Operational Plan 2015/16test.bathandnortheastsomersetccg.nhs.uk/assets/...Operational Plan 2015/16 Final Delivering key national targets in 2015/16 A&E Recovery Plan Delivery of the

Operational Plan 2015/16

Delivering the second year of our Five Year Strategy ‘Seizing Opportunities’

May 2015

1 Operational Plan 2015/16 Final

Contents Executive Summary for the Operational Plan 2015/16 ............................................... 3

Seizing Opportunities – Year Two Operating Plan 2015/16 ....................................... 9

1. Introduction .......................................................................................................... 9

2. Our Vision and Strategic Objectives .................................................................... 9

2.1 Our Key Objectives for 2015/16 .................................................................. 10

3. Benchmarking and Quantifying Delivery Priorities ............................................. 10

3.1 Benchmarking and Best Practice ................................................................ 10

4. Our Transformational Priorities – Progress so far and next steps...................... 12

4.1 Prevention Including Self-Care.................................................................... 13

4.2 Improving Diabetes Care ............................................................................ 14

4.3 MSK Service Review and Redesign ............................................................ 16

4.4 Improving Interoperability ............................................................................ 17

4.5 Improving Urgent Care ................................................................................ 18

4.6 Safe, Compassionate Care for Older People .............................................. 20

5. Other Strategic Priorities ................................................................................ 21

5.1 Community Services Redesign ................................................................... 22

5.2 Primary Care ............................................................................................... 23

5.3 Children’s Services ..................................................................................... 25

5.4 Mental Health .............................................................................................. 26

5.5 Learning Disabilities .................................................................................... 28

6. Better Care Fund ............................................................................................... 29

7. Our Commitment to Quality ............................................................................... 31

7.1 Quality in Commissioning ............................................................................ 31

7.2 Patient Safety .............................................................................................. 32

7.3 Effectiveness of Care .................................................................................. 33

7.4 Patient/ Service User/ Carer Experience ..................................................... 34

7.5 Care Quality Commission............................................................................ 35

7.6 Commissioning for Quality and Innovation (CQUINS) ................................. 35

7.7 Quality Premiums ........................................................................................ 36

7.8 Equality and Diversity .................................................................................. 37

7.9 Safeguarding Vulnerable Children, Young people and Adults .................... 38

7.10 Developing Practice Nurses ........................................................................ 40

7.11 Clinical Accountability ................................................................................. 40

8. Forward View into Action: Planning for 2015/16 ................................................ 40


8.1 Creating a new relationship with patients and communities ........................ 40

8.2 Co-creating New Models of Care ................................................................ 45

8.3 Priorities for operational delivery in 2015/16 ............................................... 47

8.4 Enabling Change ......................................................................................... 52

9. Financial Plan 2015/16 ...................................................................................... 55

9.1 Financial Strategy ....................................................................................... 55

9.2 Financial Plan 2015/16 ................................................................................ 55

9.3 Investment Plans ......................................................................................... 56

9.4 Resource Releasing (QIPP) Plans .............................................................. 57

9.5 Better Care Fund ......................................................................................... 57

9.6 Running Costs ............................................................................................. 57

9.7 Capital Expenditure ..................................................................................... 58

9.8 Cash and Balance Sheet ............................................................................ 58

9.9 Financial Risk and Mitigation ....................................................................... 58

10. Performance Management and Delivery of the 2015/16 Operational Plan ..... 58

11. Risk Management .......................................................................................... 59

APPENDICES Appendix 1 a-d Measures of Success Appendix 2 Planned Investment 2015 /16 Appendix 3 Planned Savings 2015/16


Executive Summary for the Operational Plan 2015/16

The CCG’s 2015/16 Operational Plan sets out what we will do over the coming year to improve health outcomes and the quality of health care services for the people of Bath and North East Somerset (BaNES) within available resources. This Plan is driven by the needs of the local population and continues work started last year as part of the CCG’s 5 Year Strategy ‘Seizing Opportunities’ and 2014/15 Operational Plan. In formulating our plans for the coming year, we have recently undertaken a re-prioritisation exercise to ensure resources are allocated for critical projects. There has also been further benchmarking and a review of potential efficiency opportunities for BaNES as well as ensuring our Plan responds to and is informed by “The Forward View into Action: Planning for 2015/16”. Whilst the CCG has a very detailed operational plan that sets out all of our commitments for the coming year, our top 3 priorities are:-

i). To restore system performance around the four hour target and 18 week Referral to Treatment Times

ii). To complete the Community Services re-design work to inform our future plans for the commissioning of community services across BANES

iii). To develop a Primary Care Strategy for BANES to support Primary Care to provide an increased range of services and new models of care and operate at scale.

Our performance in 2014/15 The CCG has met many key national and local targets in 2014/15 but across our broader health and care system we have been particularly challenged in sustaining performance against the NHS Constitution’s four-hour A&E waiting time target, delivery of the Improving Access to Psychological Therapies (IAPT) targets for recovery and improving delivery of dementia diagnosis rates. We will continue to focus our response and ensure robust performance management and delivery against these specific areas in 2015/16, working with providers on agreed system wide recovery plans.

In 2014/15 we have made good progress against the milestones set out within Year One of the Five Year Strategy. This includes development of a community based diabetes model which will see a hospital diabetologist offering multi-disciplinary services within a primary care setting, to be piloted in the first quarter of 2015/16. There has also been agreement across our health and care community to develop a full business case to join the Bristol, North Somerset and South Gloucestershire Connecting Care Programme which will improve patient care and treatment by enabling medical records to be shared quickly and safely by different health and care providers. A full report on our progress will be shared with the CCG’s Board in early May.

Using benchmarking to continually learn and improve

As part of the development of the CCG's Five Year Strategy we carried out extensive performance and best practice benchmarking which included a review of the


Commissioning for Value Packs. In September 2014, Central Southern Commissioning Support Unit provided us with further benchmarking and horizon scanning analysis against our main commissioning programme areas to support the preparation of our Investment and resource releasing (Quality, Innovation, Productivity and Prevention - QIPP) Plans for 2015/16. Whilst these data sources show that we deliver top quartile performance against most indicators, it suggests that there is further scope to improve our performance in areas such as alcohol related admissions, stroke care, cancer services and trauma and injuries. These areas have received targeted additional investment in 2014/15 and are subject to further investment or service improvement activity in 2015/16.

Commissioning priorities in 2015/16 Our plans for the coming year reflect our ongoing commitment to delivery of six transformational work streams which were identified in collaboration with the public, patients and partners and form an important part of our Five Year Strategy. These transformational work streams, which matter to our local population and which we know will make a measurable difference, continue to be our commissioning priorities alongside a range of other priority projects which the CCG is required by NHS England and others to progress or which will help address our key local health and care issues. Our 6 Transformational Work streams continue to focus on:-

Prevention, including self-care

Improving diabetes care

Musculo-skeletal service review and redesign

Improving interoperability of Patient Record Systems (Connecting Care programme)

Improving urgent care

Safe, compassionate care for frail older people

Other priority work streams are: -

The ‘Your care, Your way’ review of community services in BaNES

Delivery of the Better Care Fund Plan

Co-commissioning of primary care services and development of a primary care strategy to support Primary Care to provide an increased range of services and new models of care and operate at scale

Re-shaping mental health services in BaNES and delivering parity of esteem so mental health is given equal priority to physical health

Improving Children’s Services to deliver Special Educational Needs and Disability (SEND) Reforms

Continuing to improve Learning Disabilities Services


Delivering key national targets in 2015/16

A&E Recovery Plan Delivery of the NHS Constitution’s four hour A&E waiting time target is one of the highest priorities for our health and care economy. A Recovery Plan for four-hour performance has been developed following a challenging period in late December and early January 2015 and will continue to be progressed and monitored through the System Resilience Group (SRG) which comprises senior representatives from the CCG, health providers and the Bath and North East Somerset Council.

18 Weeks Referral to Treatment waiting time targets (RTT) We plan to meet all 18 week RTT targets in 2015/16. However, some local providers including our main provider, the Royal United Hospital Foundation Trust (RUH), are indicating potential planned failures in individual months for admitted pathways, which may create risk to overall delivery. We continue to work through capacity plans for 2015/16 with our local providers to ensure we make best use of our combined resources to deliver safe and high quality services for everyone.

The CCG recognises that successful to the delivery of both the four hour target and eighteen weeks are robust demand and capacity plans which are aligned across providers. We know we have more work to do in this area but through the SRG will continue to facilitate and test planning assumptions across the year.

The Better Care Fund (BCF) Plan in BaNES For 2015/16 we have allocated a BCF Fund of circa £12million and agreed a comprehensive BCF plan with our Council partners. This BCF plan is fully aligned to our shared view of increased reablement support with services that support people to take control of their lives and receive care and support in their homes and local communities.

Together with the Council and our providers, we have reviewed proposed emergency admission scheme reductions in light of 2014/15 performance and ensured they continue to be fully aligned with the QIPP agenda. This has led to a reassessment of the BCF baseline period and a robust estimate of what might be achievable in the coming year. We aim to reduce emergency admissions by 1.9 per cent in 2015/16.

Listening and responding to our local population In 2014/15 the CCG set up ‘Your Health, Your Voice’, a forum of over 20 core members of the public which supports the CCG’s public and patient involvement work on commissioning issues and acts a critical friend to the CCG in terms of reviewing proposed service changes. Members of ‘Your Health, Your Voice’ make a much valued contribution to our planning and delivery process and we look forward to continuing to work together over the coming year. In January 2015, the CCG and Council, embarked on an extensive engagement process to seek ideas and views on local community services. Entitled your care, your way, public engagement will continue throughout 2015/16 and provides an opportunity for us to work with a range of stakeholders, to listen and help us shape future service requirements.


Some key communications activities for 2015/16 are to update our Communications and Engagement Strategy, review and redesign our website, staff intranet and GP portal and expand our presence on social media platforms. These developments will enable us to strengthen engagement with and support from a broad range of stakeholders.

Staff health and wellbeing The CCG is committed to maintaining and improving the physical and mental wellbeing of its staff. The first staff survey was conducted in November 2014 and an action plan to improve a number of areas including communications and working environment is being taken forward during 2015/16. Some of these improvements are expected to have a positive impact on staff health and wellbeing.

Commissioning for Quality The CCG has a comprehensive Quality Strategy which underpins and will support our agreed programmes of work for 2015/16. We have signed up to the ‘Sign up to Safety’ campaign and our Quality Strategy incorporates actions linked to the campaign’s five pledges.

In addition, the CCG will continue to utilise Commissioning for Quality and Innovation (CQUINs) to enable us to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals, in particular around four quality domains. This is subject only to any limitations arising from provider choices in respect of the 2015/16 tariff options

We expect to implement the four themes identified as national CQUINs in the areas of: -

Dementia and delirium care and updating the physical health care of patients with mental health problems (continued through from 2014/15)

Improving urgent and emergency care across local communities

Sepsis (The RUH had a Sepsis CQUIN in 2014/15 and made good progress against it)

Acute Kidney Injury

The CCG, in collaboration with partners, held a successful local CQUIN Planning Event on 10 December 2014. This identified the following areas as the basis of developing local CQUIN schemes, of which the first three are now most fully developed with providers:-

Parity of Esteem – valuing physical and mental health equally

Discharge/handover of care/early warning systems

End of Life - agreed process for early Advanced Care Planning and embedding of treatment escalation plans (TEP) across all health sectors

Community Acquired Acute Kidney Injury

Care of the diabetic foot, catheter passport

National Institute for Care and Excellence (NICE) audit of guidance across whole health and care system

Staff health and wellbeing and Making Every Contact Count

Nutrition - Hospital/community food exemplar.


Our financial position The CCG has produced a balanced plan, including the required level of surplus for 2015/16, although the CCG’s planned financial position has been adversely impacted by recent changes to our allocation for the year. As a result of the distribution of the additional £1.5billion frontline funding, the CCG is £700k worse off than previously notified and the reduction in our distance from target, previously planned to be 3 per cent between 2014/15 and 2015/16, is now 75 per cent.

Our financial plan includes compliance with all nationally mandated planning assumptions and business rules including additional investment in mental health services, and is wholly aligned with delivery of our commissioning plans. Within this, we plan to deliver QIPP of 1.8 per cent in 2015/16 and savings have been negotiated into provider contracts where delivery of QIPP impacts on these providers.

Our financial plan also includes the requirement to deliver a reduction in our running costs budget of 10 per cent in 2015/16. This requirement has necessitated the need for the CCG to re-focus and prioritise our commissioning priorities for the coming year.

Organisational Development Organisational Development (OD) is a key enabler to ensure that the CCG is supported to be a highly effective commissioning organisation and system leader and is fully able to achieve our stated strategic objectives. We have an Organisational Development Plan that reflects locally identified OD priorities and is based around the six domains used by the CCG and NHS England to ensure that we are fully meeting our core statutory responsibilities and duties as a CCG.

Performance management and delivery of the 2015/16 Operational Plan Following our recent mapping and re-prioritisation exercise, work will be completed by the end of March to set out quarterly key milestones for delivery against all agreed project initiatives. In addition we will be reviewing the level and range of performance indicators including benchmarked performance that is shared with the CCG’s and Council’s Joint Commissioning Committee. Both will form the basis of a revised Performance Management Framework for 2015/16.

Key risks in 2015/16 The CCG has completed a risk assessment of our 15/16 operational plans. The key challenges for the CCG and our wider health and social care economy are:-

Sustaining and improving performance against the four-hour A&E waiting time target in BaNES in light of a very challenging position in quarter four of 2014/15 and against a backdrop of increased pressure on emergency services at a national level.

Reducing RTT backlogs and then maintaining good performance in the early part of 2015/16.

Delivering reductions in non-elective admissions as part of the BCF plan.

The running costs allocation reduction which requires us to identify. efficiencies in an already lean organisation, whilst maintaining our capacity to deliver significant programmes of change and sustaining the health and wellbeing of our staff.


Delivery of QIPP targets against a challenging financial allocation for the CCG in 2015/16

Working with partner organisations Working collaboratively across the health and care economy will continue to be a key priority for the CCG through building strong collaborative partnerships to secure delivery of key national targets and local priorities and to ensure that risks are shared where appropriate. We will continue to work closely with our neighbouring CCGs ensuring that we share planning assumptions and service re-design work to our mutual benefit. During 2015/16 we will work collaboratively with Gloucester, Swindon and Wiltshire CCGs on the re-commissioning of commissioning support services from 2016.

The CCG is working closely with Council colleagues to refresh the Health and Well-being Strategy to ensure that it fully aligns with and reflects our Five Year Strategy, has strengthened focus on prevention and the self-care agenda, sets out the leadership role of the Health and Wellbeing Board and details clearer milestones and desired outcomes.

In 2015/16 the recently established Bath and North East Somerset Transformation Group, which is a sub-group of the Health and Wellbeing Board, will continue to act as a forum for sharing and co-ordination of system wide service developments and transformational change. The Transformation Group will also provide a shared space for oversight of our local services and the development of future service models and enable active input into the Health and Wellbeing Board's strategic planning.


Seizing Opportunities – Year Two Operating Plan 2015/16

1. Introduction

This plan details how the aspirations set out in our Five Year Strategy will be delivered in the second year of the plan 2015-2016. It needs to be read in conjunction with the full Five Year Strategy which sets out in much greater detail:

Our Vision

Our Priorities

The National and Local Context

Our Strategy

Our Commitment to Quality

Plans for delivery in years three to five

Enabling Plans

Governance arrangements

Communication and Engagement

2. Our Vision and Strategic Objectives

When we embarked on our journey to become a Clinical Commissioning Group (CCG), we encapsulated our strategic vision in the statement ‘Healthier, Stronger, Together’. Bath and North East Somerset CCG (BaNES CCG) has been established for two years, and this vision is all the more relevant.

We believe that our role as a high performing CCG, is to lead our health and care system collaboratively through the commissioning of high quality, affordable, person centred care which harnesses the strength of clinician led commissioning and will empower and encourage individuals to improve their health and wellbeing status. The CCG’s strategic objectives summarise our commissioning intent for our local population: -

Improving quality, safety and individuals’ experience of care

Improving consistency of care and reducing variation of outcomes

Providing proactive care to help people age well and to support people with complex care needs

Creating a sustainable health system within a wider health and social care partnership

Empowering and encouraging people to take personal responsibility for their health and well-being

Reducing inequalities and social exclusion and supporting our most vulnerable groups

Improving the mental health and well-being of our population

Appendix 1a


2.1 Our Key Objectives for 2015/16

1. Deliver the 2015/16 Operational Plan including newly mandated standards and all of our statutory obligations with a specific focus on NHS Constitution targets.

2. Engage, co-produce and review community services in BaNES with the aim of determining our future commissioning intentions

3. Deliver Year Two actions set out within the Five Year Plan against our Six Transformational priorities.

4. Strengthen our joint working relationship with the Local Authority through actions including establishing a pooled mental health budget and delivery of the operational actions and system changes associated with the Better Care Fund including an agreed reduction in emergency admissions in 2015/16.

5. Deliver a robust public engagement programme through Your Health, Your Voice Group and other engagement/participation activities with a particular focus on Community Services

6. Re-design mental health services in BaNES to establish optimum future arrangements for inpatient, community and primary care services, securing linkages to the community services re-design where appropriate

7. Co-commission primary care in BaNES under a joint arrangement with NHSE. Develop a detailed strategy and action plan for shaping the future of Primary Care in BaNES in the context of the CCG’s five year strategy

8. Review CCG structural requirements to deliver CCG work programme and procure commissioning support arrangements for 2016/17 in light of lead provider framework.

9. Increase our approach to evidence based commissioning and the effective evaluation of service improvements through increasing our collaborative working with the Academic Health Science Network, such as Universities. Develop our linkages with other CCGs who are delivering innovative practice.

3. Benchmarking and Quantifying Delivery Priorities

Our delivery priorities for 2015/16 are based on:-

Our review of current areas where sustained performance is challenging

Our assessment of the priorities identified through benchmarking and best practice

Our on-going commitment to deliver the six transformational work streams set out in the CCG’s Five Year Strategy and other strategic priorities

Our commitment to delivery of nationally mandated priorities set out within the Five Year Forward View and Forward View – Planning into Action 2015/16

3.1 Benchmarking and Best Practice As part of the development of the CCG's Five Year Strategy extensive performance and best practice benchmarking was carried out, which included: a review of the BaNES Joint Strategic Needs Assessment, Commissioning for Value Packs and use of the Any Town CCG toolkit.


In September 2014, we undertook further benchmarking and horizon scanning analysis against our main commissioning programme areas. The full tools used included:-

Bench marking tools

Dashboard

Acute Benchmarking

Quality Observatory data

Benchmarking from Dr Foster

Best Practice Case Studies

NICE QIPP ideas

High Impact Innovations

Friends & Family Test

This data continues to support the perspective that the CCG and the Council have

good performance across a range of indicators but with a need to focus on the

following areas: - Older People – Life expectancy is higher for both men (80) and women (84) than the regional and national averages but by 2021 there will be a 30 per cent increase in population over 70. Of those aged over 65, half have at least three chronic conditions. Despite constituting just 18 per cent of the population, people over 65 account for over 53 per cent of CCG commissioning spend and the impacts of an ageing population growth will contribute to our anticipated financial challenge. Long Term Conditions – Whilst the life expectancy of our population is generally very good, the risk of developing multiple chronic conditions appears to increase with age. In deprived areas, multimorbidity is more common and happens 10-15 years earlier and there are more people with mental as well as physical long term health problems. The prevalence of diabetes has been steadily increasing locally, regionally and nationally and in 2012/13, 7,460 people aged 17 and over in BaNES were registered as having diabetes on GP registers. Our priority is to continue to focus both on prevention and on providing personalised care planning and intensive support to help people with long term conditions to make sustained lifestyle changes and to enable patients to manage their conditions more effectively. Urgent Care System – Most of our challenging performance issues relate to the urgent care system and include four hour A&E targets, and to a lesser extent ambulance response times, and eliminating mixed sex accommodation. Failure to address these performance issues has now impacted on the quality of care provided for patients in other parts of the health system, elective care being the most obvious area with resulting increases in cancelled operations and extended waiting times.

Musculo-skeletal Services – The Commissioning for Value benchmarking data identified musculo-skeletal services as area for BaNES to improve quality and outcomes and to reduce spend.


Prevention and Self-Care – Whilst life expectancy in BaNES is higher than the regional and national averages, there are significant variations in life expectancy related to socio- economic inequality in BaNES. In deprived areas, multimorbidity is more common and happens earlier than we would wish. A key strategic aim is to consider the preventative and self-care aspects to all pathways of care.

The latest Commissioning for Value (CfV) Data published in February 2015 identifies Stroke, Cancer and the Falls Pathway as particular areas where the CCG now needs to do further work.

Stroke Pathway - The CfV packs indicate further potential to reform the stroke pathway to improve performance against the following indicators:-

Stroke/TIA patients with BP in range

Stroke/ TIA patients with cholesterol in range

Emergency readmissions (too many)

Stroke patients returning home after treatment (too few) Cancer Services - Targeted prevention and case management opportunities exist in lung and breast cancers. Within cancer services there are opportunities for improving lung cancer detection and prevention (both CfV packs), e.g. lung cancer and smoking prevalence, successful quitters. For breast cancer there are opportunities for improving breast screening and breast cancer mortality.

Trauma and Injuries - CfV data shows that the CCG is spending £0.5m more in secondary care with 400+ more admissions, fractures and falls than you might expect for BaNES – suggesting that further pathway reform is needed. All of the above feature in our work plans for the coming year and are either referred to in our Operational Plan or will form part of our more detailed milestone plan for 2015/16.

4. Our Transformational Priorities – Progress so far and next steps

Our plans for the coming year reflect our ongoing commitment to delivery of the six transformational work streams which were identified in collaboration with the public, patients and partners and form an important part of our Five Year Strategy. These transformational work streams continue to be our commissioning priorities alongside a small number of other strategic priority projects which the CCG is externally required to progress or which will help address our key local health and care issues.

Our Six Transformational Work streams continue to focus on:-

Prevention, including self-care

Improving diabetes care

Musculo-skeletal (MSK) service review and redesign


Improving interoperability of Patient Record Systems (Connecting Care

programme)

Improving urgent care

Safe, compassionate care for frail older people

4.1 Prevention Including Self-Care In our Five Year Strategy, we identified the development and implementation of a ‘Prevention, including Self Care’ (PSC) work programme, designed to guide the way in which the CCG tackles prevention, focusing on areas of higher deprivation, and enabling residents and patients to take greater responsibility for their health. Evidence suggests prevention programmes can prevent disease, improve wellbeing, slow disease progression and reduce demand for specialist services. More detail regarding the rationale and anticipated outcomes can found in our Five Year Strategy located here. http://www.banesccg.nhs.uk/sites/default/files/FV per cent20BANES_5 per cent20year per cent20strategy per cent20- per cent20full per cent20document_FINAL_19092014.pdf.

Anticipated Milestones in 2014/15

Achievements in 2014/15

Milestones for 15/16

Establish PSC Task Force

Create health inequalities framework

Identify resources

Conduct PSC needs assessment (analyse key health problems, review existing self-care initiatives)

Engage with stakeholders to develop prevention and self-care action plan

Identify outcome and process metrics

Commission/deliver agreed programmes / action

PSC Taskforce established

Work has commenced on developing a health inequalities framework by identifying practices with poorer health outcomes

A review of the literature detailing the effectiveness of self-care programmes has been completed and shared with all commissioners

Complete work to develop an inequalities framework

Engage with stakeholders to develop prevention and self-care action plan

Work with practices who have populations with poorer health outcomes to develop outcome and process metrics

Commission/deliver agreed programmes/action

Progress was made in 2014/15 to establish this work stream. Public health data on all practices has been compiled to identify practices with poorer population health

http://www.banesccg.nhs.uk/sites/default/files/FV%20BANES_5%20year%20strategy%20-%20full%20document_FINAL_19092014.pdf




outcomes with the intention of planning potential primary and secondary prevention initiatives in 2015/16.

Our commissioning Intentions for 2015/16 invited investment proposals from providers which support self-care and management where there is evidence of effective approaches. A proposal to promote self-care and address the needs of frequent attenders and patients admitted via the Emergency Department as a result of chronic benign pain is featured within our investment plans for 2015/16.

4.2 Improving Diabetes Care In our Five Year Strategy, we identified the redesign of the Diabetes Care Pathway to ensure that services are delivered by the most appropriately skilled person in the most appropriate setting and can respond to increasing demand. We are doing this by taking a whole system approach, emphasising the prevention and self-care agenda by up-skilling primary and community care providers working in partnership with specialists in diabetes care.




Establish diabetes steering group which has a sub-committee which includes patients and, if possible, Diabetes UK representatives

Review joint working arrangements with neighbouring CCGs

Benchmarking, prediction of future activity and spend – note the review of current service provision

Establish high quality evidence based model and appraise funding mechanisms

Consider pilot of virtual wards in primary care with consultant input

Consider impact of re-designing community services on provision of diabetes services.

Diabetes Care Pathway Redesign Group established

Discussions with Wiltshire CCG regarding opportunities for joint working

Work has commenced to benchmark and predict future activity and spend

Review of the evidence regarding effective models of care to agree local model

Patient survey completed to inform the supported self-care element of the pathway

Continuing care element of the local diabetes pathway agreed and implementation plans

Implement the investment in the continuing care element of the pathway in April/May in Bath West Cluster initially and evaluate

Review and evaluate the pilot and plan further roll out

Confirm options for diabetes specialist nursing and dietetics service

Establish high quality evidence based model and appraise funding mechanisms

Establish prevention strategy for diabetes with Public Health and the Council

Commence scoping work for second LTC


Consider impact of CCG primary care strategy and the potential need for investment in primary care in order to deliver the new model of diabetes care.

agreed beginning in Q1 of 2015/16

The diabetes care pathway is being redesigned in order to meet the increasing numbers of people with Type 2 diabetes. The aim is to deliver a high quality, patient-centred, cost efficient pathway across the healthcare community.

The new pathway will have an emphasis on delivering as much care as possible in a community setting with the use of care planning and robust, accessible support from specialists. This will take place alongside responsive specialist clinics in the acute setting. Emphasis will be placed on making the care as patient centred as possible, facilitating integrated working between all of the providers involved in diabetes care.

This work stream made good progress in 2014/15 with innovative work undertaken to connect data relating to diabetes patients. The Council and the CCG are working in partnership with the University of Bath to better understand current patient pathways. The work involves using patient NHS numbers to link service use and HbA1c results and the emerging findings show that:

32 per cent of the patients with diabetes also have depression

14 per cent more women than men have depression and diabetes (statistically significant)

Women with diabetes tend to be older than men with diabetes

Attendance on DESMOND group education courses is positively correlated with improved HbA1c and fewer hospital admissions

On average over the last five years, hospital admissions cost £600 more for patients who have not attended a DESMOND group educations course

Also underway is a patient survey of all patients with Type 2 diabetes. The purpose of the survey is to better understand patients’ perceptions of their diabetes and their opinions on the care they receive.


The Pathway Redesign Group has developed the ‘Continuing Care’ element of the pathway and helped to clarify the roles of primary care, secondary care and the community diabetes team. There are plans to implement a Community Diabetes Team, comprising a Consultant Diabetologist, a Diabetes Nurse Facilitator (specialist nurse) and the practice’s lead GP and Practice Nurse for diabetes with input from podiatry/dietetics as required. The Community Diabetes Team will meet regularly to discuss the care of patients with more complex needs. This arrangement is to be piloted in the Bath West Cluster commencing May 2015.

4.3 MSK Service Review and Redesign Our five Year Strategy set out plans for a whole system review and redesign of Musculo-skeletal services to achieve coordinated and integrated care across the entire MSK pathway. The review will potentially include the following services/ specialties over the five-year period:- Orthopaedics, Rheumatology, Pain Management, Physiotherapy, Osteoporosis and associated Podiatry services.




Establish Project Group to oversee MSK work streams

Establish baseline for MSK services to include reviewing current service specifications, activity and spend by provider, demand and capacity plans

Scope potential for further MSK pathway reviews and produce report

Complete review of existing community MSK models to inform decision on a preferred community MSK model for BaNES

Rheumatology - stabilise current Rheumatology service arrangements, working with Monitor. Work with Wilts CCG, Rheumatology Commissioning

Project resource allocated, scoping taking place and initial project plans developed

Joint Working with Wiltshire CCG on the MSK programme group. Pain pathway developed in conjunction with providers almost finalised

Joint working with Wiltshire CCG and Rheumatology Commissioning Alliance and providers to develop pathways

Hip and Knee pathway reviewed.

Rheumatology service acquired by RUH through stable transfer

Establish baseline for MSK services to include reviewing current service specifications, activity and spend by provider, demand and capacity plans

Scope potential for further MSK pathway reviews and produce report

Complete review of existing community MSK models to inform decision on preferred model

Pain management – implement pathway for community based service with a focus on services that will support self-care and management

Embed further the Referral Support service – improving referral support to ensure a more efficient


Alliance and providers to develop pathways

Orthopaedics – review of the hip and knee pathway reviewed

Pain management – develop pathway for community based service and implement

journey for the patient through the referral system ‘right pathway, first time’

This work stream has focused on completing work to stabilise the rheumatology service with the acquisition of the Royal National Hospital for Rheumatic Diseases (RNHRD), working jointly with colleagues in Wiltshire CCG and the Royal United Hospital and other co-commissioners.

In addition, a new pain pathway has been agreed, jointly with Wiltshire CCG. This will be implemented in 2015/16. An evaluation of our hip and knee pathway has been completed which confirmed its appropriateness and the positive impact on cost and quality outcomes.

4.4 Improving Interoperability In our Five Year strategy, we identified as a priority improving the interoperability of electronic patient records systems to improve service efficiency, effectiveness and patient safety through better use of data so that patients and professionals can access the right information, in the right place, at the right time.

We are not looking to introduce common systems but rather focus on the application of shared data that will deliver improved communications between health professionals and better patient experiences and outcomes. The programme will include tactical gains through specific improvements to existing systems and the overall aim of ensuring patients know that any clinician treating them has access to all information relevant to their care.




Establish governance and project team

Appraise technical options and existing solutions

Governance and project team established

Appraisal of technical solutions completed

Developed a shared vision for the health system and the IM&T Strategy to support it

Identified resource

Deliver approved Business Case and implementation plans

Flexible working – pilot the use of virtual desktop and server to explore mobile working and access to CCG networks from any device


requirements and potential funding for the next stage

Initial exploration with Wiltshire CCG re consistent approaches

Commence initial implementation

Excellent progress has been made in 2014/15 with support for the interoperability programme being agreed by the following organisations in our health and social care community:

BaNES GP practices

Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)

Wessex Local Medical Committee

BaNES Council

Bath and North East Somerset Urgent Care

Bath and North East Somerset Enhanced Medical Services

Dorothy House Hospice Care

Royal United Hospitals Bath Foundation Trust

RNHRD

Sirona care and Health Community Interest Company

South West Ambulance Service NHS Foundation Trust An option appraisal of the possible technical solutions has been completed and at a meeting of the Transformation Group in February, support was given for the proposal that the BaNES health and social care community joins the Connecting Care programme. This will enable the sharing of multiple flows of data between multiple organisations and offers the quickest route to a solution. This system has been piloted by the West of England Academic Health Science Network (WEAHSN) and is already live in Bristol, North Somerset and South Gloucestershire CCGs.

4.5 Improving Urgent Care In our Five Year Strategy we identified the creation of a streamlined urgent care system to ensure patients are assessed and treated by the right professional with access to the right diagnostic equipment and interventions first time. The system will have sufficient capacity to respond to increasing demands from an ageing population and the number of people living with long term conditions and will self-correct when patients present in anything other than the most appropriate setting.





Embed and assess the impact of the Urgent Care Centre on the Urgent Care System

Monitor impact of Southmead Hospital move on system and urgent care flows

Review role of the Minor Injury Unit at Paulton

Review and agree Special Patient Notes usage across the local health system

Identify priority ambulatory care pathways for development

Evaluate the 2013/14 winter pressure schemes

Pilot admissions avoidance Scheme e.g. Raising the Threshold

Fully embed demand and escalation planning

Embed new DVT pathway and service

Review of capacity and map out of hospital services

Work started to review impact of UCC

RUH as a provider have monitored Southmead impact patient flows

Project Manager appointed to lead work on Special Patient Notes

Winter pressure schemes for 2013/14 evaluated and informed decisions for 14/15

New DVT pathway and service in place

Mapping event with providers held in August – three priority projects identified as an outcome including piloting of Discharge to Assess and a proposed audit to review GP responsiveness to patients requiring an ED admission

Agreement regarding new ambulatory care pathways

Deliver actions set out within 4 Hour Recovery Plan

Complete review and agree refinements to UCC model

Re-specify the role of the Minor Injury Unit as part of community services redesign project

In conjunction with RUH implement revised ambulatory care pathways

Evaluate effectiveness of admission avoidance schemes set out as part of Better care Fund and pilot other schemes, e.g. further support for residential homes

Fully embed demand and escalation planning through whole system review via SRG of all providers capacity planning assumptions

Commission winter schemes on a substantive basis

Participate in broader emergency care networks that connect all urgent and emergency care services together

Implement national Urgent care CQUIN

In response to poor performance and failure to meet the national target of 95 per cent of patients being treated within four hours in 2014/15, there will need to be a renewed focus and commitment to restoring good performance in 2015/16. A


recovery plan has been prepared – see section 8.3.4 Meeting the NHS Constitution Standards and other Key Performance Targets.

Critical to this will be the local system’s preparation for known periods of escalation such as the periods following Bank Holiday weekends. In 2015/16 we will do further work to assess all of providers responsiveness in terms of seven day working.

4.6 Safe, Compassionate Care for Older People We have identified providing safe, compassionate care for frail older people through integrated health and social care community cluster teams as a transformational priority.




Commence new community cluster model

Embed links with the RUH ACE Unit and the community cluster team model

Launch redesigned social care pathway with expanded re-ablement services

Confirm strategy for investing the £5 per head for primary care

Roll out the active ageing service

Roll out personalised care plans shared and held by primary care and Sirona

Risk Stratification Tool to be used by active ageing service and community matrons using agreed criteria

RUH and Sirona to implement agreed frailty CQUIN

Quality Team to oversee work with providers, including third sector on safe,

Community cluster model in place

Social care pathway in place

£5 per head fully invested for 14/15 with some non- recurrent elements

Active Ageing Service fully implemented

Roll out of personalised care plans shared and held by primary care and Sirona commenced

Risk stratification tool being used by community matrons

Quality Team progressing work with providers re safe, compassionate care

Some patients have ‘special patient notes’ and project manager appointed to lead further development

Dementia Challenge Fund successful projects make recurrent

Adapt the community cluster Team in the light of first year learning

Embed links with the RUH ACE Unit and the community cluster team model

Confirm recurrent strategy for £5 per head

Scope other long term condition pathways that could be aligned to the five practice clusters

Complete roll out personalised care plans shared and held by primary care and Sirona

Review the falls pathway in the light of the active ageing service

Patients in the last 12 months of life to be on the End of Life Care Register with appropriate Do Not Attempt Cardiopulmonary Resuscitation orders if appropriate.

Every patient to have a Special Patient Note


compassionate care

Review the falls pathway in the light of the active ageing service

Patients in the last 12 months of life to be on the End of Life Care Register with appropriate Do Not Attempt Cardiopulmonary Resuscitation orders

Every patient to have a Special Patient Note

RUH and Sirona implemented frailty CQUIN

Implement Quality Premium for UTI’s in nursing homes

Implement Quality Premium based on CQUIN in nursing homes including safety thermometer

Our efforts in 2014/15 have been focused on consolidating the implementation of the community cluster teams, Active Ageing Service, and rolling out the redesigned social care pathway together with other complementary activities. To further support the potential of these arrangements we have funded primary care using part of the £5 per head allocations to engage in the multidisciplinary team meetings which are key to the success of the community cluster team model in supporting integrated management of our frail older population.

We have also agreed to fund projects from our Quality Premium to improve the care of patients in nursing homes. In 2015/16, the focus is on the care of urinary tract infections and improved patient safety using the safety thermometer.

There are significant links between this transformation project and the enabling elements of the BCF which enhance our integrated model of care for frail older people.

5. Other Strategic Priorities

Other priority work streams are: -

The ‘your care, your way’ review of community services in BaNES

Co-commissioning of primary care services and development of a primary

care strategy to support primary care to provide an increased range of

services and new models of care and operate at scale

Re-shaping mental health services in BaNES, delivering parity of esteem so

mental health is given equal priority to physical health

Improving children’s services to deliver special educational deeds and

Disability (SEND) Reforms


Continuing to improve Learning Disabilities Services

Delivery of the Better Care Fund Plan (Please see section 6)

5.1 Community Services Redesign In the early part of 2015, the CCG and the Council your care, your way has started to jointly undertake a comprehensive review of the current provision of community health and social care services in BaNES. We want to explore how we can further integrate primary, community, acute, mental health and social care for the benefit of our communities and neighbourhoods.

The contract for community services with Sirona Care & Health has been extended until 31 March 2017 to enable us to fully develop our commissioning strategy and further develop our future model for community services closely aligned with the Better Care Fund plan, the CCG's five year strategic plan, the Joint Health and Wellbeing Strategy and national drivers such as the ‘NHS’ Five Year Forward View and the Care Act 2014.

The CCG and Council will be engaging with key stakeholders and local people and communities to develop a commissioning outcomes based framework. Through this process we aim to respond to both national and local aspirations for health and wellbeing in the context of challenged resources for both the CCG and Council. We want to use this opportunity to establish ways of working that ensure people experience no fragmentation, duplication or barriers between the health (physical and mental), primary, acute and social care services. (Please see later section 8.2 re co-creating models of care).

To date the following has already been delivered:

Seven Project Work streams mobilised covering: Commissioning; IM&T; Communications; Finance; Estates; Workforce and Procurement

Project launch event at the end of January 2015 and 31 events held with a range of stakeholders including over 500 face to face contacts

The identification of some key themes from these events to support the development of future commissioning intentions

Strategic delivery model created focused around nine key community service functions – see diagram below


5.2 Primary Care The CCG has been working with NHS England to develop our arrangements for co-commissioning of primary care services and to shape the response to the key challenges facing primary care:

An ageing population, growing co-morbidities and increasing patient expectations

Increasing pressure on NHS financial resources

Growing national patient dissatisfaction with access to services (although patient experience in BaNES benchmarks very high)

Inequalities in access and a requirement to continuously improve the quality of primary care

Growing reports of workforce pressures including recruitment and retention problems

Our priorities in 2015/16 are: -

Develop a primary care strategy in conjunction with NHS England

Manage the transition to co-commissioning and develop and deliver the primary care work plan

Progress the Local Challenge Fund project

Complete a review of primary care based community services

Finalise our recurrent plans for the utilisation of the £5 per head monies to support GPs to manage over 75s

5.2.1 Developing a Primary Care Strategy for BaNES The role of primary care in BaNES is integral to the delivery of both our current operational plan and five year strategy, with a particular emphasis on its contribution to support the delivery of enhanced primary, community and mental health services provided seven days a week where appropriate. Our current high level strategy assumes the development of community-based services around clusters of practice


populations of 30-50,000. Over the coming months we will develop the component parts of our strategy further and test these with primary care colleagues and other stakeholders.

5.2.2 Co-Commissioning of Primary Care Services with NHS England We have been approved to jointly commission primary care services with NHS England. We believe that this offers the following benefits for the wider healthcare system:

Increased CCG influence on funding allocations in primary care and a greater local influence on decision making

Allows CCG to link and align the primary care strategy more fully to our five year plan.

A greater influence on service redesign across pathways and enables the CCG to more closely develop linkages between primary, community and social care

Ensures the quality of primary care is brought together under one over-arching process

5.2.3 Primary Care Work plan As part of the co-commissioning transition we have been working with NHS England and other local CCGs proceeding with joint commissioning, to develop a common primary care work plan. This will be tailored to local needs as appropriate. During 2015/16 the key work areas for NHS England and the CCG are planned to include: PMS Reviews, Local Challenge Fund, housing plan growth, premises priorities, GP IT and workforce development.

5.2.4 Local Challenge Fund We have worked with NHS England and Bath Enhanced Medical Services (BEMS+) to agree a programme of work (‘Primary Care, Preparing for the Future’) to support the development of primary care. The project in BaNES is focused on:

Focused weekend working targeted at preventing admissions from our most vulnerable patients in the community through the introduction of a GP appointment or home visiting service on Saturdays and Sundays

Partnership work with Skills for Health: to review the current workforce / skill mix in primary care and develop plans for better co-operation and collaboration between practices in BaNES

Improved use of IT: to facilitate the development of Practice IT systems, assistive technology and telephone services for primary care staff

The CCG and BEMS+ will be presenting an update on the project at a regional event hosted by NHS England in June 2015 to share initial learning. Reports from Skills for Health are expected during the course of 2015/16 and will help inform longer term planning with regard to new models of primary care.


5.2.5 Review of community based (Locally Enhanced Services) primary care services We have completed a review in conjunction with NHS England of all our community based primary care services to ensure best outcomes, quality and value for money. This review has looked systematically at all our services and has created a forward list for review and development.

5.2.6 Utilisation of the £5 per head monies for over 75s During 2014/15, the CCG applied in full the £5/head monies to support GPs to manage the over 75s. This included supporting some initiatives non-recurrently whilst we develop our longer term strategy for primary care. The initiatives supported to date are:

Enhanced primary medical services in nursing homes (the ‘Nursing Home LES’) – this was a highly successful pilot scheme to deliver proactive care to nursing home residents, which demonstrated significant reductions in admissions from nursing homes. The funding has been applied recurrently to secure the future of this service.

Supporting primary care to engage in the multidisciplinary team meetings central to the success of the community cluster team model, funded non-recurrently.

Providing additional targeted primary care capacity during the winter period to create additional system resilience alongside that funded by national and local ORCP monies, funded non-recurrently

By the end of May 2015 we will have evaluated these initiatives against options for recurrent commitment of this funding, in the context of our strategic plans to support our frail elderly population and to develop sustainable primary care services.

5.3 Children’s Services Our integrated commissioning team became responsible for Special Educational Needs Commissioning from September 2014. Our plans to implement the reform of education, health, social care planning include:

A Local offer of services for 0-25 age group

Co-ordinated assessments

Integrated plans for 0-25 age group

Personal budgets

Through our integrated commissioning arrangements with the Council we have been working to respond to emerging need and promote further emotional resilience and well-being for children and young people in BaNES. A number of initiatives/pilots have been agreed for 2015/16.

The Council has recently commenced a commissioning process for a one year pilot counselling service for secondary schools (Secondary Schools Counselling Service).


This is in response to a rise in both local and national levels of emotional distress and mental ill health in the 0-18/ 25 aged population. This is supported by funding from the Schools Forum.

The service aims to establish a system of school based counsellors, supported by a mental health practitioner from the local Child and Adolescent Mental Health Service (CAMHS). There is currently a counselling service in place for children in primary schools across BaNES, and current providers have been invited to quote for the proposed secondary school service. The service will be in place for some schools from June and available to all schools from September 2015.

The local CAMHS provider have been piloting direct access to CAMHS for 16-18 year olds in 2014/2015, this will be evaluated in 2015/16. In 2015/16 an investment proposal to develop a CAMHS one year pilot for vulnerable young people (care leavers, young people not in employment, education and training) 18-25 has been successful: this responds to local research that identified a gap between young people’s mental health criteria and adults.

The Council commissioned SHUE Survey, which will take place in the autumn of 2015, includes a series of questions around emotional health and well-being that will feed into future service review and commissioning intentions.

There are plans to develop further linkages between schools and the Health and Wellbeing College.

5.4 Mental Health To respond to the parity of esteem requirements set out within ‘Everyone Counts’ the challenge for the CCG, our local providers and other stakeholders is to consider more widely the mental health of people in BaNES through our strategies, planning, contracting and performance management. This approach requires:

Workforce development plans to show how providers will change their skill mix and support training for staff

The assessment of someone's mental health and offering psychological support to become routine

Mainstreaming prevention, promotion and self-management.

In 2014 our joint commissioning achievements include:

Establishment of a Wellbeing College – jointly commissioned between the Council, Public Health and the CCG.

The establishment of peer support workers in acute mental health settings.

Piloting of an on line counselling service for Young People.

Investing recurrently in mental health liaison support in the RUH

Establishment of a respite house.

Rolling out social prescribing.


Our priorities for 2015/16 include:

Improving inpatient facilities for mental health patients.

Meeting mental health choice and access requirements.

A focus on maintaining and strengthening emotional health and wellbeing in our community.

Working with providers to develop a methodology for them to assess performance in achieving parity of esteem for people with mental health problems.

Developing a whole system cultural and system change strategy with long term action plan.

Mental Health awareness and information support for NHS 111, ambulance and police personnel.

CCG focused training and development.

This work will incorporate and build upon our BaNES Mental Health Crisis Concordat Action Plan. BaNES was one of the first areas in the country during 2014/15 to establish a Concordat. Our successes to date include: the Section 136 suite for adults and young people; psychiatric liaison in the acute hospital, primary care and care homes; alongside an action plan for 2015/16. The Concordat underpins all the work in relation to the parity of esteem agenda as it already identifies our aspirations for 2015/16 in a wider than crisis context.

The Wellbeing College pilot also gives us an opportunity to assess the impact of a broadly educative model for self- management and early intervention by promoting healthy eating, smoking cessation, physical activity and emotional wellbeing. We can offer interventions to a wider audience and thereby address some of the differences in life expectancy experienced by people with mental health problems and improve quality of life for people who experience a reduction in emotional wellbeing due to physical health conditions. Please see Section 8.3.2 re inequalities in mental health.

We recognise that we need to strengthen our communication in the community about emotional health and wellbeing. We will work with colleagues in the Council to deliver a targeted and regular awareness and information sharing campaign related to emotional health and wellbeing across all age groups in the community. Using the available information resources, as well as linking into any new information portals provided as part of the implementation of the Care Act by the Council, we will build an emotional health and wellbeing section into our intranet site.

During 2015/16, we will continue to work to ascertain the best way to deliver improved in-patient mental health facilities in BaNES. A key aspiration is to plan for better access to integrated physical and mental health care and we hope to accommodate as much provision as possible on the site of the RUH.

5.4.1 Mental Health Waiting Times During 2014/15, we funded increased capacity in the out of hours emergency response service for social care, including the Approved Mental Health Practitioner service in light of the significant increase in activity over the past 12 months, which we are now satisfied is a longer-term trend. This service interfaces with the adult


social care services provided by Sirona care & health and Avon & Wiltshire Mental Health Partnership NHS Trust.

In order to achieve pre-existing and mandated new access and waiting time standards in mental health, we are working with other commissioners and colleagues in the specialist mental health services to ensure that appropriate data collection systems are in place. Current referral to treatment standards are set at 13 weeks and analysis at the end of 2014/15 confirms that waiting time standards are currently being met and we expect this performance to continue into 15/16.

It has been agreed with the specialist mental health and CAMHS providers that systems will be established to measure existing access times for people with a first episode of psychosis in order to identify any systems changes that need to be put in place to attain a two week referral to treatment target for 50 per cent of people needing a service. We intend to support the current service by increasing its ability to work into and across the third sector addressing the overlap within this client group between alcohol use and newly experienced psychosis.

To support delivery of these initiatives, we plan to provide additional recurrent investment in mental health services in line national planning guidance a minimum of 1.4 per cent in real terms compared to 2014/15. We also plan to establish a pooled budget with the Council for mental health services, for 2015/16.

5.5 Learning Disabilities We have well established integrated learning disabilities commissioning arrangements with the Council and a pooled budget.

Our priorities for development in 2015/16 are:

Developing housing, employment and education options for adults with learning disabilities and profound multiple disabilities, particularly younger adults moving to adulthood with complex physical needs.

Develop and implement revised assessment and care management procedures for people with complex needs who are not assessed through the re-ablement social care pathway.

Develop and implement revised transition assessments for young people moving into adulthood in line with Care Act 2014 requirements.

Commission appropriate advocacy support for adults with learning disabilities in line with Care Act 2014 requirements.

Continue to work with Sirona, children’s services and housing team to accurately scope and demand forecast need for appropriate housing, enabling people to live in their own homes.

Develop bespoke supported living options for (two) people currently in in-patient hospital beds, in line with requirements of Winterbourne View ‘Concordat of Action’ – this could include joint commissioning with neighbouring CCG’s/local authorities.

Joint working with Public Health and screening providers to improve access to national screening programmes.


Review the current provision of services for older adults with learning disabilities – this is a growing population - and develop housing and support options.

Continue joint working with local providers to support people to move from registered care to supported living arrangements

Develop an Autism Strategy in 2015/16

5.5.1 Winterbourne View Update Our well-established joint commissioning arrangements for adults with learning disabilities prevent admissions to inpatient services. Support via a range of community services is available to all people with learning disabilities, including people with significant challenging behaviours and complex needs.

There has been only one admission to inpatient services in the last three and a half years. There are currently only three inpatients from BaNES in out of county placements. Care and Treatment reviews have been held for two of these inpatients, in line with Transforming Care requirements. Named case co-ordinators are in place and active discharge plans are in development. One of the inpatients is being assessed for discharge to an identified community setting within one month. We are planning to discharge one of the remaining inpatients to a community service within three months. For the remaining patient, the care and treatment review concluded that the hospital placement remains appropriate. In all three cases, there has been family involvement in the decision-making processes.

The national stocktake completed by the Joint Improvement Programme in 2013 concluded that BaNES had agreed actions in place with regard to the funding, commissioning and discharge arrangements for people with learning disabilities. In addition the two ex- patients of Winterbourne View, who now live in their own homes, received very positive reviews from the Improving Lives team in 2014.

6. Better Care Fund Our commitment to the model of pooled and aligned budgets and common commissioning goals was re-affirmed in April 2013 in a partnership agreement between the CCG and Council. This model covers the whole of our shared agenda but is most fully realised around adult services, including mental health, learning disabilities, physical and sensory disability, carers and our older frail population. The Health & Wellbeing Board provides strong local leadership, holding the whole system to account for improving health and wellbeing outcomes, with a particular focus on prevention and early intervention. For BaNES the Better Care Fund acts as a further enabler and structure to build on and expand existing joint commissioning and provision. Our focus for the future is on further alignment of resources that influence the wider determinants of health and wellbeing.

We have framed our thinking about local whole-system integration in the context of the emerging “House of Care” model for BaNES which we will continue to develop and embed over the next five years. Key components of our integrated system are:


Step down accommodation

Support for carers

Independent living service

Community cluster teams

Social care pathway redesign

Integrated reablement

Wellbeing college

Social prescribing

Liaison services – alcohol, mental health primary care, psychiatric

Intensive home from hospital support The Better Care Fund has been a key enabler in developing and enhancing our integrated model of care, being used to secure new service developments that have, in a number of cases, been piloted and evaluated against key outcomes and also to increase capacity in key health and social care services, including those that are or will be accessible on a 24/7 basis.

We have identified a range of additional projects, using the new contribution from health resources into the Better Care Fund, which enable us to build and expand on the success of these existing schemes to further develop integrated services which benefit service users and their carers and enable more effective use of resources across health and social care.

The Better Care Fund Schemes can be categorised into the following groups:

Seven Day Working

Protection of Adult Social Care Services

Integrated Reablement & Hospital Discharge

Admission Avoidance

Early Intervention & Prevention

We are confident that in the longer term, by further embedding and developing our model of integrated care, we will relieve pressures on our acute services and help to eliminate the costs that arise from failures to provide adequate help to those at greatest risk. Over time, we expect there to be a reduction in the volume of emergency and planned care activity in hospital through enhanced early intervention and preventative services and improved support in the community

For 2015/16 we have allocated a BCF Fund of £12million and agreed a comprehensive BCF plan with our Council partners. This BCF plan is fully aligned to our shared view of increased reablement support with services that support people to take control of their lives and receive care and support in their homes and local communities. The BCF plan will be supported by a Section 75 agreement.

Together with the Council and our providers, we have reviewed proposed emergency admission scheme reductions in light of 2014/15 performance and ensured they continue to be fully aligned with the QIPP agenda. This has led to a reassessment of the BCF baseline period and a robust estimate of what might be


achievable in the coming year. We aim to reduce emergency admissions by 1.9 per cent in 2015/16. This proposed reduction in target was approved by the Health and Wellbeing Board in March and has already been shared with providers through the Transformation Group.

7. Our Commitment to Quality Quality is integral to everything we do as a CCG and we are committed to providing a culture of continuous improvement and innovation with respect to patient safety, clinical effectiveness and patient experience. As reflected in both ‘A Call to Action’ and ‘Everyone Counts’, we will ensure that quality is central to our local plans. This commitment is underpinned by sustained and effective collaboration within primary, community and secondary care and in partnership with other agencies and organisations and with the public.

The CCG adopted the key findings and learning from national reports including the ‘Francis report and the ‘Berwick report’ when published in 2013 to enable us to ensure we have a caring health system that puts ‘People First and Foremost’ in order to have open and transparent services, where staff are supported to do ‘the right thing’ and where they deliver the best possible care for our patients. We are also are currently reviewing the recommendations arising from Sir Robert Francis QC’s report February 2015 ‘Freedom to Speak Up’ on whistleblowing.

The CCG has a comprehensive Quality Strategy which underpins and will support our agreed programmes of work for 2015/16. We have signed up to the ‘Sign up to Safety’ campaign and our Quality Strategy Delivery Plan incorporates actions linked to the campaign’s five pledges. Data monitoring of outcomes and action to be taken, where required, is included in the quality dashboard and reports to Quality Committee and Board.

Find out more at http://www.banesccg.nhs.uk/sign-safety

7.1 Quality in Commissioning We take the need to provide equitable services across BaNES which meet the needs of the population very seriously. The CCG commissions services from a number of providers, commissions jointly with BaNES Council and is associate commissioner, working in partnership with the lead CCG for others. The quality and safety of provided services is assured through quality schedules, commissioning for quality and innovation indicators (CQUIN), monitoring of the quality impact of cost improvement schemes and site visits to major providers.

Provider contracts are updated each year using a collaborative approach and best practice. New guidance is reviewed and considered for inclusion and wider intelligence such as national data, incidents and complaints themes are taken into account and influence the quality schedules. Revisions and additions this year include:

Discharge and Transfer

http://www.banesccg.nhs.uk/sign-safety


Adult safeguarding- updated in line with the Care Act and new Prevent Guidance.

Children’s safeguarding- updated and strengthened with key performance indicators.

Surveys (Staff and Patient).

Reducing Antimicrobial resistance Compliance with PHE Start Smart (2013) and Focus Antimicrobial Stewardship Toolkit for English Hospitals included.

Optimising the use of Medicines - Trust Development Authority (TDA). Planning Guidance extract. Context: All Trusts should have a proactive approach to optimising the use of medicines to support high quality care included.

Clinical audit aligned with our strategic priorities.

Confirmation is provided that all new starters’ pre-employment checks are completed in accordance with NHS guidelines.

End of life care (taking into account ‘Making it Happen’. The provider will have robust processes in place to meet the needs of patients at the end of life. Reporting requirements to be agreed between the CCG and provider by the end of Quarter 1 to include measurable outcomes relating to:

- Quality of End of Life Care - Care in the last days and hours - Choice - Advance directives - Involvement of Carers

Clinical Responsibility- to implement Guidance for taking responsibility: Accountable clinicians and informed patients. (Academy of Medical Royal Colleges).

7.2 Patient Safety

NHS England Key Domain 5: Ensuring that patients in our care are kept safe from harm and protected from all avoidable harm We have and will continue to monitor commissioned provider organisations to ensure that patients are kept safe from harm and protected from all avoidable harm. We are a proactive member of the West of England Patient Safety Collaborative. The CCG Serious Incident, Complaints and Safeguarding Committee was established to review incidents and complaints and meets monthly. It reports directly to the Quality Committee and includes the review and monitoring of:

Action plans arising from serious incidents claims and complaints

Updates on Provider’s safety strategies.

Healthcare associated infections.

Safeguarding Serious Case Reviews, ensuring that the CCG and our providers work to protect vulnerable children, young people and adults at risk of harm


Other strategies for ensuring patient safety include:

Sharing and triangulating patient safety and quality information across agencies via the NHS England Quality Surveillance Group and by being proactive participants in the clinical networks and safety collaborative work streams.

Oversight by the Medical Director and Director of Nursing and Quality of the quality assurance process providers have in place for cost improvement plans to ensure there is no detrimental impact on patients.

Fostering a positive culture of reporting by introducing in 2015 a ‘purple flag’ system in primary care and with other providers to raise concerns in an open and honest way where concerns are raised across the pathways of care. A bespoke software system was introduced in December 2014 to support the recording of incidents and report on trends and themes. Feedback will be given at provider quality meetings and via primary care and care home newsletters. Pathways will be strengthened if required (examples include end of life issues where ‘handover of care’ arrangements between providers have resulted in less than optimal care for patients).

We are participating in and sharing learning from the network of safety improvement approaches shared by the regional safety improvement collaboratives. Examples of proactive engagement and sharing include: facilitating the adoption of the early warning scores across the health and social care economy; acute kidney injury guidance implementation; and further strengthening antimicrobial stewardship in 2015-2016.

Reducing the incidence of healthcare acquired infections. The multi-agency, multi CCG, and Public Health collaborative Health Care Associated Infections strategic group is led by the CCG.

7.3 Effectiveness of Care (which encompasses cost effectiveness, compassion, equality and diversity), NHS England Key Domain 1: Domain 2 and Domain 3

This means understanding success rates from different treatments for different conditions and we have and will continue to monitor commissioned provider organisations to ensure that patients receive high quality, clinically and cost effective services. This includes the review and monitoring of:

Hospital level mortality indicators/reducing avoidable deaths.

Readmission rates and discharge planning processes.

NICE compliance and Clinical Audit outcomes are reviewed at our NICE Implementation group and Quality Committee. We support provider audits in relation to the CCG strategic goals and have prepared an audit programme for 2015/2016. The priorities are: Urgent care, safe, compassionate care for frail older people, interoperability, diabetes, musculo-skeletal services and self-care and prevention.

Staff Appraisals, safer staffing levels and sickness.

Staff surveys including NHS Friends and Family Test.


Pathway development through our Transformational Programme work streams.

Research and development and innovation and initiatives. Recommendations from the national reports also include the need for improved training and education and the CCG has supported various schemes including the pilot compassion in care training for HCAs.

The CCG uses Quality Impact Assessments when reviewing new or existing services to ensure patient safety, experience and effectiveness of care provided is not compromised.

7.4 Patient/ Service User/ Carer Experience

(accessibility, acceptability and appropriateness) NHS England Key Domain 4: Ensuring that patients have a great experience of their care Quality of care includes the compassion, dignity and respect with which patients are treated. It can only be improved by understanding patient satisfaction with their experience and to achieve this, consideration is given to a wide range of information and action is implemented or monitored where required:

Quality meetings require providers to report on changes implemented as a result of feedback from FFT, complaints, Ombudsman reports, claims and other feedback including Healthwatch reports.

Trends from incidents or concerns arising from poor patient experience are shared with Healthwatch and bespoke pieces of work have been agreed with Healthwatch. Most recently these include an NHS 111 review (positive outcome) Urgent Care services and Care Home reviews (both currently being undertaken).

Care Quality Commission (CQC) reviews.

Monitoring and reporting on provider compliance with ‘Duty of Candour’.

In 2014, the CCG began using Privacy Impact Assessments when reviewing new or existing services.

Equality and diversity requirements- see section 7.8 below.

Through their Quality Accounts, our key providers of secondary, community and mental health and learning disabilities health care have demonstrated a commitment to improving outcomes for BaNES patients. This includes improving patient experience, reducing admissions and further reducing avoidable harm. We will work closely with providers of health care to ensure that they achieve this commitment to our population and that the local action as required within the implementation plan for ‘Compassion in Practice’ National Nursing, Midwifery and Care Givers strategy is reflected in the services we commission.

‘Heartfelt’ Heart failure FFT was introduced in nine practices in 2014 as part of the second phase pilot. Over 2000 patients responded. Practices implemented local changes as a result of feedback. We funded the remaining practices, enabling them to introduce FFT in December 2014 and have begun to monitor the outcomes.


7.5 Care Quality Commission During 2015/16 the CCG will continue to routinely use CQC inspection reports as one of a range of sources to support assurance of quality as well as bi-monthly intelligence sharing meetings with the Council and Care Quality Commission to flag concerns proactively, thereby minimising critical incidents occurring by taking proactive action at an early stage. Any issues highlighted will continue to be reviewed by the CCG’s Quality Committee.

7.6 Commissioning for Quality and Innovation (CQUINS) We will continue to utilise Commissioning for Quality and Innovation (CQUINs) to enable us to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals, in particular around four quality domains. This was subject only to any limitations arising from provider choices in respect of the 2015/16 tariff options but the CCG continued to plan for CQUINs across all providers and all providers with the exception of one wish to continue to have CQUINs.

7.6.1 Summary of Positive Outcomes in 2014/2015 We agreed CQUINS with the Royal United Hospital Bath NHS Trust and Sirona care and Health for frailty for implementation in 2014/2015 and we are working with our third sector colleagues to take this important work forward in a quality premium scheme called ‘Hale and Hearty’ which began in January 2015.

The number of antibiotic prescriptions that had a review or stop date documented on the medicines chart increased and the number of intravenous antibiotic prescriptions that have a documented review within 48 hours increased by over 20 per cent to 93.5 per cent in Quarter three.

Sepsis management saw a significant improvement on the 29 per cent trajectory set for antibiotics given and lactate measured within one hour at 53 per cent for quarter three.

The End of Life Care local CQUIN saw the successful implementation of the Conversation Project being undertaken on all specified wards.

7.6.2 CQUINS for 2015/2016 We expect to implement CQUINS for the four themes identified as national CQUINs in the areas of: -

Dementia and delirium care and updating the physical health care of patients with mental health problems (continued through from 2014/15).

Improving urgent and emergency care across local communities.

Sepsis (The RUH had a Sepsis CQUIN in 2014/15 and made good progress against it).

Acute Kidney Injury.


7.6.3 Local CQUINS In collaboration with partners, we held a successful local CQUIN Planning Event on 10 December 2014. This identified the following areas as the basis of developing local CQUIN schemes, of which the first three are now most fully developed:-

The 2015/2016 Local CQUIN on discharge planning has taken into account the findings and recommendations of the 2014 Healthwatch Discharge report. Expected outcomes include improved transport arrangements, increase in number of times medications are available and discussed with patients and carers, increased per centage where patient and carer involvement is demonstrated. Trajectories are currently being agreed.

Local parity of esteem CQUIN, supporting the introduction of the national ‘Brief Encounters’ resource tool which includes training and development of staff groups in all providers who may see vulnerable patients.

CQUINs and contractual clauses linked with antibiotic use and antimicrobial stewardship in development. Also Quality Premium focus and BaNES, Gloucester, Swindon and Wiltshire (BGSW) collaborative approach.

End of Life - agreed process for early Advanced Care Planning and embedding of treatment escalation plans (TEP) across all health sectors.

Staff health and wellbeing and Making Every Contact Count

Nutrition - Hospital/community food exemplar.

7.7 Quality Premiums Our proposals for the Quality Premium for 2015/16 are detailed in Appendix 1b. These include the national requirements with our local proposals for:

Urgent and Emergency Care

Increase in level of discharges at weekends and bank holidays

Reducing NHS-responsible delayed transfers of care (days) Mental health

Reduction in the number of patients attending an A&E department for a mental health-related need who:

a) wait more than four hours to be treated and discharged, or admitted (compared to all A&E attendances) together with b) a defined improvement in the coding of patients attending A&E.

Reduction in the number of people with severe mental illness who are currently smokers.

Antibiotic Resistance

Improving antibiotic prescribing in primary and secondary care: a) reduction in antibiotic items/STAR-PU b) reduction in broad spectrum antibiotics prescribed c) acute provider data validation for RUH


Local Measures

Responsiveness to In-patients' personal needs.

Increase in incident reporting in primary care by 20 per cent

Please see Appendix 1b Measures of Success.

Quality premium monies earned in 2014 were used in December 2014 to support a variety of quality initiatives. The projects in place and being evaluated currently however, initial impact has been positive with initial outcomes included below:

To date, seven care homes are participating in the FFT pilot with the first patient experience report received in March 2015.

13 Care homes are participating in the safety thermometer scheme and the CCG interim care homes nurse is already raising issues with care homes and reporting concerns to the CCG and Council. This post has also supported the Council on QA visits as required.

10 nurses have been recruited (funded via Quality premium monies) to undertake a diabetes diploma module. 7 nurses have started the training; the remainder will start in 2015/16.

The Hale and Hearty (Age UK) admission avoidance scheme supporting people living with frailty to live independently has commenced.

Antimicrobial stewardship: The existing practice pharmacists were enlisted to deliver a 3 pronged intervention over the 6 month winter period October 2014 to April 2015. Our volume of antibiotic prescribing has reduced by 14 perccent in past 12 months.

The implementation of European Antibiotic Awareness day (EAAD 2014) was promoted and supported in line with the national and local campaigns. This campaign is targeted at both healthcare professionals and the public have been fully engaged. GPs report increased patient awareness of antimicrobial resistance and the need to use antibiotics sparingly. This makes ‘no antibiotic’ discussions in consultations easier.

7.8 Equality and Diversity We are subject to the legal obligations arising from the Equality Act 2010. Section 149 of the Equality Act 2010 places a Public Sector Equality Duty (PSED) on all statutory public authorities and those who act on their behalf.

Our Equality Strategy and Action Plan supports the CCG in tackling current health inequalities, promoting equality and fairness and establishing a culture of inclusiveness that will enable health services in BaNES to meet the needs of all its population.

7.8.1 Profile of equality groups in BaNES We use a range of data and information including the Joint Strategic Needs Assessment JSNA when consulting on and commissioning services. We work closely with the Council public health and research and intelligence teams to ensure we share the most up to date information available. Knowing our community and

http://www.bathnes.gov.uk/services/your-council-and-democracy/local-research-and-statistics


recognising its diversity is pivotal to the commissioning of modern, high quality health services.

7.8.2 Equality in Commissioning Our aim is to commission modern, high quality health services that recognise and value the diversity of our communities and we believe that meeting equality needs is pivotal to this aim. To turn this intention into a reality we carry out equality analysis (equality impact assessment) as an integral part of commissioning projects.

Equality analysis uses a process of systematically analysing a new or existing policy or service to identify what impact or likely impact it will have on people of differing groups within our community. It aims to identify any discriminatory or negative consequences for a particular group or sector of the community, and to prompt us to consider what positive actions we need to take in order to meet the needs of people with protected characteristics. Equality analysis can be carried out in relation to service delivery as well as employment policies and strategies.

As we commission jointly with the BaNES Council, equality analyses are published on the CCG or Council websites. BaNES equality analysis.

7.9 Safeguarding Vulnerable Children, Young people and Adults Working with partner organisations and health providers to protect vulnerable children, young people and adults is a key priority for the CCG. Some patients and members of the public may be unable to uphold their rights and protect themselves from harm or abuse. They may have greatest dependency on our services and yet be unable to hold services to account for the quality of care they receive. In such cases, we have particular responsibilities to ensure that those patients receive high quality care and that their rights are upheld, including their right to be kept safe.

Our Adult and Children’s Safeguarding service is designed to ensure that the BaNES population are in receipt of safe, high quality services. Integral to this is assurance for people who use services, and their carers that the delivery of services is based on the following themes:

1. Strategic clinical leadership

2. Quality care

3. Partnership working

4. Robust contract management

We are working with our partners including local police, social care, education, care homes and other local statutory and voluntary organisations and with our GP practices and other health care organisations to strengthen arrangements for safeguarding adults and children in BaNES. Within the CCG, Children’s and Adults’ safeguarding issues are considered in detail at the Serious Incident, Complaints and Safeguarding Committee which reports to the Quality Committee and, in turn, to the CCG Board. The following arrangements are in place:

Bespoke adult and children's safeguarding standards are included within all provider contracts, monitored by CCG and Council. Plans were agreed using

http://www.bathnes.gov.uk/services/your-council-and-democracy/equality-and-diversity/equality-impact-assessments


the Local Safeguarding Children’s Board and Local Safeguarding Adults Board work plan and recommendations. Detailed plans are contained within the Quality Strategy and Delivery plan with regular reports on outcomes to the Quality Committee and Board. There are close links with the Local Team and Council Safeguarding team to support primary care development.

In 2014, the two prompt cards produced by NHS England – Adult Safeguarding and Mental Capacity Act were distributed to all providers including primary care with contact details of the CCG and Council lead.

The named GP distributes regular adult safeguarding newsletters to primary care.

Two Mental Capacity Act (MCA) / Deprivation of Liberty’s (DOLS) training sessions for primary care clinicians have taken place in November and February 2015. These were delivered by the Council MCA/DOLS lead with facilitation by the named GP.

Monitoring of MCA/DOLS is part of the contractual requirements and site visits are undertaken.

A pack containing a range of national literature and guidance on Prevent was sent to all providers in May 2014. Work continues with providers to ensure they have recruited named Prevent leads and are delivering against our contract.

Providers will be required to include training numbers in reports.

We are a member of the South West Prevent lead network and will report assessment criteria progress to Quality Committee.

We attend the BaNES Prevent steering group. The impact of the ‘Counter-Terrorism and Security Bill’ is to be assessed. We are working closely with providers and monitoring Prevent implementation via contracts and returns. All providers were recently requested to complete an annual Prevent self-assessment.

7.9.1 We have identified our safeguarding priorities for 2015/16: We will ensure that we continue to meet all our statutory safeguarding children responsibilities and that we are compliant with the NHS England accountability and assurance framework, and that safer recruitment processes are complied with.

Working with both children and adult health and social care services and families, we will develop strengthened strategies in health and in partnership for helping children and families cope with transition and change and minimise the risk of harm occurring during transition.

We will work with GP practices in strengthening their engagement with safeguarding children and adults processes by:

Developing a training programme in partnership with NHS England Area Team.

Support the implementation of the general practice-based domestic violence and abuse (DVA) training support and referral programme (Identification & Referral to Improve Safety- IRIS) which has been funded by the CCG in partnership with the Police and Crime Commissioner.


There is also continued engagement with Public Health to ensure the Joint Strategic Needs Assessment (JSNA) appropriately identifies the needs of the whole population including those with Learning Disabilities and that these needs are incorporated into the commissioning strategy. This ensures the CCG will continue to implement the important requirements of Transforming Care: a national response to Winterbourne View Hospital.

7.10 Developing Practice Nurses We are proactively working with the NHS England South region to support the continued development of practice nurses as part of the larger primary healthcare team working in GP Practices and using diabetes specialist nurse support to up skill primary care. The aim over the next two years is to identify the workforce planning needs for the future by working in partnership with the universities and to support practice nurses with further training and experience to provide them with opportunities to apply for senior nurse positions, including nurse practitioner level where they may then manage their own caseloads.

7.11 Clinical Accountability The Clinical Commissioning Reference Board will lead a review of the Academy of Medical Royal Colleges’ Guidance for taking responsibility: accountable clinicians and informed patients and identify actions required to embed appropriate arrangements across all care settings. This group includes representatives from primary and secondary care and neighbouring CCGs. Clinical accountability is currently implicit in some key projects but linkages need strengthening. There is work in progress but this needs mapping across the system. There is an expectation that will be a key feature of the primary care strategy.

8. Forward View into Action: Planning for 2015/16

Our plans aim to respond to the Five Year Forward View and to meet the additional requirements set out in the planning guidance The Forward View into Action 2015/16

Creating a new relationship with patients and communities

Co-creating new models of care

Priorities for operational delivery in 2015/16

Enabling change

Driving efficiency

8.1 Creating a new relationship with patients and communities

8.1.1 Implementation of personal health budgets From April 2014 patients in receipt of Continuing Heath Care (CHC) Funding have had the right to ask for a personal health budget (PHB). Working collaboratively with the Council, good progress has been made within the CCG, developing robust governance and monitoring processes for implementing personal health budgets


(PHBs) in line with the NHS England Quality Markers. This will ensure that the safety of patients is paramount.

Administrative and care planning processes have been tested to ensure that the patient experience of PHBs is positive and that PHBs can be delivered cost effectively. The aim is to embed the principles of personalisation.

From April 2015 people with long-term conditions must have a personalised care plan which could include a PHB if the CCG think the individual would benefit.

The CCG continues to roll out personal health budgets to an increasing number of CHC clients, and plans to expand the offer to young people as linked with the SEND reforms as the next group. We will be piloting the introduction of personal health budgets for children with long term conditions. Further details are included in our Commissioning Intentions. The CCG is part of the integrated personal commissioning pilot as part of the South West network.

8.1.2 Commissioning for Prevention The five steps in the Framework for Commissioning Prevention strongly influenced the CCG Five Year Strategy and the six priority work programmes, including “Increasing focus on prevention and self-care”. See section 4.1 Transformational Priorities.

The five steps in the Framework for Commissioning Prevention include:

Analyse key health problems

Prioritise and set common goals

Identify high impact programmes

Plan resources

Measure and Experiment

Our Five year plan clearly demonstrates that we are following this approach and there is a prevention element to each of our priority work streams. For example, our BCF Plan also includes an increased focus on and investment in prevention and self-care including:

Multi-disciplinary team approach aligned with GP clusters focused on prevention/early intervention for those at greatest risk of admission

Integrated reablement aimed at reducing and/or delaying the need for more complex interventions and/or admission

The planned outcomes from this approach include:

Individuals supported and confident and able to take increasing responsibility for their own health and wellbeing

Practices offered targeted intensive support to tackle health inequalities and provide health lifestyle and early intervention services

Please see also section 8.3.2 re tackling inequalities.


8.1.3 Choice The Forward View promised to make good the NHS’ longstanding promise to give patients choice over where and how they receive care. Particular priorities for 2015/16 are mental health and maternity services.

Maternity During 2015/16, we will work with other commissioners and the provider to deliver the maternity pathway tariff. Implementation of which has been delayed due to the change of provider in 2014 from Great Western Hospitals Foundation Trust to the RUH. This tariff-based funding will support women to make choices about where and how their care is provided, and this may cut across more than one provider.

We recently retendered our maternity services (June 2014) and choice of place of birth was articulated within this. Women can choose whether to deliver at home, in a midwife led birthing centre or in an acute hospital, with guidance on clinical risk for both mother and baby. Commissioners and providers continue to work with the Maternity Services Liaison Committee on women’s choice of place of birth, birthing choices in relation to space in which they give birth, pain relief and presence of others at the birth and afterwards e.g. partners staying for the first night.

As we have recently retendered the service, we do not currently have any plans to set up any additional midwife led services. However, we continue to work with service users receiving feedback through healthwatch, friends and family tests and we plan to invite service users to attend our service visits going forward.

Pre-pregnancy care is highlighted as part of our ‘self-care’ programme in relation to long term conditions e.g. diabetes and epilepsy. Women with additional physical or mental health needs are supported by specialist midwives.

Antenatal care is offered in a range of locations, although predominantly in midwife bases. Care may be supplied by one provider and transferred to another in relation to choice of place of birth. Post-natal care is also predominantly delivered from midwife bases before transfer of care to health visitors. Commissioners continue to monitor and improve the liaison between midwifery and health visitors.

Mental Health

Work will continue with current providers of NHS funded services plus GPs and assessing teams to implement choice as described in the Mental Health Guidance, December 2014.

Due to the current block contract (with a shadow tariff arrangement) with Avon and Wiltshire Partnership and five other CCGs, work will take place between commissioners and the specialist mental health provider to understand the scope and impact of cross border choice with that provider and continue to embed a tariff arrangement that is in line with national expectations of progress.

8.1.4 Listening to the Voice of Service Users In 2014/15 the CCG set up ‘Your Health, Your Voice’, a forum of over 40 members of the public which supports the CCG’s public and patient involvement work on


commissioning issues and acts as a critical friend to the CCG in terms of reviewing proposed service changes. Members of ‘Your Health, Your Voice’ make a much valued contribution to our planning and delivery process and we look forward to continuing to work together over the coming year. In January 2015, the CCG and Council, embarked on an extensive engagement process to seek ideas and views on local community services. Entitled ‘Your care, your way’, public engagement will continue throughout 2015/16 and provides an opportunity for us to work with a range of stakeholders, to listen and help us shape future service requirements.

Some key communications activities for 2015/16 are to update our communications and engagement strategy, review and redesign our website, staff intranet and GP portal and expand our presence on social media platforms. These developments will enable us to strengthen engagement with and support from a broad range of stakeholders.

8.1.5 Community Volunteering A number of our work streams recognise the potential contribution of community volunteers through a range of activities. During 2015/16 we will develop our approach for volunteering which draws together and aligns these individual initiatives, and which we anticipate may include the following elements:

Drawing together of volunteering concepts emerging from major work streams including the community services redesign project, the Better Care Fund, the developing primary care strategy and the Wellbeing College.

Linkages with existing sources of voluntary support and information.

Support for navigation through and between services.

Advocacy roles.

Targeted initiatives for groups with specific needs, for example young people and their parents, those transitioning to adult services, carers, people with multiple or complex long term conditions, and the frail elderly.

Opportunities for collaboration with the Council in the context of their wider goals for community cohesion and strengthening communities.

8.1.6 Carers and Staff as Carers We have a well-established, joint approach with the Council based on a joint strategy and joint commissioning of services for carers, and young carers. Our focus during 2015/16 will be on better developing our approach to meet the specific needs of carers who are over 85.

Arrangements for staff who are Carers are in development. In 2015/16 we will review the Flexible Working Policy, promote the Joint Carers Strategy to staff and return to work support plans. These will be developed together with staff representatives.

8.1.7 NHS Workforce Our own Staff We undertook a staff engagement survey in November 2014, developing a set of questions tailored to the CCG’s priorities and requirements and focusing on:


Job Satisfaction

Resources and Improvement

Training & Development

Team Working

Communications

Social Activities

Working Environment

Incidents of violence, harassment and abuse at work

Leadership

Living the CCG’s values

The survey had a very high response rate of 85 per cent with compares very favourably with the last national survey response rate of 49 per cent in 2013. There were many positive messages for us regarding:

Commitment and passion for the work we do

Strongly identifying with the CCG Values and Vision

High level of respect for CCG leadership

Freedom to show initiative

Effective team working

Participation in appraisals

Good communications via Staff Bulletin

New programme Management Office viewed positively

Some areas of concern were highlighted and these are addressed in an action plan approved by the Executive Team:

Concerns about numbers of staff overall and the impact on workloads

Communications between teams

Concerns about whether the current structure is ‘fit for purpose’

Concerns about the working environment

Concerns about the effectiveness of the CCG internet and intranet

Our focus during 2015/16 will be implementing the action plan and establishing a staff Health and Wellbeing Group which will have responsibility for assisting the CCG to provide comprehensive induction and respond appropriately to staff surveys; reviewing policies which impact staff welfare e.g. Flexible working Policy and Special Leave Policy; developing a healthy workplace and assisting the CCG to implement NICE guidance for the NHS workplace. The CCG inherited a Staff Health and Wellbeing Policy from predecessor organisations and this will be reviewed and updated.

Staff in the Local health Economy

All providers are and will be required to report on detailed staffing indicators (alongside safer staffing) during 2015/16. These will be monitored by the Quality Committee alongside incident, safeguarding and complaints information and supported by a quality site visit programme.


We will also continue to review Staff FFT with providers and monitor the action agreed to improve staff satisfaction. These are and will continue to be included within the Quality Dashboard as part of our routine Integrated Quality and Performance Report.

Safer Staffing levels: These indicators potentially impact on patient experience, safety and staff satisfaction. Monitoring is in place with all providers and areas of concern are raised at the contracts meetings. Local acute hospitals were below the planned day and night hours for registered nursing staff in January 2015. However the RUH and UHB exceeded their planned staffing levels for unregistered care staff.

The overriding aim is to achieve excellence and commitment to high quality clinical care and all the satisfaction that comes from doing the job well. Over the next two years we will build on existing strengths to ensure staff are properly inducted, trained and motivated and there is a high level of staff satisfaction and opportunities for innovation by:

Collaborative and multi-organisational work streams for frontline staff. These include ‘Falls Prevention Group, Pressure ulcer reduction group, Care Home Forum, Practice Nurse Forum, Infection Prevention and Control Link Professional Forum, Safeguarding lead network, Early Warning Score Collaborative, End of Life Collaborative. These empower front line staff to contribute to the delivery of safe and effective services and raise concerns.

Supporting training and development, for example currently supporting ten practice nurses to undertake a diploma in diabetes management by June 2015.

Creative use of funding e.g. Quality Premium to support developmental opportunities.

Using outcome measures including decreases in serious complaints and incidents, reduced number of bank and agency staff used, reduced levels of sickness.

Using contractual levers and incentives which encourage providers to focus on factors which influence staff wellbeing.

8.2 Co-creating New Models of Care

8.2.1 Community Services At the end of January 2015, the CCG and Local authority launched a review of Community services in BaNES through a programme called: your care, your way. We have met with a wide range of stakeholders to seek their views on how community services in BaNES could be improved to respond to the changing needs of our local population.


Our review of Community services programme has 4 phases:

Our current Community Services contract with Sirona care and health for the provision of a range of integrated health and care services has been extended until April 2017 whilst we work through the options for the future of community services in BaNES.

In our review of community services we will be taking account of the starting point of our local health and care economy and the new models of care set out within the Forward View.

Whilst we are undertaking this review process, the CCG may still seek to encourage the development of new models of service delivery and integrated working across our commissioned services. For example, we are particularly keen to develop the model of enhanced health in care homes in BaNES. The CCG has already a well-established enhanced service for the provision of support to nursing homes. Here, proof of concept has been evidenced through reductions in admissions from nursing homes to the acute sector. In 2015/16 we would like to pilot a similar approach for residential homes as part of an integrated approach and programme of work to respond to the needs of this sector.

8.2.2 The role of Primary Care Key to the development of new models of care and provision is clarity on the strategy for Primary Care services in BaNES as part of the wider requirement to deliver Out of Hospital Services.

In 2014/15, in conjunction with NHS England the CCG jointly funded a Local Challenge Fund Project, which has three distinct work streams: -

i). Working with Skills for Health in looking at primary care workface requirements and opportunities for collaboration across practices.

ii). Developing a common website and communication platform across all practices and


iii). Piloting of a GP led Proactive Weekend Service to help prevent admissions to the acute sector.

This project will continue into 2015/16 and we anticipate that the outputs will accelerate progress on shaping the future plan for primary care services in BaNES.

For 2015/16, a number of bids have been submitted by BaNES practices against the £250m national Primary Care Infrastructure fund. The CCG has confirmed support for bids in line with our local strategic direction. However, we anticipate using 2015/16 to develop fully our primary care strategy (Please see section 5 Other Strategic Priorities – Primary Care) which will support the development of other proposals against 2016/17 funding.

We are also working closely with the Council to consider the impact of the Core Strategy and housing developments in BaNES and their likely impact on future health infrastructure needs. There is a real opportunity to develop our joint approach to place based commissioning and maximise opportunities for joint location of key public services.

8.3 Priorities for operational delivery in 2015/16

8.3.1 Outcomes and Ambitions Everyone Counts set out a commitment from NHS England to improving outcomes in five key domains:

Preventing people from dying prematurely, with an increase in life expectancy for all sections of society.

Making sure that those people with long-term conditions, including those with mental illnesses, get the best possible quality of life.

Ensuring that patients are able to recover quickly and successfully from episodes of ill-health or following an injury.

Ensuring that patients have a great experience of their care.

Ensuring that patients in our care are kept safe from harm and protected from all avoidable harm.

The domains have been translated into a set of specific measurable outcome ambitions that will be the critical indicators of success, against which progress can be tracked. Our trajectories for 2015/16 are detailed in Appendix 1b – Measures of Success.

8.3.2 Reducing Inequalities From our Five Year Strategic Plan we have a baseline understanding of the health inequalities in the BaNES area and a clear commitment to actions which will reduce the gaps in experience and outcomes between different sections of our population. In 2015/16 we will work with Public Health and the Health and Wellbeing Board to create a Health Inequalities Action Plan which includes the following elements:

A refreshed view of the baseline position, drawing on the JSNA and our compilation of public health and other data by practice, completed in 2015/16.


Clear articulation of our goals in reducing inequalities, recognising the extent to which the CCG can influence this and the potential for contribution by partner organisations and through self-care and prevention initiatives.

The evidence base for existing and planned initiatives.

Capturing existing and new initiatives into a single, coherent work plan.

Work streams for areas of specific focus, for example mental health. The Health and Wellbeing Board will be discussing a draft plan in June 2015. National Audit Office Report on Inequalities

We have noted the recommendation by NHS England to include plans for the widespread systematic adoption of the most cost-effective high impact interventions as recommended by the National Audit Office report into Health Inequalities, and the public accounts committee Report into Tacking Inequalities in life expectancy. The recommendations include:

Increased prescribing of drugs to control blood pressure

Increased prescribing of drugs to reduce cholesterol

Increase smoking cessation services

Increased anticoagulant therapy in atrial fibrillation

Improved blood sugar control in diabetes

Within BaNES, currently our achievement in respect of these indicators is good however the 10 per cent of patients who do not achieve the appropriate thresholds may well be in the most deprived, chaotic and disadvantaged groups. We wish to focus our efforts on specific targeting of the health checks programme to more effectively tackle health inequalities.

We have conducted a needs assessment to identify general practices with poorer population health outcomes so that we can plan and focus primary and secondary prevention initiatives for this group. Amongst the people identified at high risk, we would plan to provide the relevant support for smoking, high blood pressure, high cholesterol, etc in a way that makes services most accessible to this group.

A particular approach is required to address the gap in life expectancy for people with a severe mental illness. Although suicide rates are higher amongst this group than the general population, evidence suggests that almost 80 per cent of the excess deaths in people with a mental illness are attributable to physical health conditions. The evidence also suggests that people with a mental illness have not benefitted to the same extent as the general population from recent advances in reducing deaths from common physical health conditions, widening the inequality gap.

Initial analysis suggests that, in BaNES, the premature death rate for people in contact with specialist mental health services is almost five times as much (1,329 per 100,000 compared to 282 per 100,000 in 2012/13) as in the general population, and slightly above the England average in each of the last four years for which data is available.


During 2015/16 we will work with Public Health in the context of the overall Health Inequalities Action Plan to identify targets and actions in respect of this specific area, recognising that these may need to be long term in nature. We will consider potential solutions including the following, based on a recent BMJ study:

Adapting existing population health and health promotion approaches to target people with a mental illness.

Use of peer supporters and healthcare skills training.

Development of coordination, case management, or liaison roles supporting. the overall health needs of people with a mental illness.

Co-location of physical and mental health services.

Health system improvement targets.

8.3.3 Improving Cancer Outcomes Our capacity planning assumptions for the coming year take account of the impact of national campaigns to improve early diagnosis of cancer. For 2015/16, we are planning for the impact of the current oesophago-gastric cancer campaign (which is expected to increase the demand for endoscopies) and have included additional activity within 2015/16 contracts. We are awaiting further guidance on plans for future national campaigns.

In 2014, we appointed a Macmillan-funded GP for two sessions a week, to work with primary care to identify where the CCG needs to focus efforts on improving cancer services in the four key areas: prevention; early diagnosis and better treatment; care and aftercare; and how GPs can be supported to improve service delivery. The Forward View notes that a new cancer strategy will be developed with national charities. The Macmillan GP will help the CCG to develop a local strategy and delivery plan following the release of the national strategy.

We will continue to monitor provider performance against national cancer targets through the monthly contract review meetings, with a particular focus in 2015/16 on waiting times for diagnostic tests.

The Bath Cancer Forum was established in 2014 and meets every two or three months. It is jointly chaired by the CCG Commissioning lead and an RUH clinician and has membership across local NHS and voluntary sector providers, CCGs (Wiltshire & Somerset) and cancer charities including Macmillan. The Forum provides an opportunity for the CCG to engage with local clinicians on initiatives to improve cancer services but also acts as a reference group for commissioning services.

We will continue to participate in the work of the South West Strategic Clinical Network for cancer services and value their advice, guidance and information to support commissioning. We will review national datasets that monitor one year survival rates, with providers on a regular basis. We also plan to involve the Bath Cancer Forum in tracking one year survival rates.


8.3.4 Meeting NHS Constitution Standards and other Key Performance Targets The CCG has met many key national and local targets in 2014/15 but across our broader health and care system we have been particularly challenged in sustaining performance against the NHS Constitution’s 4-hour A&E waiting time target, Referral to Treatment Times (RTT) delivery of the Improving Access to Psychological Therapies (IAPT) targets for recovery and improving delivery of dementia diagnosis rates. We will continue to focus our response and ensure robust performance management and delivery against these specific areas in 2015/16.

We are planning to deliver all the NHS Constitution Targets in 2015/16. Please see Appendix 1a Measures of Success.

Accident and Emergency Waiting Times Delivery of the NHS Constitution’s four hour A&E waiting time target is one of the highest priorities for our health and care economy. A Recovery Plan to secure delivery of the 95 per cent target in Quarter one of 2015/16 has been developed. This will continue to be progressed and monitored through the System Resilience Group (SRG) which comprises senior representatives from the CCG, health providers and Council.

Referral to Treatment waiting time targets (RTT) We plan to meet all 18 week RTT targets in 2015/16. However, some local providers including our main provider, the RUH, are indicating potential planned failures in individual months for admitted pathways, which may create risk to overall delivery. This is linked to the backlog position emerging due to the impact of activity in December and January. We have an 18-week Recovery plan and continue to work through capacity plans for 2015/16 with our local providers to ensure we make best use of our combined resources to deliver safe and high quality services for everyone.

Our Referral Support Service (RSS) which is designed to improve the quality of referrals to secondary care and support patient choice discussions went live on 1

December 2014 as planned starting with five practices and five specialities (Dermatology, Ophthalmology, Orthopaedics, Pain and Urology) Three more specialties were included from January (Cardiology, ENT and Gastroenterology) and the RSS is about to take referrals from another ten practices. Further roll out will take place in 2015/16.

8.3.5 Dementia We have set a target for dementia diagnosis rates of 60 per cent for 2014/15 with a plan to meet the national target of 67 per cent by 2015/16.

We have undertaken a number of actions during 2014/15 as follows:

The memory assessment service (provided by RICE) was asked to provide each practice with a list of all their patients diagnosed with dementia in the


last two years and their read code. Practices were asked to ensure that all patients on the list were coded correctly.

Implementation of the dementia support worker service. High quality support and information is essential for people with dementia and their carers but the service also gives health care professionals confidence that after diagnosis, the person can access information, advice and support which is tailored to their needs. A dementia support worker is usually present at the memory assessment service to provide support to patients immediately before and after their appointment if necessary.

Practice support pharmacists have been checking that all patients who are prescribed dementia drugs have the correct dementia code recorded in their practice medical notes.

NHS England introduced an enhanced service (ES) to incentivise GP practices to increase their dementia diagnosis rate and produced two tools for practices to use to help identify patients who may have memory problems and would benefit from a review. The CCG has encouraged all practices to sign up to the ES and to use the tools available and the majority of practices have taken up this offer.

This work to review data on GP systems and review care home Patients has driven significant improvements seen since September 2014 (47.1 per cent). At the end of March 2015, we achieved our target of 60 per cent dementia diagnosis.

As the impact of improving recorded data is now coming to an end, we are aiming to meet the 67 per cent target by the end of March 2016. By the end of quarter one we will have developed an action plan for the dementia work programme for 2015/16. This is being developed in partnership with the Dementia Care Pathway Group members but the work will include:

Continuing to encourage practices to use the tools provided by NHSE to identify patients who may have dementia.

Embedding the ‘dementia challenge projects’.

Raising awareness of dementia to encourage people to seek a diagnosis and access the help and support available.

Increasing provision of Dementia Friends sessions.

The development of a dementia prevention strategy in conjunction with Public Health.

Please see Appendix 1c Measures of Success.

8.3.6 Stroke Services As detailed in section three, we have evidence to suggest there is potential to reform the stroke pathway to improve performance and care for patients. As we have made good progress with diabetes, during 2015/16, we plan to review the evidence base and commence scoping work to select the second long term condition for focus as a transformation priority. Neurological conditions, including stroke services are on the short list for this review.


8.3.7 Primary Care Talking Therapies Access, waiting time and recovery rates for Talking Therapies for common mental health problems (Improving Access to Psychological Therapy standards) have been delivered by a new service to a local specification in 2014/15. This included introducing new national measures, doing a substantial review and cleanse of local data and co-locating with Primary Care Mental Health Liaison Services. At the end of March we achieved a 17 per cent recovery rate which exceed the national target of 15 per cent for 2014/15, although we did fall short of the 50 per cent recovery rate required with a local recovery rate of 44 per cent. Further analysis is taking place on reliable recovery rates as well as standard national recovery rates as we have a high proportion of clients at the more severe end of the treatment pathway. It is therefore our intention to ensure that our new pathways enable full achievement of positive outcomes for the whole range of service users. In addition, our forecast on current activity suggests that the service is geared towards being able to achieve the new IAPT access and waiting time targets for 2015/16. Full monitoring processes are being established. In addition we are introducing new NICE recommended approaches for people with a Borderline Personality Disorder in Primary Care and working with local teams to improve the support. Please see Appendix 1c Measures of Success.

8.4 Enabling Change

8.4.1 Seven Day Working We have a number of projects and associated investment plans relating to seven day working which are being mapped to and tested against the clinical standards – see below. 2014/15 Operational Resilience and Capacity Planning initiatives (ORCP) will be evaluated as potential recurrent solutions and include the following:

Seven day per week acute oncology service

Seven day discharge liaison service

Additional Weekend Hospice at Home capacity

End of Life Care discharge co-ordinator

Additional non-emergency patient transport provision at weekend

24/7 Mental Health Liaison service to the emergency department

Our Better Care Fund plans will enable continuation of seven day hospital social work services and the core reablement service, which is focused on hospital discharge. Implementation of the community cluster model will see further enhancement of seven day services to support discharge, including the District Nursing Service and the Access Team. Patients requiring an urgent response regarding potential admission to the “virtual ward“ will be seen within two hours by a member of the Multi-Disciplinary Team (MDT).

In addition the pilot focused weekend working service within primary care supports: targeted admission prevention from our most vulnerable patients in the community through the introduction of a GP appointment or home visiting service on Saturdays and Sundays.


The requirement to meet the ten clinical standards for seven day working has been included as a contractual requirement via the service improvement plan since 14/15 and there is an on-going requirement in 2015/16 contracts for providers to provide regular progress reports. A comprehensive statement regarding progress in 14/15 was provided to us at the end of March 2015 using the national self-assessment tool. This will form the baseline for discussion regarding priorities for further progress in 15/16.

8.4.2 Information Technology Interoperability of patient records is one of the CCG’s six transformational work streams, and is articulated in more detail in Transformational Priorities section 4.4. This is a key enabler, which will improve the effective delivery of a number of other projects, building on existing initiatives which allow some limited data sharing between providers in the interim, including the Special Patient Notes initiative.

Other information technology related initiatives include:

Roll out of electronic prescriptions to achieve at least 60 per cent usage by 31 March 2016, building on the current base of 66 per cent of practices live with the system (84 per cent by 31 March 2015) and 37 per cent usage

80 per cent of GP referrals to be sent electronically by 31 March 2016 , building on the existing arrangements with the RUH and the opportunities offered by the Referral Support Service and using contractual mechanisms as appropriate to secure compliance. By the end of quarter one, we will have mapped our position by provider and agreed milestones with individual providers. This is being managed by the CCG IM&T Steering Group and is part of their work plan.

Ensuring electronic discharge summaries are routinely in place by October 2015, building on the arrangements already in place for RUH and using the contractual process as necessary to embed with other providers. By the end of quarter one, we will have mapped our position by provider and agreed milestones with individual providers. This is also being managed by the CCG IM&T Steering Group and is part of their work plan.

Continuing our commitment to the use of the NHS number as primary identifier across health and social care, NHS number compliance is monitored for all the providers with which we contract and where necessary using contractual means to close residual gaps in compliance.

A virtual desktop pilot within the CCG to support the move to paperless systems and to enhance flexible working opportunities for staff.

8.4.3 Innovation, Health and Wealth – Our Response The CCG has well-established quality monitoring processes to track and oversee compliance with NICE Technology Appraisals through a quarterly review process with providers. In 2015/16 we will continue to align financial, operational and performance incentives to support the adoption and diffusion of innovation and best practice.

We have created a targeted local fund of £200k to support transformation and innovation in primary care in BaNES. Proposals will be invited from practices or clusters of practices by early June.


The CCG has and will continue to develop close ties with the Academic Health Science Network (AHSN) and have engaged them on the development of their 2015/16 Business Plan. Examples of current areas of focus with the AHSN include:-

Pre-term Birth Project :- This relates to the use of Magnesium Sulphate to prevent Cerebral Palsy in pre-term babies which is being implemented by all of our commissioned maternity providers.

Don’t’ Wait to Anti- Coagulate: this project relates to optimising anti-coagulation in primary care to reduce Atrial Fibrillation. Whilst this is currently being tested in 11 practices that are testing four different ways of working, locally we have taken a targeted approach on this area through the prescribing incentive scheme. Our approach is similar to AHSN work looking at identifying patients who should be coagulated based on the Primus tool identifications. This is being implemented across all practices. Our Chair is the Champion of this programme across the AHSN area.

We have an AHSN/HESW sponsored Evidence based fellow, who is working on supporting evidence based commissioning to support the delivery and spread of evidence based services. Our fellow is looking at three different projects:

a new cellulitis pathway,

investigating an evidence based falls prevention project for implementation and

assessing the impact of the Orthopaedic Interface Service, an intermediate community based service to see if how that service matches up against latest evidence.

8.4.4 Workforce Planning The CCG has established links with the Southwest Local Education Training Board and we have identified the need to re-establish the commissioning voice in setting future training and education requirements.

As part of our 2015/16 operational plan both CCG and Council commissioning staff have identified future workforce planning requirements from a commissioning perspective. These reflect the identified gaps in training needs or gaps in service provision that we think will need to be addressed in the future. They include: -

More Skilled dementia trained staff in the care home sector to support Council and CCG funded provision outside of hospitals.

Funding provision for specialist skills for the development of Out of Hospital services e.g. earmarked funding to support the training and development of portfolio based careers for GPs across a range of specialist interest areas.

Clearly defined career pathways and career progression for enhanced support staff.

Integrated training programmes for mental and physical health (to support parity of esteem).

Training in concepts of health and well-being and goal setting.

Training in attachment dis-orders.


From a CCG perspective we have also identified gaps in commissioning skills and believe there is requirement to develop placement-based approaches to support apprenticeships in commissioning.

9. Financial Plan 2015-16

9.1 Financial Strategy Our financial strategy, as set out in our five year strategy document, ‘Seizing Opportunities’, is designed to support the achievement of our priorities for the local health and care community whilst meeting all our statutory financial duties and targets. The key elements of the strategy are, in summary:

Realistic, risk based financial planning and management.

Use of clinical intelligence, comparative data and procurement mechanisms to continually test whether resources are well directed.

Effective use of the resources, levers and incentives available to us, including investment, disinvestment, transitional funding, and emerging contractual and payment flexibilities.

A proactive and collaborative approach to designing and delivering change, sharing risk and gains equitably.

9.2 Financial Plan 2015/16 The table below provides a summary of the financial plan which supports delivery of our operational plan for 2015/16.

2015/16 Plan

Recurrent £000

Non-recurrent £000

Total £000

Sources of Funds

Commissioned Services Allocation (212,957) 0 (212,957)

Running Costs Allocation (4,178) 0 (4,178)

Other Anticipated Allocations 0 (4,133) (4,133)

Better Care Fund Allocation (3,345) 0 (3,345)

Total Sources of Funds (220,480) (4,133) (224,613)

Applications of Funds

Commissioned Services 177,729 2,595 180,324

Primary Care & Prescribing 30,705 1,181 31,886

Running Costs 4,178 0 4,178

Other Program Spend 3,369 180 3,549

Reserves and unallocated investments 2,313 116 2,429

Total Applications of Funds 218,294 4,072 222,366

Planned Surplus (2,186) (61) (2,247)


The plan assumes the following, in accordance with the national planning requirements:

Income in accordance with the notified resource allocations for commissioned services and running costs.

Running costs expenditure within the notified allocation, including delivery of a 10 per cent cost reduction in 2015/16

A net decrease on Acute Services contracts of 0.5 per cent against the 2014/15 recurring forecast outturn, comprising a 3.5 per cent efficiency target and 3 per cent inflationary uplift.

An equivalent net decrease on the majority of Non-Acute based contracts of 1.9 per cent, with efficiency targets at 3.5 per cent and inflation at 1.6 per cent

Non-demographic growth for Continuing Health Care and Prescribing within the nationally recommended range.

A planned surplus of 1 per cent (£2.246m).

Draw down of £1.443m to fund specific committed investments.

Headroom set aside for non-recurrent investment at 1 per cent (£2.130m).

General contingency of 0.5 per cent (£1.123m).

CQUINs funded at 2.5 per cent.

Increased demand due to population growth of 0.66 per cent in 2015/16.

The additional investment required of the CCG to create the full value of the Better Care Fund (BCF) in 2015/16, funded from increased BCF allocation and CCG investment.

A recurrent increase in recurrent baseline spends on mental health in line with the CCG allocation per cent age growth of 1.4 per cent.

Resilience funding of £1.136m in line with the allocation received in 15/16, to be invested as agreed by the System Resilience Group.

We have assessed the impact of the above assumptions and of our QIPP and investment schemes on activity for each provider to ensure contractual and system-wide activity plans are consistent. Where we anticipate activity changes, the financial impact is based on a costed assessment of the movement in activity.

9.3 Investment Plans Within our plans we have set aside monies for investment in unavoidable cost pressures and to support delivery of our commissioning priorities. We have a robust Prioritisation and Investment Framework and scrutiny process to ensure approved investments meet key criteria relating both to alignment with our operational and strategic priorities and to deliverability. We approved investments, as summarised at Appendix 2, under the following headings through this process:

non-recurrent proposals suitable for funding from headroom

previously committed or otherwise unavoidable investment

recurrent proposals delivering quality and/or value for money improvements


The CCG is also holding a small reserve to meet emerging in-year investment priorities and proposals which were not fully developed for consideration at plan stage.

We have recognised other sources of investment in our plans, as follows:

Readmissions – we have committed to reinvest funding withheld from providers in respect of avoidable readmissions in services which are linked to improvement in this area. Our current areas of focus are the acute care of the elderly unit at RUH and community-based reablement services.

Non-elective threshold – we have committed to reinvest funding withheld at 30 per cent of the full cost of non-elective activity above a set threshold, to support providers in schemes linked to effective management of emergency activity.

We have excluded from our plan the income and expenditure relating to the Quality Premium, as the value is not confirmed. However, in line with 2014/15, the CCG will plan to commit this on appropriate schemes, with a focus on quality improvement, training and development in the care home sector.

9.4 Resource Releasing (QIPP) Plans Our resource releasing (commissioner QIPP) schemes for 2015/16 are summarised at Appendix Three, along with the investments required to deliver them, giving the net contribution made by each scheme. Schemes have been identified to the required value of £4.016m in 2015/16. Resources released through QIPP are reinvested to fund areas of improvement, development or growing demand.

Provider efficiency targets are set at £5.041m for 2015/16, giving a total efficiency gap for the health community of £9.057m.

9.5 Better Care Fund Our plans include the CCG’s contribution to creating the Better Care Fund for BaNES to a value of £12.049m in 2015/16. We have built on our existing financial commitments to the delivery of integrated care locally, and have jointly agreed plans which complement both CCG and Council financial plans through alignment with established and emerging QIPP, savings and investment projects.

9.6 Running Costs We plan to manage our delivery capability within our allocated funding envelope for running costs, although this is challenging in 2015/16 due to the 10.25 per cent reduction in allocation. The CCG reduced costs during 2014/15, through reduction of spend with our commissioning support provider, review of our staffing structures and the balance of our capacity, and efficiency savings on non-pay items.

One of our key risk areas during 2015/16 is our ability to deliver the range of our transformational change priorities whilst absorbing additional responsibilities without additional resource and maintaining our running costs within the prescribed envelope. This is exacerbated by the CCG’s running costs allocation being particularly low, being set at £20.79 per head of population compared to the regional average of £21.47 per head, which equates to the CCG receiving £0.137m less than it would if funded at the regional average rate.


9.7 Capital Expenditure Having reviewed our priority programmes of work in consultation with NHS Property Services (NHSPS), we do not anticipate any significant changes to existing estate as a result of our plans and have not included any capital expenditure in our financial plan. Our focus in 2015/16 is to work with NHSPS to ensure excess or underutilised space is either disposed of or tenanted, removing costs of vacant space chargeable to the CCG. This forms part of our resource releasing plans.

9.8 Cash and Balance Sheet We have prepared initial cash flow and balance sheet forecasts for 2015/16, and do not anticipate any difficulties with either cash flow or working capital during the planning period.

9.9 Financial Risk and Mitigation We have reviewed the financial plan for 2015/16 in detail to assess and quantify the level of risk to delivery. Areas of potentially significant risk have been identified as follows:

increased demand in non-elective activity above that anticipated in the plan, and including acuity as well as volume factors.

under-delivery of QIPP schemes, following risk assessment by QIPP leads.

tariff not delivering the expected level of deflation when applied to local activity.

inability to contain the costs of commissioning delivery within our running costs allocation.

Financial mitigation of the consequences, should any of these risks materialise, will be achieved through:

use of general and specific contingency reserves.

diversion of uncommitted investment funds.

review of planned investments for potential delay or reduction in costs.

over-delivery or bringing forward of alternative QIPP schemes.

risk-sharing arrangements with partner organisations.

10. Performance Management and Delivery of the 2015/16 Operational Plan Following our recent mapping and re-prioritisation exercise, work is underway to set out quarterly key milestones for delivery against all agreed operational plan and project initiatives. Lead managers have been identified with responsibility for delivery of the milestones. A comprehensive Operational Delivery Plan 2015/16 will be reviewed by the Joint Commissioning Committee which has responsibility for overseeing seeing delivery of the joint operational agenda with the council. The Board will receive quarterly reports regarding delivery across all areas of the plan, starting in July. An example report was shared with the CCG’s Board in May.


In addition we will be reviewing the level and range of performance indicators including benchmarked performance that is shared with the CCG’s and Council’s Joint Commissioning Committee. Both will form the basis of a revised Performance Management Framework for 2015/16.

The Transformation Group will receive regular progress reports regarding the progress of the Transformation projects and will provide system overview and support for delivery.

11. Risk Management

In relation to the delivery of CCG’s 2015/16 Plan there are a number of key risks which have been identified as follows, along with actions to manage or mitigate

Risk Mitigation

Urgent care system performance

Sustaining and improving performance against the four hour A&E waiting time target in BaNES in light of a very challenging position in quarter four of 2014/15 and against a backdrop of increased pressure on emergency services at a national level

Oversight and leadership of Urgent Care System by the System Resilience Group.

Implement four hour Recovery plan and monitor impact.

Identify robust schemes for 15/16 Recurrent ORCP funding

Robust Demand and escalation planning

Review of our local response to eight High Impact Actions

Referral to Treatment

Reducing RTT backlogs and then maintaining good performance in the early part of 2015/16

Development of a robust 18 week Recovery Plan Robust Demand and escalation planning

Oversight by RTT Working Group

Close performance monitoring

Reductions in non- elective admissions and achieving reductions set out within Better Care Fund Plan

Risk assessed plans, QIPP project plans and monitoring via Transformation Group

Health community commitment and engagement


Capacity and Capability to deliver the CCG’s two year operational plan priorities. (The CCG has an ambitious programme of work and may not have sufficient capacity to deliver the operational plan).

The running costs allocation reduction which requires us to identify efficiencies in an already lean organisation, whilst maintaining our capacity to deliver significant programmes of change and sustaining the health and wellbeing of our staff.

On-going review of CCG capacity and structure to ensure fit for purpose.

Project prioritisation framework

Staff wellbeing initiatives and staff survey action plan

Comprehensive delivery plan

Appendix 1a


Measures of Success 2015/16

1. NHS Constitution - National Standards for Access to Care with National Targets

Reference

Description Target 2013 /14 2014 /15

2015/16 plan

Plans for Delivery

E.B.1

The percentage of admitted pathways within 18 weeks for admitted patients whose clocks stopped during the period on an adjusted basis

90% 93% G 90% G 89%

There have been growing waiting lists due to: the

impact of the pressure on emergency care in the Winter 2013/14 period continuing into early

2014/15, cancer campaigns driving referrals and a

general increase in referrals. Certain specialties have

been particularly impacted and BaNES CCG are

working with providers to improve the clinical

pathways. NHS England set up initiatives for delivering additional work in 2014/15 and these have helped but

work to clear the backlogs at local acutes will continue

into 2015/16 and are a risk to delivering these targets.

E.B.2

The percentage of non-admitted pathways within 18 weeks for non-admitted patients whose clocks stopped during the period

95% 96% G 93.5%

A 95%

E.B.3

The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period

92% 94% G 92% G 92%

E.B.4 Diagnostic test waiting times - under 6 week waits

99.0% 99.4%

G 99.3%

G 99.0%

The Diagnostic test standard has performed well in

2014/15 and this should continue into 2015/16.

E.B.5 A&E Department - % of A&E attendances under 4 hours (RUH)

95% 94% A 90% A 95%

BaNES have implemented the new national Operational

Resilience Planning approach and set up a

System Resilience group to manage this. Though daily operational performance

management of the whole Urgent Care System has

been in place throughout the winter, the very high levels of demand seen nationally

have placed significant challenge on the system.

Information on improving the Urgent Care System can be

found in section 4.5.

E.B.6 All Cancer 2 week waits 93% 96% G 94% G 94% The Cancer standards have been impacted by the early


E.B.7 Two week wait for breasts symptoms (where cancer was not initially suspected)

93% 97% G 95% G 93%

identification campaigns and pressure on planned care in

2014/15. There are targets that are not hit on a monthly basis

but overall 8 of the 9 sandards met target for the

year. For the standard that

missed target there were only 3 breaches in the year.

Pathways with small volumes of patients with individual circumstances

and choice make it difficult to hit every target but we will

continue to work with providers to improve results

where possible.

E.B.8

Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis (measured from ‘date of decision to treat’)

96% 99% G 97% G 97%

E.B.9 31-day standard for subsequent cancer treatments-surgery

94% 99% G 94% G 95%

E.B.10 31-day standard for subsequent cancer treatments-anti cancer drug regimens

98% 99% G 100%

G 99%

E.B.11 31-day standard for subsequent cancer treatments-radiotherapy

94% 99% G 99% G 94%

E.B.12 All cancer two month urgent referral to first treatment wait

85% 91% G 89% G 85%

E.B.13 62-day wait for first treatment following referral from an NHS cancer screening service

90% 94% G 89% A 94%

E.B.14

62-Day wait for first treatment for cancer following a consultants decision to upgrade the patient’s priority

n/a 98% G 100%

G 94%

E.B.15i Ambulance clinical quality – Category A (Red 1) 8 minute response time (SWAST)

75% 70% A 74.7%

A 75% These indicators have showed recovery of

performance for BaNES across 2014/15 though have dipped again with the Winter

Pressure. NB - 2013/14 results are for

SWASFT and 2014/15 results are for BaNES.

E.B.15ii Ambulance clinical quality – Category A (Red 2) 8 minute response time (SWAST)

75% 72% A 72% A 75%

E.B.16 Ambulance clinical quality - Category A 19 minute transportation time (SWAST)

95% 94.9%

A 94% A 95%

E.B.S.1 Mixed Sex Accommodation (MSA) Breaches (RUH)

0 24 R 10 R 0

The mixed sex accommodation breaches

have all been in MAU during periods of escalation in the Emergency Department.

Improved processes reduced breaches in

2014/15.

E.B.S.2 Cancelled Operations - not rebooked within 28 days (RUH)

1% 16% R 9% R 0%

This indicator's poor performance has improved in Q3 and Q4 even with the

Winter pressures. Improvements to the Urgent Care system and reducing Planned Care waiting lists

should support the recovery


of this indicator during 2015/16

E.B.S.3 Mental Health Measure – Care Programme Approach (CPA) 7 day follow up on discharge

95% 98% G 94.9%

A 95%

There were breaches in Q2 that have impacted 2014/15.

Processes have been tightened up and

performance has improved and should continue into

2015/16.

E.B.S.4 Number of 52 week incomplete referral to treatment pathways

0 4 R 56 R 0

During 2014/15 North Bristol Trust have had a significant backlog in Spines surgery.

This is the regional specialist service and similar

pressure is being felt elsewhere in the country.

Recovery plans are underway and 52 week

waiters will be cleared early in 2016.

Please note:

2015/16 plan targets are locally set except for E.B.S. 1-4 - set nationally. 2015/16 plan targets for E.B.5 and E.B.15 are set at Trust level.

Appendix 1b



2. Quality Premium (metrics) 2015/16 - A small group of national metrics focussed on quality of care with locally set targets and two local metrics.

Domain Description Baseline

Local Ambition

Plans for Delivery 2015/16

% of QP

Domain 1

1 Potential years of life Lost from causes considered amenable to healthcare: adults, children and young people. (Years lost per 100,000 people)

1572 2013/14

reduction on recent

trend 10%

Impact anticipated from CCG's combined commissioning work plan over years 1-2 and 3-5.

Urgent and Emergency Care Menu

Achieving a reduction in avoidable emergency admissions

1500 2013/14

reduction on recent

trend 5%

The CCG was top quartile for this indicator in 2013/14 though we are seeing increased admissions in 2014/15. The QIPP plan and, community cluster model will support this ambition.

An increase in level of discharges at weekends and bank holidays

22.04% 2014/15

22.54% (0.5%

increase) 10%

The SRG as part of its work on capacity and resilience planning has an ongoing focus on 7 day services to support patient flow. The CCG’s A&E recovery plan includes targeted work to support reductions in Medically Fit for Discharge patients.

Reducing NHS-responsible delayed transfers of care (days)

1839 2014/15

less than 2014/15

15%

There has been a continued focus on reducing DTOCs over the Winter period with a continued focus in 2015/16. This has resulted in some improvement in the 2nd half of 2014/15 that we will aim to maintain into 2015/16.

Mental Health Menu

Reduction in the number of patients attending an A&E department for a mental health-related need who: i) wait more than four hours to be treated and discharged, or admitted (compared to all A&E attendances) together with ii) a defined improvement in the coding of patients attending A&E.

i) 87% 2014/15

95%

15%

This is an area of focus for the CCG, though the stretch in a

single year may be too much for the CCG to achieve.

Reducing breaches due to mental health is part of the local

A&E 4 hour recovery plan ii) 69% 2014/15

90%


Reduction in the number of people with severe mental illness who are currently smokers.

no data available

reduction on

2014/15 15%

There is no data available nationally or locally for this new indicator. The local mental health inpatient wards (Hill view) are being made no-smoking this year, so this measure should reflect the impact of this change.

Antibiotic Prescribing

Improving antibiotic prescribing in primary and secondary care: a) reduction in antibiotic items/STAR-PU (5%)

1.015 (Oct 13-Sept 14)

106%

10%

There is a BaNES CCG Antimicrobial Stewardship work programme being set up and we have an Antibiotic QP working group up and running to share activities across BGSW. The incentive prescribing scheme for GP practices is part of the BaNES programme to deliver the QP targets.

b) reduction in broad spectrum antibiotics prescribed (3%)

15.91% (Dec 13-Nov 14)

15.89%

c) acute provider data validation for RUH (2%)

not required

RUH set deadline

of 15/06/15

RUH and CCG medicines management team have PHE validation programme. CCG is engaged with pharmacy leads, RUH and Wilts CCG medicines management lead to support the validation.

Local Measures

C4.5 Responsiveness to In-patients' personal needs. (Local measurement from Q56 of CQC inpatient survey.)

5.1 / 10 RUH score

2013

increase on

baseline 10%

CCG is working with local provider to determine what actions can be taken to improve performance in this area. CCG has agreed a discharge CQUIN (further to Healthwatch report) which includes ensuring that patients are given information about their medication on discharge.

Increase in incident reporting in primary care by 20% from 14/15 baseline number of 32 cases reported directly to the CCG.

32 38 10%

Promoted the process for reporting incidents to CCG through GP newsletter and at GP Forum. Meeting with Comms in May to discuss the feeding back of themes, trends and actions taken through newsletter to further encourage reporting. Dedicated GP Feedback email box set up and monitored daily by CCG quality team.

Appendix 1c



3. NHS CCG Outcomes Indicator Set (selected) - National Metrics that the NHS have chosen for CCGs to set local / meet national ambitions

3 NHS CCG Outcomes Indicator Set (selected) - National Metrics that the NHS have chosen for CCGs to set local / meet national ambitions

2015 / 16

E.A.2Improve the health related quality of life for people

with long term conditions77.8

Embed new Community Cluster Team Model, Establish

a diabetes pathway group to re-design local services,

Develop clinical model for community COPD service

E.A.3 Improving access to psychological therapies 15.2%

The service has improved data quality and made

orpeational changes and is meeting targets in2014/15

year end.

E.A.S.2Recovery following talking therapies for people of all

ages55%

Recovery rates have dipped in 2014/15 but are back to

target levels in Quarter 4 and due to operational

changes should stay there.

E.A.S.1 Estimated diagnosis rate for people with dementia 67%

Improve diagnosis rates for people with dementia

working with primary care and community dementia

support workers to ensure equality across BaNES.

E.A.S.5 Incidence of health care associated infection - C. difficile 47

The CCG run a Health Care Acquired Infection (HCAI)

collaborative. The CCG are focussed on the reduction

of antimicrobial prescribing.

4 Primary Care Patient Satisfaction 2015/16 - Local ambition set jointly by CCG and NHS E as Co-commissioners of primary care

Local

Ambition

2015 / 16

E.D.1

% of patients who gave positive answers to five selected

questions in the GP survey about the quality of

appointments at the GP practice

434

E.D.2

% of patients who gave positive answers to the GP

survey question ‘Overall, how would you describe your

experience of your GP surgery?’

93.0%

E.D.3

% of patients who gave positive answers to the GP

survey question ‘Overall, how would you describe your

experience of making an appointment?’

87.7%

Reference Description

Reference Description

429

76.5

92.7%

Plans for Delivery

2014 / 15

432

92.1%

2013/14

Co-commission primary care in B&NES under a joint

arrangement with NHSE. Develop a detailed strategy

and action plan for shaping the future of Primary Care

in B&NES in the context of the CCG’s 5 year strategy.

Although patient experience in B&NES benchmarks

very high, there is increasing expectation of access to

services

The CCG is supporting the uptake of the Friends and

Family Test in primary care which provides immediate

feedback to the practices.88.1%

Results

86.4%

49

Actual 61

g

Results Local AmbitionPlans for Delivery

2013/14 2014 / 15

15%

Actual 17%

g

77.6

50%

Actual 44% g

60%

Actual 60%

g

56

46%

53%

9%

Appendix 1d



5. Better Care Fund - National Health and Social Care indicators to measure the impact of the Better Care Fund spend, with locally set ambitions and a new local indicator.

Baseline

2013/14 2015/16

1

Total Non-Elective Admissions in to Hospital

(general & acute), all age

NB. All data is restated as at 2015/16 plan as the

specification for this indicator has been changed.

14,715 14,976

(1.9%

reduction)

•The key schemes that will drive the 2015/16 change are

all aimed at the frail elderly :

The Social Care Pathway Re-design (scheme 6) will assess

and provide packages to service users more quickly, the

Community Cluster Model (scheme 17) will focus on

patients / service users already in poor health and pull

together health and care services to specifically focus on

keeping the patients / service users well enough to stay

out of hospital.

2

Permanent admissions of older people (aged 65 and

over) to residential and nursing care homes, per

100,000 population

913.6

(305

admissions)

764.8

(269

admissions)

• The Extended Hours Services (scheme 1) are expected

to save 10% on the June 2014 rate of 11, an additional 1.1

admissions per month (for 6 months in 2014/15 and full

year 2015/16).

• In 2014/15 Integrated Re-ablement & Rehabilitation

(scheme 4) is also expected to save 10% on the June 2014

rate of 11, an additional 1.1 admissions per month (for 6

months in 2014/15 and full year 2015/16).

3

Proportion of older people (65 and over) who were

still at home 91 days after discharge from hospital

into reablement / rehabilitation services

86.3%

(140/160)

87.8%

(158/180)

This metric relates directly to the Integrated Re-ablement

& Rehabilitation service (scheme 4) and the Extended

Hours Services (scheme 1) . It will supported by a range of

enabling services including:

• The Hospital Discharge - Handyperson, Step Down and

Intensive Home from Hospital service (scheme 2).

• Social Care Pathway Re-design (scheme 6) and

Protection of Social Care (scheme 9).

• The Community Cluster Model (scheme 17)

4

Delayed transfers of care (delayed days) from

hospital per 100,000 population (aged 18+) due to

Social Care delays

2906

(4240 days)

2876

(4200 days)

At this time specific impacts have not been quantified for

the individual schemes but the strongest drivers will be:

• The Extended Hours Services (scheme 1) will move

services to 7 days with extended hours.

• The Hospital Discharge - Handyperson, Step Down and

Intensive Home from Hospital service (scheme 2).

• Integrated Re-ablement & Rehabilitation service

(scheme 4).

• Social Care Pathway Re-design (scheme 6) and

Protection of Social Care (scheme 9).

5

Patient / service user experience: How many users

of care and support services said they were

'extremely satisfied' or 'very satisfied' with their

care and support? (ASCOF 3A) For respondants over

65.

65% 68%

This survey is sent to random sample of everyone

receiving support in the year from the adult social care

service including almost all the schemes within the Better

Care Fund. The survey is run once a year and there are no

indicative results.

6 - Local

Proportion of high risk people being case managed

via Intensive Community Support and Intensive

Community Tracking (Community Cluster Teams)

with a personalised care plan and lead accountable

professional (snap shot at period end)

85% 95% The Community Cluster Model (scheme 17).

Please note: These plans are as the final BCF submission September 2014, except for emergency admissions.

The Indicative results for 2014/15 are at February or March 2015)

Metrics Description

Planned

15,259

Actuals On Targetg

66%

90%

Actuals On Target

g

Plans for Delivery

2014/15

846.6

(293 admissions)

Actuals On Target

g

87.1%

(148/170)

Actuals Off Target

g

2662

(4857 days)

Actuals Off Target

g

Appendix 2


2015/16 Total Planned Investments

Rec

£000

Non Rec

£000 T ota l £000

Resilience 1,136 1,136

BCF Investment 4,500 4,500

Community Continence Service 121 121

HCP Calls 120 120

Preparing for the future: Year 2 930 930

Acute emergency care schemes 724 724

Other Acute care schemes 278 314 592

Wellbeing College 70 70

Mental Heath Investments 965 263 1,228

Community Providers Investments 438 234 672

Interoperability 150 150

Primary Care Transformation 200 200

Other Investments 67 58 125

Held for Emerging in Year Priorities 52 116 168

Total Planned Investments 7,677 3,059 10,736

Appendix 3


2015/16 Planned Savings

Investment Gross saving Net saving

£000 £000 £000

Planned Care

ISTC - GFV (575) (575)

ISTC - RSS Impact (242) (242)

Musculoskeletal review - Orthopaedics (155) (155)

Musculoskeletal review - Pain (9) (9)

Ophthalmology (33) (33)

Chronic benign pain 28 (140) (112)

Total Planned Care 28 (1,155) (1,127)

Unplanned Care & Long Term Conditions

Assisted Discharge service:Phase 1 15 (112) (97)

Assisted Discharge service:Phase 2 15 (112) (97)

Community Continence Service - NEL admissions (92) (92)

Community Continence Service - Other (130) (130)

Urgent Care - Ambulatory Care (40) (40)

Urgent Care Centre (46) (46)

Total Unplanned Care & Long Term Conditions 30 (531) (501)

Improving Medicines Management

Practice\Medicines\Optimisation Schemes 30 (382) (352)

Total Improving Medicines Management 30 (382) (352)

Mental Health

Peer support workers MH inpatient units (60) (60)

Total Mental Health (60) (60)

Improving Learning Disabilities

Learning Disabilities (150) (150)

Total Improving Learning Disabilities (150) (150)

Other

Disposal/occupancy of vacant properties (301) (301)

CHC (186) (186)

Contractual savings (226) (226)

Other (420) (420)

Total Other (1,133) (1,133)

BCF Schemes

Community Cluster Team Model (103) (103)

GP Opportunity Fund (247) (247)

Re-ablement (249) (249)

Social Care Pathway (93) (93)

Total BCF Schemes (692) (692)

Total Commissioner QIPP 88 (4,104) (4,016)

Documents

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