maternal Obesity

Review of Exercise on Referral; Physical activity

interventions for pregnant and post natal women.

Appendix 2





Palliative Care: Percentage of

registered patients on palliative

care register


Community Nursing;

Intermediate Care Beds;


Clusterwide:




Nursing;

Establish a Gold Standard Framework for Locality

Registers for Patients who are in their last year of life

due to their illness and diagnosis

The end of life rapid response pilot would contribute toward

the end of life part of the palliative care pathway

Mental Health: Mental Health

prevalence


Practice attached Community Psychiatric Nurse;

Personality Disorder Pathway

Clusterwide:

Align mental health staff to general practice; Expansion

of Improving Access to Psychological Therapies;

Improve equity of autism assessment an diagnosis;

Deliver the dementia strategy;

Re-commission out of area placements.

Dementia: Dementia prevalence

Darlington specific: none

Clusterwide:



Nursing

Epilepsy: Epilepsy prevalence

Darlington specific: None

Clusterwide:

DDES CCG are developing an outreach Epilepsy

service (which could cover the whole of the cluster)

Appendix 2





Ageing Practice Population:


Community Nursing


Clusterwide:




Nursing

Appendix 3


Appendix 3 –

Overview of Programme Budgeting

Using the NHS County Durham and Darlington Annual Population Value Review (the local

interpretation of programme budgeting data developed in-line with national best practice

guidelines) the CCG has been able to understand (within the limitations of the data), the

relationship between past investment and health outcomes.

As Darlington CCG shares a boundary with the predecessor commissioning PCT, a direct

interpretation of the programme budget data is possible.

The figure below depicts the high level relationship between spend (low to high) and

outcome (poor to good):

Infectious Diseases Inf Hearing Hear Disorders of Blood Blood

Cancers & Tumours Canc Circulation Circ Maternity Mat

Respiratory System Resp Mental Health MH Neonates Neo

Endocrine, Nutritional & Metabolic End Dental Dent Neurological Neuro

Genito Urinary System GU GI System Gastro Healthy Individuals Hlth

Learning Disabilities LD Musculoskeletal Musc Social Care Needs Soc

Adverse effects & poisoning Pois Trauma & Injuries Trauma

Programme Area Abbreviations

No outcome indicators readily availableOutcome indicators available

Appendix 3


The figure below Darlington 2009/10 shows the programme budget spend and outcome summary.

In 2009/10 Darlington PCT had:

3 programme areas within the high spend better outcome quadrant

5 programme areas within the lower spend better outcome quadrant

2 programme areas within the lower spend worse outcome quadrant

4 programme areas within the higher spend worse outcome quadrant

8 programme areas did not have a recommended outcome measure.

Darlington PCT has 1 outlying programme area (greater the 2 standard deviations from

the national average) within the quadrant analysis, which was the Trauma and Injuries

programme area. The Trauma and Injuries programme area had a level of spend

significantly greater than the national average.

30%

70%

34% 66%

37% 63%

0.00%

20.00%

40.00%

60.00%

80.00%

PrimaryCare

SecondaryCare

PrimaryCare

SecondaryCare

PrimaryCare

SecondaryCare

2007/2008 2008/2009 2009/2010

Expenditure Split - all programmes

Appendix 3


In 2009/10 expenditure across all but 5 programme areas for Darlington PCT is greater in

secondary care than primary care. Over the past three years the difference in proportion

has decreased.

Expenditure benchmarking analysis across the 23 programme areas informs that for

Darlington PCT:

4 programme areas are within the lowest quintile;

5 programme areas are within the second quintile;

5 programme areas are within the third quintile;

1 programme areas are within the forth quintile;

8 programme areas and within the highest quintile, of which 6 were within the top 20

highest expenditure level and 1 in the top 10 highest expenditure across all 152 PCTs.

Darlington PCT spends the 9th highest amount per head of population on the Trauma and

Injuries programme area out of 152 PCTs.

0

1

2

3

4

5

6

7

8

9

LowestQuintile

SecondQuintile

Third Quintile Forth Quintile HighestQuintile

Nu

mb

er

of

Pro

gram

me

Are

as

Expenditure Level

Expenditure Benchmarking

High Spend Areas

- Endocrine, Nutritional

and Metabolic

Programme - Problems of Learning

Disability - Neurological Disorders - Problems of Circulation - Problems of the

Respiratory System - Dental Problems - Problems due to

Trauma and Injury - Adverse Effects and

Poisoning

Appendix 3


Across 55 outcome areas during 2009/10 Darlington PCT has: 21 outcomes better than

SHA, Industrial Hinterland and England Average; 17 outcomes between worst and best of

benchmarking averages; 17 outcomes worse than SHA, Industrial Hinterland and England

Average. Three of the worse outcome areas are within the Problems of the respiratory

system programme area.

0 5 10 15 20 25

Outcomes better thanbenchmarking averages

Outcomes between worst andbest of benchmarking averages

Outcomes worse thanbenchmarking averages

Number of Programme Areas

Outcome Benchmarking

Outcome Hotspot

3 worse outcomes in:

- Problems of the Respiratory System

2 worse outcomes in:

- Cancers and Tumours - Endocrine, Nutritional and

Metabolic Problems - Problems of Circulation - Problems due to Trauma

and Injuries - Problems of the Genito

Urinary System

Appendix 3


A more detailed programme level summary is given in table below:

Appendix 4


Appendix 4 – Commissioning Intentions

Q4 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

Contractual

negotiation

► Diabetes Foot

care

► Carpal Tunnel

pathway

Review

Countywide

schemes or

led

externally

► Community nurses, matrons

and specialist nurses

► Primary care counselling and

psychology to include psychiatric

nursing attached to GP practice.

► Community bed provision

including intermediate care beds.

► Darzi centre review

► Urgent care provision for

nursing and care homes.

► Weight management/

integrated obesity

pathways

Pathway re-

design

► Anterior / Mechanical Knee

pain

► OA knee

► Osteoporosis

► Lower back pain

► Asthma and wheezing

pathway

► Community diabetic clinic

pathway

► Personality disorder pathway

► Paediatric pathway

(non-elective) in

secondary care

► Paediatric pathway to

improve access to

physiotherapy and

audiology.

► Shoulder pain

► Foot pain

Trans-

formation

fund pilot

► Acute

exacerbation

pathway for COPD

(countywide pilot)

► Intermediate

care bed provision.

► Psychosexual

counselling

provision

► Psychosexual counselling

provision

► Erectile dysfunction pilot

► On-line education tool for

diabetes

► Community COPD Clinic

► Community diabetic clinic

► E-mail rapid advice

service

► Community

ophthalmology clinic

► Community

Cardiology clinic

► Pilot primary care

support for urgent care

provision to nursing

homes- (from review)

Commission

new/extend

current

(grey text

dependent

on outcome

of

review/pilot)

► Urgent care co-location with

A&E

► Chiropody/podiatry.

► Acute exacerbation pathway

for COPD (countywide pilot)

► Community bed

provision including

intermediate care beds.

► Pulmonary

rehabilitation

► Community COPD

clinic

► Community diabetic

clinic

► Erectile dysfunction

pilot

► On-line education

tool for diabetes

► Community

ophthalmology

clinic

► Community

Cardiology clinic

► Pilot primary

care support to

nursing homes-

(from review)

► E-mail rapid

advice service

Appendix 5


Appendix 5 – Communications Strategy

Darlington Clinical Commissioning Group (CCG)

Localised Operational Engagement Plan 2011/12

Introduction:

The document below has been produced in line with NHS County Durham and

Darlington’s GP Led Commissioning Engagement Plan 2011/12.

It is essential that patient and public engagement expectations are both understood and

fulfilled. The draft plan will assist in the consideration and development of ongoing

involvement mechanisms for the CCG and will support the key drivers for engaging with

key stakeholders and the local population of Darlington.

The plan will enable the CCG Board to have an awareness of the need for engagement

activity, including a high-level overview of legislation and policy ‘must-do’s’ and an

understanding of engagement considerations and challenges at different stages of the

commissioning process.

What do we mean by patient public and carer engagement?

Patient, public and carer engagement is primarily about listening to feedback from local

people with a view to informing service improvements. Engagement activity may range

from informing patients to proactively seeking views through to the co-production of

services with full participation from patients. Engagement can be proactive and reactive,

formal and informal, quantitative and qualitative. Patient involvement also encompasses

the personalisation agenda and an increasing priority to ensure individuals are active

partners in their own care.

Appendix 5


Strategic engagement is another type of engagement which involves ensuring partner

organisations, potential co-deliverers of any service or pathway, any monitoring bodies

and key local influencers are kept informed and involved with clinical commissioning as

appropriate. Communication is an essential pre-cursor to high quality engagement activity.

It embraces a range of activities from giving information and raising awareness to

promoting services, media management, marketing communications and campaign

management and generating a positive public image. Both strategic engagement and

communications are out with the scope of this plan.

Benefits of good patient and public engagement:

There are many short and long term gains to be obtained from identifying and addressing

engagement needs including the development of:

Insights into positive and negative aspects of existing services

Understanding of who is key to the CCG Board’s success

Informed and empowered service users

Greater community awareness of the CCG and local commissioning process

More use of choice and greater involvement in own care

More people using services

More satisfied patients from better experience of service

Positive public image for service

Higher quality health services

Healthier communities.

Legislation and policy drivers:

In addition to the benefits highlighted above, there are several statutory requirements

surrounding patient, carer and public engagement which mean that not involving local

people is not an option. The legislation listed below mandates all NHS organisations to

involve patients in the planning and provision of services and any proposals for service

change. It includes obligations to consult Overview and Scrutiny Committees and work

with Local Involvement Networks

Section 242 of the NHS Act 2006

Section 244 of the NHS Act 2006

The Local Government and Public Involvement in Health Act 2007

NHS Constitution.

Appendix 5


The draft Health Bill 2011 reinforces these legislative requirements and requires GP

Commissioning Consortia to seek outcomes which deliver a positive patient experience.

Furthermore, the Revision to the Operating Framework for the NHS in England 2010/11

introduced four tests for all proposals for service reconfiguration which require all

reconfiguration proposals to demonstrate:

support from GP commissioners;

strengthened public and patient engagement;

clarity on the clinical evidence base; and

consistency with current and prospective patient choice.

Support for Clinical Engagement:

The NHS County Durham and Darlington involvement team can provide a range of advice,

knowledge and support to the CCG on the following:

legislation and policy around engagement and consultation

audience appropriate engagement methods and feedback mechanisms

development of engagement and consultation plans

impact assessment of engagement activity from an equality and diversity perspective

local demographics, facilities, service users and/or representative bodies

brokering links with local service user/representative groups

liaison with health overview and scrutiny committees and Local Involvement Networks

facilitating discussions to generate patient/public engagement ideas

links to communications colleagues, cascades and mechanisms

links to involvement colleagues to synchronise work and maximise shared resources

share sample engagement tools, templates and documents

Appendix 5


Darlington Clinical Commissioning Group Localised Engagement Action Plan 2011/12

Objectives Actions Methods of Delivery Responsibility Timescale

Enable patients,

carers and the

public to

influence

commissioning.

Review and further develop systems

for ensuring patient and public

involvement within the CCG

structure.

Practice representative groups

(PRG) to be set up in line with

DES and a patient

representative to be identified

and represent each practice on

the Darlington Commissioning

PRG.

Involvement Officer /

Practice Manager

March 2012

Develop process to ensure patients

and the public are involved in all

stages of the commissioning

process including:

Patient and public involvement in

setting/agreeing commissioning

priorities on annual basis.

Service users included in the

planning, review, design,

development and de-

commissioning of services.

Future commissioning intentions

set with input from PRG locality

group.

Dedicated engagement activity

with patients/carers per pathway

to:

Identify strengths/weakness with

Clinical Commissioning

Project lead,

Involvement Officer,

Performance &

Intelligence Team,

Project lead

Annual

Implemented

Ongoing

Appendix 5


Service users involved in service

procurement.

current pathway and suggest

improvements

Patient Rep to be identified

from the PRG to participate in

relevant steering groups

To gain wider service user

experience, engagement

activities such as focus

groups/questionnaires/

interviews / workshops

Understand existing service

user/staff experiences.

Existing data – engagement,

performance and intelligence,

PALS, complaints incidents

Patient experience survey

feedback from providers.

3rd Sector organisations

involvement where

appropriate. e.g. Age UK,

LINk etc.

Service users to be on

procurement panel and

engagement criteria / patient

To be

implemented

as required

Appendix 5


Service users involved in ongoing

evaluation of services’

effectiveness

Develop Board standards for patient

and public involvement, against

which projects can be assessed.

experience to be part of the

procurement process.

Patient feedback to be

embedded in all new service

contracts

PPE Project outline form, to be

completed for all new projects

(pages 1-4). Projects requiring

consultation will need the full

plan completing

Project lead / clinician

with support from

Involvement Officer

To be

implemented

as required

To be

implemented

as required

Appointment of one patient

representative on CCG Board until

guidance is received on

appointment of lay members

To be agreed

CCG Chair, Involvement

Officer

To be

implemented

Develop individual involvement and

consultation plans for service /

pathway developments and

changes, including potential

decommissioning of services.

Follow statutory guidance

including involvement of

relevant OSC.

CCG/Locality Board with

support from comms

and involvement team.

Project leads

Ongoing

Appendix 5


Patient and Public Engagement

evidence log already being

completed for each pathway

development

Implemented

Develop and use core patient

experience outcome measures in

service specifications

Patient questionnaire included in

service specifications.

Consider PALS/Complaints

trends.

Project lead,

Involvement Officer,

Implemented

Implement a model for involving key

stakeholders in the work of

Darlington CCG.

Stakeholder group to be

established with regular

meetings

Project lead,

Involvement Officer

To be

implemented

Utilise existing practice-based

engagement mechanisms to support

the work of Darlington CCG linking

with DBC.

Work with DBC, 3rd sector

stakeholders utilising the PCT

database and practice patient

reference groups.

CCG Chair, Involvement

Officer

Implemented

Appendix 5


Develop an

understanding of

patient and

public

involvement,

including legal

and policy

requirements and

involvement

methodologies

Board members and any key

practice leads as identified by the

Board to undertake training in

involvement, including legislation

and policy and methods of

involvement and a level of

understanding of Overview and

Scrutiny.

Training to be delivered through

the PCT Involvement Team and

DBC.

Involvement Officer

March 2012

Share, promote and use relevant

sections of involvement toolkit

developed by NHS County Durham

and Darlington Involvement Team

Available via PCT website,

Involvement Team and intranet.

Comms and

Involvement Team

To be

implemented

Board members and any key

practice leads to gain an awareness

of Health and Wellbeing Boards and

future HealthWatch, including

mechanisms for engaging with

these organisations.

Direct communication with

LINks and emerging

HealthWatch, supported by

publications and briefings.

CCG Board

Comms and

Involvement Team

Ongoing

Appendix 5


Manage

relationships with

all key

stakeholders to

support robust

engagement and

involvement.

Map key stakeholders and

engagement mechanisms including,

Overview and Scrutiny functions

(and future Health and Wellbeing

Board), LINks (and any future

HealthWatch organisation), patient

groups, key public representatives

and the voluntary / community

sector:

Stakeholder map developed Support from:


Project Lead/

Involvement Officer

Implemented

– to be

reviewed on

a regular

basis

Consolidate and refresh knowledge

about local demographics to identify

potential target audiences for

engagement activity, including

seldom heard groups such as rural

communities, mental health service

users and carers and people of a

black, minority or ethnic origin etc.

Use Health Profiles and JSNA Comms and

Involvement Team,

Public Health

Implemented

– to be

reviewed

regularly

Appendix 5


Identify, understand and/or develop

a consistent process for working

with Darlington Borough Council,

Scrutiny and LINKs/or any evolving

Health and Wellbeing Board/

HealthWatch organisations.

Utilise existing processes and

mechanisms via PCT Comms &

Involvement.

Encourage a patient

representative to be a co-opted

member on the Overview and

Scrutiny Committee.

Encourage a CCG PRG

member to also a member on

the Darlington LINk.

Involvement and

Scrutiny Manager

CCG Board

Implemented

To be

implemented

Produce an annual consultation

report in line with legislative

requirements

To be included in annual report

Comms Team

CCG Board

Annually

Develop and agree communications

plan

Communications plan to be

developed to support the

engagement plan

Comms Team To be

implemented

Consider the establishment of

regular annual stakeholder

engagement events

Hold annual stakeholder events

(AGM)

CCG Board, Clinical

Commissioning Project

Lead/

Involvement Officer

DBC

March 2012

Appendix 5


Develop

processes to

proactively seek

patient

experience data,

and to ensure

this is used to

shape services.

Implement processes to ensure a

range of patient experience data is

collected, triangulated and informs

the review and improvement of local

services.

Patient feedback to be

embedded within new service

contracts to gain ongoing patient

experience through liaising with

the Involvement Team.


Project Lead,

Contracting Team,

Involvement Officer

Implemented

when

required

Ensure patients

are actively

involved in their

own care

Promote greater patient involvement

in own health care, including choice,

direct payments, personalised care

plans and access agendas.

Monitor and evaluate services’

performance against patient

involvement standards.

CCG Board to gain an

understanding of how patients

can influence their own

personalisation budget.

Performance mechanisms in

place.

Darlington CCG

Support from:


Project Lead,

Involvement Officer

Contracting team

To be

developed

Implemented

Appendix 6


Appendix 6 –

Medium Term Financial Strategy

2011/12 - 2016/17

Introduction

As commissioners of health and healthcare for Darlington we are working towards

delivering excellence today for a healthier tomorrow.

2011/12 has marked the continued development and progression of a significant

modernisation of the NHS in the shape of the Government’s Health and Social Care Bill,

which together with the current challenging economic environment and impact of the

Government Spending Review, will ensure the coming years remain challenging.

We will continue to manage these challenges and invest our funding to ensure quality,

promote innovation, maximise efficiency and maintain a focus on prevention, whilst also

evolving and developing as a separate commissioning organisation.

All of this must be delivered within available resources and our robust financial planning

process supports the delivery of recurring financial balance, providing a firm financial

foundation upon which to progress our strategic objectives.

Our Clear and Credible Plan (CCP) is under-pinned by a comprehensive medium term

financial strategy (MTFS), which is a key element of the framework setting out our

ambition for the future and enabling an effective transition to the new system of clinical led

commissioning. The MTFS is a financial expression of the CCG's strategic plan and is

fully integrated with the CCP.

The MTFS is supported by a comprehensive governance infrastructure including Standing

Orders, Standing Financial Instructions and a Scheme of Delegation that clearly identifies

budget responsibility. It has been developed from a shared understanding of staff from all

disciplines and across all functional groups. It will be communicated to all staff and partner

organisations.

Appendix 6


Background

Purpose

The MTFS is intended to describe the CCG’s financial intentions and so support

commissioner led provider development across the County Durham and Darlington health

economy.

The MTFS will facilitate effective financial planning and help to provide a robust financial

position to support the transition to clinical led commissioning.

In addition the MTFS provides assurance to the CCG sub-committee and to the PCT

Board that:

commissioning intentions and service plans described in the CCP are both realistic,

achievable and affordable;

value for money will be delivered over the medium term timescale as well as the short

term;

expenditure will be contained within available resources to deliver a position of recurring

financial balance.

The MTFS has been updated to reflect the 2012/13 Operating Framework and revised

resource and expenditure assumptions. The key changes relate to the impact of the new

Spending Review period and the modernisation of the NHS detailed in the Government’s

Health and Social Care Bill.

Strategic objective

The objective is to achieve recurring financial balance whilst delivering our CCP.

Key financial intentions

The key intentions underpinning our financial planning are as follows:

Achievement of recurrent balance in each of the years covered by the CCP with all

recurrent and non-recurrent resources and expenditure separately identified to minimise

the danger of developing unaffordable strategies where non-recurrent resources mask

recurrent deficits.

Available financial resources will be allocated over the five year timeframe of the CCP to

enable effective management of developments and resources

Appendix 6


All services commissioned by Darlington CCG will be undertaken within a clear financial

framework. Service plans will link performance targets that include clearly defined

outputs, outcomes and efficiencies to the required investment. They will identify

associated risks and have exit plans prepared should performance deviate

irreconcilably from target.

Any assets held by the CCG will be reviewed annually in order to ensure the best use of

resources and achievement of clear, agreed service improvements.

Recognising the service development pressures facing the NHS and finite funding

available through the allocation process we will actively seek all appropriate external

funding and explore all opportunities to make efficiency savings with local partners and

national agencies to ensure value for money in the medium as well as the short term.

Management of financial risk by maintaining a contingency amounting to 2% of

recurrent revenue funding which will be deployed non-recurrently to support change and

innovation.

We will engage with local organisations across sectors to ensure that the healthcare

market is well placed to deliver the best healthcare and to manage the financial risks to

the health economy collaboratively.

Appendix 6


Financial situation

Financial history

Although the CCG is a newly emerging organisation with little direct financial history, we

are developing from a financially successful organisation in Darlington PCT, utilising the

relevant experience and knowledge which has brought financial stability and a sound track

record of delivery of statutory duties and financial targets.

The achievements of the PCT in respect of revenue resource can be seen below, with the

PCT also meeting capital and cash limit targets. PCTs are assessed on these targets

whilst still needing to achieve the operational targets set out elsewhere in this document.

Historical financial performance

Financial Year Darlington PCT

2006/07 All limits met

Revenue under-spend: £56k








Revenue under-spend of £315k

2011/12 Forecast revenue under-spend

of £300k

Appendix 6


Delivery of revenue, capital and cash limits

The PCT has a history of good financial performance which has enabled them to continue

to forecast delivery of financial balance and to remain within revenue, capital and cash

limits. This knowledge and experience will be an essential component of the effective

financial planning and management developed by the CCG.

Financial pressures have emerged in-year in acute healthcare in particular, continuing

healthcare and prescribing, which are being directly managed by the CCG. Continued

strong financial management and contract management will be required to ensure that

these pressures are managed within revenue, capital and cash limits without adverse

impact on operational performance targets.

Financial trends

Darlington PCT has received confirmation of growth levels in its allocations for 2012/13.

Modelling work has been undertaken to estimate the funding required for inflation, and

identify the resources available for investment, both on a recurring and non-recurring

basis.

Recurrent baseline and growth

The new funding available (growth) for Darlington PCT is shown in the table below:

Darlington PCT 2012/13

PCT growth excluding additional reablement funding £4.9m (2.8%)

PCT share of additional £150m reablement funding £0.3m

Total PCT Growth £5.2m (3.0%)

As a result of this growth funding, total current revenue allocations for Darlington PCT are

shown below. This includes recurring revenue allocations and non-recurring allocations

confirmed to date.

Darlington PCT 2012/13

Total recurring revenue allocation £179.3m

Non-recurring revenue allocations confirmed to date £10.1m

Total revenue allocations £189.3m

Appendix 6


Transition to fair shares budget and distance from target allocation

The Department of Health currently allocates funding directly to PCTs on the basis of the

relative needs of their populations. A weighted capitation formula determines each PCT’s

target share of available resources, its target allocation, to enable them to commission

similar levels of health services for populations in similar need, and to reduce avoidable

health inequalities. Depending on how their current funding position then compares to

their target allocation, PCTs receive growth in line with the pace of change policy.

The fair share formula is currently being reviewed by the Department of Health, and the

impact of any revision to the current formula will impact upon the financial resources

available to the CCG. Until CCG allocations are published at the end of the calendar year

2012 the potential impact of this remains unknown.

Appendix 6


Financial Strategy and Context

The scale of the financial challenge we face in the future is great. Every year we face

additional pressure on the funding we receive due to inflation, demographic changes of an

ageing and growing population and the cost of innovative new technologies and drug

advancements. In recent years we have received unprecedented levels of new money

that have enabled us to fund growth in our health services to deal with these pressures.

This level of new money into the system is not expected to continue into the future.

This means that we need to drive high levels of efficiency out of the current system in

order to maintain a stable and high performing health service that can meet the growing

needs of the population.

On top of this, if we are to continue to invest in additional new services, especially in our

priority areas, we will need to fund them through disinvestment from services that are

addressing a lower priority to us and by de-commissioning services that are performing

poorly.

In addition, we are currently facing one of the most significant changes to the NHS in its

history and trying to develop as a separate organisation in order to assume full

responsibility for commissioning healthcare for our population.

Incorporated within the CCP is a comprehensive financial strategy underpinned by detailed

financial models which allow dynamic scenario modelling and risk assessment, essential in

this current transition period for healthcare commissioning.

The financial planning assumptions which support the CCP have been driven by a range

of issues, the most important of which are set out below:

Government Spending Review

Despite the UK economic downturn, the outcome of the Spending Review represents a

relatively favourable financial settlement for the NHS and we are now planning on a small

element of real term growth from 2012/13. This supports all the information available at

the current time and is in line with the PCT allocations already confirmed for 2012/13.

Move to Fair Share Financial Allocation

Financial allocations have been set using the existing funding formula, and no estimate of

the impact of any revision to this formula has been included.

Appendix 6


Impact of tariff changes

The 2012/13 Operating Framework set out a number of changes to the tariff pricing

framework including significant national efficiency requirements.

Implementation of Equity and excellence: Liberating the NHS

The impact of the modernisation of the NHS set out in ‘Equity and Excellence: Liberating

the NHS’ has been recognised in our financial planning where possible, including the

integration of social care with local authorities and support required to develop the CCG.

Implications of the QIPP initiative on the local health economy

The QIPP initiative has been developed to help with the management of the likely financial

pressures to be experienced from 2011/12 and the need to generate significant

efficiencies. QIPP is fully integrated into the CCP and the financial impact has been

incorporated into our financial models.

Current year activity pressures

In year information on material activity pressures have been reflected in the revised plan,

particularly in respect of the acute secondary care sector and continuing healthcare.

Taken together these changes will substantially reduce the scope for new investment

during the current financial planning period. It is expected that the QIPP initiatives will

generate significant efficiencies over the planning period, through innovation, tariff

changes and service redesign, which can be used to fund additional strategic investments

and cost pressures arising from demographic changes, for example. Demand led cost

pressures will need to be robustly managed for this methodology to be successful and to

ensure that the increased activity levels experienced in the current year do not absorb a

significant element of the expected efficiency savings.

The financial plan considers how the total resources of the CCG may be deployed. In

addition, it focuses in some detail on the impact of potential changes in activity, price/cost

inflation as well as on priority areas for new investment.

The financial plan makes provision for investment in the initiatives set out in our CCP to

support delivery of our strategic aims. The current investments within the financial plan

have been determined following a process of review and prioritisation based upon a

combination of updated population needs assessments and national and local targets.

Appendix 6


The combined impact of the performance savings and investment in our priorities is

expected to result in a reduction in the relative level of expenditure on hospital based

activity and an increase for community and primary care based services.

Regular review of investments against criteria used in the investment planning process will

be undertaken and will help to inform the disinvestment process.

Appendix 6


Financial Planning and Modelling

The financial models developed by the CCG ensure we can provide swift financial

information on the impact of changing health needs, revised economic planning

assumptions and evolving environmental and political factors.

In addition to the ongoing scenario modelling, which will be continually reviewed and

refreshed throughout the planning period, the financial model will be formally reviewed and

updated on at least an annual basis or more frequently when issues with a significant

financial impact become apparent.

Our financial planning is also supplemented by a suite of Financial Management and

Governance Policy documents including the Cash Management Policy, Standing Financial

Instructions, Standing Orders, Financial Limits and a comprehensive scheme of

delegation.

The detailed financial model itself takes the form of a set of interdependent spreadsheets.

Based on the input of basic funding and expenditure information, predicted activity and

inflationary and growth assumptions, the spreadsheets produce operating cost statements

and balance sheets covering a range of scenarios.

The financial model incorporates expected future developments and the related resource

implications through the inflationary and growth assumptions applied, as well as additional

investment included in respect of the initiatives highlighted in our strategy. The impact of

any other potential developments and risks are assessed via scenario planning and

sensitivity analysis.

Key assumptions

In preparing the financial models which support the CCP, we have utilised planning

assumptions developed regionally.

For 2012/13 figures are based on the NHS Operating Frameworks published in December

2011. For 2013/14 to 2016/17, assumptions have been determined for three different

scenarios which incorporate potential differences in the level of tariff uplift to be agreed

nationally, together with the level of funding allocation received from the Department of

Health. The key assumptions applied across three scenarios are as follows:

Area Scenario Assumption

12/13

(estimated)

13/14

(estimated)

14/15 - 16/17

(estimated)

Downside scenario UPLIFT 3.0% 2.0% 0.0%

Base Case scenario UPLIFT 3.0% 2.1% 2.1%

Upside scenario UPLIFT 3.0% 2.5% 2.5%

Commissioning Allocation

Appendix 6


The main non-financial demographic assumptions included within the plan are set out

below. These demographic assumptions have been generated with reference to historical

demographic increases observed in previous years, utilising the work on the refreshed

JSNAs and reviewed for consistency regionally.

Area Scenario Assumption 2012/13 2013/14

2014/15 -

2016/17

INFLATION 2.2% 3.0% 3.0%

EFFICIENCY -4.0% -4.0% -4.0%

CQUIN 1.0% 1.0% 1.0%

NET -0.8% 0.0% 0.0%

INFLATION 2.2% 3.0% 3.0%

EFFICIENCY -4.0% -4.0% -4.0%

CQUIN 1.0% 0.5% 0.5%

NET -0.8% -0.5% -0.5%

INFLATION 2.2% 2.0% 2.0%

EFFICIENCY -4.0% -4.0% -4.0%

CQUIN 1.0% 0.5% 0.5%

NET -0.8% -1.5% -1.5%

INFLATION 4.5% 4.5% 4.5%

EFFICIENCY -3.5% -3.5% -3.5%

NET 1.0% 1.0% 1.0%

INFLATION 4.5% 4.5% 4.5%

EFFICIENCY -4.0% -4.0% -4.0%

NET 0.5% 0.5% 0.5%

INFLATION 4.5% 4.0% 4.0%

EFFICIENCY -4.0% -4.0% -4.0%

NET 0.5% 0.0% 0.0%

INFLATION 5.0% 5.0% 5.0%

EFFICIENCY -3.0% -3.0% -3.0%

NET 2.0% 2.0% 2.0%

INFLATION 5.0% 5.0% 5.0%

EFFICIENCY -4.0% -4.0% -4.0%

NET 1.0% 1.0% 1.0%

INFLATION 4.0% 3.5% 3.5%

EFFICIENCY -4.0% -3.5% -3.5%

NET 0.0% 0.0% 0.0%

INFLATION 4.0% 4.5% 4.5%

EFFICIENCY -4.0% -4.0% -4.0%

NET 0.0% 0.5% 0.5%

INFLATION 4.0% 4.0% 4.0%

EFFICIENCY -4.0% -4.0% -4.0%

NET 0.0% 0.0% 0.0%

INFLATION 4.0% 3.5% 3.5%

EFFICIENCY -4.0% -4.0% -4.0%

NET 0.0% -0.5% -0.5%

Downside scenario

Base Case scenario

PRESCRIBING

Downside scenario

Base Case scenario

Upside scenario

OTHER / LA

Upside scenario

Base Case scenario

Upside scenario

TARIFF (also applied to non-

tariff, MH, community service,

specialised services etc)

Downside scenario

Base Case scenario

Upside scenario

PRIMARY CARE

Downside scenario

Appendix 6


DEMOGRAPHIC ASSUMPTIONS

2012/13 - 2016/17

DOWNSIDE

SCENARIO

BASE

CASE

UPSIDE

SCENARIO

% % %

Acute 2.7% 2.0% 1.5%

Mental Health 2.5% 2.0% 1.5%

Prescribing 2.0% 2.0% 2.0%

Primary Care 1.5% 1.0% 0.7%

Community services 3.0% 2.5% 1.5%

CHC 4.0% 3.0% 2.0%

Specialised commissioning 2.5% 2.0% 1.5%

A key non-financial assumption is that there will be no increases in elective referrals and

emergency admissions to secondary care other than those driven by the assumed

demographic changes above. The model, however, does build in the recurrent impact of

forecast out-turn activity for 2011/12. Where known we have included specific changes in

demand, for example in respect of specialised services.

Base Case Scenario

The Base Case Scenario describes the expected financial position in which the Clear and

Credible Plan will be delivered based on analysis of past contracting, activity and budget

performance and planning assumptions on expected levels of income. In the Base Case

Scenario, we will contract for a fair and realistic level of acute activity across the range of

providers. This increased level of activity reflects changes in levels of service usage driven

by referral patterns, changes in service models agreed between commissioner and

provider and the impact of demography (i.e. an ageing, growing population).

Appendix 6


Downside Case Scenario

The Downside Case Scenario describes a financial position in which the Clear and

Credible Plan will be delivered where a lower level of income is assumed and/or

contract/budget performance is higher than forecast then at the outset of the plan.

This Downside Scenario has meant that:

commissioning initiatives have been further prioritised and targeted to remain affordable

within the smaller funding envelope

greater focus has been placed on managing demand and activity to minimise risk

more management capacity directed to the release of efficiency over commissioning for

longer term health gain

Upside Case Scenario

The Upside Case Scenario describes a financial position in which the Clear and Credible

Plan will be delivered where either a higher level of income has been assumed and/or

contract/budget performance has come in under-forecast than at the outset of the plan.

This Upside Case Scenario has meant that:

commissioning initiatives have been widened or extended to deliver greater

improvements

greater focus has been placed on the re-investment of funding to deliver the CCG’s

strategic priorities or improved health outcomes and care closer to home

Appendix 6


Income and expenditure

Revenue resources

An extract from the financial model showing income and expenditure forecasts for 2011/12

to 2016/17 under the most likely ‘base case’ scenario is included for the CCG below.

The financial model has been built using several key assumptions as listed below:

Starting point is forecast financial outturn for 2011/12 as at 31 January 2012

Estimated investments for 2012/13 have been included

Estimated reductions for public health transfers to the Local Authority and Public Health

England have been included.

Estimated reductions for specialised services transfers to the NHS Commissioning

Board have been included.

It should be noted that these assumptions will be revisited during the planned updates of

the financial model during the financial year 2012/13 as shown in the timeline below:

Baseline Budget

adopted by CCG

(March 2012)

Estimated

Investments

included for CCP

(April 2012)

Refresh using

11/12 full year

activity

(June 2012)

Refresh using

confirmed CCG

Allocations

(December

2012)

Darlington Clinical Commissioning Group (CCG) Financial Summary

Recurring

Outturn

FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 FY 2016/17

£'000 £'000 £'000 £'000 £'000 £'000

COMMISSIONING BUDGETS:

Acute Services 76,557 76,391 77,537 78,700 79,880 81,078

Mental Health / Learning Disability Services 14,788 15,150 15,377 15,608 15,842 16,079

Community / Primary Care Services 13,622 15,571 15,882 16,200 16,524 16,854

Continuing Healthcare / Funded Nursing Care 8,649 8,943 9,122 9,304 9,490 9,680

Childrens Services 353 629 641 654 667 681

Prescribing 17,118 17,157 17,671 18,201 18,747 19,310

TOTAL COMMISSIONING BUDGETS 131,087 133,839 136,230 138,666 141,150 143,682

CORPORATE BUDGETS & RESERVES:

Management & Organisation 158 158 2,844 2,844 2,844 2,844

TOTAL CORPORATE BUDGETS & RESERVES 158 158 2,844 2,844 2,844 2,844

TOTAL CCG BUDGETS 131,245 133,997 139,074 141,510 143,994 146,526

Forecast period

Appendix 6


Scenario Planning

There are a significant number of up and downside risks to the assumptions included in

the plan and, as a consequence, work has been performed to review the impact of

different scenarios, a process which continues as new information comes to light.

As one of our key goals is sustainable financial health, the ability to flex the financial plan

to take account of new and as yet unforeseen requirements and opportunities, whilst

remaining in recurrent balance, is very important. Our in-year contingency reserve is just

one element of our approach to risk management. Another is our approach to investment

planning which has proven to be successful within the PCT in previous years in effectively

managing the planning process without exposing the organisation to excess financial risk.

A third is the flexing of the timing and scope of implementation of some of the initiatives

identified in line with the QIPP agenda, and increasing the pace of service

redesign/innovation to secure a more cost effective delivery of services to patients.

In terms of upside risks (or opportunities), we have been very prudent in our assumptions

around securing new income from sources other than the general allocation from the

Department of Health. It may also be possible to bring forward the profile for delivery of

certain efficiency savings within the QIPP programme. Both could result in the ability to

accelerate our healthcare investment programme.

On the downside, our assumptions around limiting the growth in hospital activity may

prove too optimistic, and future national decisions on tariff uplifts and pay increases could

add further cost pressures. Whilst this could be addressed using general contingency

reserves, investment profiles will need to be kept under continuous review and the drive to

secure best value for money in all areas of operations must be relentless.

As highlighted above, assumptions have been developed regionally for three different

scenarios, each with different financial and non-financial assumptions around the level of

the tariff uplift, allocation of funding and demographic growth.

Appendix 6


Risks & Opportunities

Significant activity pressures continue to be seen in certain key areas, including in

particular the acute sector, prescribing and continuing health care which cause potential a

financial risk and this pressure has been recognised in our financial planning. There are a

number of other risks to the CCG’s financial plans which are incrementally compounded

through each additional year of the plans. These risks could either release or reduce

resource availability and the potential impacts have been modelled through the MTFS as

far as possible. These include, but are not limited to:

Impact of transition to fair shares budgets for the CCG and constituent GP practices;

Detailed PbR guidance develops each year and will undoubtedly change over the term

of the plans;

Contracts (along with relevant performance indicators) have yet to be agreed with

provider organisations;

Expectation driven demand which may increase as waiting times are driven lower along

with costs and benefits associated with clinical and technological advances;

Assumed receipt of allocations which have yet to be confirmed;

Non-delivery of saving plans and QIPP initiatives;

Increased exposure of the organisation, due to its reduced scale in comparison to the

existing PCT, to fluctuations in demand particularly in respect of areas of relatively high

cost per individual case.

These risks will continue to be actively monitored and managed to reduce the potential

financial impact. The crystallisation of risks and opportunities would need to be viewed in

light of the overall position of the CCG. In broad terms the CCG’s financial strategy

requires the maintenance of certain contingency reserves and allows for acceleration of

future years investments. Ongoing in-year review of the financial strategy and financial

performance will allow aims to be achieved, including delivery of financial targets.

Whilst there are a number of generalised risks to the CCG’s MTFS, some of which are

highlighted above, the main risks revolve around the accuracy of the planning assumptions

used throughout the plans. A prudent approach has been applied in developing those

planning assumptions which should minimise any risks arising and in financial terms there

are some other potential opportunities and ways to mitigate these risks which include:

Potential ability to access 2% headroom on a non-recurrent basis;

Unplanned gain from additional investment into social care for example;

Financial gain from embedding more stringent business rules into contracts;

Potential financial gain from performance penalties and underperformance against

CQUIN;

The negotiation of marginal rates and price discounts.

Appendix 6


Cost Drivers

Our financial plan and the level of investment required is impacted by a range of cost

drivers and the approach to the forecasting of costs is determined by our ability to

influence and control those costs.

Factors influencing the future position can be categorised into those that are external

(driven by factors external to the CCG) and internal (those within the CCG’s decision

making ability).

Applying the well-recognised PESTEL (Political, Economic, Sociological, Technological,

Legal/regulatory) methodology the following cost driver headings are identified:

External cost drivers:

o Economic, legal, regulatory and national policy

o Demographic, technological and environmental

Internal cost drivers:

o Efficiency/savings programme

o Investment programme

Economic, legal, regulatory and national policy drivers include:

Equity and excellence: Liberating the NHS – the impact of transition to the new health

and social care system with clinical led commissioning.

Growth uplift - the annual growth increase in the CCG resource limit which is influenced

by weighted capitation targets intended to ensure an equitable distribution of funding

Tariff uplift/efficiency – the annual uplift/efficiency for healthcare providers operating

under Payments by Results (PbR) which reflects the impact of inflation, service quality

enhancements and efficiency improvements

Legal changes – an example is the impact of legislation upon health and social care

budgets of changing continuing healthcare eligibility criteria

National policy changes – this area includes the annual operating framework which sets

out policy initiatives and health targets which could impact upon CCG budgets.

Appendix 6


Demographic, technological and environmental drivers include:

Population growth – estimated changes in total population numbers

Population mix – demographic changes in terms of age, gender, ethnicity within the

overall population

Deprivation – the impact of deprivation within communities compromising the total

population

New technologies and drugs – the effect of technological change within the NHS

Impact of patient choice and expectations – the financial impact of increasing patient

expectations in respect of access to and quality of healthcare

The key internal cost drivers include:

Efficiency/savings programme – within the financial plan are both national and local

expectations in respect of efficiency gains to be delivered over the period covered by

the MTFS.

Investment programme –we have a framework for developing investment proposals

which, although demonstrating value for money, do impact upon our financial position.

Where we have a significant degree of control over costs, financial forecasting is largely

based on activity forecasts and predictive planning of cost drivers.

Where we have limited indirect control or no control over costs, benchmarking such as

programme budgeting and some trend analysis is performed, along with additional

scenario planning and sensitivity analysis.

Appendix 6


Investments and support for the Commissioning Intentions

As set out above, significant new recurring funding is available (growth) for Darlington PCT

in 2012/13.

The table below sets out in broad terms the application of funds at a total PCT level:

Summary showing deployment of additional revenue resources available in 2012/13

Darlington PCT

£000

Source of funds:

Increase in recurring revenue resource limit 5,181

Other non-recurrent allocation adjustments (55)

Resource committed on non-recurring basis in 2011/12

(including 2% contingency)

3,923

Efficiency savings on tariff contracts, non-tariff contracts and

prescribing

7,345

Other QIPP efficiency savings 2,167

18,561

Application of funds:

Tariff / inflationary uplifts 5,756

CQUIN 2,866

Application of 2% allocation on non-recurring basis 3,585

Additional investment to fund demographic growth, national

priorities and ISOP strategic initiatives

6,354

18,561

The allocation of revenue resources set out above delivers a balanced budget in 2012/13.

Appendix 6


The financial plan makes provision over the course of the planning period for investment in

the initiatives set out in our strategy and commissioning intentions to support delivery of

our strategic aims. It is, however, important to note that not all initiatives will require

additional resources, as some are as much about changing the way services are delivered

and the way we work with strategic partners and local communities.

Our aim is to have a transparent and accountable process for prioritisation of investment

which will allow our partners, including provider organisations and local patients and the

public, to have a clear understanding of our priorities and direction of travel.

The current investments within the financial plan have been determined following a

process of review and prioritisation based upon a combination of updated population

needs assessments and national and local targets. The risks related to the proposed

investments are taken into account as well as the wider impact to the health system as a

whole. The final decisions on investments over the next few years will be defined and

agreed following our well-established business and investment planning processes,

including the determination of exit strategies as required.

Internal processes that are now embedded produce and review business cases to ensure

investment decisions are based upon achievement of required clinical outcomes, value for

money and sustainability. The process allows for both clear financial information and

robust challenge at different levels throughout the organisation. Regular review of

investments against criteria used in the investment planning process will be undertaken

and will help to inform the disinvestment process.

Further use of benchmarking and comparative performance information is fundamental to

our approach. Programme budgeting information linked to public health outcome

measures is being used to monitor progress and outcomes from investment as well as to

inform financial investment and disinvestment strategies. While the absolute data is not

robust at this stage, it is anticipated that this will improve over the financial planning cycle

and will facilitate improved healthcare investment decision making.

Careful financial planning and strong financial management and forecasting over the

planning period will allow us to remain on a sound financial footing and therefore to deliver

our strategic aims.

Investment priorities and commissioning intentions will continue to develop over the next

12-18 months as the transition to the new health and social care systems continues and

the CCG begins to take increased responsibility for healthcare commissioning decisions.

Appendix 6


In line with the requirements of the Operating Framework, the PCTs will continue to set

aside 2% of recurring baselines to be invested on a non-recurring basis.

In 2011/12 this contingency allowed the PCTs to manage in year pressures without

compromising service delivery or financial balance. To ensure flexibility of the contingency

reserve, commitments against it have been non-recurrent, thus ensuring the reserve

remains uncommitted from 2011/12 and available for investment by the PCT cluster,

allowing support to be provided for non-recurring transition costs and to develop pilot

schemes designed to support delivery of QIPP initiatives and allow redesign of services

where necessary.

Appendix 6


Cash management and other financial policies

The management of revenue and capital resources cannot be undertaken in isolation.

There is a clear relationship between the cash limit, resource allocations and income and

expenditure levels. All three elements must be planned and managed through both the

short and the medium term. To facilitate this there is a separate cash management

strategy that highlights the cash management arrangements within the financial services

team to ensure robust and accurate cash management.

The cash management strategy focuses on minimising month end cash balances and

ensuring that the PCT, and in due course the CCG, meet their year-end cash target. All

actions to achieve this will be in accordance with the rules in cash management laid down

by the Department of Health and will avoid any excess interest charges.

In addition the delivery of the MTFS will need to be underpinned by effective and robust

financial management procedures. This will help ensure awareness of the financial

position, both recurrent and non-recurrent, and facilitate improved financial planning by

investment planning, commissioning and performance, public health and finance teams.

The financial governance framework will be kept under review to ensure that it remains fit

for purpose and well suited to the environment in which we operate.

Conclusion

The economic and financial environment remains uncertain and significant challenges are

expected in the coming years, however the MTFS provides assurance that a balanced

financial position will be maintained whilst delivering on our strategic objectives, providing

a stable financial foundation to enable an effective transition from PCTs to clinical

commissioning groups.

The uncertain economic environment means that there are many assumptions and

potential risks attached to this strategy which will require continuing management and

review looking a number of years ahead and refreshing of the strategy as necessary.

In the NHS there is an underlying duty of care to ensure that public funds are spent on the

purposes for which they were intended and that good value for money is sought. This

MTFS supports that duty of care by providing a robust financial planning framework to

support the clear and credible plan of the CCG.

Appendix 7


Appendix 7 - Governance

CCP and ISOP

The Integrated Strategic and Operational Plan for NHS County Durham and Darlington

2011/12 - 2014/15 outlined the strategic direction for the cluster both in terms of

operational activities and transition to the new commissioning landscape.

Our clear and credible plan is the next phase in the establishment of this new landscape

whilst exploiting the opportunities of clinical leadership and improved clinical engagement

in the commissioning of services reflecting the needs of Darlington population.

The main themes of the CDD Cluster ISOP are:

1) The delivery of improved services for patients across the full range of programme

areas

2) Ensuring that gains made in previous years in terms of improvements in health

outcomes are protected

3) Ensuring that the delivery or operations and management of the local system was

carried out within a balanced commissioning budget

4) That commissioners would safeguard the stability of the provider landscape within

the health economy for the lifetime of the plan

5) That transition to the new world would be carried out quickly, effectively and safely

with no impact on services that patients use.

Our clear and credible plan is consistent with these ISOP themes and covers a three year

period, 2012/13 – 2014/15 and therefore runs concurrently with the remaining lifespan of

the cluster ISOP.

Appendix 8


Appendix 8 – Full Risk Assessment

The CCG has used a standard risk scoring process that measures the likelihood and

severity of each risk and combines them to create a compound risk score. The scoring

system works as follows:

Likelihood

1 = Rare

2 = Unlikely

3 = Possible

4 = Likely 5 = Almost certain

Sev

eri

ty

5 Catastrophic 5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

Once these initial risks have been assessed, mitigating actions are identified and the risk

is then re-assessed. This re-assessment measures the residual level of the risk in terms of

both likelihood and severity.

The overview of the risk domain can be found in figure 1 (strategic delivery risk), figure 2

(financial resilience risk) and figure 3 (organisational readiness risk).

Appendix 8


Domain Risk S L R Mitigation Res S Res L Res R

Str

ate

gic

De

live

ry

Insufficient clinical

leadership capacity

to support the plan

5 4 20 Current clinical

leadership capacity is

identified at CCG and

locality level. There is a

clinical lead identified

against each

commissioning initiative.

There is a clinical

leadership development

programme within the

OD plan to support

current leaders and

identify future emerging

leaders.

4 3 12

Lack of pathway

redesign, project,

procurement and

transformation skills

within the CCG or

commissioning

support organisation

to support the plan.

5 4 20 Organisational

development plan

identifies actions to

secure resources

through the NE CSU or

procure support on a

project by project basis

by 31/03/12

4 3 12

Failure to achieve

economies of

delivery through

joined up working

between localities.

4 4 16 CCG support structure

has been developed to

facilitate joined up

working. Governance

arrangements include

joint operation group,

finance and

performance and

strategy and

organisational

development.

4 3 12

Failure to establish

to right level of

commissioning

technical expertise

from the

commissioning

support organisation.

4 4 16 Commissioning support

arrangements are in

development in the

cluster and across the

NE working to a similar

trajectory as the CCG.

4 3 12

Appendix 8



Fin

an

cia

l R

esili

ence

Increases in elective

activity above

affordable level in-

year.

5 4 20 Clinically led review of

referral activity.

Monthly contract

performance meetings

with provider.

5 3 15

Increases in non-

elective activity

above affordable

level in-year.

5 5 25 Commissioning

initiatives in 2012/13

seek to put in place

alternatives to

emergency admissions.

Clinically led review of

referral activity.

Monthly contract review

meetings with provider.

5 3 15

Increases in

prescribing costs

above affordable

level in-year.

5 5 25 Procurement of

medicines management

support at practice and

CCG level.

5 3 15

Increases in

Continuing

Healthcare (CHC)

costs above

affordable level in-

year.

5 5 25 Share and pool risk

across CCGs in patch.

Review CHC policy and

process with other

CCGs and social care.

5 4 20

Impact of ageing and

growing population

and

technological/drug

advances driving

service and therefore

cost pressures

above affordable

levels over the life of

the plan.

5 4 20 Commissioning

initiatives aimed at

managing risk

4 4 16

CCG receives

allocation below

current base case

during the life of the

plan.

5 4 20 Clear investment and

operations plan outlined

within downside

scenario.

5 3 15

Appendix 8


CCG receives

allocation below

current levels in year

immediately after

plan following next

CSR

4 4 16 Review of

commissioning

initiatives and financial

plan in year

4 3 12

CCG commissioning

activities destabilise

wider health

economy / major

providers increasing

risk of reduced

quality/patient safety

levels

4 4 16 Discussing of initiatives

with providers to

understand supply side

risks and mitigate.

4 3 12

CCG too small to

effectively manage

risk

5 4 20 In discussion with other

CCGs to discuss risk

pooling and sharing and

plan to have

arrangements in place

by 31 March 2012

4 3 12

New tariffs for

Mental Health and

Ambulance Services

introduces more

financial risk to

commissioners

4 4 16 Continue to work with

provider and NHS North

to understand any

impact and mitigate

through an appropriate

contract

4 3 12

Failure to follow

recent Competition

Commissioning

ruling around

contracting activity

and principles for

subsequent contract

management

5 4 20 CCG through CSU

contracting team to

have detailed activity

plans in place for each

provider and to ensure

effective contract

management against

these.

4 3 12

Appendix 8



Org

an

isatio

na

l R

ead

iness

Failure to identify the

right organisational

development

priorities that will

support the SCGG at

the start and

throughout the

journey to becoming

a viable and effective

commissioner

5 4 20 Use of external support

and diagnostic tool to

assess and agree

priorities throughout the

transition process.

4 3 12

Establishing

unrealistic

timescales that don’t

recognise the scale

and depth of

organisational

development

required to develop

the capacity or the

skills needed to

assume

responsibility from

the PCT cluster

5 4 20 Greater involvement of

clinical leads and

locality groups in setting

timescales based on the

trajectory to be an

authorised statutory

body.

4 4 16

Not building effective

relationships either

internally with

member practices or

externally with our

main providers, the

local authority, NHS

commissioning

board and the local

community

4 4 16 An engagement

strategy and

implementation plan.

Allocated representative

from social care aligned

to the CCG,

representatives aligned

from mental health and

acute and community

services.

3 3 9

No effective and

robust governance

and performance

arrangements to

ensure the safe

stewardship of the

organisation

5 4 20 Draft constitution

developed. Governance

arrangements for

delegation of

commissioning budget

and process in place for

1 April 2012. Plan to

develop governance

5 3 15

Appendix 8


arrangements in place.

Not putting in place

and developing the

right leadership both

clinically and

managerially to

enable to

organisation to move

forward

5 4 20 OD plan identified a

range of agreed actions

to develop clinical

leadership, emerging

talent and put a CCG

management support

team in place.

5 3 15

Shortage of the right

skills and resources

to provide the

technical

commissioning and

corporate support,

whether directly

employed in the

CCG or undertaken

by the CSU or other

third party provider.

5 4 20 OD plan identifies

action to put in place

CCG management

support team and

requirements needed

from the commissioning

support organisation.

We know we need more

skills in transformation,

pathway design and

development and

procurement.

5 3 15

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DARLINGTON CLINICAL COMMISSIONING GROUPdarlingtonccg.nhs.uk/wp-content/uploads/sites/2/2016/09/Darlington-CCG-Clear...7. Our Strategic Approach 56 7.1 Getting a grip of the system