Subject: 2016-17 Operational Plan Meeting: NHS Milton Keynes
Transcription
Subject: 2016-17 Operational Plan Meeting: NHS Milton Keynes
Enc No 16/22 Subject: 2016-17 Operational Plan Meeting: NHS Milton Keynes CCG Board Date of Meeting: 24th May 2016 Report of: Donna Derby, Director of Transformation & Delivery Alison Joyner, Head of Strategic Planning Is this document: Commercially Sensitive For the Public or Private Agenda To be publically available via the CCG Website N Public Y 1. INTRODUCTION 1.1.1 In order to respond to the significant challenges that the NHS is facing, CCGs must take a leading role in developing and implementing transformative long term strategies and plans for their commissioning of services. Delivering the Forward View: NHS planning guidance 2016/17/ - 2020/211 describes the requirement for CCGs to now consider their planning and delivery across a wider geographical footprint through the development of a 5 Year Sustainability and Transformation Plan [STP] and for the 2016/2017 Operational Plan to effectively form Year 1. 1.1.2 An overview of the emerging plan was presented to the Board at its meeting on 22nd March and following draft submissions to NHS England in March and April changes have now been made to finalise this annual plan. 1.1.3 The CCG Operational Plan was submitted to the Area Team on 18th April 2016. This sets out the key health issues and commissioning priorities which will be addressed to improve the health and wellbeing of the population of Milton Keynes. It summarise the key commissioning intentions for 2016/17 as developed by the clinical Programme Boards and how these (where appropriate) will contribute to driving forward the emerging Sustainability & Transformation Plan2 (which will be developed in conjunction with Bedfordshire & Luton health and care systems). Finally it outlines how the CCG will deliver the national ‘must do’ requirements. 1 2 NHS England: Delivering the Forward View: NHS planning guidance 2016/17/ - 2020/21, December 2015 To be developed by end of June 2016 Enc No 16/22 1.1.4 The plan, which is currently with NHS England for review, outlines six key areas (in line with the NHS 5 Year Forward View3) in which the CCG needs to continue to explore, agree and build new models of care delivery during the next 5 years. Namely: Citizen & participation empowerment Wider primary care, provided at scale A modern model of integrated care Access to the highest quality urgent and emergency care A step change in productivity of elective care. Sustainable hospital services 1.1.5 It draws upon the Joint Strategic Needs Assessment 2014-15, the Health and Wellbeing Strategy 2015-18, reflects the proposed CCG financial plan for 201617, provides an update on the development of QIPP saving plans to address the gap in planned funding requirements and identifies any remaining risks associated with these plans. Finally, it includes the specific performance measures and outcomes that the CCG will deliver during 2016-17. 2. KEY ELEMENTS 2.1.1 The plan has been built up based on planning guidance issued by NHS England in December 2015 and continues to be refined as further guidance is released. 2.1.2 The plan is fully reflective of the 2016/2017 CCG Financial Plan, including the Quality, Innovation, Productivity & Prevention (QIPP) target which is being addressed by the development of QIPP saving plans across each of the Programme Boards and other identified areas. 2.1.3 Delivery of Year 2 of the Better Care Fund Plan4 (BCF) is broadly reflected within the plan, although a final submission of this is due on 29th April. 2.1.4 It reflects and addresses the national ‘must do’ requirements including NHS Constitution targets, care for people with Learning Disabilities, national CQUINs and the agreed Quality Premium measures. 2.1.5 An overview of the plan is shown on the following page, with links to the wider strategic context indicated. 3 4 NHS England: The Five year Forward View, October 2014 MKC & MKCCG, Better Care Fund Plan: 2014-2018: September 2014 (Final) Enc No 16/22 Enc No 16/22 3.0 NEXT STEPS 3.1.1 Following earlier submissions, a final draft of the plan has been submitted to the Local Area Team of NHS England for their review. 3.1.2 As the work across the wider BLMK ‘footprint’ continues to develop, there will be a requirement on the CCG to consider how best to entwine internal work streams & clinical programmes with the emerging themes of the STP shown in the diagram below. This will be of particular importance once transformational funding becomes dependent on identification and agreement of key priorities across the STP. Emerging STP priorities across Bedfordshire, Luton & Milton Keynes (1) • The STP does not substitute for local leadership or responsibility of the health and social care agenda • STP emerging priorities reflect those where significant benefits are expected through collective action by bodies operating across Bedfordshire, Luton & Milton Keynes • Other local priorities exist and will remain firmly gripped by individual bodies • STP priorities break down into four themes within which nine workstreams have been identified Theme 1 – public-facing initiatives Theme 2 – service user-facing initiatives Prevention Primary, Community & Social Care Urgent & Emergency Care Theme 3 – Enabling Initiatives Workforce Shared patient care record, digitisation and communications New models of care Theme 4 – initiatives to reduce system overheads Clinical support services Back-office support services Estates and estates management 3 4.0 RECOMMENDATION The Board is asked to approve this final version of the 2016/2017 Operational Plan and note its relationship with the wider STP in due course. Enc No 16/22 Strategic Summary Year 1 (2016-2017) Operational Plan v6 - FINAL 24th May 2016 Strategic Summary & Year 1 Operational Plan 2016-2017 Final Draft v. 5 Delivering the NHS Forward View: 1|Page Enc No 16/22 Strategic Summary Year 1 (2016-2017) Operational Plan v6 - FINAL 24th May 2016 Reader Information Version control v.6 Publication Date 24 April 2016 Sign Off Date CDG – 3 May 2016 Lead Author Donna Derby Key Contributors th rd th Governing Body/Board – 24 May 2016 Director of Transformation & Delivery [email protected] Alison Joyner Head of Strategic Planning [email protected] Wendy Rowlands Deputy Chief Financial Officer [email protected] “Delivering the Forward View: NHS Planning Guidance 2016/17 - 2020/21” sets out the priorities for the NHS in meeting the commitments and vision set out in the NHS Five Year Forward View, including the planning requirements to be fulfilled by CCGs in England. This plan fulfils the requirements for each organisation to produce a 1 Year Operational Plan for 2016/17. It covers the operational period April 2016 - March 2017, and sets the scene for the wider, emerging Sustainability & Transformation Plan. It incorporates the existing priorities of the CCG’s 5 Year Strategic Plan and also reflects the current work associated with the Bedfordshire/MK Healthcare Review. Description Contact Details [email protected] Equality Impact Analysis We understand our responsibilities in relation to equality impact analysis; the reviews and projects that will arise as a result of this plan will each undertake their own equality analysis (as per MKCCG’s Planning & Delivery process), and address any potential inequalities appropriately. Glossary AT NHS England Area Team MKUHFT Milton Keynes University Hospital Foundation Trust A&E Accident & Emergency LETB Local Education & Training Board BCF Better Care Fund QIPP Quality, Innovation, Productivity & Prevention Plan CCG Clinical Commissioning Group PCOCs Primary Care Outpatient Clinics CIPs Cost Improvement Plans PAF Patient Advisory Forum CNWL:MK Central North West London Foundation Trust PBR Payment by Results CQC Care Quality Commission PPG Patient Participation Groups CQUIN Commissioning for Quality and Innovation RMS Referral Management Service DoH Department of Health TDA Trust Development Agency EIA Equality Impact Assessment RTT Referral to Treatment LIT Local Implementation Team SCAS South Central Ambulance Service MKi Milton Keynes Intelligence Observatory SRO Senior Responsible Owners MKUCS Milton Keynes Urgent Care Services JSNA Joint Strategic Needs Assessment 2|Page Enc No 16/22 Strategic Summary Year 1 (2016-2017) Operational Plan v6 - FINAL 24th May 2016 Table of Contents Reader Information & Glossary Executive Summary 2016/2017 Plan on a Page 2 4 6 1. 2. 3. 4. 5. 6. 7 7 8 10 13 16 Purpose Introduction Strategic Context National Context Health & Wellbeing in Milton Keynes System Vision 1.1 1.2 1.3 1.4 1.5 1.6 7. 17 19 23 26 29 31 Transformation & Delivery 7.1 7.2 7.3 7.4 7.5 8. 9. 10. 11. 12. Citizen Participation & Empowerment Wider Primary Care at Scale Modern Model of Integrated Care Access to High Quality Urgent & Emergency Care Increase in Productivity of Elective Care Sustainable Hospital Services Urgent Care (SRG) Care Pathways & Primary Care Integration & Better Care Fund Mental Health & Learning Disabilities Maternity, Children & Young People Integration & Partnership Governance Improving Quality & Outcomes Commissioned Activity Plan Sustainability & Finance Appendix A Appendix B Appendix C Appendix D Appendix E 5 Year Outcome Ambitions 2016/17 NHS Constitution Trajectories 5 Year Financial Plan & QiPP Health Care Review Timeline Better Care Fund Plan 36 36 38 39 40 42 46 48 50 61 63 71 78 80 83 84 3|Page Enc No 16/22 Strategic Summary Year 1 (2016-2017) Operational Plan v6 - FINAL 24th May 2016 Executive Summary This Operational Plan sets out the focus of MKCCG’s activities in 2016-17, and summarises the overall direction we will take in Year 1 of our emerging 5 Year Sustainability & Transformation Plan, which we are developing in conjunction with neighbouring systems, Luton & Bedfordshire. It describes the specific programmes of work we intend to prioritise to drive better care delivery and health outcomes for our local population, whilst at the same making significant progress in ensuring a sustainable financial position going forwards. Improving Local Health & Wellbeing The health of people in Milton Keynes is varied compared with the England average. Data from the 2015 Health Profile1 indicates that deprivation is lower than average, however about 19.0% (10,500) children live in poverty. Life expectancy for women is lower than the England average and life expectancy for men is 6.6 years lower in the most deprived areas of Milton Keynes than in the least deprived areas. The main causes of life expectancy gaps are cardiovascular diseases, cancers and respiratory disease. Obesity is a significant issue with 18.6% (547) of Year 6 children classified as obese and 23.4% of adults are classified as obese. Recorded diabetes prevalence is rising. The rate of smoking related deaths was 304*, which represents 289 deaths per year. The percentage of hospital admissions that are emergencies is higher in MK than the national average; with the percentage being higher among people from a Black or Asian ethnic group. Priorities for tackling this therefore need to focus on reducing early deaths (particularly from cancer and lung disease), to reduce physical inactivity, and to reduce emergency hospital admissions. There have been tangible improvements in health in MK since the 2014 health profile; namely a small improvement in the life expectancy for men, however MK CCG recognises that there has been no real change in the very real health inequalities experienced by certain communities in the borough and will continue to work closely with our Public Health colleagues to drive a reduction in those inequalities. Improving healthy life expectancy through primary prevention will be key to reducing the burden of an ageing population. Delivering Better Care & Higher Quality The NHS has been subject to a number of high profile reviews relating to patient safety in recent years. MK CCG will continue to make progress in ensuring that all recommendations of Francis, Berwick and Winterbourne View are fully implemented and assure our population that will continue our relentless drive for better quality and safe services from all of our providers. This includes establishing a Transforming Care Partnership with Luton & Bedfordshire. We will also continue to drive progress on the delivery of appropriate seven day services, ensure a common core offer of high quality, patient centred primary care and put in place mechanisms to ensure that patient and staff experience continues to improve, including specifically responding to the recently published National Maternity Review. Services will be commissioned as locally as possible and practices will be encouraged to respond and provide services. Delivering Better Outcomes – A Transformed System MK CCG needs to find ways within its commissioning to ensure that it can play its part in delivering improvements in patient health outcomes, reducing inequalities and improving access to services. Through the Quality Premium, commissioners are incentivised to support the national outcome priorities as set out in the Five Year Forward View and the NHS Mandate, but also through the selection of local indicators which allows the CCG to engage and drive improvements in areas agreed with its partners. The CCG Improvement and Assessment Framework is the mechanism by which progress will be monitored. The Operational Plan sets out the progress against the delivery of those outcomes that will be achieved by the end of 2016/2017. The CCG has agreed, with system partners, to focus on the following local indicators: 1 % of patient returning to their usual place of residence following hospital treatment for a stroke % of mothers who give their babies breast milk in the first 48 hours after delivery Reported prevalence of hypertension on GP registers as % of estimated prevalence http://www.healthprofiles.info 4|Page Enc No 16/22 Strategic Summary Year 1 (2016-2017) Operational Plan v6 - FINAL 24th May 2016 Access The CCG has delivered strongly against the NHS Constitution Standards, such as 18 week waits and urgent referrals for cancer in 2015/16, though there are areas that need improvement and more importantly sustainability moving into 2016/17. This is particularly with cancer where too many people are diagnosed too late and A&E access where there has been a growth in attendances. Access to primary care remains an issue for the CCG with primary care experiencing significant and increasing pressure in patient activity, increasing complexity and challenges in being able to recruit and retain key practice staff. In order to meet future demands and make primary care an attractive career choice we need to do things differently. With increasing workloads across GP practices, challenges to access and patient demand means that this work needs to start urgently and involve close working with NHS England, our practices and neighbourhoods. The CCG Joint Commissioning colleagues continue to improve access to mental health services in collaboration with providers, to implement the locally agreed Mental Health Strategy 2014-17. This includes meeting the new mental health standards relating to people with the first episode of psychosis commencing treatment within 2 weeks, and ensuring people with common mental health conditions referred to Improved Access to Psychological Therapies (IAPT) programme within six weeks of referral and treatment within 18 weeks. Parity of Provision MK CCG strongly supports the national focus on putting mental health on an equal footing with physical health and is committed to the parity of esteem for mental health investment. It will ensure parity of esteem for mental health services in terms of % funding growth and through Joint Commissioning good progress has been made in the last year to deliver better outcomes for people with mental illness through sustained delivery against the IAPT & EIP indicators, and ensuring that those with mild to moderate illness are able to access high performing services within the new waiting times standards. The CCG has also made significant progress in ensuring that a bigger proportion of people with dementia are diagnosed and treated, and are confident that the Prime Ministers challenge of a 66.7% diagnosis rate for people with dementia will be achieved and maintained during 2016/17. In addition an implementation plan will be agreed to improve post diagnostic support for people and their carers. Finance & Efficiency Gap The NHS continues to face a period of unprecedented change and financial challenge, increasing the need for both commissioner and providers to deliver both improved productivity and quality. The updated planning guidance for CCGs was issued in December 2015, along with refreshed financial allocations to CCGs for the next five years. Milton Keynes has again benefited from a high level of growth in 2016-17 of £16.8m; however the % increase drops significantly during the next three years so it is important that this first year of the five year plan is a year of stability bringing the system back into financial balance. The high level of growth in allocation funding has been more than offset by the underlying pressure from the previous year. There is a continued requirement to contribute part of the CCG funding allocation to the system wide Better Care Fund. The minimum contribution for Milton Keynes is £14m. In its planning, MK CCG anticipates a net QIPP target of £7.3m in its Programme Budgets for the forthcoming year. A number of the QIPP schemes already have well developed business cases and closely relate to the BCF and new community based services, which were implemented during 2015. It is anticipated that they will result in a reduction of acute emergency admissions. The CCG has just agreed an 18 month pilot managed care pathway for ophthalmology with Milton Keynes hospital. The service went live in February 2016. Joint work is also well progressed to transform urgent care services and the hospital has completed estate works in A&E to facilitate an integrated urgent care service. A further £1m will be saved through prescribing initiatives in 2016-17. Where possible, the CCG will aim to take a collaborative approach with all partners – using the same language, having the same vision and aims for our population and bearing in mind the priorities outlined in the Sustainability & Transformation Plan (STP). The diagram on the next page outlines our summary ‘plan on a page’ for 16/17 of key initiatives, transformation & actions we will take to deliver the plan, with links to the wider strategic context. 5|Page Enc No 16/22 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 1. Purpose This document sets out the key health issues and commissioning priorities which will be addressed to improve the health and wellbeing of the population of Milton Keynes and to meet the objectives set out in the local Health & Wellbeing Strategy2. At this point in time it summarises the key operational commissioning intentions for 2016/17 and how these (where appropriate) will contribute to driving forward the emerging Sustainability & Transformation Plan3 at a wider geographical level and how the CCG will deliver the national ‘must do’ requirements. This plan effectively forms Year 1 of that 5 Year Transformation journey. The plan describes the monitoring of quality and safety assurance process; how financial resources will be used and how the CCG will deliver its key priorities. 2. Introduction NHS Milton Keynes Clinical Commissioning Group (MK CCG) has delegated responsibility in 2016-2017 for commissioning services estimated at around £295 million. It has a geographic area of responsibility that covers all the wards in Milton Keynes Local Authority plus the wards of Great Brickhill and Newton Longville which are in Aylesbury Vale. Its members are 27 general practices organised into 4 neighbourhood groupings, geographically based in the north, south, east and west of Milton Keynes. Milton Keynes CCG is largely (98%) co-terminous with Milton Keynes Council and has a registered population of around 286,0004. The CCGs main acute provider is Milton Keynes University Hospital NHS Foundation Trust (MKUFTH), accounting for approximately 45,000 admissions p.a. (85% of the total for that hospital) while Mental Health & Community Services are provided locally by Central Northwest London NHS Foundation Trust. As the primary organisation within Milton Keynes for commissioning health services to meet all the requirements of patients, the CCG will work collaboratively to ensure that it can meet the needs of the local population whilst living within its delegated resource limit. Improving the health of the local population is key to this aim, and is being delivered through the implementation of a number of locally agreed individual commissioning strategies for Urgent Care5, Mental Health6, Older People7, Dementia8, and Children & Young People9. A Care Closer to Home strategy10 has also been developed, which lays out the ambition to commission a greater proportion of activity in community and home settings in order to rebalance the health economy and a Primary Care Development Strategy11 which underpins how the CCG can support NHS England in the delivery of high quality of services in primary care. MK CCG is likely to oversee significant changes in acute care configuration within the next few years, with greater centralisation of specialist care, to achieve better patient outcomes. The local provider landscape is evolving and will experience significant shifts over the next 2-5 years. The CCG will need to improve the efficiency and value of the funding currently invested in the secondary care sector if it is to be able to commission the necessary resulting increases in breadth and volume of care required to be provided in communities and primary care. Joint work in this area is currently underway across Milton Keynes & Bedfordshire via the review of acute hospital services, supported 2 H&WB Board, Milton Keynes Joint Health & Wellbeing Strategy: 2015-2018: June 2015 To be developed by end of June 2016 4 Taken from Research & Intelligence Team at Milton Keynes Council using Population Bulletin 2013/14 data 5 MK CCG, Urgent & Emergency Care Strategy: 2013-2016: October 2013 6 H&WB Board: Mental Health Strategy: 2014-2017: December 2013 7 H&WB Board: Older People’s Strategy: 2014-2017: August 2013 8 H&WB Board: Dementia Strategy: 2014-2017: September 2013 9 MK CCG: Children & Young People’s Strategy (in development) 10 MK CCG, Care Closer to Home Strategy: 2013-2015 (Working Draft), September 2014 11 MK CCG Primary Care Development Strategy, 2013-2015, June 2013 3 7 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 by Monitor, TDA & NHS England. The outcomes of the October 2014 Progress Report has already influenced the CCGs 5 Year Strategic Plan12 and immediate priorities for 2015/2016 are included in this plan. 3. Strategic Context MK CCG is committed to improving health, reducing health inequalities and ensuring that the public have access to safe, high quality services. As a commissioner, the CCG’s intentions are to shift care from hospital to community settings where truly integrated care across a range of partners will be the norm, whilst maintaining sustainable hospital services for care that cannot be delivered elsewhere. There remains a compelling case to modernise services and to improve the degree of co-ordination with other partners, particularly in primary and social care. The MKCCG approach to creating a system which delivers high quality safe services for its population is illustrated below. Deliver more Care Closer to Home Ensure Sustainable Hospital Services Make a Positive Impact The CCG has organised delivery of its strategic approach and commissioning priorities through four interdependent Clinical Programme Boards, plus the Clinical Executive. Additionally, a Programme Board is in place for both delivery of the Better Care Fund Plan and the Healthcare Review. The detailed focus for each board for 2016/17 is summarised later in this document, but the overall approach is summarised in the Plan on a Page shown on page 2. However, Delivering the Forward View: NHS planning guidance 2016/17/ - 2020/2113 describes the requirement for CCGs to consider their planning and delivery across a wider geographical footprint through the development of a Sustainability and Transformation Plan [STP]. Covering the period between October 2016 and March 2021, STPs will become the local blueprint for accelerating the implementation of the Forward View, to deliver the triple aim of better health; transformed quality of care delivery; and sustainable finances. The diagram below illustrates how the development of the STP might fit with existing plans and local strategies and demonstrates how this plan effectively forms Year 1 of that 5 Year transformation journey. 12 13 MKCCG, 5 Year Strategic Plan: 2014-2019, January 2015 NHS England: Delivering the Forward View: NHS planning guidance 2016/17/ - 2020/21, December 2015 8 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Strategic Planning Landscape (2016-2020) MK Health & Wellbeing Strategy 2015-2018 MK Joint Strategic Needs Assessment Sustainability & Transformation Plan(s) Yr 1 [2016-2020] Strategic Estates Plan 2016-2018 MKC Corporate Plan & Service Plans Operational CCG Plan Yr 2 HCR Options Agreed Yr 2-3 Transf £ Dependent Better Integration Plan 2017-2020 Primary Care Strategy BCF Delivery Plan 2016-17 System Wide DTOC Plan 2016-17 Digital Roadmap & IT Strategy Transformation footprints for STPs should be locally defined, based on existing working relationships, patient flows and other footprints such as learning disability units. They must also take into account where geographies are already involved in success regime or other programmes of work and so MK CCG is currently in discussion with its neighbouring CCGs regarding a possible footprint that would encompass Bedfordshire, Luton and Milton Keynes. Placed-based planning on this scale accounts for the work being undertaken within the healthcare review of services in Bedfordshire and Milton Keynes, acknowledges wider patient flows for more specialist services to both Bedford Hospital and the Luton and Dunstable Hospital and reflects the existing planning footprint for the development of our Learning Disability Transforming Care programme. As NHS planning guidance suggests, however, the STP will be an umbrella plan, with differing levels of shared planning. Transformational change for care pathways such as urgent emergency care will be mapped across this broad footprint, whereas locality specific plans for Primary Care will be described on CCG organisation-based levels. The diagram below illustrates how this might work for MK CCG in practical terms. Layers of Strategic Planning Footprints MK NHS Only Footprint Electiv e Care Productiv ity & Efficiency Wider Primary Care at Scale Modern Model Of Integrated Care MK NHS/MKC Footprint MK & Bedfordshire Footprint (HCR Sustainable Hospital Services) MK, Beds & Luton Footprint (LD Services only) High Quality Urgent & Emergency Care Specialised Services, centres of excellence 9 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 4. National Context 4.1 NHS Mandate The NHS Mandate14 between the Government and NHS England sets out the ambitions for the health service for 2016-17 and a series of objectives for delivery by 2020. Effectively it is a multi-year mandate to enable local commissioners to plan more effectively and over a longer term. Objectives for 2016/17 are:NHS Mandate 1. To improve local and national health outcomes, particularly by addressing poor outcomes and inequalities; 2. To help create the safest, highest quality health and care services; 3. To balance the NHS budget and improve efficiency and productivity; 4. To prevent ill health and support people to live healthier lives; 5. To maintain and improve performance against core standards; 6. To improve out of hospital care; 7. To support research, innovation and growth; Measurable Goals The table below indicates clear priority deliverables for CCGs during 2016/17 along with how they will be measured. Goal 2016/17 Deliverable Performance/ Improving Outcomes 7 Day Services Patient Experience Maternity EOL PHB Consistent improvement against new National CCG Assessment Framework Achieve significant reduction year on year. 7 day services to 100% population in 4 clinical priority area (& progress on other 6 standards) Reduce avoidable deaths Reduce rate of stillbirths/neonatal and maternity deaths and brain injuries Measureable improvement of antimicrobial prescribing Maintain and increase the number of people recommending FFT (88 – 96% current) 50-100,000 people to have PHB or IPB (increase) Building on F&F Test results, enhance proposals Improve patient choice -MAT / EOL / LTC / CANCER Deliver Independent Cancer Taskforce Improve 1 year survival to achieve 75% 28 day diagnosis or clear from 14 Prevention Publish Avoidable Deaths data (MKUHFT) And improvement plan from Mar 2016 Baseline. Achieve 7 Day Services in 4 clinical priority standards, delivered to 25% of population National Maternity Review Recommendations Progress on Sign Up to Safety Set baseline for antimicrobial prescribing and resistance rates Plan for improving patient choice in Avoidable Deaths/ Cancer Publish CCG assessment framework performance data for 2015/16 (June) Cancer Dementia Maternity MH & LD Diabetes 2020 Ambition 62 day cancer wait Progress to achieve diagnosis standard (6 wks) Increase diagnostic capacity (Yr 1 figure) £ Investment in cancer treatments not through Cancer Drugs Fund Recommends from Cancer Taskforce delivered https://www.gov.uk/government/publications/nhs-mandate-2016-to-2017 10 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Child obesity improvement plan and improved trajectories in % terms year on year. 10,000 people (nationally) referred to prevention programme Maintain 2/3 diagnosis rate A&E, Ambulances & RTT Improvement trajectory and deliver plan for year 1 of ambulance response and Red 1 pilots 18ww RTT achieved New models of care covering 20% population Enhanced GP services evenings and weekends Same day appointments for over 75s Publish practice level metrics on quality Develop MCP contract for 17/18 implementation Year 2 BCF implemented Agreed plan for wider H&SC Integration by March 2017 Agree and support improvements local development deals Obesity & Diabetes Dementia New Modes of Care/ General Practice H&SC Integration MH & LD/Autism Agree implementation plan for PM challenges Achieve A&E target Urgent & Emergency Care Networks in 20% country System wide plan for DTOCs with overall goal and trajectory improvement; Implement Year 1 Increase people with LD/autism in cared for community settings 50% access within 2 weeks (psychosis) Implement actions of MH taskforce. 75% access to talking therapies in 6 weeks, 95% in 18 weeks Improve crisis care for all ages Locally transformation plan for YP’s MH Measurable reduction in line with national child obesity strategy Reduce risk of Diabetes (DPP) Measurable reduction in variation of management of diabetes Same Improvement on all areas of PM challenges 96% achieved Roll out to 100% U&EC networks covering 100% 75% CAT A achieved 92% 18ww RTT 0/52 weeks achieved 100% access to weekend / evening routine GP appointments Reduction in age/std. emergency admissions rates, emergency IP bed days H&SC integration, urgent and emergency care (SPOC & EHRS) 5000 extra doctors in P Care. Better integration Improvements in performance against CCG metrics Significantly reduce DTOC’s Longer term implementation Years 2-4 implementation Close health gap Access and waiting times embedded including; st 50% people experience 1 episode of psychosis – access 2 weeks 75% people access to talking therapies in 6 weeks, 95% 18 weeks 4.2 NHS CCG Assessment Framework NHS England is introducing a new Improvement and Assessment Framework (IAF) for CCGs from 2016/17 onwards 15. It has been designed to work in conjunction with the Five Year Forward View, NHS planning guidance and the Sustainability and Transformation plans with the “triple aim” of improving the health and wellbeing of the whole population; better quality for all patients, through care redesign; and better value for taxpayers in a financially sustainable system. The framework should be used as a dynamic learning tool to measure performance and improvement and support CCGs in delivering the “triple aim”. The IAF will cover four domains: 1. Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve; 2. Better Care: this principally focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas; 3. Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends; 15 NHS England: CCG Improvement & Assessment Framework, March 2016 11 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 4. Leadership: this domain assesses the quality of the CCG’s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity for example in managing conflicts of interest. The Forward View and the planning guidance sets out national ambitions for transformation in a number of vital clinical priorities such as mental health, dementia, learning disabilities, cancer, maternity and diabetes. The first assessment for each of these six areas will be published as soon as possible, derived solely from the metrics in the new framework looking at current baseline performance. This initial assessment will offer a useful starting point for all CCGs. 4.3 NHS 5 Year Forward View The NHS Forward View sets out three interdependent and essential tasks: first, to implement the following principles 6 Principles of 5 Year Forward View 1 Citizen Participation & Empowerment in Service Design & Change Wider Primary Care, provided at Scale 2 5 6 3 A modern model of Integrated Care 4 Access to the highest quality urgent & emergency care Step-change in the Productivity of Elective Care Specialised services, concentrated in centres of excellence Secondly to restore and maintain financial balance; and third to deliver core access and quality standards for patients. Whilst developing long-term plans for 2020/21, the NHS has a clear set of plans and priorities for 2016/17 that reflect the Mandate to the NHS and the next steps on Forward View implementation. Some of the CCGs most important delivery for 2016/17 involves partial roll-out rather than full national coverage as outlined above. Nationally, the ambition is that by March 2017, 25% of the population will have access to acute hospital services that comply with four priority clinical standards on every day of the week, and 20 percent of the population will have enhanced access to primary care. There are three areas where good progress will need to be made under the banner of seven day services. These are: reducing excess deaths by increasing the level of consultant cover and diagnostic services available in hospitals at weekends. During 16/17, a quarter of the country must be offering four of the ten standards, rising to half of the country by 2018 and complete coverage by 2020; improving access to out of hours care by achieving better integration and redesign of 111, minor injuries units, urgent care centres and GP out of hours services to enhance the patient offer and flows into hospital; improving access to primary care at weekends and evenings where patients need it by increasing the capacity and resilience of primary care over the next few years. Both this and the development of new care models will feature prominently within the CCGs wider STP, which will be developed and agreed by end of June. However, first steps towards this (within the framework of the 6 Forward View areas shown above) are reflected within this 2016/17 Operational Plans. 12 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 5. Health & Wellbeing in Milton Keynes The Health and Wellbeing Board is a partnership designed to ensure an integrated and coordinated approach across the NHS, social care and public health services in Milton Keynes. In 2015/16, MK CCG alongside its health and social care partners published its refreshed Health & Wellbeing Strategy covering the period 2015 – 2018. This builds on the achievements of the first strategy as well as recognising some of the more challenging areas being faced, but maintains the commitment to place our community at the heart of our commissioning to improve health and wellbeing, whilst reducing inequalities. By working together the partners aim to improve the opportunities for adults and children to enjoy a healthy, safe and fulfilling life. The Joint Strategic Needs Assessment (JSNA) provides a comprehensive picture bringing together what we know about the health and wellbeing of the people living in Milton Keynes. Drawing from the Joint Strategic Needs Assessment 2014/1516, the Social Atlas 2013 and the latest Director of Public Health Annual report17 the strategy focuses on four new priorities that the system needs to jointly focus on over the next three years, illustrated below. Starting Well Giving every child the best chance in life Living Well Working with communities to live longer & healthier lives Ageing Well Improving outcomes for older people Mental Health Good mental health is essential for people of all ages The Place Making Milton Keynes a healthy city improving outcomes for older people Each priority will have key objectives which describe the short, medium or longer term actions that are required to deliver against the priorities. The CCG has a key partnership role in supporting their delivery and in particular in targeting appropriate services to help reduce health and healthcare inequalities, as well as developing a more preventative approach to how we commission services. The Health & Wellbeing priorities outlined in the strategy form the framework for NHS commissioning plans which the CCG needs to take forward, as its part, towards shaping how the health and care system will look in 5 years’ time. There are a number of factors which will impact upon an individual’s health and wellbeing such as their income, employment, education and the place in which they live. Therefore understanding the local position and what needs to be done is crucial to improving health and wellbeing in Milton Keynes. This is particularly important for those areas and populations that are more deprived. 5.1 Population & Health in Milton Keynes Milton Keynes is a mainly urban location with relative low levels of deprivation and is considered to be a desirable place to live and work. Nationally, Milton Keynes ranks 211 out of 326 local authorities in England for deprivation. However, this average rating masks pockets of significant deprivation that fall into the 10% most deprived areas 16 17 MKCCG & MK Council: JSNA 2014-2015, March 2015 Milton Keynes PCT: DPH Annual Report 2011, September 2012 13 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 nationally and 19% of children live in poverty. Two key aspects of the local population stand out in relation to what and how the CCGs must commission services now and into the future. They are:- A GROWING AN AGEING BUT POPULATION STILL YOUNG POPULATION In 2015 Milton Keynes Borough was home to approximately 256,000 people, which is an increase of 38,100 (17.3%) since 2003. The population is expected to continue to grow, rising by a further estimated 49,700 (another 19.7%) between 2012 and 2026. The population is growing due to increasing life expectancy, a rising birth rate and net inward migration; both from other national locations and internationally. Since 2004, Milton Keynes Borough has experienced major inward migration from the European Union Accession countries, particularly Poland and Lithuania. Numbers entering the Borough peaked in 2005/06, and subsequent years have fluctuated. The number of people registered with the 27 Milton Keynes General Practices was 278,383 in November 2014. The number of births has increased steadily by an average 2.7% annually between 2001 and 2013 from 2,830 to 3,901. The number of people in each group is growing at a different rate but overall the average age of the population of Milton Keynes is increasing more than the England average. Most significantly, the population over 85 years of age is forecast to increase by 95% from 3,635 in 2010 to 7,060 in 2026. In 2012 there were 29,500 people aged 65 and over in the borough, and this number is expected to increase by 82.8% to 53,900 by 2026. The corresponding increase nationally is 33.3%. However, the Milton Keynes population age profile is younger than that for England as a whole and is set to remain so. 22.4% of the Milton Keynes population are currently aged under 16, compared with 18.9% in England. Life expectancy at birth is a good overall indicator of health and wellbeing. In Milton Keynes the average life expectancy at birth (2010-12) has increased steadily over the past decade and is currently 78.7 years for men (78.4 in 2009-11) and 82.5 years for women (82.6 in 2009-11). This is 0.5 year below the national average of England for both males and females. Life expectancy over the period 2002-12 increased 2.5 years for men and 2.2 years for women compared to England average of 3.2 and 2.3 years respectively. However, life expectancy is 6.6 years lower for men in the most deprived areas than those in the least deprived. In summary then:- Milton Keynes population is growing in size and diversity. Too many children have a poor start to life and suffer health problems. Premature deaths contribute to life expectancy at birth, which is 6 months less than the national average. Significant health inequalities persist between the more affluent and more deprived areas but the gap in life expectancy is slowly narrowing. Mental health problems affect people of all ages. Partners need to ensure that services that are provided or commissioned to meet the above needs provide the best possible value for money. The city’s environment could contribute more to healthy outcomes. 14 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 5.2 Reducing Inequalities Life expectancy is now 7.1 years lower for men (8.0 years in 2009-11) and 5.3 years lower for women (6.4 years in 2009-11) in the most deprived areas of Milton Keynes compared to the least deprived areas. This compares to 9.2 years for men and 6.8 years for women for the England average. Wards with the lowest life expectancy (2008-12) for both men and women are Woughton and Eaton Manor, followed by Wolverton for men and Walton Park for women. The main diseases that are causing the differences in life expectancy within Milton Keynes are for males’ coronary heart disease and COPD, followed by lung cancer. For females the main causes are all main cancers (breast, lung, and bowel) and COPD. This gap is slowly narrowing for both men and women, but more can be done to contribute to this. Long term conditions are more common in more disadvantaged communities and happen earlier in life. They live therefore not only shorter, but also many more years in ill health. Having two or more long term conditions is linked to higher death rates, more hospital admissions, reduced quality of life, and higher levels of depression. Certain ethnic groups are at increased risk of some long term conditions. People from South Asian backgrounds for example are at higher risk of heart disease, strokes and diabetes. Many long term conditions are preventable – lifestyle changes could prevent half of all cancers and more than half of new cases of cardiovascular disease. Mental health and wellbeing is important. Good mental health and resilience are fundamental to our physical health, relationships, education, training, work and to achieving our potential. There is a strong association between mental illness and deprivation and also between mental ill health and reduced life expectancy. 5.3 Focus for 2016/17 Ensuring a focus on prevention and early identification of ill health, in order to manage increasing demand is will be a key factor in how the CCG will work with partners (especially local Public Health) to commission services with a focus on reducing health inequalities and allocating resources in relation to identified need across the whole population. Key areas of particular focus will include:• To reduce smoking prevalence by promoting uptake of stop smoking services. • To invest further in: • prevention of obesity by promoting physical activity and healthy diet to reduce existing health inequalities, and prevent future ill health, especially in children • better obesity treatment at tiers 1-3 as outlined in Healthy Weight Strategy 2014-19. • Increase opportunities to prompt healthier lifestyles e.g. through Every Contact Counts, Health Checks programme, and utilising social marketing techniques. • Increase the capacity of the ‘identification and brief advice’ alcohol services across primary and secondary health care. • Deliver good quality universal drugs and alcohol education through the Personal, Social and Health Education (PSHE) curriculum, and ensure that children affected by parental alcohol and drug misuse are identified early and high quality support is available to meet their needs. • To implement the recommendations of the Milton Keynes HIV Needs Assessment: increasing early identification and treatment, particularly through continued and improved routine HIV testing for hospital admissions and new GP registrants. 15 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 • To intervene to reduce the predicted high rise in the level of long term conditions in our population through investing in prevention by supporting healthy lifestyles across all age groups and improve health outcomes in people in the early stage of disease by promoting self-care. • To ensure our population receives the maximum benefit from a higher uptake of immunisation and screening programmes. 6. System Vision The NHS is founded on a set of fundamental and enduring values: that the NHS should be a universal, tax-funded service, with equal access for all, free at the point of use and provided according to clinical need rather than the ability to pay. Naturally these values underpin all of the work of MK CCG, as we strive to ensure equity of access to appropriate high quality healthcare across our local population – whether that healthcare be provided by an NHS body or another organisation. The challenge we face however is to ensure adequate provision of such care to meet all existing and future clinical need, within an extremely tight funding mechanism that has not always reflected the continuing growth of the Milton Keynes population. MK CCG wishes to plan and buy services that are high quality and provide the best outcomes, whilst achieving value for money for the local community. Its 4 Strategic Aims, as set out below, will underpin its approach to achieving the vision set out above:- 1. Commission Services Which Are Value For Money 2. Involve Clinical Leadership To Make A Real Difference 3. Improve Quality And Safety To Positively Impact On Clinical Outcomes And Patient Experience 4. Develop A High Performing Organisation The overall vision for Milton Keynes is for a system that is as simple and straightforward as possible, with patients aware of and able to access appropriate high quality clinical care and support at the right time and in the right place, such that inequalities in access to this care are eliminated. The CCG is committed to commissioning a greater proportion of activity in community and home settings to support the required rebalancing of the health economy away from local acute services, with a real emphasis on ‘care closer to home’. This is necessary to support acute provider sustainability and to ensure that services are delivered in the best location. Far too many people currently access care in an acute hospital setting when they could be treated just as well within the community, often with less delay. Overuse of the acute sector is not sustainable because that specialist care is very expensive – and as the population grows and demand rises with people living with one or more long term conditions18 it will increasingly become unaffordable. The current healthcare review across Bedfordshire and Milton Keynes indicates that current service provision is fragmented, difficult to navigate through and delivered through traditional models of care, emphasising the need for consideration of new ways to deliver NHS care that can deliver improved patient outcomes but within a tight financial environment. The CCG is also looking to understand where other care providers can offer support to the population at least as effectively as statutory providers. Greater emphasis on prevention and self-care are important long term strategies for the CCG. Helping those with long term conditions to take more responsibility for managing their care and using support networks outside of the NHS are important future options, and are reflected in the joint Better Care Fund 18 th MK & Bedfordshire CCGs: Bedfordshire & Milton Keynes Healthcare Review: A Case for Change; 9 April 2014 16 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Plan submission that sits alongside this plan and within the Urgent & Emergency Care 8 High Impact Interventions Delivery Plan which has been developed. For those requiring on-going health and social care it will be important to further strengthen links between the statutory commissioners – working closely through the Joint Commissioning arrangements. Our vision for how the whole health system should look and be working by the end of 2020, including how we will deliver the ambitions of the 5 Year Forward View is summarised below and fully outlined in sections 6.1-6.6. CURRENT STRATEGIC AMBITION From To Variations in performance and quality Challenges in accessing primary care 1. Transform primary care & elective care closer to home • • Fragmented Care Pathways From • • • • From • Managed Networks of Care Mat, C & YP BCF/ MH & LD Mat, C & YP Integration around Patient Streamlined care pathways and referral routes into services. Increasing no. of elective services delivered in primary care settings Managed Networks of Care New models of Care New models of Care Integration around Patient Mat, C & YP CPPC Mat, C & YP B & MK HCR To Fragmented, inequitable service provision Variable quality of care Clinical workforce shortages Financial challenges CPPC BCF/SRG Single point of access for urgent care services • Access to a range of health and social care professionals depending on To need Fragmented pathways of care Inconsistent referral processes Overlapping service provision From 5. Sustainable local Hospital Services for the future Pro-active support/focus on self-care Fully integrated health, social and mental health teams to provide services Earlier discharge planning at admission Range of home-based care & support services • From 4. Efficient Planned Care which is provided closer to patient’s homes New models of Care To Multiple overlapping services leading to confusion in access Limited access to non-acute services out of hours • 3. Rapid Response to Urgent Health Needs Integration around Patient To Fragmented services leading to duplication of effort People kept longer in hospital because appropriate services are not in place 2. Integrated Care for complex health & social care needs Consistent quality of where/how to access Access to primary care services 7 days, 12 hrs Pro-active care and support within the community/focus on self-care • GP Coordinated Care, increasingly supported by community level services Patients admitted to hospital only for acute specialist interventions & more care delivered ‘closer to home’ Financially and clinically viable services New models of Care Managed Networks of Care CPPC Mat, C & YP SRG 5 6.1 Citizen Participation & Empowerment Since its formation in April 2013, Milton Keynes Clinical Commissioning Group (MK CCG) has worked to develop a strong framework for engaging with patients, the public and key stakeholders. This has led the CCG into a regular pattern of engagement, and to effective partnership working with the local Healthwatch. Engagement is at the heart of the CCG’s vision and principles since Milton Keynes CCG is a membership organisation comprising the 27 GP practices that serve the population of Milton Keynes. Together, Board members, members of staff and patient representatives work to develop the strategic direction and to deliver the Group’s commissioning plans and intentions. Being co-terminus with Milton Keynes Council supports close working with our Local Authority commissioners – this includes some joint commissioning arrangements and also public health advisers. The CCG recognizes that its relationships with all our partners are evolving. The avenues of engagement currently used by the CCG include Healthwatch and a number of other forums. Healthwatch provides patient representatives at all the CCG’s programme boards, which help to advise the boards on engagement and consultation. The engagement, communications and marketing team have worked to develop comprehensive means of communicating and engaging with local stakeholders through existing databases held by the local authority, Healthwatch and the voluntary sector. 17 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Additionally, work with member practices has developed ways in which to ensure they are informed and involved with the CCG work, including a Clinical Forum Group and Neighbourhood Group meetings. The CCG has continually strived to embed further co-operation with multi-agency partnerships where health commissioning makes a key contribution, such as the Safer MK Board which meets to assess and review joint programmes of work to reduce crime and make our city safe, and the Safeguarding Boards. The CCG has established strong relationships and close working with the Local Authority with arrangements in place for joint commissioning through the Joint commissioning Board and the Health and Wellbeing Board. The Bedfordshire and Milton Keynes Review continues to explore ways to improve future local healthcare for the populations of Bedford Borough, Central Bedfordshire and Milton Keynes (including North Buckinghamshire). Following a period of extensive engagement where individuals and representatives from many different communities had the opportunity to get involved to help shape thinking around future service needs, a joint programme by Milton Keynes CCG and Bedfordshire CCG has now been established. This recognises the importance of primary and community services in relation to future hospital provision across both health economies, drawing on the insights already gained and the wider national context. Further work, including an integrated impact assessment and the collection of local HES data to support activity modelling, will provide more detailed, valuable information on local populations and how they use and access local healthcare services, highlighting potential issues and opportunities that can be considered and developed by the CCGs. Clinicians, public and patient views will continue to be at the heart of this process, both in developing recommendations and during formal public consultation which is due to take place in July 2016. More details are available on the Review website - www.bedsandmkhealth.org 5 Year Vision Through our approach to public engagement we will ensure that Milton Keynes CCG develops quality services, based around people’s individual needs and aspirations and values the contributions they can make. The recently published Patient & Public Engagement Strategy19 contains the following objectives which will guide future engagement approaches:- 1) Ensure that engagement is part of the everyday work of the CCG, at each level 2) Equip key leaders in the CCG with the knowledge and expertise to carry out effective engagement and consultation 3) Create and maintain effective avenues of engagement 4) Strengthen key relevant partnerships e.g. with Healthwatch, local authority, voluntary sector, neighbouring NHS bodies 5) Obtain assurance that there is an appropriate programme of engagement for each Programme Board 2016/2017 Actions Overall, the CCG aspires, when planning and commissioning services, to take account of the complete ‘engagement cycle’, which shows how engagement and consultation can feed ceaselessly into commissioning decisions as shown below. 19 MK CCG: Patient & Public Engagement Strategy 18 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Specifically, during 2016/17 the CCG will: Establish a set of guiding principles for future engagement Streamline the current structures and embed engagement more firmly into the CCG’s governance structures by creating a Patient and Public Engagement Steering Group Set a strategy and objectives for the next year and beyond 6.2 Wider Primary Care at Scale Primary care, and in particular care delivered by general practice has been a cornerstone of the NHS since its inception. Whilst GP services are likely to see changes to who and how they are commissioned in the future, it will be imperative that Clinical Commissioning Groups continue to support and encourage the development of primary care services and work jointly with NHS England to ensure the way primary care is transformed fits alongside the wider aims of the overall strategic plan. MK CCG has been co-commissioning GP services from October 2015 at Level 2, giving it an expanded role in primary care commissioning so that it can to drive up the quality of care, cut health inequalities in primary care, and help put their local NHS on a sustainable path for the next five years and beyond. Having high quality and equitable primary care chosen by patients and local residents is central to our vision. We recognise the need to be linked with the community, acute and mental health strategies so that patient pathways are seamless and the health economy works well. Improving health outcomes and significantly reducing inequalities remain a key focus. Access, clinical effectiveness and patient experience are key components of our direction of travel. The strategy promotes a patient-centred integrated care service. As set out in its existing Primary Care Development Strategy20 and the draft Care Closer to Home Strategy21 MK CCG will focus on transformation which:- 20 21 Has a clear focus for improving overall quality. Establishes primary care at the heart of integrated care networks with other health and social care providers. Acts as the catalyst for encouraging practices to work together with a focus on enablement and empowerment, so that delivery at greater scale can be achieved. MK CCG: Primary Care Development Strategy: Achieving Excellence in Primary Care. 2013-2015; October 2013 MK CCG: Care Closer to Home Strategy, 2014-2018 (draft); September 2014 19 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Maximises the role of information management technology to ensure practices are able to access high quality information in order to improve quality and value for money. Recognises the recommendations for the future of primary care outlined in A Call to Action22 and the work needed to develop the necessary clinical and organisational models. It is recognized nationally that general practice in its current physical form may not be suited to take on a new role delivering a wider range of care or providing that care closer to the patient’s home. There have been a number of reports including the Royal College of General Practitioners “A Plan for Primary Care in the 21st Century”23, The King’s Fund report “Improving Quality of Care in General Practice”24 and the Nuffield Report “Primary Care in the 21st Century”25. All three reports suggest there are benefits in closer collaboration between practices and the provision of a wider range of services under one roof that are integrated with social care. This theme continues in the NHS document “Five Year Forward View” which sets out a range of new models of care including Multispecialty Community Providers (MCP) which would become the focal point for a wider range of health and social care needed by their registered population and primary and acute care systems with vertical integration. 5 Year System Vision Our vision is to create a sustainable primary care service operating on a single clinical system with collaborative working between practices. If we are to meet our overall strategic direction of delivering care closer to home then this will require a substantial shift of care from hospital to community settings. Evidence shows us that many people could be treated more locally;26 hospital based care is not necessarily the best way to care for people but with 90% of patients/users already using primary care services as their first point of contact with healthcare – increased use of primary care and plans to develop 7 day working will require both additional capacity and capability, and funding. The CCG will therefore need to develop and reward innovation and quality improvement in primary care and promote and support mechanisms for improved integrated working. The NHS reforms put General Practice in a unique position as both provider and commissioner of healthcare services, but unlike many other areas, the high rate of population growth and creation of new communities provides Milton Keynes with both challenges and opportunities for the provision of modern, efficient high quality primary healthcare. It is therefore important that the CCG is able to articulate clearly to NHS England and Milton Keynes Council its aspirations for healthcare estates that are fit for purpose. Services need to be delivered from wellpositioned, functional estate that provides value for money and it is recognised that individual small practices may lack the capacity and capability to provide an extended range of services. The table below illustrates desirable attributes for the healthcare estate in order that MK CCG can deliver its strategic objectives and clinical priorities. Premises Attribute Location Physical condition Explanation Premises should be accessible by sustainable public transport, on foot and have sufficient parking for patients either on site or nearby. Premises should be safe, clean and in a good state of repair. They should provide a positive experience for the patient and have good accessibility. All practices must meet the requirements for CQC registration. 22 NHS England: A Call to Action, July 2013 st RCGPs: Patient Centred Care for the 21 Century, November 2014 24 Kings Fund: Improving Quality of Care in General Practice, March 2011 25 st Nuffield Trust: Primary Care in the 21 Century, September 2012 26 MK Public Health Team (S Godward); Urgent Care Needs Assessment; August 2013 23 20 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Functional suitability Fit for future developments Space should be multipurpose where possible. In order to deliver the breadth of services in primary care, GP practices will need to work together within and across the physical constraints of buildings. A number of practices will be identified as expansionist practices to facilitate delivery of a wide range of services to patients within a local area. There is a fine balance between these two and in Milton Keynes it is envisaged that primary care will increasingly both work collaboratively as providers of services, but also work within geographic neighbourhoods to commission an appropriate range of care. Member practices are encouraged to actively engage in the commissioning work of the CCG, by contributing to clinical pathway and service redesign, engaging with local communities and understanding local health needs. Services beyond core GMS will be delivered through a collaborative working approach. Like minded practices will federate to deliver an enhanced range services that move care close to home. Primary care at scale (to deliver 7 days a week, 8am to 8pm) will be delivered through an integrated approach. The vision for developing excellence in primary care, delivered through the establishment of federated working across Primary Care is illustrated below. All this means we need to commission a greater proportion of activity in community and home settings to support the required rebalancing of the health economy away from local acute services. This is necessary to support acute provider sustainability and to ensure that services are delivered in the best location. An illustration of how this can be achieved is shown below. 21 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 What will it look like? From Transformed primary care & elective care closer to home Variations in performance and quality across practices Challenges in accessing primary care at times & location convenient to patients Fragmented Care Pathways and multiple patient hand-offs Fragmented approach to responding to population increases To Consistent quality regardless of where and how people access services Access to primary care services 7 days a week, 12 hours a day Pro-active care and support within the community and a focus on self-care Federated working to provide greater range of services within primary care setting The model will ensure delivery of ‘beyond core’ GMS services, in a collaborative or ‘federated’ arrangement. Enhanced services delivered through this model would include: Access to diagnostics Vertical integration across a continuum of care with Community nurses attached to practices; delivering same range and quality of acre Integrated health and social care teams comprised of health and social care professionals from primary and community care based around GP localities supporting patients with complex needs. Neighbourhood mechanisms for monitoring information, performance and quality developments. Seek to broaden training opportunities for nurse development and AHPs. 2015/2016 Delivery & Achievements 1. Implementing a Referrals Mgt Service Evaluation of Stage 1 specialities and Stage 2 roll out of next 4 specialities completed First outpatients/follow-up 2. Development & Improvement of MSK Pathways (including Pain Mgt & PLCV) 3. Development of Managed Care for Ophthalmology Established Integrated Musculo-skeletal services in the community to allow for more patients to be managed in the community, reduce congestion (waiting lists) in secondary care, and reducing costs. Procurement and introduction of Ophthalmology Managed Care Service First out-patients for Pain Mgt; Orthopaedics and Rheumatology. MSK Inpatient Procedures First Outpatients, Follow Up, O/P Procedures, daycases and inpatients 4. Implement Practice Based Budgets Continued to promote practice based budgets to educate primary care to take some responsibility for the consumption of secondary care resources. 2015/2016 six audits have been completed, 2 of which have been escalated so that changes to clinical behaviour can be encouraged. Elective day-cases, first outpatients, In hours A/E and UCC attendances. 5. Introduce Primary Care Outpatient Clinics Pilot PCOCs have been evaluated and developed in x specialities. PCOCs provide additional services in primary care setting, allowing secondary care waiting time reduction and delivering CCG strategy of more elective care closer to home. Delivered a number of pilot projects that will prevent unnecessary emergency admissions/attendances in Secondary Care. Focus on general stroke pathway to ensure effectiveness of First Outpatients, Follow Up Outpatients, basis diagnostics 6. Primary Care Transformation Funding Pilots - Over 75’s Care 7. Improve Stroke Emergency Admissions, Non Elective cases n/a 22 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Pathway & Quality of Care current stroke unit pathway by working with the Quality and Performance teams. 2016/2017 Actions 6.3 Continue to support the development of federated primary care working to drive up quality and access standards On a federated basis, to commission and provide a greater range of diagnostics within primary care Provide new 20,000 patient health facility on Eastern Flank, with extended range of services Deliver an ‘End to End’ Trial of Ophthalmology Managed Care Pathway Implement a ‘whole-system’ approach to reducing prescribing waste Commission a new Primary Care Outpatient Clinic (PCOC) in Gastroenterology Ensure more hospital based elective activity takes place within an outpatient setting Increase the number of outpatient procedures taking place in Primary Care Outpatient Clinics (PCOCs) Ensure all NHS Constitution, Quality Premium and CCG performance targets are delivered in year. Modern Model of Integrated Care For the 5% of patients with multiple, often complex mental or physical long-term conditions, frequently compounded by being elderly and vulnerable, there needs to be a modern model of integrated care. Milton Keynes has a long history of joint working, and has a number of integrated services: Intermediate Care; Mental Health; Learning Disabilities; Integrated Community Equipment services and a Joint Commissioning team. Work is ongoing to further develop integrated services to better meet the needs of older people and those with long term conditions and/or physical disabilities. The whole system has agreed to support a specific programme focussing on services for this group. Implicit in the Joint Health and Wellbeing Strategy is the empowerment of Milton Keynes residents to be supported to help manage their own health and wellbeing through the commissioning and delivery of integrated, person centred services, which place the individual at the heart of service delivery. The Better Care Fund (BCF) is an opportunity for the CCG and Council, working in partnership, to transform local services so that people are provided with better integrated care and support. It encompasses a substantial level of funding to help local areas manage pressures and improve long term sustainability. A Milton Keynes 2 Year BCF Plan27, outlining how locally we will use this initiative to deliver improved integrated care for the population was submitted and approved during 2014 and further detail is outlined in Section 10. 5 Year System Vision Our vision for integrated care in Milton Keynes is to improve the experience of, and access to, health and social care services for citizens. More citizens will report that their quality of life has improved as a result of integrated health and care services. The number of citizens remaining independent in the community, including after hospital admission will increase with improved and seamless transfers of care. To deliver this vision we will undertake an extensive system wide programme of change that will see local services reshaped to deliver joined up care. The emphasis on integration will be focused on: 27 Services that are configured to support people to live independently in their own home, within their local communities, wherever possible. This will be our default option for service delivery. th MK CCG/MKC: Better Care Fund Plan 2014-2018: Final Submission; 30 September 2014 23 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Acute care as an inpatient will be as short as clinically appropriate for that individual. Capacity will be developed in community health and social care services to meet the delivery of this objective and will be provided by a full range of statutory and voluntary and community organisations. More effective partnerships will be developed with housing providers, employment services, transport and leisure services to enable people to improve their quality of life and improve wellbeing. GPs will be central to organising the co-ordination of people’s care and will work in a seamless integrated way with health and social care providers to better manage care and treatment of patients. This will be achieved through implementation of the national Enhanced service and the additional case management role that will be developed for the over 75s. Self-care and self-management of an individual’s health will be encouraged and people will be supported to develop strategies for managing their health and independence, including access to a range of preventative, early intervention services to support people to pro-actively manage their health. Supporting services such as telehealth, telecare and community equipment will be strengthened to support independence. Rehabilitation, re-ablement and recuperation will be offered to everyone. We are clear that everyone has the potential for restoring some level of physical and mental functioning. There will be more integrated commissioning of services through a single pooled budget (facilitated through the Better Care Fund) and delivered through integrated health and social care teams. These teams will be configured so that they can support people, within an overall integrated care pathway model:- 24 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 In the next five years it is expected that the demand for high cost secondary care (acute hospital) services will reduce as the service offer delivered in primary care, community care and social care settings will increase, as shown in the diagram above. Through the development of self-management and preventative services, ill health can be better managed at an earlier stage, and linked in to community based rehabilitation and re-ablement services to provide intensive support over the short term with a view to restoring people to independence. Delivering a new model of integrated care will require a significant shift in the make-up of the entire community workforce. Increasingly individuals and organisations providing care will need to work in cross-organisational teams, with a workforce equipped with skills to span traditional professional boundaries. Increases in nursing capacity across both primary and community care will be required to deliver the models of care outlined, along with a more diverse range of support staff. Regardless of which organisation or provider staff members will be employed by, all will need to deliver care in the setting where it is needed and manage risk within a devolved structure. What will it look like? From Integrated Care for health & social care needs To Fragmented services leading to duplication of effort and allowing people to fall through the cracks People kept longer in hospital because appropriate services are not in place for them to return home Pro-active support and a focus on self-care Fully integrated health, social and mental health teams to provide a seamless service to patients tailored to their needs Discharge planning commences at admission Range of home-based care & support services The model will help the system initially to move from fragmented services and delivery for people with long term conditions and vulnerable older people, to a system of integrated care providing ‘seamless’ care that can be tailored to the needs of patients, and which supports significant admission avoidance and a proactive focus on self-care. Initial delivery will be implemented under the auspices of the Better Care Fund Programme Board & Delivery Group which will comprise of commissioners, service providers and key stakeholders. This working group will be responsible for the day-to-day management of the implementation of the proposals within the BCF and will report on progress to the Joint Commissioning Board, using established Programme and Project Management tools and techniques. It is also proposed to establish individual work streams for each of the proposals to ensure focused dedicated effort to implementation. The diagram below outlines the governance framework. Health and Well Being Board System leaders Group (Whole system) Joint Commissioning Board (Chief Executives/lead Officers) Better Care Fund Delivery Group Commissioners BCF Working Group Scheme project Group Scheme Project Group Performance management, finance and contracting Clinical Pathways Workforce and engagement Scheme Project group Information sharing and logistics 25 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 2015/2016 Delivery & Achievements 1. Integrated Health & Social Care Teams (MDTs & Rapid Response Service) BCF1: Implemented jointly with BCF6. MDTs and 24/7 Rapid Response. 2. Recuperation Pathway BCF2: Improved pathways of care for people with complex health and social care needs and co-morbidities. Provision of intensive domiciliary support and therapy, step down beds, social care and nursing interventions through this new pathway. Well utilised with good home care BCF3: Additional Investment within existing service 3. Improved Community Equipment Service 4. Alcohol Liaison 5. 7 Day Working for Intermediate Care 6. High Impact Team for Care Homes 7. Dementia Services 8. Community Geriatrician BCF4: Additional Investment within existing service BCF6: Implemented jointly with BCF1 & 2. Weekend working for specific elements Intermediate Care Service, particularly ESD Team. Implemented new team to support Care Homes in managing people and avoiding admissions. Positive evaluation. BCF 14. Expansion of Diagnosis Support pilot. Implemented Community Geriatrician Posts to assist integration between acute and community care services. Non Elective Spells Non Elective Spells Non Elective Spells 2016/2017 Actions Actions for next year build on those implemented during 2015/16 and are very much a consolidation of the whole BCF Plan drawn up and agreed across the system in March 2015. • Increase the number of people who can be cared for at home by providing care close to home • Evaluation and further development of a 24/7 clinically led rapid service to provide realistic alternative to admission • Development of locality based Multi-Disciplinary/multi agency Teams to identify and appropriately care plan for people with complex health and social care needs Consolidation of a recuperation pathway to provide rapid and intensive packages of care to individuals not immediately appropriate for reablement support Development of social care step down alternative Better co-ordination of new and existing services to maximise efficiency and reduce system gaps. Consolidation & Procurement of High Impact teams for Care Homes Development of joint local integrated plan for reducing Delayed Transfers of Care. Ensure all NHS Constitution, Quality Premium, BCF and CCG performance targets are delivered in year 6.4 Access to Highest Quality Urgent & Emergency Care Urgent and emergency care is the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly. Everyone in Milton Keynes deserves access to the highest 26 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 quality urgent and emergency care. The report on the first phase Urgent & Emergency Care Review28 sets out an exciting vision for how we deliver NHS Services in a way that can complement current and future demand for and usage of these services. In line with that national vision, Milton Keynes CCG is developing a local approach that treats an increasing proportion of people as close to home as possible, whilst recognising that greater specialism will mean significant changes to how current hospital based emergency care may be delivered. 5 Year System Vision The overall vision for urgent and emergency care in Milton Keynes is for a system that is as simple and straightforward as possible, with patients aware of and able to access appropriate high quality clinical care and support at the right time and in the right place, such that inequalities in access to this care are eliminated. Urgent and emergency care commissioning within Milton Keynes is currently implemented through a well-established System Resilience Group, and in line with its Urgent Care Strategy29, informed by ongoing national guidance (Urgent and Emergency Care Review, etc.) and examples of good care from across the country. The vision for urgent and emergency care provision going forward must incorporate economies of scale and improved integration to decrease the number of entry points into the system, whilst recognising and progressing the recommendations from the first phase of the national “Urgent and Emergency Care review”.30 Firstly, for those people with urgent care needs we should provide locally a highly responsive service that delivers care as close to home as possible, minimizing disruption and inconvenience for patients and their families. For those people with more serious or life threatening emergency care needs, we should ensure they are treated in centres with the very best expertise and facilities in order to maximise the chances of survival and a good recovery. Local transformation of urgent care services within Milton Keynes during the next 5 years will focus on how organisations can translate local needs and national policy/guidance into local action to improve the value and quality of urgent and emergency care in Milton Keynes, specifically to: 28 NHS England, Urgent & Emergency Care Review: November 2013 MK CCG: Urgent & Emergency Care Strategy 2013-2016, October 2013 30 NHS England: Urgent and Emergency Care Review, August 2013 29 27 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Increase the number of people who can be cared for in an ’out of hospital setting’, by providing care closer to home Deliver further integration of health & social care provision Reduce the growing demand for urgent and emergency care presenting at hospital site. Reduce the variation in response to urgent & emergency care between ‘in hours’ & ‘out of hours’. Improve quality and responsiveness of GP access across Milton Keynes primary care. What will it look like? From Appropriate & Timely Access to Urgent Health Needs • • Multiple overlapping services leading to confusion over how to access care Limited access to non-acute services out of hours To Single point of access for urgent care services Access to a range of health and social care professionals depending on need 2015/2016 Delivery & Achievements 1. Define & Implement Integrated Urgent Care Service Service specification for Integrated Urgent Care service developed. New integrated service will be mobilized over April-July 2016 Reduced A&E attendances, emergency admissions 2. Additional Support to Nursing & Care Homes (HIT) High Impact Teams successfully recommissioned with revised service specification from October 2015. Reduced A&E attendances, emergency admissions, ambulance conveyances 3. Getting People Home/Discharge to Assess Implementation of a 'Discharge to Assess' service model. This is intended to ensure that people only spend time in hospital whilst they are acutely unwell and as soon as this phase is over they move into the community. Capacity for 2 patients per weekday has been made available. Reduced acute hospital lengthof-stay, excess bed-days, long term placements and Delayed Transfers of Care 4. Reduction in ambulance spend/contract value Increased “Hear and Treat” (H&T) referrals. Hear & treat; Hear See & Treat; Conveyance 5. Social Marketing Campaigns (included Structured Promotion of 111 & Self Care) Communications and social marketing activity (including on-line, face-to-face engagement with patients and the public, distribution of printed materials and branded item) aimed at informing the public about the range of available healthcare services (particularly Pharmacy First and NHS 111) so as to reduce the demand for A&E and Urgent Care. A&E attendances 28 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 2016/2017 Actions Increase the number of people who can be cared for in an non-hospital setting, by providing care closer to home Deliver further integration of health & social care provision Reduce the growing demand for urgent and emergency care presenting at hospital site. Provide integrated urgent care on the hospital site. Patients will be streamed to the most appropriate clinician for their presenting condition. One of the options available will be a primary urgent care stream. Commission an ambulance service which pro-actively utilises its Clinical Support Desk to review patients and direct them to the most appropriate services rather than defaulting to ambulance dispatch or conveyance to hospital. Paramedics and Emergency Care Practitioners (ECPs) are in a prime position to clinically triage patients and bring in other health and social care professionals as required, rather than taking all patients to an acute hospital. Reduce the variation in response to urgent and emergency care between ‘in hours’ and ‘out of hours’. Improve quality and responsiveness of GP access across Milton Keynes primary care. Ensure all NHS Constitution, Quality Premium and CCG performance targets are delivered in year 6.5 Increase Productivity in Elective Care For people who need episodic, elective care, access to those services must be designed and managed from start to finish removing error and maximising quality. For many existing patient pathways and referral routes into services, providers are not necessarily delivering them to extract maximum productivity and if we are going to transform hospital care, look to concentrate specialist services on fewer sites, and deliver more care ‘closer to home’ then the CCG needs to review how to deliver routine elective care. The provider landscape in Milton Keynes is evolving and will experience significant shifts over the next 2-3 years. For example the outcomes of the Bedfordshire & Milton Keynes healthcare services review of acute services reconfiguration will undoubtedly mean future changes in locally provided acute services. Milton Keynes Hospital became a foundation trust in 2007 but is increasingly competing with four other main hospitals within 30 minutes’ drive of Milton Keynes, and with the national drive to concentrate services for less common disorders e.g. stroke, cardiac surgery, rare cancers in fewer centres of excellence, the traditional role of the District General Hospital is likely to be required to change. 5 Year System Vision Our vision for planned care is to have a safer, more predictable and reliable planned health care system, providing a consistent quality of service that will support the delivery of more services close to patient’s homes, and ensure that they are getting the right treatment for their condition. This will mean a focus on a range of methodologies that: Provide more efficient pathways for patients and ensure that they are seen in the most appropriate setting for their condition Build on the Practice Based Budgets system that was introduced in 2013/14 Ensuring the right referrals – putting in place systems to improve referral quality via active Referral Management System (RMS) 29 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Implementing systems that manage the whole elective care pathway. Upholding the principles of prevention, health education, self-management and informed decision making throughout. Developing and improving locally agreed guidelines and thresholds for treatments and interventions. Ensuring a much wider range of outpatient appointments is available within the community through the establishment of Primary Care Outpatient Clinics (PCOS). Encourage ‘one stop shops’ which reduce significantly follow ups. Reduce cost of the pathways for the CCG and re-organise the clinical resource across different care settings All this means we need to commission a greater proportion of activity in community and home settings to support the required rebalancing of the health economy away from local acute services. This is necessary to support acute provider sustainability and to ensure that services are delivered in the best location. However, this is not simply a strategy to support a rebalancing of resources within the NHS – the CCG is also looking to understand where other care providers can offer support to the population at least as effectively as statutory providers. MKCCG needs to find efficiency gains from diverting secondary care activity to Primary care and by developing pathways that offer an alternative to traditional hospital care.Where planned hospital care is required, the best healthcare systems provide access to highly trained clinicians who are exposed to the numbers and range of patients required to develop and maintain their skills. An increasing trend in how hospital based care is delivered will mean a reduction of general clinicians, and increasing numbers of specialist or sub-specialist staff concentrated in specific locations, allowing them to see sufficiently high number of patients and effectively utilise expensive equipment. The type and nature of workforce for planned interventions will therefore be heavily dependent on the patient pathway across the spectrum of elective care. What will it look like? From Efficient Planned Care which is delivered through fully integrated Patient Pathways • • • To Fragmented pathways of care, with duplication of effort Inconsistent referral processes from primary into secondary care Overlapping service provision • • Streamlined care pathways and referral routes into services, with reduced patient hand offs. Increasing no. of elective services delivered in primary care settings 2015/2016 Delivery & Achievements 1. Implementing a Referrals Mgt Service Gateway Evaluation of Stage 1 specialities and Stage 2 roll out of next 4 specialities completed First outpatients/follow-up 2. Development & Improvement of MSK Pathways (including Pain Mgt & PLCV) 3. Development of Managed Care for Established Integrated Musculo-skeletal services in the community to allow for more patients to be managed in the community, reduce congestion (waiting lists) in secondary care, and reducing costs. Procurement and introduction of Ophthalmology Managed Care Service First out-patients for Pain Mgt; Orthopaedics and Rheumatology. MSK Inpatient Procedures First Outpatients, Follow Up, O/P Procedures, daycases and 30 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Ophthalmology inpatients 4. Implement Practice Based Budgets Continued to promote practice based budgets to educate primary care to take some responsibility for the consumption of secondary care resources. 2015/2016 six audits have been completed, 2 of which have been escalated so that changes to clinical behaviour can be encouraged. Elective day-cases, first outpatients, In hours A/E and UCC attendances. 5. Introduce Primary Care Outpatient Clinics First Outpatients, Follow Up Outpatients, basis diagnostics 6. Improve Stroke Pathway & Quality of Care Pilot PCOCs have been evaluated and developed in x specialities. PCOCs provide additional services in primary care setting, allowing secondary care waiting time reduction and delivering CCG strategy of more elective care closer to home. Focus on general stroke pathway to ensure effectiveness of current stroke unit pathway by working with the Quality and Performance teams. 7. Diabetes Single Point of Access Continued to develop and establish a single point of access and enhanced community and primary care provision 8. Enhanced Community Cardiology services Developing a single point of access for cardiology, and establishing a structure of tiered community/primary care services (including PCOC) Reduction in acute hospital outpatients and follow-up activity Reduction in acute hospital outpatients and follow-up activity n/a 2016/2017 Actions Deliver an ‘End to End’ Trial of Ophthalmology Managed Care Pathway Implement a ‘whole-system’ approach to reducing prescribing waste Commission a new Primary Care Outpatient Clinic (PCOC) in Gastroenterology Ensure more hospital based elective activity takes place within an outpatient setting Increase the number of outpatient procedures taking place in Primary Care Outpatient Clinics (PCOCs) Ensure all NHS Constitution, Quality Premium and CCG performance targets are delivered in year. Increase the number of people who receive elective care in an non-hospital setting Review and re-procure Referral Management System if evaluation of current service is positive Further develop a suite of Primary Care Outpatient Clinics to include paediatrics, headache pathway, community based atrial fibrillation clinic Investigate potential models for intermediate diabetes services Ensure all NHS Constitution, Quality Premium and CCG performance targets are delivered in year 6.6 Sustainable Hospital Services The key focus for developing safe and sustainable hospital services across Milton Keynes and Bedfordshire is the continued development of the Healthcare Review. MK CCG is working with Bedfordshire CCG to develop a comprehensive review of hospital and community health services across Bedfordshire and Milton Keynes, with the aim of developing stronger, more resilient local healthcare and a series of options that can be taken forward to formal public consultation. Both local health systems remain under significant pressure from an ageing and expanding population – whilst there is a need to improve outcomes from existing resources. This year has seen both local health systems under financial 31 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 pressure to ensure they can deliver a surplus, at the same time as delivering exciting new initiatives focused upon the integration of services, and delivering care closer to patient’s homes. However a key element of the Review has been a renewed focus upon engaging the local community in the debate about the way in which their clinical services might change. The support this the Healthcare Review Programme (HCR Programme), has run a series of events across Bedfordshire and Milton Keynes, but also across a wider geography to ensure there is a real understanding of how potential change, might impact the populations that use the hospitals in Milton Keynes and Bedfordshire that form part of the review. Finally a focus over the last year has been the reflection within Milton Keynes on the proposed clinical models. The CCG has considered the models and how their commissioning intentions are aligned with developing clinical standards, to ensure its population has safe, sustainable, high quality care for local people now and in the future. The objectives of the Healthcare Review are to: Address concerns around the challenges faced by the local health system, specifically the clinical and financial sustainability of hospital services; and Generate options for delivering high quality, sustainable health services for our residents. Ensure that our residents get the right care at the right time, and that we are able to make decisions on the best use of public spending on healthcare to meet our population’s needs, informed by our residents’ views. The first three phases of the review have now been completed: - Demonstrating the Case for Change (published April 2014) – which highlights pressures that the local health system is currently experiencing and sets out the case for transforming local healthcare services in Bedfordshire and Milton Keynes - Publishing a Progress Report31 (published late October 2014) – which describes ways in which the CCGs can and should deliver more robust care closer to home and potential solutions to ensure the future provision of high quality, sustainable hospital services. - Testing and alignment (completed in January 2016) – in which both health systems testing the proposed clinical models with their clinical communities and the wider population. The conclusion of this phase has been that both MK CCG and Bedfordshire CCG have agreed to establish a Joint Committee, which will take decisions on behalf of both sets of Commissioners in relation to the Programme. To provide assurance to this Joint Committee, the Programme will be undertaking a Strategic Sense Check with NHS England as part of the assurance framework required to support the development of the proposals. Further development would then be required in the development of the Pre-Consultation Business Case, review by NHS England’s Investment Committee and then formal public consultation on the proposals. 5 Year System Vision Local NHS hospital services have been built up incrementally in Milton Keynes, evolving gradually to deal with changing health needs, clinical standards and public expectations. This has produced some services and pathways 31 Bedford CCG/MK CCG/McKinsey: Bedfordshire & Milton Keynes Healthcare Review: Progress Report, October 2014 32 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 that may now not be right for delivering the care patients need today or may need in the future. The Healthcare Review32 being conducted across Milton Keynes & Bedfordshire is currently concluding and aims to produce a range of options for delivering affordable high quality healthcare, now and into the future, for the population. At its heart is the aim to transform and redesign services so that: People can be supported to take better care of themselves, lead a healthier lifestyle, understand where and when they can get treatment if they have a problem, understand different treatment options, and better manage their own conditions with the support of healthcare professionals if they wish Older, frailer people are supported on a 24 hours a day, seven days a week basis to maintain their health, dignity and independence at home When someone has an urgent healthcare need, they can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face to face consultations in local, easily accessible facilities as close to home as possible If they need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-coordinating the delivery of their health care If they need to be admitted to hospital, it will be only when they require acute specialist interventions that cannot be delivered in community settings, and then it will be to a properly maintained and up-to-date facility where they receive care delivered by highly trained specialists available seven days a week with the specific skills needed to treat them. The review team have gathered an evidence base which builds on national guidelines, examples of service delivery models elsewhere and academic research. The Clinical Advisory Group reviewed the clinical evidence base and, building on the Keogh33 report into emergency and urgent care, identified six clinically sustainable archetypes for the delivery of acute care. These six models take into account the complex interdependencies between different hospital services such that there was confidence that they could deliver services to a high standard. The theoretical hospital models are depicted below: 32 33 Bedford CCG/MK CCG/McKinsey: Bedfordshire & Milton Keynes Healthcare Review: A Case for Change, April 2014 NHS England, Urgent & Emergency Care Review: November 2013 33 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Six high level archetypes of hospitals What 1 Major trauma centre - MTC Services offered • Specialised centres co-locating tertiary/complex services on • Neurosurgery, Cardiothoracic surgery a 24x7 basis • Full range of emergency surgery and acute medicine • Serving population of at least 2 -3million • Full range of support services, ITU etc • Larger units, capable of assessing and initiating treatment Major Emergency 2a Centre - MEC (a) 2b Major emergency centre - MEC (b) 3 Emergency Centre - EC 4 5 Integrated care hub with emergency care - IC hub Urgent care centre - UCC • for all patients and providing a range of specialist hyperacute services Serving population of ~ 1-1.5m • • • • • • Larger units, capable of assessing and initiating treatment • for the overwhelming majority of patients but without all hyper-acute services Serving population of ~ 500-700K • Assessing and initiating treatment for majority of patients • Acute medical inpatient care with intensive care/HDU back Hyperacute cardiac, stroke , vascular services Trauma centre Level 3 ICU 24x7 consultant delivered A&E, emergency surgery, acute medicine, inpatient paeds Full obstetrics and level 3 NICU • 24x7 consultant delivered A&E, emergency surgery, acute medicine • Level 3 ICU • Inpatient Paeds • Obstetrics with level 2/3 NICU • Serving population of ~ 250-300K • • • • • Assessing and initiating treatment for large proportion of • GP and A&E consultant led urgent care incorporating out of up • • patients Integrated outpatient, primary, community and social care hub Serving population of ~ 100-250K • Immediate urgent care • Integrated outpatient, primary, community and social care • Consultant led A&E Acute medicine and critical care/HDU Access to surgical opinion via network Paeds assessment unit and obstetrics hours GP services • Step up/step down beds possibly with 48 hour assessment unit • Outpatients and diagnostics • As above but no beds hub Serving population of ~ 50-100K PRELIMINARY DRAFT 2 A steady process of evaluation and elimination which drew on clinical expertise and public/patient feedback enabled the review team to narrow the list of possible options for reconfiguring both hospitals. In doing so, the option resulting in either Bedford or Milton Keynes hospital becoming a hospital without inpatient beds – an ‘urgent care centre’ – has been ruled out as this could leave local people with insufficient access to inpatient and rehabilitation beds. In addition, the scale of change, impact on neighbouring health systems and lack of stakeholder support could make it undeliverable. The evaluation undertaken proposes the two options in the table below. Under these options, either hospital could become a major emergency centre or an integrated care centre. These options recommended by the review team retain a district general hospital with A&E, paediatric, maternity and inpatient services in both Bedford and Milton Keynes. Bedford Hospital Milton Keynes Hospital 4. Integrated care centre 2b. Major emergency centre 2b. Major emergency centre 4. Integrated care centre During the Testing and Alignment phase of the Programme, the Bedfordshire Local Health System (via the North Beds Primary / Acute Care Programme) developed the Integrated Acute and Community Service (IACS) clinical model. This clinical model was fully supported by Bedford Hospital Trust and Bedfordshire CCG, however Milton Keynes CCG reflecting upon the needs of the local population agreed that the clinical model was not suitable for its population. As a result there are currently three clinical models proposed for the Review to consider Bedford Hospital Milton Keynes Hospital 4. Integrated care centre 2b. Major emergency centre 34 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 2b. Major emergency centre 4. Integrated care centre Integrated Acute and Community Service (IACS) The next step for the Programme will be to establish a Strategic Sense Check with NHS England, to review the Options set out above. What will it look like? From Sustainable & Accessible Hospital Services for the future a) Fragmented, inequitable service provision b) Variable quality of care and safety c) Clinical workforce shortages d) Financial challenges across system To GP Coordinated Care, increasingly supported by community level services Patients admitted to hospital only for acute specialist interventions & more care delivered ‘closer to home’ Hospital care delivered by highly trained staff Financially and clinically viable services in place locally 2016/2017 Actions • Undertake a Strategic Sense Check with NHS England to allow an assessment of the areas of focus required by the Programme. • For the Joint Committee to complete the Option Selection process to allow a decision on which option is developed in detail for public consultation. • Undertake a Clinical Senate Review. This will provide assurance to the local system that the Clinical Model is safe and sustainable. Complete NHS England assurance review with the Investment Committee, as the body which can assurance the reconfiguration proposals developed by the local system Undertake a Public Consultation on the proposals that have been approved by the Joint Committee. 35 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 7. Transformation & Delivery MK CCG’s commissioning, transformation and overall delivery is currently overseen and implemented through four clinical programme boards: Urgent Care Board (SRG); Care Pathways & Primary Care Board; Mental Health & Learning Disabilities Health Board (jointly with MKC;) Maternity, Children & Young People’s Board; and also the Clinical Executive. Each programme area is responsible for ensuring that both local and national focus is considered and acted upon, and that contributions to QIPP development are clinically assured. Additionally, programme boards are also currently operating for overseeing the Healthcare Review and implementation of the Better Care Fund. The CCG has established itself as a clinically led, innovative, forward thinking CCG with a culture committed to delivering high quality care to the communities it serves. However, fulfilling the long term ambitions of the NHS, as outlined in the latest planning guidance will mean that CCGs must drive forward a change in the way that health services are delivered. Therefore, given the local needs, system vision, strategic priorities and wider context set out above, the local focus for commissioning, transformation and driving continuous improvement by each programme board will be driven by: Avoiding time spent in/referrals to hospital, if it is not necessary Improving patient flows within and through secondary care settings Promoting independent living, with better, more integrated care outside of hospital Steps we take in transforming and developing services in the next couple of years must ultimately ensure that we have local models of care that will apply to the needs of the population in 5-10 years’ time. Our programme boards’ transformation and improvement intentions for 2016/2017 are summarised below, along with their commissioning impact in terms of QIPP initiatives & activity changes. 7.1 Urgent Care (System Resilience Group SRG) Strategic Direction: MK CCG Urgent & Emergency Care Strategy 2013/2016 Principles for Change Ensure patients receive the ‘right care, first time’ Improve the flow out of the hospital Reduce variation in response to care needs between ‘in-hours’ and ‘out of hours’ Aims of the Programme Board: 1. To improve the experience and outcomes for people who use urgent care services 2. To provide whole system leadership, assurance and ownership to ensure achievement of the 4 hour standard for A&E 3. To eliminate waste and improve overall quality 4. To increase integration 5. To review and redesign services 36 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Year 1 Transformation Initiatives - 2016-2017: Commissioning Intervent ion/Intention Actions Net Risk Assessed Savings Activity Impact Area Lead 1. Define & Implement Integrated Urgent Care Service UC4: Define clinical model and develop service specification for Integrated Urgent Care service and develop plan for procurement. £354,000 A&E attendances, emergency admissions Mark Cox Delayed Transfers of Care, Excess bed-days Mark Cox A&E attendances, emergency admissions, ambulance conveyances to A&E Mark Cox Hear & treat; Hear See & Treat; Conveyance Steve Gutteridge Urgent Care Programme Manager Change Deliver ed from July 2016 New integrated service will be mobilized over April-July 2016 2. Improve hospital discharges UC10: Implement the ‘Getting People Home’ programme, firstly by extending the ‘Discharge to Assess’ scheme, and subsequently by reviewing recuperation, rehabilitation and non-weight bearing pathways £0 3. Further integration of NHS 111 with the Urgent Care system UC12: Further integration of Outof-Hours GP and 999 services with NHS 111, increased clinical input into NHS 111, and increasing utilization of NHS 111 by building on national communications £44,000 4. Ambulance demand growth management UC13: Promotion of the use of mobile Directory of Services for ambulance crews to further increase non-conveyance, and ensuring that contractual activity plans reflect MKCCG demand management schemes. £375,000 5. Procurement of NHS 111 service 6.Budget Flexibilities Re-procurement of NHS 111 service, informed by emerging national guidance and local integration efforts, to start in April 2017 Flexibility within existing budgets Urgent Care Programme Manager Urgent Care Programme Manager July 2016 April 2016 April 2015 Urgent Care Commissioner Steve Gutteridge April 2017 Urgent Care Commissioner £387,000 Mark Cox Urgent Care Programme Manager April 2016 37 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 7.2 Care Pathways & Primary Care Strategic Direction: MK CCG Care Closer to Home Strategy (currently in draft and under further development) MK CCG Primary Care Development Strategy, 2013-2015 MK Healthcare Review 2014-2015 MK End of Life Strategy 2016-2020 (localising of national ambitions for EoL Care) Principles for Change Ensure patients receive high quality consistent care Ensure patients receive the ‘right care, first time’ Bringing care closer to home Aims of the Programme Boards are: 1. 2. 3. 4. To improve the experience and outcomes of people who use planned care services To eliminate waste and improve overall quality To increase integration To review and re-design services Year 1 Transformation Initiatives - 2016-2017: Commissioning Intervention/Intention Actions Net Risk Assessed Savings 1. Ophthalmology Managed Care PC15: End-to-end trial of Ophthalmology Managed Care pathway £388,000 2. Prescribing Whole system approach to reducing prescribing waste, including care home initiatives, practice based script-switch system, prescribing team checks, dietician initiatives, repeat prescribing management and reducing waste. Renegotiation of non-acute contracts £1,000,000 PC10: Primary Care Outpatient Clinics (PCOCs) have been developed to divert a proportion of outpatient appointments that would otherwise have gone into secondary care to be seen in the Community using GPwSIs, Nurse Specialists or Consultants as clinical leads. MKCCG will be commissioning new PCOCs in £24,000 3. Non-acute contracts 4. Direct to test ‘oscopies’ Activity Reduction Area Primary care prescribing £473,000 Acute hospital diagnostics Lead Delivered from Asma Ali Programme Manager December 2016 Janet Corbett Head of Prescribing and Medicines Management April 2016 Asma Ali Programme Manager April 2016 Asma Ali Programme Manager July 2016 38 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Gastroenterology. 5. Day case to out-patient shift PC30: Shifting activity in line with BADS guidance. £25,000 Acute hospital day-cases 6. Moving care into the community PC34: Transferring outpatient procedures to Primary Care Outpatient Clinics (in addition to first and follow-ups). LTC13: Implementation of a managed care model for Diabetes services. LTC3a: Community DVT pathway – phase two PCOC hubs to be made available to all GP practices. LTC3: Streamline activity between primary and secondary care and bring in an integrated transformational value-based commissioning model providing appropriate activity in low cost settings. PC31: Audit of MKUHFT respiratory medicine case mix and procurement of a substantive service following evaluation of a pilot. Implement a managed care integrated service £24,000 Acute hospital outpatient procedures £1,000,000 12.Rationalise Primary Care initiatives Joint work commenced in 201516 to identify initiatives to manage the increase in demand and reduce the activity flow through the hospital Rationalise primary care initiatives started in 2015-16 13. Funded Nursing Care Efficiencies within services £150,000 14. Translation Services Contract negotiation for reduction in price £15,000 7. Community DVT pathway 8. Cardiology Single Point of Access 9. COPD services development 10.Diabetes Pathway 11. MKUHFT Deep Dive Joint Activity Management Action Plan Asma Ali Programme Manager Asma Ali Programme Manager April 2016 Asma Ali Programme Manager Asma Ali Programme Manager September 2016 Asma Ali Programme Manager January 2017 £150,000 Asma Ali Programme Manager April 2016 £53,000 Asma Ali Programme Manager Maria Wogan Project Manager January 2017 Alexia Stenning Asst. Director – Primary & Community Services Michael Ramsden Quality Standards Manager April 2016 £6,000 £549,000 Acute hospital April 2016 April 2016 April 2016 April 2016 Alexia Stenning Asst. Director 39 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 15. Out of Area Acute Services Activity Management £123,000 16. Improve the quality and care for End of Life patients Improve End of Life service provision, particularly in: 24/7 access to advice and support and admission avoidance Access to palliative rehab Community Ascites Diagnostics Project £0 7.3 – Primary & Community Services Jim Arnold Head of Contracts Tracey Doherty End of Life Care Commissioner Integration & Better Care Fund Strategic Direction: MKC & MK CCG Better Care Fund Plan, 2014-2018 MKC & MK CCG Older People’s Strategy, 2013-2016 MKC & MK CCG Dementia Strategy MK CCG Out of Hospital Strategy (currently in development) Principles for Change Driving integration at scale and pace. Standardise and communicate what primary care should provide for patients with long term conditions. Commission pathways that are in line with NICE Guidance or for the best outcomes available. Commission a ‘One Stop Shop’ approach wherever possible. Aims of the Programme Board are: 1. 2. 3. 4. 5. 6. To improve the experience and outcomes for people who use our services Preventing people from dying prematurely Enhancing quality of life for people with long term conditions Empower patients to manage their own conditions Supporting people to recover from episodes of ill-health or following injury Enabling and supporting people in Milton Keynes to die in their place of choice Year 1 Transformation Initiatives - 2016-2017: Commissioning Intervention/Intention Reduce the number of non-elective admissions going into MKUHFT, and prevent readmissions by improving services and pathways to support patients in the community Action A Rapid Response Team Recuperation Pathway High Impact Team Falls Prevention service Autism Diagnosis service Dementia Pathway review Net Risk Assessed Savings £1,050,000 Activity Reduction Area Lead Joint Commissioning Team Delivered from Ongoing Consolidation & further development of schemes initiated under Year 1 of BCF Plan. 40 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 7.4 Mental Health & Learning Disabilities Strategic Direction: MKC & MK CCG Mental Health Strategy, MKC & MK CCG Dementia Strategy Principles for Change To ensure parity of esteem for mental health services in terms of % funding growth Commission a shift of care from acute inpatient care to preventative and recovery based wellbeing services in the community Commission pathways that are in line with NICE Guidance or for the best outcomes available Commission services that are increasingly focussed on individual packages of treatment and care Aims of the Programme Board are: 1. To improve the experience and outcomes for people who use services 2. To ensure that people can stay well 3. To ensure that when people become unwell, they receive the right care in the right place, getting better, quicker, effective and appropriate interventions delivered in a timely and personalised way. 4. To increase integration 5. To review and redesign services Year 1 Transformation Initiatives - 2016-2017: Commissioning Intervention/Intention Action Net Risk Assessed Savings 1. Home Treatment/Crisis response MH4: Commission a 24/7 Home Treatment / Crisis Response team on a permanent basis £0 2. Primary Care Mental Health service development MH3: Develop primary care mental health service model that best meets the needs of people accessing general practice teams (may include PCOC and SMI LES approaches). 3. Recovery and Primary Care mental health pathway development MH9: Commission/ procure supported accommodation, community support and employment support from independent and voluntary sector with the active involvement of service users and carers to facilitate transition to primary care MH service. 4. Supporting patients with complex needs MH10: Commissioning step 4 psychological therapy that will deliver an evidenced based service to people with Complex Needs. Two key strands are Psychological step 4 services and Voluntary Sector services. Will involve mapping, and evidence for good practice. 5. Reducing Out-of-Area placements MH11: Reduction in number and duration of out of area placements focusing on patients with the following needs: 1. Complex needs - reliant on investment in community and crisis services by developing local care options. 2. Learning Disability and/or Autism - by developing local care options. 3. Dementia with Challenging Behaviour by developing Lead Delivered from Wayland Lousley / Tracey Chapmen 41 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 local care options. 6. Specialist Memory Service MH13: Development of Specialist Memory Service. Earlier identification of dementia and a growing elderly population in Milton Keynes requires increased capacity within our Specialist Memory Service to meet the growing demand for: • Ongoing screening (subject to Pilot evaluation) • To provide full dementia diagnosis • To complete ECG’s • To provide intensive clinical care for complex cases in the community • Post diagnosis support (Better Care Fund resourced) 7. Autism service development MH16: Development of Autism diagnosis, follow up and support service as part of a wider lifespan approach to pathway development. Will provide a base to further develop a complex needs, ADHD, Personality Disorder, Conduct/Behavioural disorders service. 8. Street Triage MH17: Mental Health Street Triage to enhance availability by 3hrs per day (3pm - 6pm). Working from 3pm - 2am in total = 93% of incidents vs current 70% incidents 9. Hospital Liaison Team Implementation of effective, sustainable service model. People experiencing mental illness or dementia will be assessed promptly and directed towards the appropriate treatment and care reducing inappropriate hospital admissions, delayed discharges, waiting time in A&E. 10. Service redesign based on evidencebased care packages and improved care pathways Clear urgent and planned care pathways will be put in place. Access target achievement will be improved within this. 11. Learning Disability Service development Develop a service model with the Transforming Care Partnership to meet the needs of CCG Learning Disability placements for Transforming Care cohort. 12. Wellbeing Service development Develop an MK Wellbeing Service, in order to prevent entry into secondary mental health and statutory social care services and prevent poor health outcomes associated with mental ill health. 42 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 7.5 Maternity, Children & Young People Strategic Direction: Milton Keynes Joint Health and Wellbeing Strategy 2015-18 – Starting Well MK CCG Care Closer to Home 2014 - 18 Future in Mind 2015 Children and Families Act 2014 Better Births 2016 Working Together to Safeguard Children 2015 Principles for Change Promote integration and collaborative working Commission pathways that are in line with NICE Guidance or for the best outcomes available Strengthen prevention to avoid the need for acute health and social care Aims of the Programme Board are: 1. 2. 3. 4. To improve the experience and outcomes for people who use services To deliver quality service that provide demonstrable value for money To benchmark services with best practice in comparable areas To commission care pathways that reflect the intent to avoid admissions to hospital and advice to allow children to be cared for in the community or close to home. 5. To focus on prevention and providing universal, accessible services with targeted care 6. To review and redesign services Year 1 Transformation Initiatives - 2016-2017: Commissioning Intervention/Intention 1. Improve Children’s Mental Health and Wellbeing Action CM24: Re-commission and/or redesign services as part of multiagency 5-year programme to transform the children and young people’s mental health and emotional well-being pathway in MK. Local Priorities include: Net Risk Assessed Savings Investment required Activity Reduction Area Lead Hannah Pugliese Children’s Service Commissioner Delivered from Ongoing Enhanced Eating Disorder Service Integrated care pathway for C&YP with complex and challenging behaviour including CYP with learning disabilities and autism Urgent Care Pathway for 24/7 crisis care - Hospital Liaison and Home Support Psychological support for CYP with specialist needs Improved confidence and capacity in Universal Services. Access to specialist C&YP Mental Health Care Pathway including implementation of CYP IAPT Perinatal Mental Health Integrated Care Pathway (Investment from parity of esteem allocation) Out Of Area Discharge and Transition Pathway 43 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Early Intervention in Psychosis (Investment from parity of esteem allocation) CYP IAPT Reading Collaborative 2. Caring for Children Closer to Home CM25: A set of workstreams aimed at insuring that children are cared for in the community and close to their home: - Supporting children and families with common health conditions - Paediatric Community Nursing Team - Enhanced Continuing Care packages - A review of Long Term Conditions pathways - Explore opportunities to undertake more procedures in the community £287,000 3. Improve outcomes for children with Special Educational Needs and Disabilities CM26: Ensuring the embedding of reforms to meet the needs of children with special educational needs and disabilities Investment required 4. Improve Maternity care CM27: Respond to national maternity review aimed at improving maternity care and implement measures to support reduction of stillbirths and low birth weight babies. 5. Safeguarding CM28: Commission a dedicated service for females who have been subject to female genital mutilation 6. Perinatal Mental Health To strengthen the Perinatal Mental Health pathway and Services. A&E Attendances Emergency Admissions Hannah Pugliese Children’s Service Commissioner October 2015 Fiona West Programme Manager Ongoing Fiona West Programme Manager Tbc Investment required Fiona West Programme Manager Ongoing Investment agreed Fiona West Programme Manager Ongoing A joint initiative has been undertaken between the C YP & M commissioners and the adult metal health commissioners to include the formation of a Milton Keynes Perinatal Collaborative. Developed a programme of work designed to improve outcomes for women and families experiencing mental ill health in the perinatal period. The work programme includes the development of a Perinatal Integrated Care Pathway for Milton Keynes and a multiagency training programme. 44 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 The CCG also committed funds to enhance the local specialist perinatal services which have created an additional 3 posts in community mental health services. 7. Continuing Care Efficiencies within service £90,000 Fiona West Programme Manager April 2016 8.Local Authority Medical Certificates Cease re-imbursement to Local Authorities £10,000 Fiona West Programme Manager April 2016 45 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 8. Integration & Partnership Milton Keynes has a long history of joint working, and has a number of integrated services: Intermediate Care; Mental health; Learning Disabilities; Integrated Community Equipment services and a Joint Commissioning Team. Work has been underway for some time to further develop integrated serves to better meet the needs of older people and those with long term conditions and/or physical disabilities. As part of this process, a number of workshops have been held with service providers and members of the public to discuss the development of integrated services. 8.1 Approach Implicit in the Joint Health and Wellbeing Strategy is the empowerment of Milton Keynes residents to be supported to help manage their own health and wellbeing through the commissioning and delivery of person centred services, which place the individual at the heart of service delivery. Through local health and social care teams we will work with local people in Milton Keynes to further develop our plans for integrated care and support to enable people to maintain their independence. Our vision for health and social care services in Milton Keynes is for services that are configured to support people to live independently in their own home, within their local communities, wherever possible, including those at the end of their life. This will be our default option for service delivery. The aim of any intervention, especially acute care, will be to support people to realise this objective. Through effective utilisation of the Better Care Fund, capacity will be developed in community health and social care services to meet the delivery of this objective and will be provided by a full range of statutory and voluntary and community organisations. By working together in this way, then the objectives of the MK Older People’s Strategy and the Better Care Fund proposals will be delivered. GPs will be central to organising the co-ordination of people’s care and will work in a seamless integrated way with health and social care providers to better manage care and treatment of patients. Selfcare and self-management of an individual’s health will be encouraged and people will be supported to develop strategies for managing their health and independence, including access to a range of preventative, early intervention services to support people to pro-actively manage their health. Supporting services such as telehealth, telecare and community equipment will be strengthened to support independence. Rehabilitation and re-ablement will be offered to everyone. We are clear that everyone has the potential for restoring some level of physical and mental functioning. 8.2 Vision MK vision for the future model of integrated care is outlined below. “We aim to configure services that support people in their own homes and local communities wherever possible, delivered on a 7 day a week basis. The use of services in the secondary care (acute) sector is essential for those people that need them where community, primary and social care services cannot meet the (acute) healthcare need.” We aim to deliver services with the following objectives: a) b) c) d) Focused on improved outcomes not solely on activity Promote individual independence for all Improving the experience of patients/service users and carers Reduce delayed transfers of care by the development of a range of community based services that can meet a range of needs for post-hospital support. e) The extension of rehabilitation and reablement to people with dementia 46 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 f) The links between physical health and mental health are well known, although our services continue to work in silos. Services (Relationships) will be strengthened to deliver the objective of “no health without mental health” g) A reduction in the rate of emergency admission to hospital and the number of permanent placements to residential and nursing care h) Support early intervention, identifying people who may need support before a crisis i) Case management and co-ordinating care to ensure people are cared for in the most appropriate environment by the most appropriate professional 8.3 Better Care Fund The Better Care Fund (BCF) will be deployed during 2016/17 in line with the Year 2 plan that was developed in March 2015. The plan provides a four year vision for delivery and enhancement of integrated care across the Milton Keynes health and social care economy. From April 2016 the CCG will transfer £14.085m into a pooled fund totalling £14.956m with the Milton Keynes Council as a means of driving further integration between health and social care. The CCG will also pool £0.307m with Buckinghamshire County Council. Locally the BCF provides an opportunity to transform local services so that people are provided with better integrated care and support and is an important enabler to take the integration agenda forward at scale and pace, acting as a significant catalyst for change. The BCF Plan34 will support integrated commissioning of services through a single pooled budget and delivered through integrated health and social care teams. These teams will be configured so that they support people either on a) a short term basis i.e. to deliver rehabilitation and reablement to help people regain confidence and previous levels of functioning or to provide support for physical health at home until reablement can be commenced. b) or on a longer term basis for people with more complex health and social care needs that may require more intensive support over a longer timeframe especially when they have an exacerbation of their condition. During 2015-16 progress with the plan has been reviewed by the BCF Programme Board on a regular basis. The BCF Programme Board recommended to the Joint Commissioning Board that these schemes continue into 2016-17. The impact of these schemes on making the shift from acute care to community based services has begun, but the schemes will take longer to bed in. The Year 2 plan delivery will consolidate transformation initiatives based on the evaluation of implementation achieved during 2015/2016. More details are shown in Appendix E. The focus will continue to be on reducing the impact on acute care, increasing the number of people who can be successfully supported to remain at home, reducing the number of people who are admitted to residential and nursing home care and named professionals for people at risk through delivery of: 34 Community MDTs Rapid Response Service Recuperation Pathway High Impact Team Falls Prevention Dementia Pathway Review Autism Diagnosis Review MKC & MKCCG, Better Care Fund Plan: 2014-2018: September 2014 (Final) 47 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 In 2016/2017 dependant on the evaluation of 2015-16 schemes a decision will be made in year on whether to invest an additional £1m which will come out of acute care to be re-invested through the BCF. This will make the total amount £8m out of £15m invested in out of hospital services. The CCG commissioning plans and local authority plans for social care have also been developed in the context of the JSNA and the Joint Health and Wellbeing Strategy, so there is a “golden thread” linking the health and social care high level strategic documents with the BCF service proposals. 9. Governance MK CCG’s commissioning changes are implemented through its 4 clinical programme boards and through work in the four neighbourhood quality & performance groups. In addition, programme boards for the delivery of the Better Care Fund and the Health Care Review have been established. These boards work alongside the current programme board structure and will eventually be integrated into the existing governance structure as the work progresses. All programme board work stream delivery is overseen by the CCG’s Programme Management Office function (PMO) and each clinical board includes clinicians and patients in its membership and has a CCG GP as the Senior Responsible Owner (SRO), who is supported by a dedicated programme manager. All programme SROs are accountable to the Commissioning Decisions Group (CDG) and through this to the MK CCG Board. Included within the remit of the programme boards is responsibility for the development and delivery of the annual QIPP plans, monitoring of delivery against plans, the management of risk and provision of programme and project management advice to the clinicians and staff involved. The governance structure for delivery is shown below:- Clinical Federation of Member Practices NHS MK CCG Board NHS MK CCG Leadership Team EXTERNAL RESOURCES NHS MK Commissioning Delivery Group Commissioning Support Hub Joint Commissioning Team Advisory Stakeholders Service Providers Health & Wellbeing Board Clinical Networks Partner Organisations Patient Congress Practice Participation Groups Programme Management Office Mental Healthcare Learning & Disabilities Programme Board Care Pathways & Primary Care Programme Board Healthwatch Urgent Care Working Group Children Young People & Maternity Programme Board Better Care Fund Delivery Group Health Care Review Programme Board NHS Milton Keynes CCG Management Framework Internal Decision Making Structure Each Programme Board has an agreed/approved Annual Work Plan which it will use to focus and drive forward its work, thus ensuring that the CCG can deliver stepped changes and transformation that will support the implementation of its overall Strategic Plan. The Programme Management Office (PMO) to support the organisation in turning its’ strategy and plans into delivery by:48 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Working with strategic leads, programme boards and finance to develop commissioning intentions (CI) that are value adding, evidence based and fit with strategic direction Turning the commissioning intentions/initiatives in the plan into realistic programmes of change/work plans through opportunity appraisal and robust business case development Monitoring, evaluating and reporting on progress towards benefit delivery and strategic objectives The PMO seeks to operate best practice public sector methodology in portfolio, programme and project management to support delivery of the CCGs’ strategic plans. Working across the organisation, the PMO drives and supports project delivery by ensuring that all key projects are managed in a controlled way by establishing real rigour, careful planning and sound processes in the management of projects including: The provision of consistent documentation whilst avoiding unnecessary bureaucracy. The development of a clear authorization process with programme and project lifecycle & governance guidance that is understood by everyone. This includes robust evaluation & post implementation process for pilots and projects The prioritisation of projects that are value-adding, realistic, strategically aligned, properly scoped and with robust business cases proving the case for change The introduction of benefit mapping and management, ensuring the anticipated benefits of programmes and projects are clearly articulated and fit with organisational strategy Robust monitoring and evaluation of progress against the plans Effective risk management This approach ensures a focus on delivery with underpinning sound governance and approval processes. 49 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 10. Improving Quality & Outcomes 10.1 OUTCOMES AMBITIONS Within the five domains in the NHS Outcomes Framework, NHS England has identified the measures best placed to provide assurance in planning and delivery, where CCG data exists and a baseline could be determined. Everyone Counts: Planning for Patients 2014/15 to 2018/19 translates these outcomes into specific measurable ambitions which are critical indicators of success and against which progress can be tracked. Milton Keynes CCG is required to ensure delivery of the following seven outcomes ambitions, which are set out below. Performance against the following standards is reported to the Commissioning Delivery Group (CDG) every month and the CCG Board bi-monthly. 5 year trajectories for improvement as set in April 2014 are shown in Appendix A. Outcome 1 Securing additional years of life for the local population, with treatable mental & physical conditions measured by Potential Years of Life Lost (PYLL) from conditions amenable to healthcare Outcome 2 Improving the health related quality of life of people with one or more long-term conditions measured by:- Health related quality of life for people with long-term conditions (EQ5D tool GP Survey) Outcome 3 Reducing the amount of time people spend avoidably in Reduction in Emergency Admissions hospital through better, more integrated care measured by:(composite rate) Outcome 4 Increasing the proportion of older people living independently No indicator currently available at at home following discharge from hospital, measured by:CCG Level Outcome 5 Increasing the number of people having a positive experience Patient Experience of Hospital Care of hospital care, measured by:Survey Outcome 6 Increasing the number of people having a positive experience Patient Experience of Primary Care of care outside hospital in general practice and the (composite rate) community, measured by:- Outcome 7 Making significant progress towards eliminating avoidable Indicator in development deaths in our hospital caused by problems in care, measured by:- The current position with regards to delivery against these ambitions is shown below, measured up to the end of Month 9 (December 2015). Supporting measures are also indicated in the table, and denoted by the pre-fix EAS. Performance against the following standards will be reported to the Commissioning Delivery Group (CDG) every month and CCG Board bi-monthly. 50 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Description E.A.1 PYLL from Causes Amenable to Health E.A.2 Health-Related Quality People w ith LTCs E.A.3 Improved Access to Psychological Services (IAPT) Roll-Out E.A.4 Emergency Measure Admissions Considered of Life for Composite Plann ed Metric Aspir ation “Annex A” - Outcomes Measures Dashboard Below 2,083.7 Above 74.70 2 0 11.12 b aseline Dec-15 Jan-16 Feb-16 1,886.9 1,886.9 1,886.9 (2014) (2014) (2014) Next update Next update Next update 09/2016 09/2016 09/2016 2015 Ambition 1,847 75.70% 2014.15 next update 08/16 2015.16 Ambition 75.80 75.1% 2014.15 75.1% 2014.15 1.25% p/m or above 1.20% 1.30% 1.80% 15% p/a Below Next update Next update Next update 1950 March 2016 March 2016 Sept 2016 2 0 11.12 b aseline E.A.4.i E.A.4.ii E.A.4.iii E.A.4.iv Unplanned Hospitalisation for Chronic ACS Conditions Unplanned Hospitalisation for Asthma, Diabetes and Epilepsy Avoidable Emergency Admissions for Acute Conditions Emergency Admissions for Children w ith LRT Infections 2 0 11.12 b aseline Below 481.40 (DSR) 2 0 11.12 b aseline E.A.7 Patient Experience of Primary Care Negative Responses Per 100 E.A.8 Hospital Deaths Attributed to Problems in Care E.A.10 One Year Survival from All Cancers E.A.S.1 Estimated Diagnosis Rate for People w ith Dementia E.A.S.2 Improved Access to Psychological Services (IAPT) Recovery Rate E.A.S.5 Below 1,082.60 (DSR) 2 0 11.12 b aseline Patient Experience of Hospital Care Negative Responses Per 100 Healthcare Acquired Infection Measure (MRSA) Healthcare Acquired Infection Measure (Clostridium Difficile) Below 272.60 (DSR) 2 0 11.12 b aseline E.A.5 E.A.S.4 Below 668.80 (DSR) Below 145.80 2 0 12 b aseline 9.6 2 0 11.12 b aseline YTD 13.90% 2015.16 Ambition 1,921 665.1 July 14June 15 Provisional data 407.2 July 14June 15 Provisional data 1,193.0 July 14June 15 Provisional data 523.8 July 14June 15 Provisional data 735.6 Oct 2014 to Sept 2015 Provisional data 467.7 Oct 2014 to Sept 2015 Provisional data 1,195.4 Oct 2014 to Sept 2015 Provisional data 549.5 Oct 2014 to Sept 2015 Provisional data 144.2 2014 2015 data due July 2016 2015 data due July 2016 2015 Ambition 132.0 10.9 2013.14 11.0 2014.15 Next update TBC 2016 2015.16 Ambition 8.9 661.7 2014/15 443.3 2014/15 1,191.2 2014/15 478.7 2014/15 Indicator in development. Should be published Autumn 2015 - Not yet out. NA NA NA NA NA 67.4% (2011/12) 68.7% (2012/13) 70.0% (2013/14) NA 66.5% or above 66.04% 65.13% 64.12% 66.32% 50% or above 54.70% 66.70% 66.70% 50.90% 0.00% 1 0 1 2 Below 81 PA 3 5 5 59 Above 68.73% N at io nal A ver ag e 51 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 10.2 NHS CONSTITUTION MEASURES Milton Keynes CCG plans to ensure that the requirements of the NHS Constitution are delivered to the local population. The CCG has put in place robust governance arrangements to ensure that all performance measures required by the NHS Constitution are delivered and any performance issues addressed with providers in a timely fashion. This is done through robust monitoring by the relevant Programme Board, with remedial action plans worked up between providers and each Programme/Lead Manager – overseen through the monthly contracting review meetings. PMO will oversee the delivery of any remedial action plans that are agreed. Current CCG performance against these measures is shown below. Performance against the following standards will be reported to the Commissioning Delivery Group (CDG) every month and CCG Board bi-monthly. The current position with regards to delivery against these indicators is shown below, measured up to the end of Month 11 (February 2016). Trajectories & ambitions for 2016/2017 are outlined in Appendix B. 52 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 “Annex B” - NHS Constitution Dashboard E.B.2 E.B.3 E.B.4 E.B.5 E.B.6 E.B.7 E.B.8 E.B.9 E.B.10 E.B.11 E.B.12 18 Week RTT Admitted Pathw ays <18 Weeks 18 Week RTT Non-Admitted Pathw ays <18 Weeks 18 Week RTT Incomplete Pathw ays <18 Weeks Diagnostic Waits >6 Weeks A&E Waits Seen Within 4 Hours (MKUHFT) Cancer 2 Week Waits -Suspected Cancer Ref errals (CCG level) Cancer 2 Week Waits -Breast Symptomatic Ref errals (CCG level) Cancer 31 Day Waits -First Def initive Treatment (CCG level) Cancer 31 Day Waits -Subsequent Treatment -Surgery (CCG level) Cancer 31 Day Waits -Subsequent Treatment -Chemotherapy/drug (CCG level) Cancer 31 Day Waits -Subsequent Treatment -Radiotherapy (CCG level) Cancer 62 Day Waits - First Def initive Treatment -GP Ref erral (CCG level) Jan-16 YTD Standard E.B.1 Description Aspiration Metric 90% 80.73% 87.06% 95% 94.35% 95.15% 92% 89.12% 91.20% 99% 98.51% 99.10% 95% 92.6% 94.50% 93% 93.06% 95.34% 93% 100% 93.95% 96% 97.18% 98.23% 94% 94.74% 95.86% 98% 100.00% 98.99% 94% 87.50% 96.78% 85% 70.45% 82.22% E.B.13 Cancer 62 Day Waits -Treatment f rom Screening Ref erral (CCG level) 90% 100% 94.12% E.B.15.i Ambulance Clinical Quality -Category A (Red 1) 8 Minute - SCAS Level 75% 71.9% 72.20% E.B.15.ii Ambulance Clinical Quality -Category A (Red 2) 8 Minute - SCAS Level 75% 71.1% 72.90% E.B.16 Ambulance Clinical Quality -Category A (Red 3) 19 Minute - SCAS Level 95% 93.80% 94.40% EIP pathw ays completed (treatment w ithin 2 w eeks of ref erral) 50% 87.50% 84.73% EIP pathw ays incomplete 50% 0% 50% 0 0 1 0% 8 63 95% TBC (Q4) 98.59% 0 1 4 0 0 0 0 0 0 411 17 432 60 6 41 E.B.S.1 E.B.S.2 E.B.S.3 E.B.S.4 E.B.S.5 E.B.S.6 E.B.S.7 E.B.S.8 Mixed Sex Accommodation (MSA) Breaches Cancelled Operations -Not Seen <28 Days (MKUHFT) Mental Health Measure -Care Programme Approach (CPA) Number of 52 Week Ref erral to Treatment Incomplete Pathw ays Trolley Waits in A&E >12 hours Urgent Operations Cancelled f or a Second Time (MKUHFT) Ambulance Handover Delays > 60 minutes Crew Clear > 60 minutes 53 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 10.3 QUALITY PREMIUM The quality premium (QP) was introduced in 2013/14 to reward CCGs for improved outcomes from the services they commission. The maximum payment for a CCG is expressed as £5 per head of population. Quality premiums must be used to improve quality of care or health outcomes and/or reduce health inequalities. The Quality premium for 2016/17 will consist of 7 measures in total. These will be made up of four national and three local measures reflecting the quality of health services commissioned by MK CCG in 2016/17. Payment for the 2016/17 QP will be made to CCG’s in 2017/18. National measures that fall into the Quality Premium this year and account for 70% are shown in the table below. National Measure Description Cancer Cancer diagnosed at an early stage (stages 1 and 2) GP Patient Survey Overall experience of making a GP appointment E-Referrals Increase the proportion of GP referrals made by E-referrals Improved antibiotic prescribing in primary care Antimicrobial resistance (AMR) Improving antibiotic prescribing in primary care Part a) reduction in the number of antibiotics prescribed in primary care Part b) reduction in the proportion of broad spectrum antibiotics prescribed in primary care Milton Keynes CCG takes a whole system approach to delivering the Quality Premium trajectories utilising financial incentives, contract levers and links with social care to maximised delivery. In 2016/17 it has chosen the following 3 Local Measures which account for 30% of the total: % of patient returning to their usual place of residence following hospital treatment for a stroke % of mothers who give their babies breast milk in the first 48 hours after delivery Reported prevalence of hypertension on GP registers as % of estimated prevalence Improvement trajectories for each local indicator have been agreed with NHS England and further details are shown in Appendix A. 10.4 QUALITY & CQUINs Milton Keynes Clinical Commissioning Group (MKCCG) seeks to commission the best possible healthcare within available resources, with a focus on reducing health inequalities and improving outcomes within the local population. The CCG is committed to continuously improving the quality of care provided to people regardless of setting through a range of activities and interventions. The three elements of quality; patient safety, clinical effectiveness and patient experience, form the basis of all commissioning decisions, in order to ensure that services deliver the best outcomes for our community. The CCG uses a range of data to ensure the approach to quality is comprehensive. Independent sources of assurance include: National and statutory guidance Links with regulators including Care Quality Commission and Monitor Reports Recommendations as a result of national reports and Internal Audit annual review of clinical quality enquiries processes National benchmarking data Safeguarding Children and Adult Boards Clinical network intelligence NHS England assurance processes Royal College audits and peer reviews Social Care 54 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 The following activities have been identified to improve the quality of commissioned services for the population of Milton Keynes. Transforming Care for People with Learning Disability and Autism Following the publication of the Department of Health’s report ‘Transforming Care: A national response to Winterbourne View Hospital’ in December 2012, a significant amount of work has been undertaken to make improvements in the care and services available for people with learning disabilities and/or autism spectrum disorders. In Milton Keynes the CCG has been working in partnership with NHS England, Local Authority, people with learning disability and autism, their carer’s and providers to reduce the numbers of people who are cared for within hospital environments. This has delivered significant progress in responding to learning from Winterbourne View. For individuals, Care and Treatment Reviews (CTRs), as set out in ‘Care and Treatment Review: Policy and Guidance’ October 2015 have been carried out with all people who are inpatient. A Milton Keynes operational ‘Winterbourne View Assurance Meeting’ has been in place since 2014, to track progress of individuals’ care and their discharge plans. In 2015, this group extended the brief to include review of those people at risk of admission, introducing a process of pre-admission CTR’s. Following the publication of the national plan ‘Building the Right Support’ Oct 2015 MKCCG has established with Luton and Bedfordshire, a Transforming Care Partnership. Local Authorities, Clinical Commissioning Groups (CCGs) and NHS England specialised commissioners from this geographic footprint are working together to build up community services and close unnecessary inpatient provisions over the next 3 years and by March 2019. This strategic partnership brings together expertise and resources to develop a service model to meet the complex needs of this group of children and adults. Milton Keynes CCG has established a local Transforming Care steering group to drive the Milton Keynes elements of this work. This feeds up to the Transforming Care Partnership Board and reports to the MKCCG Mental Health and Learning Disability programme Board. Both the Milton Keynes Transforming Care steering group and the Transforming Care Partnership benefit from inclusion of services users and carers with lived experience. Improving access to mental health services 55 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Significant progress had been made at CCG level in terms of dementia diagnosis rates and we will continue to improve performance associated with the Prime Ministers challenge of a 66.7% diagnosis rate for people with dementia during 2016/17. In addition an implementation plan will be agreed to improve post diagnostic support for people and their carers. This is currently included in the list of commissioning intentions for 2016/17 subject to the outcome of the pilot evaluation. The CCG Joint Commissioning colleagues continue to improve access to mental health services in collaboration with providers, to implement the locally agreed Mental Health Strategy 2014-17. This includes meeting the new mental health standards relating to people with the first episode of psychosis commencing treatment within 2 weeks, and ensuring people with common mental health conditions referred to Improved Access to Psychological Therapies (IAPT) programme within six weeks of referral and treatment within 18 weeks. This will be achieved through the existing Mental Health Programme Board. Safeguarding vulnerable people Our population has a right to live free from harm and abuse. Safeguarding must be at the core of Health service provision and reflected throughout our vision, priorities, values, aims and the delivery of healthcare. MKCCG’s approach to safeguarding is to make it integral to all aspects of commissioning through: Working in partnerships Seeking assurance that all our providers are delivering safeguarding responsibilities Supporting all our providers to continually improve their safeguarding. Specific areas of work to align with the CCG and safeguarding partnerships priorities are: Development of care homes and domiciliary care – prevention of safeguarding concerns and enabling care closer to home Involving people – hearing voices from those with lived experience of safeguarding Developing safeguarding practice within Primary Care Development work on the Local Safeguarding Board priorities Person centred care and support, which is personalised, co-ordinated and empowering Personal health budgets (PHB) are a new tool to increase individual choice and control within the NHS as part of the mandate to increase the role of patients as partners in the management of long-term conditions. During 2016/17 Milton Keynes Clinical Commissioning Group will develop personal health budgets for children with special educational needs and disabilities, adults and children with learning disabilities. During 2016/17, Personal Health Budgets will be included as part of the Joint Transformation Plan developed through the Transforming Care Partnership between Bedfordshire, Luton and Milton Keynes (BLMK). Focus on equality and narrowing inequalities We will ensure our quality priorities are aligned to the current and future health needs identified within the Joint Strategic Needs Assessment and are consistent with the Health and Wellbeing Board strategic priorities. All contract negotiations to improve quality take place in collaboration with other partner commissioners, social care partners, public health and clinical networks, to ensure a whole system approach to delivering improvements is in place. Contracts with providers ensure the delivery of improved local outcomes for patients and reduce inequitable access to healthcare. 56 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Actions to address unwarranted variation in health care are incorporated into the clinical commissioning process. The primary care web-tool is used to review GP practice outcome indicators and to identify where there may be variations in for example, cancer survival or A&E attendances, and reasons behind variation is explored and progressed within the GP locality teams. All CCG plans and commissioning decisions are quality and equality impact assessed to ensure that equality and health inequality issues are addressed in the local population. Community engagement relating to proposed service changes takes into account the needs of disadvantaged groups. The CCG will continue to undertake pathway redesign to address unwarranted variations locally relating to diabetes, cancer and mental health specialties, whereby ensuring that what is known to be clinically effective happens in practice. The CCG will progress the implementation of the Equality Delivery System (EDS2) within commissioning and provider settings to improve the services provided for our local community and offer better working environments free from discrimination for both staff and users. Services are created in partnership with citizens and communities The CCG has a regular programme of engagement in place with Healthwatch and a number of other forums and user groups. The CCG Patient and Public Engagement strategy provide a framework for engaging with patients, the public and key stakeholders. To support the delivery of this strategy the CCG will establish a set of principles for future engagement, streamline the current structures and embed engagement more firmly into the CCG’s governance structures. A Public and Patient Engagement Steering group has been established which will set objectives to improve engagement over the next year. Improving Patient safety The CCG is committed to supporting providers to reduce avoidable adverse events, ensuring learning is maximised when adverse events occur, and that learning is embedded to ensure that risk of harm to patients is minimised. CCG Governance processes have been reviewed in relation to patient safety incidents in line with new national guidance. The CCG provides leadership in reducing avoidable harm to patients and has established risk management and patient safety process with providers. All serious incidents are reported and analysed, and action plans associated with the root causes of the incident are agreed. Monitoring of implementation of actions plans takes place to ensure that lessons are learnt and embedded within organisations to deliver sustainable improvements in patient safety. A clear focus on patient and carer involvement, and full integration of learning across provider settings has strengthened the ability of the CCG to oversee the development of sustainable, patient focused and whole system improvements. Mechanisms are embedded within provider contracts linked to Commissioning for Quality and Innovation (CQUIN) and Quality Schedules to further reduce patient harm, for example linked to sepsis and the management of acute kidney injury and implementation of the catheter care bundle. Zero tolerance of never events is established. The CCG reviews processes design with providers during quality visits to ensure that safer design of systems, such as use of the WHO checklist, mitigate against the risk of human factors impacting on patient safety. The CCG and the two main providers have signed up to the Sign up for Safety campaign, and have aligned patient safety objectives to deliver whole system safety improvements. The CCG will work collaboratively with all providers to develop a clearer understanding of how system failures and culture and behaviour influence patient safety incidents through an open examination of human factors in relation to patient safety. Providers are supported to develop a positive safety culture by being open when incidents occur, ensuring staff are comfortable with the reporting system, treating staff fairly, maximising learning, and identifying and mitigate future incidents. The CCG will further develop this culture of learning by working collaboratively to providers through an open and engaging process to maximise learning across the wider health and social care setting in order to improve care for all service users. 57 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Reducing health care acquired infections The CCG has strengthened systems to reduce health care associated infections through the investment in further Infection, Prevention and Control expertise. Route Cause analysis of Clostridium difficile Infections is fully embedded within the acute trust, this includes processes for identifying and sharing key learning. A similar process has been rolled out in primary care settings. This will enable the CCG to identify themes and key learning from any identified lapses in care. The CCG will maintain a focus on prudent antibiotic prescribing is a key focus for reducing C Difficile infections and antibiotic resistance across all care settings. Antimicrobial prescribing and resistance rates will continue to be monitored to ensure that measurable improvements are in place. A whole health economy infection control committee will continue to meet regularly and works closely with Public Health teams to ensure key mechanisms are in place to identify, monitor and achieve health economy wide objectives linked with national priorities. Reducing avoidable deaths The CCG has established mortality governance processes and worked closely with Public Health and MKUHFT since April 2014 to understand Hospital Standardised Mortality Ratios (HSMR) and Summary Hospital Level Indicators (SHMI). In doing so a morality rates have reduced and whole system risks in terms of increase mortality rates are understood and mitigated through commissioning processes. Going forward the CCG will support MKUHT in the review of avoidable deaths using the standardised national tool to ensure action is taken to prevent future deaths. In addition specific measures for quality such as adherence to good practice guidance, disease specific outcomes, patient and staff surveys and infection rates will be used to inform improvements actions. The CCG now hosts the CDOP coordinator and has reviewed the child death overview processes. This will strengthen the identification of modification factors in child deaths and support the continued reduction in avoidable child deaths in Milton Keynes Improving maternity services The Morecambe Bay Investigation was established following concerns over serious incidents in the maternity department at Furness General Hospital (FGH). The report concluded that cultural issues and serious failures of clinical care led to unnecessary deaths of mothers and babies. Existing governance arrangements are in place to oversee the quality of the maternity services at MKUHT, in the form of an executive led Maternity Improvement Board with CCG, CQC and Monitor representation. This Board will continue to oversee the implementation of the agreed recommendations of the National Maternity Review in relation to safety, outcomes and experience within maternity units and progress will be reported the CCG Quality Board. Ensuring sustainable staffing models within provider settings The CCG works closely with all providers to gain assurance that safe staffing levels are in place and that plans to reduce agency spend are being rolled out. The CCG will work with providers to implement the refresh of the national sustainable staffing guidance for midwifery, nursing and care staff across all provider settings. This will enable the CCG to actively seek assurance about the level of safety linked to staffing capacity and capability. The CCG adopts a triangulated approach to determining risks to patients in relation to staffing levels, including incident reporting, incidence of pressure ulcers and falls, complaints and staff feedback. Further assurance in relation to patient safety linked to staffing levels is a component of quality assurance visits. Developing 7 Day services A key element of providing clinically effective and safe services is to ensure that providers work towards delivering seven day services. In line with national guidance the CCG is working with providers to focus on the four key elements of 7 day services including, time of clinical review, and access to diagnostics, access to consultant directed 58 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 interventions and access to ongoing reviews. The CCG is initially focusing on urgent and emergency care by redesigning pathways, and on relevant specialties to ensure that access to services is improved for the local population. Included within this is 7 day service access for End of Life care. Improving patient and carer experience The CCG sees the patient experience data as central to determining the quality of care provided to the local population, and is committed to using systems and processes for capturing, understanding and improving patient and carer experience, to create and improve care for individuals, families and carers. The CCG’s works with providers, patients, carers and community stakeholders to strengthen the collection of a range of patient experience information. The reporting and triangulation of this information is used to influence commissioning decisions and inform improvements in care which deliver patient centred outcomes with an emphasis on vulnerable and disadvantaged groups. Patient and carer experience is a central component of all quality visits. We will build upon the CCG use of Experts by Experience in our Winterbourne View monitoring visits by investing in a Patient Leadership programme and regular mystery visit programmes. A further priority will be working with local GP surgeries and Patient Participation Groups (PPG’s) to improve patient experience in primary care recognising that the quality of primary care services impacts on care pathways for both acute and long term conditions. Young carers are identified as a group with specific needs within the Children and Young People’s Mental Health and wellbeing Local Transformation Plan (CAMHS LTP). The CAMHS LTP 5 year programme in place seeks to improve outcomes for children, young people and families with mental health and emotional needs through transformation of the pathway. Young carers will benefit from the overall improvement to the pathway but also from some targeted work looking at the needs of a number of specific groups of vulnerable children and young people who are hard to reach. 2016/17 a plan will be developed for improving patient choice relating to maternity services. The End of Life Steering Group will be rolling out the implementation plan for the MK End of Life Care strategy linked to improving choice relating to end of life care and place of death, and achieving the preferred place of death. This will include increasing EOL training and education and access to 24/7 care, development of existing 24/7 advice and support, a reduction in inequalities of service provision and improved coordination between care providers. Building on the Friends and Family Test the CCG will work with providers to ascertain how feedback drives improvements in services at ward level. Improving patient outcomes The CCG membership ensures that clinical effectiveness and continuous quality improvement is at the heart of the CCG quality and commissioning plan. GP programme board chairs and clinical representation at programme boards ensure that the transformation agenda is clinically led, reflects evidence based practice and is outcome focused. We want to ensure that the local community is provided with the most up to date clinical models of care associated with the very best outcomes. This is achieved through the search for and application of innovative models of care based on the NHS Outcomes Framework, and guidance from NICE and other clinical bodies. In order to support this, the CCG is an active member of relevant strategic clinical networks and has developed links with Academic Health Science Network to enhance and progress the application of evidence-based research into local practice. During 2016/17 the CCG will work with the Thames Valley Stroke Strategic clinical network to review how standards of stroke services can be improved across a larger population footprint. 59 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Supporting people to live healthier lives The CCG works closely with Public Health to improve the overall health of the population through the establishment of an equalities and health inequalities working group. Within provider contracts there will be a requirement to embed the principles of Making Every Contact Count (MECC) within care settings particularly in relation to lifestyle improvements linked to obesity, smoking and alcohol. Workforce development The CCG has considered the Health Education England Mandate, the Five Year Forward Plan, and local commissioning intentions in terms of identifying the future workforce needs. We are working with the local LETB and providers to ensure that a whole system strategic workforce plan is developed for Milton Keynes, to ensure clinicians have the skills necessary to practice in different settings, and reflect values of behaviours to deliver compassionate patient centred care. The CCG will work with providers to determine how more productive use of existing staff can improve care, and how the skills of the existing workforce skills can be exploited for the benefit of service users. Developing leadership for Quality We have a duty to lead, drive and secure continuous improvement through the services we commission ensuring that high quality care is central to all commissioning decisions. In order to achieve this we will ensure that the potential of all staff is maximised through the appraisal and personal development plan process. Individuals are supported to undertake leadership programmes to work effectively across the health and social care system. The CCG will continue to lead whole system change including the development of joint outcome measures delivered across organisational boundaries. This is achieved through the CCG leadership of a number of health economy wide groups focusing on mortality, tissue viability, health care acquired infections and learning from incidents. The CCG will work collaboratively with a number of partner agencies including the Local Authority, neighbouring CCG’s, NHS England Regional teams, Monitor the Trust Development Authority and the CQC, and be active members of the Health and Wellbeing and Safeguarding Adults and Safeguarding Children’s Boards. Achieving cultural change A collaborative approach is taken with providers to support a culture of learning and patient focused care and compassion, with patients at the heart of decision-making. This values based approach we believe will embed sustainable quality improvements and support innovation. A proportionate approach is adopted when areas for improvement are identified including the use of contractual levers when formal recovery plans are required. Improving Staff Satisfaction The CCG is aware of the links between staff satisfaction and patient care and will continue to work with providers to drive improvements in staff satisfaction. Staff satisfaction is a critical element of all quality visits. National staff survey results will continue to be monitored and benchmarked against other similar providers and used within the triangulation of evidence to inform commissioning decisions. Performance against implementation of the staff friends and family test across all services are monitored, and providers supported to implement improvements as required. 60 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Proportionate use of contractual levers to support quality improvements The national contract is used to support local quality improvements. The CCG emphasises innovation and critical interventions which improve outcomes for patients through the CQUIN schemes. MK CCG incentivises providers to deliver the national CQUINs and negotiates the agreement of local CQUINs to support improved outcomes based on local needs. Local CQUINs are linked to mental health support for people following a stroke and those with COPD; breastfeeding initiation, supporting earlier discharge from hospital; child friendly services and improved patient safety. CQUIN payments are profiled to incentivise initiatives that reduce overall risk to patient safety and support innovation. Locally agreed quality schedules are linked to the outcome goals and indicators in the NHS Outcomes Framework domains. They have a strong emphasis on measuring and improving patient safety, experience and outcomes. Should the required outcomes fail to be delivered we will work collaboratively with providers to make improvements and use contractual levers if required in the form of joint reviews, the development of recovery action plans or the application of appropriate penalties. The Quality & Outcomes Framework is implemented in primary care based on the nationally set portfolio of indicators. Performance is monitored through locality teams and reported to the quality committee. Payments are made to GP practices based on points achieved and performance is published on line. Governance arrangements All providers are held to account for the delivery of quality improvements. For the two main providers the CCG governance arrangements have reporting to the Quality Committee and provider Clinical Quality Review Meetings (CQRM). The CQRM meets monthly as an operational group and quarterly as a strategic group. The strategic meetings are to gain assurance and hold providers to account, while the operational meetings are to provide an opportunity for the CCG Quality team to support providers to deliver the required improvements. Quality contract monitoring, and reviews of CQC Quality and risk profiles takes place at the strategic CQRM. The CCG will continually develop reporting to the CQRM to ensure that all provider quality issues are robustly monitored. This will in turn refine reporting to the quality committee and subsequently to the CCG Board and the Quality Surveillance Groups. The delivery of CQUINs will be closely monitored to drive up quality of care through the achievement of challenging but realistic outcomes. Assurance mechanisms The CCG receives regular assurance that existing services meet acceptable standards, through the triangulation of a range of information including both hard and soft data from a number of sources. These include independent information sources, provider visits, evidence of historic progress, monitoring of outcomes, interactions with patents’ and carers, and provider dashboard reporting. A range of nationally published information is also scrutinised and monitored at provider and CCG level against the NHS Outcomes Framework, NHS Constitution, Local Priority indicators, patient safety, quality and experience measures, the Quality Premium and the CCG assurance framework. We will continue to utilise relationships and interactions with other regulators or agencies to be alert to concerns and drive improvements. The CCG will continue to have active clinical participation in Quality Surveillance Groups. Concerns about the quality of care provided are raised either through the CCG governance arrangements or directly with providers using a transparent supportive approach to achieving improvements. Measuring and publishing quality Continuous improvement is aided through effective measurement. The CCG, based on transparent relationships with providers, requires providers to share robust, relevant and timely information. Information published nationally is reported monthly. This information will be shared and published by the CCG to ensure accountability and support patient choice. 61 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 11. Commissioned Activity Plan In line with national guidance, the CCG has ensured that its activity planning has been undertaken using an ‘openbook’ methodology, taking account of 15/16 demand, available capacity, overall financial sustainability and the implications on activity of commissioning intentions and transformation initiatives planned by each Programme Board. An overall summary of these plans are outlined below, and later within Section 12. Detailed activity plans have been submitted via the nationally mandated UNIFY returns.35 11.1 PLANNING ASSUMPTIONS The following planning assumptions have been taken into account when preparing the CCGs Activity Plan for 2016/2017: 2016-17 Baseline is based on Month 10 data multiplied by 12/10ths Whilst it was not available at the time of developing our activity plans the IHAM (Indicative Hospital Activity Model) has been utilised as a guide to help sense check the plans. It would be the aim to use this more fully as a planning tool in the future to support our internal Programme Boards as they develop future initiatives The Demand & Capacity Planning tool has been used in a similar way Population growth modelling has been applied at age specific rates to patient level data, averaging at 1.98%. The data used is from the Mk Observatory, a Council led data source which provides a more up to date forecast of the population growth rates. Further demand growth averaging at 1.5% has been applied. This aligns with the Bedfordshire / Milton Keynes Healthcare Review planning assumptions. Aligned with this the CCG has increased activity to meet the backlog for delivery of RTT in 2016-17 QIPP reductions reflect current plans listed in Section 7 above and include: o Outpatients reductions predominantly Ophthalmology project o Non Elective admissions predominantly BCF o A&E reductions predominantly Integrated Urgent Care o Non Elective excess bed days predominantly Getting People Home programme There is alignment between the CCG Activity Planning and the contract offers submitted to providers. The CCG has agreed and signed contracts with our main acute Provider MKUHFT and the other independent sector contracts that the CCG leads on. 11.2 ACTIVITY PLAN The table below shows projected activity changes for MK CCG between 2015/16 and 2016/17. 35 MK CCG UNIFY Returns: CCG Monthly Activity & Other Requirements: Annual Activity ProvComm; Financial Plan; Operational nd Resilience Template, 2 March 2016. 62 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Non-recurrent activity changes Underlying trend and demographic growth Transformational change Policy changes E.M.2 E.M.3 E.M.4 E.M.5 E.M.6 Apply the impact of transformation / allocative To capture the impact of CCG 15/16 Forecast To capture the effect of for To capture any additional efficiency. To include for new policies, for example 16/17 Annual Plan outturn example, changing activity as a result of example: NCMs, UEC, hospital 7 day services; definitions, boundaries, changes in population and RightCare, Prevention, Self primary care access, Cancer, reporting standards. underlying changes in trend care and procedures of Mental Health. limited clinical value. 0 Consultant Led First Outpatient Attendances (Total Activity) 97,603 0 3672 -5112 0 96,163 Consultant Led Follow-Up Outpatient Attendances (Total Activity) 113,283 0 4522 -5226 0 112,579 Total Elective Admissions (Spells) (Total Activity) [Ordinary Electives + Daycases ] 27,816 0 1044 -54 -157 28,649 Total Non-Elective Admissions (Spells) (Total Activity) 30,880 0 1065 -1362 297 30,880 Total A&E Attendances 70,958 0 2433 -7896 0 65,495 E.M.8 E.M.9 E.M.10 E.M.11 E.M.12 Consultant Led First Outpatient Attendances (Specific Acute) Consultant Led Follow-Up Outpatient Attendances (Specific Acute) Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases ] Total Non-Elective Admissions (Spells) (Specific Acute) Total A&E Attendances excluding planned follow ups 93,166 104,832 27,768 24,747 70,544 0 0 0 0 0 3510 4193 1125 928 2418 -5112 -5226 -54 -1362 -7817 91,564 103,799 28,601 24,747 65,145 0 0 -238 434 0 Activity changes relating to individual QIPP schemes are shown below in more detail. Financial implications of each are also recorded against each individual commissioning intervention shown within the tables in Section 7 – Transformation & Delivery above. Activity reductions for QIPP schemes Scheme CCG Ref No. Workstream Scheme Name TOP 5 SCHEME: DATA COMES FROM WORKSHEETS 1 PC15 Care Pathway & Ophthal mol ogy Managed Care Pri mary Care End to End Pathway of care Tri al 2 UC4 Urgent Care Integrated Urgent Care 3 UC10a 4 CM25 5 BCF 10 PC10 11 PC30 12 PC34 14 LTC3a 15 PC31 16 UC13a & UC12b Day Case Elective Spells Non Elective Spells Ordinary Elective Spells 2016/17 Activity Consultant Consultant Led First Led Follow up outpatients outpatients A&E Attendances 0 0 0 -4,501 -5,080 0 Other Acute Community Based -5,514 13,993 3,934 0 0 0 0 0 -6,664 0 Getti ng Peopl e Home Discharge to Assess Chi l dren, Young Cari ng for Chi l dren Cl oser to Peopl e & Home Better Care Fund Better Care Fund 0 0 0 0 0 0 -5,010 0 0 -468 0 0 0 -816 0 816 0 -884 0 0 0 0 0 0 Care Pathway Pri mary Care Care Pathway Pri mary Care Care Pathway Pri mary Care Care Pathway Pri mary Care Care Pathway Pri mary Care Urgent Care 0 0 0 -215 -146 0 0 361 Urgent Care & & Direct to Test Oscopi es- Gastro PCOC Day Case to OP Shi ft -54 0 0 54 0 0 0 0 0 0 0 -165 0 0 0 165 & Outpati ent Procedures transfer to PCOCs Communi ty DVT pathway 0 0 0 -112 0 0 -112 224 & COPD 0 -10 0 -173 0 0 0 0 Managi ng ED Demand 0 0 0 0 0 -416 0 0 -54 -1,362 0 -5,112 -5,226 -7,896 -10,636 19,493 & Further work is underway to refine activity plans to reflect the further QIPP stretch agreed within the financial plan. 11.3 RISKS AND MITIGATION This plan incorporates a number of risks which could impact on the delivery of the proposed activity plan shown above. These include: Managing demand from primary care Delivery of QIPP schemes and transformation projects Further development and expansion of hospital services by the Provider Rate of population growth within Milton Keynes To mitigate, the CCG has Embedded QIPP schemes in Provider contract activity plans Included assumptions for population and demand growth within contract activity plans created a Demand Growth reserve In addition the CCG will be closely monitoring on a monthly basis against the plan and will use contractual levers to implement activity management plans in-year with providers were appropriate. 63 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 12. Sustainability & Finance The NHS continues to face a period of unprecedented change and financial challenge, thereby increasing the need for both commissioners and providers to deliver both improved productivity and quality, but also to ensure that resources are targeted as effectively as possible to maximise patient treatment and care. Milton Keynes Hospital Foundation Trust, the main acute provider, is seriously financially challenged and the main community & mental health provider is also under financial pressure. The CCG also incurred significant financial pressure during 2015-16 and whilst the draft accounts report delivery of the planned surplus for the year, this has required a number of measures including nonrecurrent interventions to achieve this position. Given the level of financial challenge across the whole system the financial strategy requires a whole system approach which aligns with the latest planning guidance from NHS England regarding STPs, to ensure sustainability and continuity of services for Milton Keynes residents. The updated planning guidance for CCGs was issued in December 2015, along with refreshed financial allocations to CCGs for the next five years. Milton Keynes has again benefited from a high level of growth in 2016-17 of £16.8m, however the % increase drops significantly during the next three years so it is important that this first year of the five year plan is a year of stability bringing the system back into financial balance. We have used the planning guidance to refresh the 5 Year Financial Plan. The strategic implications for the CCG of this are outlined below. The CCG has received a programme allocation of £295.6m in 2016-17 which includes £16.8m growth funding (6.01% uplift). The national average growth is 3.74%. Allocations for the next four years have also been announced (last two years indicative) although the uplift reduces significantly in future years. All CCGs have been brought within 5% of their target allocations. MK CCG is now within 3.93% away from its target allocation after growth in 2016-17. The running cost allocation remains at £5.9m, the same as 2015-16. There is a continued requirement to contribute part of this funding allocation to the system wide Better Care Fund (BCF). The total minimum contribution for 2016-17 is £14.392m After modelling the planning assumptions released in December the CCG anticipates a net QIPP target of £7.3m (2.5%) in its Programme Budgets in 2016-17 and the target over the next five years is £37m. The high level of growth in allocation funding has been more than offset by the underlying pressure brought forward from the previous year and additional planning requirements. There is a further £0.3m pressure in running costs. 12.1 PLANNING ASSUMPTIONS The following planning assumptions have been notified by NHS England and factored into the CCG plan: The CCG plans to deliver a 1% surplus on its budget 1% of the allocation has been set aside for non-recurrent reserves and 0.5% for general contingency Sufficient funding has been earmarked to ensure parity of esteem for mental health services at 6.01% growth. The actual growth over 2015-16 appears higher due to the slippage on in 2015-16 on parity of esteem investments. Funds have been re-instated for GP IT, Camhs national initiatives and PbR tariff uplift which were all funded through separate NHSE allocations in 2015-16 Total funding of £15m including social care grants will be pooled with the Local Authority in the Better Care Fund. 64 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 The national tariff assumptions are based on draft PbR guidance. These currently assume a general net 1.1% uplift in Provider tariffs and circa 1.8% uplift on average in the acute PbR tariffs. MRET for emergency admissions to continue at 70% rate, but budgeted for re-investment of any rebate. Plans also assume that the Re-admissions penalty will continue, although no other penalties have been planned for. Current arrangements for CQUIN to continue The activity plans include investment of £1.4m to meet the constitutional standards The running cost allocation has been maintained Local assumptions have also been built into the draft plans as follows:- CCG surplus from previous years will be made available to re-invest non-recurrently in the following year plan Population and demand growth has been estimated at on average 3.48% in the plan. The CCG has used local Council held population figures in line with the JSNA. These reflect a more accurate picture on the population growth for Milton Keynes. The population percentages have been modelled at patient level on hospital activity reflecting the differing growth levels for each specialty. Demand growth has been built into the activity plans for the main CCG providers, partly to meet backlog RTT targets. For other providers this is currently held in a demand reserve. No additional funds have been set aside for investments other than the national requirements identified above and the non recurrent Bedfordshire / Milton Keynes healthcare review. Prescribing growth assumed at 5% per annum plus 2.55% population growth Continuing Care growth is assumed at 8.37% Running cost pressures assumed at 2% mainly increases in staff NI costs. NHS Property service rent increases assumed to be cost neutral The net impact of the planning assumptions can be seen in the table below Key Planning Assumptions Notified Allocation Change (£'000) Notified Allocation Change (%) Tariff Change - Acute (%) Tariff Change - Non Acute (%) Demographic Growth (%) Non Demographic Growth - Acute (%) Non Demographic Growth - Cont.Care(%) Non Demographic Growth - Prescribing (%) Non Demographic Growth - Other Non Acute (%) Mental Health Parity of Esteem 2016/17 16,757 5.9% 1.7% 2.0% 1.8% 1.3% 1.5% 1.5% 1.1% 7.7% 2017/18 7,328 2.4% 0.9% 1.9% 2.3% 1.5% 1.5% 1.6% 1.4% 2018/19 8,519 2.8% 1.0% 2.1% 2.4% 1.5% 1.5% 1.5% 1.4% 2019/20 9,386 3.0% 1.1% 2.3% 2.2% 1.5% 1.5% 1.5% 1.5% 2020/21 15,291 4.7% 1.1% 2.5% 1.6% 1.5% 1.5% 1.5% 1.5% 12.2 FINANCIAL PLAN Based on the above planning assumptions the table below identifies the anticipated income and expenditure over the next five years and the more detailed schedule at Appendix C shows the changes year on year. 65 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Revenue Resource Limit £ 000 Recurrent Non-Recurrent Total Income and Expenditure Programme Costs Running Costs Contingency Total Costs £ 000 Surplus/(Deficit) In-Year Movement Surplus/(Deficit) Cumulative Surplus/(Deficit) % Surplus (RAG) 2015/16 blank1 2016/17 284,810 301,567 4,569 2,880 288,879 304,447 280,695 5,804 286,499 293,950 5,929 1,523 301,402 2015/16 1,867 2,880 1.0% AMBER 2016/17 165 3,045 1.0% GREEN 2017/18 308,895 3,045 311,940 2018/19 317,414 3,120 320,534 2019/20 326,800 3,206 330,006 2020/21 342,091 3,301 345,392 301,296 5,964 1,560 308,820 309,727 5,998 1,603 317,328 319,023 6,031 1,651 326,705 334,147 6,063 1,727 341,937 2017/18 2018/19 2019/20 75 3,120 1.0% GREEN 86 3,206 1.0% GREEN 95 3,301 1.0% GREEN 2020/21 154 3,455 1.0% GREEN The CCG forecasts delivery of the business rules in each year, although in order to achieve this there is a requirement for a significant QIPP target. This is despite the higher than average allocation growth. The CCG is still required to close a QIPP gap which equates to £7.3m in 2016-17 and £37m over the five year planning period. This is in part due to the underlying pressures brought forward from 2015-16 and also additional planning requirements for five years which include the following: Population and demand growth Requirement to deliver a 1% surplus Parity of esteem for mental health investment Requirement to hold aside funds for primary care IT & CAMHS previously funded separately The table below shows the source and application of the growth funds demonstrating that 6.4% of the total 6.01% growth is required to meet ‘must do’ policy pressures and tariff and demographic growth. In addition the local requirements to re-instate slippage on investments and reserves used in 2015-16 to support the bottom line create the QIPP requirement identified above. The CCG has incorporated no new recurrent investments in 2016/17 into its budget plans other than those required as part of QIPP or those nationally mandated. £m £m Source of Funds Programme & Running Cost Allocation Growth Application of Funds Camhs Investments GP IT Top up for 15/16 tariff Sub Total Mandated Investments 16/17 Tariff & Other Inflation Population & Demand Growth Top up surplus Sub Total Must Do Pressures Additional MH top up for Parity of Esteem Increase in Cquin on contracts Other Investments (mainly NR Beds / MK HCR) Reduce Reserves by 1% for 2016-17 Reverse Non Recurrent Benefits from Slippage / Use of Reserves in 15/16 Adjustment for Other Non Recurrent Allocations Gross QIPP Saving QIPP Investment Total Application of Funds 16.9 6.01% 2.0 0.71% 15.8 17.8 6.33% -0.9 16.9 6.01% 0.5 0.7 0.8 5.4 10.2 0.2 0.3 0.3 1.0 -2.7 7.4 0.3 -10.2 2.7 The bridge chart below further explains the movement between the 2015-16 outturn and the 2016-17 plan. This is also supported by a table reflecting the actual numbers in Appendix A 66 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Summary Financial Movements 2016/17 320 £ M's 310 8.6 4.6 1.4 0.3 300 290 280 10.2 0.3 1.5 2.7 0.2 7.2 0.3 7.4 304.5 289.4 2015/16 Plus Minus 2016/17 Category Within the above bridge the non recurrent adjustments relating to the prior year reflect the use of reserves, slippage on investments and non recurrent benefits against contracts that supported delivery of the bottom line surplus in 2015-16. The budgets affected can be seen more clearly in the bridge table at appendix C. Other than population and demand growth the investments planned in 2016-17 include: Camhs National Strategy NR Beds / MK Healthcare Review Project Running Cost growth Other £0.5m £0.8m £0.1m £0.1m The underlying surplus can also be seen in the 5 year plan table at Appendix C. This shows a 2.5% surplus for 2016-17 after accounting for the non recurrent reserves, this reduces to 1.9% for the remainder of the 5 years following the cessation of non recurrent investments for the Bedford/MK Healthcare review project and the CHC retrospective topslice. These benefits offset the recurrent pressures arising with the reduction in CCG allocations over these later years. 12.3 FINANCIAL RISKS AND MITIGATION This plan incorporates a number of risks which could impact on the financial position as follows: The plan assumes that the CCG will deliver its planned forecast outturn for 2015-16 based on the month 11 reports. If further non recurrent measures are required then this will impact on the underlying financial position rolling into 2016-17. The plan assumes that the CCG will deliver its surplus each year going forward and that this funding will be available non-recurrently in the following year. The plan assumes that the CCG will deliver its QIPP targets each year and that the further stretch targets to close the QIPP shortfall in 2016-17 can be mobilised into actions during the year. If activity and population growth vary from current assumptions then this could impact on the plan. A 10% variation in the assumptions equates to £970k. No allowance has been made for support to the financial pressures within the two main providers. It is assumed that a continued topslice will apply for the CHC provision in 2016-17 and that no further pressures will arise for retrospective reviews in year. 67 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 The plan assumes that the Better Care Fund plans will deliver the required shift in expenditure from Acute settings. The plan assumes that any changes as a result of co-commissioning will be cost neutral No allowance has been made to fund the continuation of the PMCF apart from the Paediatric nursing service. The plan assumes that the continued expansion of personal health budgets will be cost neutral as a minimum. Additional investments will need to be funded from funds set aside for activity and population growth or dis-investments elsewhere. It is assumed that the running cost pressures can be managed The mitigations against these risks include the following: The financial plan has been set based on outturn from the previous year, assuming existing pressures will continue and include assumptions for population and demand growth which will not be released in full at the start of the year The CCG has reached agreement of contracts with its two main providers for 2016-17 which include realistic activity plans and embed QIPP plans into those agreements. These are factored into the financial plan. For 2016-17 development of a number of the QIPP plans is well progressed and several pathway changes are in the latter stages of negotiation with providers. The overall QIPP target is just a 25% stretch on average delivery levels for previous years. The budgets for prescribing and continuing health care are based on outturn plus realistic growth levels at 7.55% and 8.37% respectively. A 2% QIPP saving have then been applied for prescribing. 12.4 FINANCIAL STRATEGY The financial plan during this year will focus on: Delivery of the financial requirements of the NHS planning guidance “Delivering the forward view” to ensure that there is a sustainable platform from which to move forward Develop local system medium term financial plans as part of the STP planning process Ensure real shift within year of resources from Secondary Care to Primary Care and Community Services Ensure parity of esteem for mental health expenditure is maintained Appropriate use of financial incentives within contracts in order to drive up quality of services (penalties will not be applied in line with new guidance). Aligning CQUINs to the CCG’s key priorities and programme objectives Development of new mental health funding mechanisms with the Provider in shadow form Agreeing an appropriate strategy for the commitment of and use of any Transformation Funds in a way that truly incentivises strategic change and improvement in the quality of services delivered Ensure that all providers have a demand management commitment i.e. that capacity is taken out as demand for services is reduced 68 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Ensure value for money from jointly commissioned funds and resources, particularly the BCF 12.5 QIPP PLAN 2015-2016 The financial plan indicates that the total difference between programme resources available and anticipated expenditure is £7.3m. This gap has been closed through the development of the CCGs QIPP Plan which includes a range of schemes across programme areas. In addition the CCG has a running cost pressure of £0.3m, so the total savings requirements are £7.5m (rounded). Based on the above financial planning assumptions the table below identifies a summary of the CCGs proposed QIPP Plan for the year. 69 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 CCG Ref Workstream No. Scheme Name Scheme Type UC4 Urgent Care Integrated Urgent Care Transformational Jul-16 548 194 354 UC10a Urgent Care Getting People Home - Discharge to Assess Transformational Jul-16 727 727 0 UC13a & UC12b UC13b Urgent Care Managing ED Demand Transformational Apr-16 44 0 44 Urgent Care SCAS contractual activity planning Transactional Apr-16 375 0 375 NEW QIPP Urgent Care Budget Fl exibilities - Resilience Transactional Apr-16 387 0 387 PC15 Care Pathway & Primary Care Ophthalmology Managed Care End to End Pathway of care - Trial Transformational Feb-16 1,671 1,283 388 Prescribing Transformational Apr-16 1,049 49 1,000 Apr-16 473 0 473 0 Care Pathway & Primary Care Start Date Gross Saving £000 Investment £000 Net Saving £000 NEW QIPP Care Pathway & Primary Care Non-acute Contracts Transactional PC10 Care Pathway & Primary Care Direct to Test Oscopies- Gastro PCOC Transformational Jul-16 55 31 24 PC30 Care Pathway & Primary Care Day Case to OP Shift Transformational Apr-16 33 8 25 PC34 Care Pathway & Primary Care Outpatient Procedures transfer to PCOCs Transformational Apr-16 47 23 24 LTC3a Care Pathway & Primary Care Community DVT pathway Transformational Aug-15 28 22 6 PC31 Care Pathway & Primary Care Respiratory - COPD including home oxygen Transformational Oct-16 188 38 150 NEW QIPP Care Pathway & Primary Care Diabetes Managed Care Pathway Transformational Oct-16 259 206 53 NEW QIPP Care Pathway & Primary Care Acute Deep Dive Plans Transformational Oct-16 1,000 0 1,000 NEW QIPP Care Pathway & Primary Care Rationalise Primary Care Initiatives Transactional Apr-16 549 0 549 NEW QIPP Care Pathway & Primary Care Funded Nursing care Transactional Apr-16 150 0 150 NEW QIPP Care Pathway & Primary Care Translation Contract Transactional Jul-16 15 0 15 NEW QIPP Care Pathway & Primary Care Out of Area Acute Contracts Transactional Apr-16 123 0 123 BCF Better Care Fund Better Care Fund Transformational Nov-15 1,050 0 1,050 CM25 Children, Young People & Maternity Children, Young People and Maternity Children, Young People & Maternity Children, Young People & Maternity Health Care Review Caring for Children Closer to Home Transformational Nov-15 403 116 287 PAU Tariff Transactional Apr-17 Childrens CHC Transactional Apr-16 90 0 90 LA Medical Certifi cates Transactional Apr-16 10 0 10 HCR Costs moved to capitation share Transactional Apr-16 222 0 222 ALL Baseline Budget Review Transactional Apr-16 470 Running Costs Transactional Apr-16 260 0 260 10,226 3,124 7,102 2,697 0 2,697 7,529 3,124 4,405 FRP03 NEW QIPP NEW QIPP NEW QIPP NEW QIPP 0 Corporate Total QIPP Target Transactional Transformational 0 470 41% 59% Each programme of work is overseen by a CCG Programme Board which includes a range of representatives from across the local health & social care economy in addition to CCG staff. These Boards will oversee projects from business case development, through monitoring and up to final evaluation. There are also lots of informal links with the consultants at MKFT. The QIPP is monitored on a monthly basis through the CDG which includes clinical representation and reports in to the CCG Board. The Directors also undertook several QIPP challenge events during 2015-16 and plan to do the same for 2016-17. Delivery of the QIPP schemes will be closely monitored on a monthly basis during 16/17 through the PMO. 70 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 A number of the QIPP schemes have well developed business cases so a full year of savings are anticipated. The greatest savings relate to the BCF and new community based services went live at the end of 2015 so it is anticipated that this will result in a reduction of acute emergency admissions. The CCG has just agreed an 18 month pilot managed care pathway for ophthalmology with Milton Keynes hospital. The service went live in February 2016. Joint work is also well progressed to transform urgent care services and the hospital has completed estate works in A&E to facilitate an integrated urgent care service. Negotiations are ongoing regarding the contractual terms for this service change. A further £1m will be saved through prescribing initiatives in 2016-17. A detailed phasing of how the QIPP is to be achieved across the schemes is shown in Appendix C. 71 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix A Milton Keynes CCG – 5 Year Outcome Ambitions Ambition 1 (E.A.1): Potential years of life lost from causes considered amenable to healthcare. Definition: Rate of potential years of life lost from causes considered amenable to healthcare. Numerator: Annual ONS avoidable mortality for England. Denominator: ONS mid-year population estimates of the relevant age group and gender. Baseline year: 2012 (Note that this is a Quality Premium indicator in 2015/16). E.A.1: Potential Years of Life Lost (PYLL) through Causes Considered Am enable to Healthcare PYLL from causes considered amenable to healthcare - persons (all ages) (OF 1a) (directly standardised) Indicator 2 3 4 5 6 7 8 9 10 11 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 1,865 1,847 1,828 1,810 1,792 2,964 2,984 2,805 2,441 2,669 Persons Females Males Planned Rate Years of life lost GP registered population 134,408 134,408 134,408 134,408 136,019 276,088 Rate 2,401 2,432 2,255 2,048 2,103 Years of life lost 2,232 2,253 2,416 2,137 2,114 GP registered population 1,782 1,837 1,933 1,805 1,675 Years of life lost 5,197 5,237 5,221 4,578 4,783 Rate National average CCG rank 2,400 133,566 133,566 133,566 133,566 135,309 137,834 Rate GP registered population 4,672 2,271 267,974 267,974 267,974 267,974 271,328 138,254 2,077 2,135 2,097 1,927 1,886 2,262 2,182 2,079 2,001 2,303 100 101 105 73 74 Comments: To achieve this element of the 2015/16 Quality Premium, the CCG must achieve a reduction of no less than 1.2% in the rate of potential years of life lost from amenable mortality between 2012 and 2015. 72 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Ambition 2 (E.A.2): Health-related quality of life for people with long-term conditions. Definition: Average health status (EQ-5D) score for individuals who identify themselves as having a long-term condition. Numerator: The sum of weighted EQ-5D values for all responses from people identified as having a long term condition. Denominator: The weighted count from all people identified as having a long term condition. Baseline year: 2012 Indicator 2011/12 2012/13 2013/14 Planned Rate 2014/15 2015/16 2016/17 2017/18 2018/19 75.5 75.8 76.1 76.4 76.7 Weighted EQ-5D values 1,592 1,576 1,463 1,396 Weighted responses 2,133 2,096 1,941 1,856 Total EQ-5D per 100 LTC patients 74.65 75.19 75.37 75.70 72.89 73.12 73.00 74.30 National average Comments: The data source for this indicator is the HSCIC website. 73 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Ambition 3 (E.A.4): Composite measure on emergency admissions. Definition: This is a composite measure of: Unplanned hospitalisation for chronic ambulatory care sensitive conditions. Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s. Emergency admissions for acute conditions that should not usually require hospital admission. Emergency admissions for children with lower respiratory tract infections. Numerator: Includes any admission matching the criteria in any of the 4 individual indicators published by the HSCIC. Denominator: The sum of population registered with each CCG’s practices, October 2013. Baseline year: 2012/13 Time period Actual 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Ambition 1,879 1,927 1,950 1,926 2,119 1,980 1,924 % Difference 2.9% The chart above plots the proposed trajectory to reduce the growth in emergency admissions. Data source: Levels of ambition tracker 74 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Ambition 4 (E.A.5): Patient experience of hospital care. Definition: Patient experience of hospital care, as reported by patients to the CQC inpatient survey. Numerator: Total number of ‘poor’ responses. Denominator: Total number of respondents to the survey questions. Baseline year: 2012 Time period Actual 2012 2013 2014 Ambition 145.8 130.0 144.2 138.6 % Difference 4.0% Comments: The latest available data places MKHFT in the top decile of providers based on ‘poor’ hospital experience. The planned rate will improve patient experience to the current national average by the end of 2018/19. Data source: Levels of ambition tracker 75 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Ambition 5 (E.A.7): Composite indicator comprised of i) GP Services ii) GP Out of Hours Definition: Rate of responses of either ‘fairly poor’ or ‘very poor’ experience across General Practice and Out of Hours services per 100 patients. Numerator: Total number of responses of either ‘fairly poor; or ‘very poor’ experience. Denominator: Total number of respondents to the survey questions. Baseline year: 2012 Time period Actual 2012/13 2013/14 2014/15 Ambition 9.8 10.9 11.0 % Difference 9.3 18.6% Data source: Levels of ambition tracker 76 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 National Target 1 (E.A.3): IAPT Roll-Out Definition: The proportion of people that enter treatment against the level of need in the general population i.e. the proportion of people who have depression and/or anxiety disorders who receive psychological therapies. Numerator: Total number of people who receive psychological therapies. Denominator: The number of people who have depression and/or anxiety disorders. 77 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Local Quality Premium Target: Quality Premium Local Measure 1 Please select a measure from the drop down below 12 - Circulation - % of patients returning to usual place of residence following hospital treatment for stroke Please describe the 'Other' measure - 1000 characters remaining. TRUE TRUE FALSE TRUE QP Local Measure 1 - Locally agreed target Please provide the agreed level of improvement - 422 characters remaining. TRUE Suggested target - 75% The available historical data shows that over the last 4 years the % value fluctuates. The last reported MK figure was 74.12%. The figure in 2012/13 appears to be an outlier; therefore the target of 75% is suggested due to the fact that the number of people related to this measure are very small (approximately 13 per month) and Milton Keynes are currently carrying out an end to end pathway review of Stroke services which will impact achievement. Historical data - Quality Premium Local Measure 2 Please select a measure from the drop down below 24 - Maternity - % of mothers who give their babies breast milk in the first 48 hours after delivery Please describe the 'Other' measure - 1000 characters remaining. TRUE TRUE FALSE TRUE QP Local Measure 2 - Locally agreed target Please provide the agreed level of improvement - 249 characters remaining. TRUE Suggested target - 75% The Average across 2014/15 for MK was 73% in MK. The England average in Q1 is 73%. England average for 2014/15 was 74% however, due to Q1 drop, 75% for MK is a stretch target as it is unclear if this was an anomaly or if this is a downward trend for 2016/17. Breastfeeding initiation has also been selected as a 2016/17 CQUINN measure to drive improvement amongst MK Providers. It is considered an important and relevant measure for the “young” population of Milton Keynes. Breastfeeding has a number of health related benefits for both mother and child and longer term health related conditions. Quality Premium Local Measure 3 Please select a measure from the drop down below 9 - Circulation - Circulation - Reported prevalence of hypertension on GP registers as % of estimated prevalence Please describe the 'Other' measure - 1000 characters remaining. TRUE TRUE FALSE TRUE QP Local Measure 3 - Locally agreed target Please provide the agreed level of improvement - 591 characters remaining. TRUE Suggested target - 12.5% Based on previous 5 years data the target for 16/17 is suggested as 12.5% - this is an ambitious target especially when the 15/16 figure is unknown at this time. The last 5 years for MK and England sees a minimal 0.2% for MK and 0.1% for England increase year on year. Historical Data: 2009/10 - 11.3% 78 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix B Milton Keynes CCG – 2016/2017 NHS Constitution Trajectories E.B.3 National Standard 92% Monthly Diff Tolerance >> 10% Incomplete Pathways < 18 weeks APRIL 8,881 MAY 8,731 JUNE 8,915 JULY 10,275 AUGUST 9,276 SEPTEMBER 9,048 OCTOBER 8,708 NOVEMBER 8,769 DECEMBER 8,706 JANUARY 8,367 FEBRUARY 8,327 MARCH 8,609 Total Incomplete Pathways % Incomplete Pathways < 18 weeks Total Incomplete Pathways % 9,516 93.3% 8,760 9,433 92.9% 9,318 93.7% 9,117 9,773 93.3% 9,452 94.3% 9,012 9,684 93.1% 10,831 94.9% 9,370 10,154 92.3% 9,779 94.9% 9,473 10,278 92.2% 9,475 95.5% 9,904 10,737 92.2% 9,135 95.3% 10,175 11,156 91.2% 9,142 95.9% 9,224 94.4% 8,904 94.0% 8,938 93.2% 9,275 92.8% Incomplete Pathways < 18 weeks 10,665 10665 10665 10665 10665 10665 10720 10720 10720 10780 10780 10780 Total Incomplete Pathways 11,587 11587 11587 11587 11587 11587 11587 11587 11587 11587 11587 11587 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.5% 92.5% 92.5% 93.0% 93.0% 93.0% 2014-15 RTT - The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period. 2015-16 2016/17 Plan % E.B.4 National Standard 1% Monthly Diff Tolerance >> 10% Number waiting > 6 weeks APRIL 31 MAY 42 JUNE 49 JULY 24 AUGUST 12 SEPTEMBER 19 OCTOBER 16 NOVEMBER 16 DECEMBER 29 JANUARY 41 FEBRUARY 28 MARCH 36 Total Number waiting % Number waiting > 6 weeks Total Number waiting % 3,762 0.8% 27 3,491 0.8% 3,768 1.1% 30 3,896 0.8% 3,884 1.3% 23 3,797 0.6% 3,752 0.6% 28 3,721 0.8% 3,420 0.4% 21 3,059 0.7% 3,635 0.5% 19 3,262 0.6% 4,047 0.4% 22 3,523 0.6% 4,021 0.4% 3,663 0.8% 3,633 1.1% 4,001 0.7% 4,099 0.9% 2014-15 2015-16 Diagnostics Test Waiting Times Number waiting > 6 weeks 2016/17 Plan Total Number waiting % E.B.6 National Standard 93% Monthly Diff Tolerance >> 10% 2014-15 SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY 444 463 521 510 567 445 502 556 475 490 546 531 588 476 525 633 93.9% 94.6% 95.6% 93.7% 93.5% 94.5% 95.4% 96.0% 96.4% 93.5% 95.6% 95.6% 571 517 585 645 650 578 571 Total number waiting Total number waiting Total number waiting Total number waiting National Standard 96% Monthly Diff Tolerance >> 10% Number waiting < 31 days Total number waiting % Number waiting < 31 days Total number waiting % Number waiting < 31 days Total number waiting % E.B.9 National Standard 94% Monthly Diff Tolerance >> 10% Number waiting < 31 days Total number waiting % Number waiting < 31 days Total number waiting % 2014-15 Cancer - 31 Day standard for subsequent cancer treatments -surgery 2015-16 Number waiting < 31 days 2016/17 Plan Total number waiting % E.B.10 National Standard 98% Monthly Diff Tolerance >> 10% Number waiting < 31 days Total number waiting % Number waiting < 31 days Total number waiting % 2014-15 Cancer - 31 Day standard for subsequent cancer treatments -anti cancer drug regimens 2015-16 Number waiting < 31 days 2016/17 Plan Total number waiting % E.B.11 National Standard 94% Monthly Diff Tolerance >> 10% Number waiting < 31 days Total number waiting % Number waiting < 31 days Total number waiting % 2014-15 Cancer - 31 Day standard for subsequent cancer treatments - radiotherapy 2015-16 Number waiting < 31 days 2016/17 Plan Total number waiting % E.B.12 National Standard 85% Monthly Diff Tolerance >> 10% Number waiting < 62 days Total number waiting % Number waiting < 62 days Total number waiting % 2014-15 Cancer - All cancer 62 day urgent referral to first treatment wait 2015-16 Number waiting < 62 days 2016/17 Plan Total number waiting % E.B.13 National Standard 90% Monthly Diff Tolerance >> 10% Number waiting < 62 days Total number waiting % Number waiting < 62 days Total number waiting % 2014-15 Cancer - 62 day wait for first treatment following referral from an NHS cancer screening service 2015-16 Number waiting < 62 days 2016/17 Plan Total number waiting % E.B.14 602 541 604 677 694 604 597 94.9% 95.6% 96.9% 95.3% 93.7% 95.7% 95.6% 670 577 577 625 585 577 577 670 670 625 620 641 640 700 620 620 720 93.3% 93.6% 93.1% 93.6% 93.8% 93.6% 93.1% 93.1% 93.1% APRIL 97 112 86.6% MAY 73 77 94.8% JUNE 83 86 96.5% JULY 90 93 96.8% AUGUST 88 92 95.7% SEPTEMBER 100 101 99.0% OCTOBER 139 142 97.9% NOVEMBER 104 107 97.2% DECEMBER 99 105 94.3% JANUARY 92 93 98.9% FEBRUARY 84 85 98.8% MARCH 87 89 97.8% 87 54 41 39 52 69 59 92 67 46 42 57 74 59 94.6% 80.6% 89.1% 92.9% 91.2% 93.2% 100.0% 70 70 70 61 56 67 57 57 50 59 57 52 75 75 75 65 60 70 60 60 53 63 60 55 93.3% 93.3% 93.3% 93.8% 93.3% 95.7% 95.0% 95.0% 94.3% 93.7% 95.0% 94.5% APRIL 94 98 95.9% 66 67 98.5% MAY 62 66 93.9% 58 58 100.0% JUNE 62 69 89.9% 68 69 98.6% JULY 69 71 97.2% 79 80 98.8% AUGUST 56 57 98.2% 70 70 100.0% SEPTEMBER 87 92 94.6% 91 92 98.9% OCTOBER 67 70 95.7% 76 77 98.7% NOVEMBER 72 72 100.0% DECEMBER 69 69 100.0% JANUARY 64 64 100.0% FEBRUARY 78 80 97.5% MARCH 68 70 97.1% 64 60 64 80 70 84 74 70 69 64 79 70 65 60 65 80 70 85 75 70 70 65 80 70 98.5% 100.0% 98.5% 100.0% 100.0% 98.8% 98.7% 100.0% 98.6% 98.5% 98.8% 100.0% APRIL 14 15 93.3% 6 6 100.0% MAY 10 10 100.0% 17 17 100.0% JUNE 11 12 91.7% 20 22 90.9% JULY 9 10 90.0% 18 18 100.0% AUGUST 14 14 100.0% 7 7 100.0% SEPTEMBER 12 13 92.3% 14 15 93.3% OCTOBER 8 8 100.0% 10 10 100.0% NOVEMBER 9 9 100.0% DECEMBER 11 11 100.0% JANUARY 10 10 100.0% FEBRUARY 17 17 100.0% MARCH 14 14 100.0% 8 19 24 18 8 16 10 15 10 12 15 15 8 20 25 18 8 16 10 15 10 12 15 15 100.0% 95.0% 96.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% APRIL 44 44 100.0% 26 26 100.0% MAY 20 20 100.0% 38 38 100.0% JUNE 18 18 100.0% 9 10 90.0% JULY 23 23 100.0% 24 24 100.0% AUGUST 41 41 100.0% 26 26 100.0% SEPTEMBER 6 6 100.0% 29 29 100.0% OCTOBER 31 31 100.0% 32 32 100.0% NOVEMBER 20 20 100.0% DECEMBER 8 8 100.0% JANUARY 32 32 100.0% FEBRUARY 35 35 100.0% MARCH 21 21 100.0% 25 35 40 35 35 30 35 35 25 25 30 20 25 35 40 35 35 30 35 35 25 25 30 20 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% APRIL 30 36 83.3% 23 23 100.0% MAY 28 28 100.0% 16 18 88.9% JUNE 41 41 100.0% 14 14 100.0% JULY 13 20 65.0% 29 30 96.7% AUGUST 24 24 100.0% 27 28 96.4% SEPTEMBER 11 12 91.7% 25 26 96.2% OCTOBER 18 18 100.0% 21 21 100.0% NOVEMBER 13 13 100.0% DECEMBER 20 20 100.0% JANUARY 11 12 91.7% FEBRUARY 17 17 100.0% MARCH 18 18 100.0% 24 19 15 29 28 24 20 19 19 15 19 19 25 20 15 30 28 25 20 20 20 15 20 20 96.0% 95.0% 100.0% 96.7% 100.0% 96.0% 100.0% 95.0% 95.0% 100.0% 95.0% 95.0% APRIL 42 51 82.4% 33 39 84.6% MAY 27 32 84.4% 23 33 69.7% JUNE 29 37 78.4% 32 39 82.1% JULY 28 34 82.4% 32 39 82.1% AUGUST 22 32 68.8% 36 45 80.0% SEPTEMBER 40 45 88.9% 53 56 94.6% OCTOBER 29 35 82.9% 31 37 83.8% NOVEMBER 39 45 86.7% DECEMBER 28 31 90.3% JANUARY 26 37 70.3% FEBRUARY 38 43 88.4% MARCH 36 40 90.0% 40 32 41 40 41 47 29 39 29 37 36 41 46 37 48 47 47 55 33 45 33 43 42 47 87.0% 86.5% 85.4% 85.1% 87.2% 85.5% 87.9% 86.7% 87.9% 86.0% 85.7% 87.2% APRIL 12 13 92.3% 2 2 100.0% MAY 10 11 90.9% 4 5 80.0% JUNE 6 7 85.7% 2 2 100.0% JULY 7 7 100.0% 8 8 100.0% AUGUST 5 5 100.0% 5 6 83.3% SEPTEMBER 6 7 85.7% 10 10 100.0% OCTOBER 4 4 100.0% 6 6 100.0% NOVEMBER 3 3 100.0% DECEMBER 10 11 90.9% JANUARY 5 5 100.0% FEBRUARY 5 5 100.0% MARCH 2 2 100.0% 7 8 7 7 6 8 6 5 10 7 7 5 7 8 7 7 6 8 6 5 10 7 7 5 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% JUNE AUGUST SEPTEMBER 1 1 100.0% OCTOBER NOVEMBER 0 1 0.0% DECEMBER 1 2 50.0% JANUARY 1 1 100.0% FEBRUARY 1 1 100.0% MARCH 1 1 100.0% 1 1 100.0% JULY 1 1 100.0% 1 1 100.0% 1 1 1 1 APRIL 2 2 100.0% MAY Number waiting < 62 days 1 1 % 577 620 93.1% 10% Number waiting < 62 days Total number waiting % Number waiting < 62 days Total number waiting % Total number waiting 655 620 93.1% None 2016/17 Plan 600 720 Monthly Diff Tolerance >> 2015-16 600 605 93.1% National Standard 2014-15 Cancer - 62 day wait for first treatment for cancer following a consultant's decision to upgrade the patients priority MARCH AUGUST 521 % 2016/17 Plan 1.0% JULY 10% Number waiting < 2 weeks Total number waiting % 2015-16 37 3757 1.0% 502 % Cancer - Percentage of patients receiving first definitive treatment within 31 days of a cancer diagnosis. 36 3667 1.0% 480 93% 2014-15 33 3330 1.0% JUNE Number waiting < 2 weeks E.B.8 33 3357 1.0% 480 Monthly Diff Tolerance >> 2016/17 Plan 36 3686 1.0% 454 National Standard 2015-16 34 3424 1.0% MAY Number waiting < 2 weeks Cancer - Two week wait for breast symptoms (where cancer not initially suspected) 31 3171 1.0% 526 % 2014-15 29 2973 1.0% 494 Number waiting < 2 weeks E.B.7 36 3617 1.0% APRIL % 2016/17 Plan 36 3691 1.0% Total number waiting Number waiting < 2 weeks 2015-16 36 3787 1.0% Number waiting < 2 weeks % Cancer- All Cancer two week wait 33 3393 2 2 100.0% 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 79 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Milton Keynes CCG – 2016/2017 NHS Other Requirements Trajectories E.A.S.1 Dementia - Estimated diagnosis rate National Standard 66.7% Monthly Diff Tolerance >> 10% APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH Number of People diagnosed (65+) 1447 1447 1447 1450 1450 1450 1453 1453 1453 1456 1456 1456 2,168 66.74% 2,168 66.74% 2,168 66.74% 2,168 66.88% 2,168 66.88% 2,168 66.88% 2,168 67.02% 2,168 67.02% 2,168 67.02% 2,168 67.16% 2,168 67.16% 2,168 67.16% 2016-17 Plan Estimated dementia prevalence (65+ Only (CFAS II)) % E.A.3 National Standard 3.75% Quarterly Diff Tolerance >> 5% The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders (local estimate based on Adult Psychiatric Morbidity Survey 2000). Quarter 1 Quarter 2 Quarter 3 825 775 885 1,250 26,724 26,724 26,724 26,724 % per quarter (e.g. 3.75%) The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders (local estimate based on Adult Psychiatric Morbidity Survey 2000). 3.09% 2.90% 3.31% 4.68% 890 1,050 - - 26,724 26,724 % per quarter (e.g. 3.75%) 3.33% 3.93% 2014-15 IAPT Access - Roll Out 2015-16 2016-17 Plan E.A.S.2 Quarter 4 The number of people who receive psychological The number oftherapies people who have depression and/or anxiety disorders (local estimate based on Adult Psychiatric Morbidity Survey 1003 1003 1003 1003 26724 26724 26724 26724 % per quarter (e.g. 3.75%) 3.75% 3.75% 3.75% 3.75% Quarter 1 Quarter 2 Quarter 3 Quarter 4 160 195 145 140 National Standard 50% Quarterly Diff Tolerance >> 20% The number of people who have completed treatement having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved 'caseness' and at final session did not) 2014-15 The number of people who finish treatement having attended at least two treatment contacts and coded as discharged) minus (The number of people who finish treatment not at clinical caseness at initial assessment) % The number of people who have completed treatement having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved 'caseness' and at final session did not) 435 485 480 405 36.78% 40.21% 30.21% 34.57% 190 175 2015-16 IAPT Recovery Rate The number of people who finish treatement having attended at least two treatment contacts and coded as discharged) minus (The number of people who finish treatment not at clinical caseness at initial assessment) % The number of people who finish treatement having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved 'caseness' and at final session did not) 445 385 42.7% 45.5% - - 94 94 94 94 2016-17 Plan The number of people who finish treatement having attended at least two treatment contacts and coded as discharged) minus (The number of people who finish treatment not at clinical caseness at initial assessment) % 187 187 187 187 50.3% 50.3% 50.3% 50.3% Mental Health Access E.H.1 - A1 The proportion of people that wait 6 weeks or less from referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period. National Standard 75% Quarterly Diff Tolerance >> 10% 2016-17 Plan Quarter 1 Quarter 2 Quarter 3 Quarter 4 The number of ended referrals that finish a course of treatment in the reporting period who received their first treatment appointment within 6 weeks of referral 141 141 141 141 The number of ended referrals that finish a course of treatment in the reporting period. 1 187 187 187 187 75.4% 75.4% 75.4% 75.4% % E.H.2 - A2 The proportion of people that wait 18 weeks or less from referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period. National Standard 95% Quarterly Diff Tolerance >> 10% 2016-17 Plan Quarter 1 Quarter 2 Quarter 3 Quarter 4 The number of ended referrals that finish a course of treatment in the reporting period who received their first treatment appointment within 18 weeks of referral 178 178 178 178 The number of ended referrals who finish a course of treatment in the reporting period. 1 187 187 187 187 95.2% 95.2% 95.2% 95.2% % National Standard E.A.S.5 HCAI measure (C.Difficile infections) Monthly Diff Tolerance >> None 10 2014-15 2015-16 2016-17 Plan APRIL 7 8 5 MAY 11 7 5 JUNE 4 5 5 JULY 2 4 5 AUGUST 9 3 5 SEPTEMBER 5 6 5 OCTOBER 11 5 5 NOVEMBER 8 8 5 DECEMBER 8 JANUARY 5 FEBRUARY 6 MARCH 7 5 5 5 5 Total 83 46 60 80 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix C Milton Keynes CCG – 5 Year Financial Plan Revenue Resource Limit £ 000 Recurrent Non-Recurrent Total Income and Expenditure Acute Mental Health Community Continuing Care Primary Care Other Programme Primary Care Co-Commissioning Total Programme Costs Running Costs Contingency Total Costs £ 000 Surplus/(Deficit) In-Year Movement Surplus/(Deficit) Cumulative Surplus/(Deficit) % Surplus (RAG) 2015/16 blank1 2016/17 284,810 301,567 4,569 2,880 289,379 304,447 Contingency Contingency % Contingency (RAG) Notified Running Cost Allocation + Quality Premium Running Cost Under / (Overspend) Running Costs (RAG) Population Size (000) Spend per head (£) 2018/19 317,414 3,120 320,534 2019/20 326,800 3,206 330,006 2020/21 342,091 3,301 345,392 160,243 26,979 20,438 15,104 41,426 16,505 280,695 165,831 29,176 23,017 17,058 43,093 15,775 293,950 170,429 31,611 25,284 18,444 45,603 9,925 301,296 178,663 34,191 26,322 19,961 48,989 1,601 309,727 186,945 36,833 27,366 21,674 52,524 (6,319) 319,023 194,472 39,381 28,320 23,386 55,883 (7,295) 334,147 5,804 5,929 5,964 5,998 6,031 6,063 - 1,523 1,560 1,603 1,651 1,727 286,499 301,402 308,820 317,328 326,705 341,937 2015/16 1,867 2,880 1.0% AMBER 2016/17 165 3,045 1.0% GREEN Net Risk/Headroom Risk Adjusted Surplus/(Deficit) Cumulative Risk Adjusted Surplus/(Deficit) % Risk Adjusted Surplus/(Deficit) (RAG) Underlying position - Surplus/ (Deficit) Cumulative Underlying position - Surplus/ (Deficit) % 2017/18 308,895 3,045 311,940 2017/18 2018/19 2019/20 75 3,120 1.0% GREEN 86 3,206 1.0% GREEN 95 3,301 1.0% GREEN 2020/21 154 3,455 1.0% GREEN 3,045 1.0% GREEN (940) -0.3% 7,558 2.5% 6,025 2.0% 6,164 1.9% 6,315 1.9% 6,602 1.9% 0.0% 1,523 0.5% GREEN 1,560 0.5% GREEN 1,603 0.5% GREEN 1,651 0.5% GREEN 1,727 0.5% GREEN 6,474 5,804 670 GREEN 266 21.82 5,929 5,929 GREEN 269 22.07 5,964 5,964 GREEN 272 21.91 5,998 5,998 GREEN 276 21.75 6,031 6,031 GREEN 279 21.60 6,063 6,063 GREEN 283 21.46 81 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix C 2015-16 to 2016-17 Bridge Description MKUHFT OTHER ACUTE SCAS 2015-16 Recurrent FOT before CQUIN 121,855 29,794 8,594 2015-16 2015-16 Recurrent Recurrent FOT FOT before before CQUIN CQUIN 1,283 123,137 -17 29,777 -189 8,405 -2,425 -584 -166 4,547 1,087 257 0 400 0 1,819 228 124 Mental Health Investment top up £000 2,401 0 301 0 164 0 Efficiency Savings £000 Provider Infl £000 Other Changes £000 Activity Growth £000 Population growth £000 Total Before CQUIN £000 Contract top up QIPP CQUIN £000 Total Budget £000 -4,155 -178 -375 617 0 0 125,941 31,032 8,410 236 54 8 126,176 31,086 8,418 160,243 1,077 161,319 -3,175 5,891 400 2,171 2,866 0 -4,708 617 165,383 298 165,680 CNWL CONTRACT OTHER MH PARITY OF ESTEEM RESERVE CAMHS INCL CNWL LEARNING DISABILITY 19,744 206 171 2,448 3,903 -64 5 317 -56 -59 19,680 211 488 2,392 3,843 -384 -4 -10 -47 -29 595 7 15 72 119 0 0 0 456 0 281 0 0 35 36 370 0 0 46 91 0 0 354 0 0 0 0 0 0 0 200 0 -200 0 0 20,742 213 648 2,954 4,061 12 0 0 11 0 20,754 213 648 2,965 4,061 TOTAL MENTAL HEALTH 26,473 142 26,615 -473 808 456 351 507 354 0 0 28,619 23 28,642 CNWL CONTRACT OTHER CHILDRENS SERVICES OTHER COMMUNITY (INCL BCF) TOTAL COMMUNITY 13,485 216 10,159 23,860 273 33 445 751 13,758 249 10,604 24,611 -269 -5 -360 -634 417 8 575 999 0 3 0 3 194 0 187 381 256 0 284 540 0 0 0 0 0 106 727 833 319 0 0 319 14,675 360 12,017 27,052 17 0 2 19 14,691 360 12,019 27,071 ADULT CHC CHILDRENS CHC FUNDED NURSING CARE (FNC) TOTAL CHC 12,421 675 2,008 15,104 649 222 0 871 13,070 897 2,008 15,975 0 -2 -6 -7 405 28 62 495 0 -3 0 -3 196 12 30 238 493 31 76 599 0 0 0 0 0 -90 -150 -240 0 0 0 0 14,164 873 2,020 17,057 0 0 0 0 14,164 873 2,020 17,057 6,011 35,415 487 -108 6,499 35,307 -116 0 179 1,235 0 0 0 530 0 900 0 0 -347 -1,094 0 0 6,215 36,878 0 0 6,215 36,878 TOTAL PRIMARY CARE 41,426 379 41,805 -116 1,415 0 530 900 0 -1,441 0 43,093 0 43,093 OTHER COMMISSIONING OTHER CLINICAL RUNNING COSTS RESERVES NON RECURRENT PROGRAMMES QIPP GAP 1% SURPLUS TOTAL OTHER PROGRAMMES 5,332 3,033 1,424 3,799 0 0 2,880 16,469 224 -200 216 3,825 0 0 0 4,066 5,556 2,834 1,641 7,624 0 0 2,880 20,535 -111 -6 -12 0 0 0 0 -128 172 21 39 0 0 0 0 232 0 -1,000 0 -2,699 1,375 0 165 -2,159 0 0 0 498 0 0 0 498 0 0 0 658 0 0 0 658 0 0 0 0 0 0 0 0 -681 -387 49 0 -222 -470 0 -1,712 0 0 0 -950 0 0 0 -950 4,936 1,462 1,717 5,131 1,153 -470 3,045 16,974 0 0 0 0 0 0 0 0 4,936 1,462 1,717 5,131 1,153 -470 3,045 16,974 283,575 7,285 290,860 -4,533 9,841 -1,303 4,171 6,070 354 -7,269 -14 298,178 340 298,518 5,804 124 5,928 -71 101 231 0 0 0 -260 0 5,929 0 5,929 289,379 7,409 296,788 -4,604 9,942 -1,072 4,171 6,070 354 -7,529 -14 304,107 340 304,447 TOTAL ACUTE PRIMARY CARE PRESCRIBING TOTAL PROGRAMME BUDGETS RUNNING COSTS TOTAL ALLOCATION 82 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix C Milton Keynes CCG –QIPP Plan QIPP 2016/17 Local Scheme Name (over £0.5m) April May June July August Saving Profile (£000) Sept. Oct. Nov. Dec. Jan. Feb. March Total Transactional Productivity and Contractual Efficiency Savings Reduction in agency costs Contract Management Cease Primary Care Investments Sub Total Balance of Schemes under (£0.5m) (39) (43) (82) (39) (46) (85) (39) (46) (85) (28) (39) (46) (113) (29) (39) (46) (114) (29) (39) (46) (114) (29) (39) (46) (114) (29) (40) (46) (115) (29) (40) (46) (115) (29) (40) (46) (115) (29) (40) (46) (115) (29) (40) (46) (115) Balance of Schemes under (£0.5m) Total (71) (7) (12) (32) (18) (9) (149) (71) (7) (12) (32) (18) (9) (149) (71) (7) (12) (32) (18) (9) (1) (150) (1) (71) (7) (12) (32) (18) (9) (1) (151) (1) (71) (7) (12) (32) (18) (9) (1) (151) (1) (71) (7) (12) (32) (18) (9) (1) (151) (2) (71) (8) (13) (32) (19) (9) (1) (155) (2) (72) (8) (13) (32) (19) (9) (1) (156) (2) (72) (8) (13) (32) (19) (10) (1) (157) (2) (72) (8) (13) (32) (19) (10) (1) (157) (2) (72) (8) (13) (32) (19) (10) (1) (157) (2) (72) (8) (13) (34) (19) (10) (1) (159) (260) (473) (549) (1,282) (15) (857) (90) (150) (386) (222) (112) (10) (1,842) Transactional Productivity and Contractual Efficiency Savings (231) (234) (235) (264) (265) (265) (269) (271) (272) (272) (272) (274) (3,124) (61) 20 (81) 81 (34) 10 (7) (25) (88) (61) 22 (81) 81 (34) 10 (7) (25) (88) (61) 22 (81) 81 (34) 10 (7) (25) (88) (167) (9) (87) 4 (442) (33) 5 2 (4) (30) (61) 22 (81) 81 (34) 10 (7) (25) (88) (167) (9) (87) 4 (442) (33) 5 2 (4) (30) (61) 22 (81) 81 (34) 10 (7) (25) (88) (167) (9) (87) 4 (442) (34) (1) 6 2 (4) (31) (61) 22 (81) 81 (34) 10 (9) (25) (88) (167) (9) (87) 4 (444) (34) 6 2 (4) (30) (61) 22 (81) 81 (34) 10 (9) (25) (88) (167) (9) (92) 5 (448) (34) (1) 6 2 (4) (31) (548) 194 (727) 727 (403) 116 (88) (300) (1,050) (1,000) (53) (1,049) 49 (4,132) (337) (5) 92 22 (45) (273) (4,405) (7,529) Transformational Service Re-design and Pathway Changes Integrated Urgent Care Service Integrated Urgent Care Service Getting People Home - Discharge to assess Getting People Home - Discharge to assess Paediatric Community Nursing Team Paediatric Community Nursing Team Opthalmology Managed Care Pilot Opthalmology Managed Care Pilot Better Care Fund Acute Deep Dive Variations Diabetes Managed Care Pathway Prescribing Initiatives Prescribing Initiatives Sub Total Balance of Schemes under (£0.5m) (29) 8 (7) (25) (82) (34) 8 (7) (25) (88) (34) 10 (7) (25) (88) (60) 20 (79) 79 (34) 10 (7) (25) (88) Balance of Schemes under (£0.5m) Total (87) 4 (218) (19) (1) 9 1 (3) (13) (87) 4 (229) (22) 9 1 (3) (15) (87) 4 (227) (24) (1) 9 2 (3) (17) (87) 4 (267) (28) 11 2 (4) (19) (87) 4 (268) (21) 11 2 (4) (12) (87) 4 (266) (22) (1) 11 2 (4) (14) (61) 22 (81) 81 (34) 10 (7) (25) (88) (165) (8) (87) 4 (439) (33) 4 2 (4) (31) Transformational Service Re-design and Pathway Changes (231) (244) (244) (286) (280) (280) (470) (472) (472) (473) (474) (479) (462) (478) (479) (550) (545) (545) (739) (743) (744) (745) (746) (753) Unidentified QIPP Total Unidentified QIPP Total QIPP Schemes 83 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix D Year 2015 Workstreams: Phase 1 Dec Jan Feb InternalProgramme Review (1) Scope, governance, ToR, structure, workstreams and resources for Acute Services confirmed Agree PID with all providers and inform Health Watch / HOSCs /HASSC Undergo strategic Sense Check with NHS England Agree SRO, Clinical Lead Mar Apr May Finalise outstanding tripartite reqm’ts Internal Programme Review (4) Checking PCBC progress; 3-month Benefits Check Point Joint Committee Milestone Gear up for Assurance Programme plan with Programme Board Deadline for papers Jul Internal Programme Review (3) Alignment of MK CCH and Acute Services strategies and plans in advance of PCBC; ready to implement short-term delivery Internal Programme Review (2) Baseline information confirmed; working grous established for CCH and Acute Services Revised Governance structure Go live Implement ToR and Committee membership Jun Joint MK/B CCG Progress Review Alignment of MK and Bedford Acute Services strategies and plans in advance of PCBC Phase 2 Joint MK/BCCG Programme Board Review Sign off Programme Next Steps, Joint Governance and Resource Plan Programme Governance 2016 Nov Present outcomes of Strategic Sense Check / Option Evaluation Soft launch of Programme Next Steps Tri-partite / NHSECheck Point meetings Joint MK/Beds Programme Board Meeting (monthly) H&WB Board(s) Deadline for papers Joint Executive Operational Meeting (monthly meetings) HASCC/JHOSC Deadline for papers Internal Programme Review at Programme Board (bi-monthly) Commissioning Delivery Group (strategic) MK CCG Board (bi-monthly) Deadline for papers Milton Keynes Hospital Board of Directors (bi-monthly) Deadline for papers Bedford Hospital Trust Board s (monthly) Bedford CCG Board (monthly) Deadline for papers Deadline for papers OGC Review – Gateway 3 OGC Review – Gateway 0 Legal Review Procurement of supporting work required To discuss scope, • Integrated Impact governance, ToR, Assessment •structure, Health data analysis worksteams • Scenario Modelling and resources • Capital review • Transport study (refresh) Interim Report Under take Health data and activity analysis Patient Flows - Agreed Clinical Standards Clinical Model development Pre-consultation Report Duties Integrated Impact Assessment Sign off – Clinical Models 1. Intermediate Clinical Models \ Pathways / Choice / Personalisation 2. Detailed Clinical Model(s) Emergency Care -Task and Finish (tbc) Planned Care -Task and Finish (tbc) LTC -Task and Finish (tbc) Women and Children's -Task and Finish (tbc) Six Week Lead Time for Clinical Engagement* Specialised Services Surrounding Commissioner Decision-Making 1. 2. 3. 4. 5. 6. Specialised Services Clinical Sensitivity Analysis Outcomes / Benefits Training & Research Commissioner Duties Standards Clinical Senate Report Transport Study PTS & Ambulance Senate Council Recommendations Review Revised Protocols & Costs Confirm and Challenge Surrounding Provider Support - Letters Sustainability Narrative Financial Sensitivity Review Commissioner/Provider Boards Financial Capital Review Draft PCBC PCBC Preparation / Decision Making / Formal Consultation Report Strategic Context - Chapters Evaluation Criteria Transitional Costs Provider Boards Detailed Implementation Plan / Capacity Model / Costs Provider Boards Option Development - Chapters Regulator(s) / HMT Capital Letter of Comfort Option - Chapters Draft Submission Commissioner Decision on Option(s) Option Evaluation (Commissioner) Commissioner Boards HASCC/JHOSC Undergo strategic Sense Check with NHS England Joint Committee Approval Public Consultation Draft Detailed Consultation Plan Review identity/channels/messaging update to reflect joint programme Refresh C&E strategy Formal External Provider Engagement Commissioner Boards Strategy Communications & Engagement Update events IIA Support Pre-consultation engagement ‘relaunch’ – public events Ramp Up for Public Consultation Ongoing Comms & Engagement 09 84 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Appendix E Scheme Name Objective BCF allocation 16-17 24/7 Rapid Response team To prevent hospital admission £327,000 Appointment of two Consultant Geriatricians To support more complex patients in the community £157,000 Multi-Disciplinary Case Reviews To support more complex patients in the community £60,000 Extension of the Recuperation Pathway To ensure timely discharge from acute hospital care for patients not ready for £480,000 reablement Community Equipment To enable people to be more independent at home Alcohol Liaison Service To minimise hospital admission for people with alcohol problems by diverting to £50,000 community based services High Impact Team for Care Homes A specialist team to support care homes to manage more complex patients in the home rather than acute care £254,000 Community Dementia Service Funding for a scheme supporting GPs to diagnose dementia in primary care; improving post-diagnostic services e.g. carer support, community dementia £63,000 Community based falls prevention To reduce the incidence of falls in the older population, reducing hospital £98,000 admissions for people who have fallen and preventing re-admission Schemes previously funded through S256 Various schemes supporting protection of community and social care £3,130,000 Social Care Grants Disabled Facilities Grant and Other Social care Capital grants £871,000 Care Act Funding to support the implementation of the Care Act £528,000 £385,000 85 Enc No 16/22 Strategic Summary & Year 1 Operational Plan (v5) – 18th April 2016 Phased reduction in acute sector activity To support the acute care sector and the CCG whilst the new community £8,000,000 services above bed in. Inflation Reserve/ Contingency Funds set aside to cover inflationary increases / in year contingency Total 2016/17 £553,000 £14,956,000 86