Download Part 1 High Level Strategic Plan - Wiltshire Clinical Commissioning

1
Main heading
Text
Two year strategic Plan 2013-2015
PART 1 High Level Strategic Plan (2012/13 to 2014/15)
The right healthcare
for you, with you,
near you
www.wiltshire.nhs.uk
PART 1 | Section 1 Section Header
The right healthcare for you, with you, near you...
Contents
PART 1 High Level Strategic Plan (2012/13 to 2014/15)
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 2
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 3
Section 1. Commissioning Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 4
Section 2. About us – the Clinical Commissioning Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 7
Section 3. Our Vision and Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 9
Section 4. The National Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 14
Section 5. The Local Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 16
Section 6.
Our Key Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 21
- Priority 1 Staying healthy and preventing ill health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 23
- Priority 2 Planned care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 26
- Priority 3 Unplanned care and frail elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 28
- Priority 4 Mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 31
- Priority 5 Long Term Conditions (including dementia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 34
- Priority 6 End of life care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 37
- Priority 7 Community services and integrated care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 40
Section 7. Medicines Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 43
Section 8. Joint Health and Wellbeing Strategy for Wiltshire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 45
Section 9. National Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 46
- Maternity and Newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 46
- Children and Young People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 48
Section 10. Meeting the Healthcare Needs of Armed Forces Personnel, their Families and Veterans . . . . . . . Page 49
Section 11.Safeguarding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 50
- Safeguarding Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 50
- Safeguarding Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 52
Section 12. Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 54
Section 13. Finance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 55
Section 14. Annexes to Support the Finance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 67
Section 15. Performance Management Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 70
Section 16. Quality Improvement Productivity and Prevention (QIPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 72
Section 17.Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 74
Section 18. Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 75
Section 19. Patient Safety and Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 76
Section 20. Commissioning Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 78
Section 21. Workforce and Organisational Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 79
Section 22. Listening to Our Public and Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 80
Section 23. Equality and Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 83
Section 24.Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 84
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 85
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 88
Contents
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Page 1
Foreword
We are delighted to present our first strategic
commissioning plan for our new Wiltshire Clinical
Commissioning Group. From April 2013, Clinical
Commissioning Groups (CCGs) will become the statutory
bodies responsible for commissioning local health
services in England.
This plan covers the period 2012/13 to 2014/15.
The introduction of Clinical Commissioning gives Wiltshire
General Practitioners an unprecedented opportunity to
realise their simple but bold vision to reorganise patient
services for the population of Wiltshire.
This vision will ensure that the NHS care can operate with
improved efficiency, offering high patient quality. This will
require greater integration between community services,
general practice and closer working with our partners in
Wiltshire Council.
The vision puts the patient in control whilst ensuring that
every opportunity is given for the population to improve
their (or its) health. Wiltshire CCG will have a budget
of approximately £500 million to deliver care to our
population. We will work with all providers ensuring that
we establish a relationship that will enable us to live within
the total resources available.
We will put General Practitioners back in the driving seat
for care delivery and care co-ordination in the community.
They will be supported by “wrap around teams” of high
quality community resources to support our older people
in order for them to remain healthy in their own homes,
reducing the need for unplanned hospital admissions.
We will ensure the quality of patient care in every setting
remains safe, effective and appropriate.
In order to ensure the benefits of this localism are
maximised Wiltshire Clinical Commissioning Group will
operate as three local groups. The geography of Wiltshire
naturally divides into three areas of population separated
by the sparsely populated Salisbury Plain. The three groups
cover the natural communities of South Wiltshire centred
around Salisbury, (Sarum Group) with its population mostly
choosing to use Salisbury Foundation Trust for its hospital
based services, the community of North and East Wiltshire,
mostly choosing to use the services provided by Great
Western Hospital (NEW Group) and the area covering the
market towns of West Wiltshire (WWYKD Group) where
the population mostly choose Royal United Hospital in Bath
for its services.
The local Groups have a track record of joint working and
recognised that there was a firm foundation already in
place to become one CCG with a strong locality focus to
retain a ‘bottom up approach’ and local autonomy.
The organisational and governance structures have been
designed to ensure that all practices have a voice through
each of the group committees which comprise of a majority
of GPs, Locality Director and a non-executive Director.
The new organisation will be patient centred and outward
facing, maximising opportunities to form collaborative
partnerships with others for the benefit of the health and
socialcare of the population of Wiltshire.
We are confident that this plan is totally patient focused
at all times and its implementation will be led by a range
of very able and enthusiastic local clinicians supported by
a creative, dynamic and experienced management team.
The key to success of clinical commissioning in the
dispersed rural community of Wiltshire will be ensuring we
utilise the collective knowledge of the general practitioners
with respect to their communities, their patients and the
current care pathways available to their patients.
Dr Steve Rowlands Chair
Deborah Fielding
Accountable Officer
Foreword
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Page 2
Introduction
Wiltshire Clinical Commissioning Group (CCG) is passionate about
commissioning the highest quality care for our patients as close to their
home as possible. Hence our overarching vision:
‘The right healthcare,
for you, with you, near you’
We have listened to our patients, individual practices and partners to develop
our priorities through a ‘bottom up’ approach whilst taking account of the
national and regional objectives.
The Government’s long-term plans for the future of the NHS are set out in
the NHS White Paper, ‘Equity and Excellence: Liberating the NHS’ and the
subsequent Health and Social Care Act 2012. The Bill signals the biggest
re-organisation of the NHS in its history, and once implemented, the reforms
will have a significant impact on almost every organisation that delivers NHS
care. The leadership, governance and commissioning of NHS services will
transfer from Primary care Trusts to Clinical Commissioning Groups.
From April 2013, Clinical Commissioning Groups (CCGs) will become the
statutory bodies responsible for commissioning local health services in England.
In preparation for this, Wiltshire CCG is currently working in shadow form and
is taking on a greater degree of accountability for managing NHS budgets and
developing commissioning plans.
This document is our integrated plan for the period 2012/13 to 2014/15. It has
been developed by the CCG with the purpose of outlining our vision for local
health services and to set out our strategic priorities and key initiatives for the
next three years.
This document is structured to reflect
the domain requirements of the CCG
Authorisation process, “A clear and credible
integrated plan which includes an operating
plan for 2012-13, draft commissioning
intentions for 2013-14 and a high level
strategic plan until 2014-15.” The plan is set
out in three parts:
PART 1
a High Level Strategic Plan to 2014/15
PART 2
our Operational Plan for 2012/13
PART 3
our Draft Commissioning Intentions
for 2013/14
Introduction
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1
Commissioning Responsibilities
Wiltshire CCG will be responsible, from April 2013,
for commissioning emergency, urgent care, including
ambulance services and out-of-hours services, and planned
care for anyone present in our geographical area.
The areas that the CCG is responsible for include:
• Community Health Services
• Maternity Services
• Elective hospital care (planned care)
We will be responsible for commissioning healthcare
services to meet the reasonable needs of patients
registered with Wiltshire general practices and unregistered
patients living in the area, except for those services that
the NHS Commissioning Board or Local Authorities are
responsible for commissioning.
• Rehabilitation services
•Urgent and emergency care including A&E, ambulance
and out-of-hours services (unplanned care)
• Mental Health services
• Older people’s healthcare services
• Healthcare services for children
• Healthcare services for people with learning disabilities
• Continuing healthcare
• Abortion services
• Infertility services
• Wheelchair services
• Home oxygen services
• Treatment of infectious diseases
We will also be responsible for meeting the costs of
prescriptions written by our GPs.
Section 1 Commissioning Responsibilities
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Page 4
1 What is Commissioning?
The word ‘Commissioning’ is
frequently used but often without
the knowledge or full understanding
of the term. To better understand
Commissioning, the following
definition provided by The Audit
Commission is useful. This reads:
“The process of specifying,
securing and monitoring of
services to meet people’s needs
at a strategic level. This applies
to all services, whether they are
provided by the local authority,
NHS, other public agencies or by
the private and Third Sector.”
Audit Commission; Making Ends Meet,
Oct 2003.
Commissioning of NHS services is all
about the Clinical Commissioning
Group (CCG) working with people
in the community, Local Authorities
and other organisations to identify
and understand patients’ needs so
that services can be designed to
meet those needs. This is done by
working within a structured and
planned process that is continuous
and ongoing to ensure that services
are improved and developed against
past experience and current need. The
CCG will also decide on how best to
provide these services and the process
for making this happen. GPs being
in touch with patients every day are
ideally placed to talk to patients, their
carers and families and understand
what their needs are to keep healthy
and receive the best treatment when
and where it is needed. This is a
summary of what is a complex
process that will take time to
establish and deliver.
d
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Joint Health and
Wellbeing Board
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Check for best practice
Measure and Review
Rapid
Implementation
Path w
ay
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Roll out
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Com m
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CCG with patient and
public engagement and
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The Commissioning Cycle (Diagram 1)
Identify ‘hot spots’
Change pathway
Section 1 Commissioning Responsibilities
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1
Wiltshire CCG will commission
services which meet the needs of the
population of Wiltshire based upon
information in the Joint Strategic Needs
Assessment (JSA), what trends GPs and
their teams in practices are identifying,
what the people who live in Wiltshire
are telling us and looking at how
services are being delivered now.
We recognise that joint commissioning
with the local authority and significant
public health involvement will be
fundamental to achieving successful
outcomes for the people of Wiltshire.
To this end we have worked with
Local Authority colleagues to develop
a Joint Working Framework which
describes our commitment to and
arrangements under which the CCG
and Wiltshire Council will work
together for the benefit of local
people and we have established a
Joint Commissioning Board, reporting
to the Health and Wellbeing Board.
In developing our plan, we have
worked closely with our constituent
GP practices and partners including
the Local Authority and we are full
partners in the Health and Wellbeing
Board. We also held a series of
stakeholder events to provide an
opportunity to present our priorities
and emerging plans to various
stakeholder groups. This provided
us with some valuable feedback,
elements of which have been
incorporated within the plan.
The plan begins with an introduction
to the CCG and its vision and values.
It then sets out the national and local
context within which the plan was
developed and a number of themes
which influenced the decision making
around the key priorities for this plan
period. The document then goes on
to describe the priorities and high level
plans for each of the service areas.
Section 1 Commissioning Responsibilities
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2
About us - the Clinical Commissioning Group
The geography of Wiltshire naturally divides into three
areas of population separated by the sparsely populated
Salisbury Plain. The residents are concentrated around a
number of thriving market towns across North, East and
West Wiltshire and the city of Salisbury and surrounding
villages. Although Wiltshire CCG is the main commissioner
for Salisbury NHS Foundation Trust, historically patients
from the north, east and west of Wiltshire look towards
the Royal United Hospital (RUH) in Bath and Great Western
Hospitals NHS Foundation Trust (GWH) in Swindon. The
CCG will work collaboratively with Bath and North East
Somerset CCG (B&NES) and Swindon CCG to commission
services from these providers.
Wiltshire Clinical Commissioning Group encompasses 58
GP practices. GPs in the practices have already built excellent
links with the hospitals in their areas and have a foundation
of good relationships with consultants upon which to build
clinical commissioning and changes in models of care.
In July 2011 the Board of NHS Wiltshire approved the
establishment of the Wiltshire Clinical Commissioning
Group (CCG), with an Executive Board and the three
local Groups around the natural geographical areas West
Wiltshire, Yatton Keynell and Devizes (WWYKD), North
and East Wiltshire (NEW) and Sarum NHS Alliance (Sarum).
In March 2012, GPs in each of the localities recognised
the benefits of working collaboratively within a single
organisation to create value for money through economies
of scale, sharing expertise and capacity. As a result, they
agreed to join together as one large Clinical Commissioning
Group serving the whole of Wiltshire giving the advantage
of a co-terminous boundary with the Local Authority.
The CCG will commission on behalf of the 3 groups with
a consistent vision across the county. In parallel the 3
groups may take different approaches to implementing
the overall strategy as each area is at a different starting
point with their current services and their health needs are
not the same. GPs are used to focusing on the needs of
the individual patients, managing risk and making quick
and accurate responses. As clinical leaders in the CCG, GPs
can utilise these skills to develop commissioning processes
that will enable more responsive and accelerated decisions.
We have taken this approach in each of our key priority
areas – identifying where we want to be and using small
scale projects to test out new ideas, rolling out successes,
abandoning those that are not successful and spreading
the learning across the CCG.
Section 2 About us - the Clinical Commissioning Group
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2
Wiltshire CCG Area Map
Ashton Keynes
Cricklade
A419
Minety
Purton
Malmesbury
Sherston
WEST WILTSHIRE
A429
DOWNS
Swindon
Corston
A3102
Great
Somerford
Wootton
Bassett
M4
Wroughton
Lyneham
A350
Chiseldon
A3102
A346
A4361
Ford
A420
Chippenham
Ogbourne
St George
MARLBOROUGH
DOWNS
A4
Corsham
Lacock
Box
A342
Savernake
A361
Atworth
Bath
Marlborough
Avebury
A4
Calne
Melksham
A363
A361
Trowbridge
A346
Oare
Rowde
Bradford
on Avon
Devizes
A350
Potterne
Pewsey
A342
Farleigh
Hungerford
A345
Urchfont
Yarnbrook
Upavon
West Lavington
Collingbourne
Ducis
Everleigh
Bratton
Ludgershall
A338
Westbury
Warminster
SALISBURY
PLAIN
A360
Tidworth
A345
Tilshead
Netheravon
Chitterne
Heytesbury
Larkhill
Durrington
Bulford
Stonehenge
A36
Longbridge
Deverill
Amesbury
A303
A338
A360
Monkton
Deverill
Steeple Langford
A350
A346
Durnford
Winterbourne
A303
A30
Chicklade
A36
Mere
Firsdown
Barford St Martin
Bourton
East
Knoyle
A30
A3094
Tisbury
Coombe Bissett
Swallowcliffe
Broad Chalke
A338
A354
Shaftesbury
Salisbury
Wilton
Charlton
All Saints
A36
Whiteparish
Downton
Landford
0
0
5
Approximate scale
10km
5 miles
Section 2 About us - the Clinical Commissioning Group
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3
Our Vision and Values
The right healthcare, for you, with you, near you
The vision of NHS Wiltshire CCG is “To ensure the
provision of a health service which is high quality,
effective, clinically led and local”. The focus of
delivering care to people in their own homes or as close
to home as possible remains of paramount importance.
Values
The CCG will promote good governance and proper
stewardship of public resources in pursuance of its goals
and in meeting its statutory duties and this is critical to
achieving the CCG’s objectives.
The values that lie at the heart of the CCG’s
work are:
• Decisions will be clinically led and locally focused
• Clear accountability to our communities
• Do the best we can and strive for value for money
• Transparent in our decision making
•Promote innovation and best practice
•Value the opinions of staff, stakeholders and partners
– a listening organisation
•One size does not always fit all, however we recognise
that consistency is important to our partners and to
the population
•Adhere to the Nolan principles of standards in
public service
Aims
The CCG’s aims are:
•To make clinically led commissioning a reality in
providing local solutions to local needs
•To deliver strategic plans which address the needs
of local populations and involve patients, practices
and partners
•To address the growing needs of our ageing population,
and the mental health and emergency needs of our
combined populations
•To encourage and support the whole population in
managing and improving their health and wellbeing
•To ensure sustainability of the emerging organisation
in delivering cost effective healthcare
Wiltshire CCG exists to improve the health of the population
and, should they fall ill, to commission for them the best
possible, seamless, effective and safe care, within its financial
resources. We will do this by working in partnership with our
staff, providers, communities and local government.
We will develop the most appropriate models of care by:
•Supporting all people to live healthier lives in their
community
•Increasing the focus on the prevention of ill-health
•Working to innovate and develop models of care in line
with best practice
•Focusing on the needs of inequalities and the different
groups of people in Wiltshire by working through the
localities
Our patients and the public tell us that they would prefer
to be in their own home when they are sick, or recovering
from an illness or operation. Hence, our preferred model of
service prioritises care close to home and shifts the balance
from hospitals to community care.
•To communicate effectively, staying engaged with all
of our patients, partners and stakeholders
Section 3 Our vision and Values
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3 Clinical Commissioning Group Structure
The local Groups have a track record of joint working
and recognised that there was a firm foundation already
in place to become one CCG with a strong locality focus
to retain a ‘bottom up approach’ and local autonomy.
The organisational and governance structures have been
designed to ensure that all practices have a voice through
each of the group committees which comprise of a majority
of GPs, Locality Director and a non-executive Director.
During the transitional year 2012/13, the Clinical
Commissioning Committee (CCC) is the shadow CCG
Governing Body. This is a formal committee of the Board,
established in September 2011, working within an agreed
Scheme of Delegation. Its principle functions are to oversee
the development of the Wiltshire Primary care Trust’s (PCT)
commissioning strategy, clinical policy development and the
PCT’s annual operating plan on behalf of the Board.
Clinical Commissioning Group Structure (Diagram 2)
Practice Membership
NEW practice
Representatives:
- East Locality
- North Locality
Sarum Practice
Representatives:
- Southern
- Northern
- Western
WWYKD practice
Representatives:
- Melksham and
Bradford on Avon
- Trowbridge
- Devizes
- Warminster and
Westbury
NEW group
Committee
Sarum group
Committee
WWYKD Group
Committee
Health and
Wellbeing
Board
Patients
CCG Governing body
Finance
Committee
Quality and
Clinical
Governance
Committee
Remuneration
Committee
Audit and
Assurance
Committee
Section 3 Our vision and Values
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Page 10
3 Clinical Leadership
A major theme that will underpin much of our strategic
plan outlined in this document is our establishment as the
leader of the NHS in the local area and as a commissioner
of health services.
The key features of the Clinical Commissioning
Committee (CCC) are:
•GPs have a majority membership
The role of the commissioner is to ensure that there is full
engagement with the local population and with providers,
and through this to drive innovation, efficiency and quality
in the health services. GPs are in a strong position to make
this happen.
•There are two lay representatives, both Non-Executive
Directors of the PCT Board. One is a champion of
‘Patient and Public Involvement’ and the other of
‘Governance and Audit’
•The PCT Cluster Chief Executive is not a member but
is in attendance
•The Chair of the CCC is a full member of the PCT
Cluster Board
The key functions of the Clinical Commissioning
Group are to:
•engage with the local population to improve health
and wellbeing
•Its line of accountability is to the Board but also has
a role in the Wiltshire Health and Wellbeing partnership
Board recently established by the Local Authority
•commission a comprehensive and equitable range of
high quality, responsive and efficient services, within
available resources
•provide access to high quality, responsive and efficient
services where this provides best value
Composition of Governing Body (Diagram 3)
4 Voting non-clinicians
9 Voting clinicians
(3) Loc
(2) Lay
(1) Acc
(1) Chie
Memb
ounts
f Finan
(Nomin
ers
Clinicia
icer
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Section 3 Our vision and Values
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Page 11
3 The benefits of our structure are:
A Wiltshire Wide Clinical Commissioning Group
•Provides a platform for key stakeholder involvement
with the advantage of co-terminous boundaries with the
Local Authority
•Is a platform for county wide partnership working
for integrated health and care
•Increases formality and scope of joint working
arrangements
Local Groups with Executive Teams
(GPs, Practice Managers)
•Increased local decision making
•Increased informality
•Increased proportional costs of administration
•Local engagement with GPs and providers
•Real time knowledge of health needs
•The umbrella body has more power
•Local priority setting
•Increasing size has more potential influence
•Control and responsibility for what is happening
in the patch
•Secures a single representative voice
•Has a greater voice which avoids being ignored for
being ‘small’
•Shared staff and expertise and thereby reduced
management costs
•Shared access to rare and/or expensive resources
•Improving the cost efficiency of running the
CCG’s functions
•Develops greater resilience and reduces risk
•Opportunities to pilot change in delivery of services
•Bottom up approach will facilitate change
•Integrated Governance Arrangements
From 1 April 2013, the CCG will be established as a
statutory body and this will require a step change in
function and responsibility. We have been developing
new governance arrangements in accordance with good
practice and the NHS Commissioning Board guidance
on authorisation.
•Presents an opportunity to spread innovation across
a significant number of practices and large population
•Can undertake a joint and coordinated response in the
event of a major incident or emergency
Section 3 Our vision and Values
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3
Proposed Governance Structure for NHS Wiltshire Clinical Commissioning Group (Diagram 4)
THE GOVERNING BODY
QUALITY & CLINICAL GOVERNANCE COMMITTEE
Monthly Meetings in Public
Bi-monthly Meetings
Voting:
- Chair of CCG (GP)
Non-voting:
- 3 Group Directors
- Accountable Officer
- 2 Lay Members
- Chief Financial Officer
- Other members
co-opted as
appropriate
- 3 Group Chairs
- 3 other GP
Representatives
- Executive Nurse and Quality Lead (Chair)
- GP representative (s) from CCG Groups
- CCG lay member with lead for
patient safety
- Public representative from Wiltshire Council
- Designated Adult and Children’s
Safeguarding Leads
- Registered Nurse
- Registered Nurse
- Secondary Care
Specialist Doctor
- Secondary Care Specialist Doctor
Statutory Functions:
• Demonstrate value for
money
• Operate within the
boundaries set out by
their establishment orders
and other legislation,
e.g. equality legislation
• Work within the annual
revenue and capital
limits, and break even
every financial year
- Other members of the CCG management team
Other key decisions
(which can be allocated
to committees):
• Leading and settling of
vision and strategy
• Signing off annual
commissioning plan
• Providing assurance
of strategic risks
Develop and understand service quality issues
and provide assurance, ensuring:
• The mainstreaming of consideration of service and
clinical issues
• Identification and management of risks to quality
• Poor performance is acted upon
• Implementation of plans to drive continuous
improvement, including focus on patient
feedback and its direct relationship to
commissioning decisions
Remuneration Committee
Audit & Assurance Committee
Meetings as required
Bi-monthly Meetings
- Lay member (Chair)
- Other lay member
- CCG Chair
- 1 x GP Group Chair
- Lay member (Audit, Remuneration
and Conflicts of Interest Matters)
(Chair)
- Lay member (Patient and Public
Participation Matters)
Financial Committee
Bi-monthly Meetings
- CCG Chair (Chair)
- Accountable Officer
- Chief Financial Officer
- 3 Group Directors
- Group Chair
- GP representation as required
- CFO
- 1 x lay member
- Internal & External Auditors
Functions:
• To make recommendations
to the Governing Body
about the pay and Terms of
Service offered by the
organisation
• To provide reassurance to
the Governing Body that
remuneration is fair and
appropriate
Functions:
• To ensure the governance
arrangements of the CCG are in
place, well designed, and used as
designed
• To ensure robust and effective
financial management systems
are in place and being followed
• To ensure that risks are effectively
managed
• To ensure the publication of the
Annual Report, including the accounts
• To ensure the probity of decision
making is in line with the scheme of
delegation, SFIs, terms of reference,
standing orders and the declaration of
interests policy
The Finance Committee will:
• Agree detailed revenue and capital financial
plans, budgets, income generation programmes
and financial monitoring reports
• Monitor the financial performances of the CCG
against the detailed plans and seek assurance
that remedial action is happening
• Act as an Assurance Committee of the CCG’s
business and finance risks via the Assurance
Framework and Risk Registers which will be
presented to the Committee quarterly
• Review any financial activity which impacts
on the financial performance or reputation
of the CCG
• Take any legal or other professional advice with
regard to the financial performance of the CCG
as necessary
Section 3 Our vision and Values
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4
The National Context
The NHS Constitution
The NHS Mandate
We recognise our obligations to patients as set out in the
NHS Constitution. Our patients have a right:
•To non-emergency treatment starting within a maximum
of 18 weeks from referral
The Government’s first draft mandate to the NHS
Commissioning Board is currently out to public
consultation. The mandate sets out the Government’s
objectives for the Board for the period from April 2013 to
March 2015. It also sets ambitions for improving outcomes
over five and ten years, to provide continuity for the NHS
commissioning system and Wiltshire CCG expect to adopt
it as a performance and quality measure.
•To be seen by a specialist within a maximum of two
weeks from GP referral for urgent referrals where cancer
is suspected
•To a choice of a number of hospitals for elective care
•To view their personal health record
•To be treated with dignity and respect, including single
sex accommodation
•To have complaints dealt with efficiently and
investigated properly
For further information on the NHS Constitution please see
www.nhs.uk/choiceintheNHS/Rightsandpledges/
NHSConstitution/Documents/nhs-constitutioninteractive-version-march-2012.pdf
We expect to see the outcome measures incorporated
within the 2013/14 Operating Framework guidance later
this year.
www.mandate.dh.gov.uk/2012/07/04/mandateconsultation/
The Operating Framework for the NHS 2012/13
The ‘Operating Framework for the NHS in England
2012/13’ describes the planning, performance and
financial requirements for NHS organisations and sets
out four key themes:
•Putting patients at the centre of decision making
•Development of the new system of delivery
•Quality, innovation, productivity and prevention
•Maintaining and improving performance
The Framework also identifies a number of key priorities
for 2012/13 including:
•Dementia and the care of older people
•Carers
•Military and veterans’ health
•Health Visitors and Family Nurse Partnerships
Section 4 The National Context
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Page 14
4 The NHS Outcomes Framework
The NHS Outcomes Framework describes the health
outcomes required from NHS organisations under 5
domains. These requirements are reflected in the CCG
and JSA priorities for the plan period and various initiatives
Outcomes Framework
have been developed to help achieve these outcomes. The
diagram below demonstrates how our programmes of
work link to the framework:
Wiltshire CCG
Effectiveness
Domain 1
Preventing people from dying prematurely
• Staying healthy and preventing ill health
• Mental health
Domain 2
Enhancing quality of life for people with
• Long term conditions (including dementia)
long term conditions
• Mental health
Domain 3
Helping people to recover from episodes
• Community and integrated care
of ill health or following injury
• Planned care
• Unplanned care
Patient Experience
Domain 4
Ensuring that people have a positive
• Listening to our patients and others
experience of care
•Quality
• End of life
Safety
Domain 5
Treating and caring for people in a safe
•Safeguarding
environment and protecting them from
•Quality
avoidable harm
Appendix A (page 88) demonstrates how the national frameworks, Local Authority and our CCG plans link together.
The plans for meeting these commitments during 2012/13 are set out in Part 2 Operational Plan for 2012/13
Section 4 The National Context
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Page 15
5
The Local Context
Understanding our population and what we need to
do to help people stay healthy
Wiltshire is a large, predominantly rural and generally
prosperous county with a population of 459,800. Almost
half of the population resides in towns and villages with less
than 5,000 people and a quarter live in villages of fewer
than 1,000 people.
Population by age
The population age structure for Wiltshire is broadly similar
to the population of the South West region. However,
the proportion of people of working age (ages 15-59) in
Wiltshire is smaller than both the South West and England
overall figures (see Figure 1.1 below).
% of Wiltshire population aged 15-59, mid-2010 (Chart 1)
Approximately 90% of the county is classified as rural and
there are significant areas with a rich and diverse heritage
of national and international interest, such as Avebury,
the Kennet and Avon canal, Stonehenge and Salisbury
Cathedral. The relationship between the city of Salisbury and
the larger towns in Wiltshire and the rest of the county has
a significant effect on transport, employment, travel to work
issues, housing and economic needs.
In order to design health services that provide the right
care for people both now and in the future, it is important
to understand some basic information about the make-up
of the population, and how this is going to change in the
future. Using this, and other information that we have about
the prevalence of disease we can build up a picture of what
services we need to develop or change in order to keep
our population as healthy as possible. A detailed analysis of
the population and its needs is set out in the Joint Strategic
Needs Assessment (JSA) for Wiltshire which is available at
www.intelligencenetwork.org.uk. Here we set out some of
the key issues that necessitate change and hence underpin
our strategy.
Population in context
With 141 people per sq km, Wiltshire has a lower
population density than the South West or England overall
(see Chart 1). The rural nature of the county has implications
for the planning and provision of health and social care
services, particularly with a shift towards more provision of
services in the community.
Wiltshire
South West
England
40%
% Age 15-29
% Age 30-44
% Age 45-59
Source: ONS 2010 mid-year estimates: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=
tcm%3A77-231847 reprinted from the JSNA
Wiltshire’s population is ageing more rapidly than England or
the South West, reflected by higher growth of 15% increase
in the over 65s between 2010 and 2014. This is significantly
greater than recorded in England at 11.6% or in the South
West at 14%. This increase in population has implications for
the provision of a wide range of services, including health
and social care particularly for the more vulnerable groups
(the very young and very old), housing and transport.
Future population change
For our CCG, population projections are important in order
to plan provision of all health services to ensure that we
meet the needs of the local populations. By 2021, Wiltshire’s
population is projected to reach 494,200, a 7.5% increase
on the county’s estimated population in 2010. Chart 2
illustrates that the population of Wiltshire is projected to
change differentially according to particular age groups.
In England, the South West and Wiltshire, the population
structure is shifting towards that of an ageing population;
in Wiltshire people aged 65 or over reaching 21% by 2016,
and exceeding 23% by 2021. Implications of an ageing
population are great in terms of people living longer into
older age, with an increased demand for health services,
a higher burden of chronic disease and susceptibility to
the negative impacts of social isolation. In parallel to this
there will be a reduction in working age people, a reduced
contribution to the economy and lower incomes, and an
increased need for care services (paid and unpaid carers).
Section 5 The Local Context
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Page 16
Projected Populations for 2015
The chart on the right illustrates
the projected population for 2015,
comparing populations in Wiltshire
and the South West. The pattern of
population distribution by age for
Wiltshire compared to the South
West is broadly similar, with the
exception of ages 20 to 34 years
in which Wiltshire’s population
is proportionately smaller. This is
slightly compensated for by a larger
proportion of 40 to 59 year olds and
children and young people of ages
5 to 19. The obvious implication of
this is that for the next ten years at
least Wiltshire will continue to have
a smaller proportion of working
age population contributing to the
economy and care for older people as
compared to the South West.
Changes in population by
ethnic group
Wiltshire is a largely white and rural
area and people in minority groups
are often not present in sufficient
numbers to form coherent groups.
This can result in an unknown
demand for services and hence unmet
need which the CCG is aware of in
planning services. Chart 3 represents
the proportionate change in the
ethnic minority groups in Wiltshire as
compared to the South West
and England.
Projected changes in dependency ratios (Chart 2)
2016
2011
2021
80%
Percentage dependent on 15-64 population
5
Overall dependency
70%
60%
50%
65 and over
40%
Under 15
30%
20%
10%
0%
Wiltshire
England
Wiltshire
England
Wiltshire
England
Source: Subnational Population Projections Unit, ONS: Crown Copyright.
Estimated population change by ethnic group, 2001 to 2009 (Chart 3)
Wiltshire
South West
Chinese or
other ethnic
group
Black or
Black British
Asian or
Asian British
Mixed
ethnicity
0%
1%
1%
2%
2%
3%
Source: Population estimates by ethnic group mid-2009, ONS experimental statistics
Health in Wiltshire
Wiltshire compares reasonably well with the rest of England and the South
West. The population in the South West has a higher life expectancy than
England as a whole and people in Wiltshire also live longer than the general
population in the South West. Life expectancy in Wiltshire (2008-2010) is 79.6
years for males and 83.7 years for females. However there are inequalities
within the county, life expectancy is 6 years lower for men and 4 years lower for
women in the most deprived areas of Wiltshire than in the least deprived areas.
Section 5 The Local Context
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Page 17
5 Health Needs by Locality
Index of Multiple Deprivation 2010
Wiltshire quintiles
Key
Most deprived quintile
NEW Practices
WWYKD Practices
Average deprivation
CRICKLADE
SNHSA Practices
A419
PURTON
Least deprived quintile
MALMESBURY PC CTR
TOLSEY
TINKERS LANE
A3102
A429
M4
WEST WILTSHIRE
DOWNS
The Great Western Hospital
NEW COURT
A350
A3102
JUBILEE FIELDS
A346
A4361
A420
HATHAWAY
MARLBOROUGH
DOWNS
BEAVERSBROOK MED CTR
Chippenham Community Hospital
A4
ROWDEN
RAMSBURY
NORTHLANDS
MARLBOROUGH
A4
LODGE
BOX
PORCH
A342
Savernake Hospital
PATFORD HOUSE
A361
OLD SCHOOL HOUSE
Royal United Hospital
A346
Melksham Community Hospital
A363
GIFFORDS
BOA & MELKSHAM HP
SPA MEDICAL CTR
BRADFORD ROAD
PEWSEY
SOUTHBROOM
A361
SPRAYS
ST JAMES
A350
Trowbridge Community Hospital
Devizes Community Hospital
LANSDOWNE
ADCROFT
LOVEMEAD
A345
A342
MARKET LAVINGTON
WIDBROOK
AVON VALLEY
WHITE HORSE
HEALTH CENTRE
Westbury Community Hospital
AVENUE
CASTLE PRACTICE
COURTYARD
A338
A360
SALISBURY
PLAIN
BOURNE VALLEY
A345
CROSS PLAINS
TILL VALLEY
Warminster Community Hospital
ST MELOR HOUSE
SMALLBROOK
A36
A303
BARCROFT
A360
A338
A346
A350
BEMERTON HEATH
HINDON
MERE
A303
A36
CASTLE STREET
WILTON HEALTH CTR
TISBURY
SILTON
A30
ENDLESS STREET
SALISBURY WALK IN CENTRE
THREE SWANS
ORCHARD PARTNERSHIP
A30
SALISBURY
MEDICAL PRACTICE
ST ANN STREET
A3094
HARCOURT
Salisbury District Hospital
A338
WHITEPARISH
A354
A36
0
0
5
Approximate scale
DOWNTON
10km
5 miles
SIXPENNY HANDLEY
Section 5 The Local Context
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Page 18
5
Sarum
Sarum locality has a total list size (population) of 134,132
which is 28.9% of the Wiltshire population. The patients
mainly live in the Community Areas of Amesbury, Mere,
Tisbury, Wilton, Tidworth, Salisbury and Southern Wiltshire.
Sarum has the highest number of deprived areas within
Wiltshire CCG. Ten GP practices in SARUM are in the most
deprived quintile in Wiltshire (see map page 18).
The two major causes of all age mortality in Sarum are
cardiovascular (or circulatory) disease (CVD) and cancers
(malignant neoplasms). Together they account for around
60% of all deaths in Sarum.
West Wiltshire, Yatton Keynell and Devizes
(WWYKD)
WWYKD locality group has a total list size (population) of
165,714 which is 35.8% of the Wiltshire population. The
patients mainly live in the Community Areas of Bradford
on Avon, Devizes, Melksham, Trowbridge, Westbury and
Warminster.
WWYKD is more deprived than NEW but less deprived
than Sarum based on the average deprivation score from
the Index of Multiple Deprivation 2010. 2 GP practices in
WWYKD are in the most deprived quintile in Wiltshire
(see map page 18).
The key things to note are:
In Sarum 11.1% of children aged under 16 live in poverty
compared to 11.6% in Wiltshire overall and Sarum has
a higher estimated percentage of vulnerable families
(15.2%) than in Wiltshire overall (11.6%) as reported in the
Vulnerable Families Survey.
•Sarum has a higher teenage conception rate (20.6 per
1,000) than Wiltshire overall (18.6 per 1,000)
The two major causes of all age mortality in WWYKD are
cardiovascular (or circulatory) disease (CVD) and cancers
(malignant neoplasms). Together they account for around
60% of all deaths in WWYKD.
•Sarum has a statistically significantly higher admissions
rate (23,386 per 100,000) than the overall Wiltshire rate
(21,175 per 100,000)
•W WYKD has a lower estimated percentage of
vulnerable families (10.3%) than in Wiltshire overall
(11.6%) as reported in the Vulnerable Families Survey
•Sarum has a statistically significantly higher elective
admissions ratio for CVD (122) and mortality ratio for
CVD (108) compared to the Wiltshire baseline of 100
•WWYKD has a higher estimated percentage of obese
children than Wiltshire overall in Reception (9.7%
compared to 8.6%) but the same estimated percentage
of obese children in Year 6 (16.4%)
•Sarum has statistically significantly higher elective and
non-elective admissions ratios (149.6 and 116.5) for
CHD than Wiltshire (100). Its recorded and estimated
prevalence rates (3.53% and 4.34%) are also higher
than the Wiltshire values (3.25% and 4.04%)
•Sarum has a statistically significantly higher admissions
rate for falls and fall injuries (3,5 69 per 100,000) than
the overall Wiltshire rate (3,117 per 100,000)
•Sarum has a significant number of military families living
in the area
The key things to note are:
•13.4% of children aged under 16 live in poverty
compared to 11.6% in Wiltshire overall
•WWYKD has a higher percentage of people with long
term conditions who are smokers (15.2%) than the
Wiltshire value (14.5%)
•WWYKD has a slightly higher percentage of smoking
attributable deaths (17.1%) to the Wiltshire value (16.6%)
•WWYKD has a higher incapacity benefit claimant
rate for mental illness (17.8 per 1,000) than the overall
Wiltshire rate (16.3 per 1,000)
•WWYKD has a higher teenage conception rate (19.8 per
1,000) than Wiltshire overall (18.6 per 1,000)
•WWYKD has a higher prevalence rate of asthma
(6.40%) than the overall Wiltshire prevalence (6.07%)
•WWYKD has a higher prevalence rate of diabetes
(5.01%) than the overall Wiltshire prevalence (4.74%)
Even though WWYKD has a higher prevalence of
disease the elective admissions rate is lower than Wiltshire
as a whole.
Section 5 The Local Context
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Page 19
5
North and East Wiltshire (NEW)
NEW locality has a total list size (population) of 163,505
which is 35.3% of the Wiltshire population. It has a
similar age structure to Wiltshire but with a slightly lower
proportion of people in the 70 plus age range. The patients
mainly live in the Community Areas of Malmesbury,
Wootton Bassett and Cricklade, Chippenham, Calne,
Corsham, Marlborough and Pewsey. The patients in NEW
are relatively healthy compared to the rest of Wiltshire and
England as a whole. Prevalence of disease and admissions
are both low and practices are high achievers on screening
and patient satisfaction.
The key things to note are:
•The two major causes of all age mortality in NEW are
circulatory disease and cancer; together they account for
around 60% of all deaths
•NEW is the least deprived of Wiltshire’s three locality
groups based on the average deprivation score from the
Index of Multiple Deprivation 2010. No GP practices in
NEW are in the most deprived quintile in Wiltshire. The
map on page 18 highlights the most deprived areas
•The Wiltshire Vulnerable Families Survey has been used
to help assess the health needs of children and families
across Wiltshire. Families were assessed as vulnerable if
they were experiencing 4 or more factors in the survey
or if a child in the family was considered to be at risk
of significant harm. NEW has a lower estimated
percentage of vulnerable families (9.3%) than in
Wiltshire overall (11.6%)
Primary care in Wiltshire
Some 90% of all patient contacts with the health service
are currently with primary care and therefore GPs and
other practice staff are in a prime position to understand
the pattern of disease and illness in their populations and
the quality of local services.
There is good evidence to suggest that the quality and
structure of primary care services has a significant effect
on the way that hospital services are used. In Wiltshire we
are fortunate as the quality of general practice is high (as
measured through the QOF indicators) with no issues of
recruitment or retention.
The Quality and Outcomes Framework (QOF) is the annual
reward and incentive programme detailing GP practice
achievement results.
QOF is a voluntary process for all surgeries in England and
was introduced as part of the GP contract in 2004.
QOF awards surgeries achievement points for:
•Managing some of the most common chronic diseases
e.g. asthma, diabetes
•How well the practice is organised
•How patients view their experience at the surgery
•The amount of extra services offered such as child health
and maternity services
The latest results we have for QOF are for 2010/11.
Practices in Wiltshire scored 96.1% of the total QOF points
available indicating high quality in clinical care. The patient
experience indicator was disappointing lower at 75.9%.
As a CCG we will be involving patients at every level to
ask how we should improve our services and we aim to
improve on this score over the next 3 years.
Section 5 The Local Context
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Page 20
Our Key Priorities
Model for Care Closer to Home in Wiltshire (Diagram 5)
Tertiary Care
T e r t i ar y c a r e
Acute Care
e
b o urh o o d T ea
m
End of
care/case
management
Primary Care
s
Pharmacy
Dia
Discharge
support
Optometry
y
cs
it
ti
Step
up/down short
stay nursing
home beds
un
os
Nursing
and care home
support
m
gn
hin g into
y reac
co m
Dentistry
wa
PATIENT
th
Integrated
Community
case mgt for
based
y
r
a
c
LTC and frail
a
im
re reablement
elderly
Pr
GP Practices NHS 111
x3
Rapid
assessment
and urgent
care packages
Patient
Pa
ut
ig h
re
Be
s
Ne
Neighbourhood Teams
Ca
d
A cute C are
Ac
6
A c u te C are
The population of Wiltshire currently enjoys relatively good
health and access to reasonable quality, safe services.
However, as the profile of the population changes we must
consider the opportunities that are emerging to in order
that we can plan and develop our health service to meet
future needs. In order to achieve this we must consider the
changing and ageing population and its needs, alongside
the way that people are currently using our health services.
This is dependent on both patients’ needs and the location
of services.
We have a very simple but bold vision to reorganise patient
services. The vision must ensure that an NHS can operate
with higher efficiency but still offer high patient quality.
It also needs greater integration between community
services and general practice and closer working with
social care.
The vision must put the patient in control whilst ensuring
that every opportunity is given for the population to be
healthier. Wiltshire CCG has a total budget of circa £500
million to deliver care to our population. We will work with
all providers to agree system rules and behaviours that
mean we can live within the total resources available to us.
We will put primary care back in the driving seat for care
delivery and care co-ordination. General Practices will be
supported to use risk stratification tools to ensure they are
aware of the patients in the practice who are most in need
of community based support. This support will be provided
by neighbourhood teams in close liaison with general
practice to enable patients to live safely in their own homes
and ensure that acute exacerbations of their condition
can be predicted and avoided and if they occur can be
managed without an admission to hospital.
Groups of General Practices will cluster together where
appropriate to work with one generic Neighbourhood
Team covering a population of between 20-40,000 people
or as appropriate to that community. The Team will provide
“wrap around” care for all vulnerable individuals in the
neighbourhood as identified by the practice and other
providers. The skill mix and numbers of staff in the teams
will vary depending on the needs and geography of the
neighbourhood.
Section 6 Our Key Priorities
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Page 21
6
The neighbourhood teams will provide assessment,
treatment and case management/care coordination for:
•Patients with long term conditions
•People at risk of being admitted to hospital who could
be managed at home with the right support
•Patients who are fit to be discharged from hospital but
still have unstable health needs and require hospital
type care
•Patients identified by the a range of services (ambulance
service social care homes) who would be better
managed at home than being taken to hospital
e.g. Patient who has fallen but suffered an injury that
requires a transfer to hospital
Each team will have access to specialist support and advice
e.g. Diabetes, COPD, stroke and will share expertise and
skills and capacity across the teams. The teams will have
access to pharmacist support for medicines management
expertise. Each team will have a clinical leader with
administrative support and each practice will have a
practice co-ordinator who will meet with the practice team
on a regular on-going basis.
Neighbourhood Care will be integrated with social care
providers and local authority commissioners at a local level
to ensure patients are “helped to live at home” in the
most straightforward way possible. Each patient will have
their care co-ordinated by a single named individual with a
simple contact point.
In addition to care provided directly in the homes of
housebound patients where possible we will bring more
out-patient services normally provided in a hospital setting
by a specialist to a local community setting to enhance
accessibility for our rural population.
Rehabilitation will be provided in the community with
lengths of in-patients stay being as short as possible. This
applies to both routine (e.g. following a stroke or broken
hip) and specialist rehabilitation (e.g. following traumatic
brain Injury) and to adults as well as children and individual
in transition. Access to community rehabilitation will be
based on support to achieve self-set goals (e.g. to return
home) rather than any subjective decision about potential.
This acute care in the community will include pre op
assessments within general practice, management of long
term conditions in primary care and more effective use of
community beds to reduce the time patients are in hospital
or being treated within the community instead of being
admitted to hospital. This reduces the risk to the patients
of hospital acquired infection, allows them to be near their
family and friends and be treated by their GP and nursing
team who know them well.
We will work closely with our hospital partners and other
providers to understand the potential for developing new
pathways of care to decrease the numbers of surgical
interventions required in conditions like muscular-skeletal
conditions of the back and neck or hip and knee
to ensure patients are offered low risk interventions as a
first option. We would like to provide more diagnostic and
assessment services in the community and will look at
affordable ways of achieving this close to patients home.
The financial model within the strategic plan has to take
account of increase in the ageing population and the
advance of medical technology and drug applications. In
order to invest in primary and community
care resources need to “shift” from the hospital into the
community and we will be working with our partners to
enable this to happen effectively whilst sustaining a smaller
but more “acute” and specialist hospital
bed base.
The information we have gathered from the JSA and
other documents highlight key trends and themes for
the local population and provision of health services. This
information, together with our experience as clinicians
working in the local health system has highlighted 7 key
priorities we will need to address during this plan period
and beyond.
These are:
Priority 1 Staying healthy and preventing ill health
Priority 2 Planned care
Priority 3 Unplanned care and frail elderly
Priority 4 Mental health
Priority 5 Long Term Conditions (including dementia)
Priority 6 End of life care
Priority 7 Community services and integrated care
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6 Priority 1 Staying healthy and preventing ill health
Wiltshire CCG is keen to ensure that activity over the next
2 years is targeted to improve the overall health of the
whole population through a variety of public health
initiatives delivered in partnership with local surgeries,
local voluntary and community sector organisations and
other local stakeholders.
We believe that a ‘healthy community’ should form
the bedrock for the delivery of effective and efficient
services. This depends on the population having a level of
understanding of health determinants, their own condition
and the services available so that people feel confident and
empowered to care for themselves where appropriate and
access services effectively and efficiently when necessary.
Critically people need to understand the positive role they
can take in their own health and health care and the value
of the support they can offer to others.
Current situation
Wiltshire compares reasonably well with the rest of
England and the South West. The population in the South
West has a higher life expectancy than England as a whole
and people in Wiltshire also live longer than the general
population in the South West. Life expectancy in Wiltshire
(2008-2010) is 79.6 years for males and 83.7 years for
females. However there are inequalities within the county,
life expectancy is 6 years lower for men and 4 years lower
for women in the most deprived areas of Wiltshire than in
the least deprived areas.
The main principles of healthy living remain the same:
smoking, poor diet, lack of exercise and too much alcohol
are the main reversible causes of ill health.
It is increasingly understood that lack of self esteem
through not working, loneliness or isolation, are
increasingly problems which affect people’s health, well
being and use of the NHS.
Modern medicine cannot easily reverse the effects of a
lifetime of self-neglect and we will work with the Health
and Wellbeing Board to address the areas out of our direct
control so that future generations make better lifestyle
choices and not only live longer but healthier lives.
Section 6 Our Key Priorities
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6
Staying healthy and preventing ill health - Programme of Work
Expected end state - 2015
Commissioning Intentions:
• Implementation of the Joint
Health and Wellbeing Strategy
(JHWS)
• E nabling people to have access
to physical activity through
Active Health programme,
according to the referral criteria
set out for this programme
• A
ll providers to offering stop
smoking service to target specific
client groups; pregnant women,
young persons and people with
long term conditions
• Improving coverage and uptake
for antenatal, new-born, bowel,
diabetic eye, breast and cervical
cancer screening
• D
epartments to report to
Public Health on 6-8 week
breastfeeding prevalence
and coverage and Newborn
bloodspot screening
• Improving awareness of falls
prevention through the falls and
bone health strategy
• E nsuring that GPs undertake
the 6-8 week mother and
newborn checks in accordance
with national guidance; that
all information is recorded
(including breastfeeding status)
and returned to Community
Child Health in a timely way
• Maternity providers agreeing a
consistent definition and routine
collection and reporting of
women’s breastfeeding status at
discharge from maternity service
in addition to breastfeeding
initiation
• E nsuring implementation of the
Health Visitor/Midwifery Liaison
Pathway across Wiltshire
• O
ptimising childhood
immunisation coverage of all
primary antigens to 95% (current
payment threshold 70 and 90%)
• Increasing awareness of cancer
symptoms and routes to early
diagnosis
• P roviding a range of high quality
and effective alcohol and drugs
services
• Improving local health care
management and support to
patients newly discharged from
hospital and those with long
term conditions
• R
eferral to Health Trainer
programme as appropriate
• E ducation programmes for
communities on caring for self
and family
• G
ood access to a wide range of
psychological therapies
• Increasing uptake of NHS Health
Checks to exceed 75% target
• G
Ps undertaking the Seasonal
Influenza campaign
• E nabling children to stay fit and
healthy through use of child
obesity pathway, referral to
MEND programme (from January
2013), slimming and physical
activity on referral and initiatives
such as free child swimming
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6
Staying healthy and preventing ill health - How we will get there – 2013/14
The CCG, and Local Authority will
work in partnership to achieve
these priorities by:
• Using the Joint Strategic
Assessment evidence and
intelligence to identify need and
inform commissioning of services
• Implementation of the Joint
Health and Wellbeing Strategy
(JHWS)
• E nabling people to have access
to physical activity through
Active Health programme,
according to the referral criteria
set out for this programme
• O
ffering stop smoking service
to target specific client groups;
pregnant women, young
persons and people with long
term conditions
• R
aising awareness of Smokefree
homes, helping young people
stop smoking and prevent them
from starting
• P romoting effective enforcement
of tobacco legislation
• Improving coverage and uptake
for bowel, diabetic eye, breast
and cervical cancer screening
• Improving awareness of falls
prevention through the falls and
bone health strategy
• Increasing uptake of NHS Health
Checks to exceed 75% target
• K
eeping people healthy in winter
through the Affordable Warmth
Strategy and Seasonal Influenza
campaign
• E nabling children to stay fit and
healthy through Healthy Schools
programme, child obesity
pathway, referral to MEND
(from January 2013), slimming
and physical activity on referral
and initiatives such as free child
swimming
• Increasing awareness of cancer
symptoms and routes to early
diagnosis
• P roviding a range of high quality
and effective alcohol and drugs
services
• S upporting communities and
individuals to maximise local
assets, social capital and
inclusion to sustain good
mental health
• M
aking consistent and high
quality contraceptive and sexual
health services available to all
who require them
• M
inimising domestic violence
and mental health issues
through initiatives such as
Hidden Harm, suicide and selfharm prevention strategy
• S upporting the military civilian
integration partnership
• R
educing military, veterans’,
and Service Families’ health
inequalities
• Reducing health inequalities
through referral to Health Trainer
programme, where available and
as appropriate
• S upporting person centred
assessments and personal health
budgets
• S arum Group aim to pilot
Community Health Awareness
Teams (CHAT) who will
inform and advise on physical,
mental and emotional health
and facilitate links between
organisations
Implementation could vary in
each of the three local groups
depending on current service
configuration and pathways.
Staying healthy and preventing ill health - How we will measure success
• Reduction in smoking prevalence
• R
eduction in hospital admissions
for preventable illnesses against
2011/12 baseline
• R
eduction in premature mortality
from preventable illnesses
against 2011/12 baseline
• Increased take up of NHS Health
Checks by every GP practice
• R
eduction in the prevalence in
the population of preventable
illnesses against 2011/12 baseline
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6 Priority 2 Planned care
The CCG will closely monitor activity and patient ‘flows’
through our hospitals. A monthly ‘hotspot’ report identifies
the areas that need to be looked at in much more detail
and actions taken.
Challenges in the system
An analysis of the number of days people are in hospital
showed that there is a significant number of patients
who were medically fit for discharge and yet remained in
hospital because arrangements for the discharge had not
been completed. We regard this as unacceptable, since it is
generally in patients’ best interests to return to their family
environment as soon as they are medically fit to do so.
Furthermore, increasing patients’ length of stay in hospital
is using resources that could be put to better use caring
for patients.
Current ‘hotspots’ (September 2012)
• of concern, actions required • on target
Total referrals
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
Royal National Hospital for Rheumatic Dieseases
•
•
•
•
GP referrals
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
Royal National Hospital for Rheumatic Dieseases
•
•
•
•
Waiting list (18 week breaches)
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
•
•
•
Delayed transfers of care (DToCs)
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
•
•
•
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6
Planned Care - Programme of Work
Expected end state - 2015
• Achieve key national targets
• Improved support for self care
• S hift some services out into the
community to make access both
faster and more convenient
• R
educed dependence on
interventions
• C
are pathways implemented
with a clear understanding of
evidence for each intervention/
pathway
Planned Care - How we will get there – 2013/14
• R
eviewing care pathways to
maximise potential care in the
community
• E xpand the development
of Referral Support Systems
(RSS) and implement referral
guidelines across a range
of services
• E nable specialist support to work
more closely with primary care
• Increasing the skills, expertise
and knowledge available to GPs
and practice nurses to manage
patients in the practice
• D
eveloping non attendance
based models of care such as
advice only referrals, resultsonly ‘virtual clinics’ which can
prevent the need for some
patients to travel, and rapid
access telephone help lines for
expert patients to access higher
acuity level care on demand e.g.
management of diabetes
• R
oll out consultant led
orthopaedic clinics and hip
and knee pathways across
NEW and WWYKD
Implementation will vary in
each of the three local groups
depending on current service
configuration and pathways.
• Improve access to diagnostics
and other therapies
• R
oll out consultant led
dermatology clinics across NEW
and WWYKD
Planned Care - How we will measure success
• Delivery of the key targets
• B
eing able to measure increases
in the delivery of local services
e.g. outpatient services outside
of District General Hospital
• U
se post op surveys to assess
benefits and quality of provision
• G
Ps do not have enough time to
develop care pathways
• Implementation of care
pathways and referral support
systems take longer than
anticipated
Planned Care - Risks
• N
o impact of moving outpatient
appointment into the community
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6 Priority 3 Unplanned care and frail elderly
Challenges in the system
Wiltshire CCG’s vision for urgent and emergency care is
of universal, continuous access to high quality urgent and
emergency care services.
In practice this will mean that whatever a patient’s urgent
or emergency care need, whatever the location, they get
the best care from the best person, as close to home as
possible and in a timely way.
Although Wiltshire benchmarks 20% below national
average for emergency admissions, many of the patients
taken, and then subsequently admitted to hospital could
have been more appropriately managed at home, or
closer to home. We are working with our community care
providers and the Local Authority to develop a seamless
model for community neighborhood teams to support
people in times of crisis and help them stay in their homes
with their family and friends and looked after by their
primary and community care team who they know and
who know them well.
Current ‘hotspots’ (September 2012)
• of concern, actions required • on target
Great Western Ambulance Service
(GWAS) – ambulance handovers
over 20 minutes
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
•
•
•
A&E attendances
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
•
•
•
A&E waits - under 4 hours
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
•
•
•
A&E admissions
Royal United Hospital
Salisbury Foundation Trust
Great Western Hospital
•
•
•
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6 Subheading
Unplanned care and frail elderly - Programme of Work
Expected end state - 2015
• P rimary care and community
services are able to provide a
same day service for patients
with a perceived urgent care
need regardless of tenure (i.e.
including residents of care
homes
• P eople who access urgent and
emergency care services receive
a consistent response and a
seamless approach to their
assessment and care
• P eople with an emergency
ambulatory care condition
receive same day access to
diagnostics and treatment
• P eople who need to be admitted
stay in hospital for no longer
than is clinically necessary
• C
are homes are confidently
caring for residents in a
partnership between GPs,
community nursing, therapies
and social care, accessing
specialist services as required, so
that non-elective admissions to
hospital are appropriate
• T hat frail and vulnerable people
(defined as people over 80
who have one or more LTCs,
one of which is dementia) who
are admitted to hospital are
discharged in a timely way and
do not have their transfer of care
(discharge from hospital) unduly
delayed
• P eople over the age of 75
admitted to hospital will be
screened for dementia by the
hospital (following admission).
The results of the screening and
assessment will be included in
the discharge summary to GPs
Unplanned care and frail elderly - How we will get there – 2013/14
• P rovision of proactive and
supportive care by all health care
providers to care homes and
their residents
• A
dvanced care plans will be in
place for care/nursing home
residents
• D
eveloped care plans to be
loaded onto shared data bases
(e.g. Adastra) or for data bases
to be accessible by emergency
and urgent care services
• E nhanced care coordination in
place in order to support people
in their communities
• R
isk stratification tool used to
identify individuals (likely to be
frail older people and those
with LTCs) where active case
management will support carers
and individuals to manage
changes and crisis without
reporting to emergency and
urgent care services – ‘put the
planned back into planned care’
• R
eview of use of community
hospital beds and nursing
home beds to ensure the most
effective use of all bed
based care
• A
directory of services will be
developed to assist professional
and user/carer use of emergency
and urgent care services and in
order to support implementation
of the NHS 111 in April 2014
Implementation may vary in
each of the three local groups
depending on current service
configuration and pathways.
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6
Unplanned care and frail elderly - How we will measure success
• A
chievement of agreed response
times for all community based
services
• 9
0% of care/nursing home
residents to have active care
plans in place
• Improved user and carer
experience of community based
and hospital based care
• S teady state in A&E attendances
to hospital (the demographic
growth would ordinarily drive an
increase in admissions)
• R
educed numbers or people
from care homes attending or
being admitted to hospital from
care homes
• S teady state in emergency
admissions to hospital (the
demographic growth would
ordinarily drive an increase
in admissions)
• R
eduction in emergency
bed days
• T he level of DToCs will be
maintained at no more than 3%
Unplanned care and frail elderly - Risks
• E ffectiveness of investment in
community services less than
expected
• O
rganisational change for
community services and
social care
• C
oordinated discharge does not
reduce bed days
• Demand exceeds supply
• N
ursing and care homes do not
implement care plans
• T echnology does not support
the service
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6 Priority 4 Mental health
The rate of mental health problems in
the population is broadly stable: For
‘common mental illness’ (the majority
of depression and anxiety problems)
the estimate is 1 in 4 people and for
‘severe and enduring mental illness
(mostly psychosis - schizophrenia and
bi-polar disorder) it is 3 per 1000
people. Mental health promotion and
prevention of mental health problems
are crucial and practices have a role to
play in the local population through
support for improved wellbeing
at community level; promoting
volunteering and other forms of
social inclusion and development of
social capital; supporting asset-based
community development strategies
and linking good mental health with
good physical health through lifestyle
improvement programmes.
Prevalence data suggests that in
Wiltshire there are currently an
estimated 49,000 individuals of
working age and 12,000 older
people with some form of mental
health problem (neurosis, psychosis
or dementias). All of this presents
the NHS with an unprecedented
opportunity to move from reactive
diagnosis and treatment to be able to
proactively predict and prevent mental
ill health.
Best for people to be treated
at home
There is extensive evidence that it is
best for people in a mental health
crisis to be supported and treated
at home or in another community
setting (such as intensive day support),
whenever possible. Most service
users and carers prefer home-based
treatment and research has shown
that clinical and social outcomes
achieved by community-based
treatment are at least as good as
those achieved in hospital. For
example, the National Audit Office
suggests that more admissions should
be avoided and that improving
service quality and outcomes should
be the primary imperative to reduce
unnecessary or overly long inpatient
stays. Time spent as an inpatient
can weaken people’s connections to
their family, community and support
networks. It found that areas with
Crisis Resolution and Home Treatment
(CRHT) teams saw a 21% reduction in
admissions over five years compared
to those without (10%).
Some service users do not feel safe
in hospital. This is especially true for
women, and for individuals with a
history of abuse, as well as for young
people. New psychiatric ward building
and renovation work is partially
addressing these concerns, by using
only single sex and/or single roomed
wards, the latter helping to make
inpatient care more personalised.
Treatment at home or in the
community reduces the stress and
anxiety of people who are acutely
unwell and enables them to stay in
touch more easily with friends and
family, to maintain their independence
and their normal routine, to continue
making choices about their lives and
to avoid the risk of institutionalisation.
All of these improve outcomes
for people.
It is also what the majority of people
who use services say they want,
in both national surveys, such as
Listening to Experience, Mind’s review
of acute and crisis services, and local
discussion, with people in Wiltshire
in recent years. Carers in areas with
similar services say that they are
glad not to have their relatives going
into hospital and find 24 hour oncall service availability particularly
supportive, even when they do not
use it that often.
Changes to mental health services
over recent years therefore mean
that effective, and where necessary
intensive, treatment at home is
now much more widely available
and accepted.
Wiltshire Clinical Commissioning
Group have been working on
designing the services that are
needed for the changing society and
times that we live in and many of
the building blocks of our vision are
already in place and now simply need
refining and collecting. The changes in
the NHS give the ideal opportunity to
see the vision implemented.
As we move towards providing
health and social care in community
settings it is important that mental
health services are delivered in a
similar way to enable people to be
treated at, or closer to home. An
essential component of this model
is excellent communication between
GPs, community mental health teams,
consultant specialists and social care.
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6
Challenges in the system
•Mental disorder accounts for
around 5% of A&E attendances,
25% of primary care attendances,
30% of acute inpatient bed
occupancy and 30% of acute
readmissions
•Self-harm accounts for
between150,000 and 170,000 A&E
attendances per year in England
•Medically Unexplained Symptoms
(MUS) may account for up to 50%
of acute hospital outpatient activity
•13–20% of all hospital admissions
and up to 30% of hospital
admissions via A&E at weekends
are related to alcohol
•Most patients who frequently
re-attend A&E departments do
so because of an untreated
mental health problem
•In England, alcohol-related hospital
admissions doubled in the 11 years
up to 2007, and alcohol-related
deaths also doubled in the 15 years
to 2006
•Two thirds of NHS beds are
occupied by older people, up
to 60% of whom have or will
develop a mental disorder
during their admission
•One quarter of all patients admitted
to hospital with a physical illness
also have a mental health condition
that, in most cases, is not treated
while the patient is in hospital
Mental Health - Programme of Work
Subheading
Expected end state - 2015
• F ar greater understanding in
the community about how to
maintain mental health and
wellbeing and challenge the
stigma attached to having
mental health problems
• P eople with common mental
health problems or signs of
psychological distress - including
those where these problems
are secondary to a long term
physical health condition
can access a range of talking
therapies and support in Primary
care to prevent escalation into,
and extended use of, health and
social care services
• P roviding high quality care
and support for people who
become acutely mentally ill and
need specialist in-patient and
community services (specialist or
generic services)
• P eople with mental health
problems remain in or as near
to Wiltshire as they wish in a
genuine home with support to
remain in or get employment/
meaningful occupation
• A
n improved confidence in the
Mental Health services provided
Mental Health - How we will get there – 2013/14
• C
ommunity based campaigns
to raise awareness of public
health mental health and actions
communities and individuals can
take to improve resilience and
good mental health
• C
ommunities are supported to
identify and use local resources
and assets which enhance good
mental and physical health
• C
ommissioners will review
acute care pathways and service
specifications as part of pre-
procurement exercise – October
2012 in order to either tender for
new services or review current
contracting and commissioning
arrangements with existing
provider – March 2013
• T o develop and implement a
robust all age mental health
liaison service – March 2013
• T o complete the dementia
pilot in South Wiltshire and
begin rolling out benefits as
appropriate across Wiltshire
• T o improve local working with
AWP in Wiltshire
• T o take forward the Older
Peoples’ redesign work; shifting
setting of care to the community
• Improving support for dementia
sufferers and their families
through the role out of
Dementia Advisors, (working
with the third sector)
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6
Mental Health - How we will measure success
• A
udit - Reduction in the
conversion rate of people
attending an acute hospital
with a Mental Health Disorder
resulting in an inpatient stay
• A
udit– Reduction in the number
of people presenting at ED more
than once for a Mental Health
Disorder
• A
udit – No patient will be
delayed in an acute setting
waiting for a mental health
assessment
• M
aintenance of performance
against quality indicators
for people in specialist
mental health services in
settled accommodation and
employment
• P atient reported experience of
specialist mental health services
• Improved feedback from GPs
• R
educed emergency and hospital
bed days (all ages) for people
with mental health problems
• A
ctive and visible public
mental health messages as
part of World Mental Health
Day, October 2012 with
ongoing programme of public
information across the next year
Mental Health - Risks
• Recruitment of additional staff
• Increase in demand
• Appropriate accessing of service
• E fficiency not realised to meet
waiting times and care closer
to home
• A
cute Providers to do not
recognise their responsibility
to provide a Liaison Service
• A
lternative pathway not
adhered to
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6 Priority 5 Long Term Conditions (including dementia)
Care for patients with Long Term
Conditions (LTC) accounts for a very
large proportion of all NHS care
and in Wiltshire many patients are
registered as having more than one
LTC. Unsurprisingly then many of our
initiatives described in other sections
relate in some way to changing
the way we provide care for these
patients, particularly in relation to
reducing the necessity for emergency
care. Underpinning the new models
of care is the further development
of neighbourhood teams to support
patients with complex needs in their
own home without a constant trail
of ‘specialists’ up and down the
garden path.
The term ‘dementia’ is used to
describe the symptoms that occur
when the brain is affected by specific
diseases and conditions. Symptoms
of dementia include loss of memory,
confusion and problems with speech
and understanding. About 750,000
people in the UK have dementia
– and this number is expected to
double in the next thirty years.
Wiltshire CCG is committed to
improving the care and experience of
people with dementia and their carers
by transforming dementia services
to achieve better awareness, early
diagnosis and high quality treatment
at every stage and in every setting.
We have included dementia with long
term conditions as it is a disease that
can be managed but not cured and
in a way that is similar to diabetes,
arthritis and asthma, or a number
of cardiovascular diseases. Although
dementia has not traditionally been
considered a long-term condition it
is becoming increasingly experienced
and regarded as such.2 Dementia is
also secondary to a range of other
LTCs (e.g. diabetes, LD).
Care for people who are elderly and
have LTCs is best commissioned and
delivered in a partnership between
health and social care.
Challenges in the system
Although data is collected to identify
people with LTCs in general practice,
information is not always collated to
identify those patients most ‘at risk’.
Care coordination is not in place
for all those patients who have
been identified.
A large number of patients with
dementia often have other long term
conditions such as respiratory disease
and/or diabetes and/ or heart failure.
These patients have complex needs
and require the same basic nursing
and medical care with the added
complication of their dementia and
we should look at the whole needs
of the patient and their family not
disease specific.
2. Long-term conditions and mental health - The cost of co-morbidities, Kings Fund 2012
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Page 34
6 Subheading
Long Term Conditions - Programme of Work
Expected end state - 2015
• P eople in Wiltshire with any or
a combination of LTCs, have a
care coordination plan in place
and developed with them. The
plan will use descriptors such
as ‘this is me’ and note routine
observations. It is systematically
shared with services likely to
be called by the person or
their carers in an emergency or
urgent situation. This will result
in people being supported in
their own homes rather than
escalating unnecessarily to
secondary care
• C
arers will feel supported and
people living at home with a
carer will have been offered a
carers assessment (Social care)
and to be put on the carers
register (Primary care)
• A
ll patients will have joint care
plans written by community
services, including mental health
services and primary care
• A
dvanced care plans will be in
place for care/nursing home
residents. Risk stratification tool
used to identify individuals (likely
to be frail older people and
those with LTCs) where active
case management will support
carers and individuals to manage
changes and crisis without
reporting to emergency and
urgent care services – ‘put the
planned back into planned care’
• P atients with complex illnesses
will have their care coordinated.
This will ensure the patient and
their family receive the right
treatment at the time agreed
with the patient
• A
ll people ‘at risk’ of admissions
to hospital or who use other
health services inappropriately
will be identified and a care plan
put in place
• P atients will be supported to
take responsibility for managing
their illness wherever possible
and appropriate
Long Term Conditions - How we will get there – 2013/14
• E xplore options for telehealth
and telecare
• T he Devon risk stratification tool
will be introduced to identify
complex patients
• R
obust community based care
pathways will be developed for
dementia and diabetes
• P ractices will be encouraged
to obtain accreditation with
the Carers Support Wiltshire
programme
• R
ollout of community based
cardiac service currently available
in West Wiltshire to other
local groups
• P eople will be given information,
skills and relevant technology for
self-management so that they
understand what to do when
their condition is exacerbated
e.g. Chronic Obstructive
Pulmonary Disease (COPD)
• R
oll out of Sarum dementia pilot
across Wiltshire
In addition projects may
be implemented locally in
response to a locally identified
need.
• E mbed opportunistic health
promotion in all health contacts
across community services,
primary care and secondary care
• E xplore and implement in year
tools/mechanisms for enabling
an IT system that shares
appropriate information
across agencies
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6
Long Term Conditions - How we will measure success
• S teady state for emergency
admissions (the impact
demographic growth would
usually result in an increase)
• R
educed avoidable use of Out
of Hours i.e. the number of
weekend and bank holiday
requests for repeat prescriptions
• 9
0% of people with a LTC holds
a care coordination plan that
they and their carer(s) have been
involved in developing
• R
educed Lengths of Stay (LoS)
for people who are admitted as
an emergency
• Increased self-confidence in
people with LTCs to self-manage
– survey of patients
• A
n increase in the number of
people diagnosed with dementia
in a GP surgery
• R
educed use of all urgent and
emergency services (in addition
to secondary care admissions)
• Improved life expectancy (to
upper percentile performance)
– can this be measured in the
period of the plan?
• R
eduction in the number of
dementia related admissions
• L ack of clarity on requirements
of investment in community
services
• T echnology not sufficient
to meet service needs
• Improvement in carers
experience - on-going surveys
Long Term Conditions - Risks
• R
esources insufficient to
meet demand
• Service unable to meet demand
• A
vailability of suitably competent
frontline staff to meet increased
requirements of capacity
• Engagement of partners
• C
apacity to introduce
personalised care plans is
insufficient
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6 Priority 6 End of life care
We already know that the profile of
our population is changing and we
expect to see an increase in people
over the age of 65 years. As this
trend continues and we improve the
management of people with long
term conditions, leading to greater life
expectancy, so the end of life planning
and care will become more important.
End of Life (EOL) is defined as ’the
care that helps those with advanced,
progressive, incurable illness to live as
well as possible’ National Council for
Palliative Care 2006).
End of Life in this strategy applies to
adults with long term conditions such
as advanced cancer, heart failure,
COPD, stroke, chronic neurological
conditions, dementia etc. It covers
care and support given to patients and
their family or carer in the last year
of life and for the family following
bereavement, and in all care settings home, acute hospital, residential/care
home, hospice, community hospital
and other institutions.
Current performance
•
20.8% of deaths (for people aged
65+) at their own residence (as a
% of all deaths). This compares
favourably with other areas in the
south west.
•
Although Wiltshire is doing well in
terms of people dying at home we
know that this option should be
available to more people.
Challenges in the system
•
Increasing the use of IT systems to
support emergency and urgent care
•
Too many admissions (including
from care homes) in the last few
hours before death. This is based
on anecdote and formal reporting
by acute care
•
Confidence in the Continuing
Healthcare fast track mechanism
as a means of providing out of
hospital care
•
Inequitable and consistent hospice
and other EoL services
Our overall aim is that people in
Wiltshire are supported to be cared
for and die in their preferred place
of care with community support as
needed across a 24 hour period care
coordination, nursing and symptom
control and access to community
equipment. More people, and their
carers, will feel confident to state
and achieve their own home as their
preferred place of death.
Section 6 Our Key Priorities
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6 Subheading
End of Life - Programme of Work
Expected end state - 2015
• P atients are supported and
able to die in their preferred
place of death where this is
safe and possible
• P atients die pain free, with good
symptom control, provision of
psychological, social, spiritual
and practical support
• A
ll providers are competent,
confident and skilled in the
management of people at the
end of life
• P atients and their families are
treated with dignity and respect
of their wishes at end of life
• C
arers and families experience
supportive care of their
loved one
• C
are homes are accredited
against the Gold Standards
Framework (GSF)
End of Life - How we will get there – 2013/14
• E nsuring that all surgeries are
utilising GSF tools and having
monthly multidisciplinary end
of life care meetings involving
neighbourhood teams and
other specialists
• G
SF meetings held in each care
home, to ensure comprehensive
plan for each patient at the end
of their life
• E ngage practices in the Find
Your 1% campaign run by
Dying Matters
www.dyingmatters.org/gp
• Improving skills in primary
care to undertake advance
care planning discussions with
patients and their families
• E nsure all primary care clinicians
know about the mechanism for
securing 24/7 specialist palliative
care advice e.g. pain control
• E lectronic Palliative Care
Coordination System (EPaCCS)
is embedded across all
organisations to ensure patients
are managed appropriately in
the right setting
• E nsure interagency agreement
on Do Not Attempt resuscitation
(DNAR) documentation
• E valuate the nursing care
home local enhanced service
with a view to continuation
and potentially expanding into
residential homes
• A
ll end of life patients to have
an advanced care plan in place
• S etting up mechanisms to
support further care homes
in Wiltshire towards GSF
accreditation
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6
End of Life - How we will measure success
• C
ontinual increase in the
percentage of patients who die
in the preferred place of death
• N
umber of people on the EOL
register by GP surgery
• R
educed conveyance of patients
at end of life to hospital –
exception reporting by Great
Western Ambulance Service
(GWAS) of people taken to
hospital who were on EOL
register / had Advanced Care
Plan (ACP) in place at home
and stated not wanting to go
to hospital
• R
educed emergency hospital
bed days relating specifically to
palliative and end of life care,
more specifically for those with
an Advanced Care Plan in place
• A
ppropriate use of CHC fast
track packages as measured by
CHC, secondary care, hospices
and GPs
• C
arer and family reported
experience of the death of
a loved one
• S taff reported experience of
dying and death for patients
and carers/families
• Improving Access to
Psychological Therapies (IAPT)
data on patients accessing
psychological therapies as a
result of bereavement or an
end of life diagnosis
End of Life - Risks
• Engagement of partners
• P ractices not able to hold
monthly meetings
• Uptake of training
• F ailure to implement training
tools effectively
• C
ommunity infrastructure not
robust enough to care for
patients at home
• Insufficient access to equipment
• E mergency services not aware
of pathways to support patients
dying at home
• T echnology to support shared
records
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6 Priority 7 Community services and integrated care
Our strategic vision over the next 2 years
is to ensure that older people are better
supported in the community so they can
age more healthily and put less demand
on hospital services. They should feel
more secure and supported by greater
coordination between social care and
the health service.
In order to deliver locally based
services that ensure the health care
meets the needs of local populations,
integrated community services will be
commissioned around the 3 locality
groups and neighbourhood teams.
Challenges in the system
•
The capacity of community teams
to respond in cases of urgent and
planned need
•
The capacity of community services to
respond in a robust way, rather than
a minimalist or delayed way
•
Disconnect between referrers and
community teams
•
The potential in the current system
for duplication and gaps for some
care groups (e.g. LTC management)
Each Group will develop care pathway
changes to allow integrated care
solutions to start taking shape to meet
the needs of their population e.g.
around long term conditions, with
the services of community matrons,
community nursing, community
therapies, social care and primary care.
Section 6 Our Key Priorities
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6
Community services and integrated care - Programme of Work
Subheading
Expected end state - 2015
• T o have multidisciplinary
integrated health and social care
neighbourhood teams in place
working in neighbourhoods
clustered around GP practices.
The population of each
neighbourhood will be circa
30,000 - 40,000. The teams
will include a skill mix of nurses,
therapists, social care and mental
health in sufficient number to
provide referrers with confidence
that, following a simple referral
process, the individual referred
will received ‘wrap-around care’
• S kill mix and numbers of staff in
the teams will vary depending
on the needs and geography
of the neighbourhood. The
neighbourhood teams will
provide assessment, treatment
and case management/care
coordination for:
-Patients with chronic long term
conditions
-People at risk of being
admitted to hospital who could
be managed at home with the
right support
-Patients who are fit to be
discharged from hospital but
need additional help
-Patients identified by the
ambulance service e.g. Patient
who has fallen, who would be
better managed at home than
being taken to hospital
• E ach team will have access to
specialist support and advice e.g.
Diabetes, COPD, stroke and will
share expertise and skills and
capacity across the teams
• T he teams will have access
to pharmacist support for
medicines management
expertise
• T he team will be led by a clinical
leader with administrative
support
• E very patient will have a named
care co-ordinator to manage
the times of the member(s) of
the team providing care and
treatment
• E very patient will have in place
a care management plan
which each clinician can access
electronically. The plan will be
shared with other agencies who
might be called by a patient out
of hours and/or at times
of actual or perceived urgent
care need
• T he team will have regular
planned meetings with the GP
practice team and will have one
member of the team allocated
to be the key contact for each
practice
• R
eferral mechanisms will be
robust and transparent
• R
eferrals will be received from
acute and specialist hospitals,
ambulance services, social care
and care homes
• T he GP will identify patients
through a risk stratification
process
• E ach team will receive urgent
and planned care referrals,
delivering care within agreed
timeframes and taking
ownership of people referred
• C
are will be delivered to all
adults (children not requiring
specialist CYP services) regardless
of tenure
Community services and integrated care - How we will get there – 2013/14
• P lanned and focused investment
into community services
• E nable primary care to act as
a real hub of care
• A
gree criteria and protocols
for referral
• D
evelopment detail as to the
vision of what the service will
look like
• E nable and encourage better
integration between primary
care and neighbourhood teams
• A
gree protocols with social
care providers and mental
health providers
• Agree principles for the service
• A
greed roles and responsibilities
for members of the
neighbourhood teams
• R
eview of the access route
for the teams putting in place
a system for a simple point
of access
• R
apid stocktake of where we are
now and the gaps
• T raining put in place for clinical
leadership
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6
Community services and integrated care - How we will measure success
• P atients will have a better
experience by being treated and
cared for at home with their
friends and relatives and a GP
and nurses who know them
• Increase in the volume of
funding that is invested in joint
commissioning with Wiltshire
Council
• Reduced lengths of stay
• Reduced emergency admissions
Community services and integrated care - Risks
• P oor data quality leading to
difficulty in assessing ‘where
we are now’
• Recruitment of competent staff
• T ime required for leadership
training
• R
edesign of pathways in excess
of available resources
• C
hange in pathways will take
longer than anticipated
• Engagement of key stakeholders
Section 6 Our Key Priorities
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7
Medicines Management
Medicine is an important aspect of healthcare delivery,
like surgery, access to a GP, management of long term
conditions etc. It involves many organisations which
include pharmacy, doctors and nurses who prescribe
pharmaceutical companies and the National Institute of
Clinical Excellence (NICE). It therefore needs to be
carefully managed.
Excellent management of medicines by health professionals
and well-targeted prescribing for patients and users delivers
health improvement. This is true for both acute and chronic
disease, and underpins many of our programmes of work
to improve the quality of patient care.
Wiltshire CCG is building on the excellent work that has
already delivered savings on prescribing across Wiltshire.
We will continue to aim to make the use of medicines
as effective, safe and efficient as possible, through good
medicines management we will:
•
Put in place the necessary safeguards involving multiple
agencies
•
Maintain well-being
•
Improve health
•
Enable people to care for themselves
•
Offer better access to pharmaceutical services
•
Improve choices for patients
Medicines management is about enabling people to make
the best possible use of their medicine.
Through its assessment of its capacity and capability to
deliver its commissioning function the CCG has identified
that it wishes the medicines management function to be
delivered within the CCG structure.
•
Make better use of the skills of healthcare professionals
such as doctors, pharmacists and nurses
•
Give more information to patients
•
Reduce waste and save money
In other organisations this function may be delivered under
contract by commissioning support units.
PART
1 Section
1 Section
Header
Section
7 Medicines
Management
The
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with you,
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7
There are some interesting facts about how medicines are
prescribed and how people use them:
•
Medicines are the most frequent treatment intervention
and cost the NHS over £12.9 Billion in 2011
•
In 2010/11, adverse drug events were attributed to
115,178 episodes in hospital and were associated with
over 664,800 bed days
•
Between 30 and 50% of prescribed medicines are not
taken as recommended
•
10 days after starting a new medicine, 30% are already
non-adherent and 61% of patients feel they are lacking
information. Half report a problem with their medication
and at four weeks, in 22% of cases, the problem
is still there
Practice prescribing
The prescribing team has worked both at a strategic level,
on formularies and controlled new drug implementation,
and at a local level, targeting areas of projected overspend
to contain growth across Wiltshire.
•
Actively targeting the variation practice prescribing
•
ScriptSwitch – annual return on investment £176k.
ScriptSwitch works at the point at which a drug is
prescribed within the GP system and automatically
displays a recommendation which may be clinically safer
and more cost effective
•
Specials (unlicensed medicines) prescribing – spend
during 2011-12 was more than £450k
•
Introducing and monitoring formularies
•
At four weeks, 26% of patients say that a new problem
has emerged
•
Working with secondary care to agree drugs which
should be prescribed only in secondary care
•
Just 16% of patients who are prescribed a new medicine
are taking it as prescribed, experiencing no problems
and receiving as much information as they believe
they need
•
Horizon scanning of new drugs
Costs of medicines in Wiltshire CCG
Approximately 20% of the CCG budget is related to
prescribing. 68% of which is Primary care prescribing
and 32% Secondary care, of which 60% is Payment by
Results (PbR) excluded drugs. Secondary care prescribing is
increasing nationally by 13% and PbR excluded drug spend
by 20%.
Currently, growth in prescribing spend across NHS Wiltshire
is 1%, in line with the national average. However, we
are already starting from a low spend as we are the 14th
lowest in the country which is due to the intensive work
programme run by the medicines management team over
the last two years to ensure cost effective prescribing
across the county.
•
Planned introduction of new drugs
•
Monitoring and local implementation of NICE
recommendations
•
Issuing prescribing guidelines
We will continue to raise the profile of prescribing across
the CCG. Our overall goal is to help optimise prescribing,
and the experience and outcomes involving medicine for
each patient. High quality, cost effective prescribing will
lead to better patient outcomes and reduced waste, giving
the CCG good value for the large investment that the
prescribing budget represents.
Our aim is to:
•
Maintain low prescribing growth
•
Maintain low cost per weighted prescribing unit in
primary care
•
Attain low cost of prescribing in secondary care
•
Promote cost effective use of medicines to ensure costs
are within budgetary constraints
Section 7 Medicines Management
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8
Joint Health and Wellbeing Strategy for Wiltshire
The Wiltshire Health and Wellbeing Board (HWB) has a
strategic leadership role in promoting integrated working
between the local authority, the NHS, and in relation to
Public Health services and is the key partnership and focal
point for strategic decision making about the health and
wellbeing needs of the local community. Its focus is on
securing the best possible health and wellbeing outcomes
for all local people.
The Joint Health and Wellbeing Strategy (JHWS) sets
out our priorities for working together to support
people throughout their lives to: live healthily; to live
independently; to be engaged in the support they receive
and; to be kept safe from avoidable harm. It sets out the
expectations that people might reasonably expect to be
met under each of these themes and which the agencies
involved will be working hard to deliver.
One of the functions of the HWB is to ensure that all
commissioning decisions and plans, regardless of provider,
are in line with the Joint Health and Wellbeing Strategy
and take account of the JSA and another is to oversee and
coordinate effort to make sure that public money invested is
being used in the most efficient and effective way to deliver
the priorities in the Joint Health and Wellbeing Strategy. This
could be through the development of aligned or pooled
budgets where this will enable improved service delivery.
The JHWS is not about taking action on everything at
once, but about setting priorities for joint action and
making a real impact on people’s lives. This strategy will
see an increase in integration between services, more joint
commissioning of services, and, in the fullness of time,
more pooled budgets between agencies.
At the Health and Wellbeing Board on 13th September
2012 our plan received support from the Board.
We have four overarching outcomes for the JHWS:
•
Living – for longer;
•
Living healthily – for longer, and enjoying a good quality
of life;
•
Living independently – for longer;
•
Living more fairly – reducing the higher levels of ill health
faced by some less well-off communities.
Section 8 Joint Health and Wellbeing Strategy for Wiltshire
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9
National Priorities
In addition to the local key
priorities identified through the
locality groups Wiltshire CCG
has important responsibilities to
commission or work with partners
to provide services for other
groups.
Maternity and New-born Services
Local maternity services report
increased numbers of births causing
pressure within the service. The
Office for National Statistics (ONS)
and Wiltshire Council projections of
the number of births (2010 onwards)
showed an expected decrease. This
does not reflect the local situation.
Local projections are for an increase in
births (2010 onwards) of around 1%
or 2%. Natural variation in births each
year makes predictions for individual
years difficult, as past figures highlight.
Nationally it is know that the health of
women before they become pregnant
is poorer, for example related to
overweight, physical inactivity and
chronic health conditions. As a
result an increasing proportion of
pregnancies is reported as ‘high risk’
and requires greater clinical input,
which comes at a cost.
Smoking during pregnancy is a
contributory factor to low birth
weight. There is a proven association
between low birth and poor long term
health outcomes.
Nutrition in the early years of life
is a major determinant of infant
mortality, growth and development,
and influences adult health. Breastfeeding provides clear short and long
term benefits for both infant and
the mother. Breast-fed babies are
five times less likely to be admitted
to hospital with infections such as
gastro-enteritis in their first year,
and are less likely to become obese
in later childhood. Mothers from
disadvantaged groups, including the
young and/or poorly educated, are
least likely to breast-feed.
Current performance and
Challenges in the system
At September 2012 the rates for
Caesarean sections as a percentage of
normal births are:
•Salisbury Foundation Trust – 22.7%,
expected rate 22%
Wiltshire Breastfeeding Strategy
2011-201460 outlines the strategy
to increase the number of women
initiating breastfeeding by 11%, to
reach 90% by 2014. In addition,
Wiltshire has the ambition to increase
the number of women breastfeeding
at 6-8 weeks by 8% to reach 58% by
2014, with a focus on closing the gap
in breastfeeding between Wiltshire’s
most deprived areas and the county
average.
Data for 2010/11 estimates that
13.4% of pregnant women in
Wiltshire are smoking in pregnancy,
in line with England as a whole at
13.5%. Smoking levels are significantly
higher among routine and manual
workers compared to the rest of
the population.
•Great Western Hospitals NHS
Foundation Trust (GWH) – 28.41%,
expected rate 23%
•Wiltshire Community Services
– 20.57%, expected rate 19.5%
Section 9 National Priorities
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9 Subheading
Maternity and new-born - Programme of Work
Expected end state - 2015
• E xcellent links between
maternity services, health
visitors, children’s centres and
GPs to ensure women and their
families have multidisciplinary
antenatal and postnatal care
• W
omen with additional needs
identified early in pregnancy and
appropriate support put in place
• R
ange of choices available, based
on clinical needs of mother
and baby to include supporting
community birth centres and
home births, secondary care and
tertiary care
• E ach woman to have a named
midwife to support care
• F amily nurse partnership rolled
out if appropriate once RCT
results published in March 2013
Maternity and new-born - How we will get there – 2013/14
• W
ork with maternity providers,
users, GPs, health visitors and
early years partners to agree and
implement pathways ensuring
close communication
• W
ork with maternity providers,
users, GPs, health visitors and
early years partners to identify
additional needs and ensure
services available to meet them
• Q
uality and appropriate levels
of support provided to all
women in the antenatal and
postnatal period e.g. improved
breastfeeding advice and
guidance pre/post birth, parent
craft classes, early identification
of postnatal depression, smoking
cessation, healthy lifestyle advice
• T o work with providers to
understand the practice
implications of PbR for maternity
services from 2014 onwards
• T o ensure funding implications
of PbR are understood and, if
appropriate are planned for in
the Annual Operating Plan for
13/14
• T o continue to work with the
Maternity Services Liaison
Committee, who ensure women
are a strong voice in the review
and development of maternity
services and act on available
data and new government policy
Subheading
Maternity and new-born - How we will measure success
• M
aintaining low rate and
prevent increasing rate of
Caesarean sections
• A
chieve UNICEF breastfeeding
friendly accreditation in all
providers
• D
ecreasing rate of readmissions
to hospital from home
postnatally
• A
chieve upper quartile
performance in Maternal and
infant mortality rates
• A
ll pregnant women and
their partners have access to
appropriate support services
(family support, young parent
support, breastfeeding support)
• A
chievement of a full range
of screening Key Performance
Indicators (KPI)
• E arly identification of
vulnerability and complex social
factors and effective pathways
to support them
• A
ll teenagers who are pregnant
will have a Common Assessment
Framework (CAF) in place
Section 9 National Priorities
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9 Children and Young People
The Children and Young People
in Wiltshire Needs Assessment
(www.intelligencenetwork.org.uk/
health/children-and-young-people/)
highlights key areas to focus on to
deliver services which meet the needs
of children and young people.
Of particular concern are the
health and wellbeing of Looked
after Children, reducing teenage
pregnancies and prioritising the needs
of children with disabilities including
smoothing the transition from
children’s to adult services.
Challenges in the system
Coverage of childhood vaccination
rates for all immunisations in Wiltshire
are above the rates for England and
the South West. However, MMR
coverage still falls below the 95%
needed to achieve herd immunity.
Children and Young People - Programme of Work
Expected end state - 2015
Children, Young People and
Their Families:
• Are satisfied with the services
they receive and are able to
contribute to and engage
with service development and
evaluation in a manner which
is empowering and convenient
to them
• E xperience high quality, evidence
based services
• E xperience clear paediatric
pathways in which primary care,
community and acute clinicians,
including mental health, work
together to offer care closer to
home where possible
• E xperience a multidisciplinary
approach to assessment and
care, receiving early intervention
as necessary
• A
re seen promptly and in a
child or young-person friendly
environment
• R
eceive all appropriate
immunisations and screening
• A
re empowered to stay healthy,
safe and emotionally resilient,
narrowing the gap for morbidity,
mortality and life outcomes
• T ransition seamlessly to adult
services where appropriate
Children and Young People - How we will get there – 2013/14
• M
aintain high uptake rates
for breastfeeding, new-born
screening and immunisations
• E nsure that GPs access
paediatric advice/guidance,
through Choose and Book, to
reduce non-urgent outpatient
appointments
• C
are Quality commission (CQC)
action plan being implemented
to address safeguarding issues
by April 2013
• S ecure additional resources
for School Nursing to enable
fulfilment of safeguarding
responsibilities
• C
QC improvement plan for
improving the health of Looked
after Children, by April 2013
• S mooth transition of contracts to
be commissioned nationally and
locally through Public Health e.g.
School Nurses, Health Visitors,
immunisations, screening Tier
4 and Child and Adolescent
Services (CAMHS)
• W
ork with education and social
care in Wiltshire as a Pathfinder
for the SEN and Disability Green
paper ‘Support and Aspiration’,
including development of
personal health and education
plans and single assessment
processes for children with
disabilities
• E nsure that the Primary
Mental Health Service, recently
transferred from the local
authority to Oxford Health
CAMHS, meets the needs of
children and young people
• R
eview of therapy services,
including resolution of capacity
issues
• A
ct on recommendations of joint
review of overnight short breaks
for children with disabilities
(including the health-run
residential unit)
• R
esolve Autism Spectrum
diagnosis issues in South
Wiltshire, by reconfiguring
services as, as agreed by CCG
• C
ommission community
enuresis service
• B
e an active partner of the
Wiltshire Children & Young
People’s Trust and contribute to
multiagency working to improve
the health and wellbeing of
Children and Young People
(CYP)
Section 9 National Priorities
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Meeting the Healthcare Needs of Armed Forces
Personnel, their Families and Veterans
The South West region is home to around 24% of the
military personnel in the UK amounting to almost 39,000
individuals. Including the families of these personnel gives
an estimated total of 81,000 people for the south West.
Annually there are approximately 4,000 service leavers in
the South West and 60% of these leavers will return to the
South West region.
We recognise the importance and value of what the armed
forces do. This recognition extends not just to those in the
Services but also their families and veterans, and especially
the injured and the bereaved.
Military personnel constitute around 3.3% of Wiltshire’s
total population, with around 15,000 personnel stationed
at sites across the county. Military personnel and
dependants are estimated to constitute over 20% of the
total population in Tidworth, Bulford, Durrington, Upavon,
Warminster East, Lyneham, Nettleton and Colerne wards,
with this figure reaching 75% in Tidworth. The population
in the most strongly military-influenced wards is dominated
by younger adults (particularly males) and these areas also
show higher than average proportions of pre-school and
primary school children. Military personnel typically use
military health services, but a large number of military
dependants rely on the general, civilian health services.
There is a growing mental health problem in the military
associated with the increased level of deployment on
combat operations. Currently, the demand on mental
health services is distributed in the areas of high military
population in the county due to the tendency of military
personnel to return to their “home” areas on leaving the
services. It is likely these needs will continue in the future,
as personnel are stationed for longer in one area.
•We will continue to develop and participate in local and
regional Armed Forces Health Networks to ensure the
principles of the Armed Forces Network Covenant3 are
met for the armed forces, their families and veterans
•We will ensure the implementation of the Murrison
Report to improve access to mental health services by
veterans
•We will ensure the requirements of the Murrison Report
relating to those who have been seriously injured in the
course of their duty are implemented, including meeting
veterans’ prosthetic needs
•We will ensure NHS employers are supportive towards
those staff who volunteer for reserve duties
•We will work to ensure military personnel, their
dependents and veterans are not disadvantaged in terms
of health care provision in Wiltshire
3. http://www.mod.uk/NR/rdonlyres/0117C914-174C-4DAE-B755-0A010F2427D5/0/Armed_Forces_Covenent_ Today_and_Tomorrow.pdf
Section 10 Meeting the Healthcare Needs of Armed Forces Personnel, their Families and Veterans
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Safeguarding
Safeguarding Children
For children and young people, the key legislation includes
the Children Act 1989 and the Children Act 2004. Sections
11 and 13 of the 2004 Act have been amended so that the
NHS Commissioning Board (CB) and CCGs will have identical
duties to those of PCTs, i.e. to have regard to the need to
safeguard and promote the welfare of children. The revised
version of Working Together 4 will set out expectations as to
how these duties should be fulfilled.
The CCGs and the NHS CB will have a statutory responsibility
to ensure that the organisations from which they
commission services provide a safe system that safeguards
children. Wiltshire CCG will have a statutory duty to be
members of the Local Safeguarding Children Board (LSCB).
The accountability framework being developed by the NHS
CB will set out in more detail how the NHS CB and CCGs
will work together to minimise risk, improve outcomes for
children and develop and sustain effective partnerships,
and ensure they are able to access the necessary clinical
expertise and advice.
Wiltshire CCG is committed to developing capacity to
better support their statutory responsibility to promote
the safety and welfare of children. As a CCG we will be
required to provide assurance that safeguarding children
activity within all commissioned services meets national
safeguarding children standards and demonstrates a model
of continuous improvement. The Board of the CCG will
include a Director of Nursing who will be the executive
lead for safeguarding children providing a clear line of
accountability for safeguarding arrangements, properly
reflected in the CCG governance arrangements. This post
will be responsible for assuring the quality of care across all
health providers.
Wiltshire CCG has secured the expertise of a designated
doctor and nurse for safeguarding children and the CCG
will establish appropriate arrangements to co-operate with
the local authority in the operation of the LSCB.
Wiltshire CCG plans to train staff in recognising, acting
upon and appropriately reporting safeguarding concerns.
The governance arrangements the CCG will have in place
will ensure rigor and challenge of health providers and
ensure scrutiny and oversight of significant safeguarding
children incidents and resulting provider action plans. The
CCG will participate and actively contribute to the work of
the LSCB including multi- agency serious case reviews. The
CCG will ensure that the lessons learnt from such reviews
are embedded in health practice to promote the safety and
wellbeing of children accessing health services.
A comprehensive review of safeguarding children
arrangements in commissioned services was recently
undertaken. This review was complemented by the Care
Quality Commission announced inspection of safeguarding
children arrangements in February 2012 with the
following results:
Child and adult safeguarding (including OFSTED reviews)
OrganisationAlert
Details
Status
NHS Wiltshire
CQC adequate CQC inspection for Safeguarding
Children Arrangements March 2012
Amber
Multiagency safeguarding children
improvement plan in place
Ofsted – inadequate for
multiagency safeguarding
children arrangements
Red
4. HM Government (2010) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children London: Department for Children, Schools
and Families (now Department for Education).
Section 11 Safeguarding
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11
How these will be addressed
•
A CQC Improvement plan is in place. The SHA and PCT
are managing the performance of health providers and
the PCT against the plan
•
The Local Authority has been issued with an
improvement notice by the Government. The CCG
will be represented on the multiagency strategic and
operational improvement board tasked with leading
and sustaining the remedial multiagency actions. The
improvements are currently under regular review by the
Department for Education
•
Wiltshire CCG will ensure that priority is given to
ensuring oversight of the required practice improvement
across the health providers. This will be undertaken via
the existing quality and performance arrangements
•
The PCT and CCG has approved additional funding to
increase the commissioned capacity of safeguarding
children team and school nursing workforce in the
children’s community services to respond to the deficits
identified by single and multiagency audits following the
Ofsted inspection
•
The schedule for safeguarding children arrangements
in health provider contracts has been strengthened.
More work will be required to ensure robust monitoring
of workforce capacity, training and supervision in
provider organisations
•
Improvements will be made to the current provider
reporting to strengthen the governance of safeguarding
children arrangements. This will include an increase in
the support available to the quality and contracts team
from designated professionals
How will we measure success?
•
Processes in place and evidence can be easily obtained
from health providers that demonstrate robust high
quality performance across the organisation in relation
to safeguarding children practice
•
Contract monitoring ensures that training,
supervision and practice in health providers are
appropriately embedded
•
All staff in health providers receive safeguarding
supervision that supports their safeguarding children
roles and responsibilities and promotes child centric
ways of working. Audit demonstrates that staff receive
safeguarding supervision commensurate with their
safeguarding children role and responsibility
•
All health employees are trained in line with the
intercollegiate guidance and statutory guidance
•
An audit of staff by each of the named health providers
demonstrates they hold satisfactory safeguarding
children knowledge commensurate with their role within
the organisation. The audit demonstrates the ability to
safeguard children and work in an integrated way with
other agencies to protect children and prioritisation is
given to safeguarding children
•
Case reviews indicate that health practice is in line with
the legal framework
•
Case reviews demonstrate that practice is child centric
and provides evidence that the actions of health staff
take into account the requirement to safeguard and
protect children
•
The CCG will work with the LSCB to develop and deliver
reporting mechanisms that provide assurance of health
safeguarding children arrangements
Section 11 Safeguarding
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Safeguarding Adults
Safeguarding adults is a core responsibility in NHS
Commissioning – Safeguarding Adults: The role of NHS
Commissioners, DH 2011.
Adult Safeguarding is an overarching philosophy
underpinned by 6 principles:
•
Empowerment: Presumption of person led decisions
and consent
•
Protection: Support and representation for those in
greatest need
•
Prevention: Prevention of neglect, harm and abuse is
a primary objective
•
Proportionality: Proportionate and least intrusive
response appropriate to the risk
•
Partnerships: Local solutions through services working
with their communities
•
Accountability: Accountability and transparency in
delivering safeguarding
Adult Safeguarding is a framework supporting best practice
and encompasses prevention of harm and protection from
abuse. A robust and integrated governance framework
incorporating risk and complaints management, learning
from local incidents and national reports will deliver many
elements of the framework. Adult safeguarding is an
inherent part of The NHS Outcomes Framework domains
4 and 5. It is also closely linked to the QIPP agenda.
The operational response to a safeguarding alert is adult
protection, an element of safeguarding, which ensures
the safety of an individual and protects them from further
harm. Integration of the safeguarding process and risk
management systems is crucial to achieving safety for
the individual and learning from the incident to prevent
harm to others in the future. Adult safeguarding has been
incorporated into the National Patient Safety Agency (NPSA)
document ‘National Framework for reporting and learning
from serious incidents requiring investigation’ (2010).
There are several definitions of a vulnerable adult. No
Secrets (2000) defines a vulnerable adult as “a person
aged over 18 who is or may be in need of community
care services by reason of mental or other disability, age
or illness and who is or may be unable to take care of
him or herself, or unable to protect themselves against
significant harm or exploitation”; whereas the Safeguarding
Vulnerable Groups Act defines all patients as vulnerable.
The No Secrets definition is the one commonly used in
adult safeguarding. It is clear, whichever definition is used,
that the protection of vulnerable adults is a core element
of healthcare provision.
Abuse is defined as a violation of an individual’s human
and civil rights by any other person or persons which
results in significant harm or exploitation of the vulnerable
person. It may be perpetrated by anyone who has power
over the person whether they are a carer or relative, a paid
member of staff or professional or may occur as a result of
persistently poor care or a rigid and oppressive regime
(DH 2000).
Anyone who is living in an abusive situation is at risk of
becoming disempowered and unable to make decisions
and choices independently. The adult safeguarding and
domestic violence agendas currently operate in isolation
in most statutory bodies with the current definition of
a vulnerable adult excluding people subject to domestic
violence unless they have a specific disability. Domestic
violence is closely affiliated with the child protection
agenda. Staff working the in the arena of domestic abuse
are experienced in supporting people to manage abusive
situations and identify their personal choices; closer
working with colleagues who work domestic violence
would facilitate shared learning.
Section 11 Safeguarding
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The draft paper ‘Safeguarding Adults: A guide for
NHS Commissioners and Provider Boards (NHS South
West 2010)’ identified some common themes in adult
safeguarding which relate to healthcare:
•
Patient’s voices not heard
•
Patients not empowered to make choices about their
care and protection
•
Neglect and abuse not always recognised
•
Poor practice not always recognised as abuse and
sometimes accepted as a consequence of staff shortages
•
Complaints relating to abusive / neglectful care are not
always recognised as safeguarding issues
•
Where neglect or abuse is recognised within services,
there is a lack of transparency and openness in
investigation – incidents are not managed through
multi-agency safeguarding adults procedures
•
Safeguarding adults is often seen as the responsibilities
of others such as the local authority
Our CCG governance framework will reflect a clear line
of accountability for safeguarding as recommended
in ‘Arrangements to secure children’s and
adult safeguarding in the future NHS, the new
accountability and assurance framework – interim
advice’. NHS Commissioning Board. 2012.
In addition to NHS provision in Wiltshire there are 205
residential care providers and 55 agencies providing
domiciliary care ranging from housekeeping support
through to 24 hour care at home. The size and geography
of Wiltshire has been identified earlier in the document
along with the deprivation index, these need to be
considered when developing adult safeguarding strategies
in partnership with the Local Authority and the Local
Safeguarding Adults Board (LSAB).
We will be an active partner in the Local Safeguarding
Adults Board. Our governance framework will include
systems to monitor the quality of provision and offer
assurance that adult safeguarding concerns are identified
and dealt with robustly.
Services commissioned should be appropriate to the
individual including their communication needs, physical
needs, mental abilities, culture, religion, gender and
sexual orientation and should reflect the 6 principles of
safeguarding identified above.
We will work proactively with service providers to
commission high quality and safe services for adults
contractually under our care and we will adopt a zero
tolerance approach to adult abuse In situations where
there is a duty to intervene, that intervention will be
proportionate to the level of risk.
Adult safeguarding is a theme which runs through this
strategy and key elements have been incorporated into
the various work-streams.
In response to the above we recognise the need to increase
capacity for safeguarding adults and children to ensure
we have robust governance arrangements and to enable
us to monitor and challenge all providers. The team will
provide expert advice to contractors and commissioners
and support providers in the development of practice and
competencies.
Section 11 Safeguarding
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Information Technology
Our transformation of community and integrated care
and key programmes of work are dependent upon data
being readily available across various care settings. Within
the business cases for all these initiatives there has been
a strong underpinning assumption about the availability
of information systems to support clinicians and share
information about patients.
To achieve this goal we will need to monitor all elements of
the patient pathway from initial referral to provider contract
payments to ensure that:
•Patients are referred to appropriate clinical services
according to need
•Patients with complex or long term conditions are
managed pro-actively in order to improve outcomes and
reduce emergency admissions
•Patient pathways are actively managed in general,
especially where there are alternative referral routes that
do not involve primary care
•Providers are monitored to ensure that they meet
performance targets in terms of activity and cost
To enable us to make the right decision about our
information and technology requirements we have
developed a set of core objectives:
•Understanding the Patient - Key information about
the patient should be available for a clinical decision
to be made about appropriate services and treatment.
The information needs to be concise and relevant at the
decision point
•Know your Services - A comprehensive up to date
regional Directory of Services is evolving which allows
clinicians and patients to select an appropriate service
matching the patient’s needs with the appropriate
clinical skill set delivered by the service
•Know your capacity - Once a patient enters the care
pathway the process should be appropriate and timely.
In order to make the right decisions about referring a
patient it is important to understand the capacity in the
system at any one time. Choosing between two services
where the waiting times vary will improve the experience
of the patient and the ability of the clinicians to deliver
an effective service
In order to do this, we will need access to relevant
information to support each stage of the patient pathway.
Critical to achieving success in these dimensions is the
ability to work effectively with partner organisations.
In turn this requires agreement to share information
appropriately and to identify consistent and understandable
data sets for the relevant purposes.
•Keep it Simple (KiS) - In the current digital age access
to information can be overwhelming to the point of
confusion. For access to information when anyone is
under stress or very busy they will resort to familiar and
simple mechanisms rather than invest time and resources
in researching the correct solution. Therefore a simple
access mechanism needs to be available for people to
get the right information and support
Underpinning Information Objectives
The recurrent theme throughout our programmes is the
desire to improve and simplify the patient experience.
By making up to date, clear, key information available to
patients and clinicians, both parties will be able to select
the most appropriate service at the time.
Meeting the objectives
An information strategy to meet the objectives of a whole
system approach will involve providers, commissioners and
primary care providers across the local health communities
and wider regions. Each provider will need to understand
the principles and strategic direction.
Underpinning the Information Management and
technology (IM&T) strategy is the need for a comprehensive
training programme so that clinicians and managers know
how to access the right information and have the skills to
interpret it in a meaningful way.
Section 12 Information Technology
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Finance Plan
NHS Wiltshire in 2012/13 has been able to generate a
strong financial position which will deliver a strong financial
position for the CCG as well as paying off all residual debt.
For 2012/13 NHS Wiltshire is planning on achieving a £2m
surplus as well as paying back £6.2m of historical debt.
NHS Wiltshire has consistently achieved all its financial
targets over the last few years in line with the planning
assumptions and Strategic Health Authority expectations.
The CCG will therefore be starting its life with no legacy
debt from the PCT.
The Financial Framework for 2012/13 and beyond sets out
to put in place resource allocations to ensure that all national
targets and standards are met or exceeded. Performance
management is integrated with the management of
resources, so that resources follow priorities.
The medium term financial strategy sets out the key
assumptions for the CCG and demonstrates how they
will be used to support delivery of the CCG strategic and
operational objectives set out in the integrated plan. The
plan builds on the financial plans delivered by NHS Wiltshire
and are underpinned by:
•A sustainable strong financial position throughout the
2 years of the plan
•Growth and inflation assumed in line with the NHS
Operating framework assumptions
•Maintaining a 2% of allocation contingency to fund cost
pressures and other non-recurrent initiatives
•Activity model based on the forecast out-turn for
2011/12, impact of population growth and the impact
of initiatives to reduce demand and move care closer to
home
•Savings plans assumed above national Cash releasing
efficiency Savings (CRES) requirements to support
investment, targeted on QIPP proposals which
ensure that the CCG benchmarks good/excellent on
all efficiency indicators to support below capitation
position. Currently the CCG benchmarks average to
good
•Focused investment planned during the period to
support the delivery of the CCG strategy with particular
focus on shifting the settings of care, supporting more
patients in the community and managing the ever
increasing demand on acute health services
•Upside and downside scenarios have been worked
through based on national assumptions and mitigation
strategies have been assessed
Risks and opportunities have been assessed. Key risks
include the economic position and its impact on Wiltshire
CCG. Other key risks are continuing growing demand
for healthcare services, continuing changes to tariff/
counting arrangements which drive inflationary pressures
and the difficult economic climate placing further savings
requirements on health.
Section 13 Finance Plan
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Assumptions
The key assumptions within the model are as follows:
•The anticipated CCG allocation is yet to be notified,
however it is envisaged that the recurrent resource
allocation will increase by 2% year on year in line within
the national operating framework
•Uplift to providers for inflation and other mandatory
cost pressures will be 3.5% across the period
•Providers will be expected to deliver on-going year on
year efficiency of between 2.5% and 4% which will be
delivered through the national tariff
•Population growth based on current experience is
assumed to be worse case 2% although this could
reduce to 0.8%. Percentage growth in the over 75s
is running at 2.8%
•The CCG will plan for a 2% headroom in the first
instance to manage in year financial risk and to
fund non recurrent costs
•The CCG will endeavour to produce a surplus
year on year
Resource Allocation and Future Growth
•The draft allocation is based on an estimate of historic
spend of CCG responsibilities and assuming that the
existing recurring expenditure continues
•The Operating Framework for the NHS in England
2012/13 sets out an average growth rate of at least
2.5%. In line with the average uplift position, NHS
Wiltshire received growth of 3.0% in 2012/13, including
the additional allocation to support reablement. Table 1
below sets out the growth allocation available to NHS
Wiltshire in 2012/13 and the anticipated growth for the
following 3 years
•Included in Table 1 is £4.86m to support joint working
between health and social care. The funding for 2012/13
has been funded to Wiltshire Council to invest in social
care services to benefit health and to improve overall
health gain and it is assumed that future resources will
be transferred and managed through joint governance
arrangements
•Wiltshire Clinical Commissioning Group will work with
Wiltshire Council to agree jointly on appropriate areas
for social care investment and outcomes from this
investment, taking into account the Joint Strategic Needs
Assessment and existing commissioning plans for both
health and social care
Description of 12/13 growth and growth assumptions 2013-16 (Table 1)
Description
Anticipated Resource Limit
2012/132013/142014/15
2015/16
489.9
505.1
515.2
525.5
Growth (Actual and Predicted) %
3.0
2.0%
2.0%
2.0%
Growth (Actual and Predicted) £m
15.2
10.1
10.3
10.5
Other Allocations
6.36.36.3
6.3
Total Resource
511.4
522.0
532.3
542.8
Section 13 Finance Plan
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Applications of Funds
The CCG will be responsible for a range
of services on behalf of its registered
population. Responsibilities will cover
secondary acute care, community care,
mental health, continuing health care
and specialist placements. It will also
have responsibility for prescribing and
primary care enhanced services. The
CCG does not have any responsibility
for specialist commissioning which
will be undertaken by the National
Commissioning Board. Chart 1 below
shows the percentage split between the
individual areas.
Percentage Split of 2012/13 CCG Application of Funds (Diagram 6)
Assumptions on Application of funds
The financial plan follows a number of
assumptions across the range of applications of funds.
These principles are as follows:
•Providers will be funded for the impact of inflation.
This is assumed at 2.5% year on year up to 2016
•The impact of inflation on primary care prescribing is
assumed at an annual increase of 8%
•Our secondary care acute providers will be expected to
deliver their services on 4% less resource year on year
in line with the NHS operating framework. All other
providers will be expected to deliver their services on
2.5% less resource year on year
•We are expecting to achieve savings of 3% on primary
care prescribing
•Our population is growing and the health demand is
increasing. This is assumed to be 2% year on year
Secondary care 58.3%
Primary care - Out of Hours 1.2%
Primary care - LES 1.0%
Prescribing 12.8%
Placements 0.0%
Continuing Health Care 3.9%
Joint Arrangements with WCC 3.1%
Mental Health 7.7%
Community Services 11.9%
•The CCG will not increase its running costs over the 2
year period. Running costs will be funded at the current
rate of NHS Wiltshire which is approximately £21 / head
of population
•The CCG will maintain a recurrent reserve of 2% of the
recurrent resource limit to fund cost pressures and other
non-recurrent expenditure
•The CCG will set out to achieve a 1% surplus per year
•The expenditure associated with our providers will
include payments for achieving the predefined quality
and innovation targets (CQUIN). This is assumed to be
funded annually up to 2.5% of the contract value for the
period of the financial plan
Summary of the financial assumptions is shown in
Table 2.
Inflation, efficiency and growth assumptions 2013-16 (Table 2)
Description
2013/14
2014/152015/16
Inflation uplift for providers
2.5%
3.5%
3.5%
Inflation of prescribing
8.0%
8.0%
8.0%
Secondary care efficiency
4.0%
4.0%
4.0%
Other service efficiency
3.5%
3.5%
3.5%
Prescribing efficiency
3.0%
3.0%
3.0%
Expected growth
2.0%
2.0%
2.0%
Section 13 Finance Plan
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Investment Assumptions
The clear and credible plan will focus on doing more for
patients in the community and reducing the amount of
activity that happens in secondary care. To support this
strategy the CCG will set out to invest in community care,
primary care, mental health and integrated working with
social care over the term of the financial plan. This will
enable the CCG to deliver the demand challenge that the
NHS will face over the next 2 years. Table 3 presents the
levels of growth and specific investment over the 2 years
of the financial plan.
Growth funding and future investments (Table 3)
Description
2013/14
£m
2014/152015/16
£m
£m
Growth
Secondary care
5.8
5.7
5.6
Community Services
1.1
1.2
1.2
Mental Health
0.7
0.8
0.8
Joint Commissioning
0.3
0.4
0.4
Investments
NICE and Innovation
2.0
1.0
1.0
Community Care
2.5
2.0
1.0
Mental Health
1.0
0.5
0.5
Joint Arrangements
2.0
2.0
1.0
Primary care Services
1.5
1.0
0.5
CHC
0.5
The investments support the strategic intentions for the
CCG and will be actioned under the CCG’s governance
framework.
From the summary above the CCG will be planning to
produce a surplus of £2m year on year and in line with
the current national planning assumptions. To deliver
this the CCG will have to deliver significant efficiencies
and transformational savings in order to achieve this
financial target.
Providers will be expected to deliver significant amounts
of efficiency some of which will be supported by the CCG
through changing the settings of care and treating more
patients in the community.
In total the health economy will have to deliver efficiency
and transformation savings of £79m for the period 20132016. Table 4 shows the commissioner and provider QIPP
requirements for the financial period 12/13 to 15/16.
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Levels of provider and CCG efficiency and CCG QIPP savings (Table 4)
Description
2012/132013/142014/15
2015/16
Provider efficiency
14.0
14.5
14.6
13.7
CCG efficiency
2.9
3.0
3.2
3.0
CCG QIPP
11.2
9.0
6.5
6.0
Total
28.1
26.5
24.322.7
In summary the total sources and applications of funds over the period of the plan are set out below in Table 5
Source and application funds 12/13 to 15/16 (Table 5)
2012/132013/142014/15
2015/16
Resources
511,905
522,018
532,332542,853
290,525
291,968
288,212
287,445
Community Services
57,513
60,588
63,800
66,714
Mental Health
38,187
38,559
39,830
41,525
Partnerships
15,000 17,150 19,493
21,078
Continuing Health Care
18,960
19,650
20,043
20,644
Applications
Secondary care
Placements
203
212
224236
Prescribing
62,594
64,936
68,18371,592
Primary care
10,912
12,562
13,694
14,330
Other CCG Responsibilities
3,519
3,501
3,484
3,466
Running Costs
9,636
9,644
9,653
9,661
Reserves and Headroom
14,100
10,100
10,100
10,100
Total applications before savings
521,149
528,870
536,715
546,792
Transformation
---
-
Savings targets
11,244
9,000
6,500
6,000
NET position
2,000
2,148 2,117
2,062
Section 13 Finance Plan
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Bridge diagram of the anticipated source and application of funds for 2013/14 (Diagram 7)
QIPP
£9m
Recurrent
Applications
£509m
Provider
Efficiency
£18m
Growth
Funding
£10m
Other
Income
£6m
Anticipated
Resource Limit
£505m
Inflation
£19m
Demographic
Growth Impact
Represents Income to the CCG
Represents Expenditure incurred by the CCG
Represents Savings to be achieved by providers and
commissioners through transforming services and
changing the settings of care
Investment in
New models of Care
£8m
Planned Surplus
Represents the Planned CCG Surplus
A diagrammatical representation of the 2103/14 financial
plan is shown above as a bridge diagram. The resources,
anticipated efficiency and QIPP savings are represented
as building blocks rising to the top of the bridge while
the recurrent applications, growth funding and predicted
investment are represented by the downside of the bridge.
Diagram 7 shows the bridge diagram for 2013/14.
Any changes to the resource assumptions built into the
plan will change the balance of the bridge requiring
reductions in the expenditure even through increased
efficiency or reducing the investment proposals.
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Financial Risk and Sensitivity Analysis
The CCG will need to be able to deal with a range of
financial risk throughout the term of the financial period.
Areas of risk that may be experienced are listed below:
•Growth funding received is less than the anticipated
level of 2%
•Transformation savings are not delivered recurrently
leaving to larger costs in secondary care
•Demand on acute services is larger than the 2% growth
assumption in the financial plan
•Continuing Healthcare requests are significantly higher
than planned
•The impact of high cost drugs and new devices exceeds
planned increases
•Primary care prescribing increases in excess of the 8%
growth assumption and efficeny savings are not delivered
Table 6 demonstrates the financial impact of varying
financial risks that could be experienced over the term
of the financial plan.
•Inflation rates in the UK exceed the planning assumptions
of 2.5% across the period of the financial plan
Impact of financial risks (Table 6)
Financial risk description
Plan/Scenario
13/14
14/15
15/16
Base
8.4
8.4
8.6
Scenario
12.6
12.6
12.8
Impact on Financial Plan if no action taken
4.2
4.2
4.2
Growth funding is reduced to 1% instead of expected 2%
Base
10.1
10.3
10.5
Scenario
5.1
5.1
5.2
Impact on Financial Plan if no action taken
5.0
5.2
5.3
50% of the QIPP savings are not delivered
Base
9.0
6.5
6.0
Scenario
4.5
3.2
3.0
4.5
3.3
3.0
Acute provider growth is 1% higher than the 2% planning assumption
Impact on Financial Plan if no action taken
The detail figures representing the impact of increased growth is shown in annex 1 page 67 along with a chart presenting the impact on the Transformation
Savings compared to the base model.
The CCG team has assessed the impact of a number of
financial risks and have worked through how each scenario
would be dealt with. The CCG would undertake a strategy
of reviewing planned investments as well as increasing
the level of the transformation savings that the health
community needs to achieve. However the CCG will take
a stance that the investment for 2013/14 will need to
continue as far as possible as this is seen as instrumental
in the delivery of future transformational savings into
the future. The following section outlines the financial
impact of the above scenarios and the resultant impact on
predicted future investment and transformation savings.
Impact of Acute Provider Growth
If activity increases by 1% over and above the planned
2% level then the recurrent impact at the end of 2015/16
would be £12.6m additional cost if no action was taken. The
immediate action would be to reduce the planned additional
investment for 2014/15 by 50% in community and primary
care services. Given the level of investment in 2013/14
in community and primary care these services would be
required to deliver more activity than the current upper
range of the benchmarked position for community and
primary care. The following table summarises the change
in the financial plan if growth in acute activity occurs.
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Financial impact of potential growth in acute activity (Table 7)
2012/13
2013/14
2014/15
2015/16
Total Resources
511,905
522,018
532,332
542,853
Total Applications before Transformation Savings
521,149
533,044
538,092
549,636
Transformation Savings
-11,244
-13,000
-7,800
-8,800
2,000
1,974
2,041
2,017
Net Position
Although some of the impact of the increased demand
will be offset by reduced investment the level of
transformational savings will have to increase. This will be
achieved by supporting more patients and clients within
the community and enabling patients to be discharged
from hospital more efficiently and quicker. The impact on
the level of transformational savings is shown in the
graph below.
Growth Funding Reduction
The recurrent financial impact of growth funding being
reduced from 2% to 1% at the end of the financial period
2015/16 would be £15.5m. As with the increased demand
scenario the CCG would reduce the level of planned
investment in 2014/15 and 2015/16 as well as requiring all
providers to achieve a 4% efficiency requirement in line
with the NHS Operating Plan. The impact on the financial
plan and the transformation savings are shown below.
Financial impact of potential reductions in growth funding (Table 8)
2012/13
2013/14
2014/15
2015/16
Total Resources
511,905
516,961
522,068
527,226
Total Applications before Transformation Savings
521,149
527,396
529,172
532,840
Transformation Savings
-11,244
-12,500
-9,200
-7,700
2,000
2,065
2,097
2,086
Net Position
The detail figures representing the impact of reduced growth funding is shown in annex 2 page 68 along with a chart presenting the impact on the
Transformation Savings compared to the base model.
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Non Delivery of the CCG Transformation Savings
The transformation challenge for the CCG for the period
2013/14 to 2015/16 is £20m. The impact of not achieving
50% of the recurrent transformation savings target would
be to increase the financial risk to the CCG by £10m. The
CCG would plan to negate £5.5m of this risk by increasing
the efficiency savings requirements for all providers as
well as reducing investment by £4.3m over the period of
the financial plan. Services would be expected to deliver
a greater level of efficiency that the current benchmark
suggests which would add to the pressure on the current
system. Table 9 summarises the impact of not delivering
the transformation savings on the applications and
transformation savings for the financial period of the plan.
Potential financial risk of not delivering transformation savings (Table 9)
2012/13
2013/14
2014/15
2015/16
Total Resources
511,905
522,018
532,332
542,853
Total Applications before Transformation Savings
521,149
524,477
533,578
543,792
Transformation Savings
-11,244
-4,500
-3,250
-3,000
Net Position
2,000
2,041
2,005
2,062
The detail figures representing the impact of not achieving 50% of the transformation savings is shown in annex 3 page 69 along with a chart presenting the
impact on the transformation savings compared to the base model.
Transformation Savings or the
Quality Improvement Productivity
and Prevention Targets (QIPP)
QIPP is about creating an environment
in which change and improvement
can flourish. It is about leading
differently and in a way that fosters
innovation and it is about providing
staff with the tools, techniques and
support that will enable them to take
forward their plans to improve the
quality of care.
It is important to state at the outset
that we do not view QIPP as a
separate project or piece of work.
We have taken a clear approach of
building QIPP into our contracts with
all our providers. On this basis, if
we deliver in conjunction with our
providers, on our contracts then we
will deliver on the QIPP challenge.
During the past two years the PCT has
delivered on significant QIPP initiatives
which to date have changed the
demand on local providers.
Impact of not delivering the efficiency targets for providers
and Transformation Savings on expenditure over the term of the plan (Chart 4)
570,000
560,000
CCG Expenditure £000’s
13
550,000
540,000
530,000
520,000
510,000
500,000
490,000
2012/13
2013/14
Expenditure without Efficiency and QIPP
The economic forecast for demand
identified a potential gap of £9 million
at a PCT level, if no action was taken.
2014/15
2015/16
Expenditure with Efficiency and QIPP
The graphical representation of the
efficiency and transformational savings
(QIPP) on expenditure is shown in
Table 9.
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Where will we find savings?
The CCG has assessed a number of sources of
benchmarking information to identify where focus work
should be undertaken. Benchmarking has been done with
other organisations within the South West and nationally
to determine areas of difference.
For many areas Wiltshire benchmarks very strongly with
other areas however the CCG will focus on the areas
where benchmarks are low and also push performance
to a higher level. This will be linked into the CCG strategy
where focus will be placed on enhancing community and
primary care to support the ever increasing operational and
financial challenges that the health economy faces.
The following summary on page 65 identifies the key
areas where the CCG does not benchmark well and would
therefore be the focus of our transformation agenda.
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High Level Summary of Key Benchmark Positions
Area of spend
Data Source Spend level
Benchmarking position
Programme Area Programme budgeting Average for cluster
PCT is high spend in maternity, trauma and orthopaedics,
2011/12
cancer, admissions for alcohol, primary care services.
Low spend on diabetes, ophthalmology, GU-Average on
most other categories
Community
Reference costs 2010/11 Average
101 compared to average of 100. This is a reduction from
110 in 2007/8 and equivalent to approximately £1.5m
above target. It also excludes the value of surplus estate
Community Bed Review Average
The PCT has average numbers of beds but very high
length of stay and high reference costs. Combined with
high length of stay for elective and non elective in the
acute sector means that there is a huge productivity
opportunity. Length of stay is still high across the whole of
the pathway with many beds blocked by patients
Elective
Elective standardised
Low to Average
admission rates
101 against national median of 106 and top decile of 89.
National ranking 64. Significant opportunities
predominantly in cardiology, general surgery,
orthopaedics (admissions higher than national median),
urology, gynaecology (below national median but higher
than top decile)
Elective length of stay
Average to high
Hip and knee replacement LOS above national average
Daycase rates benchmark well (26/152 nationally). Excess
bed days per admission benchmark high (135th
nationally). 9% of elective admissions exceeded trim
point compared to national average 8% and top decile 7%. Elective re-admission rates are average
Outpatient attendances Poor
Relative level of new OP appointments benchmarks poorly
(149 of 152), however Wiltshire PCT best in country for
new to follow up rates, and 10th best in country for DNA
rates. Number of of patients discharged after 1st
appointment higher than SHA and national average
Outpatient new to
Low
follow up rates Data issues are causing a problem with this benchmark. Further work is required to resolve
Non elective
Managing variation in
Good
emergency admissions
Non electives benchmark good compared to national
and SHA areas. Spend looks high compared to
national average
Non-elective Low
standardised
admission rates
105 against average of 100, top decile 81. A&E/
admissions rates worse than average particularly for RUH.
Excess bed days per admission in top 10% (ie more excess
bed days)
Ambulatory care
Low
sensitive admissions
11% of total admissions compared to national average of
12%, top decile of 10%
CHD Admissions
Low
Wiltshire benchmarks poorly compared to national and
SHA averages for admissions per 100 patients (Wilts 15.2,
SHA 13.2 National 13.5
Length of Stay
High
Fractured neck of femur between national average and
top decile. Generally length of stay benchmarks very high
– productivity opportunity. Excess bed days per admission
very high (147th nationally). Wiltshire average 1 day,
national average 0.6 day, top decile 0.4 day
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High Level Summary of Key Benchmark Positions - continued
Area of spend
Data Source Spend level
Benchmarking position
Prescribing
Low
Astro PU £7.96 against national top decile of £7.80 so
very near top decile performance
Out of Hours
Out of Hours
High
benchmarking
Same OOH spend benchmarks high. The OOH service also
runs the single point of access to the community hospitals
and neighbourhood teams
Mental HealthMental health spend on adults of working age is average
and spend on older adults is slightly above average.
Overall spend is low compared to nationally but slightly
higher than SW average. Length of stay is very high
(136/152 PCTs). Wiltshire adults of working age stay is on
average 86 days compared to national average of 45 and
top decile of 35. National ranking 136. For older adults
average length of stay is 160 days compared to national
average of 90 days and top decile of 47 days. Rank 134
nationally
Section 13 Finance Plan
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Annexes to Support the Finance Plan
Annex 1
NHS Wiltshire CCG 3 Year Financial Plan with Acute Provider Demand
Exceeding the Original 2% plan (Table 10)
2012/13 2013/14 2014/15 2015/16
Resources
511,905 522,018 532,332 542,853
290,525 294,853 289,399 289,139
Community Services
57,513 61,163 63,998 67,058
Mental Health
38,187 38,931 40,599 42,723
Partnerships
15,000 17,300 18,819 20,572
Continuing Health Care
18,960 19,839 20,434 21,252
Placements
203 214 228 243
Prescribing
62,594 64,936 68,183 71,592
Primary care
10,912 12,562 13,194 13,830
Other CCG Responsibilities
3,519 3,501 3,484 3,466
Running Costs
9,636 9,644 9,653 9,661
Reserves and Headroom
14,100 10,100 10,100 10,100
Total Applications before Savings
521,149 533,044 538,092 549,636
Transformation Savings Target
-11,244 -13,000 -7,800 -8,800
2,000 1,974 2,041 2,017
Applications
Secondary care
Net Position
Impact of a 1% increase in demand over the expected 2% across the health system
on Transformation Savings (Chart 5)
14,000
Recurrent Transformation Savings
to be achieved £000s
14
12,000
10,000
8,000
6,000
4,000
2,000
2012/13
2013/14
Base Plan Transformation Challenge
2014/15
2015/16
Transformation Challenge with less growth funding
Section 14 Annexes to support the Finance Plan
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14 Annex 2
NHS Wiltshire CCG 3 Year Financial Plan with Recurrent Growth Funding reduced to 1% uplift (Table 11)
2012/13 2013/14 2014/15 2015/16
Resources
511,905 516,961 522,068 527,226
Applications
Secondary care
290,525 290,968 283,145 278,554
Community Services
57,513 60,301 62,205 63,638
Mental Health
38,187 38,373 39,449 40,540
Partnerships
15,000 17,150 19,493 20,578
Continuing Health Care
18,960 19,650 20,043 20,644
Placements
203 212 224 236
Prescribing
62,594 64,936 68,183 71,592
Primary care
10,912 12,562 13,194 13,830
Other CCG Responsibilities
3,519 3,501 3,484 3,466
Running Costs
9,636 9,644 9,653 9,661
Reserves and Headroom
14,100 10,100 10,100 10,100
Total Applications before Savings
521,149 527,396 529,172 532,840
Transformation Savings Target
Net Position
-11,244 -12,500 -9,200 -7,700
2,000 2,065 2,097 2,086
Impact of a 1% reduction in growth funding on Transformation Savings (Chart 6)
Recurrent Transformation Savings
to be achieved £000s
14,000
12,000
10,000
8,000
6,000
4,000
2,000
2012/13
2013/14
Base Plan Transformation Challenge
2014/15
2015/16
Transformation Challenge with less growth funding
Section 14 Annexes to support the Finance Plan
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14 Annex 3
NHS Wiltshire CCG 3 Year Financial Plan with the Impact of not achieving the base level of
Transformational Savings (Table 12)
2012/13 2013/14 2014/15 2015/16
Resources
511,905 522,018 532,332 542,853
Applications
Secondary care
290,525 290,968 291,665 293,741
Community Services
57,513 59,801 61,698 63,623
Mental Health
38,187 38,373 39,449 40,540
Partnerships
15,000 17,075 18,331 19,606
Continuing Health Care
18,960 19,555 19,848 20,146
Placements
203 212 224 236
Prescribing
62,594 64,936 68,183 71,592
Primary care
10,912 12,312 12,944 13,580
Other CCG Responsibilities
3,519 3,501 3,484 3,466
Running Costs
9,636 9,644 9,653 9,661
Reserves and Headroom
14,100 8,100 8,100 7,600
Total Applications before Savings
521,149 524,477 533,578 543,792
Transformation Savings Target
Net Position
-11,244 -4,500 -3,250 -3,000
2,000 2,041 2,005 2,062
Impact on Planned CCG Investment from Reduced Transformation Savings Delivery (Chart 7)
10,000
9,000
Level of Planned Investing
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
2012/13
2013/14
Level of Investment in the Base Plan
2014/15
Level of Investment if Transformation Not Delivered
Section 14 Annexes to support the Finance Plan
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15
Performance Management Arrangements
‘Equity and Excellence: Liberating the NHS’ published in
July 2010 sets out a vision of an NHS that achieves health
outcomes that are among the best in the world. To achieve
this two major shifts were outlined:
•A move away from centrally driven process targets
which get in the way of patient care; and
•A relentless focus on delivering the outcomes that
matter most to people
The reforms of the NHS, Public Health and Adult Social
Care are designed to enable services to deliver these
improved outcomes. The cornerstone will be a framework
of accountability that focuses squarely on how well services
are improving outcomes for people.
We are currently in the second year of using the NHS
Outcomes Framework. Once the NHS Commissioning
Board is in place the Secretary of State for Health will hold
the NHS Commissioning Board accountable for the delivery
of the Outcomes Framework.
The Outcomes Framework sets out the outcomes and the
corresponding indicators that each NHS organisation will
be held to account for and these are identified with the
12/13 Annual Operating Plan for NHS Wiltshire.
The NHS Outcomes Framework is structured around five
domains, which set out the high level national outcomes
the NHS and thus the Wiltshire CCG will be aiming to improve
and are embedded in our key priorities. They focus on:
Domain 1 Preventing people from dying prematurely;
Domain 2 Enhancing quality of life for people with
long-term conditions;
Domain 3 Helping people to recover from episodes of
ill health or following injury;
Domain 4 Ensuring that people have a positive
experience of care; and
Domain 5 Treating and caring for people in a safe
environment; and protecting them from
avoidable harm.
Where are we now?
The Outcomes Framework is an evolving piece of work
which eventually will see the development of three
strategic outcome frameworks:
1. NHS Outcomes Framework
2. The Public Health Outcomes Framework
3. The Adult Social Care Outcomes Framework
The idea behind these three frameworks is to facilitate
alignment, collaboration and integration between the NHS
and Social Care to ensure that people get the best possible
health and well-being outcomes.
During the autumn of 2012 the Commissioning Outcomes
Framework for 2013/14 will be published. This framework
will play an important part in driving up quality within the
new Health Care system.
Performance management arrangements for 2012/13
NHS Wiltshire has developed a performance management
regime which holds the organisations who deliver health
services for its population to account for delivery of
the contract.
This regime includes being the main commissioner for
Salisbury Foundation Trust and Great Western Hospital
Foundation Trust for Community and Maternity Services
and therefore the performance of them is through the
contract for services. NHS Wiltshire is also an Associate
Commissioner for a range of other providers with which
they have contracts.
NHS Wiltshire is currently holding to account the emerging
Wiltshire CCG for a range of outcomes described in the
Accountability Agreement between the CCG and the PCT.
See Appendix A page 88.
The performance meetings that take place between the
PCT, CCG and SFT and GWHFT happen monthly and
include delivery from a quality perspective as well as an
activity and financial one. The emerging Commissioning
Support organisation will in future take on the role of
contract management on behalf of the CCG.
The outcomes from these meetings are reported through
to the Executive Management Team of the CCG and then
to the Clinical Commissioning Committee in the outcomes
report on a monthly basis. An exception report is then
generated for the Cluster Board meeting.
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A monthly performance meeting is held by the South
of England SHA between the CCG and the PCT. The
designated Chair, AO and CFO of the CCG take the lead
in these meetings supported by the PCT.
Performance Management 2013/14
Wiltshire CCG is building on the PCT performance
management arrangements to ensure robust delivery of
strategic priorities including QIPP.
The overall CCG lead for performance will sit with the
Chief Finance Officer. Each group within the CCG will
have a Group Director with executive responsibilities for
the delivery of performance. This will include CCG wide
programmes of work e.g. mental health, specific local
projects and also management of provider
contract performance.
Within the Groups are Commissioning and Contract
managers who have responsibility for the operational
management and development of the key programmes
of work as identified in the strategic plan. As part of the
emerging staff structure a matrix is being developed which,
upon completion of the recruitment of staff to these
substantive posts, will clarify responsibilities.
The performance management culture which is in
development will require leads to have a ‘can do’ attitude
and an appetite to deliver success. This will involve the
identification of issues affecting performance and also
the development of balanced solutions which ensure the
remedial action is identified and subsequently delivered.
This requirement will form part of the Organisational
Development (OD) plan.
The CCG is committed to delivering its priorities and its
full commissioning responsibilities. It recognises that there
is a broad agenda and that the work spans many internal
and external organisations – many of which are new.
In order to ensure delivery the CCG has identified the
need to introduce robust systems and processes to track
performance and evaluate success or otherwise.
Included within the CCG structure there is a Head of
Information with a team of information leads embedded in
each Group. These leads will adopt a business partnering
approach to produce the data required for performance to
be measured and monitored. This will involve close working
with the Commissioning Support Unit.
The CCG will adopt a programme management approach
to the delivery of its objectives. A Head of Programme
Management will be recruited to the structure to assist
with the development of this approach which will tie
in with the performance arrangements that are being
developed by the Chief Finance Officer.
The Head of Programme Management will manage the
Programme Management Office (PMO) team and will
track progress against clearly defined deliverables in each
workstream area. This will enable all elements of the
Commissioning Outcomes Framework, strategic plan,
service transformation plans and the financial picture
to be brought together in one place, thus facilitating an
intelligent understanding of what is actually happening to
the population of Wiltshire.
The PMO will also provide support to develop the skills
and knowledge in the local Groups so that the right data
is being collected and the team are able to convert it into
meaningful information to manage current contracts and
inform future commissioning.
Reporting on outcomes will continue through to the
governing body of the CCG and from there through to the
Local Area Team of the National Commissioning Board.
Wiltshire CCG Performance
Management Framework (Chart 8)
Provider
Performance
Review
Meetings
Focus on the Issues
and Provider Actions
Provider/
Provider
Commissioner
Performance
response to
Review
performance
Focus on the Group
Meetings
issues
Performance Issues, actions to be
delivered and Project
Implementation
Clinical
Group
Performance
Meetings
Integrated
outcome
reports
for Finance,
Information
and Quality
Section 15 Performance Management Arrangements
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16
Quality Improvement Productivity
and Prevention (QIPP)
QIPP is about creating an environment in which change
and improvement can flourish. It is about leading
differently and in a way that fosters innovation and it
is about providing staff with the tools, techniques and
support that will enable then to take forward their plans
to improve the quality of care.
It is important to state at the outset that we do not view
QIPP as a separate project or piece of work. We have taken
a clear approach of building QIPP into our contracts with
all our providers. On this basis, if we deliver in conjunction
with our providers, on our contracts then we will deliver on
the QIPP challenge.
During the past two years the PCT has delivered on
significant QIPP initiatives which to date have changed the
demand on local providers.
The economic forecast for demand identified a potential
gap of £9 million at a PCT level, if no action was taken.
Section 16 Quality Improvement Productivity and Prevention (QIPP)
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Wiltshire CCG Breakdown of the 3 Year Transformation Savings (Table 13)
Strategic Area
2012/13 Transformation Target
2012/13
Planned Transformation Targets from the Base Plan
-11,244
Planned Care
Orthopaedics Elective Activity Reduction
1,374
Prior Approvals for Daycases
1st Outpatients Attendances discharged
New to Follow-up ratio
616
Clinical Exceptions
354
Non Elective
Reduce Non elective admissions by 2.9% (1498 FFCE)
2,740
Mental Health
1,000
Long Term Conditions and End of Life
1,300
Other
3,500
360
Medicines Management
Primary care
Total
Strategic Area
2013/14 Transformation Target
11,244
2013/14
2014/15
2015/16
Planned Transformation Targets from the Base Plan
-9,000
-6,500
Planned Care
Community and primary care based outpatient clinics
1,000
-6,000
Impact of Map of Medicine and reviews of clinical pathways
Help and Guidance schemes
- reduces the impact of PbR tariff for outpatients
500
Diagnostics in the community
500
Improved access to physiotherapy services
400
Non Elective
Shift 10% activity to Ambulatory Care
reducing the exposure to full tariff
Reduce A&E attendances by 10%
Impact of Community Physician and support into Care Homes
to reduce conveyance rates and emergency admissions
Reducing excess bed days through step up and step down beds
800
Reducing inappropriate activity in Minor Injury Units
300
Mental Health
Primary care Mental Health Liaison
1,000
Long Term Conditions
and End of Life
Impact of Risk Stratification, Community Care Coordinators
Primary care Dementia Services
Increased Impact of Community Neighbourhood teams
1,000
Other
Further impact of Generic Drugs
1,000
Total
1,000
1,000
500
1,000
9,000
Section 16 Quality Improvement Productivity and Prevention (QIPP)
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Innovation
The focus on innovation as the key driver for sustained
quality improvements and productivity gains calls for a
system wide focus on designing and implementing more
efficient and productive services that do not compromise
on the quality and safety of patient care. Our programmes
of work underpinned by the transformation of community
and integrated services, in conjunction with the Local
Authority and other healthcare providers will provide
opportunities for smaller scale projects at a local level
which, if successful can be rolled out across the county.
Implementing changes takes time and money so it will be
important to test changes and measures on a small scale
first because:
•It involves less time, money and risk
•The process is a powerful tool for learning which ones
work and which ones don’t
•It is safer and less disruptive for patients and staff.
The impact can be measured on a small scale first and
problems addressed before spreading the changes
more widely
•Where people have been involved in testing and
developing the ideas, there is often less resistance
Section 17 Innovation
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Risk Management
We recognise our statutory responsibility to patients, staff
and the public to ensure that effective processes, policies
and people are in place to deliver our objectives and to
control any risks to achieving them. Our approach to risk
management will be comprehensive, covering financial,
organisational, clinical, project and reputational risks.
The CCG has a Risk Management Strategy approved by
the Governing Body which provides the framework for
the continued development of risk management processes
throughout the organisation and describes levels of
accountability, processes and frameworks.
We intend to commission support for risk management
services from a Commissioning Support Unit under contract
arrangements but overall responsibility and accountability
for risk will reside with the CCG.
Risk Strategy
We have identified a number of objectives which have
formed the basis of our Risk Management Strategy:
•Through the organisational development plan we will
promote awareness of risk management and embed
the approach through all functions and management
throughout the organisation
The objectives will be achieved through:
•Leadership and commitment from the top, supporting a
culture of risk awareness and personal, professional and
corporate responsibility and accountability
•Providing a clear system and framework within which
risks and adverse events may be identified, reported,
analysed, managed and monitored
•Sharing good practice, effective risk management
actions and audit recommendations which reduce
exposure to risk
•Providing appropriate training to ensure staff have the
correct knowledge and skills
•Complying with legislation, regulations and standards;
•Reducing the impact of and learning from adverse
events, complaints and claims
•Working in collaboration with providers to sustain the
provision of high quality and effective healthcare that
demonstrates value for money
•To ensure the CCG has and maintains the required level
of risk management support to successfully manage
its risks
•To seek to identify, record, measure, control, report and
monitor any risk that will undermine the achievement of
objectives, both strategically and operationally, through
appropriate analysis and assessment criteria
•To protect the services, patients, staff, reputation and
finances of the organisation through application of
sound risk management
•To provide the Governing Body with assurance that risk
is being effectively managed through the establishment
of appropriate risk management escalation mechanisms
for the purposes of decision-making, coupled with
proportionate monitoring and compliance with
agreed processes
Section 18 Risk Management
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Patient Safety and Quality
Wiltshire CCG recognises the importance of ensuring
patient safety and quality and is developing its approach
with a strong focus on clinical leadership and embedding
patient safety and quality in the commissioning and
contracting process.
We wish to ensure that our approach to contracting
concentrates on the following key areas:
•Patient experience – both more effectively acting
upon what patients tell us and strengthening their
voice in service improvement and in targeting specific
aspects of patients’ experience, such as privacy, dignity
and communication
•Safety of clinical services: targeting areas of concern
raised by external or local intelligence including proactive
assurance of performance against national standards
and ensuring that action from lessons learned is
taken effectively
•Good clinical practice. Ensuring that clinicians and
services are systematically working to accepted best
practice guidelines, and that there are systems of clinical
communication which are timely, accurate, relevant
and systematic
•Agreed pathways of care, ensuring effective adoption
by primary, community and secondary care services of
agreed care pathways in Wiltshire, with care indicators
which measure the quality of a whole pathway of care
•Patients treated closer to home, with agreed care plans
and the right multi-disciplinary team in place to support
the patient and carers
Our Quality Objectives
Our strategy has four objectives that will be addressed at
every stage of the commissioning cycle. These objectives are:
•To ensure that services being commissioned are safe,
personal and effective
•To ensure the right quality mechanisms are in place
so that standards of patient safety and quality are
understood, met, and effectively demonstrated
•To provide assurance that patient safety and quality
outcomes and benefits are being realised, and
recommend action if the safety and quality of
commissioned services is compromised
•To promote the continuous improvement in the safety
and quality of commissioned services
We will be reporting on selected outcome measures to
demonstrate progress against our key aim of reducing
preventable morbidity and mortality. We propose an
ambitious strategy for improving the outcomes for people
who live in Wiltshire. Using a process of quality assurance,
quality improvements and by working collaboratively with
key partners in the health community we aim to reduce
preventable morbidity and mortality by:
•Improving the safety of the services we commission
•Improving the effectiveness of the services that
we commission
•Improving peoples experience of health,
social care and housing services
In each area there will be a strong emphasis on integration
of care between primary, community and secondary care
providers, with the CCG recognising its responsibility as
a partner to ensure that primary care works effectively
as part of the health system. The CCG understands
integration to mean the effective management of care
for a patient between providers, requiring collaboration
and communication. Promoting and supporting that
collaboration will be a key feature of the contracts
with providers.
Section 19 Patient Safety and Quality
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Our top ten patient safety and quality measures
Patient Safety
NHS 5.3
Safety measure
Quality measure
1. To reduce preventable morbidity and mortality
HSMR within agreed range
2. Reduce incidence of category 2, 3 and 4
pressure ulcers across all providers by 50%
Number of acquired pressure ulcers:
Grades 2, 3 & 4
3. Elimination of “Never Events” and incremental
reduction of rates of avoidable harm
(Sum of community and hospital)
Number of Never Events
Clinical Efficiency
4. Reduce the number of bed days occupied as a
result of avoidable infection
HQU 16
5. Reduce Emergency Readmissions (To be set)
Readmission within 30 days – elective
Readmission within 30 days – non-elective
SQU02
Patient Experience
19
HQU08
6. Improve timeliness of assessment for people
with dementia
All patient over 75 years old admitted as
an emergency to have an assessment
7. To improve the percentage of deaths at home
Number of registered deaths at usual
place of residence/number of registered deaths
8. Improve patient experience
Split by inpatients and outpatients, A&E,
primary care and maternity care
9. Improve privacy and dignity by eliminating
mixed sex accommodation
Numbers of non-clinically justified
breaches
10. Complaints/PALS
Monitor complaints and rates of
reopened complaints
How will we achieve the outcomes?
With GP leadership, the CCG regards contracting as a major lever, for both
commissioners and providers, in driving attention to and improved performance
in the patient safety and quality of health care in Wiltshire. We wish to see
contracting used as an integrated part of its commissioning processes to
support the focus on quality.
Section 19 Patient Safety and Quality
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Commissioning Support
Commissioning Support Units
are organisations that are being
developed as part of the changing
NHS environment. These organisations
will provide a range of supporting
commercial commissioning functions
which will allow CCGs to discharge
their primary commissioning functions
with a focus on clinical leadership at
the helm. CSUs are able to provide
support services to multiple CCGs.
Commissioning Support Unit
Area of Support
To provide support for:
Strategic Planning and Service Design including
Procurement, Benchmarking and Innovation
Support
Commissioning Cycle
Provider Performance including clinical quality
assurance and contracting
Information Technology support and Informatics
including data analysis
Business Support
Quality Assurance and Safety including clinical
quality and patient experience
During the establishment of the CCG
and the CSU negotiations have taken
place between the CCG, as customer,
and the CSU, as supplier, for services
that the CCG will require. A summary
list is shown right.
Human Resource Management
Finance
Corporate services including Risk Management
support, Information Governance and Freedom
of Information
The support required is based on the CCG’s assessment of the functions
and capacity that it will need to discharge its commissioning responsibilities.
Negotiations have been lead by the Chief Financial Officer on behalf of the CCG
to ensure that the CCG obtains the correct support and also value for money.
The CCG will be responsible for leading the work to be delivered by the CSU.
It will be important to establish sound working relationships between the CCG
and the CSU to ensure that the required services are delivered and that any
limitations are managed effectively. The process for managing the interface
between the two organisations is in development and will be concluded once
the contract for services is finalised on 30th november 2012.
At present, following receipt of the proposed contract for services from the
CSU, discussions are ongoing in order to develop high quality commissioning
support. The CCG is currently exploring all options to ensure that the CCG
has the right resources in the right place to deliver the strategic intent which
will in turn manage the risks to delivery based on the proposed split of
existing PCT staff across the new NHS environment. There is no expectation
that commissioning support will necessarily have the same geographical or
functional footprints as clusters and their constituent PCTs.
Section 20 Commissioning Support
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Workforce and Organisational Development
The CCG Constitution sets out the CCG’s approach as an
employer to ensure that its staff, recognised as its most
valuable asset, have their skills and experience enhanced
to enable them to deliver their functions and thus the
responsibilities and objectives of the organisation. Employees
will be informed about the constitution, the commissioning
strategy and the relevant internal management and control
systems which relate to their field of work.
The Governing body has demonstrated its commitment
to the education and training of the NHS workforce. It
agrees to work in partnership with the local education and
training boards to ensure that the system for the planning,
commissioning and delivery of education and training is
able to respond to service commissioning priorities.
The CCG has developed its organisational structure in
response to its assessment of the capacity and capability
it will need. The complement of direct employees is being
revised as the negotiations with the CSU continue. This will
ensure the CCG has the correct functions.
Processes are in place to fill vacancies and through
induction staff will understand the behaviours required to
reflect the values, aims and principles of the CCG.
The CCG is an emerging organisation and is currently only
made up of a small number of staff in designate positions.
The CCG is reliant on the support it receives now from
the existing PCT staff and the support that it will receive
from the Commissioning Support Unit and the National
Commissioning Board in the future. This is all part of the
changing NHS environment. This position is reflected in
the organisational development plan which sets out the
journey to maturity.
This plan, which has been developed following the use
of a self assessment tool will address:
•Clinical and added value
•Engagement with patients /communities
•Clear and credible plan
•Capacity and capability
•Collaborative arrangements
•Leadership capacity and capability
Section 21 Workforce and organisational development
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Listening to Our Public and Partners
We value and recognise the importance of its developing
relationships with stakeholders and it is important to
maintain strong and effective partnerships with NHS
provider organisations and fellow CCGs, Wiltshire Council,
third sector and voluntary organisations and local interest
groups. As a CCG we will regularly seek the views of
stakeholders, not just in commissioning decisions but in
how effectively the CCG, as an organisation, develops and
performs. Our CCG Executive, Group Directors and Lead
GPs have led presentations to two Stakeholder Assemblies
in October 2011 and May 2012. The response from the two
assemblies was very encouraging and has been used to
shape our Communications and Engagement strategy.
In addition we have committed to adopt, evolve and
continue engaging through the Stakeholder Assemblies
which are highly valued by delegates.
Feedback received showed that although no one work
stream was identified as being more important than
another, some very constructive suggestions were provided
from each table for consideration, including:
•The requirement for intelligent use of the
voluntary sector
•General improvements in mental health service
provision, specifically regarding dementia care in
acute settings
•The importance of consistent and regular
communication across GP practices
•Consideration and strategy for the long term impacts
of alcohol
•The inclusion of expert patients and data networks
in the prevention and improvement of care of long
term conditions
Ninety three delegates attended the last assembly,
including representatives from the voluntary and
community sector, the three main acute hospitals, the
Deputy Leader of Wiltshire Council, the mental health
Trust, town councillors, patient groups and a range of
other organisations including Wiltshire Blind Association.
Voluntary and Community Sector representatives
included Alzheimer’s Society, Wiltshire and Swindon
Users’ Network, Wiltshire Involvement Network, St John’s
Ambulance, Grow, Wessex Community Action, Voluntary
Action Kennet, Wiltshire Citizens Advice and Order of St
John. Carers Support Wiltshire, residents associations and
hospices were represented, together with a number of
parish councillors, Area Boards representatives, health and
social care forums, hospital Leagues of Friends and practice
participation groups. The CCG/GP leads presented our
plans for the 7 priority areas which were well received
by all delegates.
Health and Wellbeing Board
Much of this strategic plan clearly involves close liaison
with a number of agencies and partners within the health
system. We cannot deliver this plan without the full
involvement of local authority partners both in the delivery
of public health targets and the development of our model
for integrated care as described above.
The Wiltshire Health and Wellbeing Board is currently
in shadow form. NHS Wiltshire and Wiltshire CCG are
active participants of the Board and work with other
partner organisations to deliver the best quality care for
patients and public in Wiltshire. We are working with the
Health and Wellbeing Board to develop the Joint Strategic
Assessment and shape the priorities from the Joint Health
and Wellbeing Strategy for 2012.
Section 22 Listening to our Public and Partners
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Wiltshire Council Health Select Committee
Wiltshire Council has reorganised its Committee structure
for the overview and scrutiny function and from March
2012, the Health and Social Care Select Committee, which
hosted the Health Overview and Scrutiny Committee, has
been disbanded. From July 2012 the function of the Health
Overview and Scrutiny Panel will be hosted by a newly
formed Health Select Committee.
Our CCG will ensure that as the arrangements for the
Health Select Committee are revealed, we will have in
place professional and appropriate working relationships in
order to respond to any requirements. The Committee will
meet 6 times a year and will establish ad hoc task groups
as required. The work programme will be directed by a
management committee in line with rules set out in the
Council’s Constitution, including the statutory powers of
Health Scrutiny.
Community Area Boards
Wiltshire Council has established a network of 18
Community Area Boards, each representing an area of
the County. Each area board is made up of councillors
that local people have elected, together with a member
of the Council’s Cabinet. Residents and key organisations,
including the local NHS, play an active part in Area Boards.
The Area Boards hold public meetings every two months
which provide the opportunity to identify issues from
within the community. NHS Wiltshire has attended the
Boards when required by agenda item and relationships
between elected council members and other community
representatives and the NHS continue to grow. As a CCG
we will adopt the same approach. Area Boards provide
a unique opportunity for further understanding at a
local level and will undoubtedly provide a platform for
discussions about service development moving forward.
Through our Locality Groups the Area Boards will receive
presentations from the CCG about health and wellbeing,
based on the Joint Needs Assessment, but broken down to
community area level, so that members of the public
are made aware about health profiles and priorities in
their own area.
Healthwatch
In 2012 the functions of the Wiltshire Local Involvement
Network (WIN) will transfer to local Healthwatch, which
will be the responsible body for scrutinising all health
and social care services and supporting patients in their
feedback on health and social care in the county. It will
be important to continue to be involved in the work that
sees the development of Healthwatch as it takes up some
of the reins previously held by WIN and assumes other
responsibilities. There will be opportunities for partnership
working with Healthwatch as it emerges which will provide
the CCG with new opportunities to seek the views of
patients and the public, in addition to direct engagement
with patients through, for instance, membership schemes
and topic focused discussions on health care. We will
work closely with Healthwatch as critical friends of health
services, and share our learning and plans as these develop.
Our Practices
Every general practice in Wiltshire has a team of supporting
staff from receptionists who face the public every day to
administrative staff and practice managers who play a
vital role in making the practice function effectively and
efficiently. These staff are also members of the public and
ambassadors for the CCG in their communities. We will
harness this knowledge by listening to their views and
regularly providing information on service developments,
being honest about what we can and cannot do.
Patient Participation Groups
Almost every practice in Wiltshire has a patient
participation group. The CCG will support, develop and
help to coordinate them widely across the county through
a Patient Participation Forum where patient groups can
come together with the CCG leaders to discuss plans for
health services across the county and to enable groups
to share their local experiences and network. Practice
managers will play a vital role in delivering this vision.
Section 22 Listening to our Public and Partners
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Patient Experience, Complaints,
Comments and Compliments
Our CCG will harness ways of capturing patients’ and
carers’ experiences, feedback and insights and use them to
monitor services. In addition we will scrutinise complaints
received directly or by provider organisations (for instance,
through the Patient Advice and Liaison Service) and look
for any underlying trends. We are committed to learning
from complaints, concerns, compliments and comments,
and communicating action taken, for instance at Board
Meetings and through the Annual Report.
Media management
Key to effective relationships with the media and the press
will be the support from the CCG Communications Team,
which has established strong relationships with local and
regional media.
The CCG will ensure a robust media handling policy exists
and that all media enquiries are handled effectively to
deadline and any inaccuracies are addressed to prevent
misunderstanding and confusion. Media evaluation, design
and delivery of targeted strategies to improve media
coverage will form part of the policy.
In addition, the media handling policy will cover particular
areas including communication for crisis management,
specific planning and delivery of ministerial and other
briefings, parliamentary questions and adjournment
debates and other large stand-alone pieces of
parliamentary business.
When communicating with the news media, Wiltshire
CCG will work both proactively and reactively to ensure fair
and accurate reporting, rebuttal of inaccurate media and
support for critical reputational issues.
Editorial coverage and briefings will be the preferred
approaches in dealings with the media and press. Use of
paid press or radio advertising will be limited to support
for health campaigns or formal public consultations.
Section 22 Listening to our Public and Partners
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Equality and Diversity
Legal framework
Equality Act 2010: The Act is based on the principle that
everyone has the right to be treated fairly at work or when
using services. It applies to all individuals and organisations
who provide goods, facilities or services to the general
public or a section of it; and protects people from
discrimination on the basis of 9 “protected characteristics”.
Clinical Commissioning Groups upon becoming legal
entities will be subject to the Equality Act 2010:
•Age
•Disability
•Gender reassignment
•Marriage or civil partnership
•Pregnancy and maternity
•Race
•Religion or belief
•Sexual orientation
•Sex (gender)
The Act prohibits direct and indirect discrimination,
victimisation and harassment. It imposes a general duty on
public authorities (and bodies carrying out public functions)
to tackle unlawful discrimination, advance equality of
opportunity and promote good relations between different
groups of people. The Act also imposes specific duties to
publish one or more equality objectives (at least once every
4 years starting 6 April 2010) and annual information to
demonstrate compliance with the general duty
(starting 31 January 2012).
As a healthcare commissioner, the Act applies to both
operations (commissioning decisions, commissioning
support, facilities management, strategic communication)
and people management (recruitment, retention, bullying,
and harassment).
A detailed joint work plan is currently being developed
focused on developing systems and structures that enable
all staff to build Equality, Diversity and Human Rights into
their everyday business. Progress will be monitored against
the work plan at regular meetings held between the
relevant staff and executive leads. Key areas of work are:
•Continuing to develop our Equality Impact Assessment
processes, in order to ensure they are manageable
and effective
•Ongoing training and awareness raising at all levels,
as a key enabler of delivery (this will form part of our
Organisational Development Plan)
•A programme of community engagement to support
inclusive approaches to strategic visioning, objectivesetting and performance monitoring
•Developing assurance frameworks, governance
arrangements, work plans and leadership for Equality,
Diversity and Human Rights
•Improving equality of outcomes in workforce
recruitment, experience, retention, development
and promotion
The Act requires employers and providers of goods,
facilities and services to take positive action to enable or
encourage people who share a protected characteristic to
overcome or minimise the effects of disadvantage, to meet
their different needs and to improve their take-up
of employment, training or services.
Section 23 Equality and Diversity
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Sustainability
Carbon reduction and sustainable developments are
corporate responsibilities and an inherent part in the
new CCG’s commissioning and corporate performance.
The Climate Change Act (2008) gives the legal framework
to ensure that a legally binding target of at least an 80%
cut in greenhouse gas emissions by 2050 (baseline 1990)
is delivered.
As part of the authorisation process we are being asked to
demonstrate commitment to promoting environmental and
social sustainability.
Sustainable Development
Demonstrating high quality healthcare will not be possible
without embedding sustainable development into the
management and governance processes. This requires all
our boards/managers, clinicians, nurses and other NHS
staff to champion sustainability. The Social Value (Public
Services) Act 2012 when in force early in 2013 will include
a duty to consider social value ahead of a procurement
exercise involving public service contracts (i.e. CCGs must
consider how they might use those contracts to improve
the economic, social and environmental wellbeing of the
community they serve).
The NHS Sustainable Development Unit has produced
a valuable guide to Sustainable Development for Clinical
Commissioning Groups (2011) which will help us in the
development of a CCG specific approach to sustainable
development and ensure a ‘whole system’ approach
to commissioning.
We will develop a Board approved Sustainable
Development Management Plan and also sign up to the
Good Corporate Citizenship Assessment Tool (2) as part
of our commitment to the NHS Carbon Reduction Strategy
over the next twelve months. This is included in our
Organisational Development Plan.
Support from the appropriate body (e.g. NHS Property
Services Ltd., Central Southern) will be negotiated under
a contract as a number of these initiatives involve the estate
and procurement functions.
Section 24 Sustainability
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Glossary of Terms
TermDefinition
Accident and Emergency (A&E)
Accident and Emergency departments rapidly assess and treat people with serious injuries and those in
need of emergency treatment
Acute careMedical and surgical treatment usually provided by a hospital, often for diseases or illnesses that progress quickly,
feature severe symptoms and/or have a brief duration
Acute servicesMedical and surgical interventions usually provided by a hospital, often for diseases or illnesses that progress quickly,
feature severe symptoms and/or have a brief duration
Acute Trust
An NHS body that provides hospital-based healthcare services from one or more hospitals
Allied Health Professional (AHP)Covers a wide range of professionals working in health and social care, including physiotherapists, speech and
language therapists, radiographers, occupational health therapists, chiropodists, podiatrists and dieticians
Cardiac
Relating to or affecting the heart
Cardiovascular disease
A disease of the heart or blood vessels
Cardiovascular system
The organs and tissues involved in circulating blood and lymph through the body
Care pathwayThe route that a patient will take from their first point of contact with an NHS or Social Services member of staff
(usually their GP), through referral to the completion of their treatment
Care planAn agreed written document which states what an individual’s needs are and how those needs will be met.
The plan should include social, personal and health needs, and should also provide information on what to do in the
event of a crisis
Carer
Someone who provides help or support to relative, partner, friend or neighbour
Case managementAn approach designed to supporting an individual with numerous long term conditions and complex needs involving
a named contact (e.g. a community matron) who actively manages and joins up care to ensure a coordinated
approach
Choice
Giving patients more choice about how, when and where they access health services
Choose and BookA computer system that allows patients to make their first consultant outpatient appointment at a time, date and
place that suits them
Chronic Obstructive
Persistent or recurring disease of the lung that also affects the heart
Pulmonary Disease (COPD)
Civil Contingencies Act 2004Provides a single framework for UK civil protection against any challenges to society, specifically focusing on local
arrangements and emergency powers
Clinical Commissioning GroupA Board led by GPs and other health professionals supported by managers and non-executive directors who lead
commissioning of services tailored to the needs of the local community.
Clinician
A healthcare professional, i.e. physician or nurse, involved in active patient care
Clostridium difficile (C.diff)An anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants. When certain
antibiotics disturb the balance of bacteria in the gut, C. diff can multiply rapidly and produce toxins which
cause illness
Clinical Network
A group of health professionals from different NHS organisations working across institutional and local boundaries
Commissioning
The review, planning, purchasing and monitoring of health and social services
Community ServicesHealth or social care and services provided outside of hospitals. They can be provided in a variety of settings including
clinics and in patients’ homes. Includes a wide range of services such as district nursing, health visiting services and
specialist nursing
Glossary of Terms
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Coronary Heart Disease (CHD)
Narrowing of the coronary arteries that supply blood to the heart
Crisis Resolution TeamA service aimed at treating adults with severe mental health difficulties in the least restrictive environment and with
the minimum disruption to their lives. It acts as a gatekeeper for admission to acute mental health services, and where
appropriate, provides intensive multi-disciplinary treatment at the service user’s home. Where hospitalisation
is necessary, the team also assists in planning and facilitating early discharge
Department of Health (DoH)The government department responsible for ensuring better health and wellbeing, care and value in England. The
DoH sets direction and standards for the NHS; supports the delivery of healthcare, leads the integration of health and
wellbeing into other areas of government policy; and supports the Secretary of State for Health and health ministers
in accounting to Parliament and to the public for delivery of health services
Dementia
The loss (usually gradual) of mental abilities such as thinking, remembering and reasoning
Diabetic RetinopathyOne of the most common causes of blindness in the UK. Retinopathy means damage to the
tiny blood vessels (capillaries) that nourish the retina (the tissues in the back of the eye that deal with light)
DiagnosticsTests or procedures carried out in order to reach a diagnosis that is a decision on the nature of a patient’s
condition, e.g. x-rays
Emergency Care
Provided to patients suffering a medical or surgical emergency, such as stroke, heart attack or severe injury
Expert Patient ProgrammeA six week course for people with chronic or long term conditions. The course is delivered by trained and accredited
tutors who are also living with a long term health condition. It aims to give people the confidence to take more
responsibility and self-manage their condition, whilst encouraging them to work collaboratively with health and social
care professions. The programme has had success in reducing GP consultations and hospital admissions for people
with long term conditions
Foundation TrustIntroduced in 2004 and have been given much more financial and operational freedom than other NHS Trusts. They
are run by local managers, staff and members of the public, which are tailored to the needs of the local population
Gold Standards FrameworkA framework to enable effective palliative care to all those in their last year of life and improve the quality of life for
both patients and carers
General Practitioner (GP)GPs are doctors who work from a local surgery or health centre providing general medical advice and treatment to
patients who have registered on their list
HCAHealthcare assistants (also known as nursing assistants and nursing auxiliaries) support healthcare professionals with
the day-to-day care of patients, either in hospitals or in the patients’ own homes
Healthcare Associated Infections (HCAI)Infections such as MRSA or C. Diff that are acquired in hospitals or as a result of healthcare interventions
Health inequalities
Used in public health to describe the differences in health and health outcomes between different
groups of society
Holistic careCan be described as the care of the whole person, taking into account physical, social, psychological and
spiritual needs
Life expectancyThe average number of years of life remaining for groups of individuals at a certain age. Most commonly we refer to
life expectancy at birth, which is the average age that an individual could expect to reach if they were born today
Local Area AgreementThree year agreement that sets out the priorities for a local area in certain policy fields as agreed between
government, local authority and other partners
Local AuthorityInclude country councils and unitary authorities, and are responsible for a wide range of local services, including
transport, housing, planning, education, social services and sports facilities
Local Involvement Networks (LINk)Aim to make it easier for citizens to say what they want from health and social care services, to talk with the people
who run them and hold them to account. Run by local individuals and groups, a LINk is being established in every area
in England
Long term condition (LTC)Defined as health problems that require on-going management over a period of years or decades. This includes a
wide range of health conditions, including non-communicable diseases (e.g. diabetes, cancer and cardiovascular
disease), communicable diseases (e.g. HIV/AIDS), certain mental disorders (e.g. schizophrenia and depression), and
on-going impairment in structure (e.g. blindness and joint disorders)
Glossary of Terms
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Mental Health Trust
Provides treatment and care for patients who are mentally ill. These services may be provided from
a hospital or in the community
MRSA
Bacteria that can cause infection in a range of tissues such as wounds, ulcers, abscesses or bloodstream
Medium Super Output Area (MSOA)Government identified areas of greatest social and economic deprivation
National Institute of Clinical Excellence (NICE)An independent organisation that provides national guidance on the promotion of good health and the prevention
and treatment of ill health
NHS CampusNHS-provided long term care in conjunction with NHS ownership/ management of housing (residents do not have
an independent landlord and housing rights) and is commissioned by the NHS. It can include people who have been
in assessment and treatment services for more than one year who are not compulsorily detained or undergoing a
recognised evidence based treatment programme
OptometristTrained professional who examines eyes, tests sight, gives advice on visual problems, and prescribes and dispenses
spectacle or contact lenses. Also recommends other treatment or visual aids where appropriate
Out of Hours (OOH)This service is provided from 6.30pm-8.30am on weekdays and all day at weekends and bank holidays. The service is
designed to give 24 hours access to GP care
Palliative CareThe total care of patients whose disease is incurable. Control of pain, of other symptoms, and of psychological, social
and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients
and their families
Phlebotomy
The process of taking blood for medical testing
Podiatry
The care and treatment of feet in health and disease
Primary careThe first point of contact for most people’s healthcare needs. Many health professionals work as part of this front line
team, including GPs, dentists, pharmacists, opticians, community nurses (such as health visitors and district nurses)
and a range of specialist therapists. NHS Direct and NHS walk-in centres are also part of primary care
Primary care PractitionersHealth professionals such as GPs, dentists, pharmacists, optometrists and ophthalmic medical professionals, together
with community nurses such as district nurses and health visitors who care for people in the community
Quality and Outcomes Framework (QOF)The annual reward and incentive programme detailing GP practice achievement results. QOF is a voluntary
programme for all GP surgeries in England, and was introduced as part of the GP contract in 2004
Respiratory DiseaseAn umbrella term for diseases of the respiratory system. These include diseases of the lung, bronchial tubes, trachea
and pharynx. There are many such conditions, ranging from mild and self-limiting (e.g. the common cold) to life
threatening (e.g. bacterial pneumonia or pulmonary embolism)
Social CareCovers a huge variety of services. It includes community support such as care in your own home, meals and day
services right through to care homes. It also includes support for carers
StatinsA form of drugs used to lower cholesterol levels in people with high risk of cardiovascular disease. Also known as
HMG-CoA reductase inhibitors
Strategic Health Authority (SHA)Responsible for developing plans for improving health services in the local area. SHAs manage the NHS locally and are
a key link between the DoH and the NHS
Strategic Needs AssessmentIn partnership with the local community identifies priorities for action that will improve the health and wellbeing of
the population. Assessments will improve access to data about the needs of the population by those who, now and in
the future, plan and deliver services
ThrombolysisThe main treatment for heart attack is the administration of clot-dissolving drugs (thrombolysis) which held to restore
blood supply in the coronary arteries to the affected parts of the heart
Vascular surgeryA sub-specialty of general surgery in which diseases of the vascular system, or arteries and veins, are managed, largely
by surgical intervention
Glossary of Terms
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Appendix A
The table below illustrates how the key priorities for health and social care interlink and support each other.
Supporting National and Local priorities
Theme
Children and
Young People
(Local Authority)
Adult Social Care
(Local Authority)
NHS Outcomes
Framework
Public Health
Wiltshire CCG
Key Priorities
and programmes
of work
Prevention
Be healthy
Enhance the
quality of life for
people with care
and support needs
Preventing people
from dying
prematurely
Health
improvement
Staying healthy
and preventing ill
health
Prevention of ill
health
Management of
long term
conditions
Healthy life
expectancy and
preventable
mortality
Mental health
Tackling the wider
determinants of ill
health which affect
health and well
being
Community and
integrated care
Enhancing the
quality of life for
people with long
term conditions
Independence
Enjoy and achieve
Delaying and
reducing the need
for care and
support
Helping people
recover from
periods of ill health
or following injury
Achieve economic
well being
Engagement
Making a positive
contribution
Ensuring people
have a positive
experience of care
and support
Ensuring people
have a positive
experience of care
Stakeholder
engagement
Keeping safe
Stay safe
Safeguarding
vulnerable adults
and protecting
from avoidable
harm
Treating and caring
for people in a safe
environment and
protecting them
from avoidable harm
Safeguarding
adults and children
Providing
Treatment
Planned care
Unplanned care
and frail elderly
Management of
long term
conditions
including dementia
Mental health
Appendix A
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Wiltshire Clinical Commissioning Group
Southgate House, Pans Lane
Devizes, Wiltshire SN10 5EQ
www.wiltshire.nhs.uk