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Part of NHS South East London: a partnership of Primary Care Trusts in Bromley, Greenwich, Lambeth, Lewisham, Southwark and BexleyCare Trust
Chair: Caroline Hewitt CCG Chair: Dr Hany Wahba Interim Chief Executive: Christina Craig
25 September 2012
Greenwich Clinical Commissioning Group
Integrated Plan2012/13Improving Health
1
Contents Page
Chair’s Foreword 5
Section 1 Greenwich 6
1.1. Introducing Greenwich 6
1.2. The Greenwich Context: Joint Strategic Needs Assessment 7
1.3. Partnership Working 13
1.4. Introducing NHS Greenwich CCG 19
1.4.1 The Greenwich Story 19
1.4.2 Current Challenges: South London Healthcare Trust 20
1.4.3 NHS Greenwich CCG Governance 21
Section 2 Improving Health 24
2.1 NHS Greenwich CCG Strategic Overview 24
Table 1 Key Health Challenges across Greenwich & South East London 27
Table 2 Outcomes & Measures to be achieved in tackling the 28
Strategic Priorities
2.2 NHS Greenwich CCG Strategic Priorities 32
Table 3 High level plans for the achievement of strategic priorities 33
2.3 Meeting our responsibilities in 2012/13 43
2.3.1 Performance Management 43
2.3.2 2012/13 Performance Priorities 43
2.4 Compliance with the National Operating Framework 46
2.5 Enabling Actions and Additional Service Delivery 47
2.5.1 Primary Care Engagement 47
2.5.2 Eltham Community Hospital 49
2.5.3 Heart of East Greenwich 51
2
2.5.4 CCG Organisational Development Plan 52
2.5.5 Sustainable Commissioning 52
Section 3 Financial Sustainability and the Case for Change 54
3.1 Financial Overview 55
3.2 Financial Position 2012/13 55
3.3 Financial Assumptions 56
3.3.1 2012/13 – 2014/15 Assumptions 56
3.3.2 2013/14 Allocation Assumptions 59
3.4 QIPP 60
3.5 Summary Income and Expenditure Plan 62
3.6 Investment Proposals and Cost Pressures 63
3.7 Ensuring Financial Delivery through Transition 64
Section 4 Delivery 65
4.1 Implementing the Plan and Commissioning Intentions for 2013/14 65
Table 4 Improving & delivering QIPP in 2012/13 and Commissioning 65
Intentions for 2013/14
4.2 What are we proud of? Success stories in delivering the Plan 70
4.3 Managing Provider Performance 76
Appendix 1 NHS Greenwich CCG Governance Structures and Responsibilities
Appendix 2 Table Demonstrating Compliance with National Operating Framework
Appendix 3 QIPP Programme Summary for 2012/13 Month 5
Appendix 4 Aspirations for Community Based Care
Appendix 5 More detailed table of Greenwich Commissioning Intentions 2013/14
Appendix 6 Managing Risk
3
Evidence for authorisation
Domain
ReferenceIntegrated
Plan Section
Document
Page Number
Additional
Comments
2012-13 integrated plan and draft commissioning intentions for
2013-1414Governance, decision-making and
planning arrangements where quality is a
priority and clinical views are foremost.
1.1 1.4.3, 2.1 p.21-26
CCG can demonstrate it has taken steps to
communicate its vision and priorities to
stakeholders, patients and the public.
1.4.1 1.3 p.13-18
CCG has mapped and analysed constituent
communities and groups.
2.1.1 1.2 p.7-12
CCG integrated plan aligns with JHWS(s)
and enables integrated commissioning,
depending on local timeframes.
2.1.2 2.1, 2.2 p.24-31
p.33-42
Systems in place to convert insights about
patient choice/s in practice consultations
into plans and decision-making.
2.4.1 1.4.3, 2.5.1 p.21-23
p.47-49
CCG has a clear and credible integrated
plan, which includes an operating plan for
2012-13, draft commissioning intentions
for 2013-14 and a high-level strategic plan
until 2014-15.
CCG has detailed financial plan that
delivers financial balance and any other
requirements set by the NHSCB and is
aligned with the commissioning plan.
QIPP is integrated within all plans. Clear
explanation of any changes to existing
QIPP plans.
CCG plan sets out how it aligns with
national frameworks and strategies,
including the NHS Outcomes Framework.
3.1.1 2.2, 2.3.2, 2.4,
4.1
3.5
3.4
2.1
2.4 & 3.4
p.32-42, p.43,
p.46 & Appendix
2, p.65-69 &
App.5
p.62
p.60 & Appendix 3
p.24-31, p.46 &
App.2, p.60
CCG can demonstrate that the process for
developing its plans and priorities was
inclusive and transparent.
3.1.2 2.1, 1.4.3, 1.3 p. 24-31, p.21-23,
p.13-18
4
Plans reflect JSNA, stakeholder
engagement, and evidence/data analysis.
3.1.3 1.3, 1.2 p.13-18, p.7-12
Where the area covered by the CCG is not
on track to meet the plan for 2012-13,
there is a clear and time-limited resolution
path to recover.
3.1.4 2.3, 2.3.2, 2.4,
2.2
p.43, p.46, p.32-
42
CCG has arrangements in place to
collaborate with neighbouring CCGs in
areas such as lead commissioning where
there is more than one CCG contracting
3.3 1.3 p.13-18
Health inequalities issues identified and
addressed in integrated plan.
4.2.3 1.2, 2.2 p.7-12, p.32-42
Where the need for integrated
commissioning has been identified by the
health and wellbeing board and in the
JHWS(s), CCGs are collaborating with the
local authority(ties) to develop shared
plans.
5.3 1.3 p.13-18
List of collaborative commissioning arrangements, joint commissioning draft
agreements or plans, including pooled budgets, Section 75 agreements where
appropriate
Plans clearly demonstrate where and how
the CCG is working with other CCGs to
meet QIPP, and can demonstrate that
stakeholders are aware of and understand
CCG priorities.
3.1.2 1.3 p.13-18
5
Chair’s Foreword: Clinically-led Commissioning in Greenwich
Being a GP commissioner in Greenwich Clinical Commissioning Group is a very exciting challenge
that allows us to transfer our frontline clinical experience into key commissioning decisions. This
means that what we learn from our day to day contact with our patients can then influence the
decisions we need to make to provide the best care for all the people in Greenwich. We can apply
our clinical knowledge to the data and information we have about the needs of patients and the
performance of our providers. We can ask questions and identify trends which help us to predict and
prevent difficulties arising in service provision. At the same time as utilising our clinical skills we have
the CCG support structure that will provide the professional background and knowledge that GPs do
not have. We have the right team in place and the proper governance, clear accountability,
partnership working and engagement with the public that means we are not only ready for
authorisation, but fully prepared for the new clinical commissioning world thereafter.
As a membership organisation we are well placed to engage the GPs in Greenwich in improving
services for our population both in terms of their management of their patients within general
practice, as well as through their role in demand management and referral. We have GP syndicates
in place that meet regularly to undertake peer review of patient care. We also have in place an
effective Commissioning Incentive Scheme which encourages and rewards high quality practice
which supports and enables the goals of NHS Greenwich CCG.
We are continuing to bring care out of hospital and closer to where patients live in the community.
We are identifying vulnerable people who are likely to fall ill and preventing crises before they
happen, thereby avoiding unnecessary hospital admissions for many. We started last year with the
fifteenth lowest rate in the country for unplanned admissions for conditions amenable to
ambulatory care i.e. conditions that could be better treated in the community and by March 2012
the results for ‘Better Care, Better Value’ Indicators showed that Greenwich is now the best in the
country.
Greenwich as a commissioning organisation has an excellent record of financial management over
the last 10 years, achieving all of its financial obligations at the same time as delivering high quality
care. With the GPs at the heart of our decision making we can make even better informed decisions,
making sure every penny will be spent in the best way to maximise healthcare for the people of
Greenwich.
Our strategy will be to continue to ensure we have the best configuration of services for our
population, with even more out of hospital care and more integrated care delivered in partnership
with the Royal Borough of Greenwich. In terms of hospital services our main provider, South London
Healthcare Trust, is facing a significant financial challenge and is currently being run by a special
administrator. A new strategy for South East London will be completed in October and we are
working with colleagues across south east London to secure the best possible outcomes for our
population.
This integrated plan outlines our commissioning expectations beyond authorisation whilst being a
key tool in our authorisation armoury in the meantime.
Dr Hany Wahba, Chair, NHS Greenwich CCG, September 2012
6
Section 1: Greenwich
1.1 Introducing Greenwich
Greenwich has a population of approximately 241,000 residents, according to the 2010 Greater
London Authority population projections for 2011. Greenwich is predicted to see the largest increase
in population of any South East London borough, with growth over the next five years of 13%.
Greenwich is also projected to have the biggest increase in births of any South East London borough,
with an 11% increase in the period 2011 to 2016. Whilst Greenwich contains areas of relative
affluence, it is mainly a borough with significant deprivation. Measured against the Indices of
Multiple Deprivation, the most common tool for examining deprivation levels in England, Greenwich
is rated as the 19th most deprived local authority out of 326 in England.
South London Healthcare Trust (SLHT) is the main provider of hospital services to Greenwich
residents, and also to the populations of Bexley and Bromley. In June this year SLHT was the first
trust to be put into the Regime for Unsustainable NHS Providers following the appointment of a
Special Administrator. There is now a process underway to secure clinically and financially
sustainable services for the long term for the people of south east London.
Greenwich residents are also served by other acute trusts across south east London. Guys and St.
Thomas’ NHS Foundation Trust (GST) primarily serves the population of Lambeth, Lewisham and
Southwark but activity does flow across the whole of south east London and it provides specialist
services for patients from much further afield.
King’s College Hospital NHS Foundation Trust (KCH) is one of London’s largest teaching hospitals,
providing a full range of general hospital services for over 700,000 people in the boroughs of
Lambeth, Lewisham and Southwark and providing specialised services that are available to patients
across a wider area.
Lewisham Healthcare NHS Trust, located in the centre of Lewisham, offers medical, surgical and
emergency services for the local community and specialised services for south east London and
beyond. It is in the process of applying for Foundation Trust status.
Oxleas NHS Foundation Trust provides a wide range of health and social care services and specialises
in caring for people with mental health problems and learning disabilities. It is the main provider of
mental health and adult learning disabilities services for Greenwich as well as forensic mental health
services. It is also the provider of community health services for Greenwich patients. Additionally,
Greenwich residents are served by South London and Maudsley Foundation Trust (SLaM) which
provides the most extensive portfolio of specialist mental health and substance misuse services in
the UK.
In South East London we have one of only five Academic Health Sciences Centres (AHSC) in England.
King’s Health Partners (KHP) is a partnership between King’s College London, Guys and St. Thomas’
7
Foundation Trust, Kings College Hospital Foundation Trust and South London and Maudsley NHS
Foundation Trust.
In Greenwich there are 45 General Practices made up of Personal Medical Services (39), General
Medical Services (3) and Alternative Provider Medical Services (3) contracts.
1.2 The Greenwich Context: Joint Strategic Needs Assessment
Greenwich faces some major healthcare challenges with significant health inequalities existing within the
borough. Overall, life expectancy is worse than the England average. Men living in the least deprived wards of
Greenwich can expect to live for an average of 7 years longer than those in the most deprived wards and for
women the difference is nearly 5 years.1 NHS Greenwich is one of 13 PCTs identified by the National Health
Inequalities Support Team that account for 40% of the national gap in life expectancy.
Population Size and Growth
The 2010 Greater London Authority population projections indicate there were approximately
241,400 residents in Greenwich in 2011. A large percentage of these residents (89.9%) were
registered with Greenwich GPs, meaning that 10.1% of Greenwich residents have a GP outside the
borough. Of the total residents living in Greenwich, 52% are female and 48% are male. In 2011 there
were approximately 275,000 people registered with Greenwich GP's. 260,385 (95%) of them are
Greenwich residents. 5% of Greenwich registered population reside in neighbouring boroughs.
Similarly some Greenwich residents (10.1%) will be registered with GPs elsewhere, most commonly
in Bexley and Lewisham. It may also be that this figure includes some "ghost patients" –patients who
have moved away or died without the GPs register being updated. Systems are in place to ensure
that GP's lists are updated when someone dies but in a very mobile population it is harder to track
when people move out of the borough.
Greenwich Resident Population Pyramid, GLA estimated resident + GP registered resident
population, 2011
Sources:Exeter GP Registrations Feb 2011, GLA, 2010 Projections for 2011
8
Diversity – Ethnicity
The GLA population projections indicate that the largest ethnic group in Greenwich is White (66%),
followed by Black and Minority Ethnic (BME) (34%). These proportions are in keeping with those for
London. The largest BME group in Greenwich is from Africa. This sub-group has increased to 13.2%
in 2011 (an increase of 106% since 2001). This means that in Greenwich there is a sizeable group in
the population who are new to the area and to the country. The next largest BME group is the Indian
population (4.7%) (see figure 1 below). This is the largest Asian population in the South East London
health sector.
Black Caribbean and Black African population are more prone to problems such as hypertension and
diabetes. People from Asian communities are high risk of diabetes and heart disease. Patterns of
risk factors such as diet and exercise and beliefs about disease may differ between different
communities.
Figure 1 Breakdown of population by main ethnic groups, Greenwich, 2011
Source: GLA 2010 Round Ethnic Group Population Projections
9
Diversity – Deprivation and Wealth
Greenwich contains the breadth and extremes of deprivation and wealth with a large percentage of
the population being amongst the most deprived fifth in the country while other parts of Greenwich
contain those who are in the most affluent fifth of the population in England. However, Greenwich is
mainly a deprived borough. The Indices of Multiple Deprivation, the most common tool for
examining deprivation levels in England, scores and ranks areas across 15 domains. On the ‘rank of
average rank' approach, where the average rank for the borough across all 15 domains is calculated,
and boroughs are then ordered according to this score, Greenwich is the 19th most deprived local
authority (LA) in England (out of 326 Local Authorities) in 2010. Alternatively it is possible to order
the boroughs by average score across the domains, in which case Greenwich has a score of 31.94
and comes out as the 28th most deprived of the 326. Areas of greater deprivation are located mainly
in the north and east of the borough but there are areas of higher deprivation across the whole of
Greenwich (Map 1). There is a well-established link between deprivation and ill health with
increased incidence and prevalence of disease amongst most deprived population groups with
increased risk of early death and shortened life expectancy.
Map 1: Greenwich Lower Super Output Area (LSOA) by deprivation quintile, 2010
Source: Indices of Multiple Deprivation 2010
10
Life Expectancy
Life expectancy has increased for both men and women according to the latest official set of figures
for 2007-09 (see figure 4). Life expectancy is also increasing in England as a whole and these figures
show that the life expectancy gap between women in Greenwich compared to England is now 0.4
years, a slight increase on the previous year although still part of an overall reduction in the gap over
the past four years. For men the gap increased each year from 2002-04 to 2005-07, and although
there has been some reduction in the gap from 2005-07 to 2007-09 the difference remains
significant and inroads small (see figure 3).
Figure 2. Life Expectancy at birth Greenwich and England 1996-1998 and 2007-2009
Index of Inequality
There are major health inequalities in life expectancy and healthy life expectancy (life lived without
disability or illness) with those living in the most deprived 20% of the borough experiencing
significantly shorter lives and more illness and disability. The Slope Index of Inequality (SII) can also
be used to reflect the socioeconomic dimension to inequalities in health. The SII can be interpreted
as the difference in life expectancy in years between the best-off and worst-off within a borough.
The SII results show the most deprived areas within a borough have lower life expectancy than the
least deprived areas. The extent of this inequality (as indicated by the value of the SII) differs greatly
between London boroughs. A low SII value indicates that there is a small gap in life expectancy
between the most and least deprived areas within a borough, while a high value indicates a greater
gap in life expectancy1.
Greenwich has very high inequality levels for both males and females, being above the London,
England and Deprivation Comparator average2 for 2005-09. Whilst data is not yet available for
comparison for 2006-10, local data for Greenwich show that health inequalities for males are
declining sharply whilst increasing rapidly for females.
1World Class Commissioning Assurance Framework, Health Inequalities Indicator: Analysis of the
Slope Index of Inequalities in Life Expectancy in London PCT’s, London Health Observatory, January2010.2
Deprivation comparators for Greenwich. Based on the rank of average ranks of IMD scores.Boroughs with similar deprivation to Greenwich are Haringey, Brent, Lewisham, Lambeth, Southwark,Hammersmith and Fulham.
11
Figure 3: Slope Index of Inequality (SII): Males 2001-05 to 2006-10
Source: NHS Greenwich, Public Health Intelligence
Figure 4: Slope Index of Inequality (SII): Females 2001-05 to 2006-10
Source: NHS Greenwich, Public Health Intelligence
Premature mortality
An important place to start is to focus on premature deaths i.e. deaths under the age of 75 years,
where there is potential for action that will prolong life especially through better management of
long term conditions (LTCs). While there is a trend for improvement there remains more to be
achieved for both men and women in Greenwich.
12
Figure 5 South East London Premature Mortality by Borough
Learning from local differences in health outcomes
As part of the overarching approach to QIPP in South East London, a “Staying Healthy” plan has beenimplemented over the last couple of years to support cluster-wide shared approaches andmonitoring of improvements in key areas of public health importance. The areas the planconcentrates on, linked to borough and cluster-wide JSNA priorities, are as follows:
Tuberculosis
Childhood Immunisations
Cancer Screening
Smoking Cessation
NHS Health Checks Programme Implementation
Obesity
Sexual Health
Through the Directors of Public Health (DPH) regular meetings in South East London, the plan hasmonitored and action to bring about improvements in performance considered. The group reviews aset of KPIs linked to performance in all of these areas which are updated on a quarterly basis. A DPHis identified as the lead for each of the areas listed above; their role is to review performance acrossthe cluster, support boroughs to share good practice and make recommendations aboutimprovement actions to be considered.
Where there are concerns about performance against these key priorities and targets are not ontrack to be delivered, action plans are escalated to the full Cluster Board meeting to provideassurance that arrangements are in place to make the necessary improvements.
With the move of Public Health to the local authority, local authority health scrutiny will play a rolein the governance of the system, whilst at the same time it will be for the CCG to hold the publichealth department of the Royal Borough of Greenwich to account for delivery of the Memorandumof Understanding on public health via the CCG governing body. The CCG will also have a right to askfor debate of these issues at the Health and Well Being Board.
13
1.3 Partnership Working
Engaging with Patients and the Public
In February and March 2012 NHS Greenwich CCG undertook a ‘Help Us Help You’ survey. The surveywas part of a wider consultation exercise around Greenwich Clinical Commissioning Group’sCommissioning Strategy Plan. The aim of the survey was to gain feedback from the general publicon the initiatives put forward in the Commissioning Strategy Plan. Participants were recruitedthrough various routes including the NHS Greenwich Health Panel, Twitter, Greenwich Council E-Panel’, Greenwich LINk and NHS Greenwich Have Your Say website.
The key findings are being taken into consideration in planning processes at Greenwich, and are
summarised below:
Priority Key themes
Improve services for people(children and adults) withlong term conditions
Agreement that services need to be better co-ordinated
Increase in the number of support groups, initiatives andprogrammes for self-management
Staff training on long-term conditions
Financial advice for people with long-term conditions
Provide more opportunityfor care in the community
Concern that waiting times for GP appointments would increase
Services should be physically and geographically accessible
Conflict with current over-reliance on A&E services
Co-ordinate the provision ofurgent and out of hourscare
Lack of information for residents and professionals
Mixed reports on quality of out of hours services
Over-reliance by professionals on A&E
Use of A&E due to lack of alternatives
Improve services for people(children and adults) withmental health problems
Strong preference for preventative and early interventioninitiatives
Concern over opening of Community Crisis House
CAMHS overburdened and lack of information on alternativeservices for support
Improve children’s services CAMHS and paediatric unit in QE in need of review
Concerns about quality at the special baby care unit
Early intervention and initiatives with schools
Improve the quality of endof life care
Increase and monitor staff training in terms of skills and attitudes
More information available on services and options
Service to be based around the needs of the individual
Additional priorities: toincrease quality
Increase and monitor staff training in terms of skills and attitudes
Better and more consistent information
Modernise communication methods
Waiting times are too long
Maternity services need to be improved
Bi-lingual health advocates and closer working relationships withlocal third sector organisations
Additional priorities:financial efficiencies
Modernise communication methods
Prioritise finance on ‘prevention rather than cure’
Agreement on improvements should be made to the waymedicines are prescribed
Introduce paid-for services in the NHS
14
The Royal Borough of GreenwichIn Greenwich we recognise the importance of putting in place strong joint commissioningarrangements with the local authority. Greenwich PCT and the Royal Borough of Greenwich have ahistory of working in partnership to meet their responsibilities for carrying out Joint Strategic NeedsAssessment (JSNA) and using high quality local and national data on patterns of health and disease.This joint approach will continue and be strengthened as NHS Greenwich CCG develops. The JSNAand other key data sources inform local plans which in turn inform commissioning decisions.Through the Health and Well Being Board and well-developed joint commissioning arrangementsbetween NHS Greenwich CCG and the Royal Borough of Greenwich, opportunities to integrate keyservices are considered across health and social care sectors, with integrated governance andmanagement a shared philosophy and common objective.
Using a joint commissioning approach leads to improved integration and delivery of front line
services. Joint Commissioning tends to be used to support people who need both health and local
authority service (social care/housing) support. To underpin this approach a number of joint
commissioning posts have been developed to support delivery and monitoring of commissioning
plans. Typically the services commissioned jointly with the local authority are:
Substance Misuse (Drugs & Alcohol)
Children & Young People Services and CAMHS (Children and Adolescent Mental HealthServices)
Adult Mental Health Services
Adult Physical and Sensory Disability Services
Learning Disabilities (Greenwich Council Lead Commissioners)
Older People and Dementia
Third Sector Services
Carers Support
Hospital & Community assessment teams and intermediate care services
Community Equipment and hospital stores
All these services are commissioned with the involvement of service users and carers.
There are benefits from undertaking joint commissioning. These are to:
Secure the best services
Ensure services represent good value for money
Ensure the greatest impact for service users
Ensure equity of access for all service users
London Wide Joint Commissioning
To ensure that our patients have access to high quality specialised care, such as neonatal intensivecare, complex arterial surgery and rare cancers, we work closely with the London SpecialisedCommissioning Group, clinical networks such as the cancer and the cardiac and stroke networks andLondon Health Programmes. Our clinical leaders are involved in developing cases for change, settingpriorities and in ensuring that the interface between local services and specialised services isdesigned and operates effectively. A separate commissioning strategy for London is published by theLondon Specialised Commissioning Group. As the NHS Commissioning Board assumes responsibility
15
for specialised commissioning and primary care commissioning the CCG will seek to engageconstructively with these agendas.
Joint Working across South East London and Commissioning SupportNHS Greenwich CCG has subscribed to collaborative working arrangements across all south eastLondon CCGs that are aligned with the common set of commissioning functions purchased fromSouth London Commissioning Support Unit (SLCSU). The diagram below provides, at high-level, theareas where CCGs wish to collaborate and how this relates to local and SLCSU activities. The modeloutlines initial priority areas for CCG collaboration, other areas where CCGs may wish to collaboratemay be added as new clinical commissioning arrangements develop.
Accountable CCG Governing Bodies
Area CCG Collaboration CCG Local SLCSU
AcuteLead Commissioner
(acting as host)Lead Contracting team
Multi-disciplinary contract
team
Non Acute
‘Common Standards, Local
Delivery’ – shared
programmes and common
approach to contracting
Local Commissioning and
redesignNone
Strategy
Strategic development -
(Six Borough / LSL and
BBG)
Local leadership of:
Integrated Plan,
Commissioning Intentions
and QIPP
Health intelligence to
support decision making
Risk
South east London Risk
Sharing agreement
Local CCG arrangements
within contracts and with
local authority
Support to derive risk
assessment / decision-
making
Other areasCommon Assurance
Committees
CCG Governance
Structures
Delivery of common
policies and reporting (e.g.
IFRs and Integrated
Performance reporting)
Key: Within CCGs Within SLCSU
The CCG also recognises that it will be necessary to collaborate to manage relationships with boththe National Commissioning Board (NCB) and the SLCSU. Our CSG, supported by the South EastLondon Chief Officers Group (COG), provides an effective forum to provide coherent and consistentinvolvement in the LCCC where each CCG will also be represented. The CCGs have elected a lead CCGChair (NHS Lambeth CCG) for this area.
NHS Greenwich CCG has been working together with the South London Commissioning SupportService (SELCSU) to develop arrangements for commissioning support during 2012/2013, and postauthorisation. In order to support CCGs as they prepare for authorisation, and to support thedevelopment of the CSU in such a way as to meet its own authorisation requirements, aMemorandum of Understanding (MoU) describes the proposed offer of the CSU to meet bothorganisations’ needs at this stage. It also recognises a shared commitment to co-develop the detailrequired to conclude a robust Service Level Agreement (SLA) by October 2012. The MoU andsubsequent SLA will govern the relationship between the two organisations, as they work in shadowform until March 2013, and from April 2013 onwards.
16
In order for the CCG and the CSU to demonstrate that sustainable plans for commissioning supportare in place to support authorisation, the parties have agreed to a four year partnership (transitionyear plus three years, with the possibility of further extension) that will be further described anddeveloped during 2012/13 and reassessed on an annual basis, subject to the terminationarrangements described in this document. Greenwich has opted for the Core Service offering,comprising:
Acute contract management (including quality)
Individual Funding Requests (IFR) management
Provider Performance Management
Advice & Support on Clinical Procurement
Performance and activity reporting and analysis
Financial Governance & Control, Counter Fraud
Financial Management and Planning
Estates and health and safety
Human Resources and organisational development
Purchasing (non-clinical)
ICT Support
Communications and Engagement
Joint Working with Bexley and Bromley CCGs
Bexley, Bromley and Greenwich work together to actively manage supplier relationships and clinicalengagement. They are focused on identifying opportunities to jointly work with providers to improveservices for the population, promote innovation, quality and cost effectiveness. For example, Bexley,Bromley and Greenwich are acting together to negotiate and monitor contracts with acute careproviders. Overlaps between Bexley and Greenwich QIPP initiatives which impact acute contractinghave been identified and incorporated in contracts. A specific concordat/proposed strategicframework that looks to the next three to five year planning cycle has been put in place with SouthLondon Healthcare Trust, and a Bexley, Bromley and Greenwich Clinical Contract Group isresponsible for negotiating the detail.
Other examples of working with providers include quality monitoring groups for South London
Healthcare Trust and Oxleas Mental Health. For instance, clinical leads across Bexley Bromley and
Greenwich are meeting with South London Healthcare Trust’s Orthopaedic and Rheumatology
Directorate to monitor performance and explore joint working arrangements across musculoskeletal
services.
The Bexley, Bromley and Greenwich Clinical Strategy Group has been established to drive forward
collaborative working; monitor, challenge and report progress of joint work streams; and identify
further areas which would benefit from a joint approach. This group is chaired by theCCG Chair of
Bromley, and membership comprises the CCG Chairs of Bexley Clinical Commissioning Cabinet and of
Greenwich Health, as well as the Managing Directors (Accountable Officers) of Bexley, Bromley and
Greenwich CCG’s and the Bexley, Bromley and Greenwich Programme Director.
A Clinical Strategy Commissioner and Provider Group have been established to facilitate
collaboration with providers. A Bexley, Bromley and Greenwich Stakeholder Reference Group has
also been established, reporting to the Bexley, Bromley and Greenwich Clinical Strategy Group.
17
Membership includes representatives from Bexley, Bromley and NHS Greenwich CCGs, LINks,
Voluntary and Community Groups, NHS Trusts and other providers. The Bexley, Bromley and
Greenwich Stakeholder Reference Group does not replace local stakeholder engagement and it does
not engage directly with patients and the public. Its role is to challenge and provide assurance over
the impact of proposed service changes that cut across the boroughs on engagement with the public
and patients, including local authorities and the development and support of patient choice.
The Shared Standards Programme Board has been established to provide strategic direction,
challenge and governance to the work of the team. This Board will work under the governance
framework established for the Bexley, Bromley and Greenwich Clinical Strategy Group, with overall
accountability to the Bexley, Bromley and Greenwich Clinical Commissioning Groups for achieving its
objectives within the timelines. The Shared Standards Programme has established its own dedicated
BBG Programme Management Office (PMO) which will work in close alignment with the Clinical
Transformation Implementation Programme PMO to ensure that dependencies are managed and
monitored accordingly.
The Programme has inherited 5 projects where BBG CCGs have been working together or sharing
their learning with one another since the summer of 2011. These work streams are being brought
into these new programme management structures and will be reported through the BBG
Programme Management Office. These work streams are the Elderly Care, Cardiology,
Musculoskeletal, Urgent Care and Diabetes pathways. An early step in implementing these new
governance arrangements is to review and prioritise projects i.e. those started and new proposals to
ensure that the BBG PMO and project management capacity focuses on those work streams likely to
deliver the greatest outcomes in the shortest time. This work will be complemented by the out of
hospital work streams linked to the consultation on the future of SLHT and the above approval
process by-passed. The overall Governance architecture is described in the diagram below:
18
Greenwich Partnership Working Case Study
NHS Greenwich CCG has forged such an effective, innovative relationship with the Royal Borough ofGreenwich, that it has been shortlisted for the Secretary of Health Award for Health Service Journalin recognition of strong examples of joint working between CCGs and local authorities.
The CCG regularly meets with representatives from the local authority and has begun to invite morestakeholders to these meetings, including patients’ representatives, voluntary sector organisations,community health providers and the acute provider to discuss the health needs for Greenwich.
NHS Greenwich CCG has also formed a close working relationship with the Bexley, Bromley andGreenwich clinical strategy group to discuss where there can be integrated services for cardiology.Greenwich has also held discussions with Lambeth, Southwark, Lewisham CCGs exploring possibleareas for joint working.
The CCG also asked a number of stakeholders including hospitals, and local authorities to undertake360 degree appraisals of the CCG services. These reviews proved extremely successful with the vastmajority of stakeholders offering positive feedback on the clinical strategy.
Patient engagement is also a priority of the CCG. Before any tender for a service, a market day isheld giving service users the opportunity to express their views. The CCG has also engaged with arange of ethnic, voluntary and age groups including the Greenwich voluntary sector heathorganisation, the black and minority ethnic health forum, and children and young people’s groupsto understand how various patients feel about the services on offer, and what improvements can bemade.
The CCG is working to address the historic health inequalities that exist within the borough, and isexploring how to change the tendering process to reflect the needs of the population, ensuring thaturgent care centres and GP services are situated in areas where the need is greatest. Healthoutreach programmes aimed at engaging with hard-to-reach groups have also been established.
The CCG has also worked with GP member practices, creating a borough wide forum for them to allattend. By working closely with GPs, the CCG is also able to increase patient engagement levels bymonitoring GP involvement with public and patients advisory groups (PPAGs).
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1.4 Introducing NHS Greenwich CCG
1.4.1 The Greenwich Story
In 2004 The Audit Commission undertook a benchmarking exercise of average London PCT spend
against the key areas of General/Acute/A&E, Mental Illness, Prescribing, Community health,
Learning Disability, and ‘Other’. This benchmarking suggested a structural imbalance in Greenwich,
with the borough spending in excess of the London PCT average in the acute sector and an under-
utilisation of community health. The gap in the acute sector budget against commitments for
Greenwich PCT needed to be addressed. It was clear that:
Efficiency needed to be improved.
There was an overuse of hospital services
There was a need to move from fire-fighting and an over-concentration on secondarycare to an improved strategy, incorporatingo Spending more ‘upstream’ on prevention.o Spending more on intermediate care.o Changing ways of working to effect this change
Whilst the main provider, South London Healthcare Trust, embarked on a major cost reduction
programme, Greenwich commissioners began to implement the strategy of moving the delivery of
care out of hospital and as near to the patient as possible – a strategy that has delivered positive
outcomes and continues to this day.
This included a major capacity utilisation project aimed at both reducing costs and improving the
patient experience whilst also delivering the Local Delivery Plan target of achieving a reduced level
of emergency admissions. This took place on 2 levels:
Identifying the most regular vulnerable high users of service or ‘frequent flyers’ inaccordance with recent national directives and evidence-based practice. This embraced theLong Term Conditions Management focus on risk stratification and early intervention.
Looking at where the possible ‘step down’ service gaps may be with a view to assessingwhich acute sector services and further community support services could, in the future, beprovided out in the community for the same or less cost. This has meant:
o Ensuring that fewer people are admitted incorrectly by providing a better selectionof integrated service outside of hospital services, with a fully trained workforce, and
o Helping people to be, generally, ‘more healthy’ by providing more appropriate out ofhospital integrated services, restructuring of workforce and accessible facilities andproviding clear Public Health messages.
Greenwich priorities for current and future years continue to concentrate on reducing emergencydemand and developing integrated community services. Redesigning the pathways also involvesredesigning the workforce to better support the new service improvements. These new models ofintegrated care are producing innovative and exciting changes throughout the borough, resulting inbetter quality care for patients.
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1.4.2 Current Challenges: South London Healthcare Trust (SLHT)
In June this year South London Healthcare NHS Trust was the first trust to be put into the Regime forUnsustainable NHS Providers following the appointment of a Special Administrator. Since then theTrust Special Administrator (TSA) team have been working together with clinicians, patients and thepublic, staff, partner organisations as well as others who are involved in health services in south eastLondon, including NHS Greenwich CCG, to address the significant financial challenges facing SouthLondon Healthcare NHS Trust (SLHT) in order to secure clinically and financially sustainable servicesfor the long term for the people of south east London.
Early analysis identified SLHT’s challenge as tri-fold with a need for us to collectively address all threeareas in order to reach a sustainable solution for the future. These are:
1. The need to improve operational efficiencies within SLHT2. The need to resolve the PFI challenges3. The need to better design the whole south east London health economy and the way all
health partners work together to ensure we get the best healthcare in the most sustainableway for our population.
CCGs in south east London are making planning assumptions for how they want to change the modelof care to deal with this challenge:
Shifting volumes from the acute to primary and community care
Reinvesting in primary and community care to achieve this
Reducing unit costs in community based care
By 29 October 2012, the TSA will publish a draft report outlining recommendations to securesustainable services across south east London. Consultation on the draft recommendations will befor a statutory 30 working days through November until 14 December after which the TSA willconsider the feedback and finalise his recommendations and report to the Secretary of State by 8January 2013, expecting his final decision on how health services in south east London can besustainably delivered to be made by 4 February 2013.
The Accountable Officer for NHS Greenwich CCG has been chairing one of the key Working Groupsthat is supporting the development of the TSA report. This is the Community Based Care (CBC)Working Group. The CBC working group is tasked with developing these plans by the middle ofOctober to feed into the final report on 29th October 2012.
Community Based Care is a key building block to the design of future health services in south eastLondon. It is critical that primary care is developed as the hub for multi professional service deliveryand ensure services in community based settings and hospital services are networked togetheraround patients. A number of workshops are being held to bring together community basedclinicians to further develop the vision for health services delivered outside acute hospital settings insouth east London. The workshops have examined access to good quality care, simplified patientpathways and integrated care for vulnerable groups. Early discussions have focused on recognisingthat there is a spectrum of different needs across the south east London area, and that there willneed to be clear borough-based, local delivery but delivered to shared standards designed aroundhealth outcomes.
The emerging strategy coming from the CBC working group fits well with the continuing Greenwichstrategy of moving services out of hospital, avoiding admissions and delivering care closer to thepatient, and the work to produce this Greenwich Integrated Plan has been closely linked in with thedevelopment of the TSA plan.
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1.4.3 NHS Greenwich CCG Governance
The mission of NHS Greenwich Clinical Commissioning Group is to secure the best possible health
and care services for the population that we serve, specifically in primary care settings and in
hospitals as necessary. In doing this, we will work with patients and the wider public to develop the
services that we offer, reduce health inequalities and improve health outcomes.
In everything we do we seek to obtain the best quality we can – quality in terms of clinical
effectiveness, patient safety and patient experience.
The geographical area covered by Greenwich Clinical Commissioning Group is coterminous with theRoyal Borough of Greenwich and with Greenwich Teaching PCT. All the 45 general practices inGreenwich comprise the members of Greenwich Clinical Commissioning Group. The combinedregistered population of Greenwich’s 45 practices is circa 275,000.
Since September 2010, GPs from across Greenwich have been meeting together with colleagues atthe PCT and the Royal Borough of Greenwich to develop a vision for a Greenwich wide GP clinicalcommissioning group. The GP Commissioning Interim Steering Group was mandated to design aShadow Board structure for a Greenwich wide GP commissioning consortium, to organise anelection process for Shadow Board members and to implement the Shadow Board within anappropriate timescale. GPs in Greenwich were invited to nominate themselves for election duringDecember 2010, twelve candidates stood for the seven posts. A postal election process using theSTV voting system was administered by the Borough Returning Officer, supported by ElectoralReform Services. There were 109 valid votes cast, a turnout of 70%, and seven GPs were duly electedto form a shadow board.
Awarded ‘Pathfinder Status’, the Greenwich GP Commissioning Consortia Board (the Shadow Board)was duly established to lead the transition from PCT commissioning to GP Commissioning inGreenwich, guiding the Shadow Consortia through a two year process preparing the foundations forthe Greenwich GP Commissioning Consortia Board which is expected to come into effect from April2013. Building on a strong track record of local clinical commissioning the members of theconsortium have been able to demonstrate compliance with the three tests set by the secretary ofstate (relating to local GP leadership and support, local authority engagement and an ability tocontribute to the delivery of the local QIPP agenda) and have now worked with the NHS South EastLondon Cluster to develop the capacity and capability to assume delegated responsibility for someareas of commissioning in 2011/12, and for most aspects of commissioning since April 2012.
Members of the GP Leadership team have three key responsibilities that will allow them to operatewith increasing delegated responsibility over time:
A leadership, management and engagement role for their syndicates
A commissioning portfolio across the borough with responsibility for securing agreed QIPPplans in each area; and
A business portfolio across the borough with responsibility for ensuring the effectiveperformance management of each area of local commissioning.
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A new organisational governance structure has been agreed, as per the diagram below, in order to:
assure the Governing Body;
to discharge delegated authority in decision making on behalf of the Governing Body; and
to effectively manage day-to-day operations on behalf of the CCG
The current leadership clinical responsibilities are as follows:
GP Lead Clinical Portfolio
Dr Hany Wahba Unplanned CareOverall Clinical Strategy
Dr Rebecca Rosen Long term ConditionsEnd of Life & Cancers
Dr Junaid Bajwa Mental Health
Dr Eugenia Lee Maternity, Women’s Health,Children
Dr Nayan Patel Planned care & utilisationreview
Syndicates
NHS Greenwich CCG has been keen to ensure that the CCG membership structures are kept simple,transparent and with as little bureaucratic process and structures as possible. As a result aGreenwich wide Forum has been established, comprising all Greenwich GPs and practices, with aflexible syndicated structure which groups together GP practices.
23
Syndicates have, therefore, been formed around ‘natural partnerships’ which share a combination ofgeographical proximity, shared or complimentary clinical skills, and/or information systems.Syndicates based on clinical areas of interest and clinical experience will influence commissioningand the provision of clinical services. Syndicates based on a geographical basis will ensure all thepopulation of Greenwich, whether registered with a GP or not, are represented. Coupled withshared information systems this ensures that the syndicates are able to take a pan Greenwichpopulation based approach and ensures best practice is shared throughout the Consortium.
One of the key functions of the Syndicates is to provide a mechanism whereby patient choice, firstexpressed in the patient’s consultation with their GP, becomes central to the planning and decisionmaking processes of the CCG.
The Greenwich wide Forum provides a key opportunity for GPs across Greenwich to meet andinfluence plans and strategies being developed by the Board.
Appendix 1 “ Greenwich Governance structure and responsibilities” shows the relationshipbetween the GP Board members, the GP syndicates and syndicate leads, clinical and corporateleads, their individual domains of leadership and the local CCG managers who support the Board.
A Constitution for the CCG has now been drafted that describes the organisational and legal form ofthe NHS Greenwich Clinical Commissioning Group. It is subject to any changes in law, and may needto be modified in response to evolving regulation and guidance. The aim of this Constitution is toestablish NHS Greenwich Clinical Commissioning Group as an organisation focused on improving thehealth and well being of the people of Greenwich and securing high quality health and care servicesfor that population. This Constitution is made between the members of NHS Greenwich ClinicalCommissioning Group and has effect from 1st day of April 2013, when the NHS Commissioning Boardwill establish the Group.
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Section 2: Improving Health
2.1 NHS Greenwich CCG Strategic Overview
Based on local assessment our current strategy for Greenwich builds on the NHS South EastLondon Commissioning Strategy Plan 2012/13-14/15 ‘Better for You’, while incorporating thestrategic priorities identified in the Greenwich Health Clinical Commissioning Strategy 2012-2015, and by the latest Greenwich Joint Strategic Needs Assessment. It is also aimed ataddressing the five domains of the NHS National Outcomes Framework as follows:
Domain 1 - Preventing people from dying prematurelyDomain 2 - Enhancing quality of life for people with long-term conditionsDomain 3 - Helping people to recover from episodes of ill health or following injuryDomain 4 - Ensuring that people have a positive experience of careDomain 5 - Treating and caring for people in a safe environmentand protecting them from avoidable harm
Our Mission
Our mission is to meet the three key ‘must do’ challenges we have identified for Greenwich:
Tackling poor health and Long Term Conditions
Driving Improvement whilst sustaining the clinical and financial viability of the local health
economy
Managing pressures resulting from population changes and the economic downturn
Our Vision
Secure the best possible health and care services
Developed with patients & public, & in collaboration with health & social care professionals &
partner organisations
In primary care and community settings when possible & in hospital when necessary to reduce
health inequalities & improve health outcomes.
Our Principles
We will improve quality and the quality of patient experience by:
Improving health outcomes with a relentless focus on the seven main health conditions and
diseases in Greenwich and using evidence based approaches.
Reducing health inequalities by taking a preventative, proactive approach and focusing on
the health needs of black & minority ethnic communities and ‘hard to reach’ groups.
25
Simplifying clinical care pathways to ensure better quality care through aligned incentives
and integrated approaches and services.
Encouraging self-management of conditions wherever possible to reduce avoidable hospital
admissions and to increase patients’ confidence using evidenced based measures and
adopting best practice.
Improving collaboration to harness economies of scale and scope in order to do more or
better with available resources in the future through closer integration with Social Care,
Public Health and other partners.
Ensuring service development is better connected to and wraps around primary care by
commissioning service improvements that link to clinical processes in primary care.
Managing demand effectively through referral management, seeking to support patients to
make pathway choices and make best use of services in the community
Judicious use of integration and competition to enhance quality and offer more choice,
increasing choice through the ‘Any Qualified Provider’ policy and other commissioning
innovations.
NHS Constitution
CCGs have a legal duty to act with a view to securing health services that are provided in a way
which promotes the NHS Constitution and promotes awareness of it amongst staff and the public.
NHS Greenwich CCG is fully committed to this duty. The guiding principles of the NHS Constitution
are:
1. The NHS provides a comprehensive service, available to all
2. Access to NHS services is based on clinical need, not an individual’s ability to pay
3. The NHS aspires to the highest standards of excellence and professionalism
4. NHS services must reflect the needs and preferences of patients, their families and their
carers
5. The NHS works across organisational boundaries and in partnership with other organisations
in the interest of patients, local communities and the wider population
6. The NHS is committed to providing best value for taxpayers’ money and the most effective,
fair and sustainable use of finite resources
7. The NHS is accountable to the public, communities and patients that it serves
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Our key challenges are:
Tackling 10 major causes of ill health and the resulting 7 main disorders and conditions identified
in our JSNA. These are:
Cardiovascular disease (heart disease, stroke)
Cancers
Respiratory disorders
Mental health
Falls and fractures in older adults
Alcohol related harm
Diabetes
Managing pressures from population changes (including new populations) and the
economic downturn
Driving improvement whilst sustaining clinical & financial viability of health economy
In response to this challenge, our key strategic priorities are as follows:
Staying healthy & health protection
A whole system approach, for children and young people focusing on prevention and developing
integrated care pathways and services
Improve mental health care
Improve long term conditions care
Co-ordinate the provision of urgent care and out of hours care
Increase capacity in high quality cost effective alternatives to hospital based planned care
Enhance end of life care
In delivering these priorities, it is recognised that easy access to high quality, responsive primary and
community care will be essential. We are working with colleagues across south east London, and
have collectively identified the following aspirations for community based care (more detail can be
found in Appendix 4):
Be supported to manage their own health and any illnesses that they have and feel
confident to do so
Have access to telephone advice and triage for all community health and care services 24
hours a day, seven days a week either through their General Practice or through a telephone
single point of access
Have access to primary care service/advice 24hrs, 7 days a week for urgent needs through a
combination of appointments and walk in services, telephone appointments, 111/NHS
Direct, same day urgent care,
Be provided with high-quality, evidence-based primary and community-based care,
delivered through primary care staff collaborating with each other and with specialist and
community services, delivering care in line with agreed quality standards and outcomes.
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Table 1: Key Health Challenges across Greenwich and South East London
Greenwich
Challenges
South East
London
Challenges Example of local needs
Greenwich
Strategic
Priority
Cardiovascular
disease (CVD)CVD
A major cause of premature mortality with
variations in the outcomes for different people
CHD: Greenwich has higher mortality rates than
London and National average - linked to
deprivation
Improve long
term conditions
care
Cancer Cancer
Major cause of premature death and some rates
higher than the national average
Especially lung, breast and bowel
Staying healthy
and health
protection
Respiratory
disorders
Long Term
Conditions
Many COPD deaths are preventable and can lead
to excess demand on hospital beds if not managed
well.
COPD: standardised mortality rates are
significantly higher than the national average
associated with long-term smoking patterns.
Improve long
term conditions
care
Co-ordinate the
provision of
urgent care and
out of hours care
Mental health Mental Health
A significant cause of disability and distress
Depression and anxiety, dementia, conduct
disorder in children
Improve mental
health care
Falls and fractures
in older adults
Long Term
ConditionsMusculo-skeletal health
Improve long
term conditions
care
Alcohol related
harmHealthy Living
Many of the factors driving ill health are due to
how people eat, drink and take exercise
Staying healthy
and health
protection
DiabetesLong Term
Conditions
Diabetes: Black African, Black Caribbean and
South Asian ethnic groups are at higher risk of
developing diabetes, so a considerable percentage
of Greenwich and SEL population at high risk.
Improve long
term conditions
care
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Table 2: Outcomes and Measures to be achieved in tackling the strategic priorities:
Greenwich
Strategic
Priority Rationale Outcomes Proposed Measures
Staying healthy
and health
protection
The Greenwich JSNA identifies 10
root causes for ill-health and poor
well-being in the borough. These
include health behaviours such as
smoking, physical inactivity,
alcohol and also include social
such as the requirements of
Greenwich’s new populations and
service quality issues in relation
to identification of people with
long-term conditions and optimal
clinical management of people
with those conditions and
excellent access to health
protection measures such as
immunisation, screening and
health promoting sexual health
services.
Continued improvement in
the number of people who
quit smoking and reduction
in those taking up smoking;
improved levels of physical
activity and reduced levels
of obesity; increased
detection of people with
long term conditions in
primary care and
improvements in their
management;
improvements in uptake of
screening programmes;
reductions in use of A&E
and in-patient care for
cardio-vascular and
continued improvements
in life expectancy for men
and women.
Smoking Quitters -
Number of 4-week
smoking quitters
that have attended
NHS Stop Smoking
Services
NHS Healthchecks -
Number of eligible
people who have
received an NHS
Healthcheck
Bowel screening -
Extension of bowel
screening program
to men and women
aged 70 up to 75
birthday
Prevalence of
Chlamydia in under
20 year olds.
A whole system
approach for
children and
young people
focusing on
prevention and
developing
integrated care
pathways and
services
The Greenwich JSNA identifies a
number of areas where children’s
services are in need of
improvement; improving
outcomes of pregnancy for
mother and baby, reducing
obesity and improving diet, and
improving the health of children
with additional needs and long
term conditions. Greenwich has a
young population and higher than
average birth rate. Child health in
the borough is impacted by the
level of deprivation and this is
seen in: the high rate of
obesity/poor fitness in children,
Reduction in inappropriate
emergency attendances,
reduction in CAMHS
waiting times, decreases in
child obesity. Impact on
Domains 2,3 & 4 of the
National Outcomes
Framework.
Childhood obesity
in reception year
and year 6.
Maternity access -
% of women who
have seen a
midwife by 12
weeks and six days
of pregnancy.
Breastfeeding
prevalence at 6-8
weeks from birth.
Childhood
29
Greenwich
Strategic
Priority Rationale Outcomes Proposed Measures
two thirds of children/young
people requiring CAMHS services
are not able to access them, and
teenage pregnancy and sexual
health problems need to reduce.
There is an increasing number of
children in the borough with
autistic spectrum disorder and
few services. Greenwich has a
high percentage of Looked After
Children. Half of A&E
attendances are for children and
the majority of these could be
better managed in the
community.
immunisation rates
Improve mental
health care by
focusing on the
interface between
primary,
community and
secondary care,
increasing service
users’ choice and
access to services
that maximise
recovery, prevent
relapse and
admissions to
acute care and
maximise care and
support to people
in their own
homes.
JSNA indicates that levels of
mental ill health are high in
Greenwich, with one in three
people experiencing a mental
health condition. We also need
to drive further efficiencies from
mental health services to invest in
areas that need improvement
and deliver the six objectives for
improving health and wellbeing
as set out in the national strategy
‘No health without mental
health’. Users often express
dissatisfaction with the choice of
services locally and we need to
provide more options. For
example third sector provision.
Reductions in avoidable
referrals, improved waiting
times. Impact on Domains
1, 2 & 4 of National
Outcomes Framework.
Length of stay
(MH) - Average
spell duration for
non-same day MH
discharges
IAPT – Improving
Access to
Psychological
Therapies
Improve long
term conditions
care, through:
Prevention and
self-management
support/support
Significant increases in long term
conditions predicted, increasing
numbers of emergency
admissions for LTCs. Local JSNA
suggests that cardiovascular
disease (heart disease and
Reduction in emergency
admissions, increased
numbers of patients
actively case managed in
general practice. Impact on
Domains 1, 2 & 3 of the
People with Long
Term Conditions
feeling
independent and in
control of their
condition - % of
30
Greenwich
Strategic
Priority Rationale Outcomes Proposed Measures
to carers
Targeting
interventions
according to need
& extending the
range of services
available
Better
coordination
between providers
& integration
between health,
social and other
care
stroke), respiratory disorders,
mental health, diabetes and falls
and fractures in older adults are
five of the seven main disorders
and conditions prevalent in
Greenwich.
National Outcomes
Framework.
people with LTCs
who said they had
had enough
support from local
services/orgs
Co-ordinate the
provision of
urgent care and
out of hours care,
reducing
duplication
Better co-ordination, reduced
duplication and fragmentation
across the whole urgent care
system required. Improved
patient experience with clear
navigation of the system,
reducing the number of services
patients use inappropriately.
Need to reduce the volume of
patients who attend A&E
frequently and inappropriately
Reduction in A&E
attendances, reduction in
emergency admissions.
Impact on Domains 2, 3 &
4 of National Outcomes
Framework.
A&E Quality
Indicators -
Unplanned re-
attendance -
Unplanned re-
attendance at A&E
within 7 days of
original attendance
(including if
referred back by
another health
professional)
Emergency
readmissions
within 30 days
Increase capacity
in high quality
cost effective
alternatives to
hospital based
planned care –
linking these to
hospital services
in ways that avoid
fragmentation
and duplication.
Estimated that 40% of planned
care could take place in lower
cost community based settings
which are more convenient for
patients. Freeing up capacity in
local acute hospitals will enable
more care to be repatriated from
inner London hospitals,
facilitating greater local access for
patients and reducing costs.
Increase in number of
referrals made using
agreed pathways, decrease
in avoidable GP referrals,
and outpatient shift of
activity from acute to
community settings.
Impact on Domains 1,2,3 &
4 of National Outcomes
Framework.
Monitoring of
capacity through
MAR (Monthly
Activity Returns) by
providers.
31
Greenwich
Strategic
Priority Rationale Outcomes Proposed Measures
Enhance end of
life care through:
Better
coordination
between service
providers,
implementing an
integrated model
Enabling people to
die in the place of
their choice
Implementing best
practice pathways
and frameworks
Most people would choose to die
at home if possible, however
many people die in hospital. As
well as improving quality and
patient experience, community
based EOLC is significantly more
cost efficient
Number of people dying in
their preferred
place/normal residence.
Impact on Domain 4 of the
National Outcomes
Framework.
% deaths at home
(including care homes) -
No. registered deaths
at home/no. registered
deaths
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2.2 NHS Greenwich CCG Strategic Priorities
As set out in Section 1 above, the CCG has identified seven strategic priorities for improving health.
To deliver the strategic aims identified the CCG has planned the actions it needs to take across the
strategic planning period. These actions can be broken down into those that are planned for
implementation in the year of transition (12/13), commissioning intentions for the following year
(13/14) that build on these foundations, and medium term strategic plans covering the period
through to 2017/18. The following table 3 sets out the high level plans for the achievement of these
strategic priorities:
33
Priority Rationale Principles Opportunity Impact
Staying Healthy &
Health Promotion
The main causes of premature death are
common across south east London. We
believe that by creating opportunities for
people to choose and maintain healthy
lifestyles we will make major contributions
to increasing life expectancy, reducing
health inequalities, reducing hospital
admissions and preventing and delaying
the development of long term conditions.
Smoking is a leading risk factor for the top
causes of premature death for our
population (CVD, some cancers, respiratory
diseases). Smoking contributes to other
conditions such as osteoporosis, cataracts,
childhood infections and digestive
disorders
Physical inactivity is a leading risk factor for
the main causes of premature death for our
population (CVD, cancers, and respiratory
diseases). Childhood obesity rates are high
in south east London
Babies who are not breastfed are much
more likely to develop illnesses such as
gastroenteritis and respiratory infections
requiring hospitalisation as children. In
later life they are more likely to develop
We will:
Employ strategies aimed at
the whole population as well
as focusing on specific local
patient groups
Tailor solutions to local
populations while at the same
time applying national and
London polices at a local level.
Work together across a
broader geography where this
is the most appropriate
approach to achieve better
outcomes
Seek to achieve maximum
benefit in health for our
populations reducing
inequalities in health
Tackling Obesity, Diet and
Physical Activity
Smoking
NHS Health Checks
Implement fall prevention
programme
Tuberculosis
Reduce the level of obesity in adults and
children reducing the impact on heart,
diabetes etc.
Increase the numbers of people quitting
smoking with NHS stop smoking services
in Greenwich, reduce the prevalence of
smoking amongst our population and
reduce smoking attributable acute
activity and premature mortality
Continue to implement the new NHS
Health Checks programme in Greenwich,
reducing the major risk factors for
vascular disease and reducing the
prevalence of heart disease, strokes and
diabetes within our population over
time`
In conjunction with London-wide TB
programme, improve the early detection
and effective treatment of TB in
Greenwich and reduce the burden of
disease within the population
In conjunction with London-wide Cancer
programme, improve coverage of cancer
34
high blood pressure and cholesterol levels
and associated illness.
Mothers who do not breastfeed have
increased risk of breast and ovarian
cancers and may find it difficult to
return to pregnancy weight.
Too many people die of alcohol related
problems in south east London.
Alcohol-related problems place a
major burden on health services in
primary care, A&E, acute and specialist
services and also across wider societal
areas of crime, accidents, domestic
violence and unemployment.
Cancer
Immunisations
Sexual Health
screening programmes in Greenwich,
increasing early detection of treatable
breast, cervical and bowel cancers within
and improving survival rates
To improve the coverage of childhood
immunisation and reduce the incidence
of outbreaks and cases
To improve sexual health within our
population by reducing late diagnosis of
HIV, reducing teenage conceptions,
improving the early detection and
treatment of chlamydia and improving
access to sexual health and contraceptive
services
35
Improving Children’s
Services
Greenwich has a young population and
higher than average birth rate.
Child health in the borough is impacted by
the level of deprivation and this is seen in:
the high rate of obesity/poor fitness in
children, two thirds of children/young
people requiring CAMHS services are not
able to access them, and teenage
pregnancy and sexual health problems
need to reduce.
There are an increasing number of children
in the borough with autistic spectrum
disorder and few services.
Greenwich has a higher than average
percentage of Looked After Children.
Half of A&E attendances are for children
and the majority of these could be better
managed in the community.
Take forward the 12 priorities
for improving the health and
circumstances of young
people identified in the
2011/12 Annual Report of the
Director of Public health and
Well-being.
Decrease current poor health
in children; focus on
prevention to ensure children
are able to make healthy
choices that will mean they
grow up into healthy adults.
Develop more integrated
pathways and services.
We will take a partnership
approach with Public Health,
community health services,
colleagues in education, the
third sector, children & young
people, families and carers
We will use social marketing
and ideas from young people
to make sure our message
and information about
services is targeted in the
most appropriate and creative
way to children and young
Prevention
Improving health outcomes
for mother and baby
Reducing obesity &
improving fitness
Developing an integrated
service for children with
complex needs
Asthma pilot
Raising awareness, increasing healthy life
choices targeting key health issues
including obesity and fitness levels,
sexual health, and psychological well-
being, health needs of children from
black and minority ethnic communities –
working closely with Public Health and
Education sector.
Improve detection and management of
diabetes and hypertension, reduce
smoking, reduce obesity, improve access
to dental care, improve detection and
follow up of serious infectious disease.
Reduce teenage pregnancy.
Multifaceted programmes to improve
diet and fitness.
Commission a lead provider to join up
care across providers and along a care
pathway for children with complex and
specialist needs, including psychological
care.
Improve the management at home of
asthma by children and their
parents/carers, reducing the number of
inappropriate emergency attendances
for children
Review and redesign of paediatric
pathway at Queen Elizabeth II Hospital:
36
people.
Review of Paediatric
Assessment Unit
Child and Adolescent
Mental Health services
Autistic spectrum disorders
improved provision and diversion of
activity to the Urgent Care Centre.
Service redesign
Scoping the potential for service
development to meet the increasing
number of children in the borough with
autistic spectrum disorders.
Improving Mental
Health Care
Levels of mental ill health are high in
Greenwich, with one on three people
experiencing a mental health condition.
We need to drive further efficiencies from
mental health services to invest in areas
that need improvement.
Users often express dis-satisfaction with
the choice of services locally and we need
to provide more options, particularly with
the third sector.
We aim to transform services
by:
Working in partnership with
our Local Authority
colleagues, within our Joint
Commissioning arrangements
and in consultation with
neighbouring BSUs across the
SEL sector in order to develop
local resources that promote
choice, ensuring access to
services that maximise
recovery, prevent relapse and
admissions to acute care
Identifying mental health
problems early and
intervening across all age
Community service redesign
and development of RMS
Acute service redesign
Develop models of integrated care in the
community (Team around the patient)
Single Point of Access to all Mental
Health Services in Greenwich by
introducing of a Referral Management
system (RMS)
Increase options for places of safety and
24/7 community services supporting
patients at home as an option to acute
care. We are proposing development o
we are opening a Community Crisis
House. The project will open in April
2012 and will provide 6 beds to patients
in need of intensive 24 hour specialist
mental health support who have been
assessed by the Crisis and Home
Treatment Team as needing additional
support to avoid admission to hospital.
37
groups
Building care and support
around outcomes that matter
to patients. For example
education, housing and
employment
Challenging Stigma and
Discrimination
Improving the interface
between primary and
secondary care services
Forensic Business Case and
third sector initiatives
Interface of primary and
secondary care
CAMHS
The unit will also have 6 self-contained
flats which will offer patients
accommodation and an intense
programme to support people in their
Recovery and Rehabilitation
We aim to reduce the number of
commissioned forensic beds and
explore forensic market alternatives
within the private/ third sector (MSU
OATS patients) we are supporting the
development of a Forensic Hostel (the
TILT project) to manage patients moving
from low and medium secure services.
We want to invest in services and skills at
the interface of primary and secondary
care services, to ensure more people can
be supported well in primary care,
including greater support for self-care.
This will enable us to take a more
integrated approach to the user’s whole
health needs, addressing physical health
needs also, in particular long-term
conditions. We are exploring developing
a syndicate that will focus on mental
health.
See Children’s services
Improving Long
Term Conditions
Currently, south east London has a high
and increasing level of emergency hospital
admissions which could be managed in
Prevention and improved self-
management support for
people with long term
Finding the Vulnerable Increasing case finding, capacity and
coordination of services to prevent
unnecessary admissions to hospital. In
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care for all ages primary and community care, particularly
for patients with diabetes and respiratory
illnesses.
The Greenwich JSNA predicts significant
increases in the number of people with one
or more long terms conditions
conditions and support for
their carers
Focus on proactive,
preventative approaches
including patient education
and self-care/carer support so
that people can be managed
at home with confidence.
Targeting interventions
according to need &
extending the range of
services available
Better coordination between
providers & integration
between health, social and
other care, encouraging
adherence to Greenwich long
terms conditions pathways.
Improved medicines
management
Use and further develop risk
stratification tools to identify
people who are frequent
attenders at A&E or have
frequent admissions to
hospital to ensure they are
well supported by primary
and community care, reducing
Integrated primary care
model
Medicines management
particular: people who are taken to A&E
with blocked catheters, who are
admitted for short stays; patients who
receive IV therapies as an inpatient;
people admitted each year with flu
(pregnant women as well as vulnerable
older people); a range of other reasons
for admission which are amenable to
treatment at home – UTIs, falls, tissue
viability/ cellulitis and dementia. There
is a particular focus on reducing
admissions from care homes.
This service will include intermediate
care and an extended JET service, and
building up consultant led sub-acute
capacity in existing beds. Aimed mainly at
over 65s with UTIs, heart failure or COPD
who could better be managed out of
hospital. Capacity to be put in place
equivalent to two acute wards.
Improved wound management,
improved prescribing of SIP feeds,
scriptswitch
39
A&E attendances and
emergency admissions.
40
Co-ordinate the
provision of urgent
and out of hours
care
Better co-ordination, reduced duplication
and fragmentation across the whole urgent
care system required.
Improved patient experience with clear
navigation of the system, reducing the
number of services patients use
inappropriately.
Need to reduce the volume of patients who
attend A&E frequently and inappropriately.
Develop a comprehensive,
integrated urgent care system
for Greenwich, with effective
links and partnerships with
neighbouring urgent care
systems to ensure smooth
service for patients and
economies of scale across
local boroughs
Whole system redesign,
undertaken collaboratively
with neighbouring CCGs
Put in place incentives to
encourage better case
management of frequent A&E
attenders
Whole systems urgent care
model
Urgent Care Centre
Development of a whole systems model
for an integrated urgent care system
enabling the development of a
specification to tender for the whole
system.
The new urgent care centre at the Queen
Elizabeth site , which became operational
on 1 December, offers the opportunity to
ensure that patients are seen by the
most appropriate service for their needs
and reduces demand on the emergency
department
Increase capacity in
high quality, cost-
effective alternatives
to hospital based
planned care
It is estimated 40+% of planned care could
take place in lower cost community based
settings, which are more convenient for
patients.
Freeing up capacity in the acute hospitals
locally will enable more care to be
repatriated from inner London hospitals
which have higher costs.
Widening the scope and
capacity of primary and
community services as an
alternative to hospital based
care
Collaborative approach with
local providers and the Local
Authority
Improved medicines
management: shared
formulary with SLHT for high
cost drugs/high risk conditions
Referral management
booking scheme
Cardiology services
Diagnostics
Community Hospital
Phased extension of referral
management service pilot to cover all
referrals from all practices.
Pilot for providing integrated
comprehensive cardiology services in the
community
Review of direct access diagnostics to
reduce unnecessary testing.
Development of an effective model for
community hospital provision in Eltham.
The Eltham community hospital will be a
41
including cardiology,
introduction of new anti-
coagulation drugs, challenging
Payment by Results excluded
drugs, management of the
RAG list of drugs.
Provision
Medicines Management
key ‘enabler’ to help us to deliver on all
our priorities, providing additional
capacity for alternative community based
services. We will develop a full business
case and will work collaboratively with
Bexley and Bromley to ensure a
consistent approach to the shift in care
from SLHT to community hospitals.
Shared formulary with SLHT for high cost
drugs/high risk conditions including
cardiology, introduction of new anti-
coagulation drugs, challenging Payment
by Results excluded drugs, management
of the RAG list of drugs
42
Enhance end of life
care
Most people would choose to die at home
if possible, however many people die in
hospital.
As well as improving quality and patient
experience, community based end of life
care (EOLC) is significantly more cost
efficient than hospital based care.
We will continue to work in
collaboration with the
Greenwich and Bexley
Hospice and Marie Curie to
pilot the Marie Curie ‘choice’
model.
EOLC tender
Best practice
We have been working with the
Greenwich and Bexley Hospice to pilot
the Marie Curie ‘choice’ model. This
model provides integrated, community
based EOLC. We are still in the test and
evaluate phase of the pilot but already
the results are impressive, and once the
pilot and evaluation are complete we
anticipate tendering for this model of
care
Continuing to implement best practice
including the Liverpool Care Pathway and
Gold Standard Framework.
Part of NHS South East London: a partnership of Primary Care Trusts in Bromley, Greenwich, Lambeth, Lewisham, Southwark and BexleyCare Trust
Chair: Caroline Hewitt CCG Chair: Dr Hany Wahba Interim Chief Executive: Christina Craig
2.3 Meeting our Responsibilities in 2012/13
2.3.1 Performance Management
The CCG recognises the importance of robust performance management in support of our plans. To
this end a Governing Body has been established, as have a range of supporting committees as
follows:
Audit Committee
Remuneration Committee
Quality Committee
Risk Committee
Finance, Performance & QIPP Committee
Strategy & Commissioning Committee
In terms of commissioning and performance management of our plans, the Finance, Performance &
QIPP Committee takes the primary role in assuring the Governing Body on the progress in achieving
financial, service and QIPP elements of our plans, while the Quality Committee addresses service
quality across the full range of commissioned services. The Strategy & Commissioning Committee
oversees the development of our annual and longer term plans. Involvement from the wider GP
community is ensured by the syndicate structure whereby syndicates of six or more member
practices have been formed to develop and implement the work of the CCG at a local level.
Syndicates will meet regularly with the Governing Body, and all practices come together in the
Greenwich-wide GP Forum.
2.3.2 2012/13 Performance Priorities
During 2011/12 Greenwich performed well against a number of performance measures, notably:
Minimal MRSA bacteraemia.
Category A ambulance response times have consistently met the required standard as 75%
within eight minutes and 95% within 19 minutes.
The majority of cancer waiting time standards were met.
The proportion of people who have a stroke who spend at least 90% of their time in hospital
on a stroke unit met the required standard.
44
Smoking quitters
NHS Health Checks coverage was amongst the highest in the country
In 2011/12 there were also some areas where performance was below expected levels for
Greenwich:
Referral to treatment waiting times for admitted patients failed to meet the required
standard for the maximum wait for the 95th centile. This is a reflection of poor performance
at both South London Healthcare trust and at Guy’s & St Thomas’ Foundation Trust.
The target for a substantial reduction in C difficile cases was not met.
A&E performance was below the expected standard. The main provider for Greenwich
residents is South London Healthcare Trust, and in particular the Queen Elizabeth site in
Woolwich. Across the Trust and in Woolwich, the standard for 95% of patients being
admitted, discharged or treated within 4 hours was not met.
The 85% standard for the percentage of patients receiving first definitive treatment for
cancer within 62 days of an urgent GP referral for suspected cancer was not met (78.7% at
Q3)
An unacceptable number of breaches of Mixed Sex Accommodation standards occurred at
South London Healthcare Trust.
Greenwich priorities and additional challenges for 2012/13 acute areas in some cases lead on from
2011/12 issues:
Referral to Treatment – South London Healthcare Trust (SLHT) have a plan in place to
eliminate the admitted backlog and as at August 2012 have made significant progress in
clearing the backlog. While the backlog is being cleared it is anticipated that performance
will continue to fall short of target in the first half of the year. Guy’s and St Thomas’ NHS
Foundation Trust’s plan is to eliminate the admitted backlog by quarter 2, 2012/3. Both
Trusts have also made significant inroads in addressing diagnostics backlogs, which now fall
within the mandated tolerances.
Emergency Access- SLHT is working closely with the wider health care community to
improve appropriate use of emergency services, and maximise the use of community and
out of hospital provision. The successful re-tendering of the Urgent Care Centre (UCC) on
the Woolwich site in December 2011 has already resulted in an increase in throughput of the
UCC on that site, releasing capacity in the main Emergency Department. Further work is on-
going to improve urgent care pathways on the Woolwich site which will assist in reducing
the number of Mixed Sex Accommodation breaches, improve ambulance handover times
and reduce 60 minute handover breaches.
45
Reducing avoidable emergency admissions is a priority within our commissioning strategy
and QIPP plans, underpinned by a commitment to high quality primary care. In addition to
improvements in A&E and UCC services our approach is to identify patients at higher risk of
requiring urgent care together with disease specific case management. In quarter 4 of
2011/12 the NHS Institute for Innovation and Improvement ranked Greenwich No.1 in
England for the management of ambulatory care sensitive emergency admissions.
C Difficile – the 2012/13 objectives are challenging both at acute trust and PCT level. Acute
trusts will be participating in the NHSL Peer Review process to aid implementing best
practice examples from elsewhere.
62 day urgent referrals to treatment – Guy’s and St Thomas’ NHS Foundation Trust has
made improvements in the urology pathway earlier in the year and more recently in the
pathway for Lower GI, particularly access to colonoscopies through the use of the additional
endoscopy capacity on the St Thomas’ site.
CAT A - key events that could impact upon performance in 2012/13 are as follows:
o Olympics – separate funding has been agreed with the DH in order to maintain
business as usual and includes funding for an expected general rise in activity.
o Other large events – Queen’s Jubilee, Public Demonstrations
o Implementation of 111 – ambulance activity could potentially rise while new
providers bed in.
o Further Industrial Action
Mixed Sex Accommodation – Work with SLHT in 2011/12 appears to be delivering
improvement, with the Trust expected to meet this standard in 2012/13.
IAPT – Oxleas Foundation Trust have been commissioned to provide the IAPT programme
for adults through the Greenwich Time to Talk service. In addition to this psychological
therapies will be extended to Children & Young People. The CYP IAPT will not be a
standalone service as with the adult IAPT model. The development of CYP IAPT is a Service
Transformation Project for Child and Adolescent Mental Health Services (CAMHS). The focus
of CYP IAPT is on extending training to staff and service managers in CAMHS and embedding
evidence based practice across services, making sure that the whole service, not just the
trainee therapists, use session by session outcome monitoring
Immunisation – The priority in 2012/13 will be to improve performance in immunising
children over the age of 5 years. The Immunisations Strategy Group has been re-organised
with amended Terms of Reference and is reviewing a proposal for catch-up programme for
older children through Health Visitors. There will be engagement with primary schools and
early years providers to implement standardised collection of information on the
immunisation status of new entrants, exploring options for offering vaccinations to under-
vaccinated children, and identify opportunities to promote immunisation
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Cervical Screening Test Results – Performance will be challenging across 3 out of the 4
providers in South East London in 2012/13. Performance has been an issue at South London
Hospital Trust, Guy’s & St Thomas’ Trust and King’s Hospital. Actions have already been
taken with SLHT moving letters sent out second class to first class to hit the 14 day
turnaround target. Improvements are being made to the lab and a concerted effort to
improve the Lab Information technology systems is planned.
Bowel Cancer Screening - The bowel cancer national awareness campaign due to start on
the 28th January will pose a risk to performance in 2012/13 across the cluster as projected
demand increases. Planning with the Acute Trusts to increase capacity has commenced and
performance leads will continue to work with the Cancer Screening Lead for South East
London and the South East London Cancer Network who are concentrating on the age
awareness and national campaign in Bowel Screening. Work streams have been identified
and are currently being worked through and the recently formed South East London Cancer
Screening Board will be reviewing performance and progress.
2.4 NHS Greenwich CCG’s Compliance with the National Operating
Framework 2012/13
The Operating Framework for the NHS in England sets out the planning, performance and financialrequirements for emergent CCGs operating under delegated responsibility in 2012/13. TheOperating Framework includes the broad financial and performance responsibilities and outlines theexpectations of commissioning organisations in respect of assuring the safety and quality of localhealth services.
A further central objective in 2012/13 is that CCGs work with PCT Clusters and other keyorganisations to ensure a successful last year of transition to the new system of commissioning. Inaddition to the responsibilities noted above, there are a number of key areas that require particularattention during 2012/13. Details of these requirements and the actions the CCG and its partners aretaking to deliver them in 2012/13 are included in the table in Appendix 2 “Table demonstratingcompliance with the National Operating Framework”
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2.5 Enabling Actions and Additional Service Developments
2.5.1 Primary Care Engagement
Good quality General Practice is a key enabler of delivery of all of NHS Greenwich CCG’s strategicpriorities - staying healthy, developing integrated care pathways and services, improving mentalhealth and long term conditions care, co-ordinating the provision of urgent and out of hours care,providing high quality cost-effective alternatives to hospital based planned care and enhancing endof life care.
General practice can do this by providing easy and responsive access to patients as early in thepatient journey as possible and preventing patients seeking alternatives such as A&E; through careprovided for their registered population as an alternative to hospital outpatient care; care co-ordination for their particularly vulnerable patients with complex issues preventing potentialemergency admissions; and through their referrals to specialist care which drives the overall patientflow and resource distribution for the whole local health system.
A fully effective primary care service that is responsive to its registered population's needs, is pro-active about promoting health and well-being, prevents ill health and avoids crises in people withlong term conditions not only will provide high quality services for their patients but will also behighly cost-effective.
NHS Greenwich CCG is already working with its member general practices through visits, dataanalysis, syndicate peer review and the Greenwich Commissioning Incentive scheme to reviewpatients on the register and improve care for patients at highest risk of hospital admission. Insupport of the aspirations for improved community based care set out in Section 2.1, we willpromote initiatives to improve productivity and release clinical time. We will continue to help GPs tounderstand the important role that general practice plays in commissioning, and in the whole healthsystem of Greenwich.
How NHS Greenwich CCG is working with its constituent GP Practices
(i) Syndicates
NHS Greenwich CCG adopted a Syndicate structure as way of ensuring effective communicationsbetween GP member practices and the CCG Board, and as a way of encouraging the adoption of bestclinical practice to the benefit of patients. The primary role of a Syndicate is to peer-lead andsupport member practices with changes in clinical practice resulting from local service re-design.Membership of a syndicate also enables its member practices to access commissioning incentiveschemes. Syndicates act as focal points for the review of clinical care as it relates to commissioningincentive schemes and will support member practices in achieving the changes required by eachscheme.
In order to ensure commitment to this new way of working, the CCG allowed the Greenwichpractices to determine the configuration of their syndicates, rather than prescribe a particularmodel. All Greenwich GP Practices are members of one of five Syndicates. Each Syndicate is led by aSyndicate Lead selected by their peers. The role of the Syndicate Lead is to represent the views of
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the syndicate to the Governing Body via the GP Executive-Link Representatives, and to serve as aconduit through which information about the CCG’s activities is disseminated to the syndicatemember practices. Syndicate leads also act as champions for understanding and addressing healthinequalities and population health outcomes.
The Syndicate structure is operating robustly, with each Syndicate meeting at least four times a year(with some meeting more frequently) and their Leads meeting with a named CCG ClinicalCommissioner every two months. In addition the Syndicate Leads, as a group, meet with the GPExecutive every two months. A Syndicate Development Manager supports their work as does amonthly newsletter.
Other benefits from the Syndicate structure1. The Syndicate arrangements were intentionally designed to help practices meet QOF targets and
PMS key performance indicators and as a result this single structure has enabled practices tomeet these new demands.
2. Prior to the establishment of Syndicates there had not been a strong history of GP practicesworking together within Greenwich. By placing an emphasis upon engagement during the firstyear of its operation strong syndicate relationships have been developed.
3. Syndicates were also linked to named members of the Public Health team enabling relationshipsto be developed ahead of future initiatives to ensure primary care resources are used formaximum patient benefit that will utilise data from this service.
(ii) Commissioning incentive scheme (CIS) for GPs
The aim of the scheme is to encourage and reward high quality practice by Greenwich GPs and tosupport the goals of the Greenwich Clinical Commissioning Group. Payment is dependent onachievement of all outcomes. Greenwich has implemented two schemes so far. The current schemehas built on the experience and learning from the Commissioning Incentive Scheme of 2011-12.
The 2011/12 CIS focused on detailed clinical reviews and care planning for patients at high risk of illhealth and hospital admissions. The reviews stimulated multidisciplinary working between practicesand community services, but did not result in clearly defined goals for this work.
Part 1 of the 2012/3 scheme focuses on engagement. Building stronger relationships with peers andcolleagues is fundamental to providing an integrated care environment and achieving improvedoutcomes for Greenwich patients. Part 2 of the 2012/13 CIS asks practices to consider themanagement and diagnosis of patients with cancer. Practices are asked to reflect upon thosepatients recently diagnosed or referred on a 2 week wait and consider any learning from thisexercise. Part 3 of the 2012/13 CIS aims to build on and improve last year’s scheme and crystallisesome of the benefits by:
Promoting practice systems to support care planning for high risk patients and to linksbetween the practice and other services
Improving patient selection to ensure reviews are focused on patients with complex healthand / or care needs
Promoting multi-disciplinary meetings between GPs, other practice staff and members ofcommunity health and social care teams
The CIS strengthens the requirements of syndicates to review problems faced by high risk patientsand develop local solutions to address them.
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As previously, the CIS of 2012-13 has been designed to complement two other current initiatives:QOF requirements to establish peer review groups and local key performance indicators in PMScontracts.
Through the Commissioning Incentive Scheme (CIS), Syndicates reviewed the care of 495 patientswith complex conditions. The majority of Practices surveyed at the end of 2011-12 found that thesereviews had improved GPs understanding and the multi professional management of complexpatients. The relationship between relatives and carer and the GP in a patient’s care had alsoimproved.
(iii) Further Support for General Practice
Greenwich will continue to identify what further support and resources are needed to enablegeneral practice to play their full part in commissioning and delivery of planned and unplanned care,in addition to their day-to-day general practice work. We will build both capacity and capability inpractices through good back-up support and investment in on-going training.
We will help practices to improve the quality of their referrals through the Referral Managementand Booking Scheme. Through the syndicates and syndicate leads, and the Commissioning Incentivescheme, we will support general practice to improve their patient registers and review care plans forpatients with Long Term Conditions. In order to provide high quality care for complex Long TermConditions the role of the GP is not one just of reaction – but also being a vital, integral part of awider multi professional, multidisciplinary community team.
We will also help general practice to improve the quality and management of primary care mentalhealth services and referrals as the quality of the services available within general practice can bevariable, and the knowledge of what is available for GPs to refer to can be limited.
We will commission a secondary care service that is responsive to primary care needs and whosespecialist opinions will aid general practice decision making.
(iv) Improvement in primary care
Through building capacity and capability we will also address variability and poor practice inprescribing, referring and clinical practice and improve access and responsiveness of generalpractice, particularly for BME groups in response to general practice patient surveys in London.
2.5.2 Eltham Community Hospital
The bedrock of effective NHS care is primary care services. This is where the majority of healthcare is
provided and good quality primary care improves primary and secondary prevention, ensures that
people are seen in the right setting and drives the overall productivity of the health service.
Integrated primary and community services can deliver significant benefits and Greenwich is
committed to developing programmes of work in these areas. To improve the sustainability of the
health economy in BBG there needs to be a reduction in the reliance on acute hospital based
services for patients who can be cared for in community settings. Greenwich has a strong track
record of investing in community services and has been highly effective at avoiding hospital
admissions. However there are still far too many people in acute beds who do not need these more
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specialist services. From detailed analysis of the bed use in 2011-12 and an audit of every patient in
an acute and intermediate care bed, it appears that some 30 acute beds could be saved through
improved productivity, more integrated services and optimising patient pathways.
GCCC has adopted a principle of ‘in the community when possible, hospital when necessary’ to
facilitate a consistent approach to tackling this problem. However, there are constraints on the
amount, location and suitability of available clinical space in Greenwich. Lack of capacity in out of
hospital settings will be a limiting factor to Greenwich being able to implement its QIPP from 2014
onwards.
The older population of Greenwich who experience long term conditions, cardiovascular disease
(CVD) and cancer predominantly live in the south of the Borough, in Eltham. There are no health
centres there where GP practices and community services are co-located as investment has hitherto
focused on the more deprived but younger populations in the north. The limitations of practice
accommodation have precluded the development of extended primary care services in current
Eltham GP practices. All the new services implemented to improve productivity have been
developed in the north of the borough (e.g. dermatology, gynaecology and minor surgery services,
diabetes clinics and Time to Talk service) Therefore, additional primary and community services are
required in the south of the borough in an easily accessed setting. Greenwich Teaching PCT owns a
site near Eltham High Street on which the Eltham Community Hospital is planned, which is easily
accessible to the local population and will offer the following facilities:
2 GP practices (incl. extended hours)
Out-patient consulting rooms
Day surgery theatre suite
Diagnostic suite – low complexity
40 intermediate care sub-acute beds
Consulting rooms/base for community/mental health services
These facilities will enable the provision of a wide range of readily accessible services with
extended hours of opening, including:
General Practice consultations
Practice Nurse appointments for immunisation and vaccination, screening services and
minor procedures
Family planning service (day and evening consultations)
Child and adult asthma clinics
Child and adult minor ailments
Dermatology and diabetes management
Integrated Community and Social Care services, including Physiotherapy, Occupational
Therapy and Podiatry
Mental health services
The hospital will be designed/developed by Bexley, Bromley and Greenwich LIFT Ltd (LIFTCo) under
the exclusivity agreement with the PCT entered into in March 2005. The hospital will be built on a
site owned by the PCT which has been valued by the Valuation Office Agency at £3m. The LIFT
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contract form will be a Land Retained Agreement (“LRA”) with a 25-year concession. The adoption of
the LRA form means that the ownership of the land is retained by the NHS. LIFTCo provides expertise
in health facilities planning and management. The hospital has been designed by architects
Broadway Malyan, who specialise in the planning and architectural design of healthcare buildings.
Recent projects include Fareham Community Hospital and Harrow Mental health Centre. They bring
a wealth of experience to this project ensuring that the design is a hospital fit for the delivery of 21st
century health care services, capable of offering maximum flexibility in use.
2.5.3 Heart of East Greenwich
The Heart of East Greenwich is an initiative, in partnership with the Royal Borough of Greenwich and
the Homes and Communities Agency, to regenerate the site of the former Greenwich District
Hospital. As part of this initiative, Greenwich proposes to develop a replacement Health Centre
(1573sqm). The new Health Centre will occupy a single floor within the Greenwich Centre which also
includes a leisure pool, library and other Council services, with affordable housing on the upper
residential floors. The site occupied by the existing Health Centre is part of the wider redevelopment
and planning consent has been given by the Council for both the reprovision of the Vanbrugh Health
Centre into the Greenwich Centre and the redevelopment of the former health centre site for
housing (private and affordable).
The existing Vanbrugh Health Centre adjacent to the former Greenwich District Hospital site,
accommodates the Vanbrugh 2000 practice and a range of Community Health Services currently
provided by Oxleas NHS Foundation Trust. Overall, the current building is also in very poor condition
and considerable sums are being spent to keep the building in a useable condition. It is therefore
imperative that an alternative solution is found to accommodate the services in the longer term.
The new health centre will provide the full range of primary and community services needed by the
local populations of East Greenwich, Peninsula ward, Blackheath and Charlton. These will include a
strong emphasis on healthy living (quit smoking, healthy diet, exercise and self-management of long
term conditions) achieved through partnership working with the Royal Borough of Greenwich.
The registered population to be supported by the Vanbrugh practice is planned to increase to circa
12,000 as a result of the residential elements of the Heart of East Greenwich Development alone. In
addition, the wider local population is due to increase substantially over the next 10 years (to 2025).
Epidemiological studies have shown that the population in the area (especially Peninsula and
Charlton wards) have relatively high health care needs.
The new facility will provide a high level of flexible, generic accommodation. Generic clinical spaceswill take the form of consult/exam rooms, shared across all services and utilised on a planned,programmed basis. General areas such as waiting spaces, group rooms and open plan offices will bedesigned in such a way as to encourage and enable use for, and by, a range of Third-Sector andCommunity organisations for healthcare promotion and group working.
52
2.5.4 CCG Organisational Development Plan
As an emerging organisation, the CCG recognises the need for organisational development as a key
enabler for achieving our plans. To this end our Organisational Development Plan sets out our
approach to this. The key objectives of the plan are:
Objective 1: To develop a strong clinical and multi-professional focus across GCCG
initiatives, which brings real added value
Objective 2: To develop and embed meaningful engagement approaches and outcomes
with patients, carers and communities, translating new insight into highly competent
commissioning activities
Objective 3: To develop our implementation and monitoring skills and competencies for
leading clear and credible plans to deliver QIPP within financial resources, in line with
national requirements and local joint health and wellbeing strategies
Objective 4: To adopt and work within proper constitutional and governance arrangements
to deliver all duties and responsibilities, and commission effectively
Objective 5: To develop robust collaborative arrangements with our colleagues in Bexley
and Bromley, and beyond, for commissioning at scale, which will deliver consistent
standards in local delivery
Objective 6: To take all appropriate steps to continue to develop ourselves and the next
generation of clinical commissioners into great leaders of the Governing Body, who
individually and collectively make a difference in commissioning for the population of
Greenwich
2.5.5 Sustainable Commissioning
Greenwich is committed to the NHS Carbon Reduction Strategy. We recognise the imperative of
driving the sustainability vision through greater resource efficiency, reducing emissions and
environmental impact, and delivering positive impact on the local health economy by improving
productivity. Some examples of the schemes which are helping to deliver a more sustainable local
health system include:
Urgent Care redesign, enabling more efficient and effective use of resources to treat urgent
care needs
Rollout of schemes that promote care at home and in the community, for example the
piloting of the Marie Curie ‘choice’ model for end of life care in Greenwich
Capital developments – ensuring sustainable and energy efficient designs in development of
future healthcare premises.
53
In line with the guidance of the NHS Sustainable Development Unit a plan will be developed in
2012/13 to incorporate:
1. Energy and carbon management
2. Procurement and food
3. Low carbon travel transport and access
4. Water
5. Waste
6. Designing the built environment
7. Organisational and workforce development
8. Role of partnership and networks
9. Governance
10. Finance
This plan will address sustainability both in how the CCG operates as an organisation in its own right,
and in terms of how it contracts for services from providers of healthcare.
54
Section 3: Financial Sustainability and the Case for Change
As set out in Section Two, NHS Greenwich CCG has ambitious plans to improve local health services.
Greenwich faces continuing growth in demand and cost of health services, driven by:
Population growth
Demographic changes
The expansion of available health technologies
Increased expectations
We have assumed funding will increase by 2.4% in line with GDP deflator estimates. There is an
unprecedented level of financial challenge facing the NHS over the next few years as funding is
unlikely to cover the costs of growth and other pressures. A step change will be required in the
approach to development and delivery of Quality, Innovation, Productivity and Prevention (QIPP)
plans. This requires clinically led system and service redesign both in Greenwich and across the
wider health economy. This will include primary care clinicians working in conjunction with acute
clinical colleagues to improve care pathways and patient experience, eliminate duplication and
improve productivity.
We must secure significant efficiency and productivity savings over the next three years to provide
the financial resource to support delivery of our vision and the supporting strategies. Our 2012/13-
2014/15 Commissioning Strategy Plan predicted that if projecting forward on a PCT basis, the ‘do
nothing’ scenario would result in a deficit in 2014/15 of £16.9 million in Greenwich.
For NHS Greenwich CCG, in order to achieve the required 1% surplus in 2013/14 and 2014/15, QIPP
savings totalling just under £12 million will be needed. The Greenwich approach to this challenge is
to ‘front load’ the QIPP requirement with approximately £8m of savings in 2013/14 and £4m of
savings in 2014/15.
We are not assuming that our allocation will be affected by any pace of change policies designed to
move CCGs to their capitation target, although we understand that this is under review and that the
Advisory Committee on Resource Allocation will be reporting on this shortly.
In summary, our annual resource allocation is projected to fall below the level of costs we expect to
incur unless significant changes are made. In order to ensure a sustainable health economy and
operate as a financially responsible CCG, we will need to reduce unnecessary costs and commission
models of care and clinical pathways that are increasingly efficient, whilst maintaining quality and
clinical effectiveness. This section sets out our high level strategic financial plans and assumptions,
which allow us to model how our strategic priorities will be delivered.
55
3.1 Financial Overview
In 2001 Greenwich Teaching PCT (GTPCT) came into being, inheriting budgets that found them in
financial difficulty. As a result, Greenwich PCTs first five years (2001 to 2006) were dominated with
turning round a very difficult opening financial position due to overspending and being over-
committed. Since then, the PCT has consistently met its financial responsibilities, including
achievement of required surpluses. During 2011/12 the emerging CCG had delegated responsibility
for all non-acute spend and the PCT continued to meet its financial obligations. Greenwich ended
the year in financial balance and achieved the required surplus of 1% (£4.77m). At the same time,
Greenwich made QIPP savings of just under £10m which were reinvested in local services.
The CCG has had developed a strong track record in financial management, holding delegated
responsibility for approximately £432 million (87%) of the total PCT budget in 2012/13, covering all
areas except public health and primary care. For 2012/13 and beyond, NHS Greenwich CCG has
developed plans to deliver surpluses in line with the 1% surplus requirement although it should be
noted that this is dependent on the return of 2011/12 surpluses. A number of risks and
opportunities are inherent in plans which are set out further below, including:
The delivery of QIPP savings initiatives.
Access to 2% non-recurrent funds – providing opportunities for delivery and risks if funds are
not forthcoming to facilitate the delivery of QIPP initiatives.
Successful negotiation of contractual agreements.
The impact of changes to Payment by results (PbR) tariff, including for mental health
providers.
Return of surpluses
3.2 Financial Position 2012/13
As at the time of compilation of this plan, our forecast position at year end is consistent with our
profiled plan and we remain on target to achieve both the required 1% surplus of £4.71m and full
delivery of net QIPP savings of £9.9m. The main areas of financial risk within the 2012/13 plans are
QIPP delivery, and in-year over performance at acute trusts, which has been a problem historically.
The main mitigations against this are an earmarked acute contingency reserve and the 0.5% general
reserve, and a cap and collar arrangement which limits our exposure on our main acute contract
with SLHT. Any further risks are expected to be managed through underspends in non-acute
budgets.
56
3.3 Financial Assumptions
During the financial year 2011/12 an updated set of financial plans were developed, both at the levelof the NHS South East London Cluster, and at a local level in the Greenwich Commissioning Strategy2012/13-2014/15, ‘Improving Health’. These were drawn up in line with NHS London CSP guidance inrespect of assumptions around uplifts, tariff, efficiency and other inflationary cost changes, requiredcontingencies and surpluses. The plans also reflected a locally developed financial model sharedacross cluster and the emerging CCGs, as well as detailed activity projections. The plans were furtherrefined in light of the 2012/13 Operating Framework guidance and further work to set detailedbudgets and contracts. This section incorporates the 2012/13 Operating Plans and updates these toreflect latest assumptions around the impact of organisational transition on future budgets from2013/14 onwards.
3.3.1 2012/13 – 2014/15 Assumptions
A summary of uplift assumptions are set out below:
Acute
Clie
ntG
roups
&
Com
mun
ity
Prim
ary
Care
(12
/13
on
ly)&
Pre
scribin
g
Corp
ora
teB
udg
ets
Oth
er
Budg
ets
an
d
Reserv
es
Net
2012/13
Recurrent uplift 2.80%
demographic Growth 1.40% 1.40% 1.40% 0.00% 0.00% 1.25%
Non-demographic growth 1.66% 0.80% 0.00% 0.00% 0.00% 0.99%
Total population & incidence growth 3.06% 2.20% 1.40% 0.00% 0.00% 2.24%
Prescribing growth 6.00%
Tariff/ Inflation Uplift 2.20% 2.20% 1.00% 2.50% 0.00% 1.88%
Tariff efficiency assumption/ Price
Efficiency applied (4.00%) (4.00%) 0.00% 0.00% 0.00% (2.97%)
57
Acute
Clie
ntG
roups
&
Com
mun
ity
Prim
ary
Care
(12
/13
on
ly)&
Pre
scribin
g
Corp
ora
teB
udg
ets
Oth
er
Budg
ets
an
d
Reserv
es
Net
2013/14
Recurrent uplift 2.42%
demographic Growth 1.40% 1.40% 1.40% 0.00% 0.00% 1.25%
Non-demographic growth 1.66% 0.80% 0.00% 0.00% 0.00% 1.07%
Total population & incidence growth 3.06% 2.20% 1.40% 0.00% 0.00% 2.31%
Prescribing growth 6.00%
Tariff/ Inflation Uplift 2.50% 2.50% 1.00% 2.50% 0.00% 2.14%
Tariff efficiency assumption/ Price
Efficiency applied (4.00%) (4.00%) 0.00% 0.00% (0.00%) (3.16%)
2014/15
Recurrent uplift 2.64%
demographic Growth 1.90% 1.90% 1.90% 0.00% 0.00% 1.68%
Non-demographic growth 1.66% 0.80% 0.00% 0.00% 0.00% 1.04%
Total population & incidence growth 3.56% 2.70% 1.90% 0.00% 0.00% 2.72%
Prescribing growth 6.00%
Tariff/ Inflation Uplift 2.50% 2.50% 1.00% 2.50% 2.50% 2.12%
Tariff efficiency assumption/ Price
Efficiency applied (4.00%) (4.00%) 0.00% 0.00% (0.00%) (3.12%)
58
Further details on uplift assumptions are provided below:
Recurrent Uplifts - PCT Revenue Resource Limit (RRL) uplifts are as per confirmed allocation
uplifts of 2.8% plus a further 0.18% in respect of reablement.
Tariff and Generic Uplifts - Tariff uplifts have been assumed at a net -1.8%, including a built
in 4.0% efficiency assumption. This has been applied to acute, mental health and community
spend.
Demographic & Non-Demographic Growth - Detailed work has been undertaken to review
planning assumptions related to demographic and non-demographic acute growth for the
CSP. The objective has been to ensure robust and realistic borough based planning
assumptions related to population and incidence factors, which take account of
demographic growth estimates and historic acute demand trends. To do so the following
process has been undertaken :
o A public health review of population growth assumptions (including GLA and ONS
figures) for acute services.
o A review of historic demand trends by borough for acute services, with supporting
trend analysis completed for the following key areas of acute activity – outpatients,
elective, A&E attendances, and emergency admissions, maternity and other.
Brought Forward Surpluses - Forecast surpluses for 2011/12 have been assumed to be
carried forward into 2012/13.
Full Year effect of 2011/12 outturn - The full year recurrent impact of 2011/12 forecast
outturn expenditure has been included within 2012/13 expenditure plans, including the
costs of reinstating PCT contingencies at 0.5% of recurrent resource limits.
Investment Proposals and Cost Pressures - Investments and cost pressures have been
included in financial plans for 2012/13. While detailed expenditure plans are in place for
2012/13, these remain draft pending the release of all detailed planning guidance for
2012/13 and also further progress in the negotiation of 2012/13 contracts.
QIPP Savings Initiatives - Existing detailed QIPP savings plans have been reviewed by CCGs
with support from Cluster teams. New QIPP schemes have been initiated and included in
financial plans. In total QIPP savings schemes across in 2012/13 total £13.1m. However
schemes have been RAG rated to deliver savings of £9.9m and it is this total that is assumed
to be delivered within financial plans.
2% Non-Recurrent Funds - Plans assume and include use of the 2% funds in full as an enabler
for QIPP delivery and to effectively manage the transition to the new commissioning
environment.
59
Readmissions and reablement funds - New reablement funds allocated to PCTs in 2012/13
have been earmarked for investment. In addition it has been confirmed that the 2011/12
policy of non-payment for some emergency readmissions and matching reinvestment for
post discharge care will continue in 2012/13.
3.3.2 2013/14 Allocation Assumptions
The CCG will operate with a 2012/13 baseline commissioning budget of £383.7m as detailed in the
following baseline submission to NHS London in July 2012 (this is subject to review):
Commissioner Spend against RRL Plan 2012/13
£m
Total PCT revenue resource limit 2012/13 503.8
NHS Commissioning Board (102.1)
Public Health – Local Authority (16.2)
Public Health England (0.7)
NHS Property services (1.1)
2012/13 CCG revenue resource limit baseline 383.7
The baseline CCG budget of £383.7m consists of recurrent resources of £375.4m and non-recurrent
resources of £8.3m
60
3.4 QIPP
As outlined above, NHS Greenwich CCG faces significant pressures due to factors that increase the
demand for and the cost of health services against a background of a much reduced rate of increase
in NHS funding. In order to meet this challenge, and continue to meet the requirement for a 1%
surplus each year, NHS Greenwich CCG needs to achieve significant productivity gains over the next
three years as per the table below:
Greenwich clinical leaders have worked in conjunction with local commissioning staff, South East
London commissioners and key providers to develop the 2012/13 QIPP programme. As at the time
of complication of this document the 2012/13 QIPP programme is on track to deliver the required
savings. The plan and year to date progress are detailed in the Appendices to this plan but the key
features are as follows:
The 2012/13 QIPP plan requires productivity savings of £9.9m
Of this total, approximately £3.6m of savings were secured through negotiated contract
savings on block contracts.
For the remaining initiatives, where there is a greater degree of uncertainty and therefore
risk of underperformance, a stretch target of approximately 150% of the target figure has
been set. Overall this results in a stretch target of £13.1m against the plan of £9.9m. This
should provide flexibility if there is shortfall on individual initiatives.
New initiatives are developed on a continual basis, both to act as ‘Plan B’ schemes to cover
any shortfall on the programme, and also to support the annual planning cycle and the
development of commissioning intentions.
At the time or writing, the CCG is on track to deliver its QIPP programme in full for 2012/13.
The governance of our QIPP programme consists of a number of key elements:
Each initiative has a named manager and a designated clinical lead drawn from amongst the
elected GP clinical commissioners, and initiatives are aligned to our strategic priorities.
All new initiatives are subject to the QIPP Gateway process, which ensures that business
cases for new initiatives meet the required quality standards as well as producing a
productivity benefit.
The programme is reviewed through regular operational QIPP meetings, and is further
scrutinised by the CCG Finance, Performance & QIPP Sub Committee as well as the
Greenwich Clinical Commissioning Committee. The CCG is also held to account on QIPP
delivery through bi-monthly stock take meetings with South East London cluster colleagues,
in their shadow National Commissioning Board performance management capacity.
These governance arrangements ensure that grip is maintained on the delivery of the QIPP
programme, both in terms of financial savings, but crucially also in respect of quality.
61
The following table sets out the QIPP programme requirements up to 2014/15. It translates our
original plans which were completed on a Primary Care Trust basis, into a high level plan which
outlines the QIPP requirement from each receiving organisation. It is expected that receiving
commissioning organisations will assume responsibility for on-going QIPP savings commensurate
with existing published plans :
CCG Primary
Care
Specialised
Commissioning
Total
£'000 £'000 £'000 £'000
Forecast Surplus/ (Deficit) 2011/12 4,770
QIPP savings requirement 2012/13 (8,892) (1,000) - (9,892)
QIPP savings requirement 2013/14 (6,117) (1,000) (700) (7.817)
QIPP savings requirement 2014/15 (2,857) (500) (554) (3,911)
Total QIPP savings requirement (17,866) (2,500) (1,254) (21,620)
"No Change" Forecast Surplus/ (Deficit) 2014/15 (16,850)
Appendix 3 shows a summary of the QIPP Programme for 2012/13 for Month 5.
62
3.5 Summary Income and Expenditure Plan
Financial plans have been updated for each the three financial years 2012-13 to 2014/15 based on
NHS London planning guidance and locally developed investment and QIPP plans. Changes to
income and expenditure are set out below:
2012/13 2013/14 2014/15 Total 2012/13 - 2014/15
£'000 £'000 £'000 £'000
Income
Recurrent Uplift 13,383 9,085 10,151 32,619
Prior Year Surplus brought forward 4,612 4,710 4,830 14,152
Total Income Changes 17,995 13,795 14,981 46,771
Expenditure
Net Generic Uplifts
Tariff and generic uplifts 8,658 8,154 8,190 25,002
Efficiency with Tariff (13,629) (12,065) (12,078) (37,772)
Net Tariff/ Generic Uplift (4,971) (3,911) (3,888) (12,770)
Demographic & Non-Demographic Growth
Demographic Growth 5,698 4,704 6,434 16,835
Non-demographic growth 4,506 4,024 3,990 12,520
Total Population & Incidence Growth 10,204 8,728 10,424 29,356
Investment Proposals and cost pressures 8,043 10,225 6,472 24,740
QIPP Savings Initiatives (9,892) (6,117) (2,857) (18,866)
Change in Recurrent Expenditure 13,285 8,965 10,151 32,401
Surplus/ (Deficit) 4,710 4,830 4,830 14,370
Planned surplus as % of Recurrent RRL 1.02% 1.26% 1.22% 1.16%
63
3.6 Investment Proposals and Cost Pressures
CCG investments and cost pressures have been included in financial plans for all years. For 2012/13
this includes detailed expenditure plans in line with the 2012/13 Operating Plan. Further details are
included below:
2012/13 2013/14 2014/15
Total Total Total
Applications £'000 £'000 £'000
Contingency Reserve changes 7,287 4,493 2,604
Additional Non Acute Contingency 0 1,575 0
Prescribing Uplift 1,255 1,385 1,265
Non recurrent Investment Pool 268 181 202
QIPP Investment Proposals 2,712 751 401
Tariff Uplift not in line with national averages(net) 488 0 0
Cancer 500 1,000 1,000
Carers 500 500 500
Health Visitors 400 400 400
IAPT 100 100 100
Children & Young People (Business Case) 153 0 0
Known tariff changes 58 0 0
MFF – GSTT payment cap 160 0 0
LAS 250 0 0
Reablement (matched to increase in funding) 794 0 0
CQUIN increase from 1.5% to 2.5% 3,117 0 0
Total Expenditure before QIPP savings 18,042 10,385 6,472
64
3.7 Ensuring Financial Delivery through Transition
The complexities of transition pose a challenge in terms of managing financial risk. The CCG intends
to mitigate financial risk through a variety of mechanisms:
A 0.5% general contingency reserve
£1.4m reserve for client groups
Assumed return of 2% non-recurrent funds
Additionally NHS Greenwich CCG is collaborating with other SE London CCGs to mitigate and
effectively manage financial risks, working together and with other health partners and public
sector organisations. A range of risk management approaches are encompassed within our overall
risk sharing framework including actions through;
Individual CCG financial controls and governance through budgetary and other risk and
contingency management frameworks
Risk sharing with local commissioning partners, including local government, such as through
joint commissioning arrangements
Risk sharing with providers through contractual agreements to incentivise service change
and QIPP delivery
Risk sharing and pooling across CCGs to reflect approaches to sharing risk in specific
commissioned services and to support the delivery of shared programmes
Mutual Financial Aid to support delivery of individual CCG financial targets in the short term,
assist recovery and sustain on-going strategic direction without destabilising the health
economy.
A framework for financial risk management across SE London CCGs has been defined and set out in
terms of a stratified approach, as follows:
Risks managed by individual CCGs and through local shared arrangements joint
commissioning arrangements
Risks managed through collaborative CCG risk sharing commissioning arrangements
Risks managed through Mutual Financial Aid arrangements to ensure all CCGs in SE London
can support each other achieve their annual financial outturn targets in a way that supports
the SEL health economy to support sustainable underlying financial balance. Arrangements
to be incorporated into a Memorandum of Understanding setting out the conditions under
which Mutual Financial Support is given or received and the obligations on the partners.
65
Section 4: Delivery
4.1 Implementing the Plan and Commissioning Intentions for 2013/14
Table 4 below summarises the plans to improve quality and deliver QIPP in 2012/13, and the
Commissioning Intentions for 2013/14. Further details are available in Appendix 5.
Strategic
Priority
Plans to improve quality and
deliver QIPP in 2012/13
CCG Commissioning Intentions 2013/14
Staying healthy
& health
protection
Reduce the level of obesity in adults and
children
Increase the numbers of people quitting
smoking with NHS stop smoking services in
Greenwich
Continue to implement the new NHS
Health Checks programme in Greenwich,
reducing the major risk factors for vascular
disease `
In conjunction with London-wide TB
programme, improve the early detection
and effective treatment of TB in
Greenwich
In conjunction with London-wide Cancer
programme, improve coverage of cancer
screening programmes in Greenwich
Improve the coverage of childhood
immunisation
Improve sexual health by reducing latediagnosis of HIV, reducing teenageconceptions, improving the early detectionand treatment of chlamydia and improvingaccess to sexual health and contraceptiveservices
Future delivery of ‘Staying Healthy & Health
Protection’ priorities for Greenwich to be undertaken
by the public health function now being transferred
to the local authority. Close partnership working
between the CCG and the local authority, including
through the Health and Wellbeing Board and
Memorandum of Understanding will be put in place
to ensure this strategic priority continues to be
delivered.
Primary and secondary prevention will be
incorporated into all work streams led by NHS
Greenwich CCG. Contract levers such as CQINs will
be used to incentivise improving outcomes and
reducing inequalities. NHS Greenwich CCG has
adopted the Greenwich Health and Wellbeing
Strategy and is showing leadership in its
implementation with partners in Greenwich,
Improving
Mental Health
Care
Deliver Acute service redesign reduction in
acute bed services and an increase in
community based care
Identify Single point of access to MH
services through introduction of a referral
management system.
Use contract levers, or market testing, to seek out
innovations in provision that bring together mental
health with community health services (No Health
without Mental Health). and improve quality
Re-balance of acute care beds for older adults with
community provision including integrated care at
home including home treatment services for
66
Establish a short break Service
Support a Shared Care Model of servicedelivery
Continue to Increase Access toPsychological Therapies (IAPT
Work jointly with partners in the LocalAuthority to test the market for a ComplexNeeds Recovery Service
Develop an Integrated Care System forOlder people and Dementia
Undertake a review of Child andAdolescent Mental Health
patients with Dementia
Undertake a strategic review of the Assertive
Outreach Team
Continue to develop a potential model for a Referral
Management System with a Single Point of Access
providing, advice, telephone consultation, screening
& triage to most appropriate services.
Provide a more community based, flexible and
integrated Children and Adolescent Mental Health
Service (CAMHS) model (see also Commissioning
Intentions for Children and Young People)
Expanding the IAPT service at Greenwich Time to
Talk to focus on patient with LTC, medically
unexplained symptoms and difficult to reach groups.
Provide evidence based IAPT interventions for
patients with Learning Disabilities
Support General Practice to improve the Quality
and Management of General Practice Mental Health
Services and Referrals.
Reduce out of area placements and develop services
closer to people at home in Greenwich
Children andYoung People’sServices: Awhole systemapproach,focusing onprevention anddevelopingintegrated carepathways andservices
Procurement of an Integrated Care Service
for children with complex needs –
(completed)
Deliver a Prevention programme with
focus on obesity and fitness levels, sexual
health, psychological well-being, the health
of children from BME communities and
improving health outcomes for mother and
babies.
Undertake a strategic review of Child and
Adolescent Health Mental Health Services
(CAMHS) - (completed)
Deliver the Integrated Care Service for children with
complex needs
Provide a more community based, flexible and
integrated Children and Adolescent Mental Health
Service (CAMHS) model (see also Commissioning
Intentions for Mental Health)
Review current acute paediatric models of provisionand commission a service that meets the full rangeof acuity of needs that arise from a service modelagreed with the provider. Review to includecontracting methodology.
Review Maternity Services in order that Greenwich
commissions the best possible model in line with
national guidance
Review Unplanned Care for Children and assess
efficiency of multiple access points for children with
minor illness.
Continue with prevention programme for children
67
with a focus on obesity and fitness levels, sexual
health, psychological well-being, the health of
children from BME communities and improving
health outcomes for mother and babies (to be
delivered by public health function within local
authority)
Improve long
term conditions
care
Finding the Vulnerable. Increase casefinding, capacity and coordination ofservices to prevent unnecessary admissions
Deliver Integrated Primary Care Model –(intermediate care, an extended JointEmergency Team (JET) service, &anintegrated health and social care team).Capacity to be put in place equivalent totwo acute wards.
Expand rapidly intermediate care at homecapacity. Business case in development fornext stage of the model.
Work with general practices to reviewpatients on the register and improve carefor patients at highest risk of hospitaladmission, building on the initialengagement of GPs into clinicalcommissioning.
Provide specialist care to Greenwich
residents living with COPD through the
specialist community COPD Service
Deliver specialist, multi-professional
community Diabetes Service through
community diabetes clinics and home visits
to patients who are housebound.
Pilot Diabetes ‘Evidence Into Practice’
project - A GP practice based programme
that provides facilitated, structured
management of people with diabetes.
Improve wound management, improved
prescribing of SIP feeds, scriptswitch
deliver through a Medicines Management
programme.
Commissioning for Transformational Change. We
will be working across BBG to commission at scale
for selected LTC services, applying evidence of best
practice in the BBG context, working to shared
standards but with local adaptation and
implementation to modify the overall approach to
suit local needs. (See work with Bexley and Bromley
to implement the Plymouth model of diabetes care
below).
Our Finding the Vulnerable programme will
continue to target a range of patient and population
groups who – for reasons of physical and or
psychological ill health – may find it harder to access
health care or use health services for potentially
avoidable problems
Support the role of the GP. Work with general
practices will continue to aim to reduce variation in
general practice treatment of people with Long
Term Conditions. We will be finding ways to focus
their attention on complex patients at high risk of
Emergency Admissions.
Continue to build on the success achieved by theCOPD service leading to a reduction in the use ofacute services and possible admission.
Support Patient Self Care by ensuring pathways
include education and self care after diagnosis.
Consider psychological support to deepen patient’s
ability to cope, self-manage, incl. links to IATP
Target specific long term conditions in line with our
overall focus on transferring care into community
settings, working to develop a range of innovative
LTC clinics working in an integrated way with
specialists, GPs and other clinicians.
Build on the success of the Diabetes into Evidence
programme at delivering improved clinical
outcomes, continuing support and skills
development for primary care teams will
compliment the development of the new BBG
68
diabetes model.
Commission with Bexley & Bromley a new Diabetes
Model of Care that makes a clear distinction
between what is done in an acute trust and what is
not done, adopting the Plymouth model.
Review Stroke service and early supported
discharge for stroke
Review the delivery of Asthma care in primary care
to identify ways to improve the quality of the
service with a view to implementing an integrated
early supported discharge service
Co-ordinate the
provision of
urgent care
Develop a Whole systems Urgent Care
Model for an integrated urgent care system
enabling the development of a specification
to tender.
Deliver an Urgent Care Centre providing
both minor illness and minor injury services
within the Emergency Department and
operates from 8am until 10pm, seven days
a week,
Continue to deliver a Greenwich Virtual
Admissions Avoidance Team (VAAT)
consisting of representatives from
community services including the JET, Falls
Team, COPD Service, Continence, Long
Term Conditions and District Nursing.
Continue to deliver a Joint Emergency
Team (JET) of health and social care staff
providing swift assessment and
management of clients that require urgent
intervention.
Identify opportunities to improve access and
responsiveness in general practice to prevent
patients going directly to A&E
Continue to focus on reducing A&E attendances
from Care Homes
Identify a process for GPs to access clinical support
from secondary care specialists - Clinical
consultation, advice and supervision to help care for
difficult cases rather than admit
Discuss with London Ambulance Service the
potential to redirect ambulance patients to the
Urgent Care Centre instead of A&E – this has now
been agreed and will enacted in 12/13, ready for
13/14.
Increase
capacity in high
quality cost
effective
alternatives to
hospital based
planned care
Deliver a Referral Management & BookingService (RMBS) to reduce and improve thequality of referrals by implementing clinicalreferral pathways and triaging referrals.
Commission an Integrated CardiologyService pilot, in conjunction with Bexleyand Bromley CCGs, for an integratedcardiology service across the 3 boroughs,
Develop a full business case for communityhospital provision in Eltham. The Elthamcommunity hospital will be a key ‘enabler’to deliver our priorities and provideadditional capacity for community based
Continue to deliver the RMBS. Review and analysedata from the RMBS service to identifyopportunities for improvement including helpingGPs to follow pathways better, introducing morerobust and objective challenge procedures and toprovide more services in the community
Implement the Integrated Cardiology Service
Build capacity and capability in General Practice toinclude on-going training &good back-up support.At same time reduce variability and poor practice inprescribing, referring and clinical practice
69
services.
Undertake a review of direct accessdiagnostics to identify and reduce anyunnecessary testing.
Deliver improvements in MedicinesManagement including a shared formularywith SLHT for high cost drugs/high riskconditions, new anti-coagulation drugs,challenging payments by results excludeddrugs & management of the RAG list ofdrugs.
Implement other alternatives to hospitalbased care delivered in the community,identified as part of QIPP
Identify unused capacity in primary care settings –both in-hours and out of hours
Develop a GP engagement and marketing strategyto help GPs understand their role as a key enabler ofimproving service provision in Greenwich
Undertake a Review of how existing resources arecurrently utilised and identify how they could beutilised more effectively and efficiently withinexisting contracts.
Undertake a speciality by specialty ‘Outpatient CareAudit’ to identify potential to transfer OutpatientCare to community care based settings.
Reduce unnecessary follow ups in secondary,community & primary care. Adopt practice of ‘nofollow-ups unless there is a specific reason i.e.clinical or patient request’ to reduce the number ofunnecessary follow ups and Do Not Attends. Thiswork is being led through the Transformation Boardacross BB&G which is driving the changeprogramme at SLHT in this area.
Undertake Pathway Redesign in Primary Care for
Ophthalmology and Dental Services. Skilled primary
care practitioners, such as dentists and
optometrists, are well placed to deliver part of the
patient pathway in primary care instead of in
secondary care.
Enhance end of
life care
Pilot an integrated model of care which
aims to reduce inappropriate hospital
admissions and enable more patients to die
in their place of choice. Consists of a
palliative care co-ordination centre, a rapid
response unit, multi visit personal care and
support service & planned night care
service.
Implement best practice pathways
Procure the piloted end of life care model so that itbecomes a substantive service available to thepopulation of Greenwich in the last year of life.
Continue to implement best practice including the
Liverpool Care Pathway and Gold Standard
framework
Community
Services
n/a The contract with Oxleas NHS Foundation Trust forcommunity services comes to an end on 13 March2013. The contract will be extended for 6 monthsand it is intended to go out to tender to reprocurecommunity services early in 2013/14
70
4.2 What are we proud of? Success stories in delivering the Plan
Integrated Care System
Greenwich is in the process of drawing together existing care provision by primary, community,acute health and social care into and integrated care system. The aim is to ensure that patientsexperience integrated care, designed around their needs, and delivered by health and social careprofessionals with the necessary skills and qualifications. The first stage of this development hasbeen a rapid expansion of capacity to deliver intermediate care at home as part of the step up andstep down provision of nursing care, supporting both hospital admission avoidance and promptdischarge. Fully integrated community services provided by Oxleas and the Royal Borough ofGreenwich Social Services acting as one integrated team. This innovative approach has beenrecognized nationally when the team won the national prestigious National Health Service Journalaward for team engagement and was chosen by the Secretary of State as the overall winner ofwinners recognising the significant improvement in patient care that this has brought.
Outcomes: As at August 2012, capacity to support 53 people at home has been put in place, from a
base of approximately 25, i.e. a doubling of capacity, contributing to reduced length of stay for
medically fit patients (see below).
Referral Management & Booking Service (RMBS)
The Greenwich RMBS aims to reduce and improve the quality of referrals by implementing clinical
referral pathways and triaging against them, ensuring appropriate pre-diagnostic work is completed
prior to referral, re-directing activity to appropriate community services and challenging
inappropriate referrals. The service has been introduced on a phased basis, and currently 34 out of
45 practices are live on the RMBS, equating to approx. 3,900 referrals per month, and will handle
approx. 5,000 referrals per month by April 2013. Of 4,193 referrals triaged to date 2,925 (70%) were
71
referred onto secondary care, with 401 being returned to the GP (c.10%) and 867 referred to an
alternative community service (c.20%).
Outcome: established an improved process of referring patients from primary to secondary care withfewer wasted patient journeys and increased choice.
Other direct benefits of the service include:
Real time referral information by practice, GP, specialty and clinic type
Increase of Choose and Book utilisation across Greenwich from 28% to 60% to date
The RMBS has developed into a tool to enable other QIPP referral initiatives to be implemented, for
example procurement of Any Qualified Provider (AQP) alternatives to hospital based care for Minor
Surgery, Dermatology and Gynaecology that have improved access and patient choice.
Greenwich Virtual Admissions Avoidance Team (VAAT)
Established in 2009, the Greenwich VAAT consists of representatives from community services
including the JET, Falls Team, COPD Service, Continence, Long Term Conditions and District Nursing.
The team works collaboratively with London Ambulance service and primary care services to prevent
unnecessary A&E attendances and hospital admissions and has developed a range of clinical
pathways including lower limb cellulitis, continence (UTI), COPD, falls, blocked catheters and
palliative care. The team engages in rapid assessment and decision making and close liaison with
other health and social care services.
Outcome: The team has supported LAS in achieving a 33% reduction in the number of patients that
are conveyed to hospital overall, in the last year, the highest reduction anywhere in London.
Joint Emergency Team (JET)
JET was established in April 2011 as a multidisciplinary team of health and social care staff providing
swift holistic assessment and management of clients that require urgent intervention within 24
hours of the referral, responding to all urgent referrals within 2-4 hours. Interventions include re-
ablement at home or access to intermediate care rehabilitation with a range of high clinical and low
social and low social and high clinical services.
Outcome: In its first year JET has prevented a total of 521 A&E attendances 448 unnecessary
hospital admissions.
Urgent Care Centre
Following the successful pilot of an Urgent Care Centre at the Queen Elizabeth Woolwich site, a UCC
has been procured from the Hurley Group and commenced in December 2011. The service provides
both minor illness and minor injury services within the Emergency Department and operates from
72
8am until 10pm, seven days a week, with extra sessions commissioned on an ad hoc basis to cover
periods of anticipated increased demand, e.g. during the Olympics, bank holidays.
Outcome: Since the service went live there has been a significant shift in activity, with A&E activity
down substantially compared to the same period the previous year, and the A&E achieving
sustained improvement in waiting times. A significant shift in activity has occurs as per the graph
below, while at the same time A&E performance at the QEW site has seen sustained improvement
(95.51% at QEW w/e 22/07/2012)
Lower Limb Service
The LLS is able to prevent hospital attendance and admission by seeing patients in clinics, LEG
Groups and their own homes, and if necessary admitting patients to intermediate care beds for
intravenous antibiotics. The LLS has worked with London Ambulance Service to develop pathways
for patients with cellulitis to ensure that they are transported to hospital if necessary but referred to
LLS if this is more appropriate. Treatment is provided where appropriate and preventative advice for
those who have come through the acute phase.
Outcome: Admissions avoided in 2011/12 – 89
End of Life Care
A Greenwich Care Partnership operates alongside and supports existing core services (GP’s, district
nurses, specialist nurses etc.) to provide high quality care for patients with end of life needs in the
Royal Borough of Greenwich. Three organisations – Greenwich and Bexley Community Hospice,
Marie Curie Cancer Care and Oxleas Community Health Services are working in partnership to
provide this integrated model of care which aims to reduce inappropriate hospital admissions and
enable more patients to be cared for and to die in their place of choice by ensuring that appropriate
health and personal care services are available and that their families and/or careers have sufficient
practical and emotional support. The service consists of four integrated elements:
A palliative care co-ordination centre
A rapid response unit
Multi visit personal care and support service
Planned night care service.
Quantitative outcomes: Pilot still subject to evaluation, but currently the service that 52% of
patients referred to the service were able to die in the place of their choice, and a greater % of
people are dying at home or in a hospice.
73
Urgent Care Centre
An Urgent Care Centre is based on the Queen Elizabeth Woolwich site in A&E, and is run by the
Hurley Group.. The service provides both minor illness and minor injury services within the
Emergency Department and operates from 8am until 10pm, seven days a week, with extra sessions
commissioned on an ad hoc basis to cover periods of anticipated increased demand, e.g. during the
Olympics, bank holidays. Since the service went live there has been a significant shift in activity, with
A&E activity down substantially compared to the same period the previous year, and the A&E
achieving sustained improvement in waiting times.
Quantitative outcomes: A significant shift in activity has occurred(see graph below), while at the
same time A&E performance at the QEW site has seen sustained improvement (95.51% at QEW
w/e 22/7/12)
Falls Team
The Falls Team is a community based specialist service working with older adults in their own homes
(including care homes) to prevent falls and injuries, working jointly through a dedicated social care
link for falls. The team has received a number of awards; from the Chartered Society of
Physiotherapists for its case finding approach, and from the Health Service Journal (HSJ) in 2010 as
part of the successful admission avoidance team, and again from the HSJ in 2011 as part of the
integrated health and social care staff engagement award.
Quantitative outcomes: of 210 reviews carried out in 2011/12 86% had not fallen in the following
6-9 months, and there were zero serious injuries or fractures.
Diabetes – Community Services
74
Greenwich has commissioned a specialist, multi-professional community diabetes service from
Oxleas NHS Foundation Trust for patients with Type 2 diabetes requiring Tier 3 services who may
previously have been referred to hospital. The service is delivered through community diabetes
clinics in a number of different locations and through home visits to patients who are housebound,
and aims to:
Case-find new patients and improve clinical outcomes
Shift outpatient activity to community settings.
Reduce A&E attendances and non-elective acute admissions
Outcomes: The service went live in 2011/12 and has succeeded in shifting activity to the
community as indicated by the graph below:
Diabetes National Audit
The Diabetes National Audit identifies key findings about the quality of care for people with diabetes
and in 2011/12, through a supported programme to practices, Greenwich's participation rate
increased from 8.7% to 93.3% thus facilitating the availability of valuable comparative data. The data
has shown many improvements across the board as a result of a number of initiatives implemented
by commissioners including the development of diabetes guidelines, the extension of the
community diabetes services and the Evidence into Practice programme.
Quantitative outcomes: From a previous bottom quintile position, Greenwich PCT has moved to
the 2nd quintile for achievement of all NICE recommended diabetes care processes with over 55%
of individual care processes being in the first two quintiles. In terms of achievement of
NICE recommended treatment targets, Greenwich has moved from ranking in the
bottom quintile to the 3rd quintile overall and is now above the national average for BP at target
level and HbA1c <6.5%.
75
Evidence into Practice Diabetes project (award winning project)
A GP practice based programme that provides facilitated, structured cardio-metabolic risk
management of people with diabetes and supports the sharing of best practice. The programme is
designed to improve the health outcomes of people with diabetes through the implementation of
national and/or local guidelines.
Quantitative outcomes: The pilot indicates a decrease (5%) in outpatient diabetic medicine
attendances and circulatory admissions (1%) as compared to increases of 11% and 13%
respectively in the non-pilot group, as well as relatively fewer CHD and stroke admissions for the
pilot group - anticipated savings following roll out to all practices c. £730k.
Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatientattendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilotsites (32). Figures standardised per 1000 patients with diabetes.
Data on File NHS Greenwich, September 2011
Outcomes:Evidence into Practice: Pilot
NHS Health Check PLUS Programme
Programme targeted at 40-74 year olds without known CVD. Aims to assess risk of heart disease,
stroke, kidney disease and diabetes and support people to change lifestyle and provide treatment
where necessary to reduce that risk.
Quantitative outcomes: 20,797 health checks have been undertaken in 10-12, No 1 in London, 3rd
nationally for coverage - based on findings in 1000 sample cohort, we have found estimated 3219
people with high CVD risk (>20%), 357 people with previously undiagnosed diabetes, 915 with pre
diabetes, 4167 with elevated BP, rate of increase in CVD disease registers largest in sector.
NHS Greenwich has made major changes to health provision across the borough and has created the
turnaround necessary to improve healthcare for those in Greenwich from 2012 onwards. This
turnaround is characterised by a systematic understanding of the following:
Whole system sign up
Using every contract lever to implement and sustain change
True ‘live’ partnership and joint working
Recognising and hearing the clinical voice, and Achieving cost benefits without compromising quality or value44 69,304 460 0.7
People with diabetes 3,330 3,500 170 5.1Hba1c at target 715 890 175 24.5BP at target 1,195 1,308 113 9.5
76
4.3 Managing provider performance
Mental Health/Community Services
As commissioners we set the agenda for our regular performancemeetings with our main providerof Mental Health and Community Services, Oxleas NHS Trust, as well as asking for additional itemsfrom the trust to assure quality of services delivered. The performance reporting and activity data isin a format that is reviewed annually , as part of our contract negotiations with Oxleas, and this hasbeen undertaken with Bromley and Bexley CCG colleagues, and has resulted in being modified overtime to meet the needs of our patients and our changing requirements.
For example, for services commissioned for adult mental health (including over 65’s), CAHMS, IAPTand LD, CCG commissioning managers meet with Oxleas once a month with a standing agenda thatincludes: Performance and activity reporting, SI’s and complaints and delayed discharges/transfersof care and key indicators within each service line including acute bed/demand management andaccess to Crisis and Home treatment teams, Memory assessments in older adults and number ofpatients in recovery having accessed IAPT.
For CAHMS and LD–a schedule is in place where the Business managers from Oxleas CAHMS, LD,Older adults and IAPT present, at scheduled times across the year, to commissioners a more detailedperformance report. During 11/12 In the case of CAHMS – this is how we picked up that there wereissues with referral being accepted by the service and this precipitated our drive to review CAHMSservices.
Acute Contract DevelopmentWhilst CCGs in South East London (SEL) have responsibility for initiating the 13/14 QIPP planningprocess, the South London Commissioning Support Unit (CSU) provides support to translate CCGQIPP proposals into 13/14 activity and finance plans with acute providers.
Once NHS Greenwich CCG confirms their Commissioning Intentions for 2013/14, specifically anysignificant changes to acute contracts and planning assumptions for 2013/14, the CCG will meet withthe CSU to agree the approach and set out a high level and a detailed timetable. A formal letter willthen be sent to the acute providers outlining parameters and priorities for 2013/14 negotiations,including;
six months’ notice for any significant change in contract, including notification of termination ofcontracts.
overall process and timetable
process for determining agreed service developments
The CSU will translate the CCG Commissioning Intentions into contract proposals, including theutilisation of contracts levers, tools and techniques as appropriate and agreed activity planningassumptions. Following negotiating meetings the CCG will agree indicative financial envelopes foracute contracting, including reserves. The trusts will issue a costed response to the CCGs proposals,leading to an agreed sign off of the core contract related contract documentation and final costedproposals.
Acute Contract Management
77
The management of the delivery of the acute services contract is delivered by the CSU through anumber of mechanisms including a Senior level Contract Management Board that includes theAccountable Officers of the SEL CCGs and a Joint Transformation Board.
For example, for the South London Healthcare Trust (SLHT) current contract:
• Greenwich’s contract for 2012/13 assumes delivery of 2% acute productivity savings (c.£14m impact on SLHT). Delivery of these savings is monitored by the joint ClinicalTransformation Group (CTG), jointly led between SLHT and the Bexley, Bromley and NHSGreenwich CCGs.
• The CTG is responsible for monitoring delivery and recommending/taking corrective actionwhere necessary. Leads have been identified for each of the productivity opportunities andplans are reviewed at the CTG meetings.
• Where an opportunity looks likely to under deliver the Trust, with the support of thecommissioners, will need to identify or expand delivery of the remaining opportunities toclose the gap
• The CTG reports to the Contract Management Board where Greenwich is represented bythe Accountable Officer and the GP Acute Contracting lead.
Annabel/SharonDomain 1
GREENWICH HEALTH
Lauren/Sim/Sherry D
R
REBECCA
ROSEN
Oxleas
Community
Contract
Long Term
Conditions
Dr K J
an-M
ohamed
– Clin
ical L
ead
Sar
ita A
dams –
Non
Clin
ical L
ead
KEY TO
SYNDICATES
1 - Woolwich/Thamesmead
(Flamsteed)(Pateur)
2 - Excel/Waverley
(Halley)(Lister)
3 – GPCC
(Bradley)(Fleming)
4 – Eltham
(Maskelyne)(Crick)
5 - Blackheath/Charlton
(Pond)(Watson)
Mental
Health
Business
Intelligence
DR HANY W
AHBA
Governance/
H&WBB
Clinical
Strategy
DR
NAYAN
PATEL
SLHT
Contract
Monitoring
Planned
Care &
Utilisation
Review
Dr Sajiv Gupta –
Clinical lead
Prithipal Bhambra
– Non clinical Lead
DR
NAYAN
PATEL
Quality
(interim
Dr Rosen)
End of Life
& Cancers
(interim
Dr Rosen)
Vacant
Dr K
risha Subbarayan
Clinical Lead
David Jam
es –
Non clinical Lead
Vacan
t
DR
EUGENIA
LEE
Safeguarding
Adults
(interim
TBC)
Unplanned
care
(interim
Dr Wahba)
Health &
Wellbeing
Partnership
Maternity,
Womens
Health,
Children
Dr Paul M
cGarry -
Clinical L
ead
DR
JU
NA
ID
BA
JW
A
Dr Y
an
n L
eF
eu
vre
–
Clin
ical L
ead
Kevin
Ryan
–
Non C
linic
al le
ad
Domain
6
KEY TO DOMAINS
1 = strong clinical and multi-
professional focus, which
brings real added value
2 = Meaningful engagement
with patients, carers and
communities
3 = Clear and credible plans to
deliver QIPP within financial
resources, in line with national
requirements and local joint
health and well being strategies 4 = Proper constitutional and
governance arrangements to
deliver all duties and
responsibilities, and
commission effectively
5 = Collaborative arrangements
for commissioning and
appropriate commissioning
6 = Great leaders who
individually and collectively
can make a difference
Domain 3
Domain
5
Domain
4
Domain
2
Sharon
Davidson
All CCG
Managers
Alun
Baylis
Andrew
Thomas
Abi
Ademoyero
Chris
Costa
Irene
Grayson
Nicola
HavutcuAlison
Goodlad
Langley
Gifford
Sandra
Wallace-Millwood
& Mousumi
Kumar
Yvette London
& Kerry
Cleaver
Version 6
12-09-12
Nigel
Evason
Nicola
Havatcu
Chris
Costa
Nicola
Havatcu
Clinical
Project
LeadsPool Clinical Project Lead = Dr Vijay Bajpai
Dr Ngozi
Nwanosike
Dr Meena
Bajpai
Dr Ram
Aggarwal
Dr Ram
Aggarwal
Dr Mukul
Agarwal
(Planned Care
and IFR)
Dr Ranil Perera
(RMBS)
Dr
Gurpreet
Singh
Vacant
Appendix 2 Table demonstrating Greenwich CCG’s Compliance with the National Operating Framework 2012/13
Directive Requirement Progress
Dementia & Care of
Older People
OF Reference:
Section 2.08
Quality accounts.
Work with GPs to ensure improvements ingeneral practice and community servicesincluding improvement of diagnostic rates.Ensure participation in and publication ofnational clinical audits.Outline initiatives to reduce inappropriateantipsychotic prescribing.Continued drive to eliminate Mixed SexAccommodation.Reporting of inappropriate admission rates.Non payment for emergency readmissionswithin 30 days of discharge from electiveadmission.Ensure providers are compliant with NICEquality standards and information published inprovider
Ensure providers are compliant with NICE quality standards andinformation published in provider quality accounts: Theestablishment of Quality Meetings with Oxleas ensures that there is on-going review of the progress being made in respect of the delivery ofservices benchmarked against NICE quality frameworks andindicators agreed in the Quality and Safety Improvement Plan andCQUIN goals. Over the next year we will continue to monitor progressagainst the CQUIN indicators and the three quality domains – PatientExperience, Patient Safety and Clinical Effectiveness and work withservice users and carers to insure information is shared andappropriate training is available for health care professional.Work with GP’s to ensure improvements in General Practice andCommunity Services including improvements in Diagnostic rates:The provision of the Memory Assessment Service has seen anincrease in the number of diagnostic assessments in the last year and itis estimated that 46% of the predicated number of people withDementia in Greenwich receive a diagnosis. This number is expectedto increase as GP’s become more aware of the need for earlydiagnosis, patients, Carers and relatives respond to high profilecampaigns promoting the need for diagnosis and early treatment andhealth care professionals in acute settings receive Dementia trainingEnsure participation in and publication of national clinical audits:We are seeking to improve participation in national audit and wouldhope to confirm a programme of participation in national audits over thecoming year. Our local provider of Mental Health Services hasparticipated in the national POMH-UK audit of prescribing antipsychoticmedication for people with DementiaOutline initiatives to reduce inappropriate prescribing of anti-
psychotic medication: Following the POMH-UP audit, GP reviews inrespect of prescribing has commenced in partnership with Oxleas.Following completion of the reviews, if necessary, an Action Plan will beconstructed to support the need for regular monitoring and review.Continued Drive to eliminate Mixed Sex Accommodation:Reporting of inappropriate admission rates. Local mental healthservices are compliant with privacy and dignity requirements andelimination of mixed sex accommodation. Any breach in same sexaccommodation requirements is received in the reporting data fromproviders and monitored through the course of our contract monitoringarrangements.Non-payment for emergency admissions within 30 days ofdischarge from elective admissions: We have agreed proposals in2011/12 contracts for non-payment for emergency readmissions within30 days of discharge from elective admissions and propose a similaragreement for 2012/13 with commensurate re-investment in schemesto prevent inappropriate readmission.
Carers
OF Reference
Section 2.11
Publication by 30 September 2012 of LocalAuthority and PCT Cluster joint needsassessment with agreed plans policies andidentified budgets with Local Authorities andvoluntary groups to support carers.
To include identification of total budget to
support carers breaks and indicative number of
breaks available within the budget.
The Current Carers Strategy (2011/2012) will be reviewed and arevised version will be signed off by the Joint Commissioning Group inJune 2012 and published by September 2012. The Local Authority willlead on this process, with full engagement of NHS partners, thevoluntary sector, user groups and other stakeholders. The work will bemonitored through the Joint Commissioning Group for Older Adults andreport into the BSU/ clinical commissioning group.
The council has Service Level Agreements (SLAs) in place as follows:
Greenwich Carers Centre: provides information advice, advocacyand building social capital for carers. Adults and Older PeopleServices provides £148k funding and Children's Services funds£74k;
Crossroads provides a Carers Dementia Cafe - £19,500 from Adults
and Older People Services Volcare provides a Sitting Service - £37,000 from Adults and Older
People Services
Carer’s can benefit both directly and indirectly by the services providedto the cared for person. Therefore, the current support package inplace for the cared for person will be considered to ensure the carer’sneeds have been properly reflected in the service users PersonalBudget. Funding for carers was earmarked in 2011/12 in line with the2011/12 operating framework. Year to date, the uptake against thisallocation equates to approximately 50%. We currently fund:
Bedded respite services for people with learning disabilities andmental health
Additional hours of home care support to relieve carers of peoplewith continuing health care
Specialist respite services for people with complex and severehealth needs
Top up of placements within care homes for short breaks
Greenwich have a four year allocation towards developing andsupporting services for carers of £547, 755. £3,492 per annum isdirectly pooled with the local authority and the remainder supportshealth and social care clients packages of care as well as carersevents. We currently fund:
Bedded respite services for people with learning disabilities andmental health
Additional hours of home care support to relieve carers ofpeople with continuing health care needs
Specialist respite services for people with complex and severehealth needs
Top up of placements within care homes for short breaks
An Older Adults Joint Commissioning Plan and revised governance
structures are being reviewed and will be in place by April/May 2012.
This will not be age specific and will include dementia and cognitive
impairment workstreams.
Military & Veterans
Health
OF Reference
Section 2.12
Work with the London Armed Forces Networkto ensure the principles of the Armed ForcesNetwork Covenant are met for the armedforces, their families and veterans.
Ensure that the Ministry of Defence/NHSTransition Protocol for those who have beenseriously injured in the course of their duty isimplemented in any commissioned service.
PCT Clusters, and organisations they
commission from, should be supportive
towards those staff who volunteer for reserve
duties.
Greenwich has historically had strong ties with the military. Woolwichbarracks is home to two battalions and living quarters for currentservice personnel. Currently a small station command team is based atWoolwich barracks while the Princess of Wales troop are overseas –approximately 500 soldiers. Their families and about 200 - 300 childrenare at home in Woolwich. The King's troop (Ceremonial), a small unitwith about 36 horses - arrived on Feb 6th 2012.
We support the London Armed Forces Network with our Local Authorityto ensure that we understand any impact of having a military barracksin the Borough and the needs of current and ex-service personnel thatmay need support form statutory services outside of Ministry ofDefence provision.
Greenwich has formed links with military health leads within theborough and begun to map out how we can support them with theirdelivery of healthcare for physical and mental health. Defencerepresentatives that oversee healthcare delivery across South EastLondon. We will also assess the numbers of service personnel thatretire on health grounds within the Borough, the needs of the families ofservice personnel and veterans and ensure that we link moreappropriately with our Local Authority colleagues across housing,education, adult and children’s services.
We have developed IAPT in Greenwich with local veterans being a
priority target group. We will review activity to ensure appropriate takeup of services. PTSD treatment is available from our local secondarycare provider and additional services are purchased from otherspecialist providers if local services are not appropriate.
We commission quick access to prosthesis for current and ex-servicepersonnel and work with sector leads to ensure access to individualand exceptional treatments. Existing services provided withinGreenwich will link with future Pan London and National strategies.
We are currently reviewing care services available to service personnel
and their families and working with our local GP practices within
Woolwich to support existing health services provided by the MoD and
to ensure appropriate access to services for ex veterans within
Greenwich and South East London.
Health
visitors/Family Nurse
Partnerships
OF Reference
Section 2.13
Work towards delivering provider-based2012/13 trajectories due to be issued by NHSL5th December 2011 in line with theGovernment commitment of an additional 4200by April 2015.
Maintain existing delivery and continue
expansion of the Family Nurse Partnership
programme in line with the Government
commitment to double capacity to 13,000
places by April 2015.
We intend to commission an additional 14 health visitors in the 2012 -2013 financial Year. We will commission these HV’s from two of ourcurrent Providers, Greenwich Community Health Services and theValentine.
Mental Health IAPT to meet 15% prevalence with recoveryrate of at least 50%.
Focus needed on minority groups, older
We will be continuing to support our providers to deliver a programmethat promotes Recovery and Wellbeing and challenges healthinequalities particularly amongst difficult to reach groups such as older
OF Reference
Section 2.23
people, people with serious mental illness andlong term conditions.
Reduction of mortality from physical illness inthose with mental illness.
Focus on joint working with National OffenderManagement Service.
Focus on mental health prevention in lookedafter children and other young people at risk.
QIPP achievement monitored against MHPerformance Framework covering new casesof psychosis served by EIT, gatekeeping ofacute admissions by crisis teams, 7-day postdischarge follow up for those on CPA.
Elimination of mixed sex accommodation
Continue to meet expectations within No Health
Without Mental Health and NHS
adults, people with a learning Disability, ethnic minority groups in thecommunity and patients who have a Dual Diagnosis.
This year we have also supported the permanent appointment of anEmployment Coordinator based within our IAPT service at GreenwichTime to Talk. IAPT in Greenwich is provided by Oxleas FoundationTrust at the Greenwich Time to Talk service and we are in the third yearof the contract. The service has achieved a recovery rate of 48% andfeedback from Service Users and GP’s continues to be positive. We areconfident that there will be an improvement in Recovery Rates over thecoming year through targeted projects in respect of Long TermConditions and the provision of Mindfulness Training to staff whichspecifically supports people with recurrent depression and chronicphysical health conditions such as chronic fatigue.
Over the coming year more work is needed to build on existingprogrammes to support people with Long Term Conditions and worktowards improving access to services influenced by EDS. To achievethis we will be supporting the interim appointment of a worker to startnetworking and set up collaborations with GP’s and Long TermCondition Primary Teams and acute hospital physical health Teams.We have recently agreed to jointly fund a post with the London Boroughof Greenwich which has seen the appointment of a Coordinator to theService User Involvement Group. This post will improve service userrepresentation and feedback to the Mental Health Partnership Board.
We are continuing to support local providers to identify andcommunicate with the numerous BME communities and GreenwichTime to Talk have begun some targeted work in respect of the Tamiland Somalian communities to raise awareness and improve access toprimary care and psychological services.
The CCG supports the Shared Care Model of service delivery whichsits alongside the Recovery Model and the Health and WellbeingProgramme that has been adopted in the borough. In reality thistranslates into a more holistic assessment of a mental health serviceusers’ needs including their physical health and new approaches toscreening and treating long term conditions within primary andsecondary care.
The CCG has supported the Business Case to increase the provision oflow secure Forensic hostel accommodation at the Goldie Leigh site anda corresponding decrease in the number of Forensic bedscommissioned from Oxleas. This development will come on line in2012/2013.
The CCG is currently reviewing services for Children and Young Peoplewith a view to ensuring greater continuity of care, improvingrelationships between families and services and focusing attention onprevention and early intervention.
Local mental health services are compliant with privacy and dignityrequirements and elimination of mixed sex accommodation. Any breachin same sex accommodation requirements is received in the reportingdata from providers and monitored through the course of our monitoringarrangements
Public Sector
Equality Duty (PSED)
OF Reference
Section 2.4
Include assurance that due regard is given to
the Public Sector Equality Duty (PSED), both
specific and general, and that equality
objectives are integrated into the plan
considering using the Equality Delivery System
as the framework.
Greenwich CCC signed up to the EDS as part of the PathfinderDelegation application process. An indicative grading process has beencompleted and the outcome published according to the requirementsset out. An engagement programme with local interest groups and thepublic is being delivered which has helped to provide a self-assessmentand objective setting process for our 12/13 action plan.
A major challenge in Greenwich is the limited resources available to
ensure that meaningful engagement with all protected groups takesplace.
The Equality Impact Assessment has recently been re-designed inorder to include all protected groups and will be used in theconstruction of all QIPP plans.
Safeguarding
(Children)
OF Reference
Section 2.43
Ensure a sustained focus on robustsafeguarding arrangements
To work in partnership through LocalSafeguarding Children Boards (LSCBs) andensure ongoing access to the expertise ofdesignated professionals.
Work with developing CCGs to ensure they are
prepared for their safeguarding responsibilities.
Greenwich hosts a quarterly executive safeguarding children and youngpeople meetings. This meeting is chaired by the Managing Director andsafeguarding arrangements are discussed and agreed. Thesafeguarding risk register is presented and updated at this meeting. Asafeguarding report informing the meeting of health providers' staffingand safeguarding arrangements is presented. The meeting raisesissues and assures that section 11 duties are being delivered.GSCB (Greenwich Safeguarding Children Board) reports andworkgroup reports are taken and discussed at our Board also updateon the Children Trust Board is received. An assurance reportis provided to the Board quarterly on Provider progress andperformance, and a new scorecard is in development.
In Greenwich we work very closely with the GSCB. The DesignatedNurse is based with the GSCB staff part time and the newly appointedDesignated Doctor is planning to base himself there one half day aweek. Both the Designated Doctor and the Designated Nurse attendthe workgroups and the Designated Nurse chairs the health work groupwhich has an excellent attendance. The Designated nurse and Doctormeet regularly with the independent chair of GSCB and GSCBmanager. Our clinical expertise is called upon and utilized regularly.
CCGs will need to ensure that relationships are built and maintained
with local agencies to safeguard children; this should be achieved
through the GSCB and the designated professionals who have local
knowledge. The CCGs will need to be aware of their section 11 duties
and ensure these duties are executed appropriately and that systems
are maintained to evidence this. They will need to maintain the data
bases to ensure that appropriate level of training is delivered and that
safeguarding children remains a priority focus.
Safeguarding(Adults)OF ReferenceSection 2.43
Ensure a sustained focus on robustsafeguarding arrangements.
Work with developing CCGs to ensure they areprepared for their safeguarding responsibilities.
Areas of focus are to ensure annual reviews of all vulnerable adults out
of area by Sept 2012 and to work with nursing homes to improve
pressure area care reducing grade 3’s and 4’s by 50% by acute
providers targeting homes by Nov 2012 .
The Adult safeguarding lead at cluster in post, with Greenwich
safeguarding lead relating to borough safeguarding boards.
Adult safeguarding processes and procedures in place in all Trusts and
primary care.
Adult safeguarding meetings in place to prepare Clinical commissioners
identified as adult safeguarding leads for safeguarding responsibilities.
Any Qualified
Provider
OF Reference
Section 3.21
Extend patient choice of community and mentalhealth services to AQP in 3 service lines perCluster between April and September 2012.
Outcome-based service specifications shouldbe developed with input from CCGs and
Arrangements for Any Qualified Provider are being taken forward by
NHS South East London during 2012/13. An Implementation Group
has been established to cover the three areas which have been
selected for market testing across the cluster. The Implementation
Group with have the following remit:
patients.
The nationally developed provider qualificationquestionnaire should be used to qualifyproviders.
Include further service lines as per Governmentannouncement (expected in December).
a. To oversee the implementation of AQP implementation across SELb. To actively seek to improve the quality of local healthcare throughprovision of extended choice to patientsc. To ensure that the specifications are outcome focused and relevantto local needsd. To ensure the programme is within procurement guidelines
The three areas selected for AQP implementation across SEL are:• Hearing Services• Continence Services• Wheelchairs
There will be Working Groups for each of the service areas, with inputfrom boroughs, and the Working Groups will adapt the nationalspecifications to reflect local pathways, and determine the detailedprocess for commissioning the chosen services on an AQP basis.Greenwich CCG have already successfully procured 3 communityservices in 2011/12 under the AQP process in gynaecology, minorsurgery and dermatology. This has brought 4 new providers ofhealthcare into the Greenwich health economy, providing greaterchoice for patients and out of hospital services closer to home. The newservices are being rolled out in March and April 2012. Operational andstrategic lessons learned will be applied during 2012/13 in futureservice development areas.
Informatics
OF ReferenceSection 3.26
Include evidence of consideration of informaticscapability and capacity necessary to supportthe transition.
Include a credible proposal for giving patientson-line access to their medical records, startingwith their GP records.
Greenwich CCG uses the Cluster ICT team covering Greenwich,Lambeth, Lewisham and Southwark.
The Cluster is reviewing its informatics capability (including informationmanagement, technology and governance) to ensure that it remains fitfor purpose for current and emerging organisations. Greenwich CCGhas engaged in work with the emerging Commissioning Support Unit to
Provide an achievable trajectory for providingSummary Care Records by March 2013 to allresidents who have been written to.
shape the future of ICT provision both in 12/13 and beyond. This workwill continue to inform the service offer from South LondonCommissioning Support Service programme, which will oversee thespecific development of a capable informatics service to supportemerging Clinical Commissioning Groups.
The Primary Care Directorate is working with primary care contractors,emerging Clinical Commissioning Groups and the LMC to ensure thatgiving access for patients to their GP records, and moving forwards totheir full medical record, is considered a key priority. The ICT functionwill continue to engage with clinical system providers to ensure that a)the technical capability is in place across all GP practices within SouthEast London, and b) that a deployment plan will be created inpartnership with GPs and patients to ensure that access is granted inline with national, regional and locally agreed timetables. Progress indelivering this capability will be overseen by the Cluster’s ICT SteeringGroup, supported by a Primary Care ICT Programme Board.
There are 267 practices of which 114 practices have uploaded SCRcovering 768,000 patients (41%). SEL has a project board set up tooversee SCR which meets monthly to review progress against plans.Resource has been authorised to deploy SCR to LSL-G has thenecessary required staff allocated to deliver EMIS Web and SCR withdedicated project managers, clinical transformation leads and technicalleads, and RA. Bexley & Bromley manage their deployment withcurrent resources. SEL has a Communications Strategy that sets outthe communications plan with the key stakeholders. There remains afurther 153 deployments to be completed by 31st March 2013 with 19being deployed by 31st March 2012.
Innovation Evidence the PCT Cluster is preparing toimplement the Innovation Review. Pleaseoutline the key milestones that will ensure
The CCG will review the baseline review due to be completed by NHSSouth East London with provider trusts for the local health economy.The aim of this review is to focus on identifying opportunities for high
implementation of the review with particularreference to compliance with list of high impactinnovations and accelerating adoption anddiffusion of innovative best practice.
impact innovations. The expectation is that this will have beencompleted by autumn 2012 and that this will inform the CCGOperational Plan for 2013/14.
Olympic/ParalympicGames-time delivery
Deliver business as usual performance levels,whilst meeting any increase in demandassociated with the Games (“Games Effect”) atGames-time.
Meet the bid commitments by providingLOCOG with the necessary ambulance andparamedic resources at all LOCOG Eventsand through the Designated Hospitals (Non-designated hospitals if clinically appropriate)providing free healthcare for the accreditedmembers of the Games Family.
Provide appropriate contingency for healthresilience at Games Time in compliance withDH guidance as part of the contribution to theOlympic Security and Safety Programme.
As a host Olympic Borough, Greenwich had to ensure that business asusual performance levels were maintained, whilst meeting any increasein demand associated with the Games (“Games Effect”) at Games-time.
All the Olympic objectives have been successfully achieved.
Appendix 3 - QIPP Programme Summary – Month 5
The 2012/13 QIPP programme has achieved savings at month 5 of £3.465m which is in line with our planned trajectory.
Our financial trajectory for the year is profiled to reflect the impact of the various initiatives as they are introduced through thecourse of the year.
Within the programme, some initiatives have been identified where the projected annual savings may not be achieved. Thepotential gap, if no mitigations were in place, is estimated at £473k. Key mitigations for this include:
o Recovery plans for bringing initiatives back on track
o Stretching the achievement of other initiatives
o On-going development and introduction of so called ‘Plan B’ initiatives. These are introduced as and when theycan generate benefits, and already this year Plan B initiatives sufficient to cover the shortfall on other initiativeshave been introduced, consisting primarily of further contract efficiencies in non-acute commissioning (£400k), andan additional medicines management initiative (70k). These new schemes will also provide us with additional fullyear savings for QIPP in 2013/14, and £386k out of this total has been applied to line 4.1.1 to cover the shortfallon that initiative.
The table below lists each individual scheme and shows their current financial performance, together with their present RAGrating for financials and milestones.
1
Stretch
Target
£'000s
Risk Rated
Plan
£'000s
Planned
YTD
£'000s
Actual
YTD
£'000s
Variance
YTD
£'000s
Forecast
Outturn
£'000s
Financial Milestones
Staying Healthy & Health Promotion
1.1 A step change in tackling smoking 139 139 58 58 0 139
1.2 Develop a systematic approach to prevention in primary & secondary care 225 225 94 94 0 225
1.3 Tackling obesity, diet and physical activity 15 15 6 6 0 15
Total 379 379 158 158 0 379
Improve Mental Health Care
3.1 Local efficiency on Oxleas 480 480 200 200 0 480
Total 480 480 200 200 0 480
Improve Long Term Conditions care for all ages
4.1 Finding the Vulnerable 200 200 25 0 25 200
4.1.1 Finding the Vulnerable -Stretch 386 386 220 220 0 386
4.2 IPCM / Integrated Care at Home 1,000 500 83 0 83 600
4.3 Medicines Management LTC 650 325 90 178 (88) 325
4.4 Diabetes Primary / Community based services 224 224 52 117 (64) 480
4.5 Long Term Conditions (copd) 56 56 23 0 23 0
4.6 MSK - new (T & O) 398 398 66 90 (24) 398
4.7 Falls 49 49 8 0 8 47
Total 2,963 2,138 568 604 (36) 2,436
QIPP Programme Summary 2012/13 - Month 5
Programme / Project
Financial Impact RAG Rating
2
Stretch
Target
£'000s
Risk Rated
Plan
£'000s
Planned
YTD
£'000s
Actual
YTD
£'000s
Variance
YTD
£'000s
Forecast
Outturn
£'000s
Financial Milestones
Provision of urgent & out of hours care
5.1 Urgent Care Centre 0 0 0 380 (380) 912
Total 0 0 0 380 (380) 912
Alternatives to hospital based planned care
6.1 Decommissioning outpatients through RMBS 504 504 195 256 (61) 504
6.2.1 Cardiology incl community services & clinics 418 268 0 0 0 135
6.2.2 Heart Failure - Community Matron Service 65 65 27 0 27 65
6.3 Anticoagulation services in primary care settings 71 71 6 0 6 71
6.4 Community Efficiencies 1,699 1,699 708 708 0 1,699
6.5 Primary Care QIPP 1,000 1,000 417 417 0 1,000
6.6 Orthodontics 200 100 23 24 (1) 96
6.7 Minor Oral Surgery 36 36 15 214 (199) 386
6.8 Dermatology outpatient activity to community 39 39 7 29 (22) 141
6.9 Gen Surgery outpatient activity to community 14 14 0 0 0 47
6.10 Gynaecology outpatient activity to community 167 167 31 13 18 121
6.11 Ophthalmology outpatient activity to community 174 174 49 66 (17) 174
6.12 Medicines Management planned care 500 250 69 16 54 250
Total 4,887 4,387 1,548 1,743 (195) 4,687
Programme / Project
Financial Impact RAG Rating
QIPP Programme Summary 2012/13 - Month 5
3
Stretch
Target
£'000s
Risk Rated
Plan
£'000s
Planned
YTD
£'000s
Actual
YTD
£'000s
Variance
YTD
£'000s
Forecast
Outturn
£'000s
Financial Milestones
Enhance end of life care
7.1 Patients who choose to die at home 211 211 35 35 0 211
Total 211 211 35 35 0 211
Corporate
8.1 Estates rationalisation / additional schemes 442 442 184 292 (108) 700
0 Total 442 442 184 292 (108) 700
Stretch Targets
Further QIPP Schemes (Plan B) / Use of QIPP Earmarked Reserves 0 0 0 54 (54) 17
OP first to follow up - Lewisham 71 36 15 0 15 0
OP first to follow up - Kings 94 47 20 0 20 0
OP first to follow up - Guys 243 122 51 0 51 0
Medicines Management Planned Care 0 0 0 0 0 70
Additional Initiatives 1,287 624 260 0 260 0
CAMHS 250 125 52 0 52 0
Direct Access Diagnostics 300 150 63 0 63 0
Forensic 250 125 52 0 52 0
Urology outpatient activity to community 17 17 7 0 7 0
New community outpatients service (28) (28) (12) 0 (12) 0
Outpatients first to follow-up - SLHT 1,275 638 266 0 266 0
Total 3,759 1,854 773 54 719 87
Total 13,122 9,892 3,465 3,465 0 9,892
QIPP Programme Summary 2012/13 - Month 5
Programme / Project
Financial Impact RAG Rating
4
Appendix 4 – Community Based Care Aspirations
Our aspirations1 for community based care: people living inSEL will….
Page 2
Easy accessto high quality,responsiveprimary &communitycare
▪ Be supported to manage their own health and any illnesses that they have and feel confident to do so
▪ Have access to telephone advice and triage for all community health and care services 24 hours a day, seven days a weekeither through their General Practice or through a telephone single point of access
▪ Have access to primary care service/advice 24hrs, 7 days a week for urgent needs through a combination of appointmentsand walk in services, telephone appointments, 111/NHS Direct, same day urgent care,
▪ Be provided with high-quality, evidence-based primary and community-based care, delivered through primary care staffcollaborating with each other and with specialist and community services, delivering care in line with agreed quality standardsand outcomes.
Timely,convenientand effectiveplannedcare acrossprimary andsecondaryservices
▪ Have access to personalised support and information, in the right formats to inform choice and decisions
▪ Experience consistent quality of care and access to services including radiology, phlebotomy, ECG and spirometry as a result ofagreed SEL-wide standards and protocols
▪ Be able to access most planned care including routine outpatient appointments, diagnostics, pre-assessment and post-operativefollow-up appointments in settings closer to home, or via telephone/web-based consultations, so that travel to outpatients at theacute sites is for specialist diagnostics and consultations only
1 All the below themes apply directly to Mental Health
DRAFT
Integrated carefor people withLTCs, the frailelderly andpeopleneeding EOLcare:
▪ Receive better targeted and more personalised care appropriate to their needs, as a result of SEL-wide real-time population riskstratification
▪ Play an active part together with their health professionals in developing a care plan that sets out what they and the healthprofessionals who support them will do to ensure that they are as healthy as possible and what should happen in the event ofproblems
▪ Have a named ‘care coordinator’ who will work with them to coordinate care across health and social care
▪ Know that their GP is working together with a multi-disciplinary group of other health professionals to co-ordinate anddeliver care, incorporating input from primary, community, social care, mental health and specialists
▪ Be provided with any tests, equipment or advice that they need within 4 hours if there is a risk that otherwise they will need to beadmitted to hospital
▪ Be confident that if they are admitted to hospital, staff based in the community will be working from the day of their admission withtheir hospital staff to make sure that as soon as they are ready, they can come home, with any equipment, additional funding oradditional services such as rehabilitation in place, with every patient who is medically fit to be discharged leaving hospital within24 hours of the decision being made
Appendix 5 Greenwich Commissioning Intentions 2013/14
Priority Key Features 2012/13 Commissioning Intentions2013/14
Rationale
ImprovingMental HealthCare
CCG spends £55m on Mental HealthServices delivered mainly by OxleasFoundation Trust and some services fromSouth London and Maudsley FoundationTrust.
Year on year contract efficiencies havebeen built into the mental health contractwith Oxleas.
A reduction of £720k was made in 2011/12with £480k reductions each year from12/13 to14/15.
A number of initiatives are being developedto support the achievement of theefficiencies including acute serviceredesign (closure of 1 acute inpatient ward)
Single point of access to MH servicesthrough introduction of a referralmanagement service.
Establishment of a Respite Service
Support for a Shared Care Model of servicedelivery - Greenwich is seeking to improvethe interface between Primary and
Use contract levers, or
market testing, to seek
out innovations in
provision that bring
together mental health
with community health
services.
Reduction in Beds forolder adults
A major influence on Commissioning Intentions for
13/14 will be the “No Health Without Mental Health”
Implementation Framework, and how Greenwich aligns
the commissioning intentions with the six shared
objectives.
Given that the ‘market’ may not have a ready solution,implementation will remain a commissioning –ledprocess to design a specification and stimulate ideasbased on the available evidence.
We have invested heavily in the memory assessmentservice at the Memorial and this has meant that peopleare behind diagnosed and offered treatment earlier inthe pathway. What that has translated into has beenreduction in bed numbers across BBG in the last yearand we varied the contract in year to reduce down tounder 20 beds. There could be savings plus some newinvestment in a more robust Crisis and Home Treatmentservice to maintain and manage patients with Dementiaat home for longer. This would fit with our overalldesire to change the direction of travel away from areliance on acute beds and more robust community
secondary care and work
Increasing Access to PsychologicalTherapies (IAPT). We are committed tothe further development of the service andaim to improve access to employment,promote health and welling and develop aLong Term Conditions service
Complex Needs Recovery Service. Inseeking to improve the pathway andpatient experience we are working jointlywith partners in the Local Authority to testthe market in support of the procurementprocess
Older people and Dementia. Greenwich isworking with partners to support thedevelopment of the Integrated Care Systemwhich aims to draw together currentservice elements into a unified model thatincludes primary care, community care,social and acute care.
Child and Adolescent Mental Health -Greenwich are undertaking a review ofCAMHS in the borough which will build onthe key findings of the CAHMS needsassessment, evaluate the ability of theservice to meet the current and futureneeds of Children and Young People andreview quality and outcome measures.
Assertive Outreach TeamStrategic Review
services.
There is a concern that this team has beenunderperforming. We commission 124 places but theteam has been running at about 100 patients. Thisunderperformance coincides with an increase in thenumber of patients occupying acute beds in excess of60 and 90 days which has amounted to around 15-20patients in the last few months – a caseload for a CareCoordinator and the equivalent of a ward at Oxleashouse. Despite our suggestions that these patientswould probably benefit from a more assertive approachin engagement and facilitating discharge this has notbeen reflected in activity and we have formallyrequested a review of the team’s performance.Outcomes to be reviewed include length of time in theteam, diagnosis, impact on readmissions to hospital anddemographics. Review to be carried out in partnershipwith the Local Authority who contribute social careinput to the team.
Review to take into consideration the work that hasbeen underway to promote alternative models inmanaging and delivering care to children with complexneeds. This Team Around the Child (TAC)approach/model has been successful in terms ofengagement, monitoring and rehabilitation withoutcomes which have been successful in movingchildren out of hospital within an integrated package of
Develop a potentialModel for a ReferralManagementSystem with a SinglePoint of Access providing, advice, telephoneconsultation, screening& triage to mostappropriate services
Provide a more
community based,
flexible and integrated
Children and Adolescent
Mental Health Service
(CAMHS) model (see
also Commissioning
Intentions for Children
and Young People)
care. It may be possible to promote this model withinthe Assertive Outreach Team in order to monitor andsupport robust engagement and recovery of adult MHservice users and move them through the acutepathway more quickly.
There are currently a high proportion of inappropriatereferrals particularly from GP’s, lack of clarity aboutreferral and access protocols and scattergun approachto referrals due to lack of knowledge about whichservices exists, eligibility criteria and accessrequirements. Potential for a significant shift in referralpatterns with such a model.
As a consequence of a number of concerns, togetherwith the Local Authority we undertook a strategicreview of Greenwich CAMHS in 2012 to review thequality of services and their ability to deliver outcomesfor Children & Young People. Strategically we want toinclude CAHMS in our drive to improve integration,particularly for vulnerable groups. As a result of thereview, for 2013/14 we intend to:
Develop a Referral Management System formental health that includes CAMHS
Re-tendering of theComplex needs andRecovery Service
Expanding IAPT atGreenwich Time to Talk
Develop a seven day a week CAMHS servicewhich illustrates the shift away from a relianceon an acute bed base for children in crisis and amove towards more robust community basedservices supporting children at home for as longas possible or until the crisis is over.
We have just completed the PQQ stage of this processand there is a shortlist of 7. We have re-specified toensure that the model of service delivery is outcomefocused and based on a recovery pathway with clearachievements designed to move people towardsindependence and more mainstream service. Theservice, to date, has been characterised by
delays in the patient pathways with averagelength of stay being 2 years - some have beenin the placements for five years
an absence of a move on/recovery plan
low expectations – from service users and theirCarers and, in some cases, staff
patients ‘opting out’ of their care plan/ADL’swhich we think should be renamed ‘Supportand Recovery Plan’.
We are currently expanding the existing service toensure difficult to reach groups such as BME groups,older adults and people with a learning disability are
Review the data on IAPTactivity
Provide evidence basedinterventions forpatients with LearningDisabilities
Support General Practiceto improve the Qualityand Management of
able to access IAPT services. We will be working withOxleas to develop a long terms conditions service with aview to establishing the delivery of psychologicalinterventions to patients with a co morbid diagnosis ofmental health and chronic fatigue, musculoskeletaldisorders, diabetes and angina.
We have not yet taken any efficiencies out of the IAPTenvelope which is a separate contract to the main blockwith Oxleas. We will review potential to unbundle whatwe commission from SLAM and spend the moneylocally here – e.g. CBT for Chronic Fatigue, chronic pain,CBT for some patients on the autism spectrum, coupleand sexual therapy/psychotherapy.
We recognise that mainstream IAPT services are notaccessible or available to people with a LearningDisability and have funded a pilot to ensure thatpatients with a Learning Disability are able to access arange of evidence based interventions includingCoaching and adapted CBT centred approaches foranxiety and depression. This approach is in keeping withour drive to develop local services for local residentsand move away a reliance on block commissioningfrom SLAM.
The quality of the services available within generalpractice can be variable and the knowledge of what isavailable for GPs to refer to can be limited. QualityInitiatives that could be promoted within general
General Practice MentalHealth Services andReferrals
practice include:
Creating a Mental Health Directory, utilisinginformation technology, of available services both inhours and out of hours, including third sectorCreating primary care management plans, including selfcare and self management, for patients based aroundtheir individual ‘mental health condition’Consider potential for Annual Health Checks to includeMental Health assessmentImproving referral pathways within general practice fora number of conditions including:
AlcoholSubstance misuseLearning DisabilitiesCAMHSGHLiSDepressionPsychosisEating DisordersIAPTMINDSelf Harm
Also there is a need to link in the development ofMental Health pathways and referrals with theGreenwich community based Referral Management andBooking Service.
Improve long
term
conditions
care
.Finding the Vulnerable - increasing case
finding, capacity and coordination ofservices to prevent unnecessary admissionsto hospital. There is a particular focus onreducing admissions from care homes.Integrated Primary Care Model - Thisservice includes intermediate care and anextended Joint Emergency Team (JET)service, an integrated health and socialcare team providing rapid assessment andmanagement and building up consultantled sub-acute capacity in existing beds.Aimed mainly at over 65s with UTIs, heartfailure or COPD who could better bemanaged out of hospital. Capacity to be putin place equivalent to two acute wards.
Expansion of intermediate care at homecapacity - The first stage of thisdevelopment has been a rapid expansion ofcapacity to deliver intermediate care athome as part of the step up and step downprovision of nursing care, supporting bothhospital admission avoidance and promptdischarge.
Business case in development for nextstage of the model.
Work with general practices - throughvisits, data analysis, syndicate peer reviewand Commissioning Incentive scheme toreview patients on the register andimprove care for patients at highest risk of
Commissioning forTransformationalChange
Integrated Primary CareModel
Finding the Vulnerable
Supporting the role ofthe GP
We will be working across BBG to commission at scalefor selected long term conditions services. The aim willbe to apply evidence of best practice in the BBGcontext, working to shared standards but with localadaptation and implementation to modify the overallapproach to suit local needs.( See work with Bexley andBromley to implement the Plymouth model of diabetescare below).
This highly effective service will continue to bedelivered and is expected to deliver an additional £1mrecurrent efficiency saving in addition to providing highquality care for patients either in their homes or in thelocal community.
Targeting vulnerable groups: Unlike our neighbouringboroughs, Greenwich has a relatively young population.Along side our frail elderly residents are those with MHand drug and alcohol problems. Our FTV programmewill continue to target a range of patient andpopulation groups who – for reasons of physical and orpsychological ill health – may find it harder to accesshealth care or use health services for potentiallyavoidable problems.
Work with general practices will continue to aim toreduce variation in general practice treatment of peoplewith Long Term Conditions, building on the initialengagement of GPs into clinical commissioning. We willbe finding ways to focus their attention on complexpatients at high risk of Emergency Admissions. Reducing
hospital admission.
COPD Service - The Chronic Obstructive
Pulmonary Disease (COPD) Team provide
specialist care to Greenwich residents living
with COPD. Patients are given the tools to
self-manage their condition and stay in the
best health possible with a combination of
clinic appointments and visits in their own
home when necessary. Pulmonary
Rehabilitation, a seven week course of
twice weekly education and exercise, is also
available for patients. Patients who feel
unwell can call the service for assessment,
treatment and advice, which allows
patients in a period of ‘exacerbation’ to
remain at home, monitored by the COPD
team, avoiding an unnecessary hospital
admission. The team also manages the
oxygen prescription service for patients
registered with a GP.
Diabetes Service - Greenwich hascommissioned a specialist, multi-professional community diabetes servicefrom Oxleas NHS Foundation Trust forpatients with Type 2 diabetes requiring Tier3 services who may previously have beenreferred to hospital. The service isdelivered through community diabetesclinics in a number of different locations
Delivering COPD service
Patient Self Care
LTC Clinics
Diabetes ‘Evidence Into
variations in general practice will be supported byfurther development of the Commissioning IncentiveScheme, dissemination of syndicate level data sets andfurther development of the RMBS.
Greenwich will continue to build on the successachieved by the COPD service. GPs are now aware thatwhen their COPD patients begin to degenerate thatthey can contact - and get an immediate response from- the community based COPD service, leading to areduction in the use of acute services and possibleadmission.
As part of the LTCs pathways, such as childhoodasthma, following a prevention of re-admission episodeGPs carry out a 6 week check. At this point there shouldbe a focus on offering self-care and self-managementsupport to the patients. In some cases this isoverlooked and our intention in 2013/14 is to develop asupport package (drawing on best practice) that willimprove this aspect of the pathway.
Targeting specific long term conditions-in line with ouroverall focus on transferring care into communitysettings, working to develop a range of innovative LTCclinics working in an integrated way with specialists,GPs and other clinicians. There will a specific focus on –asthma and stroke initiatives and the development ofintegrated cardiology in Greenwich.
Building on the success of the pilot, a roll out of this
and through home visits to patients whoare housebound, and aims to case-find newpatients and improve clinical outcomes,Shift outpatient activity to communitysettings and reduce A&E attendances andnon-elective acute admissions..Pilot Diabetes ‘Evidence Into Practice’project (award winning project) - A GPpractice based programme that providesfacilitated, structured cardio-metabolic riskmanagement of people with diabetes andsupports the sharing of best practice Thepilot indicates a decrease (5%) inoutpatient diabetic medicine attendancesand circulatory admissions (1%) ascompared to increases of 11% and 13%respectively in the non-pilot group, as wellas relatively fewer CHD and strokeadmissions for the pilot group - anticipatedsavings following roll out to all practices c.£730k.
Medicines Management – Improvedwound management, improved prescribingof SIP feeds, scriptswitch
Practice’
New BBG DiabetesModel of Care
Stroke service and earlysupported discharge forstroke
Improve Asthma Care
approach to all practices in Greenwich has been
implemented and been very successful at delivering
improved clinical outcomes. The continuing support and
skills development for primary care teams will
compliment the development of the new BBG diabetes
pathway.
The Diabetes Working Group (DWG) has reviewedoutcome and commissioning data and is proposing thatBBG implement a model of care which has becomeknown as the Plymouth Model. This makes a cleardistinction between what is done in an acute trust andwhat is not done. It assumes a diabetes specialist hastwo roles: as a doctor with specialist skills for high-enddiabetes and as an educator. The model clearly sets outthe 6 conditions that require diabetologist‘s care andthe support role for the community.
CQC have raised concerns about this service and interms of utilisation of acute services the currentdelivery incurs long length of stays, This work has begunalready and will continue to be developed.
There is a need to review the delivery of asthma care inprimary care to improve the quality of the service toensure the right care is being delivered in the right way.GPs may need support to help understand better whatshould be done, and what could be done differently.
Co-ordinate
the provision
of urgent care
and out of
hours care
Whole systems Urgent Care ModelDevelopment of a whole systems model foran integrated urgent care system enablingthe development of a specification totender for the whole system.
Urgent Care CentreThe service provides both minor illness andminor injury services within the EmergencyDepartment and operates from 8am until10pm, seven days a week, Since the servicewent live there has been a significant shiftin activity, with A&E activity downsubstantially compared to the same periodthe previous year, and the A&E achievingsustained improvement in waiting times.
Greenwich Virtual Admissions AvoidanceTeam (VAAT) consists of representativesfrom community services including the JET,Falls Team, COPD Service, Continence, LongTerm Conditions and District Nursing. Theteam works collaboratively with LondonAmbulance service and primary careservices to prevent unnecessary A&Eattendances and hospital admissions andhas developed a range of clinical pathways.The team has supported LAS in achieving a33% reduction in the number of patientsthat are conveyed to hospital overall, in thelast year, the highest reduction anywherein London.
Identify opportunities toreduce costs in Out ofHours and Walk inCentres and rationaliseprovision
Identify opportunities toimprove access andresponsiveness ingeneral practice
Continue to focus onreducing A&Eattendances from CareHomes
Identify a process forGPs to access clinicalsupport from secondarycare specialists
Commissioning of WICs passes to CCGs from next year.Current provision risks fragmentation of primary careboth in-hours and out of hours, with a lack ofintegration and potential duplication. WICs operate onexpensive cost per case not block contracts.
Variability in access exists in practices, from very goodto not so good. It will be necessary to work withNational Commissioning Board local London Team whohold the primary care contract. Patients who can’t getsame day access may take themselves to A&E. Alsoconsider marketing strategy for patients, some of whommay hold the perception that their practice does notoffer same day appointments when in fact they do.
More proactive work needed between JET team andpalliative care to provide frail elderly with mostappropriate care at end of life stage.
It is often the case in general practice that swift accessto a consultant/senior registrar opinion could reducereferrals from primary to secondary care and decreaseattendances at A&E. We would wish to commission asecondary care service that is responsive to primarycare needs and identify a way that takes this forward.
Joint Emergency Team (JET)a multidisciplinary team of health andsocial care staff providing swift holisticassessment and management of clientsthat require urgent intervention within 24hours of the referral, responding to allurgent referrals within 2-4 hours.Interventions include re-ablement at homeor access to intermediate carerehabilitation with a range of high clinicaland low social and low social and highclinical services. In its first year JET hasprevented a total of 521 A&E attendances448 unnecessary hospital admissions.
Discuss with LondonAmbulance Service thepotential to redirectpatients to the UrgentCare Centre instead ofA&E
This is being done elsewhere in London. LAS work in re-directing ambulances and giving specialist adviceas opposed to taking patients to A&E could be veryeffective in keeping work within primary care both inhours and out of hours. We are not working on this inGreenwich and it would be good to consider whetherwe can initiate some work on this.
Increase
capacity in
high quality
cost effective
alternatives
to hospital
based
planned care
Referral Management & Booking Service(RMBS) - aims to reduce and improve thequality of referrals by implementing clinicalreferral pathways and triaging againstthem, ensuring appropriate pre-diagnosticwork is completed prior to referral,redirecting activity to appropriatecommunity services and challenginginappropriate referrals. The service hasbeen introduced on a phased basis, andcurrently 34 out of 45 practices are live onthe RMBS,
Integrated Cardiology Service – a pilot hasbeen commissioned, in conjunction withBexley and Bromley CCGs, for an integratedcardiology service across the 3 boroughs, inpartnership local providers. The aim is to
Support for GeneralPractice
Good quality General Practice is a key enabler of themove of services out of hospital. Consideration needsto be given to what support and resources are neededto enable general practice to play their full part incommissioning and delivery of planned and unplannedcare, in addition to their day-to-day general practicework.
Greenwich CCG is already working with generalpractices - through visits, data analysis, syndicate peerreview and Commissioning Incentive scheme to reviewpatients on the register and improve care for patients athighest risk of hospital admission.
Further work in support for general practice in2013/14 could include:
implement the service from April 2012.Two key elements of the service relate toinnovation in patient self-management andin the use of Information technology tocreate an integrated clinical record andshared access to clinical information.
Community Hospital Provision –development of a model and a fullbusiness case for community hospitalprovision in Eltham. The Eltham communityhospital will be a key ‘enabler’ to help usdeliver our priorities and provide additionalcapacity for community based services.. Weare working collaboratively with Bexley andBromley to ensure a consistent approach tothe shift in care from SLHT to thecommunity.
Diagnostics – review being undertaken ofdirect access diagnostics to identify andreduce any unnecessary testing.
Medicines Management – sharedformulary with SLHT for high costdrugs/high risk conditions includingcardiology, introduction of new anti-coagulation drugs, challenging payments byresults excluded drugs and management ofthe RAG list of drugs.
Other alternatives to hospital based caredelivered in the community, identified as
GP engagement andmarketing strategy
Utilisation Review
Scoping out what aspects of Greenwich’s futurecommissioning intentions general practiceneeds to deliver.
Build capacity and capability in practices
Invest in on-going training
Provide good back-up support
Identify unused capacity in primary caresettings – both in-hours and out of hours
Maximise the expertise and experience ofgeneral practice clinicians – there is evidence isthat they make good clinical decisions thatresult in reduced investigations and reducedacute utilisation
At same time reduce variability and poorpractice in prescribing, referring and clinicalpractice
Improve access and responsiveness of generalpractice
A model needs to be developed that can help GPs tounderstand the important role that general practiceplays in commissioning, and in the whole health systemof Greenwich. This can be described as a “hub andspoke” model with general practice as the hub andmulti professional community-based teams providingsupport for primary care, with access to diagnostics anda secondary care opinion as the core acute offer.
A second Key Challenge for Greenwich is to utilise
part of QIPP include: Heart failure service delivered by
Community Matrons
Anticoagulation services provided inprimary care settings
Minor Oral surgery
Dermatology outpatient activity
General surgery outpatient activity
Ophthalmology outpatient activity
Gynaecology outpatient activity
Outpatient Care Audit
Review data fromReferral Management &Booking Service toidentify opportunities toprovide more services in
existing resources more effectively by identifying areasfor improvement within existing contracts that do notrequire significant investment.
The QIPP challenges that have already been identifiedin the alternatives to hospital based planned care havethe potential to make savings that are relatively small(approximately 2%) in relation to the money that isspent in the main contracts of care with Greenwich’sproviders.
The intention for 13/14 will be to not only continue asappropriate the existing QIPP objectives that areproving to be effective but also to establish a morestringent monitoring process to systematically reviewcurrent contracts through a business case that modelsthe impact, opportunity costs and cost benefits ofcurrent contracts based on a set of core principles.
Also in line with the systematic approach to looking atexisting services, a speciality by specialty ‘audit’ couldbe undertaken of the potential to transfer OutpatientCare to community care based settings.
There should be full coverage of practices by the end ofNovember. The RMBS is a rich source of data about theappropriateness of referrals and any service areas thatcould be redesigned and provided differently.
the community
Aim to reduceunnecessary follow upsin secondary care, andpotentially also incommunity and primarycare.
The data will be analysed to identify opportunities forimprovement including helping GPs to follow pathwaysbetter, and introducing more robust and objectivechallenge procedures.
We will identify what % of referrals are discharged after1 appointment and identify a way to reduce these typeof referrals either through challenge by RMBS or re-design of the pathways .
Consideration also needs to be given to referrals thatcome into secondary care from other providers e.g.community, AQPs and whether these can also bemanaged.
Every year within secondary care there are 37 millionfollow-up appointments. A significant proportion ofthese have been shown to be clinically unnecessary,create inconvenience and anxiety for patients, andwaste resources. 75% of all DNAs are for follow-upappointments.
Common practice has been to invite patients for afollow-up ‘just in case’. If that practice is changed to ‘nofollow-ups unless there is a specific reason i.e. clinical orpatient request’ this would reduce the number ofunnecessary follow ups and DNAs.
As well as limiting follow-ups another aspect is toconsider where follow-ups can be delivered, which
Pathway Redesign inPrimary Care forOphthalmology andDental Services
healthcare professional such as nurses, can do thefollow-up and how it is delivered. Telephone calls orweb-based services could be used to replace thetraditional visit.
We will identify ways of reducing follow-ups eitherthrough contracts or through redesign of the pathway.
In addition to GPs, specially skilled primary carepractitioners, such as dentists and optometrists, arewell placed to deliver part of the patient pathway inprimary care instead of in secondary care.
For example ophthalmology is a high volume speciality.Optometrists with a Specials Interest could undertakeglaucoma follow ups in primary care, or work ups forcataract operations.
Dental procedures currently carried out in secondarycare could be moved back to GDPs in primary care.These could include minor oral surgery, orthodonticsand periodontics.
A procurement exercise could be carried out for dentalprocedures carried out under general anaesthetic.
Children and
Young
People’s
Services: A
whole system
approach,
focusing on
prevention
and
developing
integrated
care pathways
and services
Integrated Care Service for children withcomplex needs – Greenwich ClinicalCommissioning Group has recentlyundertaken procurement of an integratedmodel of specialist community healthservices for disabled Children and YoungPeople
The service comprises:
Children’s Community Nursing;
Continuing Care and End of Lifepathway;
Dietetics; and
Attention Deficit HyperactivityDisorder Service [ADHD].
This service assesses and manages theneeds of children with:
Acute and short-term to long termconditions;
Disabilities and complexconditions, including thoserequiring continuing care andneonates;
Life-limiting and life-threateningillness, including those requiringpalliative and end-of-life care; and
C&YP with complex dietary needsand who have been identified asrequiring an assessment for ADHD,or diagnosed with ADHD
Oxleas Foundation Trust has been awarded
Delivery of Integrated
Care Service for children
with complex needs
Provide a more
community based,
flexible and integrated
This service is in the very early stages of delivery and wehave built in robust KPI’s and performancemanagement/monitoring requirements. In addition wehave stipulated that there will be evaluated in March2013. The ISCS will also work collaboratively withstakeholders to develop shared care pathways and jointworking in areas such as child and adolescent mentalhealth, sickle cell [pain management] and diabeticservice.
Expected Benefits
Reduce the number of children admittedinappropriately to hospital.
Reduce the length of in-patient stay whenadmission is unavoidable.
Promote services users satisfaction with healthservices as a whole.
Improve clinical pathways by developing jointworking between primary and secondary careproviders and clinicians.
Reduce health inequalities by improving accessto the service.
Improve child/young person and familyexperience and participation in community life.
As a consequence of a number of concerns, togetherwith the Local Authority we undertook a strategicreview of Greenwich CAMHS in 2012 to review the
the contract and the service transferredfrom SLHT to Oxleas on 1
stSeptember 2012
Prevention – focus on obesity and fitness
levels, sexual health, psychological well-
being, the health of children from BME
communities and improving health
outcomes for mother and babies.
Redesign of Child and Adolescent Health
Mental Health Services. A number of
concerns have been highlighted with
CAMNS including gaps in the service and a
current model of delivery thought to be too
clinical and restrictive As a result, together
with the Local Authority, Greenwich
undertook a strategic review of Greenwich
CAMHS which was completed in spring
2012. The aim was to review the quality of
services and their ability to deliver
appropriate outcomes for Children & Young
People.
Children and Adolescent
Mental Health Service
(CAMHS) model (see
also Commissioning
Intentions for Mental
Health)
Review Acute PaediatricService
Review Maternity
Services
quality of services and their ability to deliver outcomesfor Children & Young People. Strategically we want toinclude CAHMS in our drive to improve integration,particularly for vulnerable groups. As a result of thereview, for 2013/14 we intend to:
Develop a Referral Management System formental health that includes CAMHS that willresult in improvement of referral pathways,information sharing, advice and consultation,screening and triaging.
Develop a seven day a week CAMHS servicewhich illustrates the shift away from a relianceon an acute bed base for children in crisis and amove towards more robust community basedservices supporting children at home for as longas possible or until the crisis is over.
Review current acute paediatric models of provisionand commission a service that meets the full range ofacuity of needs that arise from a service model agreedwith the provider. Review to include contractingmethodology.
Maternity services are a high area of spend forGreenwich. There are a high number of births whichreflects the relatively young population, with a lot oflate bookers and a relatively high number of follow ups.
Review Unplanned Care
for Children
A new Payment by Results pathway funding system formaternity services is to be introduced in April 2013.Under the new system, the commissioner will pay aprovider for all the pregnancy-related care a womanmay need for the duration of her pregnancy, birth andpostnatal care, and that in general there will be nofurther payments for individual elements of activity,although there are a small number of clearly identifiedexceptions. This presents an opportunity to review thecurrent provision of maternity services.
Parents often utilise multiple access points for children
with mainly minor ailments which results in the children
being seen 3 to 4 times for a single cold for parents
seeking antibiotics via GP, walk in centre, A+E and
Grabadoc GP Out of Hours.
Enhance end
of life care
A Greenwich Care Partnership operatesalongside and supports existing coreservices (GP’s, district nurses, specialistnurses etc.) to provide high quality care forpatients with end of life needs inGreenwich. Three organisations –Greenwich and Bexley Community Hospice,Marie Curie Cancer Care and OxleasCommunity Health Services are working inpartnership to provide this integratedmodel of care which aims to reduce
Subject to evaluation of
the pilot the intention is
to roll out the pilot
through procurement
Implementing best
practice pathways
Enhance the quality of End of Life care through:
Better co-ordination between service providers,
implementing an integrated model
Enabling people to die in the place of their
choice
Continuing to implement best practice including the
inappropriate hospital admissions andenable more patients to be cared for and todie in their place of choice by ensuring thatappropriate health and personal careservices are available and that their familiesand/or careers have sufficient practical andemotional support. The service consists offour integrated elements:
A palliative care co-ordinationcentre
A rapid response unit
Multi visit personal care andsupport service
Planned night care service.
The pilot is still subject to evaluation, butcurrently 52% of patients referred to theservice were able to die in the place of theirchoice, and a greater % of people are dyingat home or in a hospice.
Liverpool Care Pathway and Gold Standard framework
Appendix 6: Managing Risk
Strategic Corporate Risk Register
The CCG recognises the importance of robust risk management and to this end a 2012/13 risk
register has been populated with key strategic risks. The CCG monitors risks through relevant
committees and in the Greenwich Clinical Commissioning Group. For example, financial risks are
scrutinised in detail at the Finance, Performance & QIPP Committee. The overall distribution of risks
is monitored as well, with the aim being to shift risk ratings downwards over the course of the year
through close monitoring of action plans. The figure below indicates the risk distribution as at 13th
September 2012, and shows the number of risks at each level and the target distribution of risk:
0
2
4
6
83
4
6
810
12
15
target
current
As at 13th September 2012, the risk register holds a total of 21 open risks as follows:
New Entries There has been one new risk entry.
ID Description Controls C L Rating
(Current)
Rating
(Target)
Action Action
Due
Date
73 Risk: Acute contracts may
over perform 12/13
Cause: e.g. Unanticipated
demand; failure to
implement service
changes; changes in
coding;
Consequence: Usage of
financial reserves
earmarked for service
transformation
Contract management
board;
Contract monitoring;
Cap and collar
arrangements on SLHT
contract;
Provider and
commissioner QIPP
plans;
Funded for population
growth;
Potential pressure of
RTT backlog accounted
for within agreed
contract values.
4 3 12 8 TBC
High Risks >12
ID Description Controls
Rat
ing
Targ
et
Rat
ing
ActionAction Due
Date)
49 Risk: Clinical
commissioners may
not have the activity
information needed to
manage performance
of acute and non-acute
providers
Cause: Lack of timely
accurate acute
contract monitoring
data; Underdeveloped
data sets within non-
acute settings
Consequence:
Financial over
performance; risks of
over or under
commissioning as
compared to spend
Local monitoring of
acute activity and
finance at point of
delivery level;
Contract management;
Incentive scheme for
peer review;
Cap and collar
arrangements.
PBR data assurance
(Audit Commission)
Mental Heath PBR
Data meetings re:
community contracts
(Oxleas)
15 10 Establishment of
robust contract
monitoring
systems by cluster
information
department
Roll out of
practice level
acute activity and
finance derived
from SEL contract
monitoring
30/06/2012
(Sollis has
been
implemented
but is not yet
ready for use
as not all the
required data
has been
uploaded)
31/08/2012
47 Risk: Service change is
implemented but does
not realise expected
outcome - reduction in
acute activity and/or
patient take up of
community pathway
Cause: Failure to
appreciate level of
demand; failure
effectively to
communicate service
change to stakeholders
and patients; patient's
do not choose to adopt
new service
Consequence: QIPP
Robust modelling and
testing of schemes
prior to approval;QIPP
gateway
process;Monitoring by
Finance QIPP
Performance
Committee;Referral
management and
booking service that
identify opportunities
for new service
utilisation and engages
clinical commissioners
in utilisation
monitoring;Incentives
in place to encourage
good quality of referral
and management of
patients;Agreed
flexibility with Oxleas
to review QIPP
15 15 Implement plans
to communicate
with GPs where
programmes are
not delivering
Engagement with
Communications
Team to ensure
small number of
key messages are
focused on to
ensure delivery
Ensure included in
headlines for
stocktakes
30/9/12
30/9/12
30/9/12
ID Description Controls
Rat
ing
Targ
et
Rat
ing
ActionAction Due
Date)
savings not made due
underutilisation or
conversely, over
utilisation of acute
servicesShared Risk
Owner: Alison
Goodlad
investments;Working
to stretch targets to
ensure delivery.
67 Risk: Special Measures
imposed upon SLHT as
a result of
Unsustainable Provider
Regime may negatively
impact upon
performance and
quality of
servicesCause: Focus
on financial recovery,
service reorganisation,
loss of knowledge and
continuity from senior
management team as
the Board is stepped
down, lack of
confidence in service
by patients may lead
them to choose
alternative providers
exacerbating financial
problems and reducing
viability of the
service.Consequence:
Reduction in the
quality and safety of
services (5); Multiple
complaints; Failure to
meet contract KPI's
and performance
standards; (4)
Administrator
continues to have the
statutory duty of
quality Clinical Strategy
GroupQuality Sub
CommitteeSLHT
Contract Management
(SEL)SLHT Clinical
Quality Review Group
(monthly)BBG Quality
Network and joined up
working : meeting
monthly
15 10 Implement BBG
process to
triangulate soft
intelligence and
patient
experience data
Implementation
of metrics (being
led by Cluster);
metrics now
agreed but
awaiting
implementation.
06/08/2012
20/09/2012
Risk Review
There are no risks outside their review date.
Risks Reviewed since 21st August ’12.
ID Description Current
Rating
Review
45 Risk: Further significant organisational change will
destabilise an already emergent organisation
Cause: Loss of corporate memory with egress and/or
instability of permanent workforce. Strong need to
build established teams of permanent staff in order to
develop more sophisticated and streamlined
approaches for clinical commissioning.
Consequence: Capacity shortages and an inability to
deliver services or retain organisational memory
6 ↔ 13/9/12 ~ Risk reviewed: no
changes. Structure in the
process of being appointed to.
Slot in's now complete.
68 Zero Tolerance Risk!
Risk: Failure to seek assurance and ensure issues
addressed with regard to capacity issues within
Greenwich Community Health Services School Nursing
Team
Cause: Failure to address and seek assurance of interim
arrangements in provider meetings;
Consequence: Failure of provider to identify and
manage potential safeguarding issues; National media
coverage with >3 days service well below reasonable
public expectation. MP concerned (questions in the
House); Total loss of public confidence (5); Failure to
prevent / identify safeguarding incident (5)
6 ↔ 13/9/12 ~ Risk reviewed.
Awaiting confirmation that
final post appointed to before
closure.
72 Risk: Not achieving the agreed access initiative
performance levels relation to the bariatric 52 week
wait
Cause: Poor gateway design; application of treatment
policy; increased activity to maintain waiting list;
Consequence: Negative patient experience;
8 ↔ 13/9/12 ~ Risk reviewed. No
changes - review in one
month.
50 Risk: Failure to make sufficient preparations for the
Olympics in 2012
Cause: Competing priorities
8 ↔ 13/9/12 ~ Risk reviewed, Risk
time limited and no adverse
outcomes and now
ID Description Current
Rating
Review
Consequence: Lack of preparedness and damage to
reputation
recommended for closure.
61 Risk: Failure to have in place mechanisms/process to
gain assurance of quality from providers
Cause: Lack of organisational capacity, insufficient
capture of data on quality indicators
Consequence: Failure to identify provider quality issues
which will affect patient care
10 ↔ 13/9/12 ~ Risk reviewed and
action added. Score
unchanged.
65 Zero Tolerance Risk!
Risk: Insufficiently rigorous Adult safeguarding
arrangements;
Cause: No 'dedicated' nurse for adult safeguarding in
current structure;
Consequence; Lack of assurance across all
commissioned services; Incident leading to death;
10 ↓ 5/9/12 ~ Reviewed risk: GP
lead now recruited to help
lead on Safeguarding. SAF
being completed. Once
complete specific risks to take
the place of this risk on the
register.
44 Risk: Inability to build capacity identified in the OD plan
which is a requirement of authorisation
Cause: Conflicting priorities impacts upon capacity to
undertake development activity; failure to identify need
in PDPs; failure to have JDs in place
Consequence: Capability in staff is underachieved;
failure to achieve authorisation
12 ↔ 13/9/12 ~ Risk reviewed. One
action completed. Review in
one month
Closed Risks
One risk has been closed since risk register last reviewed by GCCC on 21st August ’12.
ID Description Controls C L Rating Rationale
48 Risk: Acute contracts may over
perform in 11/12
Cause: e.g. Unanticipated
demand; failure to implement
service changes; changes in
coding;
Consequence: Usage of
financial reserves earmarked
for service transformation
Contract
management
board;
Contract
monitoring;
Cap and collar
arrangements on
SLHT contract;
Provider and
commissioner QIPP
plans;
Funded for
population growth;
Potential pressure
of RTT backlog
accounted for
within agreed
contract values.
5 3 15 5/9/12 Risk realised. Growth
allowed for in 12/13 financial
plans.