ENCLOSURE: E (i) Agenda Item: 07/13 papers... · Recommended action for the Governing Body The Governing Body is asked to: A - Approve the Commissioning Intentions for 2013/14, subject

GOVERNING BODY MEETING 28th February 2013

Title Commissioning Intentions

Recommended action for the Governing Body

The Governing Body is asked to: A - Approve the Commissioning Intentions for 2013/14, subject to any changes in contract variations extensions to be considered in part 2 and further refinements to the top three priorities in the “plan on a page” B – Note and approve the south east London Community Based Care Strategy for which the Bexley specific action plan is covered in (i) the 2013/14 QIPP (ii) the QMH Commissioning Intentions both of which form key planks of the overall Bexley Commissioning Intentions C - Note the attached Contracting Round Timetable with the intent to deliver Heads of Terms for 2013/14 by 28th February for all NHS providers in order to be well prepared for contract novation and derogation between the Care Trust dissolution on 31st March 2013 and formal establishment of the CCG on 1st April 2014

Executive Summary

These papers are further updates of the Commissioning Intentions 2013/14 and Contracting Round Timetable 2013/14 shared at the January Governing Body development event. The Commissioning Intentions include the QIPP which signals a shift towards more community based care aligning with the south east London strategy for Community Based Care shaped as part of the Trust Special Administrator Process and also attached for noting and approval. The QIPP also is set to deliver £10.5M of both redesign and contract efficiency based savings to ensure that the CCG delivers financial sustainability and balance as set out in its Medium Term Financial Strategy The three locally agreed priorities are those of most strategic significance to the CCG as it embarks on its journey of transformation. The NHS Commissioning Board (London)

ENCLOSURE: E (i) Agenda Item: 07/13

shadow team has asked that we consider reframing these as our top three performance priorities. The CCG has successfully submitted its first draft Operating Plan with these three priorities, C Difficile, NHS Constitution and NHS Outcomes Framework self certification – alongside the projected delivery trajectories for IAPT (Improving Access to Psychological Therapies) and dementia care. We have said that we will meet all of these items and self certify the clinical safety of provider Cost Improvement Programmes subject to the successful outcome of contract negotiations.

Which objective does this paper support?

Patients: Improve the health and wellbeing of people in Bexley in partnership with our key stakeholders

People: Empower our staff to make BCCG the most successful CCG in (south) London

Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation

Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience

Organisational implications

Key Risks (corporate and/or clinical)

Legal – any extension of existing contracts requires legal implications to be considered Financial - ensuring that contracts negotiated and QIPP plans support financial balance and sustainability to the tune of at least £10.5M in 2013/14. Significant problems in agreeing SLHT and other acute baselines and envelopes owing to CSU and SLHT capacity and national adjustments and deductions, particularly for specialised commissioning Quality and Safety – ensuring that sustainable contracts support the 3 year TSA implementation process, the development of Queen Mary’s Hospital, Sidcup and that quality and safety is maintained and improved during Transition. CCG clinical leads are engaged in all key contract negotiations – at SLHT this is held

mainly by the Medical Director.

Equality and Diversity

Patient impact

Ensuing the safety and sustainability of services during the major service transition under way in south east London. Delivering stronger community services closer to home

Financial

Ensuring that any extended NHS contracts continue or improve public value for money and that the Commissioning Intentions deliver the QIPP and financial sustainability/balance

Legal Issues

Interpretation and following of EU procurement legislation

NHS constitution

Continuing to meet NHS Constitution deliverables in transition to the new service configuration

Consultation (Public, member or other)

N/A

Audit (Considered / Approved by Other Committees / Groups)

Executive Management Committee and two Governing Body Seminars so far

Communications Plan

Contract negotiations timetable in place. Two engagement events for GPs/CCG membership and wider partners/providers/users and carers held in October 2012 and January/February 2013

Author Mike Attwood – Interim Director of Commissioning

Clinical Lead Bill Cotter (Acute) Varun Bhalla (Community/Mental Health)

Executive Sponsor Mike Attwood Interim Director of Commissioning

Date 15 February 2013

Appendix OThe strategy for community-based care in south east London

Bexley Clinical Commissioning Group

Bromley Clinical Commissioning Group

Greenwich Clinical Commissioning Group

Lambeth Clinical Commissioning Group

Lewisham Clinical Commissioning Group

Southwark Clinical Commissioning Group

1. The context of healthcare needs of the population in south east London

1. ThedemandforhealthcareservicesinsoutheastLondonhasbeenandisexpectedtocontinueincreasing.Populationgrowth(figure1)andanageingpopulationareputtingincreasingpressuresonthehealthcaresystem(figure2).Medicaladvancesandimprovedhealthcareprovisionaresupportingpeopleinmanagingtheircareandimprovingtheirqualityoflife.However,asmorepeoplelivelongerweareseeingincreasingnumberofpeoplelivingwithlongtermconditions,orevenmultiplelongtermconditions,whichrequireeffectivemanagementtopreventadeteriorationinpeople’squalityoflife.Bestpracticemanagementoftheselongtermconditionsiskeytosupportingpeopleineffectivelymanagingtheirowncareandenablingthemtomaintaintheirqualityoflife.

Bexley

Bromley

Greenwich

Lewisham

Lambeth

Southwark

Annual population ‘000s

Annual growth 2011-21

%

224

315

246

271

296

290

228

324

276

288

313

313

232

331

298

297

325

334

1,6411,741 1,815

2011 2016 2021

11%1.0

0.3

0.5

2.0

0.9

1.0

1.4

Spend per person (£)

15-29

0-14

45-59

30-44

75+

60-74

128135142

174167195

231225233

290290291

638635603

1,4141,4221,286

SELLondonEngland

Figure 1: Projected SEL population growth1 Figure 2: Health spending per head by age group2

2. DespitetheseimprovementstherecontinuestobesignificanthealthinequalitiesacrosssoutheastLondon,withamanborninGreenwichhavingalifeexpectancythreeandhalfyearsshorterthanamanborninBromley3.Therearealsosignificantdifferenceswithinboroughs–inGreenwichtheimpactofdeprivationmeansthatthereisasevenyeardifferenceinlifeexpectanceformen.

3. AlongsidethesehealthinequalitiesthereisstillvariationintheaccesstoandqualityofhealthcareservicesprovidedacrosssoutheastLondon.Localcommissionersarecommittedtocontinuetobuildontheirmanyrecentsuccessfulinitiatives,examplesofwhicharesummarisedthroughoutthisdocument.TofurtherimprovetheaccesstoandqualityofcareprovidedinordertoreducehealthinequalitiesacrosssoutheastLondonCCGshaveagreedtoworktogetherincollaborationtoshareexperienceandresources.

4. IncreasesininvestmentintheNHSarenolongeratthelevelsseeninrecentyears,butthecostofprovidingcareisprojectedtocontinueincreasingatratesabovenationalinflation.Thisputssignificantpressureonthewholehealthcaresystemtodeliverbettercareforlessmoney.Commissionersarethereforerequiredtotakeonthechallengeofcommissioninghigh

1 GreaterLondonAuthority(2011)2011RoundofDemographicProjections

2 HospitalEpisodeStatistics2011/12;OfficeforNationalStatistics2011

3 PublicHealthObservatoryanalysis;NationalCentreforHealthOutcomesDevelopment

APPENDIXO:THESTRATEGyfORCOMMuNITy-BASEDCAREINSOuTHEASTLONDON3

qualitycarethatwillmeettheincreasingneedsoftheirlocalpopulationswithinatightfinancialenvelope.TheyhaveadutytoensurethateveryinvestmentmadedeliversthebestoutcomepossibleandthatthelatestevidenceaboutbestpracticeisadoptedsothatlocalresidentsreceiveservicesofthehighestqualityfromtheNHS.

2. The vision for commissioning care in south east London over the next five years

5. ItiswithinthiscontextthatthecommissionersinsoutheastLondonhavedevelopedtheirstrategyforthefutureprovisionofcareacrosssoutheastLondon.TherecentCommissioningStrategyPlanforSouthEastLondon,Betterforyou,outlinedthevisionforthepopulationofSELthatby2015:

“More people In South East London will stay healthy, and every patient will experience joined-up healthcare which meets their needs in the most effective way” .

underthisvisionallsixCCGshavealignedtheiraimsandagreedtomeetthefollowingfivestrategicgoals:

• IneverycontactwiththeNHSandlocalpublicservicepartners,peopleareencouragedandenabledtopositivelymanagetheirownhealth,inpartnershipwithhealthprofessionalsandtheircarers

• PatientsexperiencetheNHSasajoined-uppersonalisedservice,ratherthanadisconnectedsetofservicestheyarerequiredtonavigate

• Patientsaretreatedwithdignityandtherespectduetothematalltimes

• Clinicaldecision-makingandhealthcaredeliveryisinlinewithevidence-basedbestpracticeandtakesaccountofvalueformoney

• Thelogisticsofhealthcaredelivery,withinandacrossdifferentcaresettings,aredesignedtomeetpatientneeds,whetherlong-termoracute,inthemosteffectiveway

6. InworkingtodeliverthesestrategicgoalscommissionersarelookingtoensureaconsistentstandardofcareacrossthewholeofsoutheastLondonwithhealthcareservicescommissionedtoenablethepreventionanddetectionofhealthcareconditions.Patientsshouldexpecttohaveappropriateaccesstohighqualityprimaryandcommunitycareservicesthatmeettheireverydayandurgentcarehealthneeds.Effectiveearlyinterventionshouldfocusontheneedsoftheindividualandsupporttheminmanagingtheirownconditionsandreceivingcareinthemostappropriateplace,bethatathome,intheirlocalGPpractice,pharmacyorhealthcentre,alocalhospitaloraspecialistcentre.Greaterintegrationacrossallhealthandsocialcareserviceswillsupportpeopleinmanagingtheirlongtermconditions,preventingunnecessaryadmissionstohospital.However,toensurethatwherehospitalsservicesarerequiredthecareprovidedisofthehighestquality,appropriateservicesshouldbecentralisedacrosssoutheastLondon.Thiscentralisationofspecialistserviceswillhelpdriveupthequalityofcareandtheoutcomesforpatients,butmustbesupportedbyintegratedservicesthatwillenablepatientstoreturnhomeasquicklyaspossibletoreceiverehabilitationandfollowupcareinthecommunityandaspeedyreturntoindependence.Suchintegratedservicescanalsobeusedtoimprovetheprovisionofcareforthoseattheendoftheirlife.

4 2012/13–2014/15CommissioningStrategyPlan

4

3. The aspirations for Community Based Care in south east London

7. AcrossthesixboroughsinsoutheastLondontherehasbeensignificantimprovementinthequalityofcareinrecentyearsbutthereismoretodoinordertodeliverconsistentstandardsofcareacrossthewholeofSEL.TosupportthedrivetodeliverconsistentlyhighstandardsofcarelocalcommissionershaveagreedasetofaspirationstobeachievedacrosssoutheastLondon.

8. TheseaspirationshavebeenbuiltupfromtheexistingSouthEastLondonCommissioningStrategyPlanandfurtherdevelopedthroughaseriesofCommunityBasedCareworkshopsthathaveincludedallsixClinicalCommissioningGroupsandmanyoftheirkeystakeholdersandpartnersfromacrossprimary,community,acuteandsocialcareservices.TheseaspirationsforCommunityBasedCaresupportthedeliveryofthestrategicgoalsoutlinedintheCommissioningStrategyPlan,andarefocusedaroundthreeareasofcare:

• Primary and Community Care:providingeasyaccesstohighquality,responsiveprimaryandcommunitycareasthefirstpointofcallforpeopleinordertoprovideauniversalserviceforthewholepopulationandtoproactivelysupportpeopleinstayinghealthy

• Integrated Care:ensuringthereishighqualityintegratedcareforhighriskgroups(suchasthosewithlongtermconditions,thefrailelderlyandpeoplewithlongtermmentalhealthproblems)andthatproviders(healthandsocialcare)areworkingtogether,withthepatientatthecentre.Thiswillenablepeopletoremainactive,wellandsupportedintheirownhomeswhereverpossible.

• Planned Care:forepisodeswherepeoplerequireit,theyshouldreceivesimple,timely,convenientandeffectiveplannedcarewithseamlesstransitionsacrossprimaryandsecondarycare,supportedbyasetofconsistentprotocolsandguidelinesforreferralsandtheuseofdiagnostics

9. TheaspirationsoutlinedbelowarethosethathavebeendevelopedthroughtheCommunityBasedCareworkshopstoensurethattheplansforthehospitalservicearefullyalignedwiththecommissioningintentionsoftheSOuTHEASTLONDONClinicalCommissioningGroups.

10. TheaspirationsforcommunitybasedcareandmentalhealthwillenablethepatientsinSELto:

• Haveaccesstopublichealthprogrammesthatsupportprevention and early detectionofdiseasesbyproactivelyfindingpeopleatrisk oflosingtheirgoodhealth.

• Besupportedtomanage their own healthandanyillnessesthat theyhaveandgivenconfidencetotakedecisions about their own care,includingnavigatingaccesstospecialistserviceswhereneeded.

• Haveaccesstotelephone advice and triageforallcommunityhealthandcareservices24 hours a day, seven days a weekeitherthroughtheirGeneralPracticeorthroughatelephonesinglepointofaccess.

• Have access to primary care service/advice 24hrs, 7 days a week for urgent needsthroughacombinationofappointmentsandwalkinservices,telephoneappointments,111/NHSChoicesorsamedayurgentcareetc.

Easy access to high quality, responsive primary and community care


• Receivehigh-quality carethatmeetsagreedqualitystandardsandoutcomes,providedthroughteamsworkinginnetworksacrossprimarycare,communityandspecialistservicesthatmaybebasedinthehospital.

• Knowthattheirlocalcommissioners(CCGs)proactively planhowtomeetthehealthneedsforthepopulationtheyhaveresponsibilityforandhaveconfidencetheyaresupporting hard to reach groups of patients.

• Receivetargetedandmorepersonalisedcareappropriatetotheir needs,asaresultofsystemsthatallowto proactively identify and support more patients before a crisis.

• Playanactiveparttogetherwiththeirhealthprofessionalsandcarers indevelopingacare planthatsetsoutwhattheyandthoseinvolvedin deliveringtheircarewilldotosupportthemstayingashealthyas possible,orwhatshouldhappenintheeventofproblems.

• Haveanamed‘care coordinator’whowillworkwiththemtocoordinatetheircareacrosshealthandsocialcare.ThisrolewillbeclearlydefinedandclinicalaccountabilityforcarewillberemainwiththeirGP.

• KnowthattheirGPisworkingwithinamulti-disciplinary group of health professionalstoco-ordinateanddelivercare,incorporatinginputfromprimary,community,socialcare,mentalhealthandspecialists.

• Bewellsupportedwhentheyareatriskofbeingadmittedtohospital, receiving the expert advice, tests or access to equipment they need promptlytoensuretheywillonlygotohospitalifabsolutely necessary.

• Beconfidentthatassoonastheyarereferredtohospitaltheir CommunityBasedCareTeamwillbeworkingwithstaffinthehospital andthecommunitytocoordinateanindividual discharge plan, includingintermediatecare,reablementandrehabilitation,tosupport

efficientdischarge from the hospital within 24 hoursofbeingdeclaredmedicallyfit,knowingtheywillreceivetherightcontinuing careinthecommunity.

• Haveaccesstorelevantandcompleteinformation,intherightformatstoinform personal choiceanddecisions.

• Experienceconsistent quality of care and access to servicesanywhereisSEL,basedonagreedstandards,protocols,accesstimesandapproachestoreferralsanddiagnosticssuchasradiology,phlebotomy,ECGandspirometry.

• Receivetreatmentforplannedspecialist diagnostics and care in specialist hospitals,butbeabletoaccessotherplannedroutineoutpatientappointment,diagnostics,pre-andpost-operativeappointmentsinsettings closer to homeorviatelephone/webconsultationstoreduceunnecessarytravel.

Integrated care for people with long term conditions

Timely, convenient and effective planned care

6

4. How care will be delivered in the future 11.Deliveringcaretomeettheseaspirationswillrequirefurtherchangeinthewayservicesare

currentlyprovided.CCGshaveworkedwithprofessionalsandleadersfromacrossthehealthserviceincludingGPs,nursesanddoctorsfromhospitalstodevelopanoverviewofhowpatientswillreceivecarewithineachofthethreeareasof:primaryandcommunitybasedcare,integratedcareandplannedcare.Inthesemodels,primaryandcommunitycareservicesareuniversalandavailabletoeveryone;peoplewithlongtermconditionswillreceiveintegratedservicesandthosewithshorttermneedswillreceiveplannedcarethattheyrequiretoaddresstheirpresentingproblem.

12.Primary and community care:inthefuturethepopulationofsoutheastLondonwillhaveequalaccesstoaconsistentstandardofprimaryandcommunitycareservices.Theservicesthatwillbeprovidedhavebeengroupedagainstthefollowingfivecategories:

Area As a patient in south east London in the future you will be able to...

Supporting self-management and choice of treatment

• buildyourknowledge,confidenceandskillsabouthowtomanageyourhealthandsocialcareneedsthroughprovisionofclearinformationandsignposting

• getskilledsupportandadvicefromarangeofstaffwithinyourGPpracticeandwiderhealthcommunity(pharmacies,children’scentresetc.)tohelpyouchooseandmeetyourgoalsforimprovingyourhealth,independenceandwell-being

Prevention and detection of conditions

• enjoyopportunitiestoimproveyourhealthwithinyourlocalcommunity,school,placeofworshiporworkplace,withexpertsupporttopreventill-health

• besupportedtorecognisewhenyouhaveaspecifichealthneedandreceivetheappropriatesupporttomanageit

• workwithpeoplewhounderstandyou,yourbackgroundandcommunity,whocanhelpyounavigatetheNHSandsocialcareandunderstandwhatservicesand/orequipmentareavailabletoyouthatcandetectproblemsearlyandstaywellathome

Access to 24/7 telephone advice and triage

• get24/7healthadvicebyphoneandwebvia111andNHSChoices• communicatewithyourGPinmoreconvenientways,includingtelephone

appointments,textmessagingtoconfirmtestresults,andemailforthosewithLongTermConditions

• seeyourownhealthrecordonline,checkresults,orderrepeatprescriptionsandmakeappointments

• contactallcommunity,socialcareandprimarycareservices(e.g.districtnurses)viaasinglephonenumber

Access to 24/7 urgent primary care services

• geturgentappointmentswithaGPmoreeasily,eitheratyourownGPoratanearbyGPwithwhomyourGPworkscloselyandprovidesthesamequalityofcare

• seeaGPorotherprofessionalquicklyifthereisariskofhospitaladmission• easilymakeanappointmenttoseeaGPatanurgentCareCentreat

eveningsandweekendsbycallingthenewNHS111number

Receive care across clinical networks with consistent standards

• knowthatyouarereceivingthesamehighqualityofcareaseveryoneelseinsoutheastLondonandknowwhatyoucanexpectbyreadingouragreedsoutheastLondonstandards

• benefitfromawiderrangeofspecialistknowledgeamongstlocalGPswhichmaymeanthatyouoryourfamilymemberdonotneedtogotothehospital


13. Integrated care for people with long term conditions:inthefuturepatientsinsoutheastLondonidentifiedashavingaspecificphysicalhealthcareormentalhealthcareneedwillbesupportedtomanagetheirconditioninanyintegratedway.Theservicesthesepatientswillreceiveinmanagingtheircarehavebeengroupintothefollowingsixcategories:

Area As a patient in south east London with a specific long term healthcare need in the future you will be able to…

Shared information and effective risk stratification

• beconfidentthatallthehealthandsocialcareprofessionalswhoyoucomeintocontactwithknowwhattheothersaredoingandcommunicatewitheachother

• receivesupportandservicestailoredtoyourindividuallevelofillness,yourlevelofknowledgeandconfidenceaboutmanagingyourconditionandyourriskofhospitaladmission

• usesimpleequipmentinyourownhometokeeptrackofyourhealthandknowthatyourhealthprofessionalsaremonitoringthoseresultstokeepyousafe

• receiveexpertsupporttohelpyoupreventworseningofyourcondition

Effective care planning and risk management

• playanactivepartinsettinggoalsforwhatyouwilldotoimproveyourownhealthandwhatprofessionalhealthandsocialcaresupportandservicesyouwanttoreceiveoverthecomingyear,bothonaroutinebasisandifyouhaveproblemswithyourhealth

• participateinself-managementsupportandpatienteducationprogrammes• insomesituationsyoumaybeabletotakecontrolofthebudgetthatisused

topayforyourhealthservicesanddecideforyourselfhowyouwanttobuytheservicesthatyouneed,withsupporttomakethisworkbestforyou

Coordinated care delivery • haveasinglepersonwhoisresponsibleforensuringthatalltheservicesyouneedaredeliveredontimeandthattheyallworktogethereffectivelyandsmoothly;thismaybeaGP,nurse,socialworkerorotherhealthprofessional

Support from multi-disciplinary clinical teams

• beconfidentyourGPisintouchwiththeotherkeyhealthprofessionalswhoareinvolvedinyourcaretodiscussyourhealthandensurethatallyourneedsarebeingmet

Prompt assessment for patients at risk of admission

• speaktoaspecialistwithinthehospitalbytelephonealongside,orbeseenathome,inacommunityclinic,aGPsurgerybyacommunity-basedspecialistorsocialcareprofessionalpromptly,whenyoumayneedadmissiontohospitalsothatalternativescanbeconsidered.Specificresponsetimeswillbesetfordifferentpathways

• beprovidedwithanytests,equipmentoradvicethatyouneedifthiswouldmeanyoucanremaininyourownhomeinsteadofbeingadmittedtohospital

• besupportedbyamultiprofessionalteamathomeorinahomelikesettinginsteadofthehospitalifyourillnessmeansthatitisasafewayoftreatingyou.

Proactive discharge planning • beconfidentthatifyouareadmittedtohospital,staffbasedinthecommunitywillbeworkingfromthemomentyouarrivetherewithyourhospitalstafftomakesurethatassoonasyouareready,youcancomehome,withanyequipmentoradditionalservicesinplace,includingatweekends

8

14.Planned care:inthefuturepatientsinSELthathaveaspecificplannedhealthcareneedwillbesupportedtomaketherightchoiceoftreatmentandreceivehighqualitycareintherightlocation.Patientswillbesupportedinthisthroughthethreefollowingapproaches:

Area As a patient in south east London with a need to access planned care in the future you will be able to...

Effective patient engagement and information to support choice

• getexpertsupportfromstaffinprimarycareandoutpatientclinicstohelpyoumaketherightdecisionabouthowyouwanttomanageyourhealthproblem

• haveaccessto‘decisiontools’(suchasonlineinformationorDVDs)thatgiveyouhelpful,easily-understandablematerialstohelpyouunderstandwhattheoptionsareforyourconditionandmakeaninformeddecisionaboutwhetheryouneedanoutpatientappointmentandwanttoproceedwithtreatmentinthelightofyourindividualclinicalcircumstances,preferencesandvalues.

• getexpertsupportbeforesurgerysothatithasthegreatestpossiblebenefitforyou,includinghelpwithweightlossandhelpwithpracticingtheexercisesyoumayneedtodoafteryouroperation

Common clinical protocols • knowthatyouarereceivingthesamehighqualityofcareaseveryoneelseinsoutheastLondonandknowwhatyoucanexpectbyreadingouragreedsoutheastLondonstandardsand“patientpathways”foreachcondition

• benefitfromawiderrangeofspecialistknowledgeamongstlocalGPsandlocalhealthprofessionalswhichmaymeanthatyoudonotneedtogotothehospitalforspecialistadvice

• bereferredforspecialistadvicebyawiderrangeofprimarycareprofessionals,e.g.optometrists,withouthavingtogoviayourGP

Pre- and post- surgical care in the right location

• receivemuchofyourcarebeforeandafteranoperationinappropriatelocalsettings,thismayincludeconsultantoutpatientappointments,somediagnostictests,pre-assessmentbeforesurgery,follow-upoutpatientappointmentsandphysiotherapy

• haveanassessmentbeforeyouenterhospitalofwhatyourneedswillbeondischargesothattheappropriatehealthandsocialcareservicescanbeready

• engagewithhealthprofessionalswhoprovideplannedcareinthecommunityviatelephoneappointmentsorweb-basedappointmentsusingsystems

• havesomeprocedures,suchasminorsurgery,thatwouldtraditionallyhavebeendoneinahospitalwithinanenhancedcommunitysetting,wherethisisconvenientforyou

15. Effectiveprimaryandcommunityservices,asdescribedabove,willsupportpatientstoreceivecareintherightplacefortheirneed.InmostcircumstancesthiswillmeanreceivingcareathomeoratalocalGPpractice,pharmacyorhealthcentrehowever,thosewithspecificplannedandemergencycareneedswillcontinuetobetreatedinhospitalsandwillbenefitfromincreasedspecialistcoverresultinginamoreresponsiveservicebettersuitedtotheneedsofpatients.

16. Successfuldeliveryoftheseaspirationswillseeashiftfromwithpatientstraditionallyseeninhospitalbeingtreatedincommunitysettingsandintheirownhomes.Thisshiftwillenablehospitalstofocusontreatingthemostacutepatientsandusingtheirspecialistskillstobesteffectandmustbeaccompaniedbyanassociatedreductioninactivityinhospitalsinordertoprovidethenecessarybenefittothewiderhealthsystem.

17. ThistransformationofprimaryandcommunitycarewillsupportthewidertransformationofclinicalservicesacrosssoutheastLondonwhichisbeingproposedaspartoftheTSAprocess.


5. The programmes that will help deliver the changes 18.CommissionerswillberequiredtodelivertheaspirationsforCommunityBasedCareoutlined

abovewithinthetightfinancialenvelopeavailabletotheminthefuture.ThroughtheTSAprocessanassumptionontheallocationsforthenextfiveyearswascalculated.Thecommissionerallocationisexpectedtoincreaseyear-on-year(seefigure3)but,asisthecaseforallhealthfunding,itwillhavetobespentmoreeffectivelyandmadetoworkhardertopayfortheincreasingcostofcareandtomeettheneedsofagrowingandagingpopulation.

19.WorkingonthisassumptiontheCCGshaveagreedaQIPPtargetforthenextfiveyearsthattotals£128.7m.Thesesavingswillneedtobemadeacrossallareasofcareandwillinformthefundingavailableacrossthesysteminthefuture.AssuchtheyhavebeenbuiltintotheassumptionsbeingusedbytheTSA.

Figure 3 – Five year projected allocations across south east London (£m)

3,045 3,013 3,165 3,226 3,290

2013/14 2014/15 2015/16 2016/17 2017/18

Non-acute spending Acute spending

20.CCGshaveallmadeprogressindevelopingtheircommunity-basedcareservicesindifferentwayswithsuccessindifferentareas.IndevelopingtheCommunityBasedCarestrategytheCCGshavesharedtheirexperiencestodateandsetoutasetofcommonstandardsforservicesacrosssoutheastLondon.TheyarealsoworkingwiththeLondonRegionalOfficeoftheNHSCommissioningBoardtoconsideropportunitiestodriveimprovementsinprimarycareservicesbasedonlocal,regionalandnationalbestpractice.SomeexamplesofprogresstodatethatarenowbeingdevelopedanddrawnonbyotherCCGsareprovidedinthroughoutthischapter.

21.usingtheseexamples,alongwiththeirexistingCSPs,theCCGsaredevelopingintegratedplansthatwilldeliverimprovementsinqualityinlinewiththeCBCaspirationsandproductivityandefficiencysavingsinlinewiththeirQIPPrequirementsoverthenextfiveyears.Theseprojectswillbeessentialinreleasingresourcestoaddressincreasedpopulationdemandacrossthesystemandwillbedevelopedaroundthethreeareasofcareoutlinedintheaspirations.

10

Transforming primary and community based care

22.underpinningthesuccessoftheCommunityBasedCarestrategyisthetransformationofprimarycareservicesastheservicesthataredirectlyaccessedbyallpatientsandsupporttheprovisionofeffectiveintegratedandplannedcare.Highqualityprimaryandcommunitycareservicesalsoenablesecondarycaretofocusonthoseservicesthatneedtobeprovidedinahospitalsetting.

23. SoutheastLondonisnotuniqueinthechallengesitisfacingaroundvariationinqualityofandaccesstoprimarycareservices–manyotherhealthsystemsinLondonandnationallyarealsolookingtotransformtheirlocalservices.NHSNorthWestLondon’sShapingaHealthierfutureprogrammeplacesstrongemphasisontheneedforimprovingaccesstoprimarycareandensuringthatagreaternumberofservicesarecentredaroundpatientsandprovidedoutwiththetraditionalhospitalenvironment.

24. LondonisfacingdramaticdemographicchangesandunprecedentedfinancialpressuresandsoutheastLondon’sCCGsrecognisethatastrongsystemofprimaryandcommunity-basedcareismoreimportantthanever.InlinewiththistheLondonRegionalOfficeoftheNHSCommissioningBoardhasrecognisedthatthecurrentmodelofGPserviceprovisionisunlikelytobeunsustainablewithgrowingpatientneedsandexpectations,flatfundinggrowthrequiring3%annualproductivitygainacrossthesystemandvarietyincostandvalue-for-moneyacrossthesystem.

25. ThispositionisalsosupportedbyTheKing’sfundImprovingtheQualityofCare(2012)whohaveadvisedthatmajorchangesareneededtotheorganisationanddeliveryofprimarycaretomeetthesechallengesincluding:

• GPsshouldworkmorecloselywithhospitals,communityservicesandsocialcaretoimprovetheco-ordinationofcare,especiallyforpatientswithlongtermconditions.

• GPsandcommissionersmustmakebetteruseofdatatounderstandandactonlocalvariationsinperformance,andexploitthepotentialofITtoimprovethequalityofservicesforpatients.

• GPpracticescouldmovemorequicklytowardsdifferentmodelsofserviceprovisione.g.federationsornetworks–thiswillenablesmallerpracticestoretaintheirlocalfocusbutprovideawiderrangeofservices.

26. TheLondonRegionalOfficeoftheNHSCommissioningBoardisworkingwiththeCCGsindevelopingaprogrammetotransformprimaryandcommunitycare.ThisprogrammewillbuildonthetransformationframeworktheLondonRegionalOfficeoftheNHSCommissioningBoardhasdevelopedtoprovideanevolutionaryandcollaborativeproviderchangeprogrammeforprimarycarethatfocusesondeliveringtheaspirationsforprimaryandcommunitycare.

27. TwoexampleswherepatientsarealreadybenefittingfromimprovedaccesstotreatmentavailablewithintheircommunitiesasaresultoftheCCGadoptinganinnovativeapproachtoprovidingurgentcareservicesareoutlinedbelow:


Greenwich’s Integrated Care System

GreenwichCCGiscontinuingtoworktowardsfullintegrationofallhealthservicestodelivercommunitybasedcareandhaveadoptedtheprincipleof‘inthecommunitywhenpossible,hospitalwhennecessary’.Thefirststageofdevelopmenthasbeenexpandingthecapacitytodeliverintermediatecareathome.

Benefits for patients…

•Patientswhoarefittoleavehospitalareabletoreturntotheirhomeandreceiveregularsupportfromtrainedstaffinthecommunity.

•Patientswhoareatriskofrequiringadmissiontohospitalcanbecaredforintheirhomesandsupportedtoremainhealthy.

Benefits for the NHS…

•Integratedcareallowsforvariousagenciestocoordinatetheireffortstobeaseffectiveandresponsiveaspossible.Thisreducesduplicationofworkandimprovespatients’experiences.

•Theintermediatecareprogrammehasbeeninoperationsince2011andhashelpedGreenwichtoachieveareductioninnon-electiveadmissionstotopputtheminthetop20%inthecountry.

Lambeth’s Healthy Living Pharmacy

TheHealthyLivingPharmacies(HLP)initiative,launchedin2012,encouragespharmaciestosupporthealthandwellbeingtoresidentsacrossLambeth.EachsitehasalocalHealthyLivingChampionwhohasbeentrainedandaccreditedtokeepresidentsup-to-datewithhealthservicesinthelocalcommunityandcansignpostresidentstofurtherhelp–includinginformationandadviceaboutalcoholintervention,stoppingsmoking,sexualhealthandminorailments.TheChampionsaremovingaheadwithprovidinghealthinterventionsandsupportinglocalresidentswithmakinghealthierlifestylechoices.


•Easyaccesstoinformedadvicewithinthecommunity.

•Supporttofindthemostappropriateservicetomeettheirneeds.


•Improvedcoverageandpenetrationforhealthpromotioncampaigns.

•Increasedtakeupofcommunitycareofferings.

•Reduceddependenceonemergencydepartments.

12

28. furtherworkplannedoverthenextyeartotransformprimarycareisexplainedinthetablebelow.

1. Easy access to high quality, responsive primary and community care

This work stream brings together projects that will transform primary and community care by focussing on prevention and early detection and ensuring that people can access treatment at the earliest possible stage.

Focus Priorities for 2013/14 Example schemes from CCGs

Prevention and early detection

• Developincentivestoimproveoutreachandearlydetection

• WorkwithLocalAuthorityPublicHealthteamtoextendscreeninginitiativestonon-traditionalsettings

• Bromleyareexpandingtheirvascularcheckprogramme

• SouthwarkareimplementingspecialistdementiatrainingtoenableGPstoidentifyearlysignsofvasculardementia

• LambethispilotingHealthyLivingPharmacieswherecommunitypharmacistsofferadviceandsupporttopeopleonstoppingsmoking,healthchecksandpreventingalcoholrelateddisease

Support people to manage their own health

• furtherdevelopdischargesupportprogrammes

• Extendeducationprogrammestoarangeofprofessionalsinavarietyofsettings

• Developuseofpersonalhealthbudgetsforappropriateconditions

• Southwarkaredevelopingacommunitymentalhealthpharmacistrolethatwilltraincarersandfamiliesabouttheirmedication

• Lewishamareextendingtheirminorailmentsprogrammethatprovidestreatmentforapprox.2000interventionsin10pharmaciesto8000interventionsin30pharmacies

24/7 access to primary • Rollout111servicesacrossSEL• ExtendhoursinGPsurgeries• Commissionfurtherhometreatment

services

• Southwarkiscommissioninghometreatmentandcrisisteamsto24/7provisionforpeopleinearlycrisisandtosupportinpatientadmissions

• 111schemesarebeingdevelopedtoincludelinkswithlocalauthorityandmentalhealthservicestoprovide24/7supportforpatientsandhealthprofessionals

24/7 access to urgent care

• EvaluateandextenduCCofferings • SouthwarkandLambethareevaluatinguCCsatGuy’sHospitalandKing’sHospitalandarebeginningtheprocurementofauCCatStThomas’hospitaltosupportthecurrentemergencyarrangements

High quality care • WorkwithLocalEducationandTrainingBoard,acuteprovidersandNationalCommissioningBoardtodevelopworkforce

• Extendoutcomesbasedincentiveschemesforlongtermconditions

• Bromleyisworkingtodevelopcommunityneuro-rehabandstroketeamstobettersupportpatients

• Greenwichissupportingophthalmologyanddentalservicestoprovideextendedpathwaysinprimarycare

Support hard to reach groups

• ImplementHealthandWellbeingStrategiesinassociationwithLocalAuthorities

• Developservicesandengagementschemesfordeprivedareas

• Bromleyiscreatingadedicatedtravellersservice

• Lewishamisup-scalingpublichealthprogrammesandspecificallytargetingatriskgroupsandareas.

• Lambethhasagreedequalitiestargetsformentalhealth,diabetes,highbloodpressure,childhoodobesity,HIVsupportandalcoholrelateddiseasetoensurethatthosewhoneedtheservicescanbenefitfromthem


29. Thesefirstyearactivitieswillhaveanimmediateimpactonhowprimaryandcommunitycareisdelivered,supportingmorepatientstostayhealthyandensuringtheyhaverapidaccesstoappropriateserviceswhennecessary.

30.AsoutheastLondon-wideapproachprogrammemanagement(seechapter7fordetails)willcontinuallymonitortheprogressandbenefitofeachprojectacrosstheregiontoallowforhighimpactschemestobeextendedandreplicatedacrosstheboroughsinyearstwoandthreeandforappropriateinterventionstobeputinplacewhereaschemeisnotdeliveringtherequiredbenefits.Togiveanexampleofwhatmightberequiredoverthenextfiveyears,ifeachGPinsoutheastLondonpreventedasingleadmissiontoA&Eeachweekitwouldreducebothactivityandemergencyadmissions,savingaround£6mintotal.

31. Ithasbeenrecognisedthroughthisprocessthatarangeofadditionalschemessuchasthoselistedaboveontheirownwillnotbringaboutthetransformationrequiredinprimarycare.Generalpracticeinparticularisunderpressureday-by-dayandtoincreasestandards,accessandcontinuityofcarepracticeswillneedtoworkdifferently.InordertoaddressthisthereareexamplesacrossthecountryofCCGstestingoutdifferentapproachestodeliveringprimarycare,comparedwithtothemoretraditionalGPpracticeusedinsoutheastLondon.Examplesofwhatisbeingtestedoutacrossthecountryinclude:

• Smallerpracticesenteringintonetworksofpracticestosharebackofficefunctions,managementcapability,skillsandcapacity,freeingupclinicaltimetobemoreresponsivetothelocalpopulation

• Creatingnetworkstoshareclinicalcapacity,forexamplehavingsomepracticesfocusmoreondirectaccesswhileothersfocusmoreonlongtermconditionmanagementormorespecialisedcommunitycare

• Enteredintobusinesspartnershipswithoneanotherbackedbymoreformalagreementswhichallowpracticestoremainrootedintheirlocalcommunitiesbutwiththeabilitytodrawonmorecentralisedexpertiseatscale.

32. SouthEastLondonGPshavenotyetformallyconsideredthesemodels,butthroughtheworkshopsheldhaveexpressedaninterestinthinkingcreativelytoimproveclinicalservicesandmakethebestuseofthevitalworkforceingeneralpractice.

33.GoingforwardthesoutheastLondon’sCCGsandtheLondonRegionalOfficeoftheNHSCommissioningBoardwillembarkonastructuredprogrammeofengagementwithallGPpracticesandtheLocalMedicalCommitteetoexploreoptionsthatcouldimprovepatientcareandallowgeneralpracticetothrive.Thiswillincludewideengagementwithpatientsandthepublic,secondarycareprovidersandlocalauthorities.fromthisarangeofpilotswillbeshapedtotestnewwaysofworkinginasafeandprotectedmanner.Allpracticeswillbenefitfromlearningfromtheseleadersandalsotheenablersidentifiedinsection6willbetheretosupportallpracticesi.e.notjustthoseparticipatinginpilots.

34. InadditiontheLondonRegionalOfficeoftheNHSCommissioningBoardandtheCCGswillworktogetherinordertodefinewhat‘core’primarycareservicesareandagreewhatgoodlookslikeforthoseservices–includinghowimprovedserviceswillcontributetoimprovedpatientexperience,deliveringtheaspirationsincludingreducedrelianceonacuteservicesbythepopulationofSouthEastLondon.Theprincipleofpayingonceforserviceswillbeappliedwithgeneralpracticebeingthecornerstoneforallpatientpathways.

14

35.AswiththerestoftheCommunityBasedCareStrategyimplementingtransformationofthisscalewillrequiresupportfromarangeofenablers(chapter6)andeffectiveprogrammemanagement(chapter7)tomakesureitalignswithimplementationoftherestofthestrategy.ThisprimaryandcommunitycareprogrammeisthemostchallengingandrequiresapartnershipbetweenthenewlyformedCCGsandLondonRegionalOfficeoftheNHSCommissioningBoardtosupportgeneralpracticetoadoptverydifferentwaysofworkingtoenablethemtomeettheincreasingneedsoftheirpopulations.


36. Peoplewithlong-termconditionsnowaccountforabout50%ofallGPappointments,64%ofalloutpatientappointments,over70%ofallinpatientbeddaysandaround70%oftotalhealthandsocialcareexpenditure(TheKing’sfund,2012).Tobettersupportthiscohortofpatients,theCCGsinSELareworkingincooperationacrossgeographicandorganisationalboundariestodevelopaconsistentapproachtocoordinatedcare.

37. Betterintegrationofcareservicesimprovespatientexperienceandcansignificantlyreduceduplicationsanddelaysinthedeliveryoftreatment.Examplesoftheworkalreadybeingdoneareprovidedbelow.

Bexley’s Integrated Care for Older People – Case Management

AcasemanagementapproachisalreadywellestablishedinBexleywithpracticesusingariskstratificationtool(combinedmodel)toidentifypatientswithcomplexneedsandholdingintegratedmulti-disciplinaryteammeetingstoproactivelyplancareandmonitoroutcomes,sofarfor12/13therehavebeen3010patientreviewscarriedoutwiththeuseofRiskStratification.ThisjointapproachwillbefurtherstrengthenedthroughjointplanswiththeLocalAuthoritytointegraterapidresponse,dischargeandcommunityrehabilitationservices.


•Keepingtheircarewellmanagedinacommunitysetting,supportingthemtoremainhealthy.

•Reducingthelikelihoodofahospitaladmissionorlong-termcare.


•fewerpeoplegoingtohospitalrequiringcostlytreatmentandcare.

•Improvedproductivityofcommunityteamsthroughlessduplicationofeffortandmorecoordinatedcare.


Lambeth and Southwark’s Integrated Care Pilot

TheCCGsinLambethandSouthwarkhavecommissionedservicestosupportpeopletoavoidhospitaladmission.TheHome Wardprogrammesupportsthosewhowouldotherwiseneedhospitaladmissionorthosewhoaresuitableforearlydischargebyprovidingmanagedcareinthepatient’shome.TheyhavealsosetupanEnhancedRapidresponseprogrammethatprovidesarapid,2hour,responsetimetopeoplewhoneedurgentsupporttoremainintheirownhomes.


•Initsfirstyeartheprogrammehasenabledover300peopletobeadmittedtoThe Home Wardwithafurther700patientssupportedathomebyEnhancedRapidResponse.


•Providingthatlittleextrahelptopatientswhoarethenabletostayathomeallowsforhospitalbedstobythosewhoaremostacutelyillandthoserequiringplannedcare.

•Thisallowshospitalstoperformmoreoperationsandworkthroughtheirwaitinglists.

Lambeth’s Living Well Collaborative

LambethCCGisaimingtoradicallytransformtheoutcomesexperiencedbypeoplewithlongtermmentalillnessbyusing“co-production”astheframeworkforthedeliveryandcommissioningofservicesinordertodeliverour“Big3”outcomes(Recovery,ImprovedPhysicalHealthandQualityofLife)pluswidereconomicandsocialbenefits.ItisdrivingservicetransformationthroughtheLLWC,apartnershipplatformcomprisingtheCCG,SLaM,LambethCouncil,VCSproviders,PublicHealth,andusersandcarers.

.Benefits for patients…

•Supportwillbeofferedmuchsoonerandbefore“crisis”occurs.

•Supportwillbemorepersonalandrecoveryfocused.

•Patientswillbeinvolvedthedesignandcommissioningofservicesandintheiractualdelivery.


•Supportsystemtransformationtowardearlyintervention,recoveryandenablementandawayfromdependencyandcrisis.

•Supportintegratedworkingacrossprimarycare,secondarycare,voluntarysectorandsocialcareincollaborationwithusersandcarers.

16

38. Beyondtheseprojects,furtherworkbeingplannedwithin2013/14isoutlinedbelow:

2. Integrated care for people with Long Term Conditions (LTCs)

Aim: ensuring that those with long term conditions receive care that is centred around them, tailored to their needs and delivered by the most appropriate, multi-disciplinary health professionals.

Focus Bexley Bromley Greenwich Lambeth Lewisham Southwark

Proactively identify and support patients

• Establishacommunitygeriatricianservice

• Developriskstratificationtools

• Expandcommunitymatroncasefindingscheme

• ExtendFindingtheVulnerableprogramme

• Continueriskstratification,linkingtoIntegratedCarePilotworkandcareco-ordination

• Increaseaccesstovascularhealthchecksincludingthroughpharmacies

• FurtherGPtrainingtosupportunderstandingoftheneedsofthosewithmentalhealthproblems

• IncreaseengagementwithDistrictNurses/GPs

• Enhancehealthchecks

• Supportcasefindingthroughpractice-basedcommissioningincentivescheme

• Specialistdementiatrainingforpractices

Co-created care plans

• RuncasemanagementinthecommunitythroughMulti-DisciplinaryTeamsinGPpractices

• Developcareplanning,initiallyforpatientswithDiabetes,HeartFailureandCOPD

• Ensurepathwaysincludeself-careandsupportpatientsabilitytocope

• Developpatientandclinicianeducationandsupportinginformationtool

• Developpatient-specificplanswithmedicalteamintegratewithcommunitypharmacist

• Developgenericapproachtocare-planningandundertakestafftrainingwithresources

Care coordinator role

• Developpalliativecareservices

• PracticeLiaisonOfficertrainingprogrammetosupportthecoordinationofpatientcare,casemanagementandsystemnavigation

• ExtendprimarycarecasemanagerroletoLTCs

• Agreeprotocolsandlinktointegrationprogrammetoensureconsistency

• DevelopNeighbourhoodHubstosupportproactiveprimarycare

• ExtendprimarycarecasemanagertoLTCs

• Agreeprotocolsandlinktointegrationprogrammetoensureconsistency

Multi-disciplinary working

• Createa7day,0800-2000,integratedrapidresponseteam

• Developintegratedteamtosupporttarget‘active’patientsandtomonitor‘passive’patientstoidentifytriggerpoints

• WorkwithBexleyandBromleytocommissionatscaleLTCservices

• FurtherdevelopDiabetesintoEvidenceprogramme

• ReviewLocalEnhancedServicesasmechanismforpracticesengagingincareco-ordination

• Scopetheinclusionofamentalhealthoccupationaltherapistinthereablementteam

• ContinueCommunityMulti-disciplinaryteamscoveringallofSouthwarkandreviewandextendpracticeengagementandcoverage

Access to diagnostics, advice and equipment

• Developcommunityrespiratoryservice

• ReshaperapidresponseandPACEteam

• DevelopinginnovativeLTCclinicswithspecialists,GPsandothers

• Extenduseofcommunitygeriatrics

• ReviewapproachforpeoplewithmultipleLTCs

• Expandtrainingtoincreaseinterventionsdeliveredinpharmacies

Effective discharge and continuing care

• ExpandStep-up/downtohandlemorecomplexcases

• Integratecommunityrehabandreablement

• DevelopfurthertheCOPDdischargebundle

• Re-procureintermediaterehabandcareservice

• ContinueIntensiveCareathomeprogramme

• Increasestep-downandcommunitymentalhealthprovision

• RolloutHomeWard,integratingreablement/communitynursingwithrapidresponse

• RapidresponseteamintegratedwithAdmissionsAvoidanceService

• RolloutHomeWard,integratingreablement/communitycare


39. ThevarietyofschemesandapproachesbeingtakenbytheCCGsreflectthediversityofthepopulationstheyserveandthepartnerstheyworkwiththroughouttheirgeography.Italsoprovidestheopportunitybywhichtomeasurethebenefitsofdifferentapproaches.WithcommondataavailableacrossthesoutheastLondonitwillbepossibletoreadilymeasurethetakeupandimpactofvariousinitiativesandusethisintelligenceinyearstwoandthreetodevelopandexpandthemosteffectiveapproached.

40. If,throughtheseprojects,eachGPinsoutheastLondonpreventstwonon-electiveinpatientadmissionspermonththerewillbeacollectivereductioninactivityandassociatedsavingsofaround£45moverthenextfiveyears.

Timely convenient and effective planned care

41. Successfuldeliveryoftheprimaryandcommunitybasedcareandlongtermconditionsworkdetailedabovewillresultinmorecareepisodesmovingfrombeingunplannedtoplanned.Withinthisdomainliesthepotentialforcommissionerstoexercisethegreatestlevelofcontrolindevelopingaproactivesystembuiltaroundtheneedsofpatients.

42. KeytenetsofthestrategyforsoutheastLondonareallintendedtoreducecostswhilstimprovingpatientexperienceandensuringthatchoiceisstrengthened.TodothisCCGsareworkingtoofferoutpatientclinicsinthecommunityandaimtoprovidediagnosticsandfurtherassessmentinadvanceofsurgeryinanoutofhospitalsetting.Inaddition,afurthersharedaimistoimprovepatientinformationsharedpriortosurgerysothatpatientsarefullyinformedandeducatedontheirprocedureaswellasthebestwaystooptimisepre-surgeryandrecuperatepost-surgery.Someexamplesoftheschemesproposedarebelow.

Bromley’s Intermediate Dermatology Service

Providedbyateamofspecialistsincludingconsultants,advancedgeneralpractitionersandspecialistnursesinfiveoutofhospitalsettingsacrossBromley,thisserviceaimstoprovideassessment,investigationsandtreatmentforarangeofskinconditionsinonevisit.Theaimsoftheserviceistodivert50percentofreferralstointermediatecareinacommunitybasedsettingandalreadytherehasbeena30percentreductioninhospitalreferrals.

.Benefits for patients…

•Reducedwaitingtimes.

•Increasedchoiceofvenueandappointmentsavailableineveningsandatweekends.

•Improvedpatientsatisfaction.


•Reducedhospitalreferralstooutpatients.

•Acuteservicefocussedonmorespecialistcases.

18

Lewisham’s Anti-coagulation service

AlreadyinLewisham,wecommissionanti-coagulationmonitoringservicesfromagroupoflocalpharmaciesprovidinganumberofaccesspointsacrosstheboroughexpandingthenumberofconditionsforwhichongoingmanagementcanbedeliveredwithinthecommunity.Theschemeincludesmorecomplexcaremanagementinvolvingthesupplyandreviewofmedicineswhichwouldotherwiserequirehospitalinput.


•Localtopatient’shomewithchoiceof6localpharmacyproviders.

•flexibleappointments.

•Increasedtimewithhealthcareprofessional.

•Highpatientsatisfactionlevelsreported.


•LesspeoplehavingtoattendA&Eandhospitalout-patients.

•Reducedemergencyadmissions.

•Reducedcostscaringforpeoplewithlongtermconditions.

•Collaborativeworkingbetweenlocalprimarycareandhospitalservices.


3. Timely, convenient and effective planned care

This work stream focuses on developing the skills and services required to move pre and post-operative activity into the community and closer to minimise time spent in acute care settings.

Focus Bexley Bromley Greenwich Lambeth Lewisham Southwark

Information to support choice

• Procurementofanumberofnewservicesspecifiedtoimprovequalityandaccessandprovideinformationtosupportchoice.TheseincludecardiologyandpathologyandcommunityofferingsincoagulationandDeepVeinThrombosis,urology,gynaecology,dermatology,generalsurgeryandophthalmology

• DevelopmentofPatientReferralCentretoenhancetherangeofcarepathwaysactivelymanaged

• Continuetodevelopinformationprovidedtopatientsanddevelopstafftosupportedinformeddiscussion

• Evaluateandre-issuetheChooseWellCampaign

• Reviewandscopefurtherself-managementeducationopportunities

• Improveengagementwithdistrictnurses/GPs

• Evaluateresidentialcarehomes“StepstoSuccess”programme

• Tele-healthrollout

• Evaluateandre-issuetheChooseWellCampaign

• Developmaterialstosupportchoiceforplannedcare

Consistent quality of care and access

• DevelopsharedprotocolforacutecareacrossSEL

• ContinuedevelopmentofreferralmanagementservicetosupportGPsandpatientstofollowpathways

• Developreferralservices

• Testscopeforimproveddecisionssupportsoftwareintegratedintoexistingsystems

• Standardisereferralguidelines

• Developneighbourhoodhubstosupportclinicalreviewofreferrals

• ImprovediagnosisandmanagementofCardiovascularDiseaseinprimarycare

• Continuetodevelopreferralsupportservicesincludingsinglepointofreferralandchooseandbook

• Developdiagnosticsstrategyandimplementationprogramme

Care closer to home with specialist care in appropriate settings

• DevelopandembedcarepathwaysforlocalaccesstoMSK,gynaecology,oral,dermatologyaswellasoutpatient,diagnosticandminorprocedures

• Undertakeoutpatientcareaudittoidentifyserviceswiththepotentialtotransfertocommunitybasedsettings

• Re-commissionMusculo-skeletalassessmentandtreatmentservices

• Commissionopticianledophthalmologyservices

• Testnon-patientcontactapproaches

• ReviewuseofneighbourhoodresourcecentresinStreatham,BrixtonandNorwood

• ProactivePrimaryCarePilot

• IncreasecapacityinthepsychiatricliaisonbasedatLewishamHealthCentretoensureappropriateassessmentanddischarge

• Commissionnewcommunitybasedservicesinkeyspecialities;gynaecology,physiotherapyandpainmanagement

43. yearstwoandthreeoftheplannedcareworkwillcontinuetheshiftofoutpatientanddiagnosticservicesawayfromhospitalsettingsandintocommunity.Thiswillbesupportedbythedevelopmentoflocalcommunityhubs,suchasthedevelopmentofQueenMary’sHospitalinBexley,anewHealthandWellbeingCentreinBromleyandElthamHospitalinGreenwich.Thedevelopmentofthesecommunityhubsisalreadyinprogressandwillprovideincreasedcapacitytoprovideappropriateprimaryandcommunitycareservicesincommunitysettings,reducingtheactivitypressuresonlocalhospitalsalongsidethispatientchoicewillbesupportedbytheprovisionofappropriatematerialandapproachestosupportindividualsmakedecisionsabouttheircare.

44. ExamplesofcentresalreadyrunningincludetheAkermanNeighbourhoodResourceCentreinLambethwhichopenedinAugustthisyearandintegrateslocalhealthandsocialcareservicesforpatientsunderoneroof.ClaphamOnealsoopenedthisyearandprovidesPrimaryandCommunityServicesforpatients.Additionally,Lambeth,incollaborationwithLambethBoroughCouncilandKingsHealthPartnerswillopenWestNorwoodNeighbourhoodResourceCentreinSpring2014.

20

45. IfthroughtheseprojectseachGPinsoutheastLondonpreventstwounnecessaryelectivespellsamonth,activityreductionsandassociatedsavingsofaround£40msavingswillbedeliveredoverthenextfiveyears.

6. The enablers that will help to deliver the changes 46. Successfulimplementationoftransformationonthisscalewillrequirethedevelopmentand

implementationofsetofkeyenablers.BuildingonworkundertakenattheCommunityBasedCareworkshopstheCCGsandtheLondonRegionalOfficeoftheNHSCommissioningBoardhaveidentifiedfourpriorityenablersthatwillsupportthedeliveryoftheaspirationsforCommunityBasedCareinsoutheastLondon.Theseare:effectiveself-management;workforce,informationsystems,systemincentivesandcontractleversandcommunicationsandengagement.

47. Theenablerworkstreamshavebeendesignedtosupporttheworkacrossthethreeimplementerprojects.CCGChiefOfficershaveeachtakenresponsibilityforthedeliveryofanenablerandworkisplannedtocoordinatetheseactivitieswithrelevantexternalpartnerssuchastheLondonRegionalOfficeoftheNHSCommissioningBoard,LocalEducationandTrainingBoard,LocalAuthorities,SELCommissioningSupportunitandproviderorganisations.

Aim

s/O

bje

ctiv

es

1. to proactively seek to address the education needs across primary and community care as part of the process of providing more services outside hospital, and ensure better consistency of care outside CCG boundaries

2. to identify workforce development needs and to support primary, community and social care professionals in developing skills to, using economies of scale in delivery of education and training

3. to secure appropriate additional capacity in primary and secondary care

Imp

act Easy access to high quality,

responsive primary and community care



Tosupportcontractualarrangementsandincentivestoimproveaccesstoprimarycare

Througheducationensureconsistencyinhighstandardsofprimaryandcommunityservices

Toidentifyandtrainnewstafftoworkinprimaryandcommunityservices

Introduceevidencebasedpracticeforthemanagementoflongtermconditions

Supportprofessionalsinthecommunityandgeneralpracticeindevelopingspecialinterests

Ensureconsistencyofstandards

Improvehealthandwellbeingandindependence,andreducehospitaladmissionsbymorepreventivecareandgreatersupporttopatientsinthecommunity

Achieveconsistency,collaborationandhighqualityinthedeliveryofcarepathwaysineachCCG

Supportforcommunitybasedcareagendaandagreaterproportionofhealthcaredeliveredoutsidehospitals

Enabler – Workforce Dr Angela BhanChief Officer; NHS Bromley CCG


Approach – South East London wide

1. Engage with GPs, Practice Nurses and other members of practice teams in educational activities which encourage joint working between primary, community and secondary care, and social care, with the development of working partnerships within and between practices to benefit patient care, using evidence based approach.

2. Work collaboratively with the LETB, the Royal Colleges, AHSN and local professional leads to proactively address education needs across primary, community and social care as part of the process of providing more services outside the acute setting with better consistency of care across CCG boundaries.

3. Identify of workforce development needs, supporting general practice and other community and social care professionals in developing the skills to meet these needs, using economies of scale in delivery of training and education programmes, including the development of practitioners with special interests.

Mec

han

ism Use a programme delivery approach through the PMO for SE London to deliver a

strategy with a workplan. The officer lead co-ordinating and driving this forward will link CCG teams responsible for workforce development and also LETB, AHSN, Royal Colleges and educational institutions

Tim

etab

le

Year 1 Year 2 Year 3

Establishprogramme

Implementanumberofpilotstocommenceeducationalandworkforcesupporttonewwaysofworking

EachCCGtohaveclearstrategy

Commencetrainingprogrammes

ImplementationstartsacrossCCGs

Initiativesandstartchangeinjuniorhospitaldoctortraining

Newworkforceinplaceandfurtherdevelopmenttakingplace

Newtrainingschemesfullyimplemented

Exam

ple

Diabetes: bringing the expert to the communityAteamofGPs,NursesandCommissionersfromthethreeboroughsofBexley,BromleyandGreenwichhavebeenworkingtogethertoimproveservicestodiabetics.TheservicemodelchosenhasalreadybeenimplementedwithgoodauditableresultsinDerby&PortsmouthandinvolvesConsultantsworkingalongsideGPcolleaguesseeingpatientswithinthecommunity.TheConsultantgoesintothehospitalonlyforspecialistclinicssuchasobstetricsandin-patients.


•Closertohomeaccesstohelpwithmonitoringandcontrolofdiabetes.

•Achievementofthefourcaretargets(HbA1CandBPetc.)sotheykeephealthierforlonger.

•Theavoidanceoflifelimitinganddebilitatingcomplications.


•Areductioninpatientshavingtoattendsecondarycare.

•Areductioninthenumberofpatientsrequiringmajoroperation/procedurese.g.amputations.

•Moreindependentpatientssolessspentoncaringforpatientswithcomplications.

22

Aim

s/O

bje

ctiv

es 1. To increase the confidence and capability of people with long term conditions (such as diabetes, heart disease, high blood pressure and lung disease) to manage their own condition in partnership with health and social care staff.

2. To increase numbers of people self-managing minor illness and injuries.

Imp





PatientsworkingtogetherwithGPs,practicenursesandspecialisthealthstafftoplanandanticipatethecaretheyrequire.

MorepatientsusingtheirGP,practicenurseandcommunitypharmacy.

Morepatientsmanagingminorillnessandinjurieswiththesupportofcommunitypharmacies,telephoneadviceandtheirGP.

Plansforcareandsupportledbythepatientwithsupportfromhealthstaff.

Writtenplansagreedandsharedwithpatients.

ImprovedsharedinformationbetweenGPs,nurses,therapistsandconsultantsandthepatient.

Betterplanningofcareandsupporttoreducetheneedforpatientstoaccesscareasanemergency.

Patientledpathwaydesign

Enabler – Self Management Andrew EyresChief Officer; NHS Lambeth CCG

Approach – South East London wide

1. Education and publicity programmes for patients

2. Joint care planning between the patient and health staff.

Mec

han

ism

Use a consistent approach to supporting self-care across the cluster that includes:

• All newly diagnosed patients receiving information and advice on their condition.• All people with a long term conditions engaged in developing a single personal care

plan with health staff• All people with long terms conditions being offered an education programme tailored

to their needs• Education programmes for people with individual and multiple long term conditions • Development programmes with primary care and community staff to promote care

planning in partnership with patients• Simple methods of sharing care plans across organisations being developed and

implemented (this could be patient held or web based)• Education and publicity programmes across South east London to promote self-

management of minor illness and injuries

Tim

etab

le

Year 1 Year 2 Year 3

Testmodelsforeducationforpeoplewithseverallongtermsconditions

Testmodelsforcareplanning

Establishclinicalandpatientchampionsforthenewapproach

Pilotcampaignforminorillnessandinjury

Refineandrolloutmodeleducationusingclinicalandpatientchampionstosupport

EachCCGtohaveeducationprogrammeinplace

Developelectronicsharingofcareplansandrecords

Refineandextendminorillnessandinjurycampaign

Completeimplementationofeducationwork

usehealthstaffandpatientstoevaluate

Establishedmodelforcareplanninginplace

furtherrefinementofcampaignwork


Exam

ple

Lambeth Diabetes Modernisation InitiativeThisinitiativeusesbestpracticeanddiscussionswithserviceusers,providersandcommissionerstosupportselfmanagementforpatientswithdiabetes.Ithasdrawntogetherthevariousexistingservicesforpatientswithdiabetesandcoordinatedthemcentrallytoensurethatpatientshaveinformationaboutandaccesstoservicesthatbestmeettheirneeds.Byengagingpatientsineffectiveselfmanagementprogrammes,theaimisthattherewillbeasignificantreductioninunplannedadmissionsforthispatientcohort.


•Accessismoreequitableaspatientsaregiveninformationaboutallavailableservices.

•Informationandeducationisgivenatthepointofdiagnosisandthenpatientsaresupportedthroughongoingclinicalcare,review,supportandeducation.


•Effectivenessofservicescanbemonitoredcentrallyagainstsharedstandardsensuringthatservicescommissionedareeffectiveandinlinewithpatientchoice.

•Integrationisimproved,reducinginefficienciesacrossthesystem.

24

Aim

s/O

bje

ctiv

es

1. To support information sharing across primary care, community, secondary (and social care, tertiary over time) with relevant information governance arrangements to enable a shift to new models of care to deliver the CBC Strategy.

2. To establish IT solutions that effectively enable sharing of patients records across care settings through interoperability to ensure interface with existing and new IT systems across south east London.

3. To increase mobile working for staff in community settings to maximise time spent with patients

Imp





Betterclinicalmanagementofindividualpatientswithmoreeffectiveuseofscarceclinicalresources/timethroughimprovedcaseloadmanagementandincreasedmobileworkingforcommunitystaff

Providetimelyrisk-predictivetoolsbasedontheagreeddataflowsacrosscaresettings

Improvepatientexperiencee.g.throughintroductionofprogrammesgrantingpatientsaccesstotheirownrecordsandinformationaboutCBC

Effectivetreatmentofpatientsavoidingunnecessaryorduplicateddiagnosticstestsandotherclinicalactivities

Supportdeliveryofintegratedjoinedupcare

Improvepatientconfidenceinthehealthsystem,earlierdiagnosisandaccesstocare.

Supportingthemoveofactivitytomoreappropriatesettingsanddeliveryofmoreeffectiveservicesatlowerunitcosts

Supporttargetedproductivityimprovementoffewerhospitaladmissions,attendances,referralsandoutpatientfollow-ups.

Enablingmoreproactivemanagementoflongtermconditions

Potentialmitigationtoproviderreconfigurationasunderlyingdatafeedsystemsmaybealteredovertime.

Enabler – Information Systems Martin WilkinsonManaging Director; NHS Lewisham CCG

Approach – Multi-Borough collaboration

1. Define new integrated care networks based on post TSA provider configuration.

2. Develop common information strategy to support CBC delivery ensuring that shared joint standards are delivered across primary, community, secondary and tertiary providers drawing on existing borough and provider plans. There would need to be borough level work with local Social Care and Voluntary sector organisation where NHS services are delivered, supported by appropriate information sharing and governance arrangements.

3. Use of incentives and contract levers to support cultural and behavioural change to support use of information sharing tool as part of clinical practice.

4. Investigate options and agree fast-track available approaches with appropriate clinical and organisational engagement, including business case development and pilot and roll-out strategy

5. Procure solutions

6. Work with preferred IT providers to implement, including suitable training and support for staff

Mec

han

ism Delivery will be driven through a single programme to co-ordinate both the significant

level of existing work in this area and the new approaches that will be adopted over time. Coordination will be required across all CCGs, the NHS CB, all providers and the CSU with a focus on interoperability.


Tim

etab

leYear 1 Year 2 Year 3

Defineintegrartedcaresystems

Agreecommoninformationstrategyandreviewexistingopportunitiestofast-trackdelivery

Agreebusinesscase

Pilotsolution

Completeprocurement

Roll-outacrossIntegratedCareSystems

Evaluateandmodifywithcontractedsupplier

Exam

ple

Lewisham’s Virtual Patient Record InitiativeLewishamCCGisworkingwithLewishamHealthcareTrusttointroduceavirtualelectronicpatientrecordforLewishampatientsthatwillenableprimaryandsecondarycareclinicians,andintimesocialcare,toviewpatientrecordsfromacrossthehealthsystem.


•Improvesintegrationofpatientcare.

•Avoidsunnecessaryduplicationoftestsandclinicalactivities.

•Enablescliniciansandcarerstoviewrelevantpatientrecordsfromotherpartsofthehealthsystem.

•Supportsselfcareandsupport.


•DeliverscashreleasingandqualitybenefittosupporttheachievementoflocalQIPPtargets.

•Providesstrategicsupportforthedeliveryofintegratedcare,allowingvariousagenciestobeaseffectiveandresponsiveaspossible,reducingduplicationandimprovingthequalityofcare.

•Supportsriskstratificationtoidentifypatientsathigherriskofrequiringfuturecare.

26

Aim

s/O

bje

ctiv

es To incentivise a shift to new models of care to support the delivery of the CBC Strategy, through the utilisation of contractual levers, financial rewards and other incentives.

Imp





Supporteffectivedeliveryofpreventionandhealthpromotionactivitiesineverysetting,ateveryopportunity

Supportthecollaborationofprimaryandcommunitycareteamstoprovideenhancedlevelsofservicethroughnewdeliverymodels

Incentivesandcontractualleverstoreducevariationinthequalityofprimaryandcommunitycare

Providersincentivisedtoworktogethertodeliverseamlesscareforpatients

Establishfundingmechanismstoensurecareneedsarebetteridentifiedandmanagedbyanintegratedmulti-disciplinaryteamthatintervenesearliertoaddressthem

Incentivesthatdrivemoreeffectivecommunitybasedcarebyrequiringindividualisedcareplanningandco-ordinationofcare

Contractualframeworkswilldeliverenhancedandcommonstandardsandincludeclearspecificationssettingoutservicedeliverymodels

Incentivisecommonandagreedprotocols,accesspoliciesandapproachestoreferralandtheuseofdiagnostics

Incentivisechangetocurrentmodelsofdeliveryandadequatelyresourceprimaryandcommunitycaretodeliverthem

Enabler – Incentives and contractual levers Andrew BlandChief Officer; NHS Southwark CCG

Approach – South East London wide with local adjustments

Easy access to high quality, responsive primary and community care•Consistentperformancemanagementofexistingcontracts• Incentivesforthedeliveryofhigherqualitycarebasedonpatientoutcomesandflexibleapproaches

toaccesstomeettherequirementsofpatientsinformedbyengagementprogrammes•ProcurementofoutofhospitalcarethroughextendedservicecontractsorAQPmechanisms,

focusingonlocalityornetworkedmodelsofprovision• Incentivesforengagementinworkforce/traininganddevelopmentinitiatives

Integrated care for people with long term conditions•Agreementoffinancialframeworksandrisksharingagreementsthattransferfundingtowhere

integratedcareisdelivered.Thiswillincludeagreementofcapacityplanstounderpinagreedservicechange

•Supportfortheconsistentadoptionofscreening,casefindingandofrisk-stratificationinprimarycare

•CQuINSforselfmanagementandthedeliveryofcareplanningapproachesbycommunityandacuteproviders

Timely, convenient and effective planned care•Risksharingagreementswithproviderswhichreflecttheshiftofcaretolowercostsettingsand

specifythelevelofacutecaretobecommissioned•useofpaymentmechanismsthatsupportservicetransformation,suchasnon-facetofacecontacts•useofCQuINSpaymentstosupportdelivery,includingtheprovisionofadviceandguidance/

specialistsupporttocommunitybasedmodelsofcare

Mec

han

ism

Delivery across the six CCGs will be driven through a single programme to co-ordinate both the significant level of existing work in this area and the new approaches that will be adopted over time. Delivery will be on the basis of ‘Shared Standards, Local Delivery’ recognising the degree to which commissioners have already applied new and enhanced incentives and levers locally will be different by borough or group of boroughs.


Tim

etab

leYear 1 Year 2 and 3

Consistent/systematicapplicationofexistingcontractuallevers

Map,reviewandalignexistingincentives

Designandapplicationofincentivesthatsupportandappropriatelyremunerateenhancedlevelsofprovisioninlocalitiesornetworksofproviders

Ongoingdevelopmentofapproachestointegratedcare.Sharingofbestpracticetoenhanceallboroughprogrammes

Developmentofnewcontractualarrangementsthatsupportthenewmodelsofcarerequiredbythetransformationofprimaryandcommunitycaredeliveryandintegratedcare

Developmentofpathwaytariffs/yearofCarearrangementswheretheywillsupportandsecureintegrationacrosshealthandsocialcare

Exam

ple

Personal Medical Services Contracting

PMScontractingpaysGPsonthebasisofmeetingsetqualitystandardsandtheparticularneedsoftheirlocalpopulation.Theapproachhasbroughtawiderangeofbenefitsandisbeingusedtoimprovehealthoutcomes,accessandtodevelopnewserviceforpatients.TwosuchexamplesinsoutheastLondoninclude:

i SouthwarksawamarkedimprovementsinvaccinationrateswhenincentivisedbyPMScontracting.

iiSouthwarkandLambethhaveusedPMScontractingtoensurethatapercentageofpaymentislinkedtohealthoutcomesforpatients.


•Servicesaredesignedtobetargetedtotheneedsanddemandsoftheirlocalpopulationandtoreduceinequalities.


•fundingcanbetargetedtoencourageveryspecificbehavioursdependentonlocalneed.

•Outcomesbasedpaymentsareacosteffectivemechanismtopromoteandrewardinnovation.

28

Aim

s/O

bje

ctiv

es

To develop, with patient input, an approach to communicate effectively the changes taking place in primary and community based care over the duration of the programme.

To establish a programme of communication and engagement that reaches all community and acute clinicians, local community and voluntary groups.

To develop good quality resources for project teams to complete engagement activities and provide good quality communication material and branding for the Transformation Programme that gives an identity and refers to local CCG work programmes.

Imp





Ensurestrongcrossdisciplinarycommunicationandsharedinformationsystems(wherepossible)andsupportsthemonitoringofperformanceandaccountability

TostrengthenrelationshipsandunderstandrequirementsfromindividualpracticestolocalgroupsandacrosstheSELcommunity

SupportandenableeachCCGtoremainaccountablefordeliveryprovidinginformationtoallofmethodssuchasmakingcontractualchanges,drivingimprovedperformanceandcreatingacultureofintegrationbetweenproviders.

Supportandensureexpertiseissharedandbestpracticeimplemented

Todevelopandsharecollaborativeplanningandapproaches

Toinfluencepolicyandlocalinnovationindelivery

Enabler – Communications and engagement SEL Programme Director

Approach – South East London wide with local adjustments

• Create and maintain awareness and understanding of the programme, including benefits and processes, among all stakeholders

• Identify, build and maintain strong relationships with stakeholders and ensure engagement occurs at the right level, at the right time, in the right way

• Identify and manage communications issues to minimise their impact on the project• Support and provide access to detailed information analysis and financial planning

function as required across programmes• Provide clear planning, information analysis, facilitation as required• Support and provide information to help incentivise the health and social care system to

improve delivery• Make information readily available so that everyone is able to be involved and contribute

ideas / views

Mec

han

ism

Delivery across the six CCGs will be driven through a single programme to co-ordinate both the significant level of existing work in this area and the new approaches that will be adopted over time. Delivery will be on the basis of ‘Shared Standards, Local Delivery’ recognising the degree to which commissioners have already applied new and enhanced incentives and levers locally will be different by borough or group of boroughs.


Tim

etab

leYear 1 Year 2 and 3

Identifyandmanageissues

Testtitletocheckcomprehension;straplines;keymessages

DesignbrandingfortheSELCBCTransformationProgrammewhichgivesanidentityandreferstolocalCCGworkprogrammes.

draftanddistributetheregularstakeholdere‐newsletter

Developandmaintainlocalwebsite

Developcorporatematerials

Developandmaintainthecontactdatabase

Agreedandimplementknowledgesharingplatformacrossallprogrammes

Sharegoodpracticeandsupporteconomiesofscale(whatcanwedoonce)

Receiveandanalysefeedback/input

Continuetomanagegroupscriticaltofurtherengagementplanning

Supportandprovidedataonprojectandprogrammeprioritisation

supportinformationanalysisandcosting

Clearchangemanagementapproachoperationalandimplements

Continuetoprovidecrediblefacilitationexpertiseatregularpointsthroughouttheprojects

7. Delivering the community based care aspirations 48.AsoutlinedthroughoutthisdocumentdeliveringtheCommunityBasedCareaspirationswill

notonlyimprovethequalityofandaccesstocoreprimaryandcommunitybasedcareservicesforthepopulationofsoutheastLondon,itwillalsobecentraltodeliveringcontinuouslyimprovinghealthcareserviceswithinanenvironmentofincreasingfinancialchallenge.

49. SoutheastLondonCCGsconsiderthestrategytobecentraltothesuccessfulimplementationoftheTrustSpecialAdministrator’srecommendationstosecureclinicallyandfinanciallysecureservices,iftheyaresupportedbytheSecretaryofStateforHealth.

50.Accordingly,itisessentialthatthereisastrongprogrammetosupportitscontinuingdevelopmentandimplementation,includingensuringthereisclearoversightandassuranceofprogressinordertoholdallpartiestoaccountfordeliveringimprovements.TheSELCBCTransformationProgramme(CBCTP)hasbeendesignedtoprovidethisfunctionandprovidealinkintotheoverallTSAimplementationprogramme,beingdevelopedbytheTSAandhisteam.

51.AProgrammeBoardfortheCBCTPwillbeformedasasub-groupofSELClinicalStrategyGroup(CSG),agroupthatisgovernedbytheframeworkforCollaborationwhichclearlysetsoutthatCCGsremainaccountablefortheirownareasofworkandhavecommittedtoworkingincollaborationwithoneanother.ThegroupwillreportdirectlytotheCSGandwillbechairedbyacliniciandrawnfromoneoftheCCGsandhaveaProgrammeDirectorastheExecutiveLead.InadditiontothistheywillhaverepresentationfromeachCCG,eachLocalAuthority,theLondonRegionalOfficeoftheNHSCommissioningBoardandtheLocalEducationandTrainingBoardforSouthLondon.MemberswillfullyrepresenttheirorganisationssothattheProgrammeBoardcanfulfilitsfunctiontoensuredeliveryoftheCommunityBasedCareStrategy

30

52. TheCBCTransformationProgrammeDirectorwillberesponsibleforensuringdeliveryagainsttheimplementationprojectsforthethreeareasofcareandthefiveenablingprojectsofwork,outlinedinfigure4:

Figure 4: primary care transformation programme overview:

53. ToensurethereiscontinuedvisibilityandleadershipengagementinthedeliveryoftheprogrammeeachenablerhasaCCGChiefOfficerlead.IndividualCCGswillberesponsiblefordevelopingtheirlocalintegratedandplannedcareprojects,andtheCCGswillworkwiththeLondonRegionalOfficeoftheNHSCommissioningBoardtodeveloptheprimarycaretransformationprogrammeaswellastheirownlocalprimaryandcommunitycareprojects.TheProgrammeDirectorwillthenberesponsibleformonitoringprogressonalloftheseareasandholdtheCCGsandLondonRegionalOfficeoftheNHSCommissioningBoardtoaccountfordeliveringtotheagreedtimetables.TheProgrammeDirectorwill,thoughtheCommunicationsandEngagementwork,alsobemindfulofpatientfeedbackinprovidinginformationtothe6CCGsinorderthatinformeddecisioncanbetaken.

54. TosupporttheProgrammeDirectorinthistherewillbesomeprogrammemanagementsupportworkingattheindividualCCGlevel,butalsoatheprogrammelevelonprogrammesthatrunacrossmultipleCCGs.Thecurrentlyproposalis,inadditiontotheProgrammeDirector,tohaveaSELteamofthreeprogrammemanagersandadditionalsupportteam(coveringenablingfunctions.

SEL Community Based Care Transformation Programme

SELClinicalStrategyGroup

SELCBCTransformation

Board

1.PrimaryandCommunity

2.IntegratedCare

3.PlannedCare

4.Workforce

6.InformationSystems

5.Self-management

7.ContractLevers

IMPLEMENTERS ENABLERS

8.CommsandEngagement

December2012|OfficeoftheTrustSpecialAdministrator


55.DeliveringthisscaleoftransformationatthepacerequiredfortheTSArecommendationswillrequireinvestmenttosupportprogrammemanagementarrangements.Thisisexpectedtobeintheregionof£690,000peryear,andwillsupplementthesignificantplannedCCGinvestmentinlocalQIPPschemes.InadditiontothisitisexpectedthatCCGswillneedtopump-primetheirinvestmenttodeliveratpaceandtoensurethatprimarycareandcommunitybasedcareinsoutheastLondonistransformed.

56. TheCCGshaveidentifiedtherequirementsforthispumpprimingandstart-upcostsof£42mover3yearsinordertoachievethecommissionersavings,asidentifiedbytheTSA,of£128.7m.Inordertodeliverthiswillrequirefundingfromnon-recurrentsourcesacrosssoutheastLondon.

57. Inadditiontothestart-upcostsandpumppriming,therewillbeon-goingrecurrentcostsoftheredesignedservices.Oncetheprogrammeisfullyimplementedthesecostsareestimatedtobe£30mperannum.Thesewillbuildupthroughouttheimplementationperiodandwill,inpartbefundedfromreinvestmentsofQIPPsavings.

32

Bexley Commissioning Intentions 2013/14

2

I am delighted to present and commend to you our Commissioning Intentions for 2013/14 which launch our new commissioning strategy for Bexley, founded on the twin pillars of our Joint Health and Wellbeing Strategy for Bexley and our shared Community Based Care strategy for South East London. Our mantra is “Excellent Healthcare, Locally Delivered” and we are on the brink of delivering a new and innovative system of health and social care, having played a full and influential role in shaping the outcome of the work of the Trust Special Administrator at South London Healthcare NHS Trust. A reshaped Queen Mary’s Hospital, Sidcup will sit at the heart of a network of enhanced community services, closer to home diagnostic, outpatient and day services and better integrated urgent care. Many more people will be able to receive the bulk of their care in Bexley from services outside hospital that are more intensive, supported by good hospital back-up when needed. In this plan we set out our seven key “step change and transform” priorities which will see front-loaded investment in delivering new services in the community, using our hospitals much more productively for the more complex care that only they can provide. These plans for service transformation will also deliver financial balance sustainably as we move beyond transactional savings and get to the heart of a redesigned care system that pools resources with our partners to deliver better integrated services at lower cost. These step change priorities number seven; mental health, older people, children & young people, long term conditions, urgent care and planned care with our Queen Mary’s priority drawing them all together into a whole. The outcomes we seek for each priority have been drawn from a refresh of our Joint Strategic Needs Assessment as well as making sure that we deliver the national “offer” of the NHS Constitution and Outcomes Framework. We could have done none of this without our members and partners - the support and challenge that comes from strong clinical engagement with our clinical leads and three GP practice localities, our journey of development with the London Borough of Bexley and our sharing of capacity and risk across the six South East London Clinical Commissioning Groups. This is a living strategy that will also include our Health and Wellbeing priorities – particularly obesity and smoking . We have engaged with local people and wider partners to agree our priorities. We know that the citizens of Bexley are watching us closely as we change the shape and improve the responsiveness of services. Our systemic approach to engagement is essential to demonstrate that they can have confidence as we ensure a grip on quality and safety during this time of transition for the NHS as a whole – and for South East London in particular. We are determined to show improvements in patient satisfaction as the new services become a reality. As we grow a strong, clinically led commissioning organisation in Bexley, we believe that we have the will, support, optimism and pragmatism to succeed for the people we serve. Dr Howard Stoate Chair

Foreword

3

Contents

Foreword 2

Introduction 5

Our Plans at a Glance 6

Vision, Values and Commitment • Vision • Values and priorities • Step Change and Transform • Our Principles for Transformation and Clarity of Need • Developing the Organisation

7 7 8 9

10 11

Approach to Delivery • Collaborative and Partnership Working • Quality • Resources • Governance • Engagement

12 13 16 19 20 21

Case for Change • Bexley Needs Assessment • Resources

22 22 25

Key Strategic Priorities and Initiatives • Step Change and Transform/QIPP • QIPP • Queen Mary’s Hospital Sidcup • CQUINs

26 26 26 30 31

Securing Success • Monitoring Performance of Local Services and Measuring Delivery of Our Strategic Priorities • Delivering the NHS Constitution and Mandate National “Offers” • Performance Benchmarking • Finance • Contracting and Negotiations • Workforce • Estates

32 32 35 37 38 45 50 51

4

Contents

Impact on System 52

Implementation • How We Will Measure Success • Risks and Mitigations • Risks and Mitigations - Finance • Risks and Mitigations – Transformational Plans

55 53 54 57 58

Appendix • 1. QMS Draft Plan • 2. QIPP Schedule • 3. South East London Collaboration and Risk Sharing • 4. Reference documents used

60 61 62 63 64

5

The NHS is undergoing major reform and Clinical Commissioning Groups will be responsible for commissioning the majority of health services. The Department of Health has published three Outcomes Frameworks, one for each part of the health and care system intended to provide a focus for action and improvement across the system. “Everyone Counts” set out the national planning, performance and financial requirements for NHS organisations. The National Commissioning Board has been given the mandate by government to reform the system with a true focus on people and outcomes that matter most to them. Improved outcomes across the whole health and care system can only be achieved when all parts of the system work together. The right information focussed on what matters to people, supports commissioners and providers of care to drive up standards. Bold partnerships integrate services, make them easier to use and deliver financial balance in a strategic, sustainable way. 2013/14 is a year of major transition for Bexley; we took on our new role in shadow form as a Clinical Commissioning Group from 1st October 2012 and played our full part in shaping the new ten year Community Based Care Strategy for South East London, facilitated by the Trust Special Administrator for South London Healthcare Trust (SLHT), appointed by the Secretary of State for Heath. His second role is to stabilise SLHT as an organisation. His recommendations to the Secretary of State have been adopted with minor changes. A three year plus transformation programme is recommended and Bexley’s commissioning intentions will ensure that we play our part in moving services closer to home at the same time as achieving sustainable financial balance. In this plan we focus on improving health and as well as direct care and treatment for the people of Bexley. With an emphasis on local needs alongside regional and national priorities we are building effective partnerships for a Bexley single approach to commissioning , including primary care and specialised services which will be directly commissioned by the National Commissioning Board

Introduction

The NHS Mandate

6

Our Plans at a Glance

OUR DELIVERY PLANS FOR 2013/14 AND BEYOND

• Earlier intervention and access for psychological therapies via IAPT

• Swifter and more preventive care for people with mental health problems accessing general acute hospitals

•Business Case by 5/13

•Older People’s Hub starts 8/13

•OPD new QMS contract starts 7/13

Vision Deliverables

Step Change and Transform Priorities

13/14 Drivers for SuccessThe Challenge

Long Term Conditions

Tackle Hospital Readmissions and

Length of Stay

Deliver for Ageing Population

Strong on Safety in Transition

Queen Mary’s Hospital

UrgentCare

Planned Care

Mental Health

Children & Young People

Older People

BUILDING A STRONG CLINICAL MEMBER-LED COMMISSIONING ORGANISATION

SAFE

AN

D SO

UND

GOVE

RNAN

CE

Our

visio

n is

for B

exle

y’s r

esid

ents

to st

ay in

bet

ter h

ealth

for l

onge

r, w

ith th

e su

ppor

t of g

ood

qual

ity in

tegr

ated

care

, ava

ilabl

e as c

lose

to h

ome

as p

ossib

le, b

acke

d up

by a

cces

sible

, saf

e an

d ex

pert

hos

pita

l ser

vice

s whe

n th

ey a

re n

eede

d.Patients and Public at the Heart of Everything we do

• Reductions in unnecessary urgent admission

• Review and Borough-wide model agreed and procured by April 2014

• Streamlined pathways and access points

• Care closer to home with hospital back up for intensive/complex treatment

• Strengthened primary care navigation of the planned care system

• Less first outpatients - more consultant advice

• Further development of safeguarding with rise in BEAN (single) assessment rate

• Better integration of universal, specialist and mental health services for children

• Reductions in inappropriate admissions• More rapid supported discharge with

reablement• Streamlined pathways• Integrated health and social care support

• Improved pathways of care• Care closer to home with hospital back up

for intensive/complex treatment

• Redesigned Hospital Business Case• Prepare single Urgent Care Procurement• Establish Older People’s hub• Review Paediatric Assessment Unit• Contract for outpatients & day cases

Values

Strive to Achieve Best Value for Local People

Work Responsibly and Collaboratively with

Partners

Work in an Open and Transparent Way

Support New Ideas and Innovation

Accountable Ethical and Evidence Based Decisions

Respect and Meet the Needs of or Diverse

Communities

Uphold the Principles and Standards of the NHS

Constitution and Mandate

Collaborative Leadership across

Bexley & South East London to Redesign the

Care System post - TSA

Financial Grip with Sustainable

Model for Transformation

Lower Diabetes &Obesity Rates

SYST

EMAT

IC C

OM

MUN

ITY

ENGA

GEM

ENT

Enhance Patient Satisfaction

Transformational QIPP to deliver

Community Based Care StrategyEnhanced

Prevention & Care Closer to

Home

Key Results

•10.6 % of people with anxiety & depression in IAPT by 3/14

• 10% less general acute spells by 3/14

•Service mobilised by 8/13•35% reduction in target ambulatory sensitive admissions from 8/13

•Specification by 9/13;Procurement by 3/14•30% less admissions for target ambulatory sensitive conditions from 08/13

•Consultant advice service in place by 9/13

•Safeguarding Hub in place by 4/13•Integration Plans post SLHT contract novation by 9/13

• new integrated stroke/ neuro-rehabilitation service from 7/13

COLL

ABO

RATI

ON

AN

D RI

SK S

HARI

NG

ACRO

SS B

EXLE

Y AN

D SO

UTH

EAST

LON

DON

FIN

ANCI

AL C

ON

TRO

L AN

D SU

STAI

NAB

ILIT

Y

Bexley Clinical Commissioning Group (CCG), in collaboration with the people and communities of Bexley, members, the London Borough of Bexley, fellow NHS commissioning organisations and key health providers, aspires to commission high quality services, driven by real need, clear goals and within resources available, with the aim of producing visible improvements in health outcomes and patient experience.

Making a difference to people’s lives also includes improving the day to day experience of patients and those working to deliver better healthcare. We want working in Bexley health services to be a privilege and a source of pride. We now have the opportunity to enable clinicians to lead the transformational change in the way services are delivered in a more integrated way that will produce improvements in outcomes and meet the needs of the people of Bexley whilst delivering them within resources available. We will continue to ensure that local services are transformed through partnership working with patients, the public, our members, the London Borough of Bexley, our key NHS provider organisations and other key stakeholders. During this period unprecedented change across the NHS and our whole South East London system, we must show leadership and create our own certainty for 2013/14 and beyond. Partnership and collaborative commissioning are key to our success.

We will expect those providing healthcare to deliver services of the standard we ourselves would be happy to receive. Clinicians have local knowledge of health needs and we receive regular feedback on patients experiences. If a service is not of the standard we would expect we will work proactively to achieve significant improvements, using patient insight to help put things right. The NHS is facing challenging economic times and we must be responsible using the financial resources entrusted to us on behalf of the population of Bexley. This may mean, at times, making difficult decisions. We will engage with the local population in discussions concerning those decisions and we will be open and honest about the choices being made. The population profile in Bexley is changing and likely to continue to change over the next few years. There is an ageing population and Bexley also has high levels of obesity and long term conditions such as diabetes. The north is generally more deprived that the south. We will reflect our local population needs in commissioning for health.

7

Vision, Values and Commitments

Our Vision: Our vision is for Bexley’s residents to stay in better health for longer, with the support of good quality integrated care, available as close to home as possible, backed up by accessible, safe and expert hospital services when they are needed.

What matters to us Choice Give patients more power, choice and information to prevent disease and illness. This will include the implementation of the government policy on Any Qualified Provider and improving the quality of the dialogue between GP and patient as part of the consultation process Staying Healthy Through wellness education and prevention programmes, support residents to manage their health and well-being in collaboration with the London Borough of Bexley Out of Hospital Care We want services for people with long term conditions and for older people to be as close to home as possible. Unnecessary hospital care can disrupt people’s lives - where safe and appropriate, patients and professionals want to see high quality healthcare provided in the community rather than in hospital. We want to put primary and community care at the heart of Bexley’s future health system and address the long standing delivery models within the local acute hospital as well as models of care in a primary care setting.

Urgent care We will seek to divert non-complex treatment where possible to primary and community settings by transferring services to more local healthcare provision and transform services into more patient centred and effective models of care. We will improve patient access to and experience of local service providers to support the reductions in unnecessary use of urgent and unscheduled care High Quality Integrated Care We will Improve the quality and continuity of local community health and social care providers through collaboration with hospitals and the Council, to reduce delayed discharges and lengths of stay, as well as promoting self-management and limiting emergency hospital admissions Development of the Clinical Commissioning Group Even now, we are accelerating the development of the capacity and capability of the Clinical Commissioning Group and are working towards final authorisation in this financial year

8


Our Values: • We put patients and the public at the heart of everything we do • We strive to achieve the best value for local people • We act responsibly and work collaboratively with partners • We work in an open and transparent way • We support new ideas and innovation • We recognise that we are accountable to the public and take decisions that are evidence based and in the best interests of the population we

serve • We ensure that our services meet the health needs of all and respect all of Bexley’s diverse communities • We uphold the principles and standards of the NHS constitution in everything we do

STEP CHANGE AND TRANSFORM There are a number of services where more radical changes are needed to the pattern of service delivery. These will be the main areas for strategic focus and commissioning effort – and therefore the focus of these commissioning intentions. We plan to sign off our plans for a strong “hub” for borough-wide services in Bexley during 2013/14. The future of Queen Mary’s Hospital Sidcup is assured and reshaping what it offers is an important cross-cutting development that underpins all our commissioning intentions. The other six priority areas identified are: • Services for older people – a step change in community based

planned and urgent care • People with long term conditions – with a particular focus on

diabetes, cardiology, anticoagulation, musculoskeletal services and neurodisability

• Unscheduled care – including mental health, substance misuse and alcohol services, plus sustainable achievement of the A+E 4 hour target

• Planned care – redesign of referral management processes and levels, as well as the planned aspects of the long term conditions programme above

• Mental health – dementia, embedding IAPT as a preventative, demand management programme and effective unscheduled care support to general acute settings as set out in the unscheduled care programme above

• Children’s services - developing the safeguarding Multi Agency Safeguarding Hub and safe transfer of specialist children’s services to Oxleas after SLHT is dissolved

MAINTAIN AND DEVELOP The priorities to maintain and develop refer to services either where change is already well in hand and needs to be steadily embedded or where continual improvement rather than transformation or re-commissioning is the focus. We are assuming that existing plans will continue and that there will be no significant change in 2013/14 that needs to be signalled in these commissioning intentions, apart from any updated national or London-wide priorities that emerge in the next three months. The work in this programme is still focused and proactive. It centres on clear service improvement, performance management and contract management activities with providers, rather than fundamental redesign. We are building our partnership with and expectations of the South London Commissioning Support Unit, who are essential both to improving and developing current services and negotiating our step change priorities into workable contracts

9


In line with our overarching priorities and those reflected in the NHS Mandate we plan to divide our strategic commissioning priorities for 2013/14 into two categories. This is important because we have to use what capacity we have as commissioners in a focused manner at a time of major transition.

10

Vision, Values and Commitments – Our Principles for Transformation and Clarity of Need

At the centre of the transformation programme is the overriding aim to integrate all aspects of QIPP principles into each work stream. The programme will provide quality, innovative, productive services that look at whole system pathways including prevention. Until now our programmes have been largely transactional rather than transformational A critical success factor of the programme is integration of services across organisation boundaries. The need to integrate services within Bexley has been a key priority for some years and in 13-14 is something that we will deliver as a fundamental part of transformation. To achieve transformation we will work to a set of principles: • Ensure linkages at a patient management level between the six

priority areas and the wider system are standardised, accessible and responsive for patients

• Develop system based and disease specific pathways from prevention and identification to end of life;

• Break down of boundaries between primary, community, acute and social care

• Develop innovative workforce solutions including federated GP working, joint health and social care teams, and greater partnership working between primary care and acute care clinicians

• Commission redesigned services to follow a standard commissioning cycle

• Ensure we maximise the use of effective procurement and contractual options and levers.

• Ensure that patient and public engagement is systemic

The Joint Strategic Needs Assessment has been refreshed in time for 2013/14 working closely with Kings Health Partners and supported by a comprehensive Health Needs Compendium. It confirms that obesity and smoking are clear priorities from a health improvement perspective and reinforces the focus we need to have on diabetes, dementia and older people. It also underlines that from a Bexley perspective, we stand out in London for obesity and for our relatively high use of hospital services, particularly for urgent care and how we manage admission and discharge . This aligns with the Everyone Counts CCG Pack for Bexley, which shows a high rate of emergency admissions within 30 days. It also tells a story of the need for new steps in patient engagement as we do comparatively less well on the indicators relating to satisfaction with GP and inpatient hospital services, people feeling supported to manage their long term condition, and patient reported outcomes for hip and knee fractures.

How we will meet this need is through Bexley’s version of the Community Based Care Strategy in the wake of the TSA’s work addressing our need to grow and intensify community based services using some of our 2% of turnover as bridging funds and working across all South East London CCGs on a shared acute capacity reduction plan. The new services will be integrated with social care and therefore easier for people to use and more cost effective. Capacity reduction and health and social care integration are the twin levers for both improvement and cost effectiveness

The need for replacement services has therefore been modeled for our QIPP as a whole and each acute contract to be clear that the end point contributes to sustainable financial balance

Clarity of Need Principles for Transformation

11

Vision, Values and Commitments – Developing the Organisation

Our organisational development programme will inform both the how and the why we are “in business” and specifically our: • Organisational Behaviours:

• Leadership ethos and style; • Leadership development strategy (Governing Body and

Executives); • Core competencies/competency framework (acceptable

behaviours) at every level (including how they are measured and monitored);

• HR policies and strategies (including talent management and succession planning).

• Key Operating Systems: • Involvement and participation (especially with the

members); • Performance management approach (people and

outcomes); • Aligned operational management processes; • Resources management framework (get the ‘best bang

for our buck’).

We are continuing to develop Bexley CCG to ensure, as an organisation, we can deliver our vision for Bexley residents to stay in better health for longer, with the support of good quality integrated care, available as close to home as possible, backed up by accessible, safe and expert hospital services when they are needed. These developments include: • Building our commissioning capability and capacity • A robust governance structure including quality and performance • Building effective collaborative commissioning with key partners • Building strong contracting and negotiation processes with

providers supported by our South London Commissioning Support Unit

• Establishing a joint commissioning team with the London Borough of Bexley to accelerate service integration

• Consolidating all commissioning and contracting for acute and community services in one team – making sure that service redesign does follow through into deliverable contracts

• Building up and supporting a stronger public health function with London Borough of Bexley

• Ensuring GP led clinical, public and patient engagement These priorities guide our OD Programme and we have already commenced our Governing Body and Health and Wellbeing Board development programmes - as well as an internal senior leadership development forum.

Quality, Innovation, Productivity and Prevention (QIPP) – the Bexley Health System The development of Bexley CCG presents us with the opportunity to enable clinicians to lead the transformational change in the way services are delivered that will produce improvements in outcomes and meet the needs of the people of Bexley whilst delivering them within resources available. For 2013/14 and beyond , the QIPP now is our Commissioning Strategy and Transformation Plan Our approach in 2013/14 is to make a step change to create a much more transformational QIPP that becomes our core commissioning strategy rather than being a semi-detached savings plan. At its heart is a step change towards a comprehensive community/closer to home model of service that will see a suite of services underpinned by a health hub delivered both at and around Queen Mary’s Hospital . We want to have in place an integrated Urgent Care Centre; the bulk of outpatient, day surgery and diagnostics; 24 hour more intensive services for older people; a range of services for people with long term conditions starting with diabetes or needing anticoagulation therapy; integrated services for children; mental health; community integrated stroke and neurodisability services – plus specialist outreach radio- and chemotherapy. The Secretary of State has endorsed these Trust Special Administrator recommendations and we are now setting about the local implementation through a reshaped Queen Mary’s Programme Board engaging all partners. We plan to use our 2% non-recurrent resource to establish these new models of service and cover double running costs, bridging change and reducing our acute spend and capacity in an orchestrated way across South East London together with our five partner

CCGs. We are assessing our own QIPP and provider cost improvements through clinician to clinician sessions as part of contract negotiations and through our Quality and Safety Committee of the Governing Body to ensure that services are safe for patients with no reduction in quality.

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Approach to Delivery

Success depends on robust planning and governance, which we achieve through our Programme Management office processes. All commissioning “step change and transform” priorities go through a three stage process, from ideas generation, to project initiation document and on to business case. The process incorporates quality and safety and evidence/best practice dimensions as well as value for money. The key governance sign-off stages include the Finance Working Group and Executive Management Committees of the Governing Body, with sign off at the Governing Body itself. Joint venture based planning happens through the Bexley Joint Commissioning Board with the Council and the South East London CCGs’ Clinical Strategy Group with recommendations taken back through the CCG’s own decision making process. Connecting into the NCB’s commissioning priorities for primary care, specialist and other London-wide commissioning is underpinned both by the London–wide CCG Chief Officers’ Group and by anticipated NCB membership of the local Health and Wellbeing Board

Quality, Innovation, Productivity and Prevention (QIPP) – the Bexley Health System The development of Bexley CCG presents us with the opportunity to enable clinicians to lead the transformational change in the way services are delivered that will produce improvements in outcomes and meet the needs of the people of Bexley whilst delivering them within resources available. For 2013/14 and beyond , the QIPP now is our Commissioning Strategy and Transformation Plan Our approach in 2013/14 is to make a step change to create a much more transformational QIPP that becomes our core commissioning strategy rather than being a semi-detached savings plan. At its heart is a step change towards a comprehensive community/closer to home model of service that will see a suite of services underpinned by a health hub delivered both at and around Queen Mary’s Hospital . We want to have in place an integrated Urgent Care Centre; the bulk of outpatient, day surgery and diagnostics; 24 hour more intensive services for older people; a range of services for people with long term conditions starting with diabetes or needing anticoagulation therapy; integrated services for children; mental health; community integrated stroke and neurodisability services – plus specialist outreach radio- and chemotherapy. The Secretary of State has endorsed these Trust Special Administrator recommendations and we are now setting about the local implementation through a reshaped Queen Mary’s Programme Board engaging all partners. We plan to use our 2% non-recurrent resource to establish these new models of service and cover double running costs, bridging change and reducing our acute spend and capacity in an orchestrated way across South East London together with our five partner

CCGs. We are assessing our own QIPP and provider cost improvements through clinician to clinician sessions as part of contract negotiations and through our Quality and Safety Committee of the Governing Body to ensure that services are safe for patients with no reduction in quality.

13

Approach to Delivery

Success depends on robust planning and governance, which we achieve through our Programme Management office processes. All commissioning “step change and transform” priorities go through a three stage process, from ideas generation, to project initiation document and on to business case. The process incorporates quality and safety and evidence/best practice dimensions as well as value for money. The key governance sign-off stages include the Finance Working Group and Executive Management Committees of the Governing Body, with sign off at the Governing Body itself. Joint venture based planning happens through the Bexley Joint Commissioning Board with the Council and the South East London CCGs’ Clinical Strategy Group with recommendations taken back through the CCG’s own decision making process. Connecting into the NCB’s commissioning priorities for primary care, specialist and other London-wide commissioning is underpinned both by the London–wide CCG Chief Officers’ Group and by anticipated NCB membership of the local Health and Wellbeing Board

14

Approach - Collaborative and Partnership Working

South East London (SEL) Clinical Commissioning Groups

A framework for joint working, risk sharing and collaborative commissioning was agreed by all six emerging CCGs during September 2012. This is critical as we draw together the ten year strategy for the development of Community Based Care following the Secretary of State’s endorsement of the Trust Special Administrator’s recommendations. A SEL Programme Director has now been appointed to support joint delivery. We run a common Contract Management Board across Bromley, Bexley and Greenwich for the SLHT contract and will explore the same for mental health (BBG) and community services (jointly with Greenwich) for 2013/14, the first step being simultaneous working on our separate contracts to ensure alignment. We also have a shared Redesign Programme and our joint commissioning intentions cover the following: • Common standards for anticoagulation services (AQP), MSK,

cardiology, diabetes and neurorehabilitation services in readiness for procurement

• Joint re-procurement of our Patient Management (Referral) Centre with Greenwich, given that we share the same provider

• Consultant advice sessions to reduce/replace outpatients, jointly initially with Bromley

We are also setting up a SEL wide medicines management programme.

London Wide Commissioning Priorities There are a number of pan-London commissioning priorities including: • Cancer: earlier diagnosis and better co-ordination of care

for cancer survivors • Cardiovascular services • Long term conditions such as diabetes • Readiness for Mental Health PbR • Public health and prevention • Safeguarding • Childhood obesity • Alcohol abuse We will work closely with partners across London to share best practice and ensure we utilise any appropriate opportunities for collaborative commissioning

South London Academic Health Science Network (AHSN) We will also work with the South London Academic Health Science Network to ensure we align education, clinical research, informatics, innovation, training and education and healthcare delivery. The goal is to improve patient and population health outcomes by translating research into practice and developing and implementing integrated health care services. By working with the AHSN we will identify innovations and spread their use at pace. The AHSN’s four main objectives are: • Bringing academic and rigour to service improvement • Focus on key public health issues in South London • Deliver lasting improvements on a wide scale across the

whole of South London • Generate wealth for the local economy and

improvements to patient care at the same cost or reduced investment

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National Commissioning Board commissioned services The NHS Commissioning Board will directly commission services in five areas: • Primary medical, dental, pharmacy and optical services as

well as all other dental services • Specialised services • Some specific public health screening and immunisation

services • Services for members of the armed forces • Services for offenders in institutional settings Specialised Services The NHS Commissioning Board has set out how a single, national system will ensure the small number of patients requiring very specialised treatment are offered consistent, high quality services across the country. The new system will provide a clear focus on a range of rare conditions and low volume treatments ranging from medical genetics, kidney disorders and uncommon cancers to complex cardiac interventions, burn care and some specialised services for children. We will work closely with partners and the NCB to ensure the whole patient pathway is as seamless and locally responsive as possible in meeting patients needs. It has also set out its plan for a twelve national networks to improve health services for specific patient groups or conditions e.g. cancer, mental health and dementia. We will work with the locally based support teams to develop an annual programme of quality improvement in local services.

Primary Care The CCG wishes to continue and build the relationship with the National Commissioning Board to improve quality in primary care. There are clear benefits including: • Including the quality of service offered by practices as

assessed by Myhealthlondon and supporting the NCB in identifying areas where quality should be improved

• Working with NCB colleagues to increase access in primary care in areas identified by the patient survey

• Increasing the range of quality services provided by practices as under the community contract

• Collaboration in areas or poor quality and performance to support peer review and management of colleagues

• Establishment of joint plans to share information and a joint approach to improve quality

Meanwhile we are engaged in the practical handover of functions and contracts to the NCB as a successor body and ensuring that the correct financial assumptions ensure effective negotiation of our own core contracts.

Our Joint Commissioning Priorities are:

• Integration of Community Services for older people • Implementing the Multi Agency Safeguarding Hub • Consulting and acting on the new Carer’s Strategy • Joint re-procurement of voluntary sector grants and contracts • Procurement of an integrated stroke and neuro-rehabilitation

service • Implementing the Dementia Strategy • Mental Health - stronger support and diversion from general

acute services • Developing integrated plans for end of life care • Securing and embedding improvements in our Learning Disability

NHS Self Assessment Framework (SAF) to ensure that people with Learning Disability have good access to mainstream healthcare

• Review and redesign of our mutual Continuing Care processes

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Joint Commissioning During 2013/14 we aim to consolidate and strengthen our approach to joint commissioning in Bexley. We have already refreshed the Joint Strategic Needs Assessment (JSNA) and agreed joint priorities for the Joint Health and Wellbeing Strategy. We are appointing a Joint Assistant Director of Integrated Commissioning and are introducing a new structure: We are developing a joint performance and outcomes framework as well as strengthening governance, formally linking the Joint Commissioning Board to the Health and Wellbeing Board. An approach has already been agreed to refresh our Section 75 agreements and we are joining up our voluntary sector commissioning programmes during 2013/14

Joint Assistant Director of Integrated

Commissioning

Children and Young People

Adults (Mental Health, Learning

Disability, Physical Disability)

Older People (with dementia)

Our key priorities in our approach to quality are: • To work in collaboration with all providers, the public,

patients and other commissioners to promote an open culture quality of improvement across the local healthcare system

• To seek assurance that the services commissioned for the population are of appropriate quality and offer value for money

• To intervene where appropriate quality standards are not being met

These key priorities are underpinned by the pledges made to patients by the NHS Constitution which sets out the rights to which patients, public and staff are entitled based on the principles and values of NHS in England. We recognise the importance of quality and are developing our approach to quality with a focus on clinical leadership and embedding quality in the commissioning and contracting processes. The Francis report will rightly lead to a step change in both the systems and culture through which quality is safeguarded. The Family and Friends Test is a key part of this culture change

We recognise that we can’t work in isolation if we are to make a difference to the quality of our local population. Wherever possible partnership working opportunities will be explored.

We will work in partnership with: • Our members to ensure that they have a clear view of our

approach to quality, any on going quality issues and our solutions

• Other commissioners to share expertise across a range of commissioned services and disseminate knowledge of best practice across the health economy

• Clinical and care staff working in both health and social care who are best placed to identify opportunities to improve

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Approach – Quality

Patient experience – acting on what patients tell us, strengthening their voice in contract monitoring as well as service improvement - improving personal dignity, information sharing and communication

Safe clinical practice – setting an open culture that makes sure that people can talk to us and we get good local intelligence to target areas of concern including proactive assurance of performance against national standards and ensuring that action from lessons learnt is implemented effectively

Good clinical practice – ensuring all clinicians and services are working systematically to accepted good practice and recommended guidelines.. Also that there are good systems in practice of clinical communication and information sharing that are timely, accurate and relevant

Agreed pathways of care – ensuring effective management of care by primary, community and secondary care services, with care indicators that measure the quality of a whole pathway of care

Integration of care – ensuring the effective management of care between providers with clear collaboration and communication

Smart Contracting - with strong monitoring through specific quality and safety contract review meetings and CQUINS feeding into the Quality and Safety Committee of the Governing Body

Our approach will include:

Promoting and supporting collaboration will be a key feature of contracts and negotiations with providers.

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Approach – Quality

Quality outcome metrics and performance indicators that are built into service specifications

Staff focus on direct patient care, at team, ward level etc

Leadership by clinicians

Supporting skills development for clinicians

Common indicators across individual Trusts to support integrated working and improved communications

A payment scheme within contracts to promote and reward quality through commissioning for quality and innovation (CQUIN)

Quality standards, outcome measures and performance indicators will be monitored

Review standards and incentive mechanisms regularly e.g. annually

Local intelligence will be brought together with information from a broad range of data sources including lessons learnt, trend data etc. to proactively identify quality issues for action

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Approach – Resources

The CCG has a Medium Term Financial Strategy in place and has developed a 3-5 year financial plan based upon the Trust Special Administrator (TSA) assumptions plus the national planning assumptions issued in December 2012, which plans to return the organisation to recurrent financial balance, and meet the required 1% surplus. Since 2011/12, Bexley Care Trust has relied on non-recurrent support, including use of a proportion of the 2% non-recurrent resource, to meet its required financial duties. Part of the plan is for the CCG to undertake significant transformational QIPP schemes, often in conjunction with other local CCGs rather than transactional, as in 2012/13, to ensure delivery of the Operating Framework requirements.

The CCG has now received the final allocations, announced in December 2012, and has developed draft 2013/14 budgets and QIPP schemes based upon these. However, there are a number of concerns with the allocations which are being discussed with the Department of Health and need to be addressed prior to plans being finalised. The main concern surrounds the value to be transferred to the National Commissioning Board in respect of additional specialist services. Assurance has been received that this adjustment should be cost neutral and this assumption has been used in planning, as advised.

Financial issues are communicated to the Governing Body on a regular basis to ensure that all members are aware of the risks and assumptions being included in the financial planning processes. Regular reports are also taken to the Finance Working Group and the Executive Management Team.

P

The Executive Management Committee will be responsible for delivery of our Commissioning Intentions agreed by the Governing Body through the Operating Plan. The Lead Director is the Director of Commissioning. To do this successfully the other key governance building blocks are: Bexley Health & Wellbeing Board and the Joint Commissioning Board for joint priorities with the council, South East London wide through formal collaborative commissioning arrangements, South East London and BBG Programme Offices and programme arrangements for the implementation of the TSA recommendations through the QMS Programme Board. The Quality and Safety Working Group will be responsible for any governance and quality issues relating to the initiatives. Our governance arrangements are shown below.

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Approach – Governance

Audit and Integrated Assurance Committee

Governing Body

Nor

th B

exle

y

Frog

nal

Cloc

ktow

er

Challenge Executive Management Committee

Quality and Safety Working Group

Finance Working Group

Medicines Management Working Group

Information Governance Working Group

Remuneration Committee

Primary Care Advisory Group

Governance Arrangements for QMS Transition

NHS Bexley CCG will: • Involve and listen to patients, carers and the public in

decision making throughout the commissioning cycle • Use the insight of patients and carers to improve patient care • Support patients to make decisions about their own health • Ensure that all the providers we commission services from

support our principles

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Approach - Engagement

To illustrate our commitments to deliver health commissioning in Bexley we want to see a meaningful and effective engagement where: • Partnership working is the norm • The patient voice is heard throughout the process of

commissioning • All parts of the community are included, particularly those

whose voices are seldom heard • Decisions made by the governing body are fed back to

patients and the public • A clear structure to deliver engagement is developed

Patient, carers and public will: • Understand what services are available and how care is

delivered • Know how decisions are made and how to become active

partners in the decision making process • Know how to get help and support in maintaining healthy

lifestyles and managing their own conditions We will use our existing structures and networks, complementing them where necessary to ensure involvement, from as wide a range as possible of community groups, at all stages of the commissioning cycle: • Strategic planning • Specifying outcomes and procuring services • Managing demand and performance The foundations of our approach is our Patients Council with a member on our Governing Body and drawing some 50 organisations into it – as well as feeding into all of our GP Patient Participation Groups

Patients will: • Be asked whether they would recommend their hospital to

those with whom they are closest through the Friends and Family Test

Introduction We are committed to our commissioning having a clear evidence base. Critical to this is our Joint Strategic Health Needs Assessment (JSNA). We have considered the available needs evidence from the JSNA and evidence from a number of other sources such as quality and performance issues in current service delivery and the Department of Health Operating Frameworks requirements as well as the new NHS Mandate. We have based our priorities on the evidence and conclusions from these varied sources. Key findings and Conclusions On the basis of most indicators of the health of Bexley residents is good in comparison with England and Wales. However there are some general patterns that mean that the health of the population is likely to worsen in the future.

Specific Health Issues in Bexley Our JSNA has identified some specific health issues that we need to address: Obesity • About 21.3% of Year 6 children are classified as obese, higher

that the average for England • Estimated levels of adult physical activity and obesity are

worse than the England average • 26.4% of adults are obese Diabetes As obesity is a significant risk factor for diabetes it is not surprising that Bexley has a higher rate of diabetic patients diagnosed compared to the UK average. • Most adults with type 2 diabetes are diagnosed at around the

age of 40. Alarmingly, Bexley has 7 children currently being treated for type 2 diabetes

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In line with the Joint Strategic Needs Assessment the following joint priorities for 2013/14 have been agreed by the Health and Wellbeing Board: • Childhood and adult (new for 2013/14) obesity • Tobacco control • Nutrition in nursing homes • Dementia (new for 2013/14) • Diabetes (new for 2013/14)

The Joint Strategic Needs Assessment refresh also illustrates the continuing need to: • Reduce emergency/urgent admissions and length of stay across the board, including for older people, cancer, asthma and other long term

conditions by further development of risk stratified prevention and 24 hour urgent care and reablement in the community • Maximising the primary/community care components of planned elective pathways e.g. for cardiology and musculoskeletal services

integration

Case for Change – Bexley Needs Assessment

Specific Health Issues in Bexley Dementia Bexley has a lower number of patients with dementia compared to other areas in the UK. However total bed days in hospital per population for patients over 74 years with a secondary diagnosis of dementia are high. • High rates of admissions with emergency ambulatory care

conditions • High rates of admissions from nursing homes and residential

care homes • Ageing population Smoking • Smoking prevalence in England is estimated to be 21% of the

adult population, there is no precise measure of smoking prevalence in Bexley (LHO Tobacco Control Profile 2012 measures prevalence at 18.1%)

There are other health issues in Bexley that we will investigate and address but it has been agreed that additional focus should be given to the specific health issues identified. As the population in Bexley changes these health issues may change and we will continue to refresh our JSNA to ensure that we always use available and up to date needs evidence to inform our decision making. For example the proportion of residents over 65 years has been projected to increase by 2016. Therefore there will be a higher need for services associated with older age, particularly long term conditions and dementia.

Case for Change – Bexley Needs Assessment

23

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Case for Change - Bexley Needs Assessment

The needs assessment evidence would suggest that a number of challenges for Bexley. Challenges Key Issues

Improving the care of older people • The development of a comprehensive service model for frail older people – with a stronger community focus and less hospitalisation

• Further integration of care with Adult Social Care • Delivery of the national and local dementia care strategies in partnership with the local authority

Improve the care of people with long term conditions

• The development of an integrated strategy and community based model for long term conditions • Reduce the prevalence of and managing more effectively long term conditions for the people of

Bexley outside hospital • Build a stronger focus on self management and patient led outcomes

Improving mental wellbeing • Improved benchmarking and intelligence as part of the transition to Payment by Results for mental health services

• Improve access and quality of primary and community mental health services particularly learning from Improving Access to Psychological Therapies (IAPT)

• Continued focus on supporting the repatriation of service users receiving out of Bexley care • Reduce mental health episodes within the general acute hospital system

Improving the health of children and young people

• Continue to improve the integration of children’s health care across the health system and with the local authority

• Work with public health to support lifestyle improvement for children particularly with obesity • Improved access and quality in CAMHs

Reconfigure and modernise health services to provide more sustainable and high quality care

• Support the continued reconfiguration of services, particularly QMS • Transform the unplanned care system and pathways • Improve planned care pathways, particularly for cancer and cardiovascular disease

Reducing smoking particularly in young people

• Promote the de-normalisation of smoking • Prioritise tackling illegal trade in tobacco products to protect children • Focus on preventing uptake of smoking by young people • Promote smoke free homes • Ensure everyone in Bexley knows how to access help to stop smoking • Ensure sign up and representation from all partners

Nutrition in nursing homes • Widen beyond this theme to identify whether nutritional care can be improved for all vulnerable older people to prevent deterioration in health that may lead to unnecessary admissions to hospital

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Case for Change - Resources

Bexley Care Trust had an agreed 3-year plan (2012/13-2014/15) that ensured achievement of statutory duties and the 1% required surplus over the 3-year planning period 2012/13-2014/15. This has now been updated for 2013/14 onwards for the revised allocations and planning assumptions advised in the latest national planning assumptions. Achievement assumes that the plan will be delivered in each of the financial years and is reliant on significant QIPP achievement. In 2012/13, significant over-performance has once again been seen within the acute sector, which is being covered in-year from non-recurrent resources. Furthermore, the existence of a cap & collar agreement with South London Healthcare NHS Trust has resulted in a benefit to Bexley in this financial year. These non-recurrent means are in addition to the £4.8m financial support received in 2012/13. However, the Care Trust is expecting to report in line with its control total of £3.5m surplus for 2012/13 and a pro-rated proportion of this has been included in 2013/14 financial planning. In the summer of 2012, the Government appointed a Trust Special Administrator (TSA) to South London Healthcare NHS Trust to look at the viability of services across the Trust and South East London. This work looked at the financial gap across the health economy. A new set of planning assumptions were discussed and agreed with Chief Financial Officers across the CCGs and these resulted in a larger gap than the original 3-year plans submitted and agreed by each PCT. These assumptions have subsequently been adjusted across London and these have been included in financial planning for 2013/14, together with the national assumptions issued in December 2012.

QIPP Priorities Four key priorities identified for transformation that align to the Community Based Care Strategy are:- Easy Access to High Quality Responsive Primary and Community Care • Providing easy access to high quality, responsive primary &

community care as the first point of call for people in order to provide a universal service for the whole population and to proactively support people in staying healthy

This will include: • Reduction/redesign in access points for Urgent Care • Prevention and self care particularly in obesity

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Key Strategic Priorities and Initiatives

Our STEP CHANGE AND TRANSFORM priorities for 2013/14 are:- Queen Mary’s Hospital – the hub that will make everything else work services for older people – a step change in community based planned and urgent care people with long term conditions – with a particular focus on diabetes , cardiology, anticoagulation, musculoskeletal services and neurodisability unscheduled care – including mental health, substance misuse and alcohol services, plus sustainable achievement of the A+E 4 hour target planned care – redesign of referral management processes and levels, as well as the planned aspects of the long term conditions programme above mental health – dementia, embedding IAPT as a preventative, demand management programme and effective unscheduled care support to general acute settings as set out in the unscheduled care programme above children’s services - developing the safeguarding MASH and re-commissioning of specialist children’s services

Integrated Care for People with Long Term Conditions • Ensuring there is high quality integrated care for high risk

groups (such as those with long term conditions such as diabetes, the frail elderly and people with long term mental health problems) and that providers (health and social care) are working together, with the patient at the centre. They will enable people to remain active, well and supported in their own homes wherever possible.

Timely, Convenient and Effective Planned Care • For episodes where people require it they should receive

simple, timely, convenient and effective planned care, with seamless transitions across primary and secondary care, supported by a set of consistent protocols and guidelines for referrals and the use of diagnostics

Children’s Services • Strengthening safeguarding arrangements further by

introducing the new Multi Agency Safeguarding Hub

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Key Strategic Priorities and Initiatives- QIPP

The 2013/14 QIPP schemes total £12.1m with a net risk assessed value of £10.9m which need to be delivered if we are to deliver our 1% surplus and meet our statutory responsibility to break even. The delivery of a QIPP programme is complicated by the financial situation of both of Bexley’s local acute providers: South London Healthcare NHS Trust and Dartford and Gravesham NHS Trust. The former has recently been under review by the Trust Special Advisor whose recommendations are now agreed by the Secretary of State for Health. The 2013/14 QIPP consists of £0.5m relating to existing schemes carried forward from 2012/13 and £10.4m relating to newly developed schemes. Work has taken place both internally and with the CCG’s partners to identify potential QIPP areas across the full spectrum of the organisation’s commissioning and operational budgets. This has been done by reviewing the performance of service areas against the national performance indicators, the national NICE compendium and comparing the gap between our existing performance and top quartile performance in the same service area nationally. Lead commissioners explored the potential to make quality and productivity gains and a long list of potential areas were identified before being narrowed down, following extensive work, to those included in the QIPP plan. Some schemes will likely result in a significant shift in activity between providers and from acute to community, in line with the CCG’s Community based care strategy.

Providers are engaged at the QIPP planning stage to ensure that they understand Bexley’s plans. For 2013/14, all acute QIPP plans were shared at an early stage with Provider Trusts. This process is coordinated and communicated to providers in a coherent manner, by the CSU, thus enabling the providers to appropriately plan and reduce capacity. The value to be decommissioned from the acute sector is available by provider and these plans are currently being discussed in contract negotiations. The CCG has moved from transactional QIPP in 2012/13 to transformational in 2013/14 to secure the level of savings required to ensure financial sustainability and improve healthcare for the local community. Work is ongoing to identify further pipeline schemes in case of slippage on the initial schemes. However, primary resource will be on ensuring delivery of those already identified. Shown in table 1 are the shifts in the size of the QIPP challenge and that achieved compared with 2011/12 & 2012/13: Table 1: 3-year QIPP

Year Planned Achieved £ Achieved %

2011/12 10,203 8,181 80% 2012/13 7,585 7,044

(FOT) 93%

2013/14 10,900

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Significant resource has been expended in 2012/13 developing the plans, but further resource will be required to facilitate delivery. It is intended that business cases will be submitted to the National Commissioning Board (NCB), against the 2% non-recurrent resource for 2013/14 and 2014/15, as a source of investment for double running and pump priming QIPP to ensure its delivery. This formed the basis of the South East London plans presented to the NCB.

The CCG has its own Programme Management Office (PMO) whose processes are fully embedded within the organisation. Schemes follow a defined process as shown in table 2.

Table 2 – PMO process , key documents and milestones within the CCG This process is linked to a gateway approval process and ensures that account is taken of benefits and costs to patients, quality and safety implications and patient council involvement before the scheme is implemented and that the scheme is viable prior to RAG rating. Areas that will be considered at the PID stage include the magnitude of benefit (health gain), whether the scheme addresses health inequalities, evidence of clinical effectiveness, fit with national and local priorities, the net financial impact, length of time needed to realise savings, the risk of implementation and the risk of doing nothing.

The CCG has an agreed process for RAG rating of the QIPP schemes which is carried out by a multi-disciplinary group from inside and outside of the organisation. This brings integrity and governance to the process and ensures ownership. The difference between the full net value of the QIPP schemes and the RAG rated value has been set aside as a specific activity management reserve (as QIPP is primarily acute related) to mitigate the risk of failing to deliver. The Care Trust had a good track record of delivering QIPP schemes, albeit more of a transactional nature, and it is expected that the CCG will do equally well. The CCG continues to operate a system of tight financial control, focusing on addressing any financial issues as and when they arise. The PMO monitors and reports on QIPP delivery as in the following table. The PMO has robust monitoring and reporting systems in place to support delivery of the QIPP schemes. There is a South East London (SEL) PMO, across the six CCGs, which will also support the development and delivery of QIPP, in particular the community based care strategy across South East London. To ensure that the QIPP target is met in 2013/14, additional schemes will be continually sought to create a pipeline and existing schemes will be reviewed monthly to evaluate the projected savings levels that will be realised in the current financial year. In addition to working with GPs, the Local Authority and the CSU, CCG staff are meeting with South East London (SEL) CCG colleagues to explore areas that can be developed across the six boroughs. This SEL approach is being facilitated by the SEL PMO and will facilitate the decommissioning of services within the acute sector. Multi agency and Pan CCG working could impede the speed of delivery of QIPP schemes. However the CCG also views this close working as an opportunity on which to build and improve the healthcare for the residents of Bexley.

Stage Documents Output Ideas Generation

Ideas Generation Form Assessment Questionnaire

Ideas are presented to the Finance Working group (FWG) for consideration and validation. Questionnaire is used for decision to agree progression to validation stage.

Ideas Validation PID template Validation Questionnaire & Score Sheet

FWG agrees procession to business case. Questionnaire and score sheet are used to document rationale for approval to progress.

Implementation planning

Business Case template Implementation & Monitoring template

Sign off per schedule of delegation. Implementation starts. Evidenced in Financial Plans. Measurement & reporting of plan Success.

Closure Closure template Rationale for cessation of scheme.

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Table 3: Outline diagram of the QIPP assurance process

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One of our major changes is the reshaping of Queen Mary’s Hospital Sidcup

Queen Mary’s Hospital Sidcup in Bexley is one of three main sites currently run by South London Healthcare NHS Trust. We have been talking for the last two years about how the hospital site could be used in the future to provide a range of health services for local people. We have developed together a vision for the sorts of services we want to see delivered from the Queen Mary’s Hospital site. We agree we want to see it transformed into a hub at the centre of health and care in Bexley. The Trust Special Administrator and now the Secretary of State agrees with this vision for the future of QMS and recommends that a range of services will continue to be provided on the site, with some added and some moved to other hospital sites in South East London. The draft recommendations propose that South London Healthcare NHS Trust which currently owns the site is dissolved and that Oxleas NHS Foundation Trust takes ownership of the site instead. They also recommend that community health services and support continue to be included as well as an inpatient mental health ‘centre of excellence’ for patients for Bexley and Bromley. Recommendations also include a proposal for a specialist radiotherapy service at the site, run by staff from Guy’s and St Thomas’s NHS Foundation Trust which would allow patients to have cancer treatments closer to where they live rather than travel into central London. The immediate task in 2013/14 is to secure the safe transfer of SLHT contracts to Dartford and Gravesham NHS Trust , Kings Healthcare and Oxleas Foundation Trust . The QMS Programme Board will ensure the production of business cases to reshape the physical site and draw together the full set of integrated service plans.

Key Strategic Priorities and Initiatives – Queen Mary’s Hospital Sidcup

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The DH have already indicated a CQUIN may be required to help to improve data quality for the successful implementation of PbR in mental health. This will be essential to making informed commissioning decisions about services in the new world of PbR. We will meet with Directors of Quality and Safeguarding Lead nurses as part of this process to ensure a ‘catch all’ approach to the use of CQUIN Bexley CCG’s main CQUIN choice is Adult and Children's Safeguarding as this is an area where performance needs to improve across the area. The other CQUIN choice is to cover elderly care and stretch targets around pressure ulcers, fall, dementia etc. Some principles have been put forward that CQUINs: • Are NOT an income stream, they must be earned/delivered • Need to avoid the perverse incentive of paying Trusts to

deliver contractual obligations • There must be stretch • They are developmental but also sustainable, so scheme

funding is pump-priming • There is ring-fencing of funding to those delivering services, so

may include mechanisms such as funds release on achievement, and payment in kind i.e. CCGs pay for dedicated staff time and equipment out of the CQUIN budget rather than paying the value in the routine contract payments. This happens in many places

• They reinforce commissioning intentions/strategy In view of the TSA implications, schemes may need to be two dimensional (aside from being divisible by CCG/site) in terms of: • Reflecting broad quality themes currently in the integrated

governance dashboard, for example safety, prescribing and effectiveness. This will provide a measure of assurance.

• Address systematic improvement

Key Strategic Priorities and Initiatives - CQUINs

CQIN presents an opportunity for us to secure local quality improvements over and above the norm by agreeing priorities with our providers. It is set at a level of 2.5 per cent of the value of all services commissioned through the NHS Standard Contract. Current year (2012/13), National goals represented around a fifth of the overall value of the CQUIN schemes (0.5% of actual outturn value). The balance were chosen from a London list or locally agreed. Bexley CCG works closely with neighbouring CCGs, so that CQUIN schemes for South London Healthcare NHS Trust and Oxleas NHS Foundation Trust (mental health) are jointly agreed. Likewise, there are jointly agreed community provider CQUINs with the Oxleas community provider, despite Bexley and Greenwich CCG's having individual contracts. Oxleas These will be agreed jointly where applicable with Greenwich CCG (as in the previous year) with stretch where they are continuing and area wide once SLHT CQUINS have been finalised. Mental Health Bexley, Bromley and Greenwich will commence Mental Health CQUIN planning in conjunction with Borough Mental Health GP Leads in January as per previous years . BBG have discussed and agree the need to complement CQUIN schemes from Acute and Community services wherever possible. This process will take stock of progress to date with 12-13 CQUIN’s and review the necessity to stretch any existing schemes. We will also take the lead from any London wide CQUIN scheme’s which are being favoured as with the Dementia Scheme this year.

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Current Status The Bexley CCG strategy for 13/14 is to set CQUIN schemes based on a whole health economy basis, to incentivise collaborative working to achieve the goal of improving quality through integrated working. For example, in 12/13 the pressure ulcer CQUIN has been used for both Acute and Community providers. The focus for 2013/14 will be on CQUINs that not only improve quality, but also improve productivity and reduce cost. It is expected that national goals will increase for 2013/14 but it is not yet known the proportion for CQUINS in 2013/14, and Sir David Nicolson has recently flagged that he wants to see the proportion of hospital income increased to 4 or 5% over the next few years. Key Considerations Bexley is working closely with its CCG partners to agree joint CQUIN proposals for 2013/14 and further discussions between CCGs and providers will be required once details of the national CQUINS are known. There has been agreement between the BBG CQUIN leads that there are between 4 and-7 CQUINS for 13/14 and where possible that these cover across both Acute and Community and MH where applicable. Each CCG has been asked to put forward one main CQUIN and another for discussion. Further meetings will take place during January 13.

Key Strategic Priorities and Initiatives - CQUINs

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Securing Success – Monitoring Performance of Local Services and Measuring Delivery of Our Strategic Priorities

We are looking at how the information can be gathered and collated in the most efficient way and by whom. We will develop local metrics for evaluating the social and economic return on investment and other impacts of our patient and public involvement activities.

Our performance management framework has the following design principles which we are now using; • Streamline the information flow to the governing body • Facilitate governing Body discussion time on the most

pressing issues • Give clarity to staff and members on the operational and

strategic priorities of the CCG • Provide a joined up approach to organisational performance

management with • Organisational Development • Risk management • Board Reporting • Staff Management

Bexley CCG has the opportunity to develop as a new type of organisation within the NHS . We will do things differently to the Bexley Care Trust and the PCT Cluster as we have different responsibilities and less management resources to undertake management functions, therefore it is incumbent on us to work smarter. We will, as part of our statutory responsibilities, be an effective, efficient and economical organisation, and it is with that in mind that we have developed the following framework. We will be member-led, clinically focused and shift the culture to enable an open approach to quality. We currently have numerous ways of managing and monitoring performance, including (but not limited to): • Commissioner Performance reports • Provider reports • Finance reports • QIPP reports • Individual contract reports • Quality reports • Quality accounts • Internal and External Audit reports

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Improving the quality of care that patients receive and the outcomes we achieve is important to us. The five domains of the NHS Outcomes Framework help shape what we are striving to achieve for the people of Bexley.

Preventing people from

dying prematurely

Domain 1

Enhancing quality of life for people with long term

conditions

Domain 2

Helping people to recover from episodes of ill

health or following injury

Domain 3

Domain 4

Domain 5

Ensuring people have a positive experience of care

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

Effectiveness

Experience

Safety

Rewarding Quality Through Commissioning Quality Premium Subject to Regulations a Quality Premium will be paid in 2014/15 to clinical commissioning groups that in 2013/14 improve or achieve high standards of quality in the following four measures from the NHS Outcomes Framework: • Potential years of life lost from causes considered amendable to healthcare • Avoidable emergency admissions • The Friends and Family Test • Incidence of healthcare associated infections (MRSA and Clostridium difficile)

The Quality Premium will also include three locally identified measures. These measures focus on our local issues and priorities, especially where outcomes are poor compared to others and where improvement in these areas will contribute to reducing health inequalities. In Bexley we have agreed that these are: •35% reduction in admissions to South London Healthcare and Dartford and Gravesham NHS Trust acute beds for all people aged 19+ with agreed conditions sensitive to ambulatory care from Ist August 2013 - measured in spells. This is a reduction in the 12/13 forecast outturn of 5336 spells for the agreed basket of conditions by 1867 Full Year Effect and 1247 Part Year Effect. The new community service mobilises on 1st August 2013.

•44% reduction in Occupied Bed Days for people requiring neuro-rehabilitation in the new local combined community stroke and neuro-rehabilitation service from 1st July 2013. This is based on a 12/13 forecast outturn of 2600 bed days at the Elmstead Unit at South London Healthcare Trust. The Full Year Effect planned reduction will be by 1140 OBDs to a total of 1400 OBDs. The Part Year Effect in 12/13 will be 75% of this - 855 OBDs to reflect a July 2013 new service start •A 91.5% increase from 47 to 90 in children referred by a health professional to the Bexley Early Assessment of Need (BEAN) service – designed to support early intervention and support children at risk before they enter the formal safeguarding system

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Securing Success – Delivering the NHS Constitution and Mandate National “Offers”

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The NHS Constitution The CCG is well placed to deliver the NHS Constitution and has affirmed this in the first draft of the Operating Plan. We are currently doing a deep dive into the areas that present risk and feeding these into our contract negotiations. The main areas are:- •52 week waits •Waiting times for diagnostics •Single sex accommodation

The Mandate Again we are relatively well placed. The areas that require improvement are:- •Emergency readmissions – to be addressed through the new Integrated Care Service for Adults and Older People starting on 1st August 2013/14 •GP satisfaction – to be addressed through working with the South London NCB Primary Care Team and the Patients Council on a joint improvement plan •Acute inpatient satisfaction- especially at SLHT and Darent Valley – to be addressed through the quality dimension of the contract •People feeling supported to manage their long term conditions – to be addressed by building self management options into all LTC QIPP schemes – starting with the 2013/14 re commissioning of patient education for diabetes •Patient reported outcomes for hip and knee replacements

This section will be finalised for the final submission

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Unplanned Care

Planned Care

Children & Young People

Older People Long Term conditions

Carers

Mental Health

Bexley CCG has used benchmarked performance against peers in order to identify and qualify opportunities for transformational change across the local health economy. Our overall approach to performance and benchmarking is illustrated below. In advance of FY 13/14 our plan is to perform detailed benchmarking of the the following key areas: gynaecology, urology, general surgery and dermatology acute spend. This will include linking levels of service spend and activity to outcomes and level of impact.

Securing Success – Performance Benchmarking

Take Action

Monitor

Plan

Internal Benchmarking and Performance Measurement – to assure that we are delivering against our: • Step change and transform priorities • Health and wellbeing priorities • System-wide priorities (London,

National)

Refine

Identify

Qualify

Set Strategy

Analyse

External benchmarking – identifies areas of good and poor performance against our national and local peer groups. These are further qualified and triangulated with our hard and soft data to identify opportunities to transform local health services

Areas of good/poor performance/outcomes

Investigate/Analyse

Triangulation with other hard and soft intelligence

BECOMES PART OF INTERNAL

BENCHMARKING & MEASUREMENT

FRAMEWORK

Example 2: Older People • Initial crude benchmarking did not identify this

as a potential opportunity as our performance appeared similar to peers nationally

• However triangulation with Greenwich (with the same acute provider) identified potential opportunities through pathway transformation, reducing admissions and length of stay

• Included in commissioning intentions 2013/14

Example 1: Planned Care • Planned activity significantly above

supergroup top decile, London & England top quartile

• Commissioning team identified areas of over performance versus NAO activity per weighted population for key specialties

• After further analysis and triangulation key opportunities worked up as QIPP and programme budgeting schemes included in 2013/14 plans

Clinical Input and Engagement

Bexley Care Trust had an agreed 3-year plan (2012/13-2014/15) that ensured achievement of statutory duties and the 1% required surplus over the 3-year planning period 2012/13-2014/15. However, achievement of this assumed that the plan would be delivered in each of the financial years.

In the summer the Government appointed a Trust Special Administrator (TSA) to South London Healthcare NHS Trust to look at the viability of services across the Trust and South East London. This work looked at the financial gap across the health economy. A new set of planning assumptions were discussed and agreed with Chief Financial Officers across the CCGs and these resulted in a larger gap than the original 3-year plans submitted and agreed by each PCT. These assumptions have subsequently been adjusted across London and these have been included in financial planning for 2013/14, together with the national assumptions issued in

December 2012. •The main changes from original assumptions are as follows: •Decrease in recurrent resource limit •Increase in non-demographic growth •Increase in tariff / inflation uplift •Decrease in expected prescribing inflation

In addition, during 2012/13, significant over-performance has once again been seen within the acute sector, which is being covered in-year from non-recurrent means, including financial support of £4.8m. The existence of a cap & collar agreement with South London Healthcare NHS Trust has also resulted in a benefit to Bexley in this financial year. These resources will be unavailable in 2013/14 and planning has included significant QIPP assumptions to cover this shortfall.

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Securing Success - Finance

CCG allocations have now been received and these have been used in financial planning. The CCG will need to deliver net QIPP of £10.9m (£12.1m pre risk assessment), of which £0.5m relates to existing schemes carried forward from 2012/13 and £10.4m relates to newly developed schemes. The CCG has identified QIPP plans and has spent considerable time working these up. Numbers are available by provider and are currently being discussed in contract negotiations. Some will likely result in a significant shift in activity between providers, especially where a programme budget and prime contract model approach is being taken. The CCG has moved from transactional QIPP in 2012/13 to transformational to secure the level of QIPP required to ensure financial sustainability. Significant resource has been expended in 2012/13 developing the plans and it is intended that business cases will be submitted to the National Commissioning Board, against the 2% non-recurrent resource for 2013/14 and 2014/15, as a source of investment for pump priming QIPP to ensure its delivery. This formed the basis of the South East London plans presented to the National Commissioning Board. Work is ongoing to identify further pipeline schemes in case of slippage on the initial schemes. However, primary resource will be on ensuring delivery of those already identified. There is an agreed framework for collaboration agreement across South East London which includes risk sharing arrangements. No specific funding has been included for these purposes. However, it is proposed that any agreed arrangements will be funded from the 0.5% contingency as presented to the National Commissioning Board. The initial and updated financial plan submissions for 2013/14 have been compiled using the planning assumptions shown in Table 1, which are a combination of the TSA assumptions and the national assumptions issued in December 2012.

Table 1 – 2012/13 Planning assumptions

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Table 2 – Summary of Financial Plan

demographic

Growth

Non-

demographic

growth

Total

population

& incidence

growth

Prescribing

growth

Tariff/

Inflation

Uplift

Tariff

efficiency

assumption/

Price

Efficiency

applied

Net Tariff/

Inflation

Uplift

Acute 0.43% 2.00% 2.43% 0 2.90% (4.00%) (1.10%)

Client Groups and

Community 0.43% 2.00% 2.43% 0 2.70% (4.00%) (1.30%)

Primary Care 0.43% 1.00% 1.43% 1.00% 0 1.00%

Primary Care

Prescribing 4%

Corporate 0 0 0.00% 0 2.50% 0 2.50%

Other Budgets and

Reserves 0 0 0.00% 0 0.00% 0 0.00%

The assumption in table 1 will be refined as planning progresses to take account of: •Any notified changes to planning assumptions; •Any changes in Payments by Results for 2013/14; •Any changes in the market forces factor following any change in hospital configuration or patient flow as a result of TSA recommendations; •Any adjustments necessary in respect of the reductions for Specialist Commissioning; •Any adjustments necessary in respect of changes to revenue resource allocations. The CCG has submitted a balanced financial plan, including achievement of 1% surplus and setting aside of 2% non-recurrent resource, albeit with a number of risks associated with it which are articulated in the next sections. Table 2 is a summary of the financial plan being submitted. A bridge analysis is also included showing the main movements between 2012/13 and 2013/14. Running Costs The CCG’s proposals for the use of resources for running costs are drawn up within a resource envelope of £25/head of the CCG’s capped ONS population, of 226,505, including both pay and non-pay, CCG and South London Commissioning Support Unit (CSU) costs. At all times the CCG’s proposals were presented within the required £25 per head running costs limit, which for Bexley is £5,642k. The national ready reckoner was also used. The CCG’s structure has been approved and recruitment is near to completion. The budgeted running costs, submitted within financial plans, are £5,631k, £24.91 per head. This includes £7.40 for the cost of services purchased through the CSU.

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Contingency and Reserves The CCG has planned for 0.5% contingency, 1% surplus and the 2% non-recurrent resource in line with planning requirements. The latter has been assumed would be available for business case bids for double running costs and the implementation of transformational schemes (QIPP) and also to deliver Community Based Care. A £0.5m prescribing reserve is in place to mitigate the large prescribing QIPP planned for in this financial year and a further £0.4m is available as a risk reserve. £1.2m activity management reserve is also available to offset the RAG rating of other QIPP schemes. This is in addition to the agreed framework for collaboration agreement across South East London which includes risk sharing arrangements.

Risks

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We have identified the following risks in 2013/14:

New 2013/14 QIPP of £10.4m is required to achieve a 1% surplus in 2013/14, based on financial planning. This is a challenging target when considering the substantial QIPP delivered by Bexley over the previous five years.

The final allocation for the CCG is now known, however, there are a number of issues which remain outstanding in terms of the split of the specialist commissioning transfer by provider to ensure that it is cost neutral and also confirmation of any adjustments in respect of primarily property services and primary care. A number of assumptions have been made to achieve a 1% surplus plan. If any of the assumptions are found to be incorrect, then there is a possibility that it may increase the 2013/14 QIPP savings requirement.

A major risk for the CCG is the management of the acute contracts within the planned 2013/14 envelope allowing for the QIPP requirement, the TSA recommendations and assumptions and delivery of the transformation programme.

The CCG has received a large number of potential continuing healthcare unassessed periods of care claims. The most likely assessed costs have been included in 2012/13, but these are difficult to assess accurately and a risk remains that further costs may transpire in 2013/14, considering the time to assess each claim, outstanding judicial review and appeal timescales.

The implementation and shadow running of Payments by results (PbR) in Mental Health services may introduce further costs pressures. However, in mitigation, costs in line with 2012/13 baselines have been agreed for 2013/14.

The wider prescribing of anti-coagulation drugs in 2013/14, based on NICE guidance, may introduce an additional costs pressure.

There is a risk that the introduction of the audiology any willing provider (AWP) scheme may increase expenditure in this area.

There is a risk that the CCG revenue resource limit received will be reduced following further exercises to analyse the allocations.

There is an emerging cost pressure for 2013 and beyond caused by the transfer back to the Local Authority of responsibility for post-18 education for young people with learning difficulties previously funded by the YPLA. Bexley (both the London Borough and Care Trust) is one of only three areas nationally which have not contributed to the social and health elements of the funding of such places (in Independent Special list Provision) in the past.

Risks - Mitigation

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We have a number of plans in place to manage the financial risks identified for 2013/14:

0.5% contingency funding including in the financial planning model

£500k prescribing reserve

£0.4m risk reserve

Further pipeline schemes for QIPP are being developed

Additional resources have been invested in the planning and delivery of QIPP schemes to ensure delivery of the schemes. 2% non-recurrent resource assumed available to pump prime, double run etc.

Transformational QIPP schemes are being developed to ensure sustainable change.

£1.1m activity management reserve to offset the RAG rating of QIPP schemes

The CCG has its own Programme Management Office (PMO) which is integral to the organisation and the processes are fully embedded in the organisation. The PMO has robust monitoring and reporting systems in place to support delivery of the QIPP schemes

There is a South East London PMO, across the six CCGs, which will also support the development and delivery of QIPP.

The CCG is part of the South East London risk share collaboration agreement which may be called upon in certain circumstances to assist with short term financial support as well as assisting with joint working around commissioning etc

The CCG is currently screening and assessing the claims received in respect of continuing healthcare unassessed periods of care and have invested in additional support in order to undertake this work

For 13/14 the CCG has agreed with its main Mental Health provider that the contract will remain on a block basis whilst the initial clustering and PbR data is reviewed and assessed for accuracy before being used as a basis for the following years contract

The CCG will be ensuring that community based care linking with 111 is considered where possible to reduce hospital admissions and treat patients in the community or in their own homes when possible

The CCG will be working closely with the South London Commissioning Support Unit to robustly performance manage contracts with all acute providers. In-house teams will provide the same level of robust support with community and mental health contracts

Opportunities

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We have identified the following opportunities in 2013/14

The evolution of the new commissioning organisation with renewed vision and goals for the commissioning and delivery of healthcare for the residents of Bexley

The development of the Healthcare Campus on the Queen Mary’s Sidcup (QMS) site and the joint working with other partners to ensure the success of the project provides and opportunity to improve healthcare for Bexley residents

The planned integrated commissioning team across the CCG and local authority provides an opportunity to share expertise and commissioning experience and benefits from economies from increased purchasing power

To work collaboratively with other CCGs in South East London and also with our partners in the CSU to share best practice and benefit from economies of scale

To work towards a community based care model to increase healthcare closer to home and decrease reliance on acute hospital based care for the residents of Bexley

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Securing Success – Contracting and Negotiations

Through our contracting we will secure improvements in the quality of services for patients. We will ensure that we have a robust contracting and negotiations process. Quality contracting meetings will be appropriately supported at Director level with identified contract negotiation leads for each provider, with clear communication between and within organisations. We will continue to strengthen commissioning relationships, particularly with key partners in Bexley, Bromley and Greenwich, Lewisham and West Kent. We will need to ensure that all annual contractual rounds are completed by 31st March 2013 for 2013/14. This applies to Acute, Community and other services. Contracts will be renegotiated with the objective of applying any proposed national efficiencies on the 2012-13 contract value The NHS Standard Contract will be revised for 2013/14 and will support us in holding providers to account and enable innovative commissioning.

In line with the NHS Commissioning Board’s recommendations in Everyone Counts: Planning for Patients 2013/14 we will expect our secondary care providers to be able to account for the outcomes of all patients they treat and to adopt modern, safe standards of electronic record keeping by 2014/15. in 2013/14 we will expect our providers to comply with data collections approved by the Information Standards Board. Contracting Principles • Services which were contracted using the NHS Standard

Contract 2012-13 and which have not yet been extended may be extended for a maximum period of six months to one year

• Contracts which expired on or before 31 March 2011 and which have been subject to more than one extension of the original term of the contract will be reviewed, in order to investigate opportunities for delivering the service more efficiently

• Development of “year of care” programmes during 2013/14 for possible implementation in 2014/15

• Mandatory tariffs with local prices for specialist rehabilitation and HIV outpatients

BCCG intends to procure and/or implement the following services during 2013-14; • Any Qualified Provider – BCCG will implement all services

commissioned under AQP by 1 April 2013, including Adult Hearing, Anti-coagulation and Termination of Pregnancies

• Special Care Dental Services – BCCG is jointly re-procuring this service with Greenwich with a new service commencing in 1 February 2013

• Neuro-disability – BCCG have commenced the procurement of an integrated community based model of specialist rehabilitation comprising stroke and neuro-disability rehabilitation services and a new service will commence on 1 July 2013

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BCCG will re-negotiate the existing contracts with providers where the market for the provision of the service is very limited such as • Orthotics and prosthetics services commissioned from

regional centre of excellence which are in close proximity to the borough

• Palliative care services, which require a locally based in-patient facility and which can currently only be sourced from a single provider

• Minor Injuries Unit services where timescales preclude the re-procurement of this service during 2013-14

• Diabetes - Tier 1 to Tier 4 Services in partnership with Bromley and Greenwich bringing consultant diabetologists into the community to support primary and community care. This will also require commissioning Tier 1 and / or Tier 2 services through new contractual arrangements with GPs.

• Unscheduled Care – BCCG intends to review the Urgent Care and Out of Hours services delivered from the QMS site during 2013/14 to secure better integration and value for money across the 24 hour period. The procurement route is yet to be agreed.

• Patient Management Centre – a revised referral management process will be developed to replace the current PMC during 2013.

• Continuing Healthcare - BCCG may participate in the London-wide AQP for Continuing Healthcare services to be undertaken by the London Procurement Programme.

Transfer of Service • Specialist Children’s Service –a new service which is integrated with the provision of Paediatric Occupational Therapy and Physiotherapy will transfer from SLHT to Oxleas and we will work with Oxleas to review the service as this will be an opportunity to consolidate with wider children’s services . This is pending reprocurement in time for April 2015 •Outpatient and Day Surgery will, on the dissolution of SLHT, transfer to Dartford and Gravesham NHS Trust pending reprocurement in time for April 2015 Payment by Results Further Development PbR will continue in shadow form in 2013/14 for mental health , but it is essential that Bexley CCG is fully engaged in the national modelling of this and the impact on our contracts in time for go live in 2014/15. PbR overall presents a number of further new opportunities and risks in 2013/14:- • Unbundling of diagnostic imaging from outpatient tariff which

may push the pace of our service redesign programme • Implementation of the 2012/13 shadow maternity pathway

as mandatory under 2013/14 PbR • Top up funding for specialised services – a risk transferring to

the NCB • A range of new amended best practice tariffs becoming

mandatory in 2013/14 • New mandatory chemotherapy and radiotherapy tariffs • Possible changes to neurology and neurosurgery outpatient

tariffs on a mandatory basis

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We will use consistent templates for contracting all our contracts with providers

Public Health In line with Department of Health Guidance on the transfer of services, Bexley Care Trust is preparing Transfer Schemes for submission to the DH and the new receiving organisations including the London Borough of Bexley, Public Health England, National Health Service Commissioning Board, Community Health Partnerships and NHS Property Services.

We would seek to ensure that where services are to be disaggregated and transferred to more than one receiving organisations, that we put in place contractual arrangements where new receiving bodies may contract back via the CCG. This has implications for the public health elements of the Community Health Services contract with Oxleas and the Mental Health contract substance misuse element provided by South London and Maudsley Hospital.

We have met with colleagues in the London Borough of Bexley to identify the commissioning arrangements for all public health services which transfer to them directly and have put in place arrangements in the interim to secure the continued delivery of these services from the existing providers for a further period of 12 months, where these contracts are due to expire on 31 March 2013.

Where contracts do not expire until 31 March 2014, these contracts will be transferred to the local authority as currently contracted.

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Working together up to April 2013 – NHS Commissioning Board Specialised Commissioning Statement of Intent “This statement of intent is to set out a process and plan to work together over the course of the next nine months to manage these changes effectively. The key contact in the SCG will be Alex Berry, Divisional Director for South London who carries the responsibility for the commissioning round. Further meetings to clarify the detail of these arrangements will be arranged. This will allow the CCGs to effect a safe handover, set up systems and processes for effective joint working and manage risk across the system. Once the immediate issues have been successfully managed then a more strategic piece of work about collaboration over care pathways is planned. Specialised commissioning represents about 10% of NHS expenditure, and affects the lives of a highly vulnerable population of patients. Effecting a smooth transition to the new NHS system will manage risk for both patients and NHS organisations.”

Managing the transfer of remaining specialised services to the NHS Commissioning Board from April 2013 The SCG commissioned approximately 50% of the total amount of London specialised services in 2011/12. This will rise in 2012/13 as an agreed range of further services (the ‘minimum take’) such as cardiac surgery are transferred to the SCG following contract negotiations by PCT Clusters and before contracts are signed. This leaves a residual but substantial number of services still to be transferred before the start of the NHS CB in April 2013. These remaining services are generally more complicated to identify, to code and to count. The national work to clearly identify the complete range of services to go into the NHS Commissioning Board is still in hand and present some risk as we match financial allocation and activity and attempt to align them . Once this is confirmed then the SCG will need to work closely with CCGs, clusters and providers to ensure activity, finance and quality/risk contracting dimensions transfer smoothly . This needs to be carried out in a very structured way to avoid significant risk. Managing the 2013/14 commissioning round The transfers will add complexity to the 2013/14 commissioning round, compounded by the number of new organisations who will be conducting the round for the first time. Previous close working in the London health system will need to be recreated to conduct the round. Since providers are under financial pressure to maximise income, commissioners need to be highly co-ordinated to avoid costs increasing.

This is crucial to enable our healthcare workforce to effectively deliver more care in the community through service reconfigurations. We also want to ensure the future supply of skilled healthcare and other professional staff to provide quality services to people in Bexley. In practice the changes to our workforce are driven by our Community Based Care Strategy agreed by the CCGs in South East London and TSA workforce implications . Within the planned transformational and QIPP priorities, our ambition by 2013/14 is to: • Create integrated multi-disciplinary teams (across primary,

secondary and social sectors) • Re-skill staff to enable them to deliver the new models of

care effectively • Enable the community to play an care oversight and co-

ordination role and enforce consistent, high quality delivery of care

• Manage talent and ensure robust processes are in place for hiring, replacing, and retaining necessary skills

• Provide strong support for on-the-job training and development

• Develop the use of action learning • Embed the six C’s of nursing:

• Care • Compassion • Competence • Communication • Commitment • Courage

London is in the process of establishing 3 Local Education Training Boards (LETBs) to replace NHS London and its Deanery that will be in place until 31st March 2013. The South London (LETB) will be a healthcare provider-led organisation responsible for multi-professional education and training arrangements and will assess the collective workforce requirements of healthcare providers to meet the needs of the population as well as commission the education and training programmes required to meet those requirements. There are a number of key objectives: • Delivery of improved quality and value for money • Delivering a workforce for changing care settings with a new

focus on the population • Making the shift to an inter-professional approach • Planning for flexibility • Ensuring security of supply • Aligning workforce development with service commissioning • Alignment to the education outcome domains We need to have assurance that we have the appropriate workforce for today and for the future. This is particularly important with the reconfiguration of services and the need to provide continuity of care and the appropriate skills for new ways of delivery e.g. in the community. We will work closely with South London LETB and our partners to ensure we have the appropriate training provision for our current and future local workforce.

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Securing Success – Workforce

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Securing Success – Estates

We will ensure that our services are provided from appropriate places. We will:

• Ensure we have a sustainable QMS site through the transfer to our community provider Oxleas, underpinned by appropriate business

cases

• Carry out a strategic review of Bexley estate working will all our Public Sector partners to agree a joint service access approach maximising value for money and service transformation

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Impact on system - Providers

Provider Key areas of impact

Oxleas NHS Foundation Trust Mental Health • For 2013-14 the Mental Health acute and community contract will be funded in line with the

existing block contract arrangements • With the introduction of PbR for mental health) sub groups which will provide a whole system

approach to the transition from block payment to payment by results • It is our intention to continue to commission these services from 1st April 2013. The precise

length of contract is subject to legal and TSA advice linked to the special circumstances of creating the new QMS Hospital

Community We plan to enter into a contract variation with Oxleas to achieve the following: • Transfer BCTs rights and obligations for public health related services to new receiving bodies

and re-commissioning these services under this contract by adopting the multi-lateral contract • In addition to National Efficiencies within the National Operating Framework 2013-14, we will be

seeking to make recurrent the £500k of local efficiencies • Specify an integrated community rehabilitation and re-ablement service • Re-specify the provision of intermediate care beds • Re-model and specify the provision of District Nursing care • Decommission the provision of Diabetes and Parkinson’s Disease nurse • Implement new pathway for Long-term Oxygen Therapy • Identify CQUIN measures for 2013-14 contract period

The re-modelling of intermediate care provision and re-ablement and rehabilitation services may result in an investment in the Community Health service The implication of the proposed changes to the Community Health Services contracts is that there is a risk that the services currently provided may be disaggregated, potentially resulting in an increase in contract costs. The precise length of contract is subject to legal and TSA advice linked to the special circumstances of creating the new QMS Hospital

Our commissioning intentions will have an impact on current providers

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Oxleas NHS Foundation Trust (Mental Health Services)

• For 2013-14 the Mental Health acute and community contract will be funded in line with the existing block contract arrangements

• With the introduction of PbR for mental health) sub groups which will provide a whole system approach to the transition from block payment to payment by results

• It is our intention to continue to commission these services from 1st April 2013 with the length of contract to be determined in the light of legal advice and the special circumstances of QMS/TSA

Oxleas NHS Foundation Trust (Community Services)

We plan to enter into a contract variation with Oxleas to achieve the following: • transfer BCTs rights and obligations for public health related services to new receiving bodies and

re-commissioning these services under this contract by adopting the multi-lateral contract • in addition to National Efficiencies within the National Operating Framework 2013-14, we will be

seeking to make recurrent the £500k of local efficiencies • specify an integrated community rehabilitation and re-ablement service • re-specify the provision of intermediate care beds • re-model and specify the provision of District Nursing care • decommission the provision of Diabetes and Parkinson’s Disease nurse • implement new pathway for Long-term Oxygen Therapy • Identify CQUIN measures for 2013-14 contract period

The re-modelling of intermediate care provision and re-ablement and rehabilitation services may result in an investment in the Community Health service The implication of the proposed changes to the Community Health Services contracts is that there is a risk that the services currently provided may be disaggregated, potentially resulting in an increase in contract costs. The length of contract is to be determined in the light of legal advice and the special circumstances of QMS/TSA

Our commissioning intentions will have an impact on current providers

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South London Healthcare NHS Trust • Future of the Trust is subject to the Trust Special Administrator regime. Current plan is that SLHT will be dissolved on 1st October 2013 with the services currently being provided by the Trust transitioning to other local providers on an interim basis, subject to procurement by April 2015. The main contracts are specialist children’s services (SLHT Oxleas) and outpatients/day surgery (SLHT Dartford and Gravesham NHS Trust)

• Delivery of Bexley CCGs commissioning intentions is dependent on securing the reduction in acute capacity across current SLHT services corresponding to Bexley’s Community-based Care Strategy

• See below where indicated for new interim providers of former SLHT services

Guy’s and St Thomas’ Hospital NHS Foundation Trust

• Continued commissioning of specialist services such as Renal Dialysis. Potential for cancer services currently provided by SLHT such as Chemotherapy to transfer

• Reduction in elective and outpatient activity in line with programme budgeting and demand management plans

Lewisham Healthcare NHS Trust (LHNT)

• As a result of the TSA process, LHNT is likely to become responsible for services currently provided to Bexley residents at Queen Elizabeth’s Hospital

• Implementation of the new Community Older People’s model will reduce admissions at QEH from that cohort and bring length of stay for those conditions in scope in line with trim point

• Reduction in elective and outpatient activity in line with programme budgeting and demand management plans • The Trust is likely to deliver an increased level of inpatient elective services as a result of development of

inpatient elective services as part of TSA plans

Dartford & Gravesham NHS Trust (D&G)

• D&G will be responsible on an interim basis for the majority of outpatient and day case services currently provided by SLHT on the QMS Campus

• Implementation of the new Community Older People’s model will reduce admissions at Darent Valley from that cohort and bring length of stay for those conditions in scope in line with trim point

• Reduction in elective and outpatient activity in line with programme budgeting and demand management plans

Kings College Hospital NHS Foundation Trust

• As a result of the TSA process, Kings is likely to become responsible for services currently provided to Bexley residents at the Princess Royal Hospital

• Kings will deliver Ophthalmology and Oral / Maxillofacial day case and outpatient services currently provided by SLHT. These treatment centres will provide all current SLHT activity in these specialties, which represents an increase on current volumes on the site

• Reduction in elective and outpatient activity in line with programme budgeting and demand management plans.

Our commissioning intentions will have an impact on current providers as follows:-

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Implementation – How We Will Measure Success

We will measure success on our achievement of our corporate objectives as measured by: • NHS Outcomes Framework – we will, of course, look to

improve on all the domains. However we will focus on Domains 2,3 and 4 for 2013/14.

• Outcomes defined in our commissioning intentions – including the mandated NHS Constitution and other self certification measures

• Our CQUINs as defined in our commissioning intentions • our scheme by scheme QIPP Key Performance

Indicators • Patient and Public feedback including patient

satisfaction surveys, the ‘Friends and family’ test that the Department of Health has recently announced. This is a simple question of whether patients would recommend hospital wards, accident and emergency units to a friend or relative based on their treatment

• Benchmarking – national, regional and local to understand how we compare with other areas against indicators in the outcome frameworks

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Implementation – Risks and Mitigations

We accordingly adopts a balanced and proportionate approach to risk management that is substantively robust whilst not unnecessarily bureaucratic. Such an approach seeks to balance the our obligations to exercise its functions safely, effectively, efficiently and economically, with its duties to drive improvements in services, promote innovation, and reduce inequalities. This will enable us to deliver access for all patients to high quality clinical care, within the resources available. Key to this aim is effective:

• Identification of risks • Analyses and Evaluation of risk • Planning the response and managing the risk • Recording and Reviewing the risk

We have developed a framework that describes NHS Bexley Clinical Commissioning Group’s (BCCG) Risk management framework and sets out our risk strategy including our:

• Attitude to risk: our appetite for risk and the culture that underpins it. We expect all our staff and members to understand the principles set out in this document and to adhere to them at all times. This framework will guide how the BCCG governing body and BCCG leadership will take forward BCCG business.

• Risk Identification: how we will identify and prioritise risks. • Risk Management: how we will allocate responsibilities for managing and mitigating identified risks. • Risk Reporting: that provides guidance on common reporting. This will ensure that risks are viewed in the same way throughout the

organisation, including within our commissioning support structures. The aim of this framework is that throughout our organisation, from the BCCG Governing Body, through its committees and onwards to our staff and members, there will be a clearly understood series of protocols for identifying and reporting risk, and for receiving direction on ways to improve the BBCCG's position on risk.

We have identified a number of key risks that we need to manage given service reconfiguration and the shift of more care into the community: • Transition • System change • Delivery QIPP • Continuing care claims • Acute over performance In respect of each risk, our Risk Register sets out actions which the Risk Management Lead, Managers and/or Clinical Leads have or will put in place with reference to the following our Risk Register action matrix:

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QIPP of £10.9m is required to achieve a 1% surplus in 2013/14 based on bottom up and top down planning. This is a challenging target when considering the substantial QIPP delivered by Bexley over the previous five years to maintain the financial position

There is a possibility that the CCG’s Revenue resource Limit may be reduced following further work on the allocations and the 2013/14 QIPP requirement may increase as a result

A major risk for the CCG is the management of the acute contracts within the planned 13/14 envelope allowing for the QIPP requirement, the TSA recommendations and assumptions and the delivery of the transformation programme

The CCG has received a large number of potential continuing healthcare unassessed periods of care claims. It is expected that costs will be provided for in 2012/13 but a risk remains that further costs may transpire in 2013/14 considering the judicial review and appeal timescales

The implementation and shadow running of Payment by Results (PbR) in Mental Health services may introduce further cost pressures. However in mitigation costs in line with 2012/13 baselines have been agreed for 2013/14

A risk remains regarding the reductions to the CCG’s allocations with regards Specialist Commissioning. This has been assumed cost neutral, as advised, in financial plans

The wider prescribing of anti-coagulation drugs in 2013/14 based on NICE guidance may introduce an additional costs pressure

There is a risk that the introduction of the audiology any willing provider (AWP) scheme may increase expenditure in this area

The CCG has not included a specific % contribution for the South East London risk pooling arrangements in its financial model, bit it is assumed that this will be covered by the 2% non-recurrent resource, as presented by South East London to the NCB.

Implementation – Risks and Mitigations: Finance

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Mitigating Actions

Mental Health Further demand on GP time High level of demand – Autistic Spectrum Disorder Diagnosis

Training and support from secondary care Quarterly monitoring, prioritise by level of need and gather data

Unplanned Care Local Authority may have concerns about decommissioning of Walk-in Centre and integration of the QMS UCC and Out of Hours

Engagement with Local Authority through Health and Wellbeing Board

Ensuring that OOH Providers are not destabilised by commissioning changes

Engagement with NHS Greenwich to understand impact on them and what actions could be undertaken by Greenwich and Bexley to mitigate this

High set up costs for UCC hub in North Bexley area.

Ensure effective reporting systems are in place which tracks patient attendance through the system and where possible ensure that primary care systems are linked with Unscheduled Care system

UCC Hub in North Bexley may not impact on A&E attendances but generate own capacity and inappropriate use

Engage with Primary Care

Planned Care Reducing acute capacity as new community based services take effect Clinical engagement across primary and secondary care in a turbulent environment

Effective decommissioning and agree capacity reduction planned with SLHT as part of implementing TSA recommendations Bilateral clinical QIPP session built into contract negotiation

Children & Young People Uncertainty around timescales/contract durations etc in light of TSA process

Commencing due diligence work with Oxleas ‘at risk’/negotiations with TSA

CREs on CAMHS imposed internally by Oxleas 3 year agreement to protect CAMHS from the impact of QIPP in context of wider ‘risk share’ arrangement with Oxleas/possible invest to save

Reputational risk if PAU found to be unaffordable Involve partners in decision making

Potential failure to sustain improvements in audiology Work towards a sustainably sized 3 borough audiology service

Financial risk around CCHC and personal budgets for children with complex needs

Transparent risk sharing around high cost cases

Implementation – Risks and Mitigations: Transformational Plans

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Mitigating Actions

Older People Lack of provider willingness to adopt collaborative culture at an operational level

Collaboration and engagement events built into implementation plans Designing services in a way that helps build confidence and trust amongst providers

Acute bed capacity is not closed but replaced with alternative acute activity leading to cost pressures and no disinvestment

Risk reserve set aside to help fund unexpected consequences of redesign work. There is a willingness by the TSA to factor in the bed reduction as part of SLHT’s 3-year Service Improvement Plans

Lack of a single integrated IT system means patient information is not shared, reducing efficiency and effectiveness of service proposals

Encouraging closer working between professionals whereby system flow is improved through enhanced communication.

Long Term Conditions Accessing high quality data to understand current cost of long term conditions.

Close working with CSU to extract data and compare across 3 boroughs

Development of the primary care workforce.

Include all stakeholders in discussion about up skilling and factor into project costs

The introduction of ESD will financially impact on our existing acute providers due to the reduction in patient’s length of stay.

In order for the ESD component of the pathway to be effective, the specialist community neurological provider will have to gain the co-operation of the acute providers. This will need to be established during the mobilisation period.

Meeting unmet demand is likely to increase activity and increase the need for capacity.

The inclusion of non-elective activity will give the provider(s) more autonomy over secondary care referrals thus offsetting the potential associated costs.

QMS Commissioners unable to demonstrate sufficient commitment to the service portfolio and contract duration to enable providers to produce viable business cases

CCGs whose commissioning intentions impact QMS to work with Oxleas / other providers to establish appropriate shared agreements of commitment / support

All essential programme activities will not have been completed to an acceptable standard and level of assurance within the TSA timetable

Agreed roles, responsibilities, timetables, regular communications and an agreement to work collaboratively

Carers Difficulty in freeing up resources from set respite budgets to achieve wider change

Joint/pooled commissioning agreed with the London Borough of Bexley

Implementation – Risks and Mitigations: Transformational Plans

Appendices

60

61

Securing Success – Clear and Credible Activity Plans - QMS Appendix 1

62

Securing Success – Clear and Credible Activity Plans - QIPP Appendix 2

South East London CCG Collaboration and Risk Sharing

SEL shadow CCGs have a track record of collaboration and successful risk management across the health economy. A formal framework for collaboration has been agreed in 2012 and submitted by all CCGs as authorisation evidence. The principles of collaboration and risk management across all SEL CCGs centre around CCGs collaborating to improve outcomes, quality and VFM through addressing transformational change across multiple boroughs and securing long term sustainability for SEL CCGs and commissioned health services. Risk management plans include risk sharing with providers, risk sharing across commissioners and mutual financial assistance between SEL CCGs to support delivery of individual CCG financial targets in the short term, assist recovery and sustain ongoing strategic direction without destabilising the health economy. Governance arrangements underline accountability at local CCG level and brings CCGs together to make collective decisions on and take oversight of SEL wide transformational strategy (such as the community based care strategy), risk management and other health economy wide priorities. Key planning commitments include:

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Source Application

CCG allocations

SEL CCGs to set aside 0.5% of RRL in 13/14 as a general contingency to support risk management across SEL CCGs.

2% non recurrent headroom in CCG allocations

SEL CCGs to commit approx 1% non recurrent investment in 2013/14 to implement the SEL community based care strategy


SEL CCGs to commit approx 0.5% non recurrent investment in 2013/14 to implement local CCG transformational QIPP (in addition to the SEL community based care strategy)


SEL CCGs to commit set aside 0.5% non recurrently in 2013/14 to mitigate in year expenditure pressures

Return of fair share of 2012/13 PCT surpluses

SEL CCGs to plan to deliver a 1% surplus in 2013/14

Appendix 3

Source Guidance

Publication Date/Year Published

National Guidance

Draft Guide to the Collaborative Management of the 2013/14 Contracting Round between CCGs and NHSCB Commission 2012

Prescribed Specialised Services: Commissioning Intentions for 2013/14 November 2012

Securing Equity and Excellence in Commissioning Specialised Services November 2012

Frequently Asked Questions: Operating Model and Commissioning Intentions November 2012

Planning and Contracting 2013/14 2012

NHS Outcomes Framework 2013/14 November 2012

NHS Outcomes Framework 2013/14: Equality Analysis November 2012

Improving Health and Care: The Role of the Outcomes Framework November 2012

The Mandate: A Mandate from the Government to the NHS Commissioning Board: April 2013 – March 2015 November 2012

Everyone Counts: Planning for patients 2013/14 December 2012

Government Pledge for the Support of Women who have Postnatal Depression and Women who have Suffered a Miscarriage, Still Birth or the Death of a Baby

November 2012

London Guidance

Development of the Commissioning Board: Workshop Papers 2012

Reference Document references

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Appendix 4

Source Guidance

Title of Publication Date/Year Published

Bexley CCG Guidance

Joint Strategic Needs Assessment (JSNA) 2012 September 2012

Joint Strategic Needs Assessment 2012/13: Executive Summery September 2012

Compendium of Information Report for Bexley’s Joint Strategic Needs Assessment 2012 September 2012

Quality Innovation Productivity and Prevention (QIPP) Schemes

Draft TSA Report

QMS Commissioning Intentions

Step Change and Transformation Plan

Transition Adult Safeguarding Protocol and Strategic Direction for NHS Commissioners and Providers for Bexley

Update on Joint Commissioning in Bexley

Section 75 Protocols

Prevention and Partnership Framework

Joint Health and Wellbeing Strategy

Bexley CCG Communications and Engagement Strategy 2012 – 2015

London Borough of Bexley: Social and Commissioning Services: Prevention Strategy

CQUINS Briefing Paper

Bexley Clinical Commissioning Group: Organisational Development (and Design)

Bexley Clinical Commissioning Group: Integrated Risk Management Framework

Bexley Clinical Commissioning Group: Draft Performance Management Framework

Bexley Clinical Commissioning Group: Working to Improve Quality in Primary Care

Bexley Clinical Commissioning Group: List of Collaborative Arrangements (Draft)

Bexley Clinical Commissioning Group: Collaborative Commissioning Arrangements

Reference Documents

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Date

Activity

Bexley Action Who RAG Status

PHASE 1

18 Dec 12

Allocations published Planning guidance published

Construct 13/14 draft budget Produce local timetable

Julie W

Mike A

Amber Green

21 Dec 12

Supporting information published nationally Draft NHS Standard Contract published

Note and progress Issue to local contract teams to support contract negotiations

All

Neil H (acute) Alan L (all except mental health) Martin M (mental health) Sue Todd-Dunning/Alan Luke (public health contracts) Alison Rogers (children/young people)

Green Green Green Green Amber Amber

w/c 7 January 2013

UNIFY2 Data collection available Agree lead uploader – Sue Sitch

Mike A Green

w/c 14 Jan

Bottom out SLHT baseline and funding envelope Escalate delay with specialised commissioning allocations split

CSU with Neil H CSU and Sarah B

Red Red

BEXLEY CLINICAL COMMISSIONING GROUP 2013/14 OPERATING PLAN - TIMETABLE

Date

Activity

Bexley Action Who RAG Status

25 Jan 13

CCGs to share first draft of plans with Area Team Directors to include:

1. “Plan on a Page” including key elements of transformational change

2. Template Covering

Self certification of delivery of the NHS Constitution, Mandate and Clostridium difficile objective;

Self certification of assurance of provider CIPs;

Trajectory for Dementia diagnosis rates and IAPT - proportion

of people entering treatment;

Trajectories for locally selected priorities;

Activity trajectories for 4 key measures – elective FFCEs, non-elective FFCEs, first outpatient attendances, A&E attendances;

Summarise into national format from CCG Transformation Plan Review current position and construct self certification Contract Leads to ensure clinical review of CIPs

Mike A Simon E-E – supported by Michael Boyce Mike A overall lead Neil H (acute) Alan L (all except mental health) Martin M (mental health) Sue Todd-Dunning (public health contracts) Alison Rogers (CYP) Martin Murphy Mike Attwood Neil Hales

Green Green Green Green Green Green Green Green Green Green Green

Date

Activity

3. Financial Information

Test out draft submission at GP/Membership Engagement Event on 25th January

Bexley Action

Who Julie W (overall lead) Michael B (QIPP component) Howard S/Sarah B

RAG Status Green Green Green

PHASE 2 by 31 Jan (local deadline)

Accelerate heads of terms for TSA sensitive contracts (SLHT) Complete draft additional Operating Plan details to meet LAT 10 day window to complete authorisation and turn final two reds to green – clear and credible plans NOTE: Deadline slightly later now: Mike A clarifying with London NCB Test out 1st submission at Governing Body Seminar

Agree SLHT Heads of Contract Terms Commissioning Intentions Completion Overall QIPP Schedule complete Individual Scheme “plans on a page”

CSU with Neil H Mike A Michael B Clare R Mike A

Red Amber Amber Amber Amber

By 5 February

Agree baselines and funding envelopes for all other acute and non-acute contracts Update on Financial/Contracts Position to Finance Working Group

Brief Finance Status Report

Alan L (all MH) Martin M (MH) Sue Todd-Dunning (PH) Alison Rogers (CYP) Neil H (other acutes)

Julie W

Amber AmberAmber Amber Amber Amber

By 8 Feb NCB Area Directors to provide feedback to CCGs

Date Activity Bexley Action Who RAG Status

7 Feb By 20 February (or 26 February; awaiting NCB confirmation) 21 Feb

Update to EMC Submit final plans for authorisation (two redgreens) EMC second update

Agree key next steps for final submission/authorisation Overall Co-ordination Commissioning Intentions QIPP schedule Individual Plans on a Page for each QIPP scheme

Mike A Sarah V/Mike A Sarah V/Mike A Michael B Clare R Sarah V/Mike A

Amber Amber Amber Amber Amber Amber

By 28 Feb (local deadline)

Agree Heads of Terms for all non-acute and remaining acute contracts Formal sign off of Commissioning Intentions/Operating Plan by Governing Body – plus SLHT contract one month early

Alan L (all except MH) Martin M (MH) Sue Todd-Dunning(PH) Alison Rogers (CYP) Neil H (acutes) Mike A

Amber Amber Amber Amber Amber Amber

End Feb 5th March

Re-submission of Finance Templates and update on contractual negotiations - review self certification risks – NHS Constitution, Mandate, C Diff/Dementia/IAPT trajectories Second update to Finance Working Group

Financial templates Contracts update Finance and Contracts Update

Julie W Sarah Valentine/Mike Attwood

SV/MA with JW

Amber Amber Amber

11 Feb to 29 Mar 13

Discussions to support Area Team Director assurance of plans

31 Mar 13 CCG and NHS Commissioning Board contracts signed off

Sign off at Governing Body SV/MA with TO Amber

Date Activity Bexley Action Who RAG Status

5 Apr 13 Final CCG plans shared with Area Team Director Sarah Valentine/Mike Attwood

Amber

8 Apr to 19 Apr 13

NCB analyses CCG plans and plans for direct commissioning with a view to identifying risks to delivery

22 Apr to 10 May 13

NCB confirms that plans add up to a position that delivers the mandate and improves patient outcomes within allocated resources

By 31 May 2013

Each CCG publishes its prospectus for its local population Jon W Amber