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PAPER D WEST LEICESTERSHIRE CLINICAL COMMISSIONING GROUP BOARD MEETING 8 March 2016 Title of the report: Operational Plan 2016/17 Section: Setting the Strategic Direction Report by: Sam Kirton, Planning Manager Presented by: Spencer Gay, Chief Finance Officer Report supports the following West Leicestershire CCG’s goal(s) 2012 – 2015: Improve the quality of health-care Improve health outcomes services Use our resources wisely Equality Act 2010 – positive general duties: 1. The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. 2. The CCG will work with providers, service users and communities of interest to ensure any issues relating to equality of service within this report are identified and addressed. Additional Paper details: Please state relevant Constitution provision Please state relevant Scheme of Reservation and Delegation provision (SORD) Please state relevant Financial Scheme of Delegation provision Please state reason why this paper is being presented to the WLCCG Board Discussed by Alignment with other strategies Functions: 5.1.2 In discharging its functions the Group will: Act, when exercising its functions to commission health services, consistently with the discharge by the Secretary of State and the NHS Commissioning Board of their duty to promote a comprehensive health service and with the objectives and requirements placed on the NHS Commissioning Board through the mandate published by the Secretary of State before the start of each financial year N/A N/A For comment and approval Planning and Delivery Sub group Corporate Management Team Operational Plan for 2015/16 Better Care Together Programme Environmental Implications None identified. Has this paper been discussed with members of the public and other stakeholders? If so, please provide details No EXECUTIVE SUMMARY: 1. This is the second draft of the Operational Plan for 2016/17 which was submitted to NHS England on 2nd March 2016. 2. Final submission to NHS England is on 11th April 2016. BACKGROUND: 3. The Operational plan was circulated to Board Members in February for comment following the previous draft submission to NHS England. 4. Comments received have been incorporated into this version, along with CMT comments and the feedback provided by NHS England. 5. We are developing a Plan on a Page to summarise our delivery intentions for 2016/17. NEXT STEPS: 6. Board Members are asked to provide comment on the latest version of the Operational Plan. 7. Any additional comments that are raised will need to be submitted by close of play 16th March 2016 if to be included in the final version. 8. The final version will then be circulated to Board Members on 18th March 2016. 9. An Extra Ordinary Board Meeting is scheduled for 22nd March 2016 to sign off the final version of the plan. RECOMMENDATION: The West Leicestershire Clinical Commissioning Group is requested to: COMMENT on the Operational Plan APPROVE the process outlined for sign off of the final version, due for submission to the Area Team on 11th April 2016 2 West Leicestershire Clinical Commissioning Group West Leicestershire CCG Operational Plan 2016–2017 Patients, practices and partners working together to create the best value healthcare for the population of West Leicestershire Draft to NHS England 2.0 Patients, Practices, Partners West Leicestershire CCG Operational Plan 2016–2017 | 2 Draft to NHS England 2.0 Chair’s Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Mission and Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 National Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 What our Local Information is telling us . . . . . . . . . . . . . . . . . . . . .17 Population Analysis What our population is saying: People Powered Health Provider Landscape and Partnerships Quality and Commissioning Intelligence Our performance in delivering improvements to our patients Maintaining focus on the essentials . . . . . . . . . . . . . . . . . . . . . . . .36 Our local operating delivery model . . . . . . . . . . . . . . . . . . . . . . . . .42 Clinical Work-streams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Urgent Care Long term conditions (LTCs) Frail older people and dementia Planned Care and Cancer Mental Health Learning Disabilities Children’s, maternity and neonates End of Life Care and Learning Lessons to Improve Care NHS Continuing Health Care funding Enabling Workstreams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Better Care Fund Primary Medical Care Multispeciality Community Providers (MPCPs) Workforce Estates and Facilities Information Technology (IM&T) Communications and Engagement: Financial and Activity Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 The Financial Plan Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 Appendix A: Population analysis Appendix BDocuments and drivers that affect operations (key policy drivers) Appendix CFrail Older People Appendix DVoluntary Sector Draft to NHS England 2.0 3 | Chair’s Foreword Chair’s Foreword As we move into our fourth year of operation as a Clinical Commissioning Group, we are continuing to work together with patients, partners and practices to fulfil our mission of creating the best value healthcare for the 366,000 people we serve. In Leicestershire we face many of the same challenges seen at a national level. Our population is getting older and the number of people with multiple, complex long term conditions is increasing. Addressing these issues is not an easy task and, although I am extremely proud of the progress that we have already made and the many improvements which we have achieved over the last two years, it is vital we continue to create and implement a challenging agenda to meet the needs of our population. This operational plan sets out that agenda, and outlines what we will do in 2016/17. It represents the ongoing collaborative working between health and social care providers and partners as well as our neighbouring NHS Clinical Commissioning Groups within Leicester, Leicestershire and Rutland. Our partnerships are not just with other NHS services, but with social care, the voluntary and community sector and organisations such as Healthwatch, and are vital to us in tackling the changes we need to make. Professor Mayur Lakhani, Chair As you will see in the plan, our drive continues to be to deliver the highest levels of quality across all aspects of healthcare. Patient safety must be at the heart of every clinical decision and we will continue with our work to promote a positive culture, learn lessons from incidents which occur and hold our providers to the highest standards of care. Promoting a positive patient experience, where every patient and carer receives a high level of care is the key to our goals and we have introduced a new way of listening to our patients, understanding what matters most to them and empowering them to make their own decisions about the healthcare we deliver and they receive. We will continue to use this Experience Led Commissioning approach in 2016/17, and use this information to deliver better, more person centred care. As a working GP, I know our focus has to be on redesigning the healthcare we offer to provide care focused on the community and centred on the patient, led by general practice. This operational plan builds on the work already done in developing the Primary Medical Care Plan to lay out how we will achieve this through federations, groups of GPs who are working together to deliver care, improving access and providing an extended range of services for patients in the community wherever it is safe and financially sustainable to do so. We are taking the lead in implementing this, and the establishment of four Federations in the West Leicestershire area in 2015/16 is one of the achievements I am most proud of from the past year. The key to the success of all of this will be a clear vision and Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 4 leadership across the healthcare system and continued success of the Better Care Together Programme, embracing new models of care and leading on the Urgent and Emergency Care Network Vanguard, as well as taking on the responsibility for the Long Term Conditions work-stream. I am particularly proud to also be taking forward a programme of work through Better Care Together to care for people at the end of their life, enhancing services to increase the support made available to patients and their families. West Leicestershire CCG has aligned our work-streams with the Better Care Together work-streams to ensure that all the work we have done over the last few years is carried forward in a cohesive manner. Our relationship with our partners and providers underpins this, particularly with the Better Care Fund (BCF), a critical part of delivering our goals. As the chair of the integration executive I think it is important to celebrate the work BCF has done and the achievements we have made so far. The work is continued in our plans for 2016/17, aligning the actions of BCF with this Operational Plan to deliver true transformative changes. There are great challenges facing the NHS and we will only be able to meet them by working together, by thinking differently and by putting patients at the heart of everything we do. I believe that this operational plan will give us the tools that we need to meet the challenges and deliver patient centred, high quality care. The last twelve months has seen a huge amount of work from our member practices, staff and health and social care partners to improve quality and outcomes for our patients and we look forward to continuing this work in the year ahead. Draft to NHS England 2.0 5 | Executive Summary Executive Summary This Plan sets out the operational priorities for healthcare commissioning for West Leicestershire Clinical Commissioning Group (CCG) over the coming year (2016/17). It describes our vision and priorities based upon an analysis of public health information and from listening to our patients, carers and partners. It has been developed collaboratively with other CCGs locally to ensure that we have a consensus on our areas of shared commissioning. It is set in the context of the NHS ‘Five Year Forward View’ (FYFV), published in 2014, which outlines the direction for the NHS, showing why change is needed and what it will look like. Recently released guidance to the Five Year Forward View guidance has stimulated our focus on ambitious and transformative change across the health and social care economy in this Operational Plan. This will build on new models of care and relationships with communities and will work towards parity of esteem for mental health services. This Plan sets out how we will deliver our priorities whilst maintaining high quality services for all, fulfilling transformative plans as a solid foundation for year one of the five year Sustainability and Transformation Plan for Leicester, Leicestershire and Rutland (LLR). This is currently being developed, featuring significantly Better Care Together (BCT), our shared direction across LLR and the Better Care Fund (BCF). The document aligns with our Primary Care Medical Strategy which sets out our vision and ambition for primary care in which general practice is the foundation of a vibrant, joined-up, health and social care system, supported by our Federated Localities. It further aligns with our Community Services Plan which describes how we will achieve our ambition of high quality, citizen-centred care pathways close to people’s homes and in their communities. Significant drivers An ageing population and rise in Long Term Conditions together form the most significant driver in health and social care planning. The plan is informed by the Joint Strategic Needs Assessment (JSNA) priorities — reducing inequalities; focussing on prevention; using evidence; sustainability and dignity. To this we have added quality, commissioning and performance information, alongside insights from our partners, providers, patients and carers. Through the eight Better Care Together work-streams, which make up our change programme, we will support the delivery of our vision to achieve the following outcomes: Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 6 • Support children and parents to have the very best start in life • Help people stay well in mind and body throughout their life • Care for the most vulnerable and the most frail • Have services available when it matters and especially in a crisis • Help support patients and their loved ones when life comes to an end • Provide faster access, shorter waits and more services out-ofhospital. Must dos The work-streams also address the ‘must dos’ for the health system including bringing the system back to financial balance, achieving the access standard for both A&E and ambulance waits; delivering the 62day cancer waiting standard, transforming care for people with learning disabilities, improving quality, while achieving and maintaining the two new mental health standards introduced this year. Key enablers to delivery Alongside the Leicestershire Better Care Fund and service reconfiguration programme, there are a number of mechanisms which will enable us to achieve this. • Our workforce is one of the largest groups of employees across LLR, accounting for approximately one in ten of the working population and we want to enhance it to ensure that is fit for purpose now and in the future. • We also want to use information technology to share information, which is essential if we are to treat patients safely, wherever they are. • The environment and buildings used for delivery of services should meet the needs of a modern NHS and requires reconfigurations and investment to ensure that the highest possible quality care can be delivered. • Listening to patients, carers and health professionals and understanding what matters most to them is essential to ensure that everyone get a high level of care no matter the setting. This Plan outlines how these insights influence our commissioning decisions. Financial health Financial balance and financial health have been priorities for the CCG since it was established. This year we know that we are facing increasing pressure on our financial resources. To achieve the Draft to NHS England 2.0 7 | Executive Summary significant transformation of services we will work across both health and social care to grasp opportunities and carefully manage our budget to ensure that our objectives are achieved. Good governance We have developed a comprehensive governance framework which will ensure the assurance, monitoring and delivery of our plan. Where common areas of commissioning exist across the three CCGs, collaborative governance arrangements have been put in place and will be refreshed to reflect any changes required. Real opportunity We believe that we have a real opportunity to deliver our transformative plans. Implementing this Operational Plan, we can achieve our collective vision to improve the health and wellbeing outcomes that matter to our patients, their families and carers and enhance the quality of care provided, within the financial resources available. Draft to NHS England 2.0 8 | Mission and Values Mission and Values This Plan continues the work that we started five years ago with our mission: Patients, practices and partners working together to create the best value healthcare for the population of West Leicestershire. Our journey began in March 2011 when our 50 member GP practices first came together. During the first five years of operation (two of them in shadow form and from 2013/14 as a fully authorised statutory body) we have built up a strong track record of delivery. During this period we have made significant improvements to the range of Out-of-Hospital services which are now available to our patients and have worked much more closely with partners across the health and social care system to drive transformation through the Better Care Fund and Better Care Together programmes. Patients, Practices and Partners working together to create the best value healthcare for West Leicestershire Outcomes Reduced: premature death health inequalities Quality Resources providers reducing variation access efficiency integration transformation self-care and personalisation closer to home Patient Management Research Practice & Partnership Estates IT & Training locality devt Working Involvement Support Democratic Collaborative Proactive Adaptable Honest Passionate Our mission, goals, strategic objectives and organisational values remain as relevant now as they did in 2011 to address the requirements and challenges set out in delivering the NHS Five Year Forward View. Our Mission is Our three Goals are to: We realise our goals through 10 Strategic Objectives Patients, Practices and Partners working together to create the best value healthcare for West Leicestershire Improve health outcomes Improve the quality of healthcare services Use our resources wisely Tackling the major causes of premature death Ensuring our providers deliver high quality services Reducing inappropriate clinical variation Reducing health inequalities Ensuring our patients get timely, appropriate access to services Pushing providers to become more efficient Increasing service integration across health, social care and other partners Stimulating innovation & service transformation Supporting self-care and personalisation Shifting resources to support service provision closer to home Delivery will be supported by seven cross-cutting Mechanisms Practice & Partnership Patient Management Research Estates IT locality devt Working Involvement Support & Training How we do this will reflect our organisational Values Democratic Collaborative Proactive Adaptable Honest Passionate Board and Sub-Group Governance Structure We have developed a comprehensive governance framework which will ensure the assurance, monitoring and delivery of our plan. The Board is the process of making some amendments to its governance structures which are currently being authorised and should be in place Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 9 in the early part of the 16/17. The diagram shows the intended Governing Body and sub- group structure, which seeks greater integration with the collaborative committees run jointly with East Leicestershire and Rutland and Leicester City CCGs, as well as enhancing Board Development Sessions (BDS) to create more capacity for strategic development ensuring they discuss pertinent issues raised by our wider clinical and patient membership. Proposed Board and Sub-Group Governance Structure COI Screening Panel PPAG Agenda development CCB Occasional Twice monthly Monthly Bi-monthly Board PPG Network Practice Managers’ meeting CCG Fed. leads Federated locality meeting Finance & Planning Sub-Group Quality & Performance Sub-Group Locality Development Meeting Audit Committee Primary Care Commissioning Committee Procurement & Investment Committee BDS Chair, MD, Deputies meeting CMT Remuneration Committee Where common areas of commissioning exist between the three LLR CCGs, collaborative governance arrangements are in place and have been refreshed to reflect any changes required. The Commissioning Collaborative Board (CCB) oversees a number of shared areas including the development of commissioning plans, implementation of BCT work-streams, delivery of QIPP and acting upon high risk performance issues. This board will help refine decisions. The Provider Performance Assurance Group (PPAG) holds the individual CCGs to account for management of all major healthcare contracts and receives assurance on all aspects of provider performance. Reports from this group are received by the Governing Body. The Conflicts of Interest Screening Panel (COISP) and the Procurement and Investment Committee have both been recently established as part of a revised conflicts of interest policy Draft to NHS England 2.0 10 | Mission and Values NHS England Area Team Assurance Role The CCG Assurance Framework enables NHS England, through its Area Team for the Central Midlands Area, to meet the statutory responsibility to make an assurance assessment of the CCG. This process ensures there is a joint understanding of the CCGs performance against five assurance components and how its developmental needs can be supported. This assurance process has been designed to provide confidence to internal and external stakeholders and the wider public that CCGs are operating effectively to commission safe, high quality and sustainable services within their resources. This annual assessment is made available to the public via our website. Strategic Risk Management We have developed an integrated approach to risk management that is used to identify, manage and reduce the risks that threaten the delivery of our strategic objectives. This is delivered through the management of CCG sub-group risk registers and to the Board through the Board Assurance Framework (BAF). Full consideration is given to the risk priorities of partner organisations as well as the CCG in order to ensure the overall risk management system is effective and consistent with the challenges across the local health economy. Key Risks We have identified the key strategic risks to the delivery of this Operational Plan. These risks are shown below and will be included in our Board Assurance Framework (BAF). The WLCCG Board have considered and are monitoring the mitigating actions for these risks as part of the BAF. Key Risks to the Delivery of the Operational Plan Failure to deliver CCG 2016/17 financial targets Failure to deliver the NHS Constitutional targets (A&E, cancer waits, RTT) BCT consultation process leads to delay in implementation Failure to implement BCT workstream to deliver 2016/17 milestones and outcomes Patient safety risk due to the urgent care system not working effectively Failure to successfully procure and mobilise integrated urgent care contracts Non-delivery of the urgent care vanguard programme Safe Staffing (nursing) concerns across LLR providers Failure of Federations / Multi-specialty community provider (MCP) to deliver ‘left shift’ Ability to recruit and retain a sufficient number of staff with appropriate skills Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 11 Programme Management Office (PMO) — Assuring Programme Delivery WLCCG has aligned its previous Operational Plan work-streams to the work-streams in the Better Care Together programme in order to increase cohesion and ensure we fully contribute to this important programme. Programme governance processes are being reviewed to ensure they provide the level of assurance the CCG needs whilst minimising duplication with the BCT PMO. The CCG PMO supports programme leads and assures the WLCCG Board, that delivery of the programmes in the CCG’s Operational Plan is on track. A Senior Responsible Clinician (SRC) who is a GP, a Senior Responsible Officer (SRO) and an Implementation lead are jointly accountable for delivery of the programmes, which are monitored on a monthly basis using PRINCE2 tailored project documentation and reported to the CCG Board. Equality and Diversity Based on the foundations laid in 2013/14 when we developed mechanisms to collate evidence across all areas of our activities to inform the Equality Delivery System (EDS2) grading process, we have continued to monitor our performance for people with any of the nine protected characteristics to help us discharge our duties under the Public Sector Equality Duty. We are also working to meet the needs of vulnerable and hard-to-reach people, including the homeless. In 2016/17, we will continue to expand our wider community and stakeholder engagement activities as part of our People Powered Health programme and review more detailed equality monitoring information from our main providers through existing contracting arrangements. All our programmes and projects complete an Equality Impact Assessment, and are working together with our colleagues across the Leicester, Leicestershire and Rutland health and social economy to ensure a consistent and joined up approach to EDS2 as part of the BCT programme. We already have a system in place to monitor workforce metrics and staff survey findings in partnership with our commissioning support service and the Picker Institute which can be directly used against the nine metrics in the Workforce Race Equality Standard. A Delivery Plan for 2016/17 is in place based upon our four equality objectives and progress is monitored and reported to the Quality and Performance Sub-Group. We will produce and publish our Equality and Diversity Annual Report in April 2016. Draft to NHS England 2.0 12 | National Context National Context The need for sustainable place based planning in a financially challenging environment has focussed West Leicestershire CCG on planning and delivery across the LLR footprint. This will be evidenced through meeting national requirements. The 2016/17 guidance requires us to produce: • A five year Sustainability and Transformation Plan • A one year Operational Plan • A one year Better Care Fund Plan jointly designed between Leicestershire County Council and West Leicestershrie CCG The NHS Planning Guidance Delivering the Forward View: NHS Planning guidance for 2016/17–2020/21 sets out how NHS England proposes the NHS budget is invested to drive continuous improvement and to make ‘high-quality care for all, now and for future generations’ into a reality. Sustainability and Transformation Plan Development Our developing five-year LLR Sustainability and Transformation Plan (STP) signals a move away from an annual planning process that has delivered incremental, organisational-specific improvement to a longer-term view that delivers transformational change across organisational boundaries. It will be led by a single leadership group of Chief Executives across commissioner and provider trusts in health and social care, with Healthwatch representing the views of our patients and the public. Links to the System Resilience Group will also be made via this leadership group, given the make-up of each group. This new approach to partnership and planning will act as a catalyst towards “place-based” clinical commissioning, enabling the CCG to work with partners to match our investment decisions with the needs and aspirations of our local communities. The focus of our STP will be on our system priority areas, identified as: urgent care, integrated care (covering our Better Care Fund), planned care, long term conditions, learning disabilities, mental health, dementia, children’s and maternity and end of life and fit strategically with the CCG’s overarching strategic objectives and operational priorities outlined later in this plan. The co-production of the 5 Year STP will enable the health and social care community across LLR to continue to plan together with confidence and set out the work of Better Care Together alongside the Better Care Fund and emerging new models of community placed based care in a way that demonstrates collaboration of partners across organisational boundaries. It will represent the combined strategy of East Leicestershire and Rutland CCG, West Leicestershire CCG, Leicester City CCG, the three Leicester, Leicestershire and Rutland Health and Wellbeing Boards and in doing so set the framework for joint working across health, social care and public health. We will be looking at the scale and pace of this work to ensure it meets our delivery requirements. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 13 This Operating Plan and the STP This Operating Plan sets out the West Leicestershire Clinical Commissioning Group plan for health care commissioning in 2016/17. It describes our vision and priorities based upon analysis of public health information and listening to our partners and local people. It maps out how the CCG will deliver the requirements set out in the 5YFV whilst maintaining our commitment to high quality services for all, whilst concurrently driving the delivery of transformative plans which will be outlined in the STP. Our work on the Primary Medical Care Plan and our Community Services Plan, plus urgent care transformation provides a firm foundation for development of the STP. This enables commissioners and providers to work together and dissolve the artificial barriers between prevention and treatment, physical and mental health. and historical silos of primary, community, social care and acute care. This will be supported by new models of contracting and commissioning. We are progressing at pace in the development of the LLR Sustainability and Transformation Plan (STP) through our existing collaborative structure of Better Care Together. • We have representation on the operational group formed to help develop the LLR STP with an established governance structure. This group will ensure that work is completed in line with the key dates given and include support from the National Team. • We are clear on the priorities for our system and will engage communities, individuals and staff in planning. • All programmes of work follow a specific project management, monitoring and reporting function, led by a Governing Body clinician and supported by a senior manager. Clinically-led Programme Boards covering LLR have been established, with clinical input from each CCG, tasked with delivery of these objectives. Leicester City CCG • Planned Care & Cancer • Children’s & Maternity West Leicestershire CCG • Urgent Care • Long Term Conditions • End of Life Care East Leicestershire & Rutland • Frail Older People • Mental Health • Learning Disabilities Responsibility for each work-stream follows our collaborative commissioning arrangements and is as follows: Leicester City CCG West Leicestershire CCG East Leicestershire & Rutland CCG Planned Care & Cancer Urgent Care Frail Older People Children’s & Maternity Long Term Conditions Mental Health End of Life Care Learning Disabilities Draft to NHS England 2.0 14 | National Context Our business planning and subsequent delivery processes have been enacted in the following ways: • each of our commissioning projects is informed by an initial review of the available clinical evidence, needs assessment, benchmarking and review of best practice using national and local resources such as NHS England’s Commissioning for Value packs and high impact innovation evidence • we will cross-reference our plans with current innovation opportunities as part of our long term planning and horizon scanning process • we will use CQUINS in order to lever the introduction of innovative practice within our existing network of providers • we will engage with and be led by NICE and for new technologies. • clinical work-streams have ensured their plans are mapped against knowledge gained from the Right Care Programme and Commissioning for Value packs and are clear on what will be delivered to make a change. As currently, delivery is monitored through clinically-led Programme Boards with LLR representation. Information is shared collaboratively acorss organisations via the Better Care Together Programme Management Office. In 16/17, each work-stream will report into a bi-weekly implementation group and a monthly LLR Partnership Board, to ensure specific focus is maintained on delivery of both patient outcomes and organisational priorities whilst aligning with emerging STP priorities. A monthly LLR Partnership Board meets to ensure specific focus is maintained on delivery of both patient outcomes and organisational priorities. The Better Care Fund Plan and the STP In 2015/16 the Leicestershire County Better Care Fund (East Leicestershire and Rutland CCG, West Leicestershire CCG and Leicestershire County Council) provided for £38m worth of care to be jointly commissioned locally on health and care to drive better integration of health services and improve outcomes for patients, service users and carers. This was used as a catalyst towards our vision for a modern model of integrated care, and enacting our own micro ‘place-based’ clinical commissioning programme with the wider context of our local STP. This operational plan demonstrates how in 2016/2017 we will build on our locally designed model of integrated care and how the services align to our wider strategic plan. The route of delivery will be partly through the Frail Older Persons Clinical Workstream and partly through the West Leicestershire CCG Integration Team. Focus will be promoting health and well-being and prevention, rather than illness. By 2018, we will have used the Better Care Fund to mobilise a modern integrated care model that will significantly reduce the demand for hospital services. The Better Care Fund will be a key enabler in the implementation of our STP. The picture below shows how we will work with other organisations in the system: West Leicestershire CCG has internal structures in place to support the production of our STP to produce a vision document for March 2016 and final plans by July 2016. Operational Plan The work-streams will address the Must Dos for the system. This Operating Plan sets out the West Leicestershire Clinical Commissioning Group plan for health care commissioning in 2016/17. It describes our vision and priorities based upon analysis of public health information and listening to our partners and local people. It maps out how the CCG will deliver the requirements set out in the 5YFV whilst maintaining our commitment to high quality services for all, whilst concurrently driving the delivery of transformative plans outlined in the STP. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 15 The nine ‘must dos’ for 2016/17 for every local system: 1 Develop a high quality and agreed STP, and subsequently achieve what you determine are your most locally critical milestones for accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View. 2 Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through implementing the RightCare programme in every locality. 3 Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. 4 Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through making progress in implementing the urgent and emergency care review and associated ambulance standard pilots. 5 Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. 6 Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission. 7 Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. 8 Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. 9 Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts. Draft to NHS England 2.0 16 | National Context A one year Better Care Fund Plan The Better Care Fund is a critical enabler to forward the integration agenda locally at a scale and pace that will drive the local health and social care system. In 2015/16 the Leicestershire County Better Care Fund (East Leicestershire and Rutland CCG, West Leicestershire CCG and Leicestershire County Council) provided for £??? worth of care to be jointly commissioned locally on health and care to drive better integration of health services and improve outcomes for patients, service users and carers. The CCGs and Leicestershire County Council used this as a catalyst towards our vision for a modern model of integrated care, and enacting our own micro ‘place-based’ clinical commissioning programme with the wider context of our local STP. In 2016/17, as outlined later in this plan, we intend to embed our locally designed model of integrated care, aligning the services to our wider strategic plan in order to deliver a new model of care promoting health and well-being rather than focussing upon illness and a model which can be replicated easily, as described in the 5YFV. By 2018, we will have used the Better Care Fund to mobilise a modern integrated care model that will significantly reduce the demand for hospital services. Sir David Nicholson outlined the key aims to be achieved through deployment of the Better Care Fund: • a reduction in the number of hospital admissions – working towards a 3.5% reduction; • a reduction in the amount of time people spend in hospital through the provision of better and more integrated community services including improved discharge processes – reducing delayed transfers of care from inpatient to home; • improved quality of life for people with long-term conditions and carers; • reduced reliance on long-term health and social care services through delivery of effective prevention and early intervention; • increased efficiency across the health and social care economy; • improving patient and service-user experience; • reducing the number of years of life lost by the people of England from treatable conditions such as cancer, stroke, heart disease, respiratory disease and liver disease. Draft to NHS England 2.0 17 | What our Local Information is telling us What our Local Information is telling us Local information meshes with national intelligence and priorities to allow us to tailor our work to the specific needs of West Leicestershire’s residents. Population Analysis The population of West Leicestershire Population growth Between 2012 and 2037 (25 years) it has been projected that the total population of West Leicestershire will grow by 16% to 434,000: • 187% increase in people aged 85 years and over • 56% in people aged 65–84 years • 9.6% increase in children and young people aged 0–24 years; and • 0.2% increase in the working age population West Leicestershire Population (2013) 376,100 Leicestershire Deaths (2013) Directly standardised death rate (DSR) per 100,000 population (2010–12): Leicestershire England average Births (2014) Live births/1,000 mid-year population 3,210 925.6 988.3 3,831 35.5 Population projections - % increase since 2012, NHS West Leicestershire (district based estimate) 150% % Difference in Value Age group < 25 yrs 25 - 64 yrs 100% 65 - 84 yrs >= 85 yrs Indices of Multiple Deprivation in West Leicestershire. See appendix A3. 50% 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 0% Life Expectancy at Birth In 2011–13, life expectancy at birth for males in West Leicestershire was 80.2 years and for females it was 84.1 years. This is significantly higher than the average life expectancy for England (79.9 years for males and 83.1 years for females). In the 12 year period from 2000/2002 to 2011/2013 life expectancy in West Leicestershire increased by 2.5 years for men and 2.3 years for women, an increase of approximately 2 months per year. Premature Mortality (death before the age of 75) In West Leicestershire under-75 mortality from the major killers is Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 18 showing a steady year-on-year reduction. Premature mortality from liver disease is the only major cause of death that is rising. Cause of death England Leicestershire West Leicestershire Cause of Death DSR Number of DSR DSR DSR 2011– Deaths 2011 Significance 2011– 2001– % Change 13 2011–13 –13 2011–13 13 03 to 2011–13 All Cancers 144.4 2289 131.1 Better 131.1 139.4 –5.9% 78.2 1185 68.5 Better 68.5 119.8 –42.8% 33.2 409 23.9 Better 23.9 32 –25.3% 17.9 255 14.4 Better 14.4 10.1 42.6% Cardiovascular Disease Respiratory Disease Liver Disease For trends in premature mortality see appendix A1 Healthy Life Expectancy Increasingly we look beyond life expectancy as a measure of health. Healthy life expectancy captures the degree to which people enjoy good health in their lives. In 2010–12 in West Leicestershire, Healthy life expectancy was 64.9 years for males and 66.7 years for females. The rate for males is similar to the England average (63.4 years) and the rate for females is significantly better than the England average (64.1 years). These are average rates for both males and females and therefore we know that a significant proportion of our population will already be affected by poor health before they reach retirement age. See appendix A2. Health Inequalities For 2011–13, the gap in life expectancy between the most deprived areas and the least deprived areas in Leicestershire as a whole was 6.2 years for males and 5.0 years for females.Appendix A3 illustrates the main causes of death that make up the life expectancy gap. This is driven by deaths from circulatory diseases (heart disease and stroke), cancer and respiratory diseases. Health inequalities are differences in health status between different population groups. Different levels of health needs in our population are driven by wider social inequalities such as poverty and social exclusion. All commissioning decisions and service plans need to reflect the requirements of vulnerable individuals and population groups. We need to make the most of opportunities to identify and intervene early with groups at risk, through strong partnership working and community involvement. In West Leicestershire CCG we have already made significant strides Draft to NHS England 2.0 19 | What our Local Information is telling us toward addressing the inequalities and the wider determinants of health through social prescribing and social seeding. See appendix A3. Population Growth The population growth patterns described earlier have major implications for the provision of health and social care services, especially for older people. Significantly greater numbers of older people with complex care needs will require input from all parts of the health and social care system. The proportion of the population in paid work is decreasing, while long-term needs are rising. This creates an infrastructure gap which is already partially bridged by people providing unpaid care informally. (see appendix A4). The trend is likely to continue. Carers will become increasingly important in the wider health and care systems. We therefore need to ensure that their health and wellbeing needs are met. Supporting people to live independently in appropriate housing is also key for the future sustainability of health and social care. The Leicestershire health and care communities are adopting a model of preventing, reducing and delaying need across the whole of life. This starts with building community capacity to empower people and communities to manage their own health and well-being needs and ends with having the right care and support in place to meet people’s treatment and longer term care needs. Prevent, reduce, delay Prevent Universal services, promoting wellbeing for the whole population. Reduce Targeted interventions for those at risk, or with established illness Delay Delaying the need for long-support and services. Offer the right Progressive planning — using a broad set of resources to meet need flexibly. Support See Appendix A5. Draft to NHS England 2.0 20 | What our Local Information is telling us What our population is saying: People Powered Health How we have engaged our population in West Leicestershire Using Experienced Led Commissioning (ELC) methodology we have identified the journey of care of approximately 3,000 members of our communities across the West Leicestershire area since 1 April 2015. We have sought to understand what matters most to patients, carers and health care professionals by capturing their stories. These insights influence our commissioning decisions. We have paid particular attention to frail and older people, and to community care in Hinckley and Bosworth. Our range of methods for gathering insights is illustrated below: Online survey Healthwatch Carers Reference Group Voluntary and community sector engagement Patient Participation Network Qualitative interviews Social media Monthly e-newsletter Mystery shopper Listening booth Exhibitions and Fairs Understanding the journey of care Complaints and general patient feedback Patient Experience For some people, experience of NHS care leaves them feeling more like a number than a person. Despite receiving the right care and medical treatment, the human element may be missing. The Experience Led Commissioning (ELC) approach is built around the idea that if we hear and understand people’s experiences, we will design better, more person-centred services that offer better care for our people. Key parts of the ELC approach are co-design events, where patients and their carers come together with health professionals to specify the care that the CCG will go on to commission. In undertaking this research we have been supported by a wide range of organisations including local authorities, Voluntary Action Leicestershire, Healthwatch Leicestershire, Alzheimer’s Society, Age Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 21 UK, Voluntary Action South Leicestershire, University Hospitals of Leicester, West Leicestershire Patient Participation Group Network. Research undertaken by other organisations including Healthwatch Leicestershire and Leicester Lesbian Gay Bisexual and Transgender Centre is also influencing our decision making. Some of the themes that have emerged include: People with complex care needs • Loneliness emerges as a significant issue, especially for those who live in their own homes. • People who live at home are significantly more depressed and unhappy compared with those in sheltered or supported accommodation. This is likely to lead to greater frailty and immobility in the future. • People do not perceive health services as proactive. • Transport and preserving mobility are a key concern for this group, especially for those living in their own homes. • Patients and family carers fear the future. • Clinical support and support from community organisations that build social connection are equally valued by this group. Family carers • Whilst some feel involved in decisions, family carers feel ignored by health services and are not coping with caring. They are not being involved in decisions and care-planning and so are unable to do their best work. They feel stressed and exhausted. Life is on hold for them. • Their relationship with those paid to support them and their loved ones is often difficult. They feel ignored and angry. • A significant concern is ‘life after caring’. Family carers say they need help to get back on their feet and rebuild their lives. Currently there is no support. • In particular they struggle to: ➔ Support their loved one to keep physically and emotionally well ➔ Coordinate their loved ones care ➔ Get information about benefits they are entitled to. • Family carers would like simpler explanations and information. • Investing in supporting family carers is likely to keep both them and their loved ones well and reduce demands on health and Draft to NHS England 2.0 22 | What our Local Information is telling us social care. • Family carers are not being supported to cope and co-ordinate care for their loved ones. • Compared to others, they rely more on home-help and community support as a point of contact. • They see support from health professionals as key to staying independent. They want improved access, empathy and support from health professionals. • Their own health issues get in the way of independence. • They feel exhausted and trapped and wish that caring played a less prominent role in their lives and they had more time for themselves. People living with long term conditions: • are more reliant on hospital teams for support • care for loved ones as well as dealing with own health issues; find this ‘keeps me going’. They want to feel more supportive • want to be more educated about their condition and supported to prevent crises in care • if they work, struggle to keep physically and emotionally well and want more support; working people have less positive relationships with healthcare professionals; talk more about waiting; feel NHS is overstretched. • if they do not work, have a closer relationship with GP and family; feel more resilient; see health as being about personal responsibility; focus more on car parking. People experiencing brief encounters • More explanation of tests and treatments before a visit would reduce confusion and frustration • Making it easier to navigate the hospital (especially the first time they go) would also improve the experience • Working people would like more support and follow up after treatment • People who do not work would like easier parking; more forward planning for their next appointment and a big focus on the right medication. People in community beds • Low points around the support they get before hospital stay and after; discharge planning is a mixed experience — leading to more Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 23 hospital stays • Main source of support is family, friends and themselves; GPs and nurses are also important • See staying independent as something they are responsible for themselves with family; a busy life matters — very self reliant • Feel restricted in hospital; would like to maintain more control e.g., use own medicines; be able to move around themselves and have more freedom • Preventing deterioration in physical health (especially walking) is extremely important for this group. They would like more support with this • They want more personalised care; more focus on best treatment for them — less on cost e.g., medication • Want more time and attention from nursing staff (basic care — toileting, etc.) • Find some doctors abrupt • Do not rate food in hospital This information has been bought together to form plans which address what matters to our population. Draft to NHS England 2.0 24 | What our Local Information is telling us Provider Landscape and Partnerships Nottingham Derby Providers and the landscape West Leicestershire CCG operates with two main acute and community services healthcare providers: Acute and Emergency Provider — University Hospitals of Leicester is the main acute provider for LLR. There are a number of points of particular relevance when looking at this provider: The Trust is in significant financial deficit, has significant challenges in cancer performance and A&E. UHL does have improved performance in RTT. They have a clinical strategy to operate from two sites instead of three. UHL is the largest teaching hospital in our area. Our patients access a wide range of services from other providers, particularly Burton, Derby, George Elliot and UHCW. Community Services and Mental Health — Leicestershire Partnership Trust (LPT) provides services for Mental Health & Learning Disabilities patients. We also commission community nursing and rehabilitation teams, through a proactive care approach, which aligns with our four federated localities. Currently, LPT is delivering against CQC action plans and has issues around staffing and financial difficulties. Service Development Plans are in place to address data issues. Timeliness of improvement is being monitored by commissioners. There are few places in Leicestershire for PICU patients and many are placed out-of-county along with other mental health in-patients. There are plans to address this through increased provision of crisis and out-of-hours care. LPT has incurred Financial penalties re non-compliance in 18week RTT. Charnwood Burton North West Leicestershire Hinckley & Bosworth UHL George Eliot Nuneaton UHCW Coventry Acute patient flows from West Leicestershire. Arrow weights are proportional. GP Practice GP Branch Use of out of county acute services are valued at £46.281m, for 2016/17 a forecast 2.68% increase from 15/16. Primary Care General Practitioners — West Leicestershire GPs are supporting our practices in the development of four legally constituted GP Federations. The federations will enable a strong primary care orientation to the delivery of patient pathways across all settings of care. There is an increasing demand for primary care. Partnerships The CCG recognises that alignment between the one and five year plans and the Better Care Fund strengthens our capacity to deliver transformative change in these areas and will result in a sustainable high quality system for the citizens of West Leicestershire. We will deliver this by building upon the strong partnerships and leadership across our local economy, with General Practitioners, community providers and our communities, whilst concurrently keeping a focus on delivery of NHS Constitution and Mandate standards. West Leicestershire CCG has developed this One Year Operational Plan and aligned to this, our Better Care Fund Plan, to begin delivery of the transformative change required across the priority areas identified, across organisational boundaries. The four federated localities. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 25 The ‘Better Care Together’ Programme This programme sets out the vision for the LLR health and social care system and is designed to deliver three key outcomes: 1 improved LLR patients’ health and wellbeing 2 safe, high quality services restructured into the most efficient and effective settings 3 an enhanced quality-of-care and cost reduced to within allocated resources. Across LLR, the eight clinical workstreams have been developed through our Better Care Together Programme over the last two years. Full delivery of the programme will involve a shift in how and where health and social care are delivered. This will see the following: • place-based models of care • health and social care services becoming more integrated • physical and mental healthcare becoming more integrated • an expanded primary, community and social care offering reshaped to support more care closer to home • acute care services provided from a smaller estate footprint, where services focus more on specialist care, teaching and research • a shift in the emphasis of care from treatment to prevention • an overall health and social care estate reconfigured to be more effective. This whole-system change is being delivered through a set of clinical and operational work-streams. Alongside Primary Care developments, it represents a new operating model for the delivery of health and social care services for West Leicestershire and the wider LLR system. It will also address the nine mandated ‘must do’s’ outlined in the planning guidance. The CCG fully embraces the national agenda for innovation and research and has established a number of ways of ensuring that it commissions innovative services informed by researchand evidence-based practice. Delivery of the programme will see health and social care services becoming more integrated, physical and mental healthcare becoming more integrated, an expanded primary, community and social care network reshaped to support more care closer-to-home, acute care services provided from a smaller estate footprint, with services focussed on specialist care, teaching and research, a shift in the emphasis of care from treatment to prevention, and an overall health and social care estate reconfigured for effectiveness. The Better Care Fund: West Leicestershire CCG, the County Council and local NHS will work Draft to NHS England 2.0 26 | What our Local Information is telling us closely with partner organisations in district councils, the police service, the criminal justice system, the voluntary sector, the private sector, local community groups, and programmes such as Supporting Leicestershire Families. We recognise that provider organisations such as University Hospitals of Leicester NHS Trust also have a major part to play in achieving our goals. Voluntary sector Voluntary sector organisations (VSCs) are key stakeholders within the local health economy and wider community. They have a wealth of knowledge and expertise in the services they provide. They offer support to individuals outside formal commissioning routes and bridge gaps between professional support agencies. The CCG values this and contributes through grant agreements. Each supported voluntary sector organisation is to be aligned to specific Better Care Together work streams which will enable review to ensure that deliverables and funding support the aims of the CCG, achieving better outcomes for residents. In addition the voluntary sector offers a hub of experience around specialisms and supports the delivery of the Better Care Together in the wider community. Review of CCG Mental Health Grants to Voluntary Organisations The three NHS CCGs that commission health services across Leicester, Leicestershire and Rutland have reviewed the funding they provide to voluntary and community sector organisations which support people with mental health needs. This review was carried out as part of our work to implement the Better Care Together Five Year Strategy for mental health. This strategy recognises therole of the voluntary and community sector in supporting resilience and recovery of patients and in supporting carers. These organisations offer, among others, counselling, advocacy, group support, advice on practical matters such as housing and finances and support with education and employment opportunities. As part of this review, the CCGs wanted to hear from service users and members of the public, to understand what aspects of voluntary and community sector care are most important to them. The engagement period ran from 30th August to 2nd September 2015. Strategic Context An underpinning principle behind the review is to increase the capacity of individuals and communities to avoid illness and recover if they become ill. These overlapping objectives are dependent on mobilising community capacity, and enabling people to use mainstream resources where possible. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 27 Evidence indicates that a visible network from which people access resources and which stimulates communities to develop is essential. Mobilising the voluntary sector is vital to realising this ambition. The Review In addition to the review process, a series of stakeholder workshops in August and September 2015 concluded that there is: • A need to align CCG grants with strategic objectives • A strong opportunity for greater alignment across health and social care • An appetite within communities to develop support, enabling people’s independence outside of statutory primary and secondary care services • A strategic need to develop locality based recovery networks and a clear and accountable role for VSC organisations. During 2016/17 a locality, outcomes-based specification will be coproduced with voluntary sector groups and service users. The Health and Wellbeing Board The Health and Wellbeing Board’s role is crucial. It will to seek assurance that all commissioning plans and budgets within the local system, including any pooled budgets, are used effectively by commissioning partners to achieve the outcomes set out in Leicestershire’s Health and Wellbeing Strategy: this is being refreshed for 2016/2017. The emerging Health and Wellbeing Strategy for Leicestershire will identify local priorities for promoting health and wellbeing, within which ‘top priorities’ will be made explicit where we feel progress is required immediately. This strategy is driven by the Joint Strategic Needs Assessment (JSNA), an overarching assessment of the health and wellbeing needs of our population across the wider health and social care economy (undertaken jointly by the local National Health Service and County Council). This is currently being reviewed by local partners and will contribute to the development of Place Based planning and the Sutainability and Transformation Plan (STP). The Health and Wellbeing Board is also to seek more integration across NHS, public health and social care services, and provide a level of assurance and challenge across the system in this regard. The governance structure, which oversees the Better Care Fund, is as below: Draft to NHS England 2.0 28 | What our Local Information is telling us Leicestershire Health and Wellbeing Board Leicestershire Integration Executive (Commissioners and providers) LCC Cabinet Integration Performance and Finance Group (Section 75/pooled budget-commissioners only) CCG Boards Integration Operational Group Step Up/ Step Down Falls Integrated Crisis Response Frail Older People Assessment Unit Integrated Reablement Residential Reablement Integrated Discharge Help to Live at Home Unified Prevention CCG Lead Integrated, proactive Carers case management for First Contact people with long term Local Area Coordination conditions Lightbulb Housing Project Assistive Technology Pilots of 7 day working Autism Hub in primary care Mental Wellbeing Dementia Care Act (preventative elements) Adult Social Care Lead Adoption of NHS Number Locality Integrated Working project The Health and Wellbeing Board will be key in developing the five year Sustainability and Transformation plan. Enabling delivery in partnership Multispecialty Community Providers are a new type of delivery model, integrating primary and community care providers into new and efficient organisations or alliances capable of delivering a better patient experience, better population health and more efficient use of resources. This will mean throughout 2016/17 services will be integrated to provide a core offer for patients closer to home with increased availability of some specialist services in the community. Alliance Contract This is the contract in place for commissioning of planned care services delivered in the community. This is an alliance of primary care providers, LPT, UHL and Commissioners. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 29 Quality and Commissioning Intelligence We have identified quality concerns in our LLR providers as follows: • University Hospitals of Leicester — Emergency Department under-performance against national targets: quality concerns regarding staffing and timely assessments, which have resulted in a CQC section 31 ruling, Cancer Performance: quality concerns regarding waiting times to treatment, and Referral to Treatment Times under-performance • Leicestershire Partnership Trust — staffing concerns at the Bradgate Unit and Mental Health Services for Older People • Dementia Diagnosis — under-performance for patients on a dementia register • EMAS — under-performance with national targets for response times, ambulance handover and turnaround delays to UHL ED , and staffing concerns relating to recruitment of paramedics • Two WLCCG General Practices have been under CQC special measures regarding lack of robust clinical governance, and patient safety concerns • C-Difficile numbers in excess of WLCCG’s primary care target. Our actions for improvement included: • Risk Summits in collaboration with NHS England, Trust Development Authority, Healthwatch, CQC and providers • Quality Surveillance Groups • Board to Board meetings with providers • Oversight groups to monitor improvements and progress against action plans • Quality Visits by LLR commissioners to ensure quality improvements and changes in practice • Deep Dives regarding provider performance and quality concerns, reported to the WLCCG Quality and Performance Sub-Group • Monitoring of provider incidents, serious incidents, complaints and patient experience We have achieved quality improvement in the following: • CNCS Out of Hours Services —C QC rating in November 2015 of Good following a previous inadequate rating and being in special measures regarding patient safety and corporate governance concerns • Improving Access to Psychological Therapies (IAPT) — where we have now achieved the access target of 15%. Draft to NHS England 2.0 30 | What our Local Information is telling us Our performance in delivering improvements to our patients How the CCGs performance is measured We have a responsibility to deliver improved services, maintain and improve quality, and ensure better outcomes for patients. This includes delivering key Mandate requirements and NHS Constitution standards, and ensuring we are meeting standards for all aspects of quality, including safeguarding, and digital record keeping and transfers of care1. This focus on quality, performance and outcomes is continuous throughout the year, and is monitored and scrutinised by the CCGs internal governance and collaborative contracting mechanisms and our monthly performance reports are published on our website. We also regularly meet with NHS England as part of our assurance process to discuss our key performance issues and progress of actions to address them. Our main performance challenges and what we are doing about them 2015/16 has seen significant performance challenges both nationally and locally with respect to key constitutional standards. The key quality and performance concerns in our LLR providers include the following: • University Hospitals of Leicester ➔ underperformance against the A&E four hour wait, 62 day cancer waiting times and 62 day backlog and a growing incomplete RTT backlog ➔ quality concerns regarding staffing and timely assessments, which has resulted in a CQC section 31 ruling • Leicestershire Partnership Trust ➔ staffing concerns at the Bradgate Unit and Mental Health Services for Older People • EMAS ➔ underperformance with national targets for response times, ambulance handover and turnaround delays to UHL ED , and staffing concerns relating to recruitment of paramedics • 1 Nottinghamshire Healthcare ➔ IAPT access underperformance [insert footnote for NHS outcomes framework etc] Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 31 • Primary Care ➔ Two CCG General Practices have been under CQC special measures regarding lack of robust clinical governance, and patient safety concerns ➔ Dementia Diagnosis underperformance for patients on a dementia register • C-Difficile numbers in excess of the WLCCG target for primary care Our actions for improvement in light of these concerns have included: • Risk Summits regarding provider quality concerns in collaboration with NHS England, Trust Development Authority, Healthwatch, Care Quality Commission and providers (for system-wide urgent care providers and CNCS) • Quality Surveillance Groups focused on specific provider quality concerns (for UHL, EMAS, LPT, care homes, GP risk logs) • Board to Board meetings with providers (for UHL, LPT and CNCS) • Provider executives meeting the CCG Governing Body (for IAPT) • Oversight groups to monitor improvements and progress against action plans (for urgent care: UHL and EMAS, CNCS) • Quality Visits by LLR commissioners to ensure quality improvements and changes in practice (UHL, LPT, CNCS, EMAS, Derbyshire Health United, Loughborough Urgent Care Centre, Arriva, Birstall Medical Centre, Barrow Health Centre) • Deep Dives regarding provider performance and quality concerns, reported to the WLCCG Quality and Performance Sub-Group (EMAS, IAPT, Cancer, Dementia Diagnosis) • Monitoring of provider incidents, serious incidents, complaints and patient experience • Scrutiny and commissioner sign off of recovery action plans (RAP) for urgent care, cancer / RTT, diagnostics, EMAS, CNCS. As a result of our actions and robust monitoring of quality and performance of our providers via their remedial action plans we have achieved quality improvements in the following: • CNCS Out of Hours Services — CQC rating in November 2015 of Good following a previous inadequate rating and being in special measures regarding patient safety and corporate governance concerns • Improving Access to Psychological Therapies (IAPT) — where we have now achieved the access target of 15% The plan for recovery of key constitutional standards is shown below Draft to NHS England 2.0 32 | What our Local Information is telling us Standard / Area Key actions Recovery by Minimise presentations from primary and community care to LRI ED assessment services through maximising use of alternatives such as ICS, AVS and EMAS diverts A&E 4 Four Hour Wait Remodel the front door to better April 2016 manage patient flow - To ensure walk in patients at the LRI campus are assessed and streamed direct to the most clinically appropriate service Maximise forward planning for patient discharges (TTO, patient transport etc) 62 Day Cancer Waiting Times and 62 Day Backlog Reducing Incomplete RTT Backlog Diagnostics Six Weeks Wait Nurse staffing at UHL Ambulance Response Times Ambulance Handovers Further rollout of patient and GP communication to streamline referrals Operational group robust confirm and challenge sessions with individual tumour sites at UHL Maximise use of Alliance and private providers (ENT / Gastroenterology) Utilise additional endoscopy and MRI capacity Implement NHSIQ rapid improvement cycle workshop actions July 2016 March 2016 March 2016 UHL Reviewing and flexing staff levels UHL working with DMU on further student cohorts and conversion courses Maximise use of mobile Directory of Services by EMAS crews to source alternatives to ED conveyance (including OPU, LUCC) tbc tbc Review assessment bay staffing to check matching to demand and staggering of shift changes and breaks. Redefine the role of the HALO and senior decision makers in ED tbc Open new ED department at LRI site Safe Staffing at LPT(Bradgate Unit and MHSOP) IAPT Access Senior matron and team manager staffing reviews (every Mon and Thurs) Additional staff released from temporary tbc closure at the Herschel Prins Unit for 6 months from Jan 2016 Resolve recent recruitment and staffing issues affecting capacity (training PWPs, maintaining agency staff for cover etc) March 2016 Increase referrals (primary care and self care) Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 33 Our plan for achieving new performance targets Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. The Right Care Programme We have explored the information from the NHS Right Care programme to help drive QIPP, reduce unnecessary variation in practice for our patients and support the direction of our workstreams. We sought support from our colleagues at GEM CSU to interpret the data and shared headlines with managerial and clinical leads on Cancer, Emergency Care, LTCs, Mental Health and Frail Older People to ensure plans address inappropriate variation. Our Clinical Board Members have helped us identify what we are already doing in areas of variation, what we will be doing in the short term and areas we need a longer term focus on. For example, we have more admissions than our peers for those over 75years who stay in hospital for less than one day. In 2015 we commissioned schemes of support for Care Homes, an Older Persons Frailty Unit to provide an alternative to hospital admission, education around the falls pathway and an Integrated Crisis Response Service ). Our plans include increasing access to services through a single point of access and years two and three of the STP will focus on increasing utilisation of services as an alternative to admission, ensuring capacity increases with demand. The Commissioning for Value Packs released in 2013 identified key areas in terms of quality and outcomes, acute and prescribing spend and spend against quality and outcomes where West Leicestershire CCG could reduce inefficiencies and therefore improve the pathway for patients. These areas are Circulation Problems (CVD) Endocrine, Nutritional and Metabolic Problems Problems, Cancer & Tumours, Respiratory System Problems and Genitourinary, Neurological System Problems. Work is ongoing to use information from the updated Commissioning for Value Packs (released January 2016). The Atlas of Variation 2015 identifies areas where WLCCG’s performance is below that of its most similar CCGs. This information Draft to NHS England 2.0 34 | What our Local Information is telling us is is shown below and will be used in the development of the STP. Our performance team have worked to identify areas where historic data or proxy data is available from national sources (highlighted in bold in the table below) to help us measure progress. Condition Areas of performance below peer group People aged 15-99 years who survived one year after being diagnosed with any cancer Cancer Rate of colonoscopy procedures and flexisigmoidoscopy procedures Rate of computed tomography (CT) colonoscopy procedures Problems of the Respiratory System Cardiovascular Family of Diseases — Diabetes Percentage of patients with COPD who had influenza immunisation in the previous year Asthma emergency admissions to hospital for adults People with Type 1 and Type 2 diabetes in the National Diabetes Audit (NDA) who received NICE-recommended care processes People with Type 1 and Type 2 diabetes in the National Diabetes Audit (NDA) who met treatment targets for HbA1c, blood-pressure and cholesterol Reported to expected prevalence of hypertension Cardiovascular Family of Diseases — Heart Reported to expected prevalence of coronary heart disease Mortality from coronary heart disease in people aged under 75 years Mental Health Disorders Problems of the Musculo-skeletal System Care of Older People People who are recorded in GP registers of severe mental illness New cases of psychosis in adults who received early intervention psychosis services Mean length of stay for emergency admission to hospital for fractured neck of femur (FNOF) Length of stay of less than 24 hours for people aged 75 years and over following an emergency admission to hospital Admission to hospital for people aged 75 years and over from nursing home or residential care home settings Percentage of re-admissions to hospital following an elective Care of Mothers, Caesarean section that occurred within 28 days of discharge Babies, Children and Mean length of stay (days) for asthma in children aged 0-18 Young People years Critical Care Elective admissions for abdominal aortic aneurysm (AAA) or aorto-bifemoral bifurcation graft procedures that had planned access to adult critical care. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 35 Draft to NHS England 2.0 36 | Maintaining focus on the essentials Maintaining focus on the essentials Quality Commissioning for the highest levels of quality will continue to be central to our work in 2016–17. We are currently in the process of reviewing and updating our quality monitoring mechanisms that include Quality Schedules and Commissioning for Quality and Innovation Schemes (CQUINS) to ensure we have a broad range of indicators that drive improvement in our commissioned services. In addition, we will take the learning from national reviews of NHS healthcare and local experience to inform our overarching approach to quality that will be centred on the following: • Preventing Problems • Detecting Problems Quickly • Taking Action Promptly • Ensuring Robust Accountability • Ensuring Staff are Trained and Motivated • Safety & Openness. Our 16/17 quality objectives are: • Putting patients and their assessed needs at the centre of commissioning decisions • Commissioning services that are safe, clinically effective and provide a positive experience for patients • Using robust systems and processes to deliver safe services and positive experiences • Focusing quality measures on structures, processes and most importantly patient outcomes • Supporting collaborative arrangements with other health commissioners and wider stakeholders • Demonstrating that our leadership and governance arrangements meet statutory requirements and responsibilities. Our key work areas will include the following: • Patient safety • Infection Prevention and Control • Improving prescribing • Patient experience • Our work with vulnerable groups Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 37 • Continuing Health Care • Learning Disabilities: Transforming Care Programme • Care Homes • Safeguarding • Contract Quality review and monitoring • Commissioning for Quality and Innovation (CQUINs). CQC ratings for providers: ensuring safety and quality We aspire to improve safety and quality in our provider organisations as judged by the CQC. Our ambition is that no NHS trust or GP practice will be rated overall ‘inadequate’. We will continue to build on our work in sharing the learning and themes from current practices with inadequate ratings and in special measures to all our practices and at locality meetings. We will support practices with learning via the CCG Protected Learning Times events that focus on robust clinical governance: clinical leadership, accountability and responsibility, clinical supervision, delegation of care, evaluation of care, learning from incidents and changes to practice, staff education and training, policies and guidance, and evidence-based practice. Quality Premium Awaiting info —this will tell us if we need to set a local priority Patient Experience Our aim is to ensure that our patients and carers get a high level of care no matter what type of care they are receiving. In order to evaluate their experience, we will promote active and open channels of communication so that patients and carers are given the opportunity to express their opinions, share their stories and make recommendations for improvement. We will work with the People Powered Health Team at West Leicestershire CCG using Experience Led Commissioning. Safeguarding We will continue to ensure that frontline staff know how and when to raise a safeguarding concern and that we have effective systems in place to safeguard our most vulnerable patients. We will work with providers to ensure that we have multi-agency collaboration and communication in place to ensure that vulnerable patients receive personalised care and that their privacy and dignity are maintained. We will continue to monitor safeguarding via specific KPIs within our provider quality schedules that will be reported at the contract quality review meetings, and shared with our local safeguarding boards. We will ensure full participation in the Local Safeguarding Children’s Draft to NHS England 2.0 38 | Maintaining focus on the essentials Board and Safeguarding Adult’s Board. We will continue to progress work to identify and redress Child Sexual Exploitation (CSE) & Female Genital Mutilation (FGM). We will maintain joint working with the LA regarding SEND. We will focus Continued Professional Development (CPD). Priority Areas for 16/17 Patient Safety Patient safety is at the heart of clinical decision making and service planning. We will undertake the following actions in 2016/17: • Promote a positive culture where we learn from incidents and embed learning across organisations. We will continue to encourage the sharing of good practice among providers. Over the past year the LLR CCGs Serious Incident Sign Off Group has identified themes from serious incidents that have resulted in our providers focusing on improvement in falls, information governance, and risk assessment in mental health. • Detailed Key Performance Indicators (KPIs) will be included in our contracts with providers to ensure robust management of serious incidents and we will monitor these to ensure learning from investigations is embedded across organisations. • We will conduct case reviews with providers to ensure there are robust action plans to eliminate avoidable C-Difficile infections. • We will continue to focus on the overuse of antibiotics by monitoring infection control and prevention. We have infection prevention and control special nurses who evaluate reviews from these cases, raising questions with regard to why a specific antibiotic was used, whether or not it was appropriately prescribed and whether or not the infection was avoidable in the first instance. • Actions for improvement for C-Difficile will be led by the CCG Medicine Optimisation Team and via the CCG C-Difficile Action Plan. The team will monitor General Practice prescribing of antibiotics; ensure effective learning and sharing of information from case reviews and provision of education and training for practice staff. • We will be undertaking work in respect to promoting sepsis awareness across Primary Care and the use of the Sepsis Toolkit. Further, we will: • Work with our colleagues across public health, primary and secondary care, and social care on reducing key infections such as community acquired pneumonia, urinary tract infections and sepsis that would benefit from a ‘joined up’ approach to prevention, recognition and management. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 39 • Provide a focus for improvements in the recognition, management and reduction in HCAIs in order to manage the risks associated with antimicrobial resistance and protect the health and wellbeing of the public, as well as to reduce health care costs. • Continue to assess each Clostridium difficile infection cases individually to determine whether they are associated with a lapse in care. Where lessons need to be learnt we will work with clinicians and our providers to support a focus on clinical learning to improve patient safety. • Through the CCG Medicines Optimisation Team, we will monitor General Practice prescribing of antibiotics to reduce the over use and inappropriate use of antibiotics in primary and secondary care in order to reduce the spread of antimicrobial resistance. • We will ensure Protected Learning Time events for GPs and practice nurses on HCAIs and antimicrobial prescribing to provide education and training and share good practice. • Through our commissioned Specialist Support Service for Care Homes we will ensure training and education in infection prevention and control, and medicine optimisation via support of our Care Home Pharmacist to reduce incidents of HCAIs. • We will promote and drive the recruitment of additional antimicrobial champions to raise awareness and understanding of the general public of appropriate use of antibiotics. We will continue our ambition to increase the level of recording of incidents and serious incidents in primary care. We will continue the roll out of Datix and will also continue to encourage practices to use the LLR GP Issues Log, which allows practices to raise concerns or incidents regarding other LLR providers and that will be followed up by the LLR Patient Safety Team. Research and Innovation The CCG meets its statutory responsibilities to promote research and innovation, to use research evidence and to follow policy with respect to excess treatment costs for non-commercial research studies. The participation of local patients in funded research is supported through an R&D Office which hosts a service for the three Leicester, Leicestershire and Rutland (LLR) CCGs. The LLR CCGs support the goals for research and growth in the Government’s mandate to NHS England through a series of partnerships and networks linked by research, innovation and an East Midlands geography. Partners include the CLAHRC, the AHSN, and the regional Clinical Research Network (CRN). In addition, all East Midlands NHS R&D Leads, and Primary Care Research and Innovation Leads meet regularly to discuss research across the region, resolve any issues and share developments in the Health Research Authority’s Draft to NHS England 2.0 40 | Maintaining focus on the essentials (HRA) incoming Approval Process for research. Collaborations such as this will be essential through 2016–17 and beyond to ensure a coordination of research management and governance transition, and to enable a collective, regional, response to national consultations about research. HRA Approval will necessitate increased communication between the CRN as a Study Support Service, multiple sites in primary care, CCG R&D and especially new relationships with research sponsors, predominantly universities, but also commercial sponsors, nationally. R&D will continue to work with our three local university partners, and there are three funded Biomedical Research Units locally (BRUs): Leicester — Loughborough Diet, Lifestyle and Physical Activity; Cardiovascular; and Respiratory, all of which conduct clinical research relevant to local health priorities. Since 2014, the CCGs, CRN and general practices have worked together to support the Cardiovascular BRU in recruiting over 15,000 patients to the Genetics and Vascular Health Checks research study (GENVASC), extending the study beyond Leicester and into practices across all LLR areas. GENVASC study participants are making a significant contribution to the national research endeavour. In 2016–17 more patients will be encouraged to join this project which is investigating genetic links to CVD. The success of recruitment into primary care studies—due in no small part to GENVASC and to multiple studies conducted by the Leicester Diabetes Centre—has resulted in, each of the three LLR CCGs being eligible to receive Research Capability Funding from the National Institute for Health. Alongside the above, in 2016–17, the CCGs will continue to raise awareness among patients and the public, so they are informed of research studies that are relevant to their health needs, and of the opportunities available for them to become involved. The CCGs’ R&D office facilitates the approval of Excess Treatment Costs (ETCs) for patients taking part in research funded by Government and research charities. In 2016–17 there will be greater focus on engagement between providers and commissioners as per new ETC guidance, with the aim of streamlining an approval process to be agreed by all three CCGs. Ongoing liaison between service commissioners and researchers, not just about ETCs, but about research studies and prospective programme grant applications, is essential if health care challenges are to be identified and solutions developed which can be implemented in increasingly integrated health care settings. New approaches to NHS commissioning and service delivery should be reflected in new approaches to the subject matter and design of research. System re-design, technology and innovation will be supported in the design of local research studies, as will research which reflects the recommendations of the Accelerated Access Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 41 Review for patient involvement and for better use of digital services and technology. If LLR CCGs are to access robust research (and evaluation) evidence to inform commissioning decisions, more participants from local authorities, charities, the voluntary sector, industry and independent providers will become increasingly relevant. This will be promoted and encouraged as will greater emphasis on feedback of results and outcomes from research. In 2015 the LLR CCGs became active members of the Leicestershire, Improvement, Innovation and Patient Safety Unit (LIIPS) which connects local universities, health professionals and patients to improve care and treatment and share organisational learning about what works. The LIIPs is aligned to the plans for system wide improvement across the whole health economy represented by the Better Care Together Programme and its associated work-streams with the intention of working together on projects that are of strategic relevance to NHS collaborators. A research and evaluation work-stream is developing in 2016. We recognise that new models of commissioning, while challenging, will afford new opportunities for research. Co-commissioning, and the development of federated GP practices, practice hubs, and extended practice hours will lead to fundamental changes in how and when patients are recruited to research in primary care settings. In 2016–17, increased research recruitment and activity will be promoted as these ‘larger provider sites’ are developed; activity that meets the challenges of a complex NHS landscape and studies which, in their subject matter, address the LLR CCGs’ priorities for health. Performance CCG performance against national performance measures are described below with risk and recovery plans. Of the nine “Must Dos” in Delivering the Forward View: Planning Guidance 2016/17–2020/21, five relate to performance — Emergency Care (A & E and Ambulance waiting times), RTT, Cancer waits, mental health (IAPT and Dementia Diagnosis), Learning Disabilities. These have been addressed in our clinical work-streams. Improvements from last year: • IAPT access from 12% to 15% (ytd Oct 15) • IAPT waiting times have decreased • RTT (incomplete) 95% to 96% • Overall improvement of quality of GP and nurse consultations from 432/500 to 435/500 • One year survival from all cancers has increased from 67.4% to 68.3% (national average is 68.8%). Draft to NHS England 2.0 42 | Our local operating delivery model Our local operating delivery model To provide better care, and to do it affordably, we must increase the proportion of care we provide in local communities and people’s own homes. Inappropriate use = doing things where they could be done instead of where they should be done. 0 Self care and prevention 1 Primary care 2 Enhanced routine care 3 Urgent care and crisis response 4 Emergency and acute care Left shift = moving care from where it could happen to where it should happen. Currently, acute services are used too often when other forms of care would be better, reflecting a mismatch between need, setting, and provision. Many admissions to hospital and attendances at A&E are for conditions that would not need hospitalisation if earlier proactive management in the community had been in place. Nationally and locally, whenever patients feel that they are unable to access primary care, we see a rise in the pressure on urgent and emergency services. Our intention is to redress this through an accessible range of services out of hospital that respond to the planned and unplanned needs of patients. Our ambition is to develop strong, sustainable, person-centred and integrated community services which meet future demand, support the LLR Better Care Together (BCT) 5 year strategy, and improve outcomes for our patients. To do this we are making stepped changes to community-based services so that avoidable pressure on acute hospital is reduced. The CCG’s vision for integration is health and social care teams, supported by secondary care specialists, clustered around groups of GP practices within three identified districts—Charnwood, North West Leicestershire and Hinckley and Bosworth. These will work toward joint outcomes, and have the capacity and capability to accommodate a left-shift of activity from the acute sector. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 43 Nottingham University Hospitals NHS Trust Derby Teaching Hospitals NHS Foundation Trust North West Leicestershire Loughborough Hospital Loughborough Urgent Care Centre Burton Hospitals NHS Foundation Trust Charnwood Coalville Community Hospital Hinckley & Bosworth University Hospitals of Leicester NHS Trust Hinckley and Bosworth Community Hospital Hinckley and District Hospital George Eliot Hospital NHS Trust ncy Emergency e care and acute Urgent care a and spons crisis response Enhanced nced routine e care mary Primary care Self care and revention prevention 0 1 2 3 4 Above: Settings of care diagram (“Keogh” diagram) The “Keogh” diagram, based on Sir Bruce Keogh’s review, identifies five settings of care, from level 0, self care and prevention, through to level 4, emergency and acute care. The overlay triangle shows how the vast bulk of activity should be at the left hand side of the diagram. Although there is overlap, especially at levels 2 and 3, the five settings broadly reflect our four forms of provision in this plan, being self-care, primary care, Multispecialty Community Provider care, and acute hospital care. Multispecialty Community Providers (MCPs) are integrated teams working in a defined district, incorporating community hospitals, clinical teams, GP specialists, and secondary care specialists. University Hospital Coventry and Warwickshire NHS Trust These teams will create a step change in integrated and proactive care planning, particularly for frail older people and people with Long Term Conditions (LTCs). With primary care, they will offer services on a seven-day basis. This will provide a safe, effective, patient-centred alternative to hospital care, always available. Our model of care takes the insights from the Keogh diagram, which identifies five abstract settings of care, and makes them concrete. By creating a ‘place for every setting’, we are building appropriate use and appropriate care into our structures. For this we are developing Multispecialty Community Providers (MCPs, see below and side bar) at the district level, incorporating our existing community hospitals in Coalville, Loughborough and Hinckley. Each of these will serve their districts, enabling in-hospital but nonacute care, as well as urgent care and crisis response, to take place closer to people’s homes. For local people, this will mean: • Self-care at home • Primary care at their GP practice • Enhanced routine care through the Multispecialty Community Provider • Urgent care and crisis response through the Multispecialty Community Provider • Emergency acute care and specialist acute services Draft to NHS England 2.0 44 | Our local operating delivery model Our aim will always be to provide care as close to home as possible based on what is safe, effective and person-centric. GPs are expertgeneralists. With their teams, they coordinate care and ensure that patients are in the right setting of care, taking all of their health conditions into account. This means that some patients at some times will be admitted at an escalated setting of care because of the risks inherent in their combination of conditions. Integrated out-of-hospital care will mean that GPs, specialists, community and social care providers will increasingly work from the same physical buildings, which will be primary care and community sites. This means a cultural change from the way the NHS has traditionally approached the boundaries of acute and non-acute care. Implementing the Model In 2014 WLCCG worked closely with our member practices and stakeholders to develop a local strategy and plan for primary medical care that outlines the system change required by BCT and the integral role of general practice. This document sets out our vision and ambition for primary care over the next 3–5 years, in which general practice is the foundation of a strong, vibrant, joined-up health and social care system. This new system is patient-centred, engaging local people who use services as equal partners in planning and commissioning. The result will be high quality, safe, needs-based care. We will achieve this through expanded but integrated primary and community health care teams which will offer a wider range of services in the community. Access to rapid diagnostic assessment will increase and patients will be able to take greater responsibility for their own health. “Traditional”—the patient travels to where the clinicians are, often visiting several different settings. “Integrated”—GPs, specialists, community and social care providers work out of the same building, so that patients visit only the single setting of care appropriate for them. The Primary Medical Care Plan is the foundation for sustainable and excellent primary care among our member practices in West Leicestershire. It shapes our plans for 2016/17, allowing us to achieve the 2020 vision set out in the planning guidance. Building on the direction set out in the Primary Medical Care Plan, the CCG has also developed a Community Services Plan which sits alongside and responds to the NHS Five Year Forward view. It sets out how community services are to be redesigned and new models of care developed within the context of local and national drivers. Multispecialty Community Providers At the heart of our Community Services Plan is the development of Multispecialty Community Providers (MCPs). This is a new type of delivery model, integrating what, to date, have been relatively poorly coordinated primary and community care providers into new and efficient organisations or alliances capable of delivering on the “triple aim”—a better patient experience, better population health and more efficient use of resources. The Primary Medical Care Plan (‘P’) and the Community Services Plan (‘C’) feed into this Operational Plan and also respond to the NHS 5 Year Forward View. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 45 These MCPs will need to mature and grow to establish their organisational form and working relationships across the system. A full range of traditional community based services would be co-ordinated by the MCP, and outpatient and diagnostics could increasingly shift into the community under their control. MCPs are able to tailor the setting of care to patient need, working at times with the patient in their own home, and at other times in community settings including community hospitals. In order to set the foundations required we have to date: • Supported our practices in the development of four legally constituted GP Federations. The federations enable a strong primary care orientation to the delivery of patient pathways across all settings of care. • Given our federations opportunities to test models of joint working. Examples include federation QIPP schemes and the development of local weekend access services. • Commissioned community nursing and rehabilitation teams through a proactive care approach, aligned with our four federated localities. • Collaborated with our social care partners on the same geographical footprint. This enables the full integration of our practices with our community and social care teams to support further integration. • Assumed the delegated responsibility for the commissioning of general practice—this is enabling the CCG to create a joined-up, clinically-led, system that delivers seamless out-of-hospital, care based around the needs of local people. The challenge now is to support the development of our MCPs so that they will assume a greater leadership role in the provision of care and care coordination, while supporting staff from different sectors to work with them in new ways. To achieve this we will: • Rapidly explore joint venture opportunities with our key partners e.g., Federations, UHL, LPT and Adult Social Care, to agree the model for further integration of our community and primary care teams. • Develop mechanisms and approaches for GP Federations to meet these challenges by supporting their organisational and business development, enabling them to engage fully in the leadership and development of MCPs. • Develop contractual forms that enable the MCP to deliver care across our three districts in the most clinically and cost effective manner by breaking down the contractual and sectoral barriers to integrated provision. Draft to NHS England 2.0 46 | Clinical Work-streams Clinical Work-streams Atlas of variation indicators for Clinical Workstreams Urgent Care Case for Change/Strategic Direction The strategic direction for Urgent Care in LLR is to develop a consistent, integrated model of care, adaptable to local population needs. We will bring together services that have historically been operated as separate provider contracts into a network of services which reduces duplication and helps people to get the right response at the right time. We will improve access to advice, self-care resources and community-based urgent care services, and enhance senior clinical assessment services, helping people to get the right response at the right time. We have shown graphically our indicators from the NHS Atlas of Variation in this section, using three types of graph to express ratios, absolute rates and percentages (see examples, below). Our comparator group of 10 ‘prospering’ CCGs is shown in light blue, England as a whole in dark blue, and WLCCG in red, orange or green depending on performance against the peer group. NHS VALE OF YORK CCG As one of the eight national urgent care Vanguard sites, we will be implementing the recommendations of the Keogh review of Urgent and Emergency Care over 2016/2017, as well as to put in place new models of urgent care as set out in the Five Year Forward View. NHS LINCOLNSHIRE WEST CCG NHS SOUTH CHESHIRE CCG NHS NORTH STAFFORDSHIRE CCG NHS SOUTHERN DERBYSHIRE CCG NHS WEST LEICESTERSHIRE CCG NHS EAST LEICESTERSHIRE AND RUTLAND CCG In 2015/2016 we made a number of improvements to the urgent care system in West Leicestershire and across LLR. Progress included: • developing acute visiting services for people with identified high levels of need • extending access to primary care, with longer opening hours, organised around GP Federations • extending the clinical workforce at Loughborough UCC to treat patients with more complex needs • introduction of a streaming service at LRI ED • establishing our Vanguard programme work-streams and agreeing the model of care which we will begin to put in place over the coming year • commissioning the Intensive Community Support service (ICS) which acts as a step up and step down community home care service to prevent admission and facilitate discharge. Despite the addition of some successful new services, it has become increasingly evident that many of the services we have in place to support our communities are operating in isolation, not as an integrated network. Patients struggle to access the right care at the right time because, as we hear from our local Healthwatch as well as our own engagement work, they find the service fragmented and often aren’t aware of the options available to them, or how to choose between them. Clinical staff, including EMAS crews, do not always have access to the right information or senior clinical advice to prevent admission or ED conveyance. NHS NORTH EAST ESSEX CCG NHS MID ESSEX CCG NHS SOUTH WORCESTERSHIRE CCG NHS GUILDFORD AND WAVERLEY CCG 100+59= CCG 0.59 100+57= Peers 0.57 100+56= England 0.56 4039+ +45 Ratio 1:value where CCG is performing poorly against peers (red) Rate where CCG performs comparably with peers (orange) 40.18 39.08 44.99 CCG Peers England 0+0+846762 Percentage where CCG is outperforming peer group (green). CCG 83.94 Peers 67.30 England 61.64 Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 47 Performance and Service Challenges The LLR Emergency care system has been under sustained pressure for much of the past year, reflected in declining performance on a number of key indicators, particularly A&E waiting times and ambulance handover and turnaround times at LRI. Addressing performance issues is a key priority in 2016/2017. Our approach is to combine a collaborative, system wide improvement approach, led by the LLR System Resilience Group, with robust manage as well as to manage urgent care contracts with providers A&E Performance YTD at month 10 was 88.8%. As a response to the level of performance pressures in LLR, there have been two escalation meetings with NHS England to review the LLR emergency care system and we were requested to produce a Recovery Action Plan (RAP) by NHS England in October 2015. The RAP was reviewed and revised in February 2015, to focus it on a smaller number of key and high impact actions, aiming to address the key pressures facing our system, notably high numbers of patients being admitted via A&E, and flow problems impacting on ambulance handover and turnaround times. The RAP sets out actions to address the following high priority objectives: • Manage demand for urgent care through alternative pathways of provision • Reduce delays in ambulance handover times at the LRI site • Reduce the number of emergency admissions at the LRI site • Remodel the LRI front door to manage patient flow better • Improve discharge rates to increase hospital flow. Following a CQC inspection of the ED at Leicester Royal Infirmary, UHL was subject to a rectification notice in relation to A&E assessment times, staffing and sepsis management. A risk summit was called by NHS England in December 2015, followed by a second meeting in February 2016. Actions to address the identified risks are incorporated in the recovery action plan and the System Resilience Group will lead delivery of the recovery action plan into 2016/2017. The RAP is supported by a broader set of plans to improve the Urgent and Emergency Care system, including the LLR Vanguard plans, which collectively form the Urgent Care work-stream of Urgent Care. These plans are described in the remainder of this section. Meeting constitutional standards Plans to meet constitutional standards, particularly around the 95% A&E waiting standard, are encapsulated in the RAP and the Urgent Care Improvement Plans detailed above. Metrics and trajectories to improve performance are given in the RAP, and these will be scrutinised by the SRG and Operating Resilience Group. National expectations are that we should have achieved the 95% standard by Draft to NHS England 2.0 48 | Clinical Work-streams April 2016, and a whole system approach is being taken to improving the situation particularly in the LRI ED through a range of actions to reduce the number of presentations for assessment in the ED, and by diverting patients into other more appropriate pathways of care. The recent changes to the use of the Urgent Care Centre at the front door of LRI ED are having a positive impact on the way that patients with minor illnesses/injuries are streamed and treated. UHL is also implementing a number of actions intended to further remodel the ‘front door’ of LRI ED, such as relocating the Out of Hours (OOH) service to the Urgent Care Centre (UCC), increasing the range of near patient testing in UCC and improved use of ambulatory care type pathways. The increased number of ‘beds’ available in our Intensive Community Support (ICS) service, which will improve our ability to not only divert patients into other community based pathways of care to prevent hospital admission, and also facilitate earlier discharge both from acute and community hospital beds, which contributes to improved flow through the acute sector. We are seeing a weekly increase in the use of this service, both from a step-up and step-down perspective, and we will continue to actively promote it across the system. Other key actions aimed at minimising presentations to ED include use of mobile DOS by EMAS crews to source alternatives to ED conveyance, the rollout of Consultant Connect, a service to provide clinician-clinician advice between primary and secondary care, and maximising the use of the Acute Visiting Service which will improve the timing of conveyance of patients to ED should this be required. UHL continues to focus on reducing the overall number of emergency medical admissions to the LRI site, and working across the whole system and utilising alternatives to admission, we have trajectories in place (DN need to check with Nikki Bridge) to achieve this. Initiatives include better use of Senior Decision Makers prior to admission, expansion of ACPs during times of high pressure, and implementing a feedback loop to GPs where a patient is thought to have been admitted inappropriately. Draft to NHS England 2.0 43+40+53 64+16+10 43+64+76 37+54+69 Rate of emergency admission to hospital, people aged 75 years+, length of stay less than 24h per 100,000 population, 2012/13. 4325 CCG 4043 5262 Peers England Rate of admission to hospital, people aged 75 years+ from nursing home or residential care home settings per 1,000 population, 2012/13. 32.397.76 CCG 4.83 Peers England Rate of accident & emergency (A&E) attendance in children and young people aged 0–19 years per 1,000 population 2012/13. 214.7 CCG 319.2 382.6 Peers England Rate of accident and emergency (A&E) attendances per 1,000 population, 2012/13. 0+0+2221 180 CCG 269 341 Peers England Percentage of accident and emergency (A&E) attendances that result in emergency admission to hospital, 2012/13. 61+71+83 CCG 22.04 Peers 21.92 England 21.30 Rate of emergency admission to hospital for ambulatory caresensitive conditions per 100,000 population, 2012/13. 605 CCG 705 830 Peers England West Leicestershire CCG Operational Plan 2016–2017 | 49 Atlas of Variation While the data show that WLCCG, overall, has low rates of A&E attendances compared to both the national average and our peer group, there are opportunities for improvement in admission rates, particularly from care homes and for older people. Our Vanguard work, particularly our plans in relation to integrated community urgent care and changing the ED front door service at LRI, include actions to reduce A&E admission rates, and some of our other work programmes, including older people and LTC will also lead to improvements in this area. Contract and provider performance management Contract performance management is central to our approach to performance and delivery, supporting the system-wide approach to urgent care improvement. WLCCG currently manage a suite of Urgent Care contracts on behalf of LLR, such as the Provision of NHS111 service, the GP Out-of-hours service and the Emergency Patient transport. The key focus in the process of provider performance is to ensure that providers are meeting their expected performance and quality standards. Where providers are not meeting these, we work with them to address the key challenges around performance delivery of this service toward agreed improvement trajectories. The CCG will explore different frameworks to establish new contractual approaches for future models of care. It is important to note that the challenge of establishing new contractual approaches should not be underestimated, and collaboration between commissioners as well as providers will be required. We will need to develop a new range of competencies to establish and monitor these new contractual models, including a detailed understanding of procurement rules, holding organisations to account for outcomes, and working with new market entrants. It will be essential to continually engage and communicate with providers, patients and the wider community to define the problem and identify appropriate solutions in the embedding of the new competencies and contract management models. Through this process, all partners should develop a shared vision setting out what they want care to look and feel like in the future — then work back from that point to build a model that meets these aspirations. Payment mechanisms and incentives will also need to be aligned across providers. Inconsistencies in the way that different providers are reimbursed and incentivised could continue to reinforce fragmentation in future delivery of care. A number of key contracts will be re-specified and re-procured in 2016/2017, including 111, Out of Hours and the Arriva transport Draft to NHS England 2.0 50 | Clinical Work-streams contract. This process allows us an opportunity to change and respecify how services are delivered, to move towards a more integrated system, as well as allowing the CCG commissioners to procure against KPIs which will deliver improved quality and outcomes. Key areas of work in 2016/2017 include: • Re-procuring 111 services as part of the East Midlands Regional procurement, with the new contract commencing on 1st October 2016. The initial service model will include clinical triage and assessment but we intend to test an integrated model of clinical triage and assessment as part of testing a Clinical Navigation service, from October 2016, aiming to roll out the new service from April 2017. • Re-procuring patient transport services • Testing new models of Out of Hours provision; integrating telephony services within Navigation service, with home visiting and face to face visits included in the Vanguard work on integrated community urgent care. Following the test phase, new contractual arrangements will begin from April 2017. • Procuring new discharge pathways, starting with Complex Transfers (Pathway 3), for patients unable to go home. 0+0+788586 0+0+676364 % elective admissions for abdominal aortic aneurysm (AAA) or aortobifemoral bifurcation graft procedures that had planned access to adult critical care, 2013/14. CCG 78 Peers 85 England 86 % emergency admissions for excision colorectal surgery that had planned access to adult critical care by CCG, 2013/14. CCG 67 Peers 63 England 54 Programme Governance The Vanguard is hosted by West Leicestershire CCG on behalf of the LLR System Resilience Group, and the SRO for the Vanguard is Toby Sanders, MD for WLCCG. The SRG is ultimately responsible for the governance of the Programme, receiving regular reports on the Vanguard. There is a small PMO supporting the programme, and each workstream within the Vanguard has a SRO, project lead and clinical lead. The six project leads meet regularly with the programme manager to review progress across the programme, take forward cross cutting issues and ensure that the programme milestones are met. The Vanguard also reports into the BCT Delivery Board, as urgent care is one of the BCT workstreams. Managing the Urgent Care System The LLR System Resilience Group (SRG) will continue to lead the management of urgent care across the health and social care system. The SRG will provide senior leadership to the development of Urgent Care strategy, with responsibility for achieving a safe, high quality service that delivers NHS constitution standards and performance targets. . We are reviewing the governance of the LLR Urgent Care system at the level below the SRG, to ensure that we can effectively manage the strategic change agenda (Vanguard and BCT) as well as keeping control of operational resilience and surges in pressure, enabling robust delivery of the RAP and other improvement plans. This will Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 51 mean a review of the Urgent Care Board’s terms of reference and the creation of new working groups to oversee operational resilience and the delivery of our Urgent Care improvement plans. Evidence-base for change With the support of public health, we have reviewed and collated a range of evidence that supports our plans for improvement, and this is summarised in the ‘hypothesis tree’ in Appendix G. In some areas we are innovating, and there is less formal evidence to support what we are trying to achieve. Part of our work within the Vanguard will help develop an enlarged evidence base and identify ‘replicable’ models which can be used by other areas to achieve improvement. Our plans Vanguard Programme: The Vanguard will bring together all our providers of health and social care to work as one network, collaborating to put in place new models of urgent care. Our vision is to simplify things for patients, and get them the care that they need, without having to worry about having to navigate a complex and sometimes disjointed system. The Vanguard will accelerate delivery of the Keogh review and will be delivered through six key strands. The diagram below shows how the Vanguard will deliver the Keogh review, with each strand described in more detail in the following pages. Emergency Urgent ✑ GP and Primary Care Mental Health crisis response 999 111 “The smart call to make…” ed grat ity Paramedic Paramedi Community InteUrgent un m e at Home m Care Pharmacy Co nt Car ge UrCentre LRI Emergency Front E Door Emergency De Department 7 day services ☞▼ Contracting for Transformation Predictive activity Modelling Advice by Phone ✑ ✑ Specialist Emergency Cent Centre Strand 1: Integrated Community Urgent Care This project has two key elements: the development of a telephony Draft to NHS England 2.0 52 | Clinical Work-streams based Clinical Navigation service, integrating aspects of current services delivery within 999, NHS111, OOH and the Local Authority Access points for health and social care. In addition to this we will revise the way that community urgent care services link together, creating a new model of local urgent care services comprising services delivered by general practice, home based acute visiting and crisis response services, community nursing services, Urgent Care Centres and the Older Peoples This will all be underpinned by sharing of the summary care record and key information such as care plans. While the Clinical Navigation Service will be LLR wide, and linked to the 111 service, the model of integrated community urgent care services will be flexible to local conditions, including population needs and geography/location of current physical resources such as diagnostics. For West Leicestershire, this means that we will be testing new models of delivering home visiting services and face to face appointments for urgent care needs, incorporating extended access to primary care and Urgent Care Centre activity, both in and out of hours, 7 days a week. This will involve integrating OOH and UCC activity, extending the model to take more ambulatory care patients. We will work with GP Federations and other providers to deliver a more streamlined service model that reduces service duplication and uses clinical capacity to meet population needs in the most effective and accessible way. Strand 2: LRI Front Door We will redesign the front door at LRI to provide an enhanced senior clinical assessment team, merging the streaming, UCC and minors functions to provide a single service acting as a robust clinical filter to ED majors attendances. This integration will make the LRI model consistent with the rest of the system including the configuration of out of hospital services and the emergency pathways flowing from ED. The service will have a strong primary care ethos and will be integrated within UHL’s ED department, operating under shared governance. The service will have direct referral access to ambulatory clinics, UHL assessment beds and primary/ community services. The new ED floor layout (open early 2016) will be reviewed to support this. Strand 3: Mental Health We will develop our mental health services to better meet the demands of patients and enable parity of care. This will be delivered through investment in Psychiatric Liaison within the acute trust, mental health workers embedded within the police and paramedic services and improved access and referral processes to crisis support and crisis support for children and young people. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 53 Strand 4: 7 Day Service UHL are an early implementer for 7 day service within Acute hospital. We will deliver standards 2,5,6 and 8 of the Clinical standards for Urgent and Emergency Care and Supporting Diagnostics. In addition, we will seek to deliver standards 7 & 9, enabling support services, both in the hospital and primary, community and mental health settings so the next steps of a patients care pathway can be taken. Details of these standards are in Appendix I. Strand 5: Contracting for Transformation Using our experience of Alliance contracting we will develop a new urgent and emergency care alliance based model that incentivises providers to work as a network. This will be underpinned with new measures of clinical quality and patient experience increasingly focussing the whole system on a clinical outcome focus and the implementation of the new payment model. Strand 6 Predictive Modelling We will develop a ‘real time’ demand and activity model to improve the management of operational resource/capacity levels across the urgent care system. This strand will deliver a more efficient model of care delivery through pre-empting system pressure and allowing realtime distribution of workforce and activity to better meet demand. Routine joining-up and sharing of organisations’ real time and historical activity data will be established, together with modelling of workforce. This will enable whole-system triggers, not based on organisation but system needs. Draft to NHS England 2.0 54 | Clinical Work-streams Vanguard Programme Implementation Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 55 Impact and measures of success The Vanguard programme’s impacts are outlined in the below table. These benefits will be realised across the LLR UEC system. Strand 1 Reduced inappropriate ED attendances (32.65% by Q2 2017, 45.9% by Q2 2018) Strand 3 Strand 4 Strand 5 Increased Reduced ad- Supporting responsivene missions (As integration ss of MH Strand 1) of services service across the Reduced Vanguard, Reduction in variation in; both Greater ambulance Length of operationally integration conveyance stay by day and clinically and (as Strand 1) of week, Reduced improved Mortality by Improved Reduced ED day of week, provider ambulance efficiency attendances re-admittance productivity conveyances (As Strand 1) by day of (16.91% by Greater consistency Q2 2017) week (varia- Removes Reduced MH (and perverse tion 1.8% Increase in sustainability) hospital incentives between attendances Activity : highest and and potential Shares risk Urgent care Improved lowest numand reward centre/walk quality and avoidable ber across 7 safety admission across in centres days from system (9.42% by Q2 2016), Improved Increase in Q2 2017, patient appropriate access to di- Aligns 38.02% by experience and safe care agnostics organisation Q2 2018, (achievement al incentives pathways 53.15% by Better value of clinical to system Q2 2019) standards 2, outcomes 5, 6 & 8) Improved access for Reduced defront line lays in clinical clinicians for decision Specialist making advice Reduction in Greater decompensasystem tion espeintegration cially for the and elderly efficiency Reduced risk Greater especially for consistency longer of advice lengths of through a stay e.g.; single point falls, HAI of access rate, Improved quality and safety Reducing hand-offs Strand2 Reduced ED costs though channel shifting to UCC Strand 6 Enabling a left shift of service channels (from ED to Primary care) Faster hand overs Reduced ED service waiting times Improved staff rotas based on system-wide demand patterns Reduced Av loS and bed occupancy (0.2 days by 2020) The key outcome metrics that we will be using to measure the success of the programme at a macro level are: Draft to NHS England 2.0 56 | Clinical Work-streams ✻ ✻ Reduced A&E attendance Reduced hospitalisation rate across the population (stratified by age group) ✻ Reduced re-attendances and re-admission (including A&E and UCC) ✻ Reduced hand-offs and inter-provider referrals ✻ Improved patient experience We are working with public health to define and set the baseline and target improvements for these outcomes. Further work is required in the development of a complimentary set of patient experience metrics. Within the Vanguard programme we will be piloting the new urgent care ‘system measures’ being developed by the central team. We will also be using the Pi tool to bring together health and social care indicators at patient level, creating a dashboard which we can use to assess the impact of the changes we make to services in the course of 2016/2017. Modelling — impact on activity and outcomes We have worked with GEM and Arden CSU to create an activity model for the LLR UEC system. This includes assumptions about the impact of the vanguard interventions would have, applied over and above the do nothing scenario which includes demographic and nondemographic growth until 2021. The table below quantifies the impact that we will have on key activity metrics in each year. These activity measures will be used as a proxy for outcomes while we complete the work outlined above. Vanguard Impact on activity Service Activity Changes (All Providers) 16/17 17/18 18/19 19/20 20/21 % % % % % NHS 111/ clinical triage & navigation 1.33 8.61 7.61 7.56 7.83 Ambulance (excluding hear & treat) –0.09 –16.91 –16.55 –16.80 –16.54 Urgent Care Centres 1.81 8.03 11.79 12.29 12.79 LRI Front door — UCC 3.20 16.93 37.21 38.21 39.09 A&E Departments –6.79 –26.85 –37.77 –38.22 –38.38 Emergency Admissions –1.03 –1.79 –0.83 –1.49 –2.10 EM Admissions (Medical, Surgical, Women & Children — UHL Only) Average LOS 0.00 –1.25 –2.50 –3.75 –5.00 Total Bed Days 0.00 –1.25 –2.50 –3.75 –5.00 Daily Bed Days 0.00 –1.25 –2.50 –3.75 –5.00 Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 57 Finance Project Leicester City West Leicestershire East Leicestershire & Rutland Investment QIPP | Investment QIPP | Investment QIPP Vanguard – £333k | – £333k | – £333k In addition to the Vanguard work, the Urgent Care Workstream has a focus on hospital flow and discharge. Flow This work-stream aims to streamline how patients are assessed, treated and cared for during their stay in hospital, from attendance at ED or assessment ward through to planning for discharge. We aim to reduce time spent in A&E and to reduce overall length of stay in hospital. The work-stream is overseen by the Urgent Care board, also addressing the issues faced by handover delays from the ambulance service to the ED. Some of the projects being covered by Flow include: Ambulance Handovers — Reducing delays in ambulance handovers at the LRI site. This includes the introduction of routine flow management / coordination for patients arriving at LRI by ambulance to increase referrals to non-ED majors dispositions, agreement of a consistent handover assessment process, and work around the use of data and monitoring the impact of the new arrangements. Streaming of walk in patients at the LRI site — to ensure patients are directed to the most clinically appropriate service Nurse staffing levels in the ED — to maintain 5/6 assessment bays Capacity pressures — Ensuring that the hospital can respond appropriately to capacity pressures in ED Admissions process — Development of a patient facing script for bed bureau to accelerate the admissions process from ED to base wards. Outflow (Discharge) The existing discharge pathway within LLR is complex with 56 different discharge pathways within the system. To simplify this, a review was completed of the pathways and a simplified model developed with just 5 pathways. This will provide an efficient, effective and sustainable model of care. Draft to NHS England 2.0 58 | Clinical Work-streams Hospital Transfers Pathway 1 home with existing support Pathway 2 home with new support Pathway 3 complex transfers Home reablement Home Remain at home ± ongoing support Placement Bridging/ Holding team Pathway 4 last few days of life Unable to go straight home New reablement based care Home ± support Supported living Residential care Hospice at home Nursing home Community hospital LOROS Specialist transfer pathway i.e., All stroke, functional mental health, MSK, brain injury, specialist rehabilitation All follow existing pathways Nursing Home Permanent Placement The simplified discharge pathways will enable patients to leave acute care as soon as they are deemed to be medically stable. This will support earlier-in-the-day transfers and help to manage capacity in times of surge, as the ethos is ‘home first’, with eligibility assessments completed outside of the acute sector, when the patient has reached their full health potential. This will be via a combined health and social care offer. It involves working smarter and proactively with the care home sector to facilitate transfers seven days a week, with ‘Trusted Assessment’ processes and robust case management. For patients in the last few days of life, it is about ensuring that they are able to go to their chosen place of death within the day. The services required to enable this to happen will be available and integrated 7 days a week and 24 hours a day by April 2017. Planning for seasonal variation The Urgent Care Board (UCB) leads the planning for seasonal peaks in demand, including the formation, coordination and oversight of the LLR Surge and Resilience Plan. Leicester City CCG hosts the LLR Director of Emergency Care on behalf of the health and social care economy; this post is responsible for the LLR EPRR lead who coordinates the LLR resilience plan in partnership with the System Resilience Group, NHS England, the Local Resilience Forum and emergency planning leads across provider organisations. The LLR Surge and Resilience Plan is a live document which applies learning from major peaks in demand or major incidents on a rolling basis. A formal sub-group of the UCB meets monthly through the year to continuously develop this. The plans are tested annually, in conjunction with national and local planning leads, with the CCG leading this process. A multi-agency workshop will be undertaken at the end of March to reflect on the delivery of the winter plan over Christmas and New Year but also to identify gaps to address for the remainder of winter and the coming peaks in demand. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 59 Examples of the Learning opportunities identified in 15/16 to date: • putting money into the base line — gives a better opportunity to plan for resilience • review staffing levels during Bank Holiday periods and its impact on staffing mix and consistency — senior leadership worked. • use feedback to avoid ‘knee jerk’ actions — use the metrics to inform of what’s worked • update escalation plan based on learning — Practical measures to be added to the plan in terms of escalation actions • include adult MH, CAMHS; • all UCCs and primary care within the plan. • ensure mutual aid triggers early enough. • enhance communication messages across CCGs • maintaining the support for discharge across all partners. The surge and escalation group will take forward the updating of the escalation plan as this is a live document and used across the year not just for winter. Wider operational learning has been incorporated into the urgent care improvement plan and delivery will be monitored through the UCB. Planning for 2016/17 has already begun and will continue through the year in terms of learning from events; maintaining a live escalation plan; focusing on sustainable actions through the urgent care board and maintaining effective system engagement. Specific winter actions and resources will start to be articulated from the June surge and capacity meeting who will start to shape the plans for UCB discussion and adoption. In 2015/16, the System Resilience Group will oversee the delivery of these plans and provide assurance of their robustness to the Central Midlands Directorate of NHS England. As traditional winter funding will be included in CCG allocations in 2016/17, we will deliver earlier and more effective planning for operational resilience, mainstreaming those services which have enabled flow in previous periods of surge. In support of implementation of the Urgent and Emergency Care Review, NHS England has identified eight interventions that every SRG is expected to address and include in final operational plan submissions. We have developed one Leicester, Leicestershire & Rutland (LLR) wide system narrative to show how we are meeting the eight interventions and these plans are outlined in Appendix J of this plan. Draft to NHS England 2.0 60 | Clinical Work-streams Long term conditions (LTCs) Context Currently the models of care for most long term conditions are reactive, episodic and fragmented. The result is a highly hospital and progressively consultant dependent solution. This does not provide holistic, high quality, cost efficient care and is not a pattern of delivery that is economically sustainable neither does it provide high quality, patient-centred care. Locally, the number of people with LTCs using the emergency care system has contributed to the challenge of caring for emergency admissions in a timely manner. The aim of this workstream is to develop and implement an integrated, anticipatory, patient-centred model of care for patients with one or more LTCs which is high quality, evidence-based and delivered through innovative care models and methods. The Five Year Forward View outlines the benefits of new specialised care models. The national Keogh review of Urgent and Emergency care1 summarised the key issues with the current system stating there was: • fragmentation of the system • inconsistent service provision • primary and community care are risk averse thereby resulting in more referrals for admission to hospital • alternatives to hospital admission are often not known and/or exploited • some patients could be cared for closer to home outside of the hospital environment if there were home based models of care that incorporated community services, made use of innovative technology and there was community access to specialist care when needed. What are we going to do? NHS England (2013) Everyone Counts: Planning for Patients 2013/14 Wagner EH, Austin BT, Von Korff M. Organising Care for Patients with Chronic Illness. Milbank Q. 74(4)511-44.1996 2 Organisational processes Engaged, informed patients 1 The Chronic Care Model 3 Bodenheimer T, Wagner EH, Grumbach K. Improving Primary Care for Patients with Chronic Illness. JAMA. 288(14)1775-9. 10/0/2002. – Part 2 JAMA 288(15)1909-14. 10/16/2002. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving Chronic Illness Care: translating evidence into action. Health Affairs. 20(6) 64-78. Nov-Dec 2001 4 Personalised care planning Health care professionals committed to partnership working The principles of the Chronic Care Model (CCM)2345 will be adopted across the LTC programme will be used as a framework to join up and coordinate the essential elements of a health care system that encourages high-quality chronic disease care centred on support for a productive interaction between “an activated, informed patient” and “a well prepared clinical team.” Responsive commissioning (Kings Fund) Wagner EH. Chronic Disease Management: What will it take to improve care for chronic illness? Eff Clin Pract 1(1)2-4. Aug-Sept 1998 5 Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 61 The Kings Fund 10 components of care 1 healthy, active ageing and supporting independence 2 living well with simple or stable long-term conditions 3 living well with complex comorbidities, dementia and frailty 4 rapid support close to home in times of crisis 5 good acute hospital care when needed 6 good discharge planning and postdischarge support 7 good rehabilitation and reablement after acute illness or injury 8 high-quality nursing and residential care for those who need it 9 choice, control and support towards the end of life Within the framework of the CCM the LTC plans will embed the 10 components of care proposed by the King’s Fund (2014) to: 1 Deliver high quality, citizen centred, integrated health and social care pathways, delivered in the right place at the right time by the right person; including ensuring that healthy lifestyles and selfcare become a common feature of all treatment 2 Improve care outside of hospitals to the extent that we can reduce the time spent in hospital by people with LTCs 3 Reduce the inequalities in accessing care currently experienced by people with LTCs 4 Help to increase the number of people with a positive experience of physical health and social care services 5 Improve the use of physical assets by co-locating different services to enable integration 6 Integrate health and social care services thereby eliminating duplication such as repeat assessments 7 Reduce costs to health and social care commissioners 8 Develop new capacity and capabilities amongst our workforce. 10 integration to provide personcentred co-ordinated care. Making our health and care systems fit for an ageing population, David Oliver, Catherine Foot, Richard Humphries, King’s Fund 2014. Draft to NHS England 2.0 62 | Clinical Work-streams Our LTC plan will coordinate action at a system level around three key themes: PREVENT In partnership with Local Authorities and Public health we will scale up a proactive approach to Health Promotion and primary, secondary and tertiary ill-health prevention AVOID Enhance our community based treatment model and focus on patients with a history of frequent hospital use and where same day specialist input and specialist diagnostics are required, we plan to see more patients on an ambulatory basis. Shifting care to community settings will require scaling up of the capacity of community services and the clinical support they receive. Developing specialist community physician roles (in line with developments in many other parts of the country) are central to our plans to deliver these changes. REDUCE Exacerbations of key LTCs requiring admission will happen and where this is the case our intention is to keep the period spent in hospital for as short a time as possible (e.g. home with crisis support in the early reablement process). Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 63 Respiratory COPD prevalence rates in Leicester, Leicestershire and Rutland (LLR) are significantly lower than expected, particularly in Leicester City. 1.9 3.1 2.0 2.7 % WL ELR 1.8 3.8 LC Actual (left) versus expected (right) prevalence for COPD 2012/13 in 16+ age group for East Leicestershire and Rutland (ELR), West Leicestershire (WL) and Leicester City (LC). Prevalence is substantially lower than expected. However, the emergency admissions data (GEM) is showing an increasing trend across LLR. At Month 6 the COPD emergency admissions are 35% greater than the same period last year for Leicester City. Across LLR there has been a 32% increase in COPD with acute lower respiratory infection. Across LLR we expect that there will have been 270 more emergency admissions than 2014/15 and an additional cost pressure of £528,000. What are we going to do? • We will commission an accredited training and support programme for GPs and practice nurses in primary care to support diagnosis and management of COPD and Asthma. • We will commission a crisis response service to patients with respiratory disease to prevent hospital admission and develop an integrated respiratory service to enable earlier discharge from hospital and optimal management in the community. The integrated respiratory team will provide this, via a Single point of access (SPA) for all clinicians, enabling patients to be managed quickly if their health deteriorates, and so preventing hospital admissions. • The newly integrated nursing teams will have more access to specialist physician time and formal MDTs will be held regularly. • Atlas of Variation— Respiratory We will undertake an in-depth review of home oxygen provision to ensure cost effectiveness of the service. • Percentage of patients with COPD who had influenza immunisation in the preceding September–March, 2013/14. We will commission a more efficient and clinically effective outpatient clinical service for patients that present with both Cardiology and Respiratory issues, avoiding patients presenting multiple times to separate speciality clinics. This will be the Breathlessness Pathway that is currently been piloted in Q4 15/16. Cardiology 0+0+8283 80+72+88 CCG 82.39 Peers 82.74 England 82.04 Atrial Fibrillation (AF) Optimisation In 2010, stroke was the third biggest cause of premature death in the UK in terms of the number of Years of Life Lost (YLLs)6. At least 20% of strokes are likely to be directly attributable to Atrial Fibrillation (AF). Patients with AF are on average 5 times more likely to have strokes. Rate of asthma Without anticoagulation, 5% of patients with AF will get a stroke emergency admissions to every year hospital in people aged 19 years and over per 100,000 population, 2012/13. 80.18 CCG 72.18 87.79 Peers England AF strokes are much more devastating than strokes not due to AF. They are associated with (WHO Global Burden of Disease, 2012) 6 Draft to NHS England 2.0 64 | Clinical Work-streams • higher mortality (33% in-hospital mortality compared to 17% non-AF) • longer hospital stay (50 days compared to 39 days) • higher disability (48% of patients with stroke due to AF are eventually discharge to their own home compared to 69% with stroke without AF) • reduced independence (only 20% of patients having a stroke due to AF go on to live independently following a stroke). 10–20% of those who have had a TIA will go on to have a stroke within a month. The greatest risk is within the first 72 hours. The risk of recurrent stroke is 30–43% within five years.7 Effective Preventative Treatment of Atrial Fibrillation Anticoagulation reduces the risk of a stroke by about 70%. The NNT rating system for for anticoagulation in primary prevention is 37 and 12 for secondary prevention (i.e. patients who have already had a stroke / TIA) to prevent one stroke per year. Patients who are poorly controlled on warfarin are at higher risk of bleeding and stroke. Falls risk and perceived risk of bleeding is a common reason for GPs to not prescribe anticoagulation despite recent evidence that there is only a very weak association between falls and risk of significant bleeding. Heart Failure (HF) Optimisation Incidence of heart failure will increase sharply with the ageing population and improved survival following heart attack. Atlas of Variation — Circulation Problems (CVD) Heart Disease 100+59= CCG 0.59 100+57= Peers 0.57 100+56= England 0.56 100+74= CCG 0.74 100+75= Peers 0.75 100+72= England 0.72 40+39+45 Ratio of reported to expected prevalence of hypertension. Ratio of reported to expected prevalence of coronary heart disease (CHD). Rate of mortality from coronary heart disease (CHD) in people aged under 17 years per 100,000 population, 2011/13. 40.18 CCG 39.08 44.99 Peers England Untreated mortality can be as high as 70% in one year, but can be reduced to 10% with optimised management which can largely be delivered in primary care. Untreated heart failure has a mortality that is worse than all cancers apart from lung and pancreatic cancer. Currently, there is low or variable detected prevalence of heart failure in primary care. Community Stroke and Neurology Rehabilitation Up to half of all heart failure patients have a preserved ejection fraction (HFpEF), also referred to as diastolic heart failure, but they are often excluded from treatment. Rate of epilepsy emergency admissions to hospital in people aged 18 years and over per 100,000 population, 2012/13. Heart failure accounts for 5% of all emergency medical admissions and 2% of all inpatient bed days. 69% of the NHS cost of heart failure is hospital admissions. The National Heart Failure Audit shows that where heart failure patients are managed on a cardiology ward, the mortality rate is considerably better at 7.8% for cardiology wards compared to 13% on a general medical ward and 17.4% on other wards (Stroke Association, 2013) 7 76+89+99 0+0+846762 97.01 CCG 113.39 127.99 Peers England Percentage of people with epilepsy aged 18 years and over on GP epilepsy registers who were seizure-free for the preceding 12 months, 2013/14. CCG 83.94 Peers 67.30 England 61.64 Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 65 0+0+515660 0+0+3837 Clinical agreement across primary care and community xxxx Percentage of people with acute stroke who were directly admitted to a stroke unit within four hours of arrival at hospital, 2013/14. CCG 50.87 Peers 55.98 England 59.46 Percentage of people known to have atrial fibrillation (AF) prescribed anticoagulation prior to stroke, 2013/14. CCG 38.04 Peers 37.08 England 38.26 What are we going to do? • We will increase the capacity and capability in community care settings to diagnose heart failure and atrial fibrillation earlier, • We will optimise the management of patients diagnosed to reduce premature mortality and / or likelihood of a cardiovascular event such as stroke. • We will increase community provision to support GPs and patients manage these patients in the community • We will improve access to cardiologists in secondary care avoiding inappropriate waits and visits to hospital. Community Stroke and Neurology Rehabilitation Service 100+79= CCG 0.79 Standardised morratio (SMR) 100+118= Peers 1.18 tality in the 30 days fol100+117= England 1.17 lowing admission to hospital for a stroke, 2013/14. What are we going to do? We will implement the redesign of the Community Stroke and Neurology Rehabilitation Service, to provide patient centred, seamless care for both Stroke and Neurology patients requiring rehabilitation in the community, largely in the patient’s usual place of residence. Diabetes (DM) Atlas of Variation — Diabetes 0+0+5360 0+0+343536 % in National Diabetes Audit (NDA) with Type 1 and Type 2 diabetes who received NICE-recommended care processes (excluding eye screening), 2012/13. CCG 52.52 Peers 60.00 England 59.94 % in National Diabetes Audit (NDA) with Type 1 and Type 2 diabetes who met treatment targets for HbA1c bloodpressure and cholesterol, 2012/13. CCG 33.67 Peers 35.50 England 36.25 What are we going to do? • WLCCG will be increasing capacity and capability by upskilling primary care clinicians throughout 16/17 • WLCCG has been successful in a national bid to be part of the first wave of the National Diabetes Prevention Programme • Up to 500 patients that are identified as being at risk of Diabetes will be offered an intense programme of education and exercise • We will commission a service to identify patients at risk of developing type 2 diabetes. Renal What are we going to do? • We will commission a service designed to increase the capacity and capability by upskilling primary and community care staff to identify and manage chronic kidney disease (CKD) patients better • We will improve integrated working between practices and appropriately skilled pharmacists to support the management of CKD patients in the community avoiding unnecessary hospitalisation Draft to NHS England 2.0 66 | Clinical Work-streams • We will implement the East Midlands Strategic Clinical Network (EMSCN) CKD ASSIST programme (eGFR, a marker of kidney function) in UHL Pathology to proactively identify patients at risk of developing Acute Kidney Injury. The CCG launched a CKD project in 2014/15 focusing on patients with moderated CKD where both GPs and secondary care professionals may be involved in management of the condition. The project introduced a CKD Nurse to support use of the IMPAKT audit and quality improvement within primary care to ensure early identification and management of people living with CKD, in line with NICE guidance. Overall Impact of Long Term Conditions Programme QIPP Outcomes Quality — Throughout the LTC plan there is a focus on moving towards a proactive approach to managing patients with long term conditions ensuring all clinicians have the capacity and capability to manage these patients closer to home where appropriate. Innovation — Many innovate models are continually being tested, challenged and adopted where possible to maximise efficiency and avoid waste. This will mean that we will embrace advances in technology to support diagnostics and self-management initiatives. Prevention — One of the key aims of the LTC programme is to prevent disease where possible and prevent proactively manage patients to avoid unnecessary admissions and in particular readmissions into hospital due to inadequate provision in the community Productivity — Patients with LTC are growing and so will their requirements. Expected increase in prevalence has been mapped for each disease area and all new services are being developed to ensure sufficient flex for growth to maximise productivity. Measures of success ✻ Reduce the number of undiagnosed patients in Primary Care for Diabetes, Heart Failure, Atrial Fibrillation, COPD and CKD. Prevalence will be monitored at a practice level to reduce unwarranted variation (see chart, right) ✻ Increase the number of patients being optimised in Primary Care. QoF data will be monitored at a practice level to reduce unwarranted variation ✻ Reduce the number of inappropriate hospitalisation (emergency admissions, readmissions and OPD activity) — Practice level admission rates will be monitored to show cause an effect. 0+0+7675 Atlas of Variation — Renal Percentage of people on the Chronic Kidney Disease (CKD) register whose most recent blood-pressure measurement in previous 15 months was 140/85 mmHg or less, 2012/13. CCG 76.16 Peers 75.22 England 76.23 100+69= CCG 0.69 100+72= Peers 0.72 100+71= England 0.71 0+0+2219 0+0+585452 Ratio of reported to expected prevalence of chronic kidney disease (CKD), 2012/13 Percentage of dialysis patients who were receiving dialysis in the home (home haemodialysis and peritoneal dialysis combined), 2013. CCG 21.97 Peers 21.85 England 19.42 Percentage of people receiving renal replacement therapy (RRT) who had a functioning kidney transplant at a Census date, 2013. CCG 58.49 Peers 54.08 England 52.14 Forecast Prevalence Baseline 14/15 -15/16 Expected new patients 15/16 -16/17 diagnosed Forecast AF 6885 7293 407 HF 3676 3875 199 COPD DM (17+) 6947 7299 352 20657 21123 466 Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 67 Timescales High Level Implementation Plan 2016 A M J J A S O N D J F M Develop plan to mobilise training programmes in primary care (AF/HF/Diabetes/Renal) Implement the agreed plan to integrate Cardiology and Respiratory Community (crisis response, post discharge follow up) Mobilise new community based Stroke and Neurology Rehabilitation (against agreed plan) Start referring at risk patients into the Diabetes Prevention programme How much will we invest? Project Leicester City Investment QIPP Cardiology £127k Respiratory £122k Renal £103k Stroke & £215k Neurology Rehab Total Investment £566k /(Net Saving) -£31k £12k £79k -£9.6k £50k West Leicestershire East Leicestershire & Rutland | | | Investment QIPP | Investment QIPP | | | £5k -£117k| £192k -£18k | £122k £8.5k | £193k £40k | £102k £38,k | £89k -£545 | £215k -£154k| £215k -£34k | | | | | | £688k -£13k | £444k -£224k| | | Draft to NHS England 2.0 68 | Clinical Work-streams West Leicestershire CCG Operational Plan 2016–2017 | 68 Frail older people and dementia Strategic direction The strategic direction for the Frail Older People (FOP) and Dementia work-stream is to ensure that over the five year period and beyond, health and social care pathways are integrated to support and provide improved programmes of delivery. This will mean local authorities, health providers and commissioners plus voluntary sector organisations must work together to review current service offers for older people and those living with dementia. Therefore the vision is to have an integrated health and care support offer for frail older people that will deliver a person-centred, seamless and integrated approach to improving services for our population, focusing on maintaining health and independence. In working to improve services for frail older people our aim is to have: • care wrapped around the patient, whatever the setting of care, experienced as a single delivery system through multidisciplinary, multi-organisational integrated care teams • targeted identification to ensure the right services, at the right level, to the right people, reducing inequalities by delivering the best possible outcome • seamless and integrated health and care support offer around individuals transforming current services as a whole health and social care system providing value for money supported by the right financial framework. National Must Do no. 7b: “Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia.” As outlined within The King’s Fund — ‘Making our health and care systems fit for an ageing population, 2015’, life expectancy at 65 is now 21 years for women and 19 years for men and the number of people over 85 has doubled in the past three decades. By 2030 one in five people in England will be over 65 years. In 1948, when the NHS was founded, 48% of the population died before the age of 65, that figure has now fallen to 14%. Caring for the increasing number of frail older people with multiple health conditions is extremely complex. Not only does an ageing population present increasing demands on health care but also on housing and social care needs. We must therefore provide services in a different way to support people in their own homes, to live as independently as possible for as long as they and their carers would like. The local strategic direction for people living with dementia will be in line with national guidance as outlined in the Prime Minister’s Challenge on Dementia 2020 document. The focus of the work will be around the improvement of diagnosis rates, a shift of management from secondary care to within the community and primary medical care, prevention through exercise and the reduction in social isolation, support for family and carers and support after diagnosis through social action solutions, befriending services, peer support. Wrapped around our strategic direction will be the redesign of the community workforce, linked into the pathway redesign and prevention programmes and the overall shift of offering and providing Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 69 care within the community. Carers play a vital part in our society and we are committed to providing support for this group of our population, regardless of age. We have been working closely with our two local authorities (Leicestershire County Council and Rutland County Council) in the implementation of The Care Act, 2014 and the NHS Commitment to Caring — Progress Report 2015. Figure 1 below details the outcomes we are working towards. Our existing service What are we going to do? 1. Too many older people end up in hospital for too long—we need to support care to be delivered elsewhere. Develop programmes to support people to participate in society—healthy and active for longer 2. Not enough services that are joined up to support physical and mental wellbeing needs—we need to deliver integrated pathways. 3. Too many people end up in services such as residential care instead of going back home with the right changes made to that home to make it a safe environment—we need to support people to be independent Our outcomes in 5 years • Improve independence an wellbeing • More older people with agreed and managed care plans Develop care plans together to improve health outcomes to the best they can be • Fewer older people going into hospital Increase support for older people who fall • Reduced delayed discharge and length of stay Intervene appropriately and in a timely manner when older people are unwell • Reduce readmission increase ambulance service support for older people who fall • Ensure increased dignity • Increase the number of people who die in a place of their own choosing Build systems to predict those most at risk of urgent care so they can be supported beforehand Support people to leave hospital as soon as they are medically fit ears five y Next In addition Across LLR a key theme of work is to reconfigure the transfer/discharge pathways out of hospital from over 40 to five. Figure 2 below details the simplified transfer routes. Hospital Transfers Pathway 1 home with existing support Pathway 2 home with new support Pathway 3 complex transfers Home reablement Home Remain at home ± ongoing support Placement Bridging/ Holding team Pathway 4 last few days of life Unable to go straight home New reablement based care Home ± support Supported living Residential care Hospice at home Nursing home Community hospital LOROS Specialist transfer pathway i.e., All stroke, functional mental health, MSK, brain injury, specialist rehabilitation All follow existing pathways Nursing Home Permanent Placement With particular reference to frail older people and people living with dementia, a key focus of the pathway redesign work will be to map and review the current pathway programmes across the spectrum of health and social care providers within LLR to determine gaps of delivery, fragmentation and duplication of service provision and accordingly to plan the effective integration of service provision. Draft to NHS England 2.0 70 | Clinical Work-streams The overall outcome will be to provide a seamless integrated service working across health and social care ensuring that this is supported with and by the appropriate professional workforce. This work will link directly into the BCT Workforce Enabler Workstream, whereby consideration needs to be given to the connection of redesigning the pathway and reshaping the community and acute workforce to be fit for purpose. This will be informed through the NHS Five Year Forward View scoping the delivery mechanisms of services and care through the structural redesign and use of commissioning to inform this. The experience of relevant Vanguards within the East Midlands region and nationally will be used to inform us as to what this will look like on a LLR footprint. Health and social care initiatives supported through the Better Care Fund Furthermore during 15/16 our Leicestershire and Rutland Better Care Fund plans have identified and implemented a number of initiatives for delivery across health and social care. For frail older people and people living with dementia these have included: • Integrated Crisis Response • Older Person’s Unit • Care planning for older people including dementia, end of life and long term conditions • Acute Visiting Service • Rapid response for falls • Seven day services within primary medical care • Community Agents • Local Area Co-ordination Challenges In 2013 it was estimated that 661,600 people were living in Leicestershire, with 126,100 people (19.1%) aged 65 years and over and 16,200 people (2.4%) aged 85 years and over. By 2020 it is estimated that the local population aged 65 years and over will increase by 18% and by 2030 this population is projected by grow by 48%. It is considered that approximately 10% of all people over 65 years within LLR will have dementia and this proportionately increases as people age. Therefore, in line with the ageing population, complex health and social care needs, the continued focus on independent living and selfcare linked to carer support, it is important that the CCGs’ health and social care programmes of delivery are able to drive forward improved Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 71 outcomes, prevention and person-centred co-ordinated care. Following analysis of the NHS Right Care data, our key areas of improvement opportunity are (details of our current performance can be found in Appendix x): • The rate of admission to hospital for people aged 75 years and over from nursing home or residential care home settings per 1,000 population by CCG, 2012/2013 • The in-patient spend for the care of older people are neurological, circulation, gastro-intestinal, genito-urinary, trauma and injuries, respiratory, cancer, musculo-skeletal and infectious diseases • The continued improvement in dementia diagnosis rates. People living in residential care or nursing homes typically have multiple long-term conditions (80% have dementia) and/or frailty, and are receiving multiple medications. Access to healthcare — GPs, pharmacists, and hospital specialists and therapies — is more variable for older people in some long-term care settings than for fitter, older people living in their own homes. People in nursing or residential care homes can frequently be admitted to hospital for various reasons: • end-of-life care, although with advanced care planning and support many older people could receive dignified end-of-life care in their long-term care setting • acute medical illness, particularly out of hours when the person’s usual medical practitioner is not available • complications of medication use • falls — about 30% of all patients with hip fracture admitted to hospital are from the nursing or residential care home sector. A hospital admission can be distressing and disorientating for older people, leading to deterioration, healthcare-acquired infections, and falls. Pro-active and responsive healthcare planning can prevent hospital admission of older people from nursing or residential care homes. Our current performance on the dementia diagnosis has improved from our 14/15 position of 60% to 63% as at January 2016. However we still need to continue to focus on improving this further in order to achieve the constitutional standard. CCG Dementia Prevalence Rate East Leicestershire and Rutland CCG 60.1% West Leicestershire CCG 63.0% Leicester City CCG 84.4% Draft to NHS England 2.0 72 | Clinical Work-streams What are we going to do? In light of the above our overall plan for the next five years for the Frail Older People and Dementia is to: • align our plans across the system of health and care • streamline and focus our efforts on tackling a smaller number of priorities/interventions • identify those citizens at greatest risk and supporting them to maintain or regain their independence which will reduce their reliance on more costly interventions • adopt a whole system approach to pathway re-design (patient journey) ensuring integration of planning, commissioning and delivery is considered where appropriate • improve the customer experience through driving up quality and performance • deliver efficiencies through developing more effective and streamlined practices and processes • integrate care records and using more integrated technology to support joint care plans. We will do this through focussing on the following key areas of work during 2016/17: Dementia For 2016/2017 • Review and refresh the Joint Dementia Strategy for Leicestershire, Leicester City and Rutland (LLR) to reflect the Prime Ministers Challenge 2020 — timeline for completion to be confirmed post March meeting • Develop an LLR commissioning plan for the next 3 years (Years 3-5 of the BCT programme of delivery) this will be part of the LLR STP — June 2016 • Improve and maintain diagnosis rates to reflect the expected prevalence through: • Continue to implement the Shared Care Agreement in order to enable more people to be supported in primary medical care that in turn will reduce waiting times for diagnosis in memory clinics, through creating capacity. Further work is being taken forward to be able to discharge patients on Galantamine during 2016/2017 — ensuring that the drug costs stay the same in primary care as they are for our secondary health care providers. • Review and redesign the Memory Assessment Service in order Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 73 to deliver an integrated service provision with primary care so that we can increase its capacity to support meeting the increasing need • • Continued working with our general medical practices through enhanced service provision, audit programmes and educational events in order to drive the dementia diagnosis target. Implement the outcomes from the evaluation of the Hospital Liaison Scheme to Leicester Royal Infirmary and Glenfield Hospital sites. Carers Our focus on supporting carers will link directly to the Care Act (2014) and the NHS Commitment to Caring — Progress Report 2015 guidance. For: 2016/2017 we will focus on • The development of an Adult Social Care Strategy for 2016–2020, working together with partnership agencies to provide more ‘joined-up’ health and social care services • County-wide expansion of the primary medical care Carer Health and Wellbeing Service • Commitment to providing respite support particularly to older carers and those caring for people with dementia. Integrated Pathway Redesign During 2016/17 we will focus on: • Mapping work to identify all services we already commission (including BCF schemes), our gaps and interdependencies aligning the interdependencies with our other key BCT workstreams — March 2016 • Agree local definition on what we mean by frailty and how we identify our cohort of patients — to take a proposal to the FOP & Dementia Board — April 16 • Deliver a LLR Integrated Falls Pathway — August 2016 • Develop local MCP Model for Frail Older People Strategic Outline Case — August 2016 • Develop Business case and Implementation Plan — November 2016 • Commission Discharge Pathway 3 — bed based reablement for patients who are safe for transfer but due to their overnight needs require support and a period of intensive reablement to Draft to NHS England 2.0 74 | Clinical Work-streams optimise them before they are assessed for their ongoing needs at home — implementation of new pathway October 2016. The Case for Change Why is change needed? Healthy ageing is a concept promoted by the World Health Organisation (WHO) that considers the ability of people of all ages to live a healthy, safe and socially inclusive lifestyle. Age is the single most significant driver of health need, and consequently older people are the biggest and costliest users of health and social care. Measures of Success The overall focus for the initiatives to support care for older people will be to improve the quality of experience and quality of health and social care delivery through: ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ reduction in readmissions — aligned to the 90 day readmissions target in our BCF Plans reduction in length of stay — in particular for patients who are non-weight bearing and those awaiting reablement and ongoing care — this links to our local target for DTOC within our BCF plans improving the quality of experience for the service user and their family/carers improving transfer/discharge support for the patient/service user and carers increase in diagnosis rates in line with national prevalence, for dementia improved care, prevention and support within care homes improved care planning across the health and social care spectrum education, training and development for health and social care professionals including care home staff regarding dementia and falls reablement and assessment programmes being developed to support independent living for a patient/service user with a view to a patient/service user being able to return home reduction in out-patient attendances reduction in attendance in primary care. Draft to NHS England 2.0 75 | Clinical Work-streams Planned Care and Cancer NHS West Leicestershire CCG benchmarks xxx for elective referrals from GPs to acute services, which means that the improvements forecast for the productivity of elective care will need to come from better and more productive management of existing elective pathways. The NHS constitutional standard that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment is being met across the three CCG’s in the sub-region and is modelled to achieve the standard at year end. This is being overseen by our LLR Joint RTT & Cancer Board which works towards the achievement of sustainable performance against the NHS constitutional standards for elective care. This board is overseen by the Managing Director of Leicester City CCG on behalf of all three CCG’s in the sub-region. This collaborative board, formed of commissioners and providers plus representatives from the Area Team, cancer network and TDA, is mandated to improve against and maintain the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice, as outlined in the nine ‘must do’s in the NHS planning guidance. Performance Both of the 31 day standards are predicted to recover by the end of 15/16, whilst the 2 week standard has already achieved. We expect to maintain delivery of all of these 3 standards through 2016/17. What are we going to do? To continue our achievement of this standard: We will: • Continue forensic analysis of performance against national standards in collaboration with our acute provider, at both executive and operational levels. If required, we will enact contractual levers such as agreed Remedial action plans and hold the system to account for delivery of these. • Monitor performance each week in collaboration with our provider lead in order to identify deterioration of performance at specialty level at an early stage and take action to minimise impact on patient care. To do this, we will set up specific operational groups, consisting of executive commissioner and clinical and non-clinical providers, to identify and eradicate blocks at specialty level where required. • Ensure dependencies are understood and taken into account, especially for diagnostic capacity between cancer and elective care and any impact of cancelled operations. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 76 • Continue to collaboratively model our demand and ensure sufficient activity is commissioned across both NHS and independent sector providers. For example, where demand outstrips capacity within NHS providers including the LLR Elective Care Alliance, we will utilise capacity in the independent sector and enable inter-provider transfers as required. This has proved successful in 2015/16 with specialties such as ophthalmology (cataracts). • Continue to promote patient choice through our programme of patient engagement. This includes information on the use of the electronic referral system for patients and GP’s and informing patients of their rights under the NHS Constitution. We recognise that the success of the RTT and cancer Board objectives is wholly dependent on a range of initiatives we are taking under our planned care workstream to manage both demand appropriately and redesign of pathways to enable efficient flow across specialties. Our plans for this workstream are outlined in this next section. Planned care redesign Analysis of NHS Right Care We have used our C4V pack (2015) to assess where to focus our work in 2016/17. Analysis shows that our key areas are gastrointestinal and genito-urinary specialties for elective care. If we were to reach the average compared to the best of our peer 5 CCG cohort for each of these specialties the CCG could save £140,000 and £300,000 respectively. Plans to address these pathways are detailed below. What are we going to do? Implement referral guidelines Using PRISM, we will work with 18 specialties to review pathways and referral guidelines to manage patients more successfully in primary care. In Q1 and Q2 16/17 we will focus on the following specialties (tranche 1): • ENT • ophthalmology • gastroenterology • general surgery • MSK (including back pain) • Urology/Genito-urinary • Dermatology • Rheumatology Draft to NHS England 2.0 77 | Clinical Work-streams Secondary specialties (tranche 2) include neurology, pain management, respiratory, cardiology, plastics and medical day case. These are planned for Q3 and Q4 2016/17. Additional actions to manage referral activity effectively will include: • We will implement an Advice and Guidance service across these Specialities linked to the UHL Contract to provide our GP’s with an opportunity for quick access to Consultant advice. • We will work with Specialties and Primary Care colleagues to look at the benefits of referral triage in specific specialities, (MSK, Gastroenterology, Dermatology and Ophthalmology). This will reduce the number of inappropriate referrals going to Secondary Care. • We will scope and implement clinically led pathway redesign involving Primary and Secondary Care clinicians to reduce steps, remove duplication, improve patient experience and provide value for money. The work on Dermatology will commence in 2016 and the other first tranche specialties outlined above will follow. New outpatients and follow ups In 15/16, implementation of open access follow ups for patients who had had a procedure has resulted in a reduction in follow ups. We expect this reduction to increase in 16/17 as these contract agreements embed. Additional actions we will take: • We will work with the specialities above to drive down clinical variation within a speciality. • We will expand the range of virtual clinics by increasing the number of phone follow ups and encouraging the use of Skype. • We will improve the use of nurse/therapy led follow up and scope the use of group-led follow up where appropriate. • We will introduce remote follow up for knee replacements at mechanical follow up at 12 months. This has been successful for hip replacements during 15/16 and we will scope other areas where this methodology can be applied. Our modelling shows that this will lead to a minimum reduction in follow up out patients of 10% across the specialities. This has been phased across the year to take into account implementation and embedding of practice within our GP community. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 78 How much will we invest? Project Leicester City West Leicestershire Investment QIPP | Investment QIPP | | | | | | | East Leicestershire & Rutland Investment QIPP When will the project begin? High Level Implementation Plan 2016/17 A M J J A S O N D J F M Implement referral guidelines for tranche 1 specialties Implement referral guidelines for tranche 2 specialties Implement virtual clinics Implement remote follow up QIPP Outcomes • Support the reduction of Outpatient footprint within the acute care setting • Reduce day case activity and increase the use of clean room • Improve the efficiency and effectiveness of community hospitals – making further use of the Elective Care Alliance • Effective clinical triage and assessment will streamline referral processes Draft to NHS England 2.0 79 | Clinical Work-streams Cancer Cancer is one of the main contributors to early death in the city, with our public health data telling us that 25.2% of all deaths in all ages being attributed to some type of cancer. This increases to 34.8% for all deaths under the age of 75. Analysis of NHS Right Care data Our Commissioning for Value data set tells us that if West Leicestershire CCG performed at the average of the Best 5 of similar 10 CCGs in the country xxx. When looking at specific cancer pathways, it is clear that our improvement opportunities are vast in cancer, with a specific requirement to focus on: • Breast cancer (particularly improving the number of patients with first definitive treatment within 2 months) • Lower GI cancer (particularly early detection and < 75 mortality) • Lung cancer (particularly early detection and improving the number of patients with first definitive treatment within 2 months) Performance The 31 day and 2 week cancer standards were met in 15/16 and we expect to maintain delivery of these through 2016/17. For 62 day cancer, our trajectory is as follows: 62 day cancer trajectory 100 80 60 % 40 20 0 March February January December November October September August July June May April Working collaboratively with the acute trust, we expect performance to be recovered by September 2016. What are we going to do? The CCG is working collaboratively to implement the recommendations outlined in the ‘Achieving World-Class Cancer Outcomes’ strategy for England 2015/2020. As part of this ongoing work, we have started clinical engagement with our providers to agree the delivery of the following elements on a phased basis over the timeframe of the strategy. This will include: Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 80 • Formation of an LLR Cancer Alliance by April 1st 2016. • Identification of further actions to enable the delivery of the 62 day cancer waiting time as detailed below. • Implementation of inter Provider Transfer Guidance and related pathways, i.e. Oesophageal & Gastric, Prostate, Colorectal and Lung to minimise late tertiary referrals. • Review and implement (if appropriate) the developing breast timed pathway • Review and commission recovery packages • Ensuring adherence to agreed pathways and clinical guidelines, • Undertaking a six monthly review of the following pathways; oesophageal & gastric, and prostate. • Use information technology to simplify pathways, standardise process and share information. As outlined in the 9 ‘must do’s’, the CCG is committed to ensuring delivery of the NHS Constitutional requirements in relation to cancer care. Progress will be fed into the LLR Joint RTT and Cancer Board, which is chaired by the CCG Managing Director and has executive level attendance from UHL, at both managerial and clinical level. To ensure pace and rigour in delivery of pathway redesign, the Board also mandates the formation of specific clinical problem solving groups on a task and finish basis where required. In order to deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity and 31 day cancer standards: • We will continue to monitor progress against the agreed trajectories outlined in the Recovery Action Plan for these targets through the LLR Joint Cancer Board. Performance for the 62 day standard is expected to be back on track in September 2016. For the 31 day standard, performance trajectories indicate that we will meet the standard from April 2016 and this will be robustly managed at commissioner level. • Monitor performance each week in collaboration with our provider lead in order to identify deterioration of performance at specialty level at an early stage and take action to minimise impact on patient care. To do this, we will set up specific operational groups, consisting of executive commissioner and clinical and non-clinical providers, to identify and eradicate blocks at specialty level where required. For example, in 15/16, Commissioners initiated this programme for urology which enabled identification and delivery of specific actions which improved performance for this specialty. • Working with both UHL and the Elective Care Alliance, we will Draft to NHS England 2.0 81 | Clinical Work-streams have a health economy theatre capacity plan in order to understand the actions required to ensure that theatre capacity issues do not affect the delivery of constitutional standards. • • For patients on the 62 day pathway specifically: • Implement a monitoring tool which identifies the number of patients on this pathway at specific time points – for example, this will enable commissioners to understand the capacity constraints and pressures which impact on any existing backlog or result in a potential backlog. • We will roll out the pilot providing every patient who leaves hospital on a 62 day pathway knows the next step in their treatment and when their next appointment is. This enables every patient to understand each stage in the pathway and empowers the patient to hold UHL to account for delivery of their care. For diagnostic capacity specifically: • We will use demand modelling to ensure adequate diagnostic capacity is commissioned through our capacity planning process. This includes capacity at NHS Trusts, the Elective Care Alliance and the independent sector, including mobile units where required. • We will continue to commission CT colon as the first line test, replacing colonoscopy, for patients on the lower GI 2 week pathway. This is clinically safer for our patients and releases colonoscopy capacity which enables overall achievement of the diagnostic standard. In order to maintain the delivery of the constitutional two week standard: • We will encourage GP’s to appropriately refer to the 2 week wait pathways for suspected cancer to support early diagnosis via revised referral templates which supports the quality of referral information provided to UHL and helps minimise pathway delays. • We will also disseminate patient engagement material, designed to maximise patient engagement and minimise non-engagement. This will be available on PRISM. • We will roll out the gastroenterology ‘advice and guidance’ pilot to other high volume specialty areas (lung and urology) across 16/17. This enables appropriate referrals to be managed more efficiently whilst reducing the overall level of demand on the 2 week pathway. In order to make progress in improving one-year survival rates: • We will work with our newly-formed Cancer Alliance and Achieving World-Class Cancer Outcomes task group to identify Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 82 and implement actions and agree an associated trajectory for improvement. In order to reduce the proportion of cancers diagnosed following an emergency admission: • We will scope the development of and appropriately implement preventive strategies for the early diagnosis of cancer, working in partnership with our Public Health colleagues. This will include raising awareness of cancer symptoms & raising awareness of and piloting new methods of cancer screening. We will also encourage our population to use the health services that address risk factors for cancer through our Lifestyle Hub (e.g. obesity, smoking and alcohol misuse). How much will we invest? Project Cancer screening Leicester City West Leicestershire East Leicestershire & Rutland Investment QIPP | Investment QIPP | Investment QIPP When will the projects begin? High Level Implementation Plan 2016/2017 A M J J A S O N D J F M Launch Cancer Alliance Implement cancer screening Recover 31 and 62 day cancer standards Demand modelling for diagnostic capacity Patient engagement materials launched on PRISM Roll out the ‘advice and guidance’ service What will the outcome of these interventions be? • We will deliver the NHS Constitution 62 day cancer waiting standard, including adequate diagnostic capacity and 31 day cancer standards • We will continue to deliver the constitutional two week standard • We will make progress in improving one-year survival rates • We will make progress towards reducing the proportion of cancers diagnosed following an emergency admission Draft to NHS England 2.0 83 | Clinical Work-streams Mental Health The CCG’s objective is to put mental health on a par with physical health and close the health inequalities gap between people with mental health problems and the population as a whole. To tackle this in 2016/17, we will increase our spending on mental health services, as a minimum, to be in line with our 3.6% allocation growth and re-focus our commitment to pre-existing Mandate objectives. This will include working with the National IST team to improve our IAPT pathway as well as continuing to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. We will also work with our providers to ensure that we achieve and maintain the two new mental health access standards, (more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral and that 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks). Strategic direction Mental illness is the single largest cause of disability in the UK and each year about one in four people suffer from a mental health problem. Physical health and mental health are closely linked. People with severe enduring mental illness die on average 15–20 years earlier than people who do not have a severe enduring mental illness. However only a quarter of those with mental illness are in treatment and only 13% of the NHS budget goes on such treatments. There is significant inequality when it comes to access to mental health services and treatment. Our plan outlines how we aim to work with our mental health providers, clinicians and service users to improve our acute mental healthcare pathway. This is so that we can improve the care provided for mental health service users in the community that promotes independence and enables individuals to be part of their communities. In times of crisis and when patients require admission to inpatient care we want to ensure that they receive high quality care that promotes recovery within safe settings. Over the next five years we need to drive towards an equal response to mental and physical health and towards the two being treated together. During 2015/16 we had already made a start with this by implementing and maintaining waiting time standard for IAPT. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 84 Challenges Our key challenges that require improvement are the: • percentage of people who are recorded on GP registers of severe mental illness (SMI) by CCG 2013/14 • percentage of people with severe mental illness (SMI) recorded in GP SMI registers who were excepted from the calculation of QOF achievement scores by CCG 2013/14 • percentage of people experiencing a first episode of psychosis commencing treatment with a NICE approved care package within 2 weeks of referral. What Are We Going To Do? The mental health service case for change is built around the need to refocus on prevention, early diagnosis and recovery. When people need help from specialist services waiting times can be too long and those in crisis cannot always access services as quickly as they would like, often seeking help from emergency services. Alternatives to hospital admission will also be provided to ensure people are treated in the least restrictive environment. In summary: • widen choice and effectiveness in crisis response and reduce demand for beds • increase resilience and promote recovery and independence • meet challenging rehabilitation needs locally — reducing placements. An independent review confirmed the widely held view that the current mental health pathway was not working well. There is poor flow through the pathway, long lengths of stay in comparison to national benchmarking and excess delayed transfers of care; overspill placements, concerns about safety and quality in the inpatient environment, and a poor interface between primary and secondary care services. There are three strands of work within the mental health work stream • acute mental Health Pathway. • alternative Hospital and Specialist Mental Health Placements — Rehabilitation. • Resilience and Recovery. All of the projects are designed to deliver qualitative benefits for people with mental health problems in LLR by: • increasing resilience and reducing incidents of illness Draft to NHS England 2.0 85 | Clinical Work-streams • strengthening support to primary care • reducing demand and cost for secondary and tertiary care • supporting sustained recovery. Dementia The local strategic direction for people living with dementia is covered in the Frail Older People (FOP) section of this plan. The focus of the work will be around the improvement of diagnosis rates and a shift of management from secondary care to within the community and primary medical care and is in line with national guidance as outlined in the Prime Minister’s Challenge on Dementia 2020 document. Children’s Mental Well-being Children, young people and carers have told us that they are worried about a range of issues that affect their mental health and well-being. Plans to improve services are covered in the Children’s, Maternity and Neonates section of this plan. Adult Mental Health Acute Care pathway We will: • remodel CMHTs to strengthen support to primary care. • review of Psychiatric Intensive Care Units provision • provide an all age MHA Place of Safety unit that is compliant with national standards • strengthen Liaison Psychiatry to be adequate and effective • develop NICE compliant services for First Episodes in Psychosis. The anticipated outcomes will be improved quality of care and patient outcomes, reduced use of hospital beds, and associated cost. Alternative Hospital and Specialist Mental Health Placements — Rehabilitation There are currently a number of patients in specialist rehabilitation mental health hospital placements. Many of these people are out of county and have been receiving the same level of support at relatively high costs for some time. The intent is to target reviews aimed at ensuring people have appropriate care packages closer to home at reduced cost, potentially using this redirected investment to build local infrastructure. Improving Access to Psychological Therapies (IAPT) The Improving Access to Psychological Therapies (IAPT) is an NHS programme of talking therapy treatments recommended by the National Institute for Health and Clinical Excellence (NICE) which Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 86 support frontline mental health services in treating mild to moderate depression and anxiety disorders. The Leicestershire County service allows people to access the service via a GP referral, a self-referral process including through a web based portal, post and via the telephone. Predominantly the risk to achieving and sustaining performance within the IAPT service are based on the number of referrals received by the service and staffing levels. Staffing levels within the service fluctuate due to the role of psychological well-being practitioners being a transitional step to other psychological disciplines, which therefore limits the number of trained staff being recruited. In order to address this within Leicestershire, Nottinghamshire Healthcare Foundation Trust and Leicestershire Partnership Trust have developed in conjunction with De Montfort University a course which will give students the skills needed to become psychological practitioners. The first intake will be April 2016 with a subsequent course running in September 2016, this provision will be ongoing. This initiative will also support the proposed 2016/17 Service Delivery Improvement Plan (SDIP) which aims to ensure that staff are fully trained to deliver the new access standards, including a commitment by the provider to sign-up to nationallyapproved accreditation programmes Increasing referrals is key to maintaining people accessing the service and serving the population of Leicestershire, and the service has been proactive in disseminating information to the public, community groups and voluntary organisations. However in 2016/17 there will be a renewed focus on people with long term conditions and other groups. The service will be working with Adult Social Care and Community Health Services to encourage appropriate referrals through their teams, as many of these teams aid people who may not be aware of the IAPT service. Within Rutland County Council staff are to be trained in how to identify people with anxiety and depression and to give them confidence in assisting people to refer into the service, this initiative is hoped to be rolled out the Leicestershire councils. Additional proposed initiatives in 2016/17 which are being explored include webinar based therapy sessions and treating people who suffer from insomnia that are medicated using hypnotics. Access rates The service has consistently improved on the number of people entering treatment within 2015/16, meaning more people are being treated for mild to moderate anxiety and depression within the CCG. In order to continue to improve and achieve the national target, the service is focusing on increasing the number of people being referred into the service. Moving to recovery has met and exceeded national KPIs throughout 2015/16. Draft to NHS England 2.0 87 | Clinical Work-streams Waiting times The waiting time KPIs was introduced in 2015/16 and measures historically the time a person had to wait to begin treatment after they have been discharged from the service. The achievement of these KPIs have been challenging due to the service previously having reduced staffing capacity, which resulted in lower performance, however the service is now at full staffing capacity with current waiting times being consistently below 6 weeks, therefore once these patients complete treatment the waiting time performance will improve. The focus in 2016/17 is to ensure staffing levels are consistent and to further encourage self-referrals where waiting times are significantly lower. This is in addition to supporting the achievement of waiting times through the proposed Service Delivery Improvement Plan. 2016/17 Trajectories Target % Qtr 1 Qtr 2 Qtr 3 Qtr 4 % of people accessing the service 15% 15% 15% 15% 15% % of people moving to recovery 50% 50% 50% 50% 50% Waiting Times — less than 6 weeks 75% 75% 75% 75% 75% Waiting Times — less than 18 weeks 95% 95% 95% 95% 95% Nov – 15 Dec – 15 Indicator Descriptor West Leicestershire CCG Current Performance Indicator Descriptor Target % Oct – 15 West Leicestershire CCG % of people accessing the service (YTD Dec) 15% % of people moving to recovery 50% Waiting Times (nationally reported) — 6 weeks 75% 14.9% 14.3% 14.3% 50% 50% 50% 46.2% 45.8% 52.6% Early intervention for people experiencing first episode psychosis If not treated early, psychosis can cause morbidity with substantial and enduring distress and disability. People with psychosis often do not receive, when needed, assessments and treatment interventions from which they would benefit. Across Leicester, Leicestershire and Rutland, the CCGs currently commission an Early Intervention in Psychosis service for those people Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 88 aged 14–35 years based on clinical evidence. In order to meet the new national standard, we are working with LPT to redesign the current service to include people up to the age of 65 years and will consider allocating resources accordingly in 2016/17 in line with the commissioning guidance. Resilience and Recovery: Resilience The aim is to enable people to manage their health more effectively, reducing demand on statutory services that require initiatives across a number of partners. Initial targets during 2016/17 include: • promoting children and young people’s mental health through access to online support and increase support in schools • working with Public Health to promote workplace health, Five Ways of well-being and tackling stigma • social prescribing: The CCG will work with partners to adopt best practice to link users with non-medical sources of support within the community • employment practice: The CCG will work with partners to adopt best practice as described in the ‘Mindfulness’ program. Recovery network Following a review of Mental Health voluntary sector grants during 201,5 a series of workshops was held with voluntary groups, users, carers and other partners to discuss current and future service provision. An underpinning principle of the work-stream is to increase the capacity of individuals and communities to avoid illness and recover if they become ill. Both overlapping objectives are dependent on mobilising community capacity, and enabling people to use mainstream resources where possible. Evidence indicates a visible network enabling people to access resources and to stimulate communities in developing opportunities is essential. Mobilising the voluntary sector is vital to realising this ambition. During 2016/17 a locality, outcomes based specification will be co-produced with voluntary sector providers, local authorities and service users. The service will then be commissioned during 2016 with a view to locality based services becoming operational from April 2017. In addition to the above, we plan to: • increase recovery college sites by 3 during 2016/17 • work with 3rd sector organisations to support recovery. • work with voluntary sector organisations to develop a LLR MH App • develop the role of Peer support workers. Draft to NHS England 2.0 89 | Clinical Work-streams The intended outcomes will be earlier and sustained discharges from statutory care and the consequent improvements in clinical outcomes and reduced secondary care costs. The benefits will be across LLR for both users of mental health services and their carers. Supporting people with Severe and Enduring Mental Illness The consequence of a lack of, or inappropriate, treatment can mean substantially worse physical and mental health and social outcomes, including a reduced ability to secure and retain stable accommodation and employment. Currently, the life-expectancy of people with Severe Mental Illness (SMI) is 15–20 years shorter than that for the general population. Rates of psychosis, or other severe mental disorders, vary by locality. The planning of treatment and support for existing or new cases requires knowledge and awareness of estimates of the number of people with psychosis in the local population. The Quality and Outcomes Framework (QOF) SMI register reflects the level of identification of SMI in primary care as a proportion of people on GP registers: • diagnosed with schizophrenia • diagnosed with bipolar disorder • diagnosed with other psychoses • on lithium therapy. Atlas of Variation — Severe Mental Illness 0+0+667585 Percentage of people who are recorded in GP registers of severe mental illness (SMI) by 2013/14. CCG 66 Peers 75 England 85 Some work in primary care has progressed and some of our GP practices are using pro-active outreach methods: engaging people with SMI, working closely with families, carers and third-sector outreach services, and making special arrangements for the homeless and mobile populations. During 2016/17 we will work with our practices and Mental Health Provider to review practice-level data to ascertain whether some primary care services are experiencing difficulties supporting people with SMI. Working with the practices we will ensure that service users: • have a comprehensive care plan, including support to attend physical health checks • receive interventions to address physical health conditions and health risk behaviours, focusing on cardio-metabolic health monitoring. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 90 We will be working with our practices to increase the number of people on the SMI register, with our local secondary mental health provider taking a leadership role to ensure full co-operation is achieved. This will involve: • targeted local needs assessment to determine gaps in the provision of health checks or physical health interventions for people with SMI • quarterly reconciliation of people being treated in secondary care under the Care Programme Approach and people on the QOF register • skilled assistance in ensuring checks are acceptable to and accepted by service users in primary care settings or at the individual’s residence • improved collaboration and coordination between primary care and secondary mental healthcare services in support of the physical health of people with SMI, potentially including different models of integrated care • establishment of enhanced primary care services for people with SMI • workforce undergraduate and continuing professional development in mental health. Primary care service providers need to consider proactive and supportive methods of engaging with people with SMI to encourage uptake of physical health checks, including: • helping for people to understand the importance of and need for health checks • flexibility when booking appointments • providing third sector or family outreach services • appropriate framing of reminders to attend • utilising wider community resources, such as community leaders, cultural communities, and community pharmacists. For people with psychosis or schizophrenia, we will work with our secondary mental health services to specify that they follow NICE guidelines and take responsibility for people’s physical health within the first year of treatment. Draft to NHS England 2.0 91 | Clinical Work-streams Measures of Success ✻ Adult Mental Health Acute Care — efficient, effective, safe, good ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ ✻ quality, recovery focussed care will be available in an appropriate setting, in a timely way for those experiencing acute mental health problems. Alternative Hospital Placements and Specialist Mental (including Section 117 MHA aftercare packages) — care closer to home at a reduced cost case managed effectively. Resilience and recovery — People are better able to manage their own mental health and relapse prevention is addressed therefore reducing people’s need for crisis Maintain access to psychological therapies at 15% during 2016/17 Maintain recovery rates at 55% Improved wait time for IAPT from 55% to 75% for 6 weeks by Q3 and maintain waiting times at 95% at 18 weeks during 2016/17 Work towards achieving the 2 week standard for referral to NICE approved treatment for first episode psychosis. Improved crisis management within the acute environment Improved education in primary care Enabling earlier intervention and more timely support in the event of a crisis through enhanced primary care services, backed-up by excellent acute services Reduced numbers of people receiving their care outside their local community — reduction of out-of-county placements to zero by the end of 2015/16 Providing more step-down support post-discharge. Commissioners and service providers then need to review estimates of the number of cases and of new cases of SMI in relation to current service provision, and adjust provision accordingly. After triangulation of the data, service planners need to review local SMI registers. What will we invest? Project Leicester City West Leicestershire Investment |QIPP | Investment QIPP | Section 117 Care Package review £295k Rehab AHP £228k East Leicestershire & Rutland Investment QIPP Draft to NHS England 2.0 92 | Clinical Work-streams Learning Disabilities Strategic direction In line with the national guidance on Transforming Care (refreshed in January 2016), the CCG has a comprehensive plan to deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy, Transforming care is a national programme designed to improve services for people with learning disabilities and/or autism, who display behaviour that challenges, including those with a mental health condition and will enable more people to live in the community, with the right support, and closer to home. While recognising the good work that has taken place to date, LLR CCGs along with partners need to build on this with the aim of: • moving people out of hospital that should not be there • ensuring the right community services are available to support people where they live • stop people going into hospital unless they really need to. National Must Do no. 8 “Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy.” The national and local vision for Learning Disabilities is that all people with a learning disability are people first with the right to lead their lives like any others, with the same opportunities and responsibilities, and to be treated with the same dignity and respect. They and their families and carers are entitled to the same aspirations and life chances as other citizens. By 18/19, the aim, with partners is to co-produce and deliver responsive, high quality, safe, learning disability services and support that maximise independence, offer choice, are person-centred, good value and meet the needs and aspirations of individuals and their family carers taking into account the diversity and changing demographics across LLR. The estimated prevalence (based on QOF 14/15) of adults (18+) with a learning disability in West Leicestershire CCGs area is 1,408 (0.38%) of people Challenges Our key challenge will be to maintain the scale and pace to deliver enhanced community provision and continue to reduce the inpatient capacity whilst at the same time ensuring that individuals and their families are supported through this transition. Furthermore we have our ambition to roll out Personal Health Budgets for people with learning disabilities. What are we going to do? During 2016/17 we will deliver our vision by: • Providing more proactive, preventative care, with better identification of people at risk and early intervention. An online Admission Avoidance Register has recently been developed. All Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 93 professional agencies can complete an online template to alert LLR CCGs to anyone they consider to be “at risk” of admission. This will result in a pre-admission Care and Treatment Review or in urgent cases a Blue Light Meeting which will involve all relevant agencies discussing all alternative options/ additional support that could be provided to avoid an inpatient admission. • Empowering people with a learning disability and/or autism, through the expansion of personal health budgets and independent advocacy. • During 2016/17 personal health budgets will be introduced to 48 people with learning disabilities across LLR. • Work with partners to develop greater choice and security in housing. A new step-down/step-through facility opened in February 2016 managed by Affinity taking referrals from all local authorities and CCGs, with priority given to those people who meet the Winterbourne View criteria. A three and six monthly review of the service will take place during 2016/17 to determine the success and how this service could be replicated in other areas. • Ensuring people with a learning disability and/or autism whose behaviour challenges are able to access mainstream health services (including mainstream mental health services in the community). This will be carried out by: • Reviewing current building based short breaks provision in order to develop person centred and flexible provision. Initially to pilot personal health budgets for short breaks provision with young people coming though transition. • Implementing LLR Autism Strategy 2014–2019 including commissioning a post diagnostic support service for those people without an intellectual disability. • Improving communication standards and accessibility information within GP Practices. • Providing local mental health in patient services that are highquality and assess, treat and discharge people with a learning disability as quickly as possible. All patients with LD and/or Autism in in-patient settings will receive a minimum of one Care and Treatment Review every 12 months. These reviews are chaired by the Chief Nursing Officer or their Deputy from the CCG accompanied by an independent clinical assessor and experts by experience. They assess the safety and care of the patient and appropriateness of the placement. The expanded LD Outreach Team will be involved in discharge planning from admission and throughout an inpatient stay. • Providing specialist multi-disciplinary support in the community, including intensive support when necessary to avoid admission to Draft to NHS England 2.0 94 | Clinical Work-streams mental health inpatient settings through the provision of a refocused and enhanced LD Outreach team. This will be achieved by additional investment of £398k in 2016/17 in order to: a increase the service from five days a week to seven. b employ dedicated therapy staff within the team c strengthen the admission pathway by involving the Outreach team in all patients considered ‘at risk’ of hospital admission, and therefore improve the likelihood of intensive community based care. d maintain outreach team involvement during any inpatient admission to support early discharge. Further to this over 2017/18 and 2018/19 we continue with the planned closure of local Assessment and Treatment short stay beds (current planned closure of 2 beds in 2017/18 and further 2 in 2018/19). Measures of Success ✻ Reduction in the number of patients needing mental health ✻ ✻ ✻ inpatient hospital admission, measured by monitoring outcomes of blue light/pre-admission/ post admission Care and Treatment Reviews. Reduction in the number of mental health inpatient bed days per patient. Decrease in delayed transfers of care and reduced readmissions. Increase uptake in use of personal health budgets for people with a learning disability. Draft to NHS England 2.0 95 | Clinical Work-streams Children’s, maternity and neonates Context There are an increased number of children who are living longer with life-limiting / complex health conditions. There are also a significant number of children attending hospital services that could be cared for more appropriately within a community or home setting. Another driver is the lack of financial and workforce efficiency across health, social care and voluntary sectors due to the duplication of services, staff and equipment, as well as a lack of cohesion. People and staff across Leicester, Leicestershire and Rutland (LLR) tell us that services are disjointed. They tell us that we don’t communicate effectively and, in some cases, we don’t meet their needs. Staff who are working directly with children and young people say similar things, they talk about the barriers which hinder them from delivering a high quality, appropriate and efficient service. In line with national policy it is only by working better together across organisations that these issues can be addressed. An additional driver for Children’s Hospital services is the need to colocate cardiac and other specialties by 2018. The consolidation of Children’s Hospital services in Leicester provides an ideal opportunity to review all models of care and check that appropriate integration is in place with community and primary care services. In addition it provides a stimulus for adjusting pathways and services to provide age appropriate care for children and young people and ensure effective transition of care to adult services at the appropriate time. Each project within the children’s work-stream is based on the principles contained within NHS England’s 5 Year forward View. There are also a number of national and local policies that underpin our proposals including: • Every Child Matters: Change for Children (DfES, 2004) • The Children Act 2004 • National Service Framework for Children, Young People and Maternity Services (DoH, 2004) • Every Disabled Child Matters (DoH, 2006) • Local Joint Strategic Needs Assessments (JSNAs) • Local CCG/Health and Wellbeing Board Strategies Analysis of NHS Right Care data Analysis of the right care data shows improvement opportunities in a number of areas for this work-stream. The two largest opportunities are for: Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 96 a Rate of A&E attendance for 0–19 year olds by 1000 population b Rate of elective admission to hospital for tonsillectomy in children aged 0–17 years per 100,000 population. Our overall maternity and early years pathway shows that we are better than the national average on most indicators but that there is still room for improvement: 40% % difference from Similar 10 CCGs Better Worse 20% 0% -20% -40% Mean number of decayed, filled or missing teeth in children aged 5yrs % receiving 2 doses of MMR vaccine by age 5 % of children aged 45 who are overweight or obese Unintentional & deliberate injury admissions for <5s Emergency admissions rate for <5s A&E attendance rate for <5s % receiving 3 doses of 5-in-1 vaccine by age 2 Emergency LRTI admissions rate for <1s sInfant mortality rate Emergency gastroenteritis admissions rate for <1s Breastfeeding at age 6-8 week Breastfeeding initiation (first 48 hrs) % of low birthweight babies (<2500g) Smoking at time of delivery Flu vaccine takeup by pregnant women <18 conceptions rate -60% What are we going to do? Since the introduction of the Better Care Together programme the children’s work-stream has been reviewing pathways with the intention of reducing duplication and increasing productivity. • • Improve Children’s Non-Elective Care — There are a significant number of children attending hospital services that could be cared for more appropriately within a community or home setting. • We will commission a new children’s emergency department at the Leicester Royal Infirmary (LRI) in December 2016 with a single front door, with subsequent phases (2017 to 2020) focussing on the colocation of other Children’s Hospital services. • We will commission packages of training & support to Primary Care and provide targeted information to parents / carers. Joint Commissioning of Services for CYP with SEND — From September 2014 CCGs have been commissioning services jointly with social care for CYP with SEND, as a result Learning Difficulty Assessments are in transition to Education, Health and Care (EHC) Plan. Draft to NHS England 2.0 97 | Clinical Work-streams • • We will continue to work with Local Authority colleagues to develop an integrated process around the assessment, planning and delivery of services for CYP with SEND in line with new statutory guidance. • The transition from Learning Difficulty Assessments (LDAs) to Education, Health and Care (EHC) Plans will continue to take place. • Work on CYP Personal Health Budgets will also continue to progress in response to the recent development that any CYP assessed as needing an EHC Plan will have the option of having a PHB. Initial Health Assessments — the current IHA service is not meeting its 28 day ‘notification to assessment’ target. • We will continue to work with Local Authority colleagues in developing a sustainable long-term model ensuring CYP receive assessments in a timely manner. Paediatric Audiology - Following the 2013 review of LLR’s paediatric audiology services significant collaborative work remains necessary to ensure the recommendations are implemented and paediatric audiology services are sustainable and of the highest standard. Complex Health Needs (Diana Service / Short Breaks) - Coverage of the CCG commissioned short breaks service is inconsistent and inequitable (demand has increased year-on-year whilst budget has remained at a fixed figure). • We will review its support to CYP with complex health needs so that there is a clear understanding of what the short breaks offer is ensuring timely and equitable access. What will we invest? Project Leicester City West Leicestershire East Leicestershire & Rutland Investment QIPP | Investment QIPP | Investment QIPP When will the projects begin? High Level Implementation Plan 2016/2017 A M J J A S O N D J F M Launch new Children’s ED Initial health assessments Paediatric audiology Review of short breaks services Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 98 Measures of success ✻ All CYP will have an EHC Plan that meets their individual needs. ✻ Improved trajectory to meet 28 day ‘notification to assessment’ ✻ target Sustainable paediatric audiology services Children’s mental health Context The Department of Health and NHS England have issued a new strategic plan called Future in Mind. This calls for a transformation of services to meet the mental health needs of children and young people. Key elements of Future in Mind include: • Promoting resilience, prevention and early intervention • Improving access to effective support – a system without tiers • Care for the most vulnerable • Accountability and transparency • Developing the workforce Change is needed as children, young people and carers have told us that that they are worried about a range of issues that affect their mental health and well-being. These include academic pressure, peer pressure, family breakdown, sexual exploitation and cyber-bullying. They would like more support in school or through confidential helplines and websites. Parents have told us of the “battle” to access specialist support and young people being told that they are “not ill enough” to get help. They also report having to repeat their story many times to different practitioners and that organisations do not always know what each other are doing. Additional funding will be provided to CCGs to implement a Transformational Plan designed to address these issues. In total, the three CCGs in our region will receive £1.87 million. This will be used alongside existing funds from local commissioners to implement the plan. The City element of this funding is xxx. Evidence base for change Locally, we have collaboratively analysed a range of data sources to inform our plan: • We have commissioned an independent review into the specialist CAMHS and mapped the community based services which currently provide emotional help and support to children young people and carers. • We have also looked at the LLR Joint Strategic Needs Assessments Draft to NHS England 2.0 99 | Clinical Work-streams which tells us about our local population and prevalence rates for different conditions. • We have also commissioned reports into a number of serious incidents where as partner agencies, we struggled to provide the right care at the right time for children and young people experiencing acute behavioural or mental health problems. • We have also analysed the number and type of hospital beds we need for children with a severe mental health problem such as an eating disorder or psychosis. This analysis tells us that there is an increasing prevalence of mental health and developmental difficulties such as autism spectrum disorder, ADHD, self-harm and eating disorders. The referrals to the special CAMHS service have gone up 9% per year over the past four years, and it can take a long time to get support from this service. Average waiting time for an assessment from CAMHS is now over 13 weeks. There are some really exciting and innovative community based early support projects such as parental training, self –esteem workshops, school anti-bullying projects and parent led support groups. However these are inequitably spread across the region. These services are all commissioned separately and the standard and quality of therapeutic care can vary. The reports recommend that we commission two new services: a specialist community based service for children with an eating disorder, and a crisis and home treatment team that will support families experiencing acute difficulties and when the child may need to be admitted to hospital. We should also aim to have more hospital beds available closer to home. The reports also show that whilst 24% of people in our area are under the age of 20, only 6% of health spending on mental health services is for this age group. We probably spend less on specialist mental health services for children than other comparable areas. There is significant pressure on local authority budgets. What are we going to do? We have collaboratively prepared, developed and begun to implement our transformational plan for children and young people’s mental health with our patients and partners, including both other CCGs and our providers. There will be one transformational plan covering Leicester, Leicestershire and Rutland. Key partners will be the three CCGs, the three Health and Wellbeing Boards, the three local authorities, the Office for the Police and Crime Commissioner, the voluntary sector, schools colleges and GPs. Children and young people will be central to our plans. The key strands of the plan will be as follows: Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 100 Health Promotion • We will commission a campaign to promote mental health and resilience for children and families. This will be led and commissioned by Public Health Departments and involve close work with education providers, GPs and other universal settings. It will utilise social media and other innovative methods to engage with young people. It will also provide accessible information about how to find extra support. Early Help • We will establish a multi-agency first response and early help service that would respond to concerns about the emotional health and development of children and young people. The service would accept referrals from a range of sources including self-referrals from parents, carers and young people. It would offer a first assessment, guidance and advice, and choice of early help offers. • We will commission a range of low intensity early help offers that build resilience and prevent escalation to more serious or longer term mental health problems. Access to Specialist Help • We will establish a single gateway to additional help for those with enduring difficulties or at risk of significant harm to self or others. Specialist Community Interventions for Children with Eating Disorders • We will establish a specialist community eating disorder service with the capacity to receive 100 new referrals a year and meet the national access standards that all assessments are completed within 4 weeks of referral. This will provide NICE concordant interventions for children and young people with eating disorders, a serious and potentially life-threatening condition. Intensive / Crisis Support • We will commission an intensive multi-agency “out of hours” and home treatment services for those experiencing acute behavioural or mental health difficulties and at risk of serious harm to self or others. • We will ensure there is a designated “Place of Safety” for a person under the age of 18. Workforce Development • We will recruit and develop a specialist CAMHS workforce that is skilled and experienced in delivering evidence based therapies (such as CBT, Family Therapy and Interpersonal therapy) and in Draft to NHS England 2.0 101 | Clinical Work-streams using clinical outcomes. • We will develop all practitioners working with children, young people and their carers to have an understanding and skills in supporting children with mental health issues. How much will we invest? (Total across LLR) Project Health promotion Early help Access to specialist help Specialist Community Interventions for Children with Eating Disorders Intensive support Workforce development Investment LLR | | | | | | | | QIPP When will each project begin? High Level Implementation Plan 2016/2017 A M J J A S O N D J F M Health promotion Early help Access to specialist help Specialist Community Interventions for Children with Eating Disorders Intensive support Workforce development What outcomes will this achieve? Through this transformational plan we will monitor the following performance indicators: • A survey of what children and young people understand about mental health and how they feel about their own health. • The number of educational settings that are part of this plan, and are working to improve understanding on mental health and support their students. • The number of children, young people, parents and carers who access early support and interventions. • How children, young people parents and carers rate this support. • The number of children and young people assessed by the specialist CAMH service. • How long it takes from a referral to CAMHs to seeing a practitioner. • How long it takes to see a specialist if you have an eating disorder or psychosis. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 102 • How many children and young people attend the Emergency Department because of an acute mental health or behavioural problem, and how many have to wait more than four hours before they are assessed. • How many children and young people are admitted to a mental health hospital and how long they stay. Maternity services Context There are a number of factors that need to be considered in the future planning of the way we deliver Women’s services in Leicester, Leicestershire and Rutland (LLR). Across the country it is predicted that the number of births will increase each year which will put significant pressure on our maternity and neonatal services. At a local level, Leicester, Leicestershire and Rutland has high rates of infant mortality which may be linked to the population profile and the buildings we are using to deliver our services are in many cases not fit for purpose. There is also a need to fit in with the wider 5 year strategic plan for Leicester’s Hospitals, which includes reviewing where services should be delivered from. Within this work stream there is a focus on consolidating all women’s acute services and neonatal services on a single site supported by a flexible multi-disciplinary workforce that responds to changes in volume and complexity, ensuring sick, term and premature babies are cared for in the right cot at the right time, ensuring better perinatal outcomes, evaluating and improving the uptake of antenatal and parenting support; and reviewing and ensuring the availability of appropriate, and future-proofed, facilities for midwifery and obstetricled care are all key priorities. In March 2015, NHS England announced details of a major, national review of the way NHS maternity services are commissioned, as promised in the NHS Five year Forward View. The review will assess current maternity care provision and consider how services should be developed to meet the changing needs of women and babies. We will make sure these national findings are used to develop safe, sustainable Women’s services for LLR. A review into Maternity and Children’s services has also been undertaken locally. Next Stage Review was undertaken in 2010 by Leicester’s Hospitals and its commissioners. As part of the review, we engaged with local women to find out about their experience of accessing Women’s services and find out what was most important to them when they needed this kind of care. Draft to NHS England 2.0 103 | Clinical Work-streams What are we going to do? Commission sustainable Long-Term Model for Maternity and Neonatology Services Women’s services at Leicester’s Hospitals are made up of Maternity, Gynaecology, Genetics, Fertility and Neonatal (newborn babies) services. These services are currently provided across two acute hospital sites, Leicester Royal Infirmary and Leicester General Hospital; with a midwife-led birthing centre at St Mary’s Hospital in Melton Mowbray. Our aim is to provide high quality, safe maternity and neonatal services based on best practice and which are easily accessible. These services will be supported by the appropriate infrastructure across both primary and secondary care. There will also be sufficient capacity to care for all babies requiring tertiary care by consolidating and further developing neonatal services in collaboration with our Newborn Network partners in the East Midlands. This project will be underpinned by the consolidation of all women’s acute services and neonatal services onto a single site supported by a flexible, multidisciplinary workforce that responds to changes in volume and complexity where appropriate. Improve Access to Maternity LLR’s performance against the national 12 week access rate to maternity services is inconsistent although overall performance is good. Following an audit of access data, improvement can be made in relation to specific vulnerable groups that do not disclose their pregnancy in a timely manner. The CCG will also work with UHL to improve the 12 week access rate though the re-launch of a marketing campaign and a review of the supply of information from the Early Pregnancy Assessment Unit (EPAU). Review ‘Transition to Parenthood and the Early Weeks / Parenting’ Education and Support In collaboration with Public Health and NHS Trusts, the CCG will continue its review of antenatal parenting programmes and parenting education literature so that all women get the appropriate level of advice and support to ensure that parents are more prepared for, and have the best possible start on their, parenting journey. Commission sustainable maternal Mental Health services (Perinatal Depression) There have been several recent developments in the commissioning landscape of perinatal provision, both on part of the CCGs and Local Authority colleagues. As such, the CCG and its partners will continue to work with local and out-of-area provider organisations to improve maternal and perinatal mental health outcomes through the development and delivery of a clear perinatal mental health pathway. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 104 Appropriate and timely local provision will reduce escalation and the need for admissions to out-of-area in-patient Mother and Baby Units (MBUs). Develop and begin implementation of Infant Mortality Strategy Infant mortality remains one of the key issues that agencies need to work together to address. The national average for the infant mortality rate is at 4 per 1,000 live births and the mortality rates in England and the East Midlands have significantly decreased. We will jointly come together to implement our LLR-wide Infant Mortality Strategy; this addresses several high impact areas including improving breastfeeding rates, reducing maternal obesity and smoking. These priority actions have been mapped to high impact actions outlined in national documentation. The CCG will also work with UHL to look at improving the recognition and detection of ‘small for dates’ babies and women with reduced foetal movement. What will we invest? Project Leicester City West Leicestershire East Leicestershire & Rutland Investment QIPP | Investment QIPP | Investment QIPP | | When will the project begin? High Level Implementation Plan 2016/2017 A M J J A S O N D J F M Commission sustainable Long-Term Model for Maternity and Neonatology Services Improve Access to Maternity Review ‘Transition to Parenthood and the Early Weeks / Parenting’ Education and Support Develop and begin implementation of Infant Mortality Strategy Commission sustainable maternal Mental Health services (Perinatal Depression) Draft to NHS England 2.0 105 | Clinical Work-streams End of Life Care and Learning Lessons to Improve Care Each organisation developed plans to address the specific organisational actions identified through the 2014 review (see right). An LLR-wide Clinical Taskforce was also established to oversee the implementation of five system-wide actions and the progress of each organisation to implement relevant changes. The Five Part Plan comprised: 1 2 3 4 5 System-wide clinical leadership Patient and staff engagement Effective care across interfaces Transforming urgent and emergency care Transforming End of Life Care (EOL) Context—case for change In July 2014 Health Organisations in LLR published the Learning Lessons to Improve Care (LLtIC) report into the quality care of a cohort of 361 patients who died in LLR in 2012–2013. This was a proactive review of the quality of care by commissioners and providers. The reason for the review was to respond to concerns about fragmentation of care reporting by GPs and to look at a UHL SHMI rate of 1.05 (even though this was within expected limits and not a statistical outlier).The review focussed on a non-random sample of patients where we knew we would identify the greatest learning. The learning would be extrapolated to improve care across all patients in LLR. This Taskforce ensured a collective responsibility across all members to find solutions to the concerns identified. The membership has reflected this ownership across healthcare in LLR and each individual organisation has been responsible for implementing improvement actions. Membership includes LLR CCGs, UHL, LPT, Public Health, LMC LLR clinical leaders accepted the and Healthwatch. Together with the Priorities for End of Life Care, the locally identified themes have given a focus for the proposed changes. The EOL BCT work-stream has identified two keys areas of need locally: • • unified Care planning, offering greater opportunities for patients and those important to them to discuss and plan aspects of their future care and better co-ordination of care plans, through sharing these electronically across organisations the provision of appropriately co-ordinated 24/7 palliative care services for people at the end of life and those who are important to them. The 2015 Health Ombudsman’s report ‘Dying Without Dignity’ highlighted how fragmented care, with variable access each day, has a negative impact on experience and care of people who are dying and are recurrent themes in complaints. Locally, we know that emergency admissions for patients in their last two weeks of life are higher than average. Many of these admissions occur outside of GP opening hours and are initiated by the Out of Hours Service, including 111, EMAS or ED. Patients, families and professionals report that current systems are difficult for them to understand and that they do not always feel that they are directed to the most appropriate option. There are inconsistencies in the availability of services across LLR, influenced by disease group, geographical area and local facilities. findings of the report and the actions that were necessary to improve care and decided to take an open and transparent approach to the review; proactively publishing the report and taking the unprecedented step of contacting relatives of those patients whose notes had been reviewed. Locally the Learning Lessons to Improve Care Report identified key themes that warranted further improvement: DNAR orders Clinical reasoning Palliative care Clinical management Discharge summary Fluid management Unexpected deterioration Discharge Severity of illness Early warning score Antibiotics Medication Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 106 The National End of Life Care Strategy, July 2008 has recently been updated with a national End of Life Framework for Local Action 2015–2020, with this vision: “I can make the last stage of my life as good as possible because everyone works together confidently, honestly and consistently to help me and the people who are important to me, including my carer(s).” Six ambitions to achieve the vision have been identified: 1 Each person is seen as an individual 2 Each person gets fair access to care 3 Maximising comfort and wellbeing 4 Care is coordinated 5 ll staff are prepared to care 6 Each community is prepared to help And the enablers to achieve these ambitions: • • • • • • • • Personalised care planning Shared records Education and Training 24/7 access Evidence and information Involving, supporting and caring for those important to the dying person Co-design Leadership The End of Life ambitions locally for LLR are in line with this national framework. 0+0+494744 Atlas of Variation — End of Life Percentage of all deaths that occurred in usual place of residence, 2013. CCG 48.85 Peers 47.01 England 43.55 Priorities for Care of the Dying Person The Priorities for Care are that, when it is thought that a person may die within the next few days or hours: 1 This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly. 2 Sensitive communication takes place between staff and the dying person, and those identified as important to them. 3 The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. 4 The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. 5 An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion. These priorities of care have informed work to date and will continue to form the basis of the proposed changes locally. The LLR End of Life Strategy has been developed in line with the National End of Life Care Strategy, July 2008 and the national End of Life Framework for Local Action 2015–2020.What are we going to do? When the Learning Lessons to Improve Care report was published in July 2014 we committed to undertaking a further review by summer of 2016. The Taskforce felt it was important to learn from the experience of the initial review. The evidence of other mortality reviews across the country has been reviewed, along with the learning from the previous LLR mortality review, to inform the proposal for the next mortality review; this will be presented to organisational boards across LLR early in 2016. If approved, the review will take place in March 2016, as planned, with full consultation and engagement, and the findings will be subsequently reported on. a An LLR-wide electronic care co-ordination system will be developed, in collaboration with the BCT End of Life, Frail Older People, Long Term Conditions and Urgent Care work-streams, which will enable read and write access to all care plans by key providers.This system will meet National Information Standards and minimum datasets will be developed. Clear agreement will be put in place with 111 and the out of hours provider outlining how the Personalised Care Plans will be used, for example to fast track patients, or to move them into a separate triage process. b Training and education will be provided for all involved in care Draft to NHS England 2.0 107 | Clinical Work-streams c planning discussions, creating care plans and using them to inform clinical decisions. Evidence base for change Specialist and generalist 24 hour palliative care services are planned for LLR, which will include access, via a single telephone number, to a 24-hour coordination and navigation centre, clinician and patient/carer advice line and increased access to Hospice at Home. The clinical evidence for change was identified in the 2014 Mortality Review which was reported in the Learning Lessons to Improve Care report, July 2014. The review identified that around 23% of patients reviewed had received an unacceptable standard of care. Learning Lessons to Improve Care Leadership and commitment has been secured from senior leaders and institutions in LLR for Learning Lessons to Improve Care. Moreover, the programme has been embedded formally in the governance framework of Better Care Together through the Clinical Leadership Group. Each organisation has implemented their relevant actions to ensure care standards are improved; this includes use of and compliance with best practice, policies and guidelines. UHL have revised their morbidity and mortality review process which assesses whether there are and learning points from the cases reviewed. LPT have commenced a morbidity and mortality review process learning from UHL’s experiences. Work is also under way to establish a mechanism to learn from serious incidents across the patient pathway rather than at organisational level. The clinical work-streams for Better Care Together have taken forward the actions identified that can only be addressed by developing new, improved pathways designed by clinical teams from primary and secondary care. A key focus for this is the End of Life, long-term conditions, frail older people and urgent care work-streams. 24 hour palliative care Specialist and generalist 24-hour palliative care services are planned for LLR, which will include access, via a single telephone number, to a 24 hour coordination and navigation centre, clinician and patient/carer advice line and increased access to Hospice at Home. This, along with access to patients’ care plans by all healthcare professionals involved in their care, will ensure that patients’ wishes are honoured and that the appropriate care is provided to them 24/7. Families and carers will also feel supported as they will have one number to ring with any concerns about the patient and will be given appropriate advice. Clinical support will be available to generalists to ensure that the patient is referred or signposted to the appropriate care setting for the individual. Each year in England nearly half a million people die. Nearly three quarters of all deaths can be predicted. Since the first National End of Life care strategy was introduced in 2008, CCGs and provider organisations across LLR have been working to try and improve the quality and experience of care at the end of life. The National End of Life Care Intelligence Network tells us that hospital is the most common place to die, nationally 49%. Locally this varies between 46–49% across the three CCGs. Although there is a trend towards more people expressing a preference to die at home, we know that this can often change. Poor access to specialist palliative care and poor pain management in the home setting can be contributing factors. Following concerns from relatives and carers an independent enquiry was held into the use of the Liverpool Care Pathway led by Baroness Neuberger in 2013. It recommended the phasing out of a ‘one size fits all pathway’ and a focus on providing more individualised care plans based on the identifiable needs of patients at the end of life. In response to this, twenty-one national organisations formed the National leadership Alliance for End of Life Care and in their report “One Chance to Get it Right” highlighted the five key principles for End of Life Care (see main text). Building on a draft gap analysis that LOROS produced in 2014, a detailed scoping of existing local palliative care services and analysis of deaths data will be carried out by local Public Health departments, in collaboration with End of Life clinical specialists, to inform commissioning of the new 24 hour service. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 108 Measures of success ✻ Enhanced community specialist nursing palliative care provision, 7 ✻ ✻ ✻ ✻ ✻ ✻ ✻ days per week Better access to night care services and hospice care delivered in their own home A reduction in avoidable admissions to hospital and hospice Reduced length of stay in acute care Increase in patient and carer satisfaction, according to patient and carer survey Improvement in quality of care according to national quality markers A contributory increase in the number of patients dying in their preferred place, receiving their DNACPR choice Patients, carers and their families receiving specialist palliative care advice and support out of hours. QIPP Outcomes Quality — Improving quality for patients through shared care plans and increase of palliative care services to 24/7 cover. Improving quality through actions generated from the second LLtIC mortality review. Innovation — Sharing care records across the health economy leads to more patients’ wishes being recorded and clinicians making betterinformed decisions. Use of Torbay Mortality Tool to identify issues around quality of care prior to death. Productivity — Access to electronic shared care plans will reduce admin and minimise duplication of effort/data. Prevention — The identification of ‘avoidable deaths’, through use of the Torbay Mortality Tool, is currently being considered. Timeline of implementation The second mortality review for Learning Lessons to Improve Care will take place in March/April 2016. It is recommended that the findings will be in the form of a qualitative analysis and will be reported in public to the boards of constituent organisations. The findings will also be presented to an LLR-wide clinical conference to focus existing actions and further required actions. Ongoing actions will be owned by the relevant BCT workstream or individual organisation. Measures of success ✻ Continued reduction in the SHMI ✻ Reduction in number of serious incidents ✻ Increased use of early warning score Draft to NHS England 2.0 109 | Clinical Work-streams ✻ ✻ Improvement in discharge procedures Improvement in Friends and Family Test Scores Personalised Care Plans A co-ordinated system of personalised care planning across LLR would reduce variation in access and create opportunities to have the important discussions around preferences and choices at the end of life. Benefits also include the likelihood of reduced hospital admissions, as this provides an opportunity for the patient to identify their preferences for end of life care. It provides opportunities for the healthcare professionals involved in the patient’s care to plan for their care in advance and for their families/carers to be aware of the patient’s wishes. A unified approach enables familiarity for all providers involved in creating, accessing or using the care plans to inform clinical decisions about the patient and to reduce duplication of information. The IM&T Workstream of Better Care Together is currently developing a solution for sharing care plans across the health economy, in conjunction with the End of Life work-stream and other workstreams, such as Long Term Conditions, Urgent Care and Frail Older People. The focus is on finding an efficient and effective IM&T solution using, where possible, existing systems. Minimum data sets will be developed, based on the relevant national information standards, such as the recently-released information standard for Electronic Palliative Care Coordination Systems (EPaCCS). Personalised care plans have already been introduced across LLR, but there is no single unified form and no electronic care co-ordination system in use. Currently these plans are completed in different healthcare settings and not all patients are offered the chance to complete them. This leads to some patients being admitted to hospital and possibly being resuscitated, against their wishes, as their wishes may not have been documented and/or the hospital or emergency care services, for example, do not have access to the care plan. Outline cost Project Leicester City West Leicestershire East Leicestershire & Rutland Investment QIPP | Investment QIPP | Investment QIPP End of Life £42k £(11)k | £42k £(11)k | £42k £(11)k Measures of success ✻ Reduction in number of admissions and readmissions of End of ✻ ✻ ✻ ✻ ✻ Life patients Reduction of number of A&E attendances of End of Life patients Increase in after death audits in general practice Increase in number of care plans for End of Life patients Increase in number of patients on GP palliative care registers Increase in number of deaths in preferred place of death. Activity & finance shift Activity — 2011/12–14/15 The admissions activity has increased particularly in relation to out of county and UHL. For the last 4 years 2011/12–14/15 out of county has seen growth of circa 12% with UHL seeing a growth on average of 18% resulting in an overall average between the two of 15%. Patients that are admitted with a secondary diagnoses of Z5 Palliative Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 110 Outline cost The proposed model is costed at an estimated £240 per hour. Marie Curie suggests that an hourly rate for Hospital Inpatient Specialist Palliative Care is £425 per hour therefore this model has the potential to change the setting of care at the end of life, offer a quality service for patients in their own homes and contribute to the reduction of the daily cost of providing end of life care. The team staffing costs to provide this service is estimated to be £471,440, based on NHS bandings with 20% oncosts. In addition, it is proposed that 1 WTE Palliative Medicine Consultant (plus admin support) is appointed to offer immediate access to specialist advice and assessment, management of complex medical problems at home, decision-making around whether to admit to hospice/hospital to consider reversible conditions. Care, or a treatment function 315 cost for out of county emergency admissions, have an average cost of £3,732 per emergency admission. The aim for the 16/17 plan will be to focus on reducing growth by 3%. (From 15% to 12% growth) In terms of patients the expected activity reduction will be 1,493 to 1,451. High Level Implementation Plan 2016 J F M A M J J A S O N D J Health Needs Analysis Roll-out of Electronic shared care planning Learning Lessons to Improve Care second mortality review Implement recommendations from Learning Lessons to Improve Care Mortality Review 24/7 Palliative Care Draft to NHS England 2.0 111 | Clinical Work-streams NHS Continuing Health Care funding ELR CCG is the lead commissioner for CHC for LLR. Our shared vision is for the best quality for those individuals (aged 18 and over) with a primary health need who are eligible for NHS CHC funding. This includes those that may require care for an extended period of time to meet physical or mental health needs that have arisen as a result of disability, accident or illness are. To ensure this we will continue: • to develop continuing healthcare provision that is patient focused and able to meet individual needs (including the needs of carers) • to ensure services are equitable, safe and able to meet the needs of a diverse population • to determine eligibility for continuing healthcare funding, we will ensure effective and clear systems and processes, along with agreed local protocols are in place across health and social care providers to enable service users to be assessed appropriately using the continuing healthcare check-list, if required, and the national Decision Support Tool (DST) • to ensure a multi-disciplinary approach to assessments and review • to ensure an appropriate fast-track system is in place for service users that have a rapidly deteriorating conditions and may be entering a terminal phase • to include CHC and complex case management service delivery • to ensure that appropriate size packages of care are put in place to meet the individuals needs • Work closely with the PHB team to offer every individual in receipt of CHC funding a Personal Health Budget. We will work with our local health economy partners to ensure effective, fair, cost-efficient and high quality care delivery for those in receipt of NHS CHC funding. In order for this to be achieved we will be working to make sure the eligibility process to determine CHC funding is seamless, timely and integrated. NHS Continuing Healthcare (CHC) means a package of ongoing care that is arranged and funded solely by the NHS where the individual has been found to have a primary health need. Such care is provided to an individual aged 18 and over to meet needs that have arisen as a result of disability, accident or illness. Eligibility for CHC funding places no limits on the settings in which the package of care can be delivered or on the type of service provision. Therefore, individuals can receive CHC funded care in any setting, including their own home or a care home. CHC funded care is a complex and highly sensitive area which can affect people at a very vulnerable stage of their lives. A personal health budget (PHB) is an amount of money to support a person’s individual health and wellbeing needs, as agreed between the individual and their local NHS team. ”The person’s health and wellbeing needs will be set out in a personal led care plan which will be developed by the person together with a health care professional. How the budget will be used to support the health and wellbeing needs will be set out in a person led support plan agreed by both the person and the local NHS team. “ What will the impact be: • a uniform decision making process to determine patients eligible for CHC funding compliant with the requirements of the national framework for NHS CHC and FNC. • patients, including CHC funded fast-track patients, will be cared for in the right place at the right time • support to the local health economy by ensuring timely throughput of patients along the pathway • embedding of PHB delivery into the day-to-day running of NHS Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 112 Uptake CHC—there is evidence to suggest that enabling individuals to be part of the choice process of managing their own condition leads to improved quality and cost effectiveness in NHS CHC management. 250 200 150 100 50 0 Year 1 Year 2 Year 3 Long-term conditions Year 4 Year 5 Mental health services People with learning disabilities Children receiving continuing care NHS Continuing Healthcare Spend 5,000 4,000 Personal health budgets ELR CCG is the lead commissioner for PHB delivery. Our vision is that PHBs are a tool to support personalised care. As such, and to ensure a population level benefit we will continue to ensure a focus on personalised care planning, which could result in a PHB being offered. This also recognises that a direct payment PHB will not be available to all in scope to the Local Offer, and that PHBs are targeted at those with the highest, complex needs, which will be a small part of the population. Until detailed work is undertaken to restructure contracts and budgets, there is no new money locally to support PHBs. In future years the Local Offer will provide more detail on how this will be achieved. Henceforward, at a minimum, anyone expressing an interest in a PHB is entitled to a personalised conversation to explore the thinking behind the request, a focus on improving outcomes, and whether needs could be met differently, resulting in a personalised care plan. 3,000 2,000 As we consider expanding PHB to other groups, we will ensure that we fulfil our legal duties with regard to equality and health inequalities and consult widely as we develop pur local plans. The Local Offer is subject to an Equalities Impact Assessment which will be refreshed as the Offer is reviewed in future years. 1,000 0 £000s CHC providers of care There are approximately 400 providers of CHC funded care across LLR ranging from large scale Nursing Home providers to small single patient providers of domiciliary care. The CCG will, in conjunction with our local authority colleagues, plan strategically, specify outcomes and procure services, to manage demand and provider performance for all services that are required to meet the needs of all individuals who qualify for NHS continuing healthcare, and for the healthcare part of a joint care package. The services commissioned will include ongoing case management for all those entitled to NHS continuing healthcare, as well as for the NHS elements of joint packages, including review and/or reassessment of the individual’s needs. Year 1 Year 2 Year 3 Year 4 Implementation costs Long term conditions Mental Health services Children’s Services NHS Continuing Healthcare Year 5 The Government's Mandate to NHS England for 2016–17 and the NHS Planning Guidance for 2016/17–2020/21 were published in December 2015, re-affirming the Government and NHS England's commitment to the roll-out of personal health budgets. The Mandate sets a clear expectation that 50,000–100,000 people will have a personal health budget or integrated personal budget by 2020 — this translates to around 1–2 people per thousand of the Draft to NHS England 2.0 113 | Clinical Work-streams population. The Planning Guidance requires all CCGs to develop Sustainability and Transformation Plans (STPs) which should include personal health budgets and integrated budgets as a key mechanism to hand more power to patients. In addition local plans for Transforming Care will need to show how personal health budgets and integrated personal budgets will be used to help people with learning disabilities live at home rather than in institutions. There is an expectation that the CCG will move towards 1–2 in 1,000 people in the population being in receipt of a personal health budget over the next 3–5 years. It has been demonstrated that benefit from a PHB derives from the level of need rather than particular diagnosis or condition. The planning guidance for 2015–16 allowed for local flexibility on which groups will be offered personal health budgets and while this has been carried over for 16/17 there is an expectation that CCGs will be able to meet the requirements laid out in the Bubb Review. What will the impact be? The impact of PHB delivery will be: • increased control and choice for patients Impact in contracts 5,000 4,000 3,000 2,000 1,000 £000s 0 Year 1 Year 2 Year 3 Year 4 Year 5 Implementation costs • during 2016/17 personal health budgets or integrated personal budgets across health and social care will be available for people with learning disabilities, in line with the Sir Stephen Bubb’s review • expanded of Personal health budgets additionally throughout 2017/18 to people where evidence suggests that it could be beneficial and in line with local health and social care priorities and strategies this includes some individuals with enduring mental health conditions • Children’s services will continue to progress the integrated approach through integrated education, health and care plans within the SEND programme. Spend within block contracts Individually commissioned packages Timescales Planning Go live 14/15 Year 1 15/16 Year 2 16/17 Year 3 17/18 Year 4 18/19 Year 5 19/20 O N D J F M A M J J A S O N D J FM A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M CHC CC SEND LD Mental Health (section 117s) LD Childrens' LD admissions avoidance Mental Health LTC more than 4 conditions Draft to NHS England 2.0 114 | Enabling Workstreams Enabling Workstreams Better Care Fund Our vision for integration remains as set out in our original BCF plan submission in 2014: We will create a strong, sustainable, person-centred, and integrated health and care system which improves outcomes for our citizens. The Leicestershire BCF Plan is delivered under four themes. The themes are designed to group together related activity/projects so that: • These are managed and governed effectively within the local integration programme • Their contribution and outputs are connected effectively to LLRwide governance, where applicable. BCF THEME 1: Unified Prevention Offer Integration of prevention services in Leicestershire’s communities into one consistent wrap-around offer for professionals and services users. Improved, systematic, targeting, access and coordination of the offer BCF THEME 3: Integrated Urgent Response Integrated, rapid response community and primary care services 24/7 BCF THEME 2: Long Term Conditions Integrated, proactive case management from multidisciplinary teams for those with complex conditions and/or the over 75s. Integrated data sharing and records, for risk stratification, care planning and care coordination. BCF THEME 4: Hospital Discharge and Reablement Safe, timely and effective discharge from hospital, via consistent pathways, reducing length of stay Working together to avoid unnecessary “Home First” philosophy, focused on hospital admissions, supporting people at reablement and maintaining home wherever possible. independence Key Challenges for 2016/17 Urgent Care Total emergency admissions in Leicestershire have risen in 2015/16 in line with the trend in recent years. Analysis by the LLR Urgent Care Board shows that a proportion of this has occurred in the 0–10 and 20–40 age groups. Further analysis is under way to establish the detailed reasons behind the increase. In the meantime it can be demonstrated that 3 of the 4 admissions avoidance schemes in Leicestershire (GP 7 day services pilots were the Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 115 4th) have delivered measurable impact in terms of admissions avoidance in the BCF target cohort (older people). This is demonstrated in falls non conveyance figures for example, with data from care and Healthtrak, clinical audit and independent academic evaluation in progress to further support/triangulate these findings. In terms of hospital admissions avoidance, the 2016/17 BCF plan includes further improvements to the models of care and pathway redesign for the four existing schemes implemented in 2015/16, based on evaluation findings. A further admissions avoidance scheme targeted to adults with cardio/respiratory conditions who attend at the Glenfield Hospital site, is being introduced which will deliver a consistent ambulatory pathway to avoid prevent a large number of short stay admissions. Sustaining our good DTOC performance achieved in 2015/16 relies on existing interventions continuing to maintain their impact, and any additional actions to be prioritised locally from the 8 high impact changes self assessment tool recently published by the department of health. Financial Constraints Financial allocations and the scale of financial pressure and savings required across the partnership will impact on the ability of partners to commit to new initiatives, unless funds are reallocated between existing commitments, schemes are decommissioned or transformation funds can be accessed, especially for ROI within a 1–3 year horizon. Despite this, partners must maintain a medium term view of transformation for years 3–5 and will need to apply even more rigour to benefits realisation, with more sophisticated, integrated and coproduced methodologies for predictive modelling and measuring impact, in order to deliver the LLR-wide 5 year plan including the required medium term integration plan. The 2016/17 plan will include a focus on developing a commissioning framework for integrated commissioning across LA and NHS partners. This will have emphasis on seeking further savings and value for money fro commissioning, as well as assuring quality. Data Integration Although progress has been made on data integration using the NHS number and care and Healthtrak in 2015/16, further work is needed on the integration of records and data across agencies for direct care and case management in community settings. This will be a focus of the 2016/17 BCF plan in conjunction with the LLR IM&T workstream. Draft to NHS England 2.0 116 | Enabling Workstreams Our Ambition for Integration 2016/17 onwards During 2015, the Integration Executive developed a vision and ambition of integration beyond March 2016, and set out a number of priorities which fall into two main areas: 1 Embedding the model of integrated provision being developed in locality hubs; and 2 Integrated Commissioning, including a Setting an outcomes framework for integrated commissioning b Proposing what should be in scope for improving integrated commissioning beyond March 2016. Aims of the Leicestershire BCF Plan 2016/17 The aims of the Leicestershire BCF plan have been refreshed per the work to develop our vision and ambition post-March 2016 and to reflect other national and local strategic developments since the original BCF plan was submitted. The revised aims are: 1 Continue to develop 2 Deliver measurable, and implement new evidence based models of provision and improvements to the new approaches to way our citizens and commissioning, which communities maximise the experience integrated opportunities and care and support. outcomes for integration. 3 Increase the capacity, capability and sustainability of integrated services, so that professionals and the public have confidence that more can be delivered in the community in the future. 4 Support the reconfiguration of services from acute to community settings in line with: • LLR five year plan • New models of care. 6 Develop Leicestershire’s “medium term integration plan” including our approach to devolution. 5 Manage an effective and efficient pooled budget across the partnership to deliver the integration programme. Our Model of Integrated Provision in Leicestershire’s Communities Through our local community services strategies we are designing a new model of integrated care for Leicestershire’s localities. During 2015 we have started to put in place the foundations of this model, and during 2016 we will be consolidating it. The model places the patient or service user at the centre, with the GP as the primary route for accessing care. The GP is also the designated accountable care coordinator for the most complex or vulnerable patients in community settings. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 117 Our model of integration wraps around the patient and their GP practice, extending the care and support that can be delivered in community settings through multidisciplinary working, with the aim of reducing the amount of care and support delivered in acute settings, so that only care that should/must be delivered in the acute setting will take place there in the future. This “left shift” of activity into community settings is essential for the whole of LLR to deliver a sustainable health and care economy in the future and forms the basis of our 5 year plan Better Care Together. Critical to this model, in terms of the contribution from the Better Care Fund are: • Multidisciplinary services that are configured on a locality basis and wrap-around clusters of GP practice. Examples would be our integrated health and care teams who case manage vulnerable people such as those with long term conditions or frailty, and our new domiciliary care services, which are being jointly commissioned between CCGs and the LA in 2016, and which will be delivered on a locality basis. • Community based alternatives for urgent care, being implemented in conjunction with the LLR urgent care vanguard, to avoid unnecessary hospital admissions • Ensuring those being discharged from hospital are received safely back into local community services, with the right level of coordination and planned support to promote reablement and prevent readmission • Shifting demand into non-medical support where appropriate, providing a broad and consistent range of social and preventative services, such as our housing offer support to carers, and lifestyle support. The Leicestershire Better Care Fund has a whole theme dedicated to co-producing this prevention model, creating a new platform of services which will be consistent and easy to access and navigate for both professionals and the public. Integrated Commissioning Framework and Workplan A new strand of work for the BCF plan in 2016/17 will be to develop an outcomes framework for integrated commissioning with a work plan that focuses on a small number of priorities. At the time of this submission these priorities are in the process of being scoped. Through the involvement of local partners in the Commissioning Academy there is agreement that taking a joint approach to commissioning nursing and residential care placements should be one of the main areas of the work plan in 2016/17. This will build on the existing BCF-funded quality assurance team for this care sector, and lessons learned through 2015/16 in commissioning domiciliary care Draft to NHS England 2.0 118 | Enabling Workstreams services jointly. Other areas of focus area are likely to include: ➔ Integrated Personal Budgets ➔ High Cost Placements. This work will • involve researching other best practice, seeking further opportunities to achieve value for money, improve service user outcomes and quality assurance, using a shared outcomes framework • help shape the market and commissioning intentions for integrated provision, improve commissioning intelligence, and how integrated services can be specified and procured across the health and care system • involve improving oversight of all the existing section 75 agreements within Leicestershire, so they are brought into the governance of the integration programme. Emergency Admissions Target The BCF submission excel template shows the level of achievement proposed for each of the BCF metrics in 2016/17. The targets have been co-produced by CCG and LA partners, using the national BCF definition and methodology including the statistical significance calculator. Trajectories have been developed for each of the emergency admissions avoidance schemes indicating how many emergency admissions are to be avoided by each scheme in 2016/17. The total emergency admissions reduction proposed for West Leicestershire, including all components within the CCG operating plan is xx%, or xxxx admissions. The contribution of the BCF to this target for emergency admissions avoidance will be xx% or xxxx emergency admissions The impact of the BCF on all the national metrics is summarised in the section below. (Please refer to the detailed BCF submission excel sheet and the BCF narrative submission for further details). What will our health and care system look like as a result of the changes planned in 2016/17? • Integrated health and care services will be available in each locality, combining the expertise of adult social care services from Leicestershire County Council and the community nursing and therapy teams of Leicestershire Partnership Trust (LPT), working hand in hand with GP practices. Draft to NHS England 2.0 • Shared care records and care plans will be in place using the NHS Number to plan and deliver person centred care more effectively across organisational boundaries. • Xx people with long term conditions will have their risks assessed and care needs coordinated by the integrated health and social care team in their locality, working hand in hand with their GP practice. (target for 2016/17 being finalised) • Xx people with respiratory and cardiology conditions will be supported to remain the community rather than being admitted to hospital(target for 2016/17 being finalised) • Seven day services will be available in primary care, coordinated by GPs across Leicestershire localities, targeted to frail and vulnerable people, and those with long term conditions. These will supporting approx. xx people in 2016/17 (target being finalised) • Xxxx emergency admissions (target for 2016/17 being finalised) will be avoided through improved urgent care pathways, which will include the ambulance service working hand in hand with NHS providers and our integrated health and care teams in each locality. • Xx bed days will be saved from further improvements in delayed discharges, building on the success already achieved in 2015/16 (target for 2016/17 being finalised) • xx more people will receive care at home, instead of going into hospital, after a fall (target for 2016/17 being finalised) • xx fewer people will be permanently admitted to residential or nursing care, (target for 2016/17 being finalised)due to improvements to the care and support they can receive at home. • 2,800 carers will have benefited from enhanced information and health and well-being support, including via assessments being introduced by the Care Act.(checking data with ASC) • 240 vulnerable people per year will be supported by Local Area Coordinators operating in Leicestershire’s communities, to help them make the most of what’s on offer on their doorstep. • A new integrated housing service operating across all District Councils will offer practical expertise and support for people needing aids, equipment, adaptations, handy person services and advice on energy efficiency/affordable warmth. • LLR’s urgent care system will be redesigned in line with the models of care proposed by the Vanguard project , with the BCF focused particularly on • improving and streamlining points of access into the health and care system on a 24/7 basis Draft to NHS England 2.0 120 | Enabling Workstreams • delivering a number of the alternative pathways to avoid hospital admission • Our unified prevention offer will describe a clear, consistent menu of services that are on offer in each community, with First Contact Plus as the coordinating “front door” • Leicestershire people will experience significant changes in how care is planned and delivered, feel confident in community based services, and report improvements in their overall experience of integrated care and support. • By reconfiguring services and investing in community alternatives, improving delayed discharges, reducing emergency admissions, and creating enhanced locality based services, we can confidently reduce the overall number of inpatient beds in Leicestershire, at key intervals in line with the 5 year plan. • A new outcomes framework for integrated commissioning will support partners to take a joint approach to value for money, quality assurance and service user outcomes. Confirmation of Source of Funds for the Refreshed BCF Plan Better Care Fund Funding Source of Funds Comparison 2015/16 to 2016/17 Funding Source 2015/16 £ 2016/17 £ Movement Movement £ % East Leicestershire & Rutland CCG* 15,187,000 15,368,000 181,000 1.2% West Leicestershire CCG* 20,073,000 20,477,000 404,000 2.0% Social Care Capital Grants 1,344,000 1,344,000 0 0.0% Disabled Facilities Grants 1,739,000 1,739,000 0 0.0% 38,343,000 38,928,000 585,000 3.2% Total BCF Funding * Inclusive of Care Act Funding (including non recurrent element in 2015/16) 1,893,000 1,384,000 –509,000 –26.9% Health and Social Care Integration Reserve at start of the financial year 5,758,000 4,520,000 –1,238,000 –21.5% The BCF financial plan for 2016/17 includes £xxxx assigned for adult social care protected services, and £yyyy for NHS commissioned community services. Please refer to the supporting BCF excel sheet submission and the BCF narrative document for the detailed breakdown of the individual scheme within the BCF for 2016/17. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 121 Adult Social Care Providing effective, personalised care and support which helps to reduce the impact of physical and mental ill-health. Within the BCT partnership we are placing our patients at the centre of how they plan for and receive their support with the aim of empowering them to build on their strengths and meet their needs in their community. Across LLR we have already seen that working together can improve people’s lives and reduce the pressure on health and care services. Much of the work done so far has been through the ‘Better Care Fund’ (BCF) and we have successfully reduced the number of people who need long term care. There has also been a reduction in the delays people face when they come out of hospital and need extra support at home. A sample of what has been achieved to date includes: ➔ A crisis response service mobilises a team of experts to treat people at home or in a local centre to avoid a visit to A&E ➔ People are given choice over their care and support ➔ Support to people when they are discharged form hospital. This ‘reablement’ helps to avoid people going back into hospital or into long term care ➔ Technology has been invested in so that people stay independent in their own homes. Alarms and sensors have helped people to avoid falls and going into hospital ➔ An investment in technology has also helped with the sharing of information across social care and the NHS ➔ Proactive care to prevent people from falling unwell in the first place has been successful. Integrated Community Equipment Service This service is integral to the realisation of our plans. Following procurement over the last 18 months, Nottingham Rehab Supplies will be providing the service as effect from 1 April 2016. Both Leicester City and Leicester County Councils and Leicester City and County CCGs work together to improve the service. This is through the Equipment Management Board who meet monthly. Membership has recently been refreshed to include LPT and UHL to support fully integrated working. Through the Equipment Management Board, recycling has identified a potential QIPP return for WLCCG of £500k of efficency savings to be realised in 16/17 . Alongside this, schemes are in development to incentivise equipment collection, and is anticipated will result in savings to the partners in excess of £100k per year. Draft to NHS England 2.0 122 | Enabling Workstreams The Integration Executive highlighted a number of issues related to the Integrated Community Service (ICES): Demand Management Problems • legacy arrangements for prescription of equipment which have resulted in ongoing growth in NHS prescribing, particularly in areas financed by social care • lack of accountability in organisations which underpins this, leading to waste and duplication • a high level of equipment provision to support residential and nursing home placements • equipment provision is not set within the context of patient pathways, leading to difficulties with forecasting and managing demand. Incompatibility of current arrangements with the drive towards more integrated service delivery. Demand Management Action Plan • Improve accountability for prescribing activity • Robust criteria for the provision of equipment • Review of the scope of the service • Revision of the policy for the provision of equipment in care settings • Increasing the number of items of equipment collected and recycled • Operational and financial procedures. • Continue employment of an Occupational Therapist by ICES to maximise the use of recycled special (non-catalogue) items of equipment. The secondment of a tissue viability nurse to undertake an audit of equipment provision to care homes, resulting in greater recycling of equipment items. Initiatives are expected to deliver full year savings in excess of £400k, and while they benefit all partners it will be noted that the reduction in CCG expenditure is not matched by that of local authorities. This is a reflection of the legacy arrangements whereby equipment prescribed by NHS staff is coded to local authority budgets, the growth of these areas of activity and the shift from coding of prescriber activity from the former Intermediate Care Services. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 123 The Primary Medical Care Plan is a system-change plan which responds to the challenge set out by Better Care Together of a ‘left-shift’ from acute care to out-of-hospital care, and responds to the key principles established by an extensive engagement process with clinicians, stakeholders and patient representatives. The CCG builds on a strong base of achievement, but recognises that it must pay special attention to governance, systems for managing conflict of interest, funding, workforce issues and effectively managing the ‘left-shift’ so that it sees a genuine movement of resources and activity. Primary Medical Care Our Ambition The CCG’s promise to the patient is Consistently High Quality care which is Responsive and Accessible, Integrated, Sustainable and Preventative. Currently we have not fully realised the potential of general practice and too often patients receive care in hospital that could be safely provided in the community, coordinated through their general practice, supported by the wider health and social care teams. We have a clear vision for the future of primary care in our CCG in which general practice is the foundation of a strong, vibrant and joined up health and social care system. We believe that the vast majority of health problems in the population — including mental health — could be dealt with by primary and community care. To achieve this, the changes we envision will mean that primary medical care will in five years’ time be more integrated and federated, with patients co-designing services and taking increased responsibility for their own health. This new system is patient centred, and provides accessible high-quality, safe, needsbased care. This is achieved through expanded — but integrated — primary and community health care teams, offering a wider range of services in the community with increased access to rapid diagnostic assessment and co-located specialists. This will require a shift of resources from the acute sector, investment in facilities, and a greater role for nurses, pharmacists and healthcare assistants. Model Over the next five years our new model for general practice will be realised — the practice and the primary healthcare team will remain the basic unit of care, with the individual practice patient list retained as the foundation of that care. However, whilst a large proportion of care will remain within a patient’s own practice, an increasingly significant proportion will be provided by practices coming together to collaborate in federations, using their expertise, sharing premises, staff and resources to deliver care for and on behalf of each other. In this way, it will be possible to improve access and provide an extended range of services to our patients at scale. The benefits of this model have been carefully analysed in terms of the challenge laid down by Better Care Together and the principles set down through the engagement process. Plans Over the next 5 years we will create a system that can accept movement of care from the acute sector to primary care at a population level, while retaining primary care efficiencies. We envisage General Practice in West Leicestershire will transform over the next 5 years and will: • Work collaboratively with each other, and there will be full Draft to NHS England 2.0 124 | Enabling Workstreams integration with community and social care services • Improve efficiency through more effective use of existing resources including; clinical models of care and back-room services such Human Resources, Payroll • Provide and coordinate locality based services to meet the needs of their patients • Listen to patients and help them access appropriate care, taking greater responsibility for their own health and well-being. In 15/16 we developed our community services plan which sits alongside our Primary Medical Plan; it sets out our aspiration for better community services. Both plans directly influence our priorities for general practice, locally in 16/17, we will: • Maximise the potential of our Federated Localities — In 15/16 we supported our practices in the development of 4 legally constituted federations. The federations enable a strong primary care orientation to the delivery of patient care across all care settings. In 16/17 we will develop mechanisms and approaches for GP federations to meet the challenges that new models of care bring, by continuing to support their organisational and business development, enabling them to engage fully in the leadership and development of MCPs. • Deliver integrated working — Our community services plan describes our model for sustainable person centred and integrated community services. The CCGs vision for integration is health and social care teams, supported by secondary care specialists, clustered around groups of general practices within three identified districts. Our model is based on the MCP new care model formally recognised in the 5 year Forward view. In 16/17 we will rapidly explore joint ventures, including new contractual forms, with our key partners for example, our federations, secondary care providers, and community services and to agree the model for further integration of our community and primary care teams. • Enhance access to primary care — Working with our member practices, patients and stakeholder colleagues we will develop a locally sustainable approach to primary care access. In 15/16 we have tested our weekend access approach supported through the Better Care Fund. Here our federations working, with ECPs from our Acute Visiting Service have developed a pathway that provides support to our most vulnerable patients over the weekend period. In 16/17 we will use this learning to inform our approach implementing the 2020 goals to expanding both routine access to general practice and an integrated team approach supporting unplanned and urgent presentations in primary and community care settings. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 125 • Develop our primary care workforce — a competent and skilled primary care workforce is a key enabler in implementing our plan to support out of hospital care at the scale required. In so doing we need to be cognisant of the challenges we face — the nature of work undertaken by staff is changing, as the population ages primary care staff will need to care for more people with complex needs and co-morbidities. In the future we will need to work increasingly in multi-disciplinary teams that treat the whole person. This will mean changes in the skill mix in primary care as well as appropriate capacity across primary and community settings. We need to develop a workforce that is fit for purpose now and in the future rather than merely increasing numbers. In 15/16 we worked with our neighbouring CCGs, the LMC, LPC and HEEM through the General Practice Workforce Group to agree our approach and priorities for supporting general practice work force. In 16/17 we will use of the outcome of the workforce Minimum Data Set and our training needs assessment to improve recruitment and retention of the existing workforce, identify new capabilities and competencies, skills and behaviours to support new models of care. • Improving practice Infrastructure — in order to deliver the transformation of general practice at scale and pace we recognise how crucial investment in practice infrastructure will be to realise our plans. This is in terms of practice IT systems, premises, equipment. In 15/16 a number of practices were successful in bidding for and securing Primary Care Transformation Funding to support practice premises developments, practices have engaged in a constructive debate about GP clinical systems with one practice changing clinical system and a further 9 committing to dates in 2016, we have also supported practices to optimise use of existing IM&T systems. In 2016 we will continue to work collaboratively on our IM&T Enablement Strategy developing system wide solutions to the following areas: sharing records, population data analysis and system wide efficiencies to improve integrated working. • Listening to and increasing the participation of patients — Local communities across West Leicestershire need to understand the rationale to the changes needed in general practice particularly why practices working together and being federated will help communities improve their healthcare and how the community uses and engages with general practice to contribute to its sustainability. We have ensured during the development of our plans for general practice that we engaged with patients, communities and local partners to sense check our approach. In 15/16 we supported North Charnwood Federation to implement a social prescribing pilot and roll-out a very successful patient engagement model. In 16/17 we will spread the learning across all our federations and work them to engage with wider patient groups and understand what matters to them most, further detail Draft to NHS England 2.0 126 | Enabling Workstreams of this work is provided in the People Powered Health section. • Delegated co-commissioning — Since April 2015 the CCG has assumed a direct role in the commissioning and contractual arrangements for general practice. This provides an exciting opportunity to improve outcomes for our patients by providing the system leadership to transform primary care at scale. In 15/16 we formally established our Primary Care Commissioning Committee and developed robust systems and processes for this new area of responsibility. We have developed positive working relationships with the CQC providing support where necessary following CQC inspection. In 16/17 we will implement the PMS Review and associated quality contract to support delivery of high quality patient care developing capacity and capability. This will build in the work progress made identifying and managing patients with LTC, improving the use of care planning and developing an understanding of primary medical care demand and capacity. Project Plan In 2016/17 Maximise the potential of our Federated Localities Agree 2 year business plan and resource allocation Developing leadership capability of federations Encourage and support federations to articulate their vision for MCP / place based commissioning. Deliver integrated working Implement the Community Services Plan Lead stakeholder engagement to agree the approach and the development of MCPs. Develop new contractual forms that enable the delivery of integrated care in our 3 districts. Enhanced access to primary care Undertake practice level demand and capacity audit Agree and implement the local model for access to enhanced primary care services including evening, weekend and GP appointments of the over 75s. Participate in the testing of an integrated urgent care offer in our localities. (Vanguard work stream 1) Review outcomes of GP patient survey. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 127 In 2016/17 Improving Practice Infrastructure Support the implementation of a IM&T system wide enablement strategy addressing; sharing records, population data analysis and system wide efficiencies. Achieve 10% of a patients accessing primary care online or through apps, and set a trajectory for achieving a significant increase by 2020. Support 10 GP practices to migrate clinical systems. Continue to support the development and utilisation of PRISM. Complete the CCG primary care premises plan as part of the BCT Strategic Estates plan (SEP) Secure Primary Care Transformation Funding aligned to SEP priorities. Develop our primary care workforce Actively participate in the BCT workforce work stream to reflect general practice workforce requirements. Through the LLR General Practice Workforce Group develop a range of initiatives to address current and future workforce initiatives including: Practice manager academy, increase pre-registration nurse training placements in general practice, support collaborative working between general practice and community pharmacy. Listening to and Rollout of North Charnwood engagement model to other increasing the federations. participation of patients Continue to support the development of PPGs and the PPG Network and locality structures. Build on best practice and identify support for patient education events. Delegated cocommissioning Effective implementation of the PMS Review and quality contract to support delivery and improve capacity and capability and reduce unwarranted variations. Improve quality and accessibility of care plans Build on our existing Primary Medical Care Plan agree a local plan to address sustainability and quality of general practice. Support the publication of practice level metrics on quality and access to GP Services. No practice unacceptable CQQ rating Draft to NHS England 2.0 128 | Enabling Workstreams For local people, this will mean: • Self-care at home • Primary care at their GP practice • Enhanced routine care through the Multispecialty Community Provider • Urgent care and crisis response through the Multispecialty Community Provider • Emergency acute care and specialist acute services GPs and their teams, as expert-generalists, play a pivotal role coordinating the care and ensuring that co-morbidities are reflected in the setting of care. This means that, while our aim will always be to provide care as close to home as possible based on what is safe, effective and person-centric, some patients at some times will be admitted at an escalated setting of care because their spectrum of conditions creates additional clinical risks. ncy Emergency e care and acute Urgent care a and spons crisis response Enhanced nced routine e care For this we are developing Multispecialty Community Providers (MCPs) at the district level, incorporating our existing community hospitals in Coalville, Loughborough and Hinckley. Each of these will serve their districts, enabling in-hospital but non-acute care and urgent care and crisis response to take place closer to people’s homes. As an organisational form, the MCP networks generalist and specialist nurses and doctors, alongside social care and Allied Health Professionals (AHPs). Each district has its own MCP, including a Community Hospital. 0 1 2 3 4 mary Primary care Our model of care takes the insights from the Keogh diagram, identifying five settings of care, and makes these physical. By creating a ‘place for every setting’, we are building appropriate use and and appropriate care into our structures. Self care and revention prevention Multispeciality Community Providers (MPCPs) Above: Settings of care diagram (“Keogh” diagram) The “Keogh” diagram, based on Sir Bruce Keogh’s review, identifies five settings of care, from level 0, self care and prevention, through to level 4, emergency and acute care. The overlay triangle shows how the vast bulk of activity should be at the left hand side of the diagram. Although there is overlap, especially at levels 2 and 3, the five settings broadly reflect our four forms of provision in this plan, being self-care, primary care, Multispecialty Community Provider care, and acute hospital care. Multispecialty Community Providers (MCPs) are integrated teams working in a defined district, incorporating community hospitals, clinical teams, GP specialists, and secondary care specialists. See p. GPs will increasingly work with specialists co-located in primary and community settings, supported by community providers and social care to create integrated out-of-hospital care. Likewise, community pharmacies will continue to play a key role in supporting self-care: 95% of our population lives within three miles of a community pharmacy. This model relies on involvement of secondary care consultants in the MCP model, and will require secondary care doctors, nurses and therapists working in community settings. This will require a cultural change from the way the NHS has traditionally approached the boundaries of acute and non-acute care. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 129 Workforce The combined NHS and social care workforce is one of the largest groups of employees across LLR, accounting for approximately one in ten of the working population. The workforce is both our greatest asset and our greatest cost (representing approximately 70% of total health and social care spend). There are a number of challenges related to the national NHS and social care workforce that will have a local LLR impact over this planning period A competent and skilled workforce is a key enabler in implementing our plan to support out of hospital care to the new scale required. As a health community we need to develop and implement innovative workforce solutions to improve health outcomes for the people of West Leicestershire. We need to inspire a new generation within our workforce to work across organisational boundaries and with a greater focus on community provision. Both at a national and local level the health and social care workforce is facing a number of challenges: • The nature of work undertaken by staff is changing. As the population ages, our staff will need to care for more people with complex needs and co-morbidities. • In the future work will increasingly be in multidisciplinary teams that treat the whole person and not just the presenting condition. Staff will need to have more generic skills and will need to embrace new technologies • An increasing number of UK-trained doctors, nurses and allied health professionals choose to move abroad, particularly to Australia, New Zealand and the United States. Every year since 2005/6, more nurses have left the UK than have arrived from abroad. • By 2021 there will be a shortfall of between 40,000 and 100,000 nurses and there could be 16,000 fewer GPs than are needed. While it is forecast that there will be an oversupply of approximately 2,000 hospital consultants by 2020, there is today a shortage of consultants in some specialities including geriatrics. The ageing population means that by 2025 the national social care workforce will need to increase from 1.6 million to 2.6 million. Meeting these challenges will mean changes in the skill mix for primary and community care as well as appropriate capacity across primary and community settings. Workforce planning and modelling assumptions will need to incorporate new, emerging and more sustainable models of community care. We need to develop a workforce that is fit for purpose now and in the future. Developing services that span different professional perspectives and work across Draft to NHS England 2.0 130 | Enabling Workstreams the primary and secondary care interface is vital. We will also need to ensure that the workforce in each district reflects the health needs of the local population. We will achieve this by working with all partners through the BCT Workforce Enabling Group and LETC to: • Establish a clear baseline of our current workforce — against which we can map any change • Undertake workforce modelling and capacity planning — to enable scenario planning as new models and pathways or care are developed • Undertake functional mapping — getting the detail right by reviewing and refining the skill mix of teams to better understand the types of work that needs to be done in a new setting and either match these to existing roles or create new roles • Develop the ability to move people around the system — it will be vital to be able to move staff around the system quickly and efficiently e.g., moving specialist nurses from the acute setting into the community to support integrated team working. Develop new and different roles to mitigate recruitment and retention risks e.g. apprentices, assistant practitioners, physician associates. How West Leicestershire CCG will support our workforce We will continue to promote strong clinical leadership to develop a compassionate, competent and caring workforce and we will continue to work with providers to ensure front-line clinical staff receives training to support the delivery of high quality care. We will ensure our providers have appropriate levels of staffing to provide safe and effective care. In order to monitor this we will review workforce recruitment and retention across our range of providers. For our providers with staffing concerns we will monitor their risk registers and action plans for improvement. We will ensure the LLR workforce plans are system wide and will deliver the workforce response to transformation programmes in urgent care and in integrated care and that is being coordinated and led by the LLR Local Education and Training Committee (LETC) and Better Care Together workforce programme. We will build upon our workforce plans for primary care via the LLR General Practice Workforce Delivery Group, where we have already began to review the skills mix within our practices, undertaken a Training Needs Analysis of all our practices, supported practices to recruit more GPs and practice nurses, established Pre-Registration Nurse Placements in General Practice, included new roles in our primary care workforce and extend the use and role of current posts, Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 131 for example, pharmacists and Assistant Practitioners (Level 5 Health Care Assistants). We will continue to support and develop practice nurses and encourage shared learning through the CCG Practice Nurse Forums and led by our two practice nurse leads. Nursing revalidation has been a priority for 2015/16 and where we have ensured all nurses from all of our providers are able to readily produce evidence proving they are fit to practice by the Nurse Revalidation implementation date of April 2016. We will support nurses and practices with implementation of clinical supervision and reflective practice and access to the CCG Protected learning Time (PLT) to facilitate Continued Professional Development (CPD). Estates and Facilities Leicester, Leicestershire and Rutland’s health and social care system has developed an Interim Strategic Estates Plan which responds to the outputs of the Better Care Together Programme. It focuses on how the acute, community and primary care estate will develop over time to respond to the changes to services and the development of new models of care. The plan will be further developed and updated once the Better Care Together public consultation has taken place but in response to the service pathways key estate features will be: • A smaller but more specialised acute estate: overall Leicester’s hospitals will become smaller and more specialised and more able to support the drive to deliver non-urgent care in the community. With consolidation of services, enabling clinicians and patients alike to benefit from properly co-located services and eliminate the inefficiencies of running multiple sites. This will be done by only delivering acute care in the hospital setting; only keeping patients in hospital for the time taken to deliver the acute treatment — with avoidable delays in discharge reduced to an absolute minimum; and working in partnership with others to support the delivery of out-of-hospital services that can help avoid admission where appropriate and or support the early reablement or rehabilitation in the home or as close to home as possible. • An adapted community bed base that will see more patients cared for in their own homes and a higher level of acuity being managed in community hospitals rather than in the acute hospital. This will also ensure a sustainable model for safe and efficient beds and wards per facility. • Community settings offering a wider range of services this will see more elective services being provided in community settings such as community hospitals and community based hubs. This will include diagnostics, outpatients and day cases. • Adapting the primary care estate to support the left-shift of Draft to NHS England 2.0 132 | Enabling Workstreams services from the acute to community settings; provide a wider range of care within primary care; support delivery of services at a locality level; and enable general practice to respond new models of care such as the multi-speciality provider. • A smaller health care estate footprint over the next five years there is also likely to be a reduction in the square metre and number of properties across the health sector through rationalisation; implementation of the Better Care Programme (subject to consultation); better utilisation; better use of technology and agile and mobile working; and ensuring the majority of buildings are used for clinical purposes. Information Technology (IM&T) Information technology is a key enabler, as sharing information is essential for us to treat patients safely wherever they are. As patients increasingly receive care from more than one provider, timely communication of relevant information between and within care providers and with patients and carers is critical. Good communication and coordination is needed, both within and between professionals, teams, care systems and institutions. The IM&T workstream has implemented a number of initiatives that have improved patient experiences, these include: • Electronic Prescriptions — sending prescriptions directly to the pharmacy so they are ready for pick-up at a nominated pharmacy without the need to wait for medication to be processed. • Online Access — viewing of a summary of the patient record, ability to book appointments with the GP online and ability to request repeat medication online. • Summary Care Record — ability for clinicians treating patients anywhere in the country to have access to a core subset of patient records (medications, allergies and bad reactions to medicines). • Medical Interoperability Gateway — allows clinicians in provider organisations such as Out of Hours, Ambulance Service 999 and NHS 111, to access core clinical data regarding the patient, subject to their agreement. • The Summary Care Record and Medical Interoperability Gateway (MIG) are already in use, and roll-out is being completed in this year (2015/16). Communications and Engagement: The outcomes of the consultation will directly influence our emerging plans as outlined in our STP and some proposals in this plan Through 2016/17, the CCG will be launching public consultation under the Better Care Together programme to assess what our Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 133 patients and the public think about proposed high level changes in the local health and social care economy. The following are the proposed key messages • Better Care Together is the largest transformation of health and social care in Leicester, Leicestershire and Rutland to date. • Health and social care services are under pressure and need to change: doing nothing is not an option. • Better Care Together will improve health and social care services and support people to stay well. • Better Care Together is about supporting people through every stage of life. • The BCT partner organisations need the public to share their views on proposals to make the system work better for everyone. • Better Care Together is about improving quality of care, not changing to meet financial constraints. • A sustainable system is required to ensure high quality care. • Prevention and staying healthy is something we are all responsible for. Work continues to ensure by March 2016 we will have consolidated into one database all patient experience and customer insights received. We continue to use Experience Led Commissioning methodology to engage and capture cross-community experience and insights at all stages of the commissioning cycle, ensuring they influence our commissioning decisions including the development of locality federations, maternity services and services for frail older people. During 2015 we ran a campaign to re-launch and grow our patient membership using communications and engagement to retain members and involvement to attract new members. We have improved and expanded the use of our IT platforms to assist communications, engagement and involvement with patients and create digital participation spaces with Loughborough University. During 2015 we ran successful marketing campaigns to help encourage a cultural change around choice, use and access to local health services and these campaigns will continue throughout 2016. Prescribing and Medicines Optimisation Medicines remain the most common therapeutic intervention in healthcare and the Medicines Optimisation Team will work on a wide range of work streams and programmes to rationalise the use of medication and improve cost effective prescribing by all CCG prescribers. Draft to NHS England 2.0 134 | Enabling Workstreams The Medicines Optimisation Team will support Federations and general practice and other providers to: • Improve the quality of prescribing. • Optimise the management of patients at high risk of serious adverse effects. • Empower patients to self-care where appropriate Work continues to improve antibiotic prescribing in support of the UK cross-government five-year (2013–18) antimicrobial resistance strategy. In 2016/17 WLCCG will: • Reduce inappropriate use of antibiotics to reduce anti-microbial resistance and support delivery of better health outcomes • Support practices to achieve national targets mandated by NHS England for antimicrobial prescribing for reducing the total number of antibiotics prescribed as well as broad spectrum, i.e., co-amoxiclav, cephalosporins and macrolides. • Plan and ensure appropriate action for the CCG for European Antibiotic Awareness Campaign in November 2016 in line with Department of Health guidance. • Ensure that our secondary care providers validate their antibiotic prescribing data following the Public Health England validation protocol through utilisation of the new national quality premium measure in 2015/16. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 135 Financial and Activity Plans Introduction This section outlines the financial plan for West Leicestershire CCG for the 2016/17 financial year. It outlines the context within which the plan has been produced and also provides specific details on plans for investments and savings. It provides confirmation that the CCG intends to deliver financially against key NHS England requirements. Overall, since WLCCG operates within a limited financial budget, it has a duty to ensure that allocated funds are spent on efficient and effective health care services for the population ensuring value for money and appropriate use of NHS funds. Context WLCCG commences 2016/17 on the back of strong financial performance. In 15/16 WLCCG utilised £778k of brought forward surplus to assist with in year transformation, the current financial plan includes the utilisation of a further £845k in 16/17 to provide support for the Emergency Care Vanguard and Better Care Together transformation projects planned to be implemented in year. This will reduce the cumulative surplus to be carried forward from 2016/17 to 1%. The CCG operates within the Leicestershire health and social care economy, where significant financial pressures are present within partner organisations. As a result of the level of financial deficit at University Hospitals Leicester NHS Trust, Leicestershire was previously identified nationally as a “financially challenged health economy” and as such has been subject to external scrutiny regarding plans in place to deliver financial balance across all organisations over the coming years. The local response to this has been to draft an agreed Health and Social Care plan (Better Care Together — BCT) to transform the way that care is delivered and ensure improved financial and nonfinancial performance. This operational financial plan set within that context is the first year of a five year sustainability and transformation plan for the entire system. The Financial Plan In line with NHS England requirements for 2016/17, the CCG plans to deliver against all business rules: • A cumulative 1% surplus • Investment into mental health services at least in line with our allocation growth (“parity of esteem”) • Holding an uncommitted contingency of 0.5% Draft to NHS England 2.0 136 | Financial and Activity Plans • An uncommitted 1% fund available for non-recurrent investment • Delivery of significant QIPP savings to fund required investment. The table below summarises, at a high level, the increased funding which the CCG will receive in 2016/17 and how it is utilised in the current expenditure plans: Financial Plan Summary 2016/17 £'000 Recurrent Baseline Growth 13,983 Reduction in running costs allocation (10) Non recurrent allocations (4,518) NET CHANGE IN FUNDING 9,455 Full Year effects 5,838 Demographic Growth 2,578 Non Demographic Growth 4,077 Inflation 10,245 Efficiency (5,783) QIPP (14,271) Cost Pressures 3,028 Reduction in Surplus (795) Investments QIPP Investments 1,119 Other Investments 1,064 Replacement of Contingency reserve 2,355 NET CHANGE IN EXPENDITURE 9,455 Quality, Innovation, Productivity and Prevention (QIPP) Last year WLCCG planned, implemented and delivered a number of QIPP schemes. These were designed to change various elements of care pathways in order to improve either quality of care, productivity or prevention. A number of the schemes were designed to change services in such a way that funds could be moved from one care setting to another or from one service to another and in so doing, delivering increased volume and/or quality of care for the same cost. A significant level of QIPP savings (£14.2m, 3%) is required to enable Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 137 the CCG to make investments in services during 2016/17 whilst maintaining a strong financial position. These schemes will be a combination of service transformation, transactional savings and disinvestment. To date, £11.8m of schemes have been identified from these three categories leaving a further £2.5m unidentified. It is expected that the remaining target will be assigned to actions as a result of decisions to be made during March. QIPP projects have been developed for 2016/17 in conjunction with the local authority, local providers and neighbouring CCGs. All service transformation projects have undergone a rigorous challenge process to ensure they are clinically safe, move the CCG towards its goals and have been developed in conjunction with the local clinicians. Investments Following the comprehensive spending review and receipt of guidance and allocations during December 2015 and January 2016, the CCG has very little funding available for investments during 2016/17. The majority of investments will be spent in the following three areas: 1 To reinstate the 0.5% contingency reserve to manage risk during the financial year 2 To achieve mental health parity of esteem and make suitable transformation of Mental Health services — c.£2m 3 To support the delivery of QIPP savings. Other assumptions The West Leicestershire CCG financial plan is aligned with latest planning guidance received from NHS England and others, specifically including the following: • Tariff Inflation is applied at a net level of between 1.1% and 1.8% dependent on provider type (i.e., CNST adjustment of 0.7% is taken into account in this plan). • Whilst our BCF plan for 2016/17 is in the final stages of agreement, we have assumed within this plan the minimum level of funding of £20.5m will be fully spent. • CHC Non-demographic Growth has been calculated at 6% based on historic levels of growth pre-QIPP. This is similar to the average of all CCGs plan submissions during February. • Acute growth has been calculated for demographic changes, in addition, non-demographic growth is also factored into these plans taking account of the ageing population and the impact this has on healthcare required. Work continues with our local providers to model and agree detailed activity plans which will be reflected in our final plan submission. Draft to NHS England 2.0 138 | Financial and Activity Plans Activity Plan Gross activity growth included within our activity plan is broadly in line with that shown in the iHAM model. Net activity growth is planned after taking account of our QIPP schemes which are the same as those modelled in the financial plan. This is shown in the following table: Activity Type Gross Growth QIPP Net Growth OP Firsts 2.3% -2.7% -0.4% OP Follow Ups 2.5% -2.9% -0.3% Elective Admissions 3.1% -0.1% 3.0% Non Elective Admissions 2.7% -2.3% 0.4% A&E Attendances 1.9% 0.0% 1.9% Detailed activity modelling continues in conjunction with our providers. It is expected that our activity and financial plans will be finalised during March in line with contractual agreements reached with providers. Risks and Mitigations The two major financial risks at present are: 1 The delivery of QIPP at the targeted level £14.2m — this is nearly double the amount of the savings generated in recent financial years. 2 The ability to reach contractual agreement with our providers within the financial envelopes contained within our plans. Mitigation of these and other financial risks within the plan is as follows: • A 0.5% contingency will be set aside to guard against adverse risks (£2.4m) • A 1% non-recurrent fund will be set aside and not spent until the CCG is satisfied that risks are successfully being managed (£4.1m) • Further QIPP schemes will be developed and implemented during the financial year to ensure delivery of the surplus. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 139 Financial Plan Summary WLCCG commences 2016/17 on the back of previous strong financial performance. The CCG Financial plan is set to deliver on all of the requirements of the NHS Planning guidance. There is significant risk to delivery of the financial plan in line with expectations, these risks will be managed primarily between now and the creation and submission of the final financial plan. Risks will be managed in year specifically through not committing transformation funds (£4.1m) and the contingency fund (£2.4m). Draft to NHS England 2.0 140 | Appendices Appendices Appendix A: Population analysis Appendix A1 Trends in premature mortality DSR per 100,000 Under 75 mortality rate from all cardiovascular diseases (PHOF indicator 4.04i), NHS West Leicestershire (Leicestershire data) 100 50 0 2001–03 2002–04 2003–05 2004–06 2005–07 2006–08 2007–09 2008–10 2009–11 2010–12 2011–13 Under 75 mortality rate from cancer (PHOF indicator 4.05i), NHS West Leicestershire (Leicestershire data) 170.0 160.0 150 150.0 DSR per 100,000 140.0 100 50 0 2001–03 2002–04 2003–05 2004–06 2005–07 2006–08 2007–09 2008–10 2009–11 2010–12 2011–13 Under 75 mortality rate from liver disease (PHOF indicator 4.06i), NHS West Leicestershire (Leicestershire data) DSR per 100,000 15 10 5 0 2001–03 2002–04 2003–05 2004–06 2005–07 2006–08 2007–09 2008–10 2009–11 2010–12 2011–13 Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 141 Appendix A2 Long-term health problem or disability by age for Leicestershire, 2011 85+ yrs 75-84 yrs 65-74 yrs Day-to-day activities not limited 50-64 yrs Day-to-day activities limited a little Day-to-day activities limited a lot 35-49 yrs 25-34 yrs 16-24 yrs 0-15 yrs 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Disabilty and long term conditions, England Disability and long term conditions, NHS West Leicestershire (district based estimate) 40% 40% 30% 30% 20% 20% 10% 10% 0 0 16-24 yrs 25-49 yrs > 49 yrs Daily activities limited long term condition or disability: 16-24 yrs 25-49 yrs > 49 yrs A little A lot Appendix A3 Scarf chart showing the breakdown of the life expectancy gap between the most deprived quintile in Leicestershire and the least deprived quintile in Leicestershire, by cause of death, 2009–2011 100% 80% 60% 40% 20% 0 Circulatory, 31% Cancer, 21% Respiratory, 12% Digestive 11% External causes, 5% Circulatory, 24% Cancer, 22% Respiratory, 13% Digestive 9% External causes, 10% Other, 16% Other, 19% <28 days, 5% Male <28 days, 3% Female Further information on health inequalities The wider determinants of health are described and measured within Draft to NHS England 2.0 142 | Appendices the English Indices of Deprivation 2010 indices of deprivation use several measures in each of seven “domains”: • Income deprivation, including Income Deprivation Affecting Children (IDACI) and Income Deprivation Affecting Older People (IDAOPI); • Employment deprivation; • Health deprivation and disability; • Education, skills and deprivation; • Barriers to housing and services; • Crime domain; and • Living environment deprivation domain. Targeting people with increased needs The JSNA has set out the key priorities for the whole population with respect to the long term pressures on health and social care. As well as the long term demographic change there are populations that are more vulnerable and have increased care needs and the priority populations that have been identified across Leicestershire are: • vulnerable children and families; • people with learning disabilities and/ or autism; • people with physical and sensory disabilities; • people with, and at risk of, mental health conditions; • people with long term conditions and cancer; • frail older people; • people affected by poverty; and • carers. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 143 English Indices of Multiple Deprivation 2010 by national quintile for Leicestershire Appendix A4 Carers The 2011 Census data on people’s self-reported health and disability status revealed that:. • 173,691 people in West Leicestershire CCG reported that they were in very good health (47%). 131,318 reported they were in good health (35.5%), 48,146 reported that they were in fair health (13.1%), 13,134 (3.5%) reported that they were in bad health and 3,611 people reported that they were in very bad health (1%). • 36,708 people in Leicestershire reported that their daily activities were limited a lot by a long-term condition or disability (15%) and 44,851 people reported that their daily activities were limited a little by a long-term condition or disability (18%).12 • 26,283 people in West Leicestershire CCG reported that their daily activities were limited a lot by a long-term condition or disability and 32,847 people reported that their daily activites were limited a little by a long-term condition or disability. Draft to NHS England 2.0 144 | Appendices Appendix A5 Prevent/Reduce/Delay/Provision of long term care: Prevent This is primary prevention of ill health and disability in people who do not currently have care or support needs. This is providing universal services to ensure that people have access to good information and advice, are able to live healthy and active lives, live in safe neighbourhoods and have good social networks to help to support them. Reduce This is a tier of secondary prevention or early interventions. Providing targeted interventions to individuals with increased risk of developing a need for services and where service provision may prevent people from deteriorating and needing to use services. Delay This is a tier of tertiary prevention, which is aimed at minimising the effect of disability or deterioration for people with established health conditions Provision of long term care — as well as people that fall into the categories of need where interventions can prevent, reduce or delay the need for support services or treatment, there will also be a cohort of patients where these strategies will not be effective who will need long term services and support. This cohort of people may still benefit from preventative approaches including universal services, and opportunities to minimise use of long term services and support should continue to be utilised. Implementation of the prevent/ reduce/ delay model will ensure that we start to make the changes that we need across the life course to deliver a fundamental shift in services that we provide for our population from treatment services to prevention services Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 145 Appendix B Documents and drivers that affect operations (key policy drivers) NHS Constitution for England, Department of Health 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/480482/NHS_Constitution_WEB.pdf Everyone Counts: Planning for patients 2014/15 — 2018/19, NHS England https://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-stratplann-guid-wa.pdf NHS Five Year Forward View, NHS England, 2014 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfvweb.pdf The Forward View Into Action, NHS England, 2014 https://www.england.nhs.uk/wp-content/uploads/2015/07/ncmsupport-package.pdf Five Year Forward View Time to Deliver, NHS England, 2015 https://www.england.nhs.uk/wp-content/uploads/2015/06/5yfv-timeto-deliver-25-06.pdf New Care Models: Vanguards -— Developing a Blue print for the future of NHS and Care Services, NHS England, 2015 https://www.england.nhs.uk/wpcontent/uploads/2015/11/new_care_models.pdf The Devolution Bill and what does it mean for the NHS? Nuffield Trust, 2015 http://www.nuffieldtrust.org.uk/blog/devolution-bill-and-nhs-whatwill-it-mean The Keogh Urgent and Emergency Care Review, 2013–2014 http://www.nhs.uk/NHSEngland/keogh-review/Pages/about-thereview.aspx http://www.nhs.uk/NHSEngland/keoghreview/Documents/UECR.Ph1Report.FV.pdf Better Care Fund Guidance 2014 https://www.england.nhs.uk/wp-content/uploads/2014/07/bcf-revplan-guid.pdf Draft to NHS England 2.0 146 | Appendices Appendix C Frail Older People The table (below) indicates the dementia prevalence rates for the Leicestershire, Leicester City and Rutland CCGs as at January 2016: CCG Dementia Prevalence Rate East Leicestershire and Rutland CCG 60.1% West Leicestershire CCG 63.0% Leicester City CCG 84.4% All CCGs are demonstrating an improvement month on month. However, both ELR and West Leicestershire CCGs are below the dementia prevalence rate of ‘at least two-thirds’ of the estimated number of people with dementia. In line with this both CCGs are working closely with our general medical practices to continue the improvement, particularly during 2016/2017. Options for commissioners Commissioners and service providers need to work together to assess the scale of the problem locally. To enable older people to remain in nursing or residential care homes, commissioners need to specify that service providers: • use specific models of pro-active care, such as an enhanced primary care service • undertake advanced care planning, not only for foreseeable changes and deterioration in long-term conditions (including dementia), but also for end-of-life care using the Gold Standards Framework, with inclusion on primary care palliative care registers and information-sharing through the electronic palliative care coordinating system (EPaCCS) • pro-actively review and adjust medication • set up programmes to reduce falls and fractures, e.g. preventative measures, case-management by nurse specialists, and dedicated GP input, especially for high-risk residents • set up hospital-at-home teams, especially for administration of intravenous fluids and antibiotics. What is the clinical evidence for this change? The clinical evidence for change links into the ageing population, complex health and social care needs and their co-morbidities. There is increasing evidence that adopting healthy lifestyles in old age can yield health benefits and maintaining behaviours such as regular exercise, not smoking, reducing alcohol consumption, healthy eating Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 147 and preventing obesity has a protective effect well into retirement. To this end it is important that preventive programmes are at the forefront of health and social care delivery for all age groups, including older people. Loneliness, social isolation and social exclusion are important risk factors for ill health and mortality in older people. Positive and supportive relationships with close family members contribute to older people’s well-being, but those aged 75 and over are least likely to have these networks. Effective interventions to combat older people’s isolation and exclusion through integration across social care and the voluntary sector offer older people improved health and well-being that, in turn, leads to less impact on primary medical and community care and ultimately secondary care. Frail older people can suffer harm from receiving care in an acute setting when this is not absolutely necessary. The national average length of hospital stay is double for a patient with dementia which affects the well-being of the patient and their carer along with impacting on the use of acute beds for acute spells of care. The need for a skilled, integrated and educated workforce across all health and social care sectors is also required to support the programme of delivery; to recognise frailty, to treat the individual’s needs across the elements of care, not just within one disease pathway, to recognise that organisations and their workforce are interdependent of one another is paramount to changing the culture of health and social care delivery through integration and to managing the recruitment and retention of health and social care professionals. What are we going to do? The overall proposal for the next 5 years for the Frail Older People and Dementia work-stream is to: • Align our plans across the system of health and care • Streamline and focus our efforts on tackling a smaller number of priorities/interventions • Identify those citizens at greatest risk and supporting them to maintain or regain their independence which will reduce their reliance on more costly interventions • Adopt a whole system approach to pathway re-design (patient journey) ensuring integration of planning, commissioning and delivery is considered where appropriate • Improve the customer experience through driving up quality and performance • Deliver efficiencies through developing more effective and streamlined practices and processes Draft to NHS England 2.0 148 | Appendices • Integrate care records and using more integrated technology to support joint care plans. We will do this through focussing on the following key areas of work: Dementia For: 2017/2018 and 2019/2020 • Integrated IT strategy for LLR for the management of dementia, including a consistent approach to care planning • Co-ordinate support, education and training for all our providers • Review our care pathway to ensure that it is integrated effectively across health and social care • Work with our voluntary sector organisations to provide integrated support for the patient, their family and carers. Carers The focus of the Carers Delivery will link directly to The Care Act, 2014 and the NHS Commitment to Caring — Progress Report 2015 guidance. The Care Act of 2014 came into force in April 2015 and introduced new statutory duties for local authorities to support carers; giving carers parity of assessment, support planning and direct payments in line with the person they care for. In parallel to this, the NHS Commitment to Caring Progress Report for 2015 highlights 37 commitments across eight priority areas. For: 2017/2018 – 2019/2020 • More integrated support for carers as part of the overall prevention offer to carers across health and social care. Integrated Pathway Redesign The vision of the Integrated Pathway Redesign Delivery Group is to have an integrated are offer for frail older people that will deliver a person-centred, seamless and integrated approach to improving services for our population, focusing on maintaining health and independence. The focus is with regard to reviewing and developing an end to end frailty pathway across health and social care. In working to improve services for frail older people our aim, over the next three to five years is to have: • Care wrapped around the patient, whatever the setting of care and which is experienced by them as a single delivery system through multi-disciplinary, multi-organisational integrated care teams • Risk stratification to target the right services, at the right level, to Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 149 the right people, reducing inequalities by delivering the best possible outcome • Establish seamless and integrated pathways around individuals transforming current services as a whole health and social care system providing value for money supported by the right financial framework. Essentially the work within the Integrated Pathway Redesign Delivery Group is emerging and will have direct links to the work currently ongoing across health and social care led by the Urgent Care Team. Across LLR a key theme of work is to reconfigure the transfer/discharge pathways out of hospital from over 40 to five. For: 2017/2018 and 2018/2019 • Develop a business case including an implementation plan regarding the MCP model. Where will the benefit be? The Better Care Together and Frail Older People and Dementia workstream will encompass the Leicestershire, Leicester City and Rutland health and social care community including care homes. Therefore, strategic plans will be system-wide. From an implementation standpoint, to ensure responsiveness to local populations, initiatives will be developed and delivered to fit the needs of the people within each community. As a result each CCG, working with voluntary sector organisations and the coterminous local authority will reflect the strategic direction of the agreed plans through locally sensitive implementation initiatives. Draft to NHS England 2.0 150 | Appendices Appendix D Voluntary Sector Provider Coping With Cancer in Leicestershire and Rutland St Giles Hospice LOROS West Description of service CCG Only 53,130 Information, Emotional and Practical Support for People who are Coping with Cancer 9,701 Lymphoedema Clinic 767,444 Palliative Care services LOROS - MND Nurses 17,919 MND Nurses CRUSE 26,016 Provides counselling and support for the benefit of people of all ages who have been bereaved CLASP 7,919 Provide a guide to respite care services in Leicestershire Crossroads South Leicestershire 9,523 Provide support to carers Hinckley Carer Support Scheme 9,523 Provide, within the home domicile, personal assistance, support and respite care Leicester Charity Organisation Society Ltd 3,477 Community Equipment project aims to improve the effectiveness of the local services for people with mobility problems HEADWAY 11,471 To provide advice and information to people with a brain injury Vista 10,991 Ensure at point of diagnosis that there is an advice and information officer at the Ophthalmic Outpatients Departments of community hospitals in Leicestershire for those with little or no sight, including those who are dual sensory impaired Barnardos 5,916 Young carers service Family Action 20,057 Support child of sexual abuse Homestart Charnwood 22,545 Provide support and friendship of parents with post-natal depression Laura Centre 25,219 Counselling service for child following the loss of a parent or sibling Rainbows 24,776 support for children and parents with life limiting conditions Steps Work-Link Project 7,653 Programme for pre-school children with physical disabilities 13,112 To provide support for unemployed people (with special emphasis on long term unemployed people of over 12 months) and persons with varying disabilities including mental health, learning disabilities and physical disabilities. Draft to NHS England 2.0 West Leicestershire CCG Operational Plan 2016–2017 | 151 Provider LAMP West Description of service CCG Only 85,897 People experiencing mental distress and their carers have access to advice Leicester Housing Association Support Services 50,606 Provides individuals with enduring mental health problems moving from in-patient care to supported housing in communities Network for Change Limited 47,159 Work with individual clients to enable them to better manage their mental health difficulties and enjoy a good quality of life. People's Forum 9,585 Ensure that mental health service users in Leicestershire and Rutland have a voice and that their views, opinions and ideas about mental health issues and services are listened to Rethink - Focus line 29,564 Provides telephone support and information to people experiencing mental health problems and their carers Rethink - STRHomeless Outreach Project Worker 10,679 To offer an effective Support Treatment and Recovery (STaR) service to homeless people with mental health problems Rethink Carer Support 83,922 To provide support, advice and information to Carers on a one to one outreach basis, provided either in the Carers own home or a mutually agreed other venue. To provide information on local mental health services and assist the carer to access these services Leicester Counselling Centre 9,811 The service provides psychodynamic and integrative counselling Quetez 15,166 To provide a confidential non-discriminatory sensitive counselling service in a safe and professional environment to adult women survivors of childhood sexual abuse Age UK 42,033 Day Care Service Alzheimer's Society 18,000 Dementia Services Royal Volunteer Services 28,362 Service supports older vulnerable people 55+ who are patients in need of transport with support to attend chemotherapy, radiotherapy, kidney dialysis, Haematology and bone marrow, clinics for treatments at any UHL hospital Castle Donington & District Volunteer Centre 6,228 Transport scheme for residents of Castle Donington and Districts Draft to NHS England 2.0