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Leeds West Operational Plan Update

Draft Submission to NHS England Leeds West CCG is required to develop Operational Plans that meet the minimum requirements as outlined in NHS Planning Guidance “The Forward View into action: planning for 2015/16”. CCGs are required to submit plans in the form of a series of spreadsheet templates that capture numerical trajectories plus a narrative that describes the CCG approach to delivery of key national and local priorities. The content of trajectories and narrative are outlined below

Trajectories (submitted through completion of nationally defined templates)

Priority Area Trajectories Covering

Outcomes

Potential Years Life Lost

Quality of Life for people with LTC (EQ5D Score

Patient Survey Score Hospital Care

Patient Survey Score (GP)

Clostridium difficile reduction.

Dementia diagnosis.

IAPT coverage and recovery.

IAPT waiting times.

Quality Premium measures.

NHS Constitution NHS Constitution rights and pledges. E.g.

Referral to treatment (RTT) waiting times,

Cancer treatment waiting times

Activity A&E attendances

Referrals

Outpatient attendances

Elective and Non-elective spells.

Better Care Fund Improvement against the agreed BCF measures.

Financial plan 2015/16

Expected recurrent and non-recurrent allocations.

Details on movement in spend and allocation from 14/15 forecast outturn, assumptions regarding provider efficiency, inflation, activity growth, contingency and recurrent headroom.

Financial impact of QIPP schemes.

Details and valuation of identified risks plus mitigation

Planned investment including use of headroom.

Forecast spend and activity on contracts for 14/15 and anticipated contract value for 15/16.

Underlying recurrent position

Planned increase in 15/16 mental health spend

Detail of assets, liabilities and taxpayers’ equity.

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Breakdown of receipts and payments.

Planned capital expenditure by scheme.

All CCG plans are required to meet the following key requirements.

Outcomes

Delivery across the five

domains and seven

outcome measures

Your understanding of your current position on outcomes as set out in the NHS Outcomes Framework

The actions you need to take to improve outcomes

Improving health Working with HWB partners, your planned outcomes from

taking the five steps recommended in the “commissioning for prevention” report

Reducing health

inequalities

Identification of the groups of people in your area that have a worse outcomes and experience of care, and your plans to close the gap

Implementation of the five most cost-effective high impact interventions recommended by the NAO report on health inequalities

Implementing EDS2

Examination of how the organisation compares against the first NHS Workforce Race Equality Standard

Parity of esteem

The resources you are allocating to mental health to achieve parity of esteem

Identification and support for young people with mental health problems

Plans to reduce the 20 year gap in life expectancy for people with severe mental illness

The planned level of real terms increase in spending on mental health services

Access

Convenient access for

everyone

How you will deliver good access to the full range of services, including general practice and community services, especially mental health services in a way which is timely, convenient and specifically tailored to minority groups

Plans to improve early diagnosis for cancer and to track one-year cancer survival rates

Meeting the NHS

Constitution standards

That your plans include commissioning sufficient services to deliver the NHS Constitution rights and pledges for patients on access to treatment as set out in Annex B and how they will be maintained during busy periods

How you will prepare for and implement the new mental health access standards

Quality

Response to Francis,

Berwick and

Winterbourne View

How your plans will reflect the – including how your plans will make demonstrable progress in reducing the number of inpatients for people with a learning disability and improve the availability of community services for people with a learning disability

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Patient safety

How you will address the need to understand and measure the harm that can occur in healthcare services, to support the development of capacity and capability in patient safety improvement

How you will increase the reporting of harm to patients, particularly in primary care and focused on learning and improvement

Your plans for tackling sepsis and acute kidney injury

How you will improve antibiotic prescribing in primary and secondary care

Patient experience

How you will set measureable ambitions to reduce poor experience of inpatient care and poor experience in general practice

How you will assess the quality of care experienced by vulnerable groups of patients and how and where experiences will be improved for those patients

How you will demonstrate improvements from FFT complaints and other feedback

How you will ensure that all the NHS Constitution patient rights and commitments given to patients are met

How you will ensure you meet the recommendations of the Caldicott Review that are relevant to the patient experience

Compassion in practice

How your plans will ensure that local provider plans are delivering against the six action areas of the Compassion in Practice implementation plans

How the 6Cs are being rolled out across all staff

Staff satisfaction

An in-depth understanding of the factors affecting staff satisfaction in the local health economy and how staff satisfaction locally benchmarks against others

How your plans will ensure measureable improvements in staff experience in order to improve patient experience

Seven day services How you will make significant further progress in 2015/16 to

implement at least 5 of the 10 clinical standards for seven day working

Safeguarding

How your plans will meet the requirements of the accountability and assurance framework for protecting vulnerable people

The support for quality improvement in application of the Mental Capacity Act

How you will measure the requirements set out in your plans in order to meet the standards in the prevent agenda

Innovation

Research and

innovation

How your plans fulfil your statutory responsibilities to support research

How you will use Academic Health Science Networks to promote research

How you will adopt innovative approaches using the delivery agenda set out in Innovation Health and Wealth: accelerating adoption and diffusion in the NHS

Delivering Value

Financial resilience; Meeting the business rules on financial plans including surplus,

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CCGs plans are assured by the NHS England Local Team through a range of processes that include:

a) Ongoing performance review b) Quarterly Assurance Process c) Review of existing plans e.g. City Wide 5 Year Strategy and Better Care Fund d) NHS England involvement in local planning processes

In addition Clinical Commissioning Groups are required to provide a narrative that provides assurance against specific key lines of enquiry as forwarded by NHS England.

A draft narrative (attached) has been developed in response to those key lines of enquiry due to be forwarded to NHS England on 27th February. This narrative will be submitted alongside the Draft Leeds West Strategy (as reviewed in recent Governing Body Workshop).

Our revised Strategy will be presented to the May Governing Body and will be updated to reflect the requirement of NHS England Planning Guidance for 2015/16

delivering value for

money for taxpayers

and patients and

procurement

contingency and non-recurrent expenditure

Clear and credible plans that meet the efficiency challenge and are evidence based, including reference to benchmarks

The clear link between service plans, financial and activity plans

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DRAFT NARRATIVE FOR SUBMISSION 1. Leeds West CCG Vision and Objectives LWCCG vision is: ”Working together locally to achieve the best health and care

in all our communities”. To make our vision a reality our focus will be on four key

strategic objectives.

1: Priority Health Goals - To tackle the biggest health challenges in West Leeds,

reducing health inequalities.

2: Quality & Safety - To transform care and drive continuous improvement in quality

and safety.

3: Best use of Resources - To use commissioning resources effectively.

4: Organisational Development - To work with members to meet their obligations

as clinical commissioners at practice level and to have the best-developed workforce

we can.

2. CCG Plans and fit with City Wide Strategic Plan Leeds West CCG Plans have been developed both in partnership with Leeds City

Council and other Leeds CCGs and Providers through the Health and Well Being

Board and locally through our membership and engagement with patients and the

public. The following summarises the “levels of planning” within the Leeds Systems

in relation to the CCG

West Yorkshire Tier: “Healthy Futures’ Programme The Healthy Futures Programme (originally known as the West Yorkshire 10cc Transformation Programme) refers to a group of initiatives where the clinical leads, commissioners and providers are exploring ways to work collaboratively to deliver 'Better health for all across the West Yorkshire region’. The Programme workstreams are developing collective recommendations on the planning, procurement and review of services provided for populations larger than an individual CCG health economy The priority areas initially identified are; cancer, paediatrics, stroke and urgent/emergency care, a strategy for each of these areas has been developed. Work has been progressing on each of the worksteams towards developing the service models that will be implemented to effect the required change.

Leeds Health & Social Care Transformation Programme

During 2014/15 LWCCG contributed to the development of the Leeds-wide unit of planning 5-year strategic plan submitted to NHS England in July 2014. The strategic plan sets out the two key challenges in terms of sustainability:

To bring the overall cost of health and social care in Leeds within affordability limits - transformation is required to reduce current costs.

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To change the shape of health provision so that care is provided in the most appropriate setting.

Delivery of the Leeds Strategic Plan is underpinned by the work of the Leeds Transformation Programme Board. The Transformation Board, a subcommittee of the Health and Wellbeing Board, is a citywide initiative involving senior leaders from Leeds City Council, Leeds Clinical Commissioning Groups, Local Authorities and all major NHS providers operating in Leeds and provision. The Transformation Board is responsible for overseeing the delivery of a number of key transformational programmes that will change the way that care is provided to ensure that all patient care is of exceptional quality as well as being delivered closer to home with better value for money. The overall impact of the programme will be to focus investment and resource at services in community and primary care settings to avoid the need for unnecessary and costly hospital services. The Transformation Programme has made significant progress on developing and generating initiatives that will support the delivery of Transformation of services. This has resulted in a number of Change Programmes as shown on below.

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We are currently refreshing the economic modelling that underpins the strategic plan to ensure that the plans reflect what has been achieved against planned for 14/15. Transformation and Workforce: The Leeds Transformation Programme includes and HR/workforce workstream. The group is running a series of engagement events about shaping the future health and social care workforce for the city the first of which took place in November 2014. The engagement event identified a number of key actions that are to be taken forward. Information Technology enabling Change: Leeds CCG and partners have an excellent track record in working together to progress strategic developments in use of information technology to deliver change. The following outlines progress made in a number of key areas Implementing NHS number in all settings: Leeds has made good progress in using and regularly tracing the NHS number. NHS number usage in health is well above 90%. This includes hospitals and GP Practices. Adult Social Care (ASC) also has NHS number coverage above 90% for current cases. Tracing has been made possible due to ASC successfully achieving Information Governance Toolkit Level 2. The ASC tracing mechanism remains a tactical technology solution and work will be undertaken during 15/16 to implement a more strategic solution for both adults’ and children’s services.

Moving towards fully interoperable digital records: Leeds is a national leader in implementing interoperable digital records. In the last 12 months Leeds has moved from 4 GP Practices piloting the Leeds Care Record (LCR) to 90 Practices and 2 hospitals live and over 1300 users registered. The Leeds Care Record is currently a single view of essential GP and secondary care data. The technology utilises message exchange mechanisms such as the Medical Interoperability Gateway (MIG). The data sharing is based on an Information Sharing Agreement that has full sign-up from health and social care. Leeds has now implemented the LCR in the first of 13 multi-disciplinary multi-disciplinary Neighbourhood Teams. The LCR is expected to significantly contribute to:

Preventing people from going in to hospital

Improving clinical safety

Enabling speedier discharge

Enabling better care in the community Contribution of digital and assistive technologies to delivery of operational and strategic objectives: Leeds has a mature assistive technologies hub within social care. This will be developed during 2015/16 to become closer to work that has been taking place in parallel on citizen-driven health and mobile health. We have established a more formal Tele-X programme for 2015/16 which will bring together a number of technologies being used and being explored around tele-health, tele-consultation and tele–monitoring.

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Five Year Forward View - New Care Models: The Strategic Plan is currently being refreshed and updated (due end March 2015) to reflect the contribution our plans will make to the delivery of the NHS Five Year Forward View. As part of this work LWCCG is part of a city wide submission of an Expression of Interest to become a Vanguard site for design and implementation of ‘new models of care’. The proposals focuses on the development of Multispecialty Community Provider ‘hubs’, building upon the already established neighbourhood teams in the city. The EOI submission is supported by health and social care partners across the city Year of Care: The CCGs in Leeds are collectively part of the national year of Care Early Implementer programme. In 2015/16 we will conduct a year of shadow monitoring of a range of capitated budgets. The models of care presented in the Vanguard proposal will each have a pilot / early implementer project which is based on the Year of Care pilot and as such will test a capitated budget. As part of the shadow monitoring and continuous refinement of the capitated budget currency categories we will incorporate shadow testing of personalised budgets for specific categories of the cohort populations. 3. How do local plans support Place Based Commissioning Primary Care co-commissioning: The three Leeds CCGs have submitted a combined expression of interest to NHS England (NHSE) to co-commission primary care from April 2015. The three CCGs are taking a combined approach to co-commissioning with the Area Team at level 2. Under level 2 the authority for the budget remains with the Area Team. Co-commissioning will support, and act as an enabler, to allow the broader primary care change and transformation. By working more closely with the Area Team, we have a greater ability to help the city change the way it delivers primary care by:

Strengthening local commissioning and being able to potentially see the budget as one, using co-commissioning of primary care to enable greater holistic or total commissioning i.e. population based commissioning.

Providing greater investment in primary care which is required if it is to provide a high quality service and take on the shift of work from in hospital care to out of hospital care

Potentially cementing CCG relationships with their member practices and supporting practices to develop to take on new roles.

Enabling our patient and clients to be seen nearer to where they live. Clinical and primary care managerial leads from the Leeds CCGs have worked together to scope what co-commissioning of primary care across Leeds could look like including how we can:

Realise the benefits of bringing primary care commissioning closer to the CCG.

Ensure that primary care is ready to take on the challenge of new models such as more work coming from hospital settings into the community.

Work with primary care to ensure that we make the best use of the money being spent on health and social care.

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Terms of reference for a Joint Committee that will take on an assurance role for the spending of the primary care budget have been drafted. Specialist Services co-commissioning: The Leeds CCGs have strong links with NHS England and partners across the region to improve quality and links for specialist services using existing forums e.g. 10CC and strategic clinical networks. Leeds West CCG is leading a citywide response to NHS England in relation to their consultation on the principles, processes and decision making for prioritising treatments and interventions which fall under their specialised services portfolio. Leeds CCGs are also well placed to receive feedback from the pioneer pilots for co-commissioning of Tier 4 CAMHS, and will be well placed to participate in co-commissioning for that service in the future. Integrated Personalised Commissioning: IPC is a key priority for the population of Leeds. The Health and Wellbeing Board held a workshop on personalised budgets on 26 November 2014, with a follow-up briefing and debate being planned for 25 March 2015. This will inform the future strategy for Leeds on IPC to ensure we have a coordinated approach. In terms of progress to date and plans

Leeds Adult Social Care: There is an existing pooled budget in place under Section 75 that supports delivery of personal budgets for people with learning disabilities that is either health or social care funded.

Continuing Health Care: Potential extension of the CHC personal budget rollout to include joint funded packages during 2015/16.

Mental health – we are planning a pilot project for people with complex needs currently supported through our Rehabilitation and Recovery service; a service already delivered by a partnership of NHS and Third Sector providers.

Mental Health: A part-time project lead has been in place from July 2015 with NHS Leeds North CCG. With the support of a Working Group of key stakeholders, the intention is to be able to outline the local position for personal health budgets in mental health in readiness for the ‘right to ask’ by April 2015. From April 2015, Leeds is proposing to pilot the development of PHB through developing an integrated health and social care personal budget for a limited number of individuals with eligible adult social care needs and on Care Programme Approach (CPA).

Mental Health: Discussions have also commenced with Leeds City Council about the development of a pooled fund for mental health services. The first stage of this would be the combination of current funding for community based mental health services; this would support integrated commissioning and joint funding for the proposed remodelled services planned for 2016.

Work to continue on Personal Health Budgets within children's continuing care, and there will be the gradual extension of PHBs into the health component of Education, Health and Care Plans (EHCP).

4. Better Care Fund The Leeds BCF Plan, submitted in 2014/15, has been approved for implementation in 2015/16. The BCF Plan and its outcome trajectories are consistent with the Leeds CCGs’ Operational Plans for 2015/16 as well as outcomes outlined within the city’s Joint Health and Wellbeing Strategy.

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The Leeds BFC plans aim at improving integration of community and health and social care services to improve access and quality of out of hospital services. One of the key measures of success will be to reduce the need for patients to be admitted to hospital. As such Leeds CCGs have set a target for reduction of non-elective activity by 3.5%. In light of winter pressures in 2014/15 our ambition has been reviewed, as required by NHS planning guidance for 2015/16. The CCG have confirmed that we will stay with existing trajectories as outlined in our 2014/15 BCF Plan submission. We are confident that the range of schemes approved as part of the Better Care Fund will support, alongside other local initiatives, a 3.5% reduction in emergency admissions. Each scheme will be evaluated on an ongoing basis to assess the impact on admissions. This evaluation will give local partners assurance about the ability to reallocate or remove capacity linked to non-elective demand. The impact of these schemes will be factored into the CCGs major acute contract plans. Each CCG will hold a contingency fund to mitigate any risk in relation to proposed reduction in emergency admissions. 5. Improving health and Reducing health inequalities NHS Leeds West Clinical Commissioning Group (LWCCG) commissions services for a population of approximately 356,332 people registered with a GP in Leeds West CCG. Approximately 7% of the Leeds West CCG population live in the 10% most deprived LSOAs in the country. This equates to approximately 25,000 people in LWCCG population who live within the most deprived 10% LSOAs in the country and of these approximately 3000 live in the most deprived 3%. These areas are found in the inner west and inner north west areas of the city, and the three most deprived Medium SOA areas are: 7792 people in Broadleas, Ganners & Sandfords; 8528 in Armley and New Wortley; 6784 people in Farnley. The CCG has a responsibility to improve the health of the local population Leeds West Strategic Priority 1 is “To tackle the biggest health challenges in West Leeds, reducing health inequalities”. We have analysed our key health problems using a combination of local and national analysis Our local Strategy for Health outlines the key actions we will take to address key issues for our population through focussing on the delivery of eight priority health goals as follows: 1. Healthy Living 2. Sexual Health 3. Long Term Conditions 4. Cardiovascular Disease 5. Mental Health 6. Cancer 7. Elective Care 8. Urgent Care

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Further details of our plans are available in our Strategy. A plan on a page that summarises our local plans is shown below:

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6. Impact of our plans on Outcomes We have developed trajectories for key national outcomes using the information available through the Atlas of Variation and the Levels of Ambition Tool. We then worked with key stakeholders to agree proposed trajectories. Our trajectories are as follows

PYLL (Potential Years Life Lost): Leeds West CCG ambition for this measure is to deliver the national requirement of a 3.2% per annum improvement over 5 years. Our target reflects the fact that Leeds West PYLL compares favourable with other similar CCGs. Our trajectory for 2015/16 continues to reflect this ambition

Improving health related quality of life for people with LTCs: Leeds West CCG aspires to halve the gap between itself (currently on 74.2) and the best in the country (79.7) over 5 years. Our trajectory for 2015/16 continues to reflect this ambition Reducing emergency admissions: The methodology used to derive the annual trajectory for emergency admissions is consistent with BCF submission Positive experience of hospital care: Leeds West CCG aspires to improve from its current position of 149.4 to 142.1 by the end of Year 2015/16. Positive experience of care outside hospital: Leeds West CCG aspires to move to best quintile nationally (4.8) by 2018/19. Our trajectory for 2015/16 continues to reflect this ambition Promoting Equality and Diversity Implementing EDS2: In Leeds, the three CCGs and local provider trusts work collaboratively to implement EDS2. The Leeds NHS Equality Advisory Panel Assessment Event was held on 26 January 2015. The CCGs made excellent progress for most of the goals - moving from Amber to Green. Actions have already been identified for 2015 that will hopefully enable the organisation to move the remaining goals from Amber to Green for the 2015 Assessment. First NHS workforce race equality standard: Equality & Diversity and Human Resources managers will work together to gather the data required by the Workforce Race Equality Standard (WRES). They are considering applying the WRES indicators to other protected characteristics to ensure a more inclusive approach. They will analyse the data, identify any inequalities and interventions to reduce the inequalities. 7. Promoting Parity of Esteem for Mental Health The CCG has signed up to the vision set out in the joint citywide Leeds Mental Health Framework: ‘Leeds is a city that values people’s mental wellbeing equally to their physical health. Our ambition is for people to be confident that others will respond positively to their mental health needs without prejudice or discrimination and with a positive and hopeful approach to our future recovery, wellbeing and ability.’

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As a city and through local investment we are ensuring that we increase the proportion of our overall budgets that we target at improving mental health services. Our contract plans demonstrate a growth of 3.4% in investment In 2015/16. Identification and support for young people with mental health problems As part of our approach Leeds as a city is prioritising children and young peoples' emotional and mental health. A major review is underway of the whole system of prevention and provision which is due to report at the end of March 2015. The review will make recommendations for strengthening prevention and redesigning services to create a coordinated system. As part of our approach additional investment is being made in specialist CAMHS to bring down waiting lists plus the implementation of a CQUIN focusing on sustained improvement in waiting times. In addition we have also established co-commissioning relationships with education clusters in the city. Reducing the 20 year gap in life expectancy for people with severe mental illness The Leeds Mental Health Partnership Board approved a new city wide Mental Health Framework in October 2014. One of the five priority outcomes identified for 2015/16 is the integration of mental health and physical health. One example of how we are supporting our aim to improve physical health is a CQUIN we have in place with our secondary mental health provider focused on smoking cessation and nutritional support to improve lifestyle. 8. Transformation care for People with Learning Disabilities We have plans in place, developed in partnership with health and social care providers, to ensure that those people with learning disabilities and highly complex needs receive timely and effective care and support to minimise reliance on specialist inpatient care and receive improved access to and outcomes from general healthcare in the NHS.

This includes investment in a joint health and social care planning team for young people in transition from children to adult services and adults with highly complex needs to ensure that care and support is developed and commissioned on a person centred basis. Plans also include review and development of respite care, and re-development of existing inpatient and community learning disability services, and the planned development of a specialist community service provision for people currently placed in out of area hospitals.

In addition a CQUIN (2 years) has been agreed with the specialist healthcare provider trust to improve uptake and quality of annual health checks in general practice. Improved care outcomes and patient experience are also being addressed in the acute hospital trust through partnership working between the CCGs, Acute Trust and specialist learning disability health care provider.

9. Improving Services - Convenient Access for everyone The CCG is committed to delivering good access to the full range of services, including general practice and community services, especially mental health services, in a way which is timely, convenient and specifically tailored to minority groups. The following outlines current performance and risks for coming year

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NHS Constitution: The table below outlines year-end performance (2014/15) in relation to key NHS Constitution pledges and an assessment of risks to delivery in 2015/16

Pledge 2014/15 Projected Delivery

Risk to Delivery 2015/16

Referral To Treatment waiting times for non-urgent consultant-led treatment

Admitted patients to start treatment within a maximum of 18 weeks from referral – 90%

Non-admitted patients to start treatment within a maximum of 18 weeks from referral – 95%

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral – 92%

Diagnostic test waiting times treatment

Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral – 99%

A&E waits treatment

Patients should be admitted, transferred or discharged within 4hours of their arrival at an A&E department – 95%

Cancer waits – 2 week wait treatment

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP

Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)

Cancer waits – 31 days treatment

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers

Maximum 31-day wait for subsequent treatment where that treatment is surgery – 94%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen

Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy

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Cancer waits – 62 days treatment

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers

Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers) – no operational standard set

Category A ambulance calls treatment

Category A calls resulting in an emergency response arriving within 8minutes – 75% (standard to be met for both Red 1and Red 2calls separately)

Category A calls resulting in an ambulance arriving at the scene within 19 minutes

Cancelled Operations

All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice.

Mental health

Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period – 95%.

Key Risks

A&E 4 Hour Wait: The achievement of the Emergency Care Standard (ECS) remains a challenge for LTHT. The delivery of the 95% of patients being seen in 4 hours relies on maintenance of flow across the health and social care economy and is dependent of collaborative and partnership working. Whilst numbers of attendances in 2014/15 have been comparable with the previous year performance has regularly remained below 95%. The primary reason for difficulty in maintaining standard has been the an increased acuity of illness in patients resulting in the need to admit to a hospital bed and difficulties in discharging patients who require either health or social care support. Leeds CCG’s through the Leeds System Resilience Group (SRG) have invested centrally allocated non-recurrent funds of £7M to support the urgent care system Investment supported the implementation of a number of initiatives across all

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providers including the 3rd sector. These schemes have contributed to increasing capacity across the system to maintain patient flow including 7 day working across all providers. The impact of additional capacity has been monitored continuously since implementation to inform areas for recurrent and non-recurrent funding across all parts of the system throughout the year with particular focus on winter months and historic times of greater variation in demand. All schemes will be fully evaluated in March 2015 and a full “winter wash up” is planned in May/June 2015 to inform further planning for winter 2015/16. The system continues to work together to address the challenging areas especially around the discharge processes and the availability of community care.

Referral to Treatment Meeting RTT targets has proved challenging in 2014/15 and there are significant risks to delivery in 2015/16. Growth in referrals in 2014/15 for both general and specialist services alongside emergency pressures have put pressure on ongoing delivery of plans. Key challenges remain in plastics, spines and urology and some smaller specialties. To mitigate potential for breach of targets in 2015/16 LTHT will continue to attempt clear more patients in Q4 of the current year but may struggle to find sufficient capacity in services such as urology, gynaecology and T&O to mitigate against risks to admitted target going into April. Given so much depends on February and March there are risks to maintaining NHS Constitution standards in early Q1 and Q2 in 2015/16.

In recognition of growth in demand Leeds CCGs are commissioning between 4 and 5% more elective activity across all providers. Activity growth varies between specialties with activity growth commissioned focussed on areas where there is a waiting list backlog and/or where we have seen growth in demand. In the past the local Independent Sector providers have been able to provide additional capacity to support the elective care position, but this has not been forthcoming in recent month. To mitigate this LTHT is working to improve internal productivity as far as possible, including transferring some patients between settings to maximize throughput. They are also working to further increase critical care capacity (which has also been a constraint in 14/15). Trajectories have been developed on basis of commissioned activity and on assumption that providers can manage casemix in a way that ensures that patients can be seen in order of priority. Plans assume backlogs will largely be addressed in Q4 of 2014/15. If this cant be achieved there is a risk that RTT position may not be sustainable in Q1 and Q2 Cancer 62 Wait following GP referrals: Following significant improvements in 62 day performance during early part of 14/15 performance is still volatile. This has occurred due to capacity problems associated with winter pressures. It is possible that 85% is deliverable across Quarter 1, though probably not month on month and much depends on clearance in Q4 in similar specialties to RTT. There continue to be issues with the numbers of referrals coming into LTHT after day 38 from external referrers. LTHT’s executive team is working with other providers and CCGs are

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working with commissioners to reiterate the importance of the referral arriving before day 38. Ambulance Targets: Yorkshire ambulance service continues to face a growth in demand especially in red calls, Leeds CCG continue to work with their commissioning partners and YAS to address the main areas of concern including areas for additional investment. YAS have detailed recovery plans in place for the achievement of all targets and there continues to be a high level of scrutiny through a number of regional and sub-regional forums. YAS continue to explore opportunities to expand the skills and capabilities of their workforce to support developments across the urgent care system to support the growth in demand.

Primary Care : Leeds West CCG has invested significantly in increasing access to Primary Care. We have provided funding to support all member practices to increase opening hours to up to 12 hours a day and to work together in groups of practices to provide access to services at weekends. In 2015/16 we will continue to develop and implement our Primary Care Strategy, which aims to improve quality, access and the range of services that will be available locally. Our approach is consistent with the City Wide approach to support developments of new models of care. We are implementing robust monitoring and measurement systems to support evaluation of our strategy Community Services: Leeds Community Healthcare is the main provider of community health services most of which are universally available. We commission a range of services that provide targeted services towards specific minority groups. For example dieticians provide intensive support to frail older people resident within care homes to ensure they receive adequate nutrition, and diabetes nurse specialists proactively work with the BME populations within the city. We also commission additional third sector provided services that support specific minority groups. Examples of this include William Merritt Disability Living Centre and Mobility Service and DIAL (Disability Information and Advice Line) that provide support to physically disabled people; Carers Leeds and other Carers Respite Services; Eye Care Liaison Services, Cohearent Vision and Hear to Help- services for blind and deaf people; Stroke Association; Advocacy Consortia including advocacy for people with mental health conditions; bereavement support services including CRUSE.

Mental Health: The city is committed to improving access to mental health services with a notable focus on childrens’ and young people (see section re services above) One of the key areas of focus is Improving Access to Psychological Therapies (IAPT). CCGS are required to commission services whereby 15% of patients that could benefit (based on estimated prevalence) from IAPT are accessing a suitable service by the end of 2014/15 and that the position with regards to numbers accessing remains at similar levels in 2015/16. Whilst Leeds CCGS have underperformed year to date against the target our lead commissioner has provided assurance that we will met expected performance in the final quarter of 2014/15 (hence meeting national expectations) and that we will continue to meet target in 2015/16.

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To support delivery of key access targets the IAPT service has been reconfigured to improve speed of access through telephone assessment and introduction of a seminar approach as the first step in the pathway. We have also introduced increased access in evenings and weekends, and digital and on-line options. One of the IAPT consortium partners is a BME champion organisation and the whole service is monitored for BME access rates. We have also invested in third sector provision of range of community based mental health support as a way of improving access for minority groups. Choice and Personal Health Budgets: From April 2015, Leeds is proposing to pilot the development of PHB through developing an integrated health and social care personal budget for a limited number of individuals supported by the Rehabilitation and Recovery Service led by LYPFT and involving the third sector. It will target those with eligible adult social care needs and on Care Programme Approach (CPA). 10. Seven day services CCGs in Leeds are working with all our main providers to deliver improvements across 7 day working. The following provides a summary of key areas of work Acute Hospital Services: Requirements for 7 day working have been included within the SDIP for Leeds Teaching Hospitals Trust to ensure further progress is made. Leeds CCGs are represented on the LTHT working group focused on 7 day working to ensure maximum focus on areas of most benefit to health economy flow. Many elements are already in place, linked to the role of LTHT as a Major Trauma Centre and a provider of Hyper Acute Stroke Unit. An updated audit against key clinical standards is expected on near future. Mental Health Service: Requirements for 7 day working are included in the SDIP for Leeds and Yorkshire Partnerships Trust to ensure progress is made on implementation of the specific mental health standards relating to 7 day working. In Leeds our 7-day mental health services include:

Inpatient units both mental health and learning disability

Single point of access

Crisis Assessment Service – including place of safety

Intensive Community Services

Adult Acute Liaison Psychiatry Service

Older Peoples Service Liaison Psychiatry Services

Acute Liaison Psychiatry has a target to begin mental health assessment with patients in ED where mental health has been identified within 3 hours of referral by LTHT ED staff. All breaches are reported.

LYPFT are currently looking at the whole of the acute care pathway and this will include assessing whether there is enough consultant provision over 7 days to ensure discharge and transfers can be facilitated. Later this year they will carry out a scoping exercise for a review of Liaison services across the care groups (older people, acute, general).

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11. Focus on Urgent and emergency care An urgent and emergency care service review within Leeds will be undertaken by the city-wide Transformation Programme. This will be delivered in three areas, Operational, Tactical and Strategic, to ensure continuous learning and direction and the development of target operating models to deliver the core functions of an urgent care system.

The CCG is, through its work with the SRG, an active member of the West Yorkshire Urgent and Emergency Care Network is well established with monthly meetings. The key priorities have been identified:

West Yorkshire Urgent Care including 111 and Out of Hours primary care provision

Developments, quality and future sustainability of Yorkshire Ambulance Service

Delivery of Specialised Urgent Care services within West Yorkshire Operational resilience: System Resilience will continue to be monitored through the Strategic Urgent Care Board. All of the 2014/15 approved schemes have been continuously monitored against high-level KPI’s to access their impact across the system. The System Resilience Plan will be reviewed in Q1 2015/16 to ensure continuous learning across the health economy and from wider partners. The adoption of a city wide escalation plan has ensured greater collaboration across our providers and we will continue to build on this system.

12. Improving Quality and Safety CCGS in Leeds have a range of initiatives and approaches to improving the safety of services and quality of care received. The following outlines key areas of focus: Compassion in practice: In 2012 Jane Cummings, the Chief Nursing Officer for England published a vision and strategy for nursing entitled ‘Compassion in Practice’. The document set out a set of six core values by which all nurses should abide (known as the ‘6cs’). They are:

Care - care is core business and that of organisations, and the care nurses deliver helps the individual person and improves the health of the whole community.

Compassion - how care is given through relationships based on empathy, respect and dignity.

Competence - all those in caring roles must have the ability to understand an individual’s health and social needs and the expertise, clinical and technical knowledge to deliver effective care and treatment

Communication - central to successful caring relationships and to effective team working.

Courage - enables nurses to do the right thing for the people they care for, and to speak up when they have concerns

Commitment - a commitment to patients and populations is a cornerstone of what nurses do.

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The CCG endorses and supports these commitments, and will work with providers to ensure that they develop and implement plans to ensure that the values are adhered to by the nursing workforce.

Safeguarding: Leeds Clinical Commissioning Groups have identified LWCCG Director of Nursing as the Head of Safeguarding / Senior Designated Nurse to take the over leadership and assurance role in safeguarding across the health economy. The Lead Nurse works closely with the Nursing Director of the other two CCGS to ensure a clear line of accountability for safeguarding. This accountability is reflected in each organisations governance arrangements within which Chief Officers in each CCG have overall responsibility for safeguarding.

The CCG Directors of Nursing and Head of Safeguarding/ Senior Designated Nurse represent the CCGs on the Leeds Safeguarding Adult Board and the Local Safeguarding Children Board. Sub groups of both boards have representation from the CCGs by the Designated Nurse Leeds has an established safeguarding team whose membership includes

Director of Nursing and Quality for each of the Leeds CCGs.

Head of Safeguarding/ Senior Designated Nurse.

Designated Nurse Adults, Designated Nurse Children, Named GP

The team role is to work with partners to ensure services are in place to respond to children and adults at risk. The team work with partners across the health economy and within other agencies providing expert advice and support across a range of safeguarding issues. Application of the Mental Capacity Act (MCA): The Designated Nurse for Adults leads on the MCA and works closely with the main providers within Leeds to support the quality and improvement of MCA. The MCA is included as a standard within all CCG contracts, which are monitored closely through the quality contract meetings. Prevent – Implementing Standards: The Prevent agenda is included in the Safeguarding standards that are incorporated into all contracts for the main providers. All providers have identified Prevent leads at operational level and exec level. All providers have included Prevent as part of safeguarding training and have started / have plans to start delivering health WRAP training. The Prevent agenda is also a KPI that is monitored through the Quality and Contracts meetings with providers We have been monitoring provider compliance with Prevent through safeguarding contract management processes. We have also included Prevent as part of the new safeguarding children and adults commissioning policy and the regionally agreed safeguarding standards. Prevent is a standing item on the 3 CCG’s Safeguarding Committee and the 3 CCG’s Adult Health Advisory Group. Providers and the CCG are also engaged with regional prevent meetings and structures. Prevent returns are submitted as required by the CCG to NHSE.

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Response to Francis, Berwick and Winterbourne View: The CCG has assessed itself against the recommendations of these key national reports and has developed action plans in response. We will continue to implement these plans with our providers over the next two years. Lessons learned from the Francis report, Winterbourne View report, and the Berwick Review into Patient Safety have all concluded that quality is as much about our behaviours and attitudes to patients as human beings as it is about the things we need to do to make sure services improve continuously.

Learning Disabilities: Users with a learning disability who require placement in inpatient facilities are regularly reviewed to ensure that they are receiving appropriate care packages in the most appropriate environment. Families and carers are included in these reviews and the CCG has made demonstrable progress in reducing the number of inpatients. All efforts are made to ensure that people are receiving care within community settings and inpatient care is only required where specialist care is needed that is not available elsewhere.

Plans are being developed with health and social care partners to create a complex needs pathway that will include increased community residential and supported living care and support. In addition CCG commissioning intentions for learning disabilities (2015 – 2016) include developing the community learning disability team to provide a crisis support function for people with the most complex needs. This will assist in managing admissions to the local assessment and treatment unit and improve support for community services to further minimise admissions to inpatient services

Serious Incidents and Never Events: The CCG has robust assurance mechanisms in place to monitor patient safety within providers and to ensure that all serious incidents (including never events) are robustly investigated, have appropriate actions plans developed as a result and ensure that learning is shared and implemented. Every serious incident is discussed at the relevant provider quality monitoring group and all provider serious incident reports are reviewed by a director- led quality and governance team for completeness and appropriateness of actions and associated learning.

Serious incidents and never events are also overseen by the Leeds Quality Surveillance Group to ensure sharing of learning and information and triangulation with other relevant intelligence.

Patient safety alerting system: Providers are monitored for compliance with national patient safety alerts via the respective quality meetings, and action plans requested and monitored where there is continued non-compliance. A new national process for the sharing of alerts and the associated provider responses was introduced in February 2014.

Zero tolerance of MRSA: Incidences of MRSA bacteraemia are closely monitored and the CCG has mechanisms in place to ensure that we are alerted to those that occur within providers and in the community. Multi-disciplinary post-infection reviews take place on all incidences of MRSA bacteraemia to determine likely or definitive origin and identify learning. Providers are required to demonstrate that learning has been implemented and where the bacteraemia occurs in primary care, the medicines

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management team will ensure that learning is disseminated and shared with primary care clinicians. Appropriate financial penalties are applied to providers where the case has been determined as avoidable.

Reduce Clostridium Difficile infections: In primary care an antibiotic prescribing strategy has been developed to support work undertaken by the medicines management team with GPs and other clinicians. To support implementation of the strategy, consistent application and shared learning the medical director and clinical lead for prescribing will work with colleagues in Leeds West, Leeds South and East and Leeds North CCGs as part of the citywide Healthcare Associated Infections group. The medicines management team produces regular reports on antibiotic prescribing which are shared with clinicians and practices.

Harm Free Care: The National Patient Safety Thermometer (PST) is a tool that measures prevalence of the four most common types of harm – falls, pressure ulcers, venous thrombo-embolisms and catheter related urinary tract infections. Providers are assessed as to the degree of harm-free care that is provided. Safety thermometer scores are reported to the relevant provider quality monitoring groups to the CCG Quality group via the CCG quality report.

It is acknowledged that the current PST is heavily orientated to acute care and may not capture the most relevant types of harm for mental health and community providers. Specific tools are being developed nationally and the CCG will have oversight of implementation with its providers when the revised tools are released.

Quality Impact Assessment of Provider Cost Improvement Programmes: CCGs are required to seek assurance from providers that their Cost Improvement Plans (CIPs) have been robustly assessed for potential impacts upon quality and that mitigating actions are in place where this has been identified. Providers are required to present their plans and associated quality impact assessments to the CCG Medical Director and Director of Nursing and Quality at the beginning of each financial year, and quarterly monitoring meetings take place throughout the year thereafter. A robust process has been developed which also includes presentation of plans and risk assessments to a ‘star chamber’ of appropriate stakeholders including finance, commissioning and Healthwatch colleagues.

Safer Staffing: Providers are required to publish details of their staffing levels on their websites and to their Boards. The CCG ensures continued oversight of provider staffing levels via the joint CCG/provider quality meetings where staffing levels information is discussed and through inclusion of data in the Quality Report which is presented to the Quality Committee and included as a standing item at provider quality meetings.

Acute Kidney Injury: In 2015-16, a new national CQUIN (Commissioning for Quality and Innovation) indicator is to be introduced. The CCG will work with providers in implementation of the indicator, and where appropriate, agree targets for improvement.

Sepsis: The CCG recognises that sepsis accounts for 37,000 deaths annually in the UK, and will work with providers and primary care clinicians in introducing mechanisms to raise awareness of the early warning signs of sepsis, and of the

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treatment to be instigated. For acute care providers this will be supported through the implementation of the new national CQUIN indicator.

Improving Patient experience- The Patients Voice: The CCG has a responsibility to ensure that patients’ experience of care is the best that it can be and that it uses patient experience to inform its performance management and commissioning decisions. To support this the CCG monitors a wide variety of patient experience information including national patient surveys, friends and family scores, PALS enquiries, complaints and public comment mechanisms such as Patient Opinion, NHS Choices and social media sites. Providers are expected to supply regular patient experience reports that include complaints numbers, themes and trends and evidence that they have made changes as a result. The CCG supports all providers to implement Friends and family roll-out to the agreed national timescales. Friends and Family test data is reported and monitored via the quality performance meetings which take place with each provider. Both response rates and patient recommendation scores are monitored, and providers are challenged and asked to provide corrective plans of action where results are lower than expected or agreed. Friends and Family Test results are included in the CCG’s monthly quality report which is submitted to the assurance/quality committee which in turn reports to the Board.

The CCG has also introduced a number of mechanisms for GPs to feedback their or patients’ comments via an electronic feedback system. This information is collated to identify themes and trends and used in conjunction with other sources as described above in order to build a picture of patient experience. From this information we are able to identify actions to be undertaken which are recorded and monitored through CCG patient experience groups.

We will report on actions taken and improvements made as a result of FFT, complaints and other feedback via our website in order that we can demonstrate to the public that we are listening and responding to feedback and concerns.

The CCG is working with Leeds Involving People (LIP) to develop a focused quarterly patient experience survey conducted with Leeds Teaching Hospitals Trust. The survey is being developed with the intent to reduce some of the duplication of patient experience information within the inpatient setting. It is intended that the survey provides ‘soft’ data to enhance the various pieces of work currently taking place across the City regarding transfer of care.

Quality of care for vulnerable groups is assessed via a number of mechanisms including walk round visits to providers where we talk to both staff, service users and carers/family members about their experience of the care that they’re receiving. We have introduced a number of CQUIN indicators with our main mental health services provider to improve communication between secondary and primary care relating to physical health needs and communication of diagnosis of dementia.

13. Engaging communities NHS Leeds West CCG is extremely proactive in its ongoing engagement with patients, public and local communities. Engagement with patient and the public is factored into all our commissioning development and business plans.

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We have developed a commissioning template used by our commissioning and strategy team to ensure that plans include methods of capturing patients and public views. This is wholly supported by the clinical commissioning committee (CCC).

We have a Patient Advisory Group (PAG) and have recruited patients from our GP Practice Reference Groups to form the PAG. It currently represents eight GP practices in west Leeds. The group looks at commissioning plans and proposals and engagement plans, and offers their advice and comments to say whether we have made sufficient plans to involve and engage patients and the public.

We also have a Patient Insight Group (PIG) which ensures that the CCG has plans, systems and processes in place to measure, analyse and use feedback from patients, carers and partners to improve services. The methods to collect this data include:

Comments boxes

Ipads/tablets

Surveys

PALS

Website

Our PPI lay member chairs the PAG, and sits on both the CCC and the PIG to ensure that the patient voice is heard. The CCC receives updates from both these groups

We have a community involvement network which is continually growing and currently has almost 700 members, some individuals and some local organisations, who we share information with, including our quarterly magazine, Engage. The local organisations cascade information to their members giving us much greater reach. We also established our patient leader programme. Over the last year we have been recruiting patient representatives (patient leaders ) to our commissioning steering groups. Their role is to ensure that the group considers patient feedback when they make commissioning decisions (usually feedback from the engagement/consultation). We have 34 people who want to be part this programme, and 8 are already members of the commissioning groups on projects such as the Patient Empowerment Project (PEP), chronic pain and single point. of access

We engage with our member practices’ Patient Reference Groups (PRG) and proactively support these by attending meetings, supporting their development and sharing engagement plans.

We use a range of traditional and social media to communicate and promote

engagement within our communities. We are also extremely proactive in using social media to improve communications, such as Twitter and Facebook and we respond instantly to any issues raised. We have also discovered that when undertaking surveys, people are much more receptive to answering us when we use iPads rather than traditional paper surveys, so we are using this method regularly.

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We have developed a more user friendly website, and promote feedback through a number of methods, including surveys and a dedicated email address. We also use our website to promote processes with regards to making Freedom of Information requests or access to our Governing Body papers, commissioning strategy and annual report 14. Engaged Workforce - Improving Quality through improving Working Lives: Staff satisfaction is an indicator of quality within providers, as well-motivated staff deliver better care. Clinical leadership drives innovation and staff. National staff survey reports are monitored, discussed with providers and actions required where survey scores are poor. The Staff Friends and Family Test was introduced in April 2014; staff are asked to comment on the degree to which they would recommend the organisation in which they work to their friends and family and whether they would recommend the organisation as a place to receive care. Staff satisfaction surveys and scores are monitored via the relevant providers’ quality monitoring group and reported to the CCG Quality /Assurance Committee. Results are benchmarked against similar organisations.

In addition, providers’ individual results for the national staff survey are monitored and corrective actions required where survey results are lower than expected.

15. Research and innovation: Narrative to be added later 16. Financial resilience; delivering value for money for taxpayers and patients Leeds CCGs have strong track records in managing their financial resources. However this stewardship needs to be considered in the context of the Leeds wide Health and Social Care economy. A detailed analysis of the financial planning assumptions of all NHS Organisations in Leeds, NHS England’s Specialised Services spending position with LTHT and of the Adult Social Care at Leeds City Council was undertaken in 2014 as part of the City’s 5 year planning process. It concluded that if nothing changes in how Health and Social Care Services are currently provided in Leeds, collectively, those organisations will be facing a deficit position of circa £640 million by the financial year 2018/19. Given the size of the overall financial challenge, and given that all statutory organisations are closely interlinked with patient pathways crisscrossing across all their services, only whole system changes implemented and supported by all those organisations can have the requisite rectifying impact needed to retain financial balance within the Health economy. All QIPP targets are therefore agreed to be delivered on a city wide footprint by providers and commissioners through a combination of Transformation, Innovation and organisational efficiency (including CCG running costs). The 2015/16 financial plan builds on 2014/15 Operational Plan. The CCG finance plan continues to underpin our strategic priorities and has been updated to reflect:

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New commitments identified within the 2015/16 operating framework

New Initiatives that underpin the work of the Transformation Board.

Local priorities as developed by the CCG working with partners that reflect local needs as identified through the Joint Health Needs Assessment,

Emerging priorities identified through engagement with patients and public and clinicians at CCG level

Financial plans and proposed annual budgets are being developed based on our current understanding of available resources, risks and developments known at this time and are subject to change pending management and mitigation of risks associated with contract negotiation plus any impact of PbR tariff changes (given rejection of proposed national tariffs by providers). Associated activity and capacity plans: Our template submission outlines our finance and activity trajectories. Within this template Leeds CCGs have made working assumptions around the growth in both finance and activity to support the Feb 27th planning submissions. Proposals on elective care and the non-elective assumptions have been agreed through the city wide Acute Provider Management Group (APMG). These are necessarily provisional figures may be further adjusted before the next submission in early April. Elective Inpatient/Day Case activity: The15/16 plan is based on the 14/15 projected outturn plus growth 2.6% IP and 5% for Daycase to allow for demand. Capacity and activity plans reflect the expectation of further growth in cancer related specialties linked to early diagnosis; further increases in demand for hepatology, haematology and other services linked to plans to reduce Years of Life Lost and improved chronic disease management.

1st Outpatient Activity: The position with first outpatients is similar to electives where in year 1 we are planning growth of 3.9% to offset RTT waits in some specialities and demographic growth. To ensure we live within the planned growth however we have plans to move towards more non-face to face contacts/advice and different locations for some pathways. We have built in actions to help achieve this within our service development and improvement plans, CQUIN and quality requirements.

Follow up OP Activity: We are intending to reduce follow up and our plans reflect this with lower growth (3.6%) than in 1st Outpatients. Over time in some high volume specialties we are planning for some pathways to transfer to primary care and/or to no follow up, and reducing the numbers of face to face contacts/frequency of contacts/increased use of nurse-delivered pathways. However, these productivity improvements are likely to be needed in part simply to offset the growth that would be required to enable life-long follow up for patients in an increasing number of chronic disease pathways including cancer survivorship, rheumatology, ophthalmology etc. Our aim, therefore, is to minimise demand growth which is an improvement in real terms against demographic growth, and to achieve a reduction in spend for the same level of activity.

Non-Elective Activity: During 14/15 we have seen a 2+% reduction in emergency admissions overall (YTD) with notable reduction in zero and 1 day length of stay admissions. In line with planning assumptions for the three CCGs BCF, the rate of emergency admissions for 2015/16 is projected to be 2.8% (BCF% minus

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demographic growth) below comparable rates for FY14/15. This reduction will be achieved by implementing a variety of intervention (under the umbrella of the Better Care Fund and City-wide transformation programme) that aim to improve the management of patients at risk of unplanned hospital admission (reducing demand for urgent care provision) and promote out of hospital alternatives to hospital admission for urgent cases.

A&E Attendances: 2015/16 growth is planned at 2.74%. Our expectation is that attendances will plateau over the next 5 years, as the increasing impact of the Better Care Fund, seven day working, primary care development and the further work on the Urgent Care Strategy offset the growth that would otherwise be expected as a consequence of demographic growth.

Securing Provider Capacity: The CCG has worked with its providers to ensure enough capacity is planned to deliver NHS constitution standards whilst maintaining the safety and quality of care. Activity plans have now been agreed with Leeds Teaching Hospitals. The Trust are working to develop capacity and are aiming to recruit to over 50 consultants posts to support delivery of plans. In support the Trust recruited over 500 new nurses in 2015/16. Despite the additional capacity there remain some risks primarily the current reliance of the system on the independent sector capacity to support backlog delivery. The Independent sector is signalling increasing reluctance to provide additional capacity at affordable costs and as such Leeds Teaching Hospitals is seeking to bring much of this work in house. Their ability to achieve this will in part depend on their ability to both recruit to posts and to generate some efficiencies in their services. Alignment of CCG plan and provider plans: We have agreed our activity plans with Leeds Teaching Hospitals and they have embedded in their plans. It should be noted that a significant elements of LTHT activity is not commissioned by the Leeds CCGs and as such it is difficult to reconcile our plans with their overall activity plans as submitted to the TDA