paper d - NHS West Leicestershire CCG

Transcription

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

paper d - NHS West Leicestershire CCG

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