Launch date & project Completion date · Launch date & Completion date Progress Impact on practice Contact 5 | P a g e Female Continence Development of co-located community “one

West Quarter Four Work Plan January - March 2014

An indication of the range of projects and plans being developed and rolled out in quarter four

Project Brief description of project

Launch date & Completion date

Progress Impact on practice Contact

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PLANNED CARE

Pain pathway Current pathway reviewed and identified as being interventionist and lacking sufficient ‘holistic’ self- management facilities in the community. Pain Forum is developing a new model of care. The forum has representation from WSFT (Management, Consultants & Physio), WS CCG service redesign & Medicines management, GPs, Public Health, Chronic pain support group, AHP & IHT Spinal unit. The process is subject to a CQUIN.

Launch: February 2013 Complete: October 2014 Contract needed: Yes Procurement needed: Yes

Three tier model of care agreed by forum Next stage is to refine and finalise the detailed specification for tendering. Gain clinical review from nurse specialist and medical review by pain specialist.

GP practices will have more community based options for treatment of patients with chronic pain

Jon Ferdinand [email protected] Jane Pallister [email protected] Claire Jay [email protected]

mailto:[email protected]




../../../Users/samantha.fowler/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/Local%20Settings/Temporary%20Internet%20Files/Martin.Bate/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/677G95GY/[email protected]

../../../Users/samantha.fowler/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/Local%20Settings/Temporary%20Internet%20Files/Martin.Bate/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/677G95GY/[email protected]






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Ophthalmology

Development of commissioned service following the successful two year pilot and development of further pathways.

Launch: Ongoing Complete: 28 February 2014 Contract needed: Yes Procurement needed: Yes

Tender has been withdrawn due to new national e-Referral system coming on line by 2015. This is a development from Choose and Book. A fixed term ‘Prime Contractor’ model contract is being finalised.

Feedback on problems and issues for resolution

Jon Ferdinand [email protected] Dr. Nick Rayner [email protected] Martin Bate [email protected]

Shoulder pathway New pathway to assist GPs with diagnosis and referral of patients presenting with shoulder pain.

Launch: Mid-October 2013 Complete: Ongoing Contract needed: No Procurement needed: No

Revised pathway was launched as QP003 for 2013/14. Use of pathway will be monitored using data collected from WSFT.

Understanding and adoption of pathway. Feedback on any issues and suggested improvements.

Dr. Jon Ferdinand [email protected] Dr. Andrew Yager [email protected] Martin Bate [email protected]

Micro haematuria Development of a single RBC threshold and referral pathway for micro haematuria

Launch: November 2013 Complete: January 2014 Contract needed: Yes Procurement: No

A single RBC level has been agreed and now work is on the guidance within the 2WW form for when you should refer being finalised.

Practices will have assurance from across TPP of a single level and referral guidance.

Dr. Jon Ferdinand [email protected] Dr Andrew Yager [email protected] Martin Bate [email protected]





mailto:Jon.Ferdinand@nhs.















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Clinical Management Service The referral letter is reviewed by a consultant before the C&B 18 week clock starts.

The consultant either allocates an appointment or returns it to the GP with a community management plan within the contractual 72 hours (3 working days) Development of clinical pathways and education sessions to support the roll out of each specialty.

Launch: Commencing February 2013 Complete: On-going roll-out Contract needed: Yes - Tariff of £33 agreed for each Community Health Plan issued by Consultants Procurement needed: No

WSCCG agreed on-going CMS implementation plan with WSH. Paediatrics, Respiratory and T&O launched in February on a 4 month pilot basis. Pilot was a success and roll out to more specialties. Rheumatology launched August 2013 and Dermatology will be coming out in January 2014. Further specialties being considered.

All Non-2WW referrals for WSHFT to go through the Clinical Management Service clinics on the C&B system. GPs will be asked to action community management plans when provided.

[email protected]

Dermatology

Developing a number of initiatives for dermatology in the community integrated with Secondary Care. Use of telederm business case being finalised

Launch: TBA Complete: TBA Contract needed: TBA Procurement needed: TBA

Parallel clinics at WSFT between plastics and dermatology in development. CMS rolled to support GPs and telederm pathway in final stages of business case.

Views and input into the initiatives welcome

[email protected] [email protected] [email protected] [email protected]













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Lipids pathway Development of guidance for GPs regarding referral to the lipids clinic/ guidance on lipids medication/ patients groups who would benefit

Launch: October 2013 Complete: Ongoing Contract needed: No Procurement needed: No

Draft guidance developed and launched as QP003 for 2013/14.

Understanding and adoption of guidance from October 2013 (QP003 pathway)

Dr. Ian Chapman [email protected] Dr. Jon Ferdinand [email protected] Martin Bate [email protected]

Community Physiotherapy Re-provision of community physiotherapy services across Suffolk.

Services currently operated by Allied Health Professionals (AHP), Ipswich Hospital (IHT) and West Suffolk Hospital (WSFT). AHP contract due for renewal in 2014. Services will be reviewed with a view to provision of an integrated community physiotherapy service with equitable access for all patients in Suffolk.

Launch: September 2014 Complete: December 2014 Contract needed: Yes Procurement needed: Yes Procurement of the new service is due to start in April 2014 with contract awarded in September 2014.

A county wide workshop to discuss the development of physiotherapy services for Suffolk was held on 20 November. Two “Task and Finish” groups (meeting in December, January and February) are taking forward co-production of the service model which is considering MSK, BaNS, Female Continence and links with the Pain pathway.

Feedback on current service, problems and opportunities. Welcome to attend task and finish groups. Information about accessing the new service will be communicated to GPs.

Dr. Jon Ferdinand [email protected] Dr. Rakesh Raja [email protected] Claire Jay [email protected] Martin Bate [email protected]
















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Female Continence

Development of co-located community “one stop” clinics for patients referred to the physiotherapy / continence services. Tender service as part of the community MSK re-provision.

Launch: TBA Complete: October 2014 Contract needed: Yes Procurement needed: Yes

Interim contract in place until October 2014 with AHPS and WSFT. Service will be tendered from April 2014 as part of the community MSK tender process. Task and Finish group on the service is being held in January 2014

Feedback on current service, problems and opportunities. Welcome to attend task and finish group.

Jon Ferdinand [email protected] Claire Jay [email protected] Hannah Neumann-May Martin Bate [email protected]












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CANCER

Acute Oncology Service

Acute Oncology – service in place in West Suffolk. Data being collected and will be reviewed monthly. Additional AOS training post in order to extend and build on existing service provision and make 7 days a week.

Launch: April 13 Complete: Ongoing Contract needed: Contract query in place around the achievement of 100% 1 hour door to needle time. Procurement needed: TBC

Service in place, but development ongoing. Recent discussions with the WSFT AOS team to support them with the education and training of staff outside of the Macmillan unit. Especially in the acute areas such as AMU and ED when patients arrive out of hours. Potential CQuIN to support education/training and extension of the existing service.

Promoting the service and its role; the aim being to prevent emergency cancer admissions.

Dawn Barrick-Cook [email protected] Andrew Yager [email protected]











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Community Cancer Nurse Pilot

Community Cancer Nurse Pilot in West Suffolk – 2 year fixed term. Pilot practices Hardwicke House, Siam and Long Melford in the Sudbury locality

Launch: Start date confirmed - 1/8/13. Complete: 24 months from start of pilot Contract needed: Yes (with Serco) Procurement needed: Not from CCG (Provided from MCS/AngCN) Evaluation underway being conducted by the UEA.

Band 7 Nurse specialist and Band 4 support worker in post for WSCCG pilot based in Sudbury area. Working closely with WSFT, SNHC and community teams to support patients at any stage of their cancer journey. Signposting to the cancer information centre at WSFT and now providing facilitation on the HOPE programme also – supporting the National Cancer Survivorship Initiative.

Primary care cancer nurse will work with the pilot practices and will implement a system to ensure aware of all new cancer diagnosis and patients completing an acute phase of treatment.

Dawn Barrick-Cook [email protected] Dr. Andrew Yager [email protected] Martin Bate [email protected]






../../../Users/samantha.fowler/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/Local%20Settings/Temporary%20Internet%20Files/Martin.Bate/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/0YXSFU5P/[email protected]

../../../Users/samantha.fowler/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/Local%20Settings/Temporary%20Internet%20Files/Martin.Bate/Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/0YXSFU5P/[email protected]






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Endoscopy service Review how endoscopy services, in particular, colonoscopy are being provided in accordance with NICE Guidance. Increase in colonoscopies and decrease in barium enemas as first line investigation.

During Q2 Meetings between WSFT CCG to look at capacity/demand implications for commissioners WSFT have submitted action plan for NICE compliance. WSFT to fund change in practice. WSFT will provide four lists a

week, mainly in the evening,

to accommodate the West

Suffolk population.

Four Clinicians will need to be accredited as screening flexible sigmoidoscopists in the next year - the logistics of which will be managed between Addenbrookes and WSFT. All pathology needs to go to Addenbrookes who will provide the screening practitioner also.

Business case initially presented in January outlining overall endoscopy capacity plan to include a second site for outreach. Further discussions around a POD to support the additional capacity.












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Risk stratification Redesign of the cancer follow-up pathway to include nurse specialist telephone follow-up post an agreed period of consultant led follow-up. Agreed to start with the prostate cancer pathway, moving to other tumour groups in time.

Launch: April 2013 (delayed start to December 2013) Complete: Ongoing Contract needed: Yes Procurement needed: Not from CCG

Work to develop a pathway for prostatic cancer follow ups. Close working with Dr Woodward and Dr McLoughlin to develop the agreed pathway. Maximum of 25 patients per month to be transferred. Additional clinic slots allocated but will take time to fill as patients approach their 24 month follow up and are ready to transfer over

Overall reduction in number of consultant led face-to-face follow-ups being performed.


Macmillan GP Facilitator

Macmillan GP Facilitator

Launch: Dr Andrew Yager appointed - started in post 1.7.13 Complete: 24 months from start date Contract needed: Yes (MCS) Procurement needed: Not from CCG

Funding agreed from Macmillan for replacement Macmillan GPF 1 day per week for West CCG - Dr Yager now in post.

Practice visits commenced from GPF from 1.7.13 onwards.

















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Direct Access to Diagnostics

Implementation of an unexplained weight loss pathway to support patients with an isolated and unexplained weight loss of 75% of usual body weight.

Launch: Q2 Complete: End Q4 Contract Needed: No Procurement needed: Yes (Anglia Cancer Network)

Network project - Suffolk wide to support direct access to diagnostics for an agreed client group. Discussions underway in order to establish data collection within both Primary Care and the WSFT. Templates to be developed and exact process agreed.

This pathway will improve access into the system if they do not fit a 2 week waiting fast track criteria.


EoL – END OF LIFE

ACP (Advanced Care Planning)

Yellow Folders - issue of yellow folders by GPs in Primary Care / WSFT Palliative Care Team and SNHC.

Launch Date: April 13 Complete: On-going Contract: No Procurement: Transformation Funds 12/13 (£36k)

YFs being issued to all patients identified as being within 12 months of ‘end of life’. Incentive payment of £50per YF issued coming to an end as funds running out due to vast numbers issued. Letter recently sent to GPs advising them of this.

Increase in patients being cared for in preferred place and dying in preferred place / usual place of residence.

Dawn Barrick-Cook [email protected] Simon Arthur [email protected] Hannah Neumann-May [email protected]



















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EPaCCS Electronic Palliative Care Co-ordinating System.

EPaCCS - Electronic Palliative Care Co-ordinating System. Identification of patients at EoL & placing on register. SystmOne is preferred platform.

Launch Date: Phased during Q3-4 Complete: End Q4 Contract: TBC Procurement: £55k

Recent re-scoping and review of technical specification. Exact cost to be assigned. Waiver signed off & authorised by the Audit Committee 4/9/13. Agreement that St Elizabeth Hospice will host the system, including evening/weekend cover. Electronic template currently being confirmed. Phased approach to implementation starting January 2014 up until 31st March 14 when all practices will have received training along with other key provider organisations.

As above plus reduction in inappropriate admissions as care plan and choices at EoL available to all HCPs.

Dawn Barrick-Cook [email protected] Simon Arthur [email protected] Hannah Neumann-May [email protected]














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EoL Education (Care Homes)

Provision of EoL care Education in care homes

Launch Date: On-going from last Autumn Complete: End Q4 2013/2014 Procurement: Transformation Funds12/13 & 14/15

7 care homes engaged initially in the project and have received EoLc education and training. Cascade and roll-out to remaining care homes during 2013/14 along with domiciliary care training during phase II of the project. Close working with the Suffolk EoL Education Groups and Norfolk & Suffolk Academy to ensure an integrated approach to EoLC.

Better care provided to patients at EoL Improved patient/carer experience More skilled workforce Patients able to remain in preferred place due to improved standard of EoL care

Dawn Barrick-Cook [email protected] Simon Arthur [email protected]

EoL CQUIN Agreed EoLc education model in place with a sustainability plan in place to ensure on-going staff competencies maintained.

Education and training of generalist staff at the WSFT using an agreed End of Life Care education model

Launch: April 13 (Q1 TNA) Complete: Q4 2013/2014 Procurement: £230k (CQUIN)

Training needs analysis conducted during Q1 will drive and set direction until Q4 end. Progress of this CQuIN is on target.

Improve EoL Care delivery Patient remains in preferred place/usual place of residence Improved patient/carer experience

















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Crisis at Home Service

Extension and further development of the existing 24/hr support service provided by SNHC

Launch: During Q2 Complete: During Q4 2013/2014 Contract: TBC Procurement: TBC

Links made with other key stakeholders. Failure to appoint to this position now on two occasions therefore further discussion has taken place in order to agree how the funds are best spent. For further discussion at the next Integrated Care work-stream meeting. Proposal being drafted.

Seamless pathway Easy access to EoLc organisations More hands on support More OOH information, support & advice Integrated working with all providers of EoL care












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INTEGRATED CARE Family Carer Support

in Primary Care

Supporting Primary Care to identify and support family carers – including information and advice, one to one and group sessions for family carers, support at clinics, e.g. flu clinics. Complementing and linking with acute trust family carer advisor providing a continuum of support.

Project commenced in July 2013, current funding until June 2014.

The project is providing support at the majority of Practices, in line with the practice requirements / requests. Direct support commenced in September 2013 – to date 260 family carers have been identified and supported.

Support provided as requested. Feedback from practices to be gathered in Jan 2014 to inform future development.

Trisha.Stevens@westsu

ffolkccg.nhs.uk








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Integrated Fracture Liaison Service (IFLS) Service evaluation written July 2013

An IFLS for West Suffolk aims to integrate a multi-disciplinary service that undertakes responsibility secondary prevention of osteoporotic fractures. The service will ensure that every fracture patient over 50 years (excluding high trauma and road traffic accident victims) receives an osteoporosis assessment.

Launch: Phased approach from 1 November 2012 Complete: Oct 13 Now mainstream service

Currently a database of all possible osteoporotic fractures is established. Details of the role of the dedicated nurse specialists is finalised as is the protocols for the virtual bone health clinic for complex patients.

Patients who previously have not received a DXA will been seen, assessed and commenced on medication by the nurses with a treatment plan being sent to the GP, patient and secondary care. Every patient including those under the care of GP will be followed up at one month after commencement of medication for support to ensure concordance with that medication. An advice line for GPs and patients will be established. Complex patients can be referred to the nurses /virtual bone clinic for support .

Sandie Robinson [email protected] Dr Emma Derbyshire [email protected] Caroline Ratcliff [email protected]












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DVT/Ambulatory Care

Review and improve DVT pathway

Launch: LES extended and review of pathway on-going Q2 & 3 Complete: Review complete end of Q3 2013/2014

WSFT implementing changes to pathway through provision of additional ultrasound machine, recruitment of sonographers and training of one or two nurses in early 2014. Reception staff to record declined referrals and report to sonographers from Q3. Ambulatory care ward now in place to accommodate direct referrals; preventing presentation and long waits in A&E.

Request GPs keep an information log to be sent monthly to the CCG on patients declined by WSFT for ultrasound scans.

Dawn Barrick-Cook [email protected] Emma Derbyshire [email protected]











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Urgent care Develop revised whole system urgent care model that reflects the principles of the national urgent care and emergency review 2013/14 . This will include the review of contracts ending in 2015: SERCO Harmoni 111 Harmoni OOHs

A whole system Urgent Care Network launched April 13 and will take forward this development supporting admission prevention, flow within the hospital setting and pull based discharge. CGA will form part of this process where appropriate.

The Urgent Care Network will want to engage with practices on the shape of the new west Suffolk model Awareness of winter projects supporting the UCN shared with primary care to support the 3 stages of the pathway as previously mentioned.

Integrated model that is accessed through a single point of access – co-ordinated approach to care delivery, reducing hospital emergency admissions and ultimately overall length of stay.

Emma Derbyshire [email protected] Sandie Robinson [email protected]

Implementation of Integrated Care –QIPP LES – Part 1 Evaluated March 2013

Risk Stratification – integration of data to identify a cohort of registered population at risk of admission over next 12 months. Includes urgent care clinical dashboard

Launch: May2013 A longer term solution is required in line with National DES / Health & Social Care Act 2012

Plan to progress implementation of tool in a phased manner DES now out with practices. Risk tool has been re-commissioned as part of data management centre. Potential testing and launch spring 2014.

PC data required to inform risk stratification Change in practice – targeted approach to managing medium to high risk patients Contract for primary care date extraction out with practices. Need to satisfy terms of DES.

[email protected] [email protected] [email protected] [email protected] [email protected]




















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Neighbourhood teams – locality model of care with health and social practitioners. Include case management and step up beds

Launch: April 13 – March 2014 Complete: ongoing

Neighbourhood Team learning lunches arranged – topics include dementia, family carers and falls awareness. Care leadership programme for practitioners within the community and social care/ mental health is underway. The revised management and provision of step up beds is linked to the Urgent care strategy and IG (see below). Successful programme of learning lunches continued to the end of March 14. Further topics to be determined for 14/15. Care leadership programme completing March 14. Further work on joint workforce development commenced with county council and voluntary sector.

A better connected & informed care structure for patients and their family carer.

Emma Derbyshire [email protected] Sharon Stott [email protected] Caroline Ratcliff [email protected]












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Comprehensive geriatric assessment (CGA)

Comprehensive geriatric assessment (CGA) – wrap round service that compliments the IG role working out in community with advanced nursing (NSFT/SCH) practitioners, therapy, carer support & ACS

.Development of CGA is underway across the system. Family Carer support posts are commissioned to work both within the hospital and primary care.

The CGA service has commenced its role out across Sudbury(2.12.13) initially and will be across west Suffolk by autumn 2014 Family Carer support posts in Primary Care progressing well with advice /support being provided and clinics taking place. Family Carer Support hospital post insitu.

Older People will be supported by a multi- agency team and service delivery including same day diagnostics and specialist consultant advice.

Emma Derbyshire [email protected] Sharon Stott [email protected]


Empowering patients and self-care shared decision making, motivational interviewing across the health system

Contract needed: System CQUIN 2013-14/15

CQUIN agreed Course identified Bid progressed Course underway. Evaluation by participants positive. Links with cross organisation development.

A common approach to enabling the patient to manage self and promote & maintain their health & well being

[email protected] [email protected]

Dementia Refresh the existing dementia strategy. Roll out enhanced system wide workforce education & training programme working.

Complete business case proposing future service model for support for people with dementia and their carers post diagnosis.

Launch: April 13 Outline business case supported by health and care system in Nov 13 for full work up in Spring 14 for post diagnostic dementia services. Workforce development, education and training to feature in cross organisation development

Work with practice dementia co-ordinators (QP6b) to develop networks of communication and support.

Dr Roz Tandy [email protected] [email protected] [email protected]




















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Evaluate & integrate the revised dementia intensive support service (DISS)

Integrated DISS into a community urgent response and the comprehensive geriatric assessment (CGA)

Launch: April 13 DISS review took place March/April13. DISS to be integrated into a community urgent response & the comprehensive geriatric assessment (CGA). DISS to be community interface with psychiatric liaison service in West Suffolk Hospital for people with dementia. DISS is coworking with the Community Intervention Service both in community and acute. Psychiatric liaison commenced in December 2013.

[email protected]

ENT Micro-suction Provide community Micro suction

Launch: Complete: Contract needed: Procurement needed:

Not being taken forward at this stage

Claire Jay [email protected] Jon Ferdinand [email protected]










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Commissioning of a Community Endoscopy Service (Thetford)

To provide access for practices in the Forest Heath Locality who may prefer to refer to a local service.

Launch: 1 Feb 2013 Complete: 1 April 2013 Contract needed: Yes Procurement needed: Yes

Service variation and activity levels to be determined. Pathways to be agreed and onward patient transfers

Prime Diagnostics Ltd provides a service already at Thetford. Contractual discussions have commenced to allow access to this service

Jon Ferdinand [email protected] Claire Jay [email protected]

Ongoing Business

Diabetes The CCG are embarking on a programme to review and refresh the strategy for diabetes through the delivery of an integrated diabetes service for West Suffolk. This will build on the outcome of the community diabetes pilot in 2013 and current established diabetes services in primary care.

Launch: April 2014 Complete: Ongoing to deliver 5-year strategy Contract needed: Yes Procurement needed: No

Diabetes clinical forum to be established to lead and drive the development of the integrated service. Scoping of the 5-year strategy and development plan in progress. Pilot in operation in four Forest Heath practices being reviewed in Feb 2014 alongside review of the existing enhanced diabetes contracts to inform development of the new model.

Practices will be engaged to feed into the development of the model and will be offered the opportunity to deliver enhanced diabetes services. The project will include GPs as core members of the clinical forum.

Dr. Jon Ferdinand [email protected] Dr. Emma Reed [email protected] Martin Bate [email protected]











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Cardiology 24 hour ECG machines in some practices and continuation of commission reading of results for Practices.

Launch: April 2013 Complete: TBA Contract needed: Yes Procurement needed: Yes

1) Outcomes of pilot reported back to CCE for decision whether to proceed in April 2014

Practices to use 24 hour ECG machines purchase by WSCCG and send results to provider for reading.

Lois Wreathall [email protected] Sonny Aung Jon Ferdinand [email protected]

OA Hip Established or Advanced OA Hip patients should be referred onto pathway to be assessed by a senior physiotherapist/ signposted through shared decision making to appropriate treatment option

Structured physio-led assessment service for patients with established or advanced osteoarthritis of the hip

Launch: Nov 2012 Complete: Ongoing Contract needed: Yes Procurement needed: Yes

Pathway has attracted very positive feedback from patients. Consistency of referrals is an issue which is being addressed. Outcomes for patients in Stage One (conservative treatment) and Stage Two (preparation for surgery) being evaluated. Forms part of the community risk tender.

. The majority of patients follow Stage One of the pathway (conservative treatment). Patients requiring surgical intervention can be referred directly to a T&O consultant by the physiotherapist and will follow Stage Two of the pathway delivering education and information to prepare them for a good surgical outcome.
















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OA Knee

Structured physio-led assessment service for patients with established or advanced osteoarthritis of the knee

Launch: Nov 2012 Complete: Ongoing Contract needed: Yes Procurement needed: Yes

Pathway has attracted very positive feedback from patients. Consistency of referrals is an issue which is being addressed. Outcomes for patients in Stage One (conservative treatment) and Stage Two (preparation for surgery) being evaluated. Forms part of the community risk tender.

Established or Advanced OA Knee patients should be referred onto pathway to be assessed by a senior physiotherapist and signposted through shared decision making to an appropriate option for treatment. The majority of patients follow Stage One of the pathway (conservative treatment). Patients requiring surgical intervention can be referred directly to a T&O consultant by the physiotherapist and will follow Stage Two of the pathway delivering education and information to prepare them for a good surgical outcome.












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Carpal Tunnel Syndrome pathway

Revised pathway for patients with Carpal Tunnel Syndrome. Community Surgical Service at BMI Healthcare, Bury St Edmunds

Launch: Nov 2012 Complete: April 2013 Contract needed: Yes Procurement needed: Yes

Threshold policy in place. Pathway agreed with WSH consultants. Change to contract for consultant opinion on patient condition and possible steroid injection

Continue to order and use the ‘free’ splints. Advise on any procurement problems with the splints. Refer appropriate patients to the community service

[email protected] Claire Jay [email protected] Martin Bate [email protected]

Admission prevention service (APS) (QP11 C) Forecast QIPP saving £877,813 (collective admission prevention agenda)

All practices continue to be offered an opportunity to review the pathway with this service to improve utilisation and reduce unnecessary admission into hospital

Launch: April 2012 Complete: 31 March 2013 Contract needed: Procurement needed: Launch: Social, general health and mental health admission prevention pathway re-launched as QP Nov 2013. Complete: 31/03/2014 Contract needed: Procurement needed: N/A

Variable uptake Practices, review of APS now in place Piloting social care triage in care coordination centre 09:00-17:00 providing joint health and social response. Single point of access for mental health services including psychiatric liaison developed. Specialist dementia team providing hospital and community based care. Out of hours social care provision service established.

Practices will be required to meet with the service clinical lead and agree the case mix of referral activity. Practice will be required to audit the impact of their referral activity Practices should be able to access joint health and social care response in hours for admission prevention. Awaiting guidance from area team on monitoring of QP pathways.

Emma Derbyshire [email protected] Sandie Robinson [email protected] Sharon Stott [email protected] Jacqui Summers [email protected]


















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On-going Projects Medicines Management

Transfer of medication discharge information

Working with WSFT and LPC to support patients with medication adherence problems post discharge

Launch: May/June 2013 Complete: On-going Contract needed: N/A Procurement needed: N/A

Q3 progress: Small pilot completed. Evaluation from LPC pending.

If pilot successful and service rolled out fully, reduction in patients with new medicines returning to pre-admission medication regime. Increased medication compliance and reduction in medicine waste.

Linda Lord [email protected]

Joint acute-primary care formularies/prescribing recommendation

Shared formulary/prescribing recommendations between primary and secondary care, aligning treatment choices as much as possible, for a consistent and cost effective system-wide approach

Launch: April 2012 Complete: On-going Contract needed: n/a Procurement needed: n/a

Q3 progress: Some agreements made with WSH.

Cost effective prescribing. Consistency











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PIP High priority national and regional prescribing metrics. A particular emphasis is placed on prescribing within allocated budgets or significantly reducing over spend. A weighted budgetary metric supports this.

Launch: April 2012 Complete: 30/03/2014 Contract needed: n/a Procurement needed: n/a

Q3 progress: Practices continue to implement PIP 2013/14 metrics. Calculated savings achieved and remaining shown on WSCCG website.

Incentive payments received if metrics achieved. Prescribing within budget (or reducing overspend). Practices to implement recommended changes


High cost drugs Review of drugs currently included in high cost drugs list (>£5000 per patient per annum at the normal dose). Also, ensuring that any hospital only drugs being inappropriately prescribed in primary care are repatriated to secondary care (or switched to an alternative that is suitable for GP prescribing).


Q3 progress: Review of HCD list and on-going work to promote appropriate prescribing of hospital only drugs.

Cost effective, appropriate and safe prescribing











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Pharmaceutically frail patients highlighted by secondary care

Patients identified by secondary care as unable/unwilling to take complex medication regimes highlighted for review by sessional clinical pharmacist.

Launch: Potentially June 2013 Complete: On-going Contract needed: N/A Procurement needed: N/A

Q3 progress: Medication reviews carried out.

Work with clinical pharmacists. Cost effective and appropriate prescribing









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Prescribing QIPP plan 2013/14. Expected savings from total programme £600,000

Prescribing recommendations

Implementation of cost effective, evidence based prescribing initiatives. Prescribing recommendations that have been calculated to release the greatest savings should be addressed first. These are highlighted for each practice on the WSCCG website. A range of further prescribing recommendations is also provided.


Q3 progress: Calculated savings shown per practice on WSCCG website.

Cost effective and safe prescribing









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DROP-List (DRugs of lOw Priority)

Review of prescribing of drugs that are considered to be of low priority, poor value for money, or for which there are safer alternatives available



Cost effective and appropriate prescribing.

Linda Lord [email protected] Dr Daniel Knowles [email protected]

Medication reviews/ medicines optimisation

Medication reviews for patients with multiple morbidities on complex regimes to identify drugs that are no longer needed


Q3 progress: Reports available from the WSCCG medicines management team.

Cost effective and appropriate prescribing

Linda Lord [email protected] Dr Daniel Knowles [email protected]














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Dietetics Review of patients prescribed oral nutritional supplements, gluten free foods and infant formulae to ensure prescribing is cost effective and appropriate



Cost effective and appropriate prescribing

Linda Lord [email protected] Sue Wiles [email protected] Dr Daniel Knowles [email protected]

Care Home Project Medicines Optimisation to Improve clinical outcomes. Reduce prescribing costs Reduce waste Support reduction in unplanned admissions Reduce falls

1. Mildenhall and Sudbury holistic care pilots commenced: clinical pharmacists carrying out Level 3 medication reviews on care home patients, working with SCC, care homes and supplying pharmacies regarding medication ordering/administration and liaising with dieticians, continence service etc. Resulting medicines optimisation will improve clinical outcomes, reduce prescribing costs and

Launch: On going Complete: Holistic pilot needs evaluation Medication review continuing in other care homes Contract needed: n/a Procurement needed: n/a Launch: Postponed-care homes contacted re content did not think it was useful Complete:

Q3 progress: Medication reviews carried out. Other care home work currently on hold.

Work with clinical pharmacists. Cost effective and appropriate prescribing

[email protected] [email protected]
















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waste and support reduction in unplanned admissions and falls 2. Production of an aide memoire card to support care homes in reducing A&E attendance/ambulance call-out 3. Production of information packs for care homes and distribution to homes, practices and pharmacies. 4. ICE (Integrated Care homes Early Intervention task and finish group) set up with WSFT and main stakeholder groups to develop a joint approach with secondary care to improve the pathway and information flow to: a) reduce A&E

Contract needed: n/a Procurement needed: n/a Launch: Postponed until wider NHS reconfiguration embedded Complete: Contract needed: n/a Procurement needed: n/a Launch: May 2013 Complete: Contract needed: Procurement needed:






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attendances, b) facilitate early discharge 0-3 days c) develop and implement a “patient information passport” WSFT currently combining 4 discharge work streams this will be part of and inform






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Dementia Antipsychotic prescribing

Reducing anti-psychotic prescribing for people with dementia Set of guidelines developed across the NHS Suffolk healthcare system, in line with the NICE Clinical Guidelines on dementia (2006)

Launch: May 2013 Complete: Contract needed: n/a Procurement needed: n/a

Reviews on patients diagnosed with dementia taking antipsychotics to be commenced May 2013. Q3 progress: Pathway and guidelines approved for use in WSCCG. Baseline data gathered from each practice. Medicines management team assisting with identification of patients with dementia who are on antipsychotics and would benefit from a review of their treatment.

Further audits to be carried out to track progress. National requirement that all people with dementia who are receiving antipsychotic drugs must undergo a clinical review to ensure care is compliant with current best practice and guidelines. Increased practice workload due to proactive reduction in antipsychotic prescribing in patients with dementia. Initiation of prescribing to follow NHS Suffolk guidance with appropriate review Clinical support for practices available from sessional pharmacists









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Mental Health and Children Young People and Maternity

Memory service referrals

Review of memory service capacity to meet rising demographic.

Launch: July 2013 Complete: September 2013 Contract needed: Procurement needed:

Final Business case for increased service capacity to be reviewed January 2014 for implementation Q4..

Improve response and waiting times for dementia assessment and diagnosis

Karen Wood [email protected] Dr Roz Tandy [email protected]

Psychiatric Liaison Service at WSH

Psychiatric team for dedicated MH management for patients with functional and organic MH in A&E, EAU and inpatients. Service funded through joint CQUIN with NSFT and WSHNHS FT

Launch: October 2013 Complete: March 2015.

Service commenced November 2013, for all people aged 18 and above. 24/7 cover in A&E, 9 – 5 weekdays for inpatients, to increase hours to 9 – 7 inpatients in new year and planning for weekend cover.

Improved identification and care for patients with MH needs attending WSH.















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Autism Assessment and Diagnosis Pathway

Pilot Assessment and diagnosis service for children, young people and adults with suspected autism, Work with Suffolk County Council and patient reference group to agree multi-provider support for people with autism and their families.

Launch: Adult Service: operational with full roll out Oct 13. CYP aged 11-18 launch Dec 13. Complete: 2 year pilot

Adult service go live July 13, full service operational Oct 13. Adult service operational from July 2013. Youth service business case approved. NSFT currently recruiting with planned start date March 2014.

Pre-assessment counselling, assessment, diagnosis and multi-agency care plan across full age range for people with autism.


Modernised Learning Disability Service

Re model LD service provision for improved assessment and care.

Launch: April 13 Complete: Dec 13

Full multi-agency service specification developed, CCG now considering options: Task and Finish Group established including Health and Social care to commence implementation of new service spec. This will be through remodelling of NSFT LD service and the whole pathway of care for people with LD across Health and Social Care Services.

Modernised comprehensive LD service to be provided with focus on specialist assessment, short-term interventions and support for people with LD as well as targeted support for challenging behaviour















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Norfolk and Suffolk FT Service Redesign Strategy

Close monitoring of impact of NSFT service redesign. Finalising co-production with I&ESCCG and provider of service specifications for new service lines by October 2013 .

Launch: April 2013, Service specifications completed October 2013. Complete: Ongoing as service model rolls out

Contract monitoring and contractual levers through SLA process. Service specifications for NSFT community services finalised. Monthly Quality and Performance and Contract Meetings monitoring service delivery.

Comprehensive service delivery to eliminate gaps and bounce back to referrers. Simplified and streamlined access to mental health services. Direct contact and consultation between GP and clinicians still operational.


Eating Disorder Service for Children and Young People

Comprehensive service for the care and management of children, young people and adults with eating disorders.

Launch: July 2013 Complete: September 2013 for roll out by end 2013. Delayed.

Business case delayed due to financial modelling queries with NSFT. Final consideration of business case scheduled for January 2014.

Service provision for children young people and adults.

Karen Wood [email protected] Dr Rakesh Raja [email protected]













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CAHMS commissioning review Revised steering group for children and families emotional wellbeing. Focus on NSFT CAHMS provision but also across providers (e.g. schools, community health, voluntary sector) in recognition that the whole system has a role in supporting children’s mental wellbeing.

Comprehensive review of CAHMS commissioning model to inform development of new model for future commissioning.

Launch: May 13 Complete: Mar 2014

Mapping service gaps and opportunities to develop action plan for co-ordinated approach. Resilience Hub model developed for children and young people to fill service gap at tier 2. This includes increased PMHW capacity. Draft business case completed and approved by steering group 17 December, to be brought to CCG workstream in New Year . Engagement sub group working with Suffolk Children’s Health Ambassador and third sector to seek views of children and young people on services and establish mechanism for feedback and monitoring progress.

Accessible and responsive children’s mental health services which takes into account needs of child and family.

Karen Wood [email protected] Dr Roz Tandy [email protected] Dr Rakesh Raja [email protected]











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Urgent Care Paediatric GP Telephone Advice Line

Pilot service Consultant manned advice line for clinical discussion with GPs of cases which may need admission to WSH

Launch: April 2012 Complete: March 2014

Service has demonstrated reduction in unplanned admissions. Business case to mainstream service in 2014/15 to CCG Executive 3 July 2013. Public Health analysis of impact of service currently under way. CCG Commissioning Intentions to potentially mainstream advice line in 2014/15.

Clinical discussion with consultant on individual cases for GPs considering admission for children and young people

Karen Wood [email protected] Dr Rakesh Raja [email protected] Hannah Neumann-May [email protected]












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Develop paediatric pathways of care

To support GPs in the care of children through close links with general practice with suite of supportive and educational material.

Launch: June 2013 Complete: March 2014

GP Associate Dr Rachel Casey working with acute hospital consultants to roll out: NICE Guidelines – traffic light toolkit for serious illnesses Guidelines for common childhood conditions – proposed: Constipation, Eczema, Recurrent Abdominal Pain, Chronic Headache, Colic, Reflux Build links with paediatric leads in primary care Traffic light toolkit for common childhood illnesses rolled out to primary care. Asthma pathway and guidance rolled out to primary care. Further guidelines for common childhood illnesses to be released on bi-monthly rolling programme

Suite of information and tools to support decision making on referral to acute hospital. To be rolled out through practice paediatric leads from Autumn 2013.

Karen Wood [email protected] Dr Rakesh Raja [email protected] Dr Rachel Casey [email protected] Trisha Stevens [email protected] Hannah Neumann-May [email protected]















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Maternity Services Partnership approach with WSH to oversee new maternity tariff

Launch: April 2013 Complete: Mar 2014

National PbR tariff operational for maternity services. Monitoring impact of new maternity services shows no negative financial impact however highlights that consideration is needed for support for maternal mental health.

Monitoring financial impact across practices.

Karen Wood [email protected] Dr Rakesh Raja [email protected]

Management of Long Term Conditions

Community based support for children and young people with epilepsy and asthma

Launch: June 2013 Complete: January 2014

Business cases for community asthma and epilepsy nurses approved. Planning meeting for roll out of services scheduled for January 2014.

Consistent advice accessible in community for condition management - referrers & children/families

Karen Wood [email protected] Dr Rakesh Raja [email protected] Hannah Neumann-May [email protected]

Looked After Children CCGs & local authorities must comply with statutory guidance

Review shows currently not fully compliant.

Launch; August 2013 Complete:

Task and Finish group updating service specification for Looked After Children.

Compliance with safeguarding requirements

Barbara Mclean [email protected] Dr Rakesh Raja [email protected]

















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Completed Projects

Gastro enterology

Finalisation of the ALT and Dyspepsia Pathways. Information on Dietetic Services


ALT Pathway finalised and were circulated to practices. Impact is being monitored

Upload forms to GP systems

Claire Jay [email protected] Jon Ferdinand [email protected]

Headache pathway In conjunction with WSHT, developing a headache pathway.


Not being taken forward at this stage.

Jon Ferdinand [email protected] Claire Jay [email protected]

Community Gynaecology

Reviewing the possibility of offering a gynaecology service including ultrasounds, biopsy and coil fittings in the community


Not being taken forward at this stage. Plan is to further develop this next year 2014/15.

[email protected] Claire Jay [email protected]














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Antibiotic Formulary

Antibiotic treatment tables and A4 quick guide updated, published and distributed

Launch: October 2012 Complete: Circulated November 2012 and on website

Q3 progress: Work on next edition of antibiotic formulary underway.

Improve safety and quality of prescribing and contributes to reduction in Cdiff

Any additional information or copied please contact [email protected]

Community Intervention Service formerly known as: Admission Prevention Service / Emergency care practitioner

Urgent work is being progressed to integrate the ambulance ECP & CIS in preparation for winter

Launch: October Complete: March 2014

Daily SITREP calls from ECP to CIS. ECP utilising CIS office as flexible base. ECP/CIS Joint Activity training ongoing. Shared knowledge and understanding of complementary service provision.

Improved interface with admission prevention. Increased resource for rapid response

Emma Derbyshire [email protected] Sandie Robinson [email protected] Trisha Stevens [email protected] Simon Arthur [email protected]















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EAU consultant advice – GP urgent medical referrals

All GPs can discuss their medical referral with a consultant to identify if there is an alternative available to admission. Range of options will include medical advice, same day/next day OPA or rapid community response via APS


Operating from 0900 to 1900hrs. Further work is being considered to develop specific pathways outside admission

Over 85% of all medical calls to EAU will be taken by an EAU consultant Access to senior clinical advice to discuss management options and admission alternatives

Emma Derbyshire [email protected] Sandie Robinson [email protected]





Documents

Launch date & project Completion date · Launch date & Completion date Progress Impact on practice Contact 5 | P a g e Female Continence Development of co-located community “one