nhs oldham ccg strategic clinical commissioning plan 2014-2019
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NHS Oldham CCG Strategic Clinical Commissioning Plan 2014-2019. Contents. Contents. 1.Executive Summary. - PowerPoint PPT PresentationTRANSCRIPT
NHS Oldham CCG
Strategic Clinical Commissioning Plan
2014-2019
1
ContentsSection Contents Page
1 Executive Summary 42 Vision, approach and outcomes 6
3 Priorities for the CCG 31
4 Strategic transformation • Context• Our clinical change programmes• Delivering our Integrated Care Strategy • Wider primary care at scale• Better Care Fund• A step change in productivity of elective services• Specialised services concentrated in areas of excellence
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ContentsSection Contents Page
5 The Enablers• Communication and engagement –listening to patient views• IM&T• Workforce• Collaborative commissioning• Specialised services concentrated in areas of excellence
128
6 Maintaining the Essentials• Our approach to quality• Our approach to access• Our approach to innovation• Our approach to value and system management
171
7 Delivering Our Outcomes • Good governance• Our delivery model
214
8 Key References 2429 Appendices 245
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1.Executive SummaryAs a single CCG supported by 8 practice-based clusters, this plan sets out our intention to commission high quality services in an innovative, affordable and sustainable health system, whilst at the same time delivering improvements in health to the people of Oldham. The CCG has a strong local focus with clinicians and partnerships working together to provide and secure services to meet the needs of patients based on day to day experience, supported by evidence and intelligence. The clinical leadership of the CCG will make a real difference to the health of the population and their experience of healthcare. It will clearly place patients at the heart of all our discussions with providers of healthcare ,and our commissioning decisions.
This plan clearly sets out our vision, and our outcome ambitions, linked to the triple aim objectives, recognising the challenge of our current environment from a financial perspective, in the context of rising demand. Transformational change (the Quality, Innovation, Productivity and Prevention agenda) is required so that healthcare in Oldham is affordable, whilst providing excellent standards of service that the population rightfully expect. Clinical commissioning will enable Doctors, Nurses and other health and social care professionals in primary , community and secondary care, to become much more involved in planning improvements in services, than has previously been the case. The work described in this plan will be led by a senior team of clinicians, to ensure we achieve a sustainable health care system by working closely with our health and social care partners. The material presented is a result of extensive listening and engaging with clinicians, providers, patients and the public.
We will ensure that views of patients and the public are considered in all our commissioning decisions, and that meaningful public and patient engagement is embedded in the way we work. Over recent months, the CCG has actively sought the views of patients, the public and organisations in Oldham concerning our commissioning plans and intentions for the next 5 years.
The CCG will work collaboratively with Oldham Metropolitan Borough Council, Pennine Acute Hospitals NHS Trust, Pennine Care Trust, our smaller providers, and other CCG’s across the North East Sector/Greater Manchester footprint to improve care pathways and further develop integrated services. The Oldham Health and Wellbeing Board is a key forum for the CCG to work together with local commissioners from public health and social care, elected representatives and representatives from Healthwatch, to improve the outcomes of our local community and to reduce inequalities.
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Within this plan, we set out :• Our vision, approach and outcomes we are aiming to achieve• Our clinical priorities for the CCG which have ben determined in conjunction with our public health team based on
benchmarking data, the evidence base, patient feedback, and performance against key national constitution indicators• Our approach to strategic transformation with a particular focus on Wider Primary Care At Scale, Integrated Care, the Better
Care Fund and Healthier Together• Our approach to the enabling factors • Our approach to maintaining the essentials• Our approach to delivery
The main thrust of this strategy is based around the Primary Care Medical Home (PCMH) as part of the Care Vortex model (2006). We believe that in order to deliver year-on-year improvements in health inequalities we need to quicken the pace of change and the flow of investment towards Wider Primary Care At Scale. We wish to see more differentiation in traditional models of care and build on solid platforms of out of hospital services. Consistent with the Healthier Together Programme, the CCG believes that a strong, viable and coherent Primary Care sector will complement an equally strong, viable and sustainable acute and tertiary sector
This strategy has been pulled together to respond to the challenging and changing climate impacting on Health, and more general Public Services. The style and presentation of the material contained is primarily for a professional and organisational leadership audience, whether they be in the CCG, its member practices (organisations in their own right), supply partners, NHS England and colleagues in Local Authorities. A separate and complementary document is being prepared for public engagement. It is assumed that leaders in organisations are familiar with strategic, economic and planning concepts and this the material presented has deliberately not been diluted.
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2. Our vision, approach and outcomes
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Vision
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Our CCG VisionThe CCG’s vision is to improve health and healthcare for the people of Oldham, by
commissioning the highest quality healthcare in services near to the patient, in an integrated fashion and at the best value for money
Our Overarching AimTo become an authorised, Accountable Care Organisation that is
an alliance of GP practices which involves the whole multidisciplinary practice team. All members will share risk and
assume accountability for the resources used in enabling high quality care for the people of Oldham.
To achieve our triple aim objectives of:
Improving the health of the people of Oldham
Improving the care they receive and their experience of it
Delivering best value for money by using our resources effectively8
Our visionThe CCG’s vision is to improve health and healthcare for the people of Oldham, by commissioning the highest quality healthcare in services near to the patient, in an integrated fashion and at the best value for money
The development for our vision for health and social care in Oldham is centred on the concept of the ‘Oldham Family’ (see appendix 1) .Our vision for the Oldham Family is simple. We will change the balance of health and social care in Oldham so that patients receive the right care at the right time. Care will be closer to home, where that is the right place for them, and will be provided by the most appropriate person, whether that is a nurse, carer or friend.
People in Oldham will be independent, resilient and self-caring so fewer people reach crisis point. For those that need it, we will develop an integrated health and care system that enables people to proactively manage their own care with the support of their family, community and the right professionals at the right time in a properly joined up system. In a crisis, people in Oldham will know exactly what to do, who to contact, receive a rapid response and have their needs met in a completely organised, systematic and careful way.
This economy vision is underpinned by three key considerations;
• The ultimate key success factor will be for our people (our Oldham family) to tell us that they have seen a positive difference to the way in which contributors to their care are more organised, systematic and appreciative of their individual care requirements. This objective is embedded within our individual corporate strategies and corporate objectives. We have already started to invest in some core platforms for integration such as the re-procurement of community services, Clinical Director Programmes, a number of public health interventions such as our approach to affordable warmth and fuel poverty, and critically, the development of cluster based health and social care integration teams.
• Prevention and intervention also remains a key priority: and ensuring that an improved population health alongside a higher quality, more innovative and more productive health care system is delivered. This is an important principle to retain as the drive for greater control over resources should not compromise the vision for optimal care systems, including both the need to enable people to retain health status and the need to prevent avoidable exposure to interventions that add little or no health benefit. This will be aligned to the Public Health Investment Plan, to build a solid platform for intervention and prevention.
• Our local GPs will be at the centre of this system and will lead the changes necessary to deliver the future aspirations of the public. This new design will come from a shift of commissioning philosophy and practice from one which is geared around aggregated population-based services to one which is more individual, with personalised healthcare services as the norm.
This vision is aligned with, and connected to a number of key CCG strategies and approaches that drive the ambitions of the local area;
The Oldham Care Vortex places primary care at the centre of patient care and describes a way of transforming our thinking to move away from institutional care, with a move towards a managed system of service transformation. This places greater emphasis (including investment) on managing an increasing caseload within communities, closer to the patient. The model recognises international research and world-class managed care modelling and has guided the thinking, service modelling and service investment profiling in Oldham.
Our 5 year plan on a page describes our strategic transformation programme, the outcomes we are aiming to achieve, and the enablers that we will put in place to support the delivery of our plan. It also describes the process through which we will hold ourselves to account
Our principles
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The Oldham Care Vortex Model (2013)The Current & Emerging Landscape for Service Integration
Acute and Tertiary
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Subject to Significant
Re-Shaping
Healthier Together
PAHT Programme
GM CCG Association
Opportunities for Integrated Care Threats for Integrated CareResources & Investments
Managed Care
Coordinated Care
Approach
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About usThe NHS Oldham Clinical Commissioning Group operates with a clear focus on quality as its driving principle, by ensuring that clinical outcomes and quality are integral to all commissioning plans and decisions.
NHS Oldham Clinical Commissioning Group has evolved from the previous Commissioning for Oldham Practice Based Commissioning Consortia, and is broadly coterminous with Oldham Metropolitan Borough Council with a resident population of 220,000. The CCG covers an area of 35,174 acres and serves a registered population of 240,000. There are 46 Constituent GP Practices in the Clinical Commissioning Group, one of which is located in Tameside. The 46 practices are subdivided into 8 clusters, which support the CCG and practices in achieving their objectives, at a more local level.
Essential to the effectiveness of the CCG is clinical leadership, engagement and the individual professional accountability of all members of the Group. It is through these that transformational change will be enabled and a clear focus on continuous quality improvement in primary care and within all commissioned services will be established.
Signing of the membership agreement is open to all GPs on the performer’s list in Oldham. Members will become part of an accountable care organisation responsible for commissioning services for all people living within the Oldham Council area. They will also be considered to have signed up to the strategy, consulted on from March – May 2011, which sets out the CCG’s ambitious aims and the healthcare system it wants to develop to deliver.
Membership of the CCG will offer participating practices the opportunity to pool their budgets to share risks but also to influence, and where appropriate, participate in, new service delivery. The CCG wishes to foster innovation at a practice, or small group of practices level, and therefore reinvestment plans, where innovations are supported by robust business cases, will recognise these developments. The Dragons Den which ran in 2013 was a good example of this (see appendix 1).
To enable NHS Oldham CCG to deliver its vision of becoming an Accountable Care Organisation, supported by its members, a signed membership agreement is now in place with all participating GPs/practices. To ensure that CCG can achieve its vision, on behalf of its members, to become a truly accountable organisation delivering the best possible clinical outcomes for the population of Oldham, an assurance framework has been developed to measure compliance with the membership agreement. This approach will also support practices in providing evidence to support QOF indicator delivery, appraisal and revalidation and practice/CQC accreditation. The membership agreement has been jointly written by the CCG, LMC and a group of Oldham GPs who, at the AGM, volunteered to develop the Constitution and the assurance framework which is an integral part of it.
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The CCG commissions the majority of its acute services from Pennine Acute Hospitals Trust. The Trust is based across 4 sites, Fairfield, Oldham, North Manchester & Rochdale. The configuration has been reviewed by the Healthy Futures Programme, however is currently under review again, linked to the Trusts financial position, and the broader Greater Manchester Healthier Together strategy.
Mental health services are primarily provided by Pennine Care Foundation Trust, who also from the 1st April 2014, following the reprocurement of our community services, will also manage a large proportion of our community Services. The CCG has a track record of stimulating the market, and has a range of independent sector providers working within its footprint, to provide a range of different services.
The CCG has accepted the role to establish and build relationships with new and different organisations and consider the full range of perspectives, including those of patients and the public. A new more strategic, yet business focussed relationship with Oldham Metropolitan Borough Council (OMBC) is developing, building on the strengths within the Borough and the significant capabilities and altruism that exists between professionals from both social and health environments. There is a ‘One Borough’ movement building across Oldham and COG wish to see this develop further with the re-engineering of the Health and Wellbeing Board and the Joint Commissioning functions. The introduction of the Better Care Fund will accelerate this pace of change.
Other collaborative arrangements continue to develop, through the North East Sector Commissioning Board for the management of common providers (PAHT and PCFT) and the Association of Greater Manchester Governing Group linked to the Healthier Together Strategy.
The next three years are likely to be challenging ones for the population of Oldham as significant changes are made in the ways in which the public sector provides, and commissions healthcare services. It is likely that the population will remain with high levels of healthcare need and that deprivation levels will remain broadly similar. It is to be expected that many existing trends, including increases in life expectancy and the growth of the population of very elderly people, may continue.
The CCG are now fully influencing the commissioning process by understanding spend, where it is spent, and for what outcome. The CCG feel that the way to approach clinical commissioning moving forwards is clinical leadership applied to programme budget areas, to ensure clinical commissioning is established in a way that delivers enhanced services, experience and cost control.
In its first year of operation as a CCG, cost control has been demonstrated through the healthy financial position forecast, and the improving outcomes for the population, particularly in relation to elective and urgent care.
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Our core values have been developed from those of the NHS Constitution and reflect the internal culture we need to underpin our overarching aim and objectives •Commitment to Quality of Care – we strive to commission high quality care for health and well being that is individualised, appropriate, safe and effective. We assume accountability for the cost and the quality of the care that we commission•Respect and Dignity – we value diversity and recognise each person as an individual. We respect each individual’s aspirations and commitments and seek to understand their priorities and needs. We understand the importance of what others have to say and the importance of an honest dialogue about what we are and are not able to do.•Improving Lives – we work hard to improve the health of our population and their experiences of health care. We value excellence, professionalism, innovation and a commitment to service improvement and doing things better. •Listening and Engaging with Others – we find the time to listen and talk where it is needed and make every effort to understand the needs and perspectives of others. We welcome feedback, learn from our mistakes and build on our successes.•Working Together – we put our patients first and at the heart of everything we do. We will work across localities, organisations and sectors to best understand and meet their needs. •Everyone Counts – we will work to ensure that we use our resources to best meet the needs of the whole community. We accept that some need more help than others and that our resources are best used in addressing the highest levels of need. We recognise that every single community and staff member has a part to play in making our communities healthier.•Clinically Led – we are committed to the model of clinical leadership and engagement described in our constitution. We will continue to develop opportunities for clinicians to be further involved within CCG structures and decision making forums.•Being Responsible – we accept that we must work within the resources available and put these to best use for the people of Oldham. We will always strive to reduce costs and/or to improve productivity to get the best value we can without compromising care quality. We will recognise excellence but will also hold our providers to account for the care we commission from them.•Employer of Choice – although we will not directly employ many staff, we will seek to be a responsible employer. We will look after the health, safety and welfare of our staff whilst they are at work and seek to offer them learning and development to further improve clinical commissioning.
Our core values
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The development journeyThis strategic plan, is a key component of the Oldham CCG golden thread. It summarises the CCG’s strategic direction for the next 5 years, and describes the specific actions the CCG will take during 2014 – 2019, to make progress towards delivering its objectives and responding to the ‘Call to Action’. This plan will be reviewed and updated annually.
The development of this integrated commissioning plan has been taken account of a number of factors and key documents including:• CCG strategy to become an Accountable Care Organisation• CCG Integrated Care Strategy• CCG Wider Primary Care At Scale Strategy• Health and Wellbeing Strategy • CCG Business Plan • CCG Constitution and Membership Agreement • CCG Organisational Development plan • CCG Equality and Diversity strategy • CCG Quality Strategy • CCG Long Term Condition Strategy • CCG System Reform Strategy • CCG innovation strategy • CCG Communication and Engagement strategy • CCG System and Market Management Strategy • CCG Elective Care Strategy• CCG Managed Care Model• JSNA • CCG Clinical Commissioning plan 2012-2015• Oldham CCG Healthier together submission July 2013• Healthier Together standards of care• Greater Manchester Primary Care strategy
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The CCG will learn from and improve upon previous experience of planning, commissioning and delivery. The key opportunity lies within Primary Care Clinicians as micro and macro commissioner's. Micro in day to day prescribing, referrals and so forth, and macro in terms of population health. By bringing together these two roles there is opportunity to accelerate action, improvements and learning
This plan will be refreshed on annual basis in line with cycle outlined on the following page. The value and assurance process map illustrates where this document fits within the wider organisational context of the CCG, and the intention of this document as a core planning document.
Contributions to this strategy have been received from:
• The CCG membership• CCG Clinical Directors working in conjunction with partners (including providers) • CCG Governing Body members and supporting CCG internal infrastructure (including the CSU)• Patients and the public• Broader partnership forums e.g. Health and Wellbeing Board, NES Commissioning Board and the Integrated Commissioning
Partnership• Healthier Together Team• Greater Manchester Area Team
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Development Journey of the Strategic Plan
5 year CCG Strategic Plan
2 year delivery plan and prioritisation
Annual contract negotiations
Health & Wellbeing
Board Strategy
JSNA 2012
Annual Public health report
Commissioning for Value
Atlas of variation/
programme budget data
Clinical Director
Plans on a Page
Patient experience/
KPI data
Cluster ideas/ evidence from Dragon’s Den
Local CCG
strategy
Engagement with
• CCG Membership
• Health & Wellbeing Board
• Collaborative Commissioning Partners
• Public
• Patients
• Providers
Healthier Together
Greater Manchester
Primary Care Strategy
OMBC Integrated Commissioning
PlanProvider
Transformation Plans
Specialist Commissioning
Plans
External drivers
Internal drivers
Outcomes
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Our outcomesSince its beginnings as an aspirant GP Commissioning Consortium, and before that a PBC Consortium, the CCG has had a clear view on its intentions for the outcomes of clinical change programmes, in line with vision of the Oldham Care Vortex. This on-going work has created a body of knowledge, which has shaped our 5 year plan, taking into account our current landscape from the perspectives of population health, quality and economics, in line with our triple aim objectives.
Our 2-year plans have been clearly defined over the past 6 months, through the leadership of our Clinical Directors to deliver improvements in our triple aim objectives. Since the publication of the national outcome ambitions, these have been aligned to our triple aim objectives, as can be seen through our 5 year plan on a page. We see nothing different published in ‘Everyone Counts’ than was our initial ambition as a CCG, and the journey we are already on to achieve our strategic vision.
The CCG has been chosen as the unit of planning, though we will work collectively with our partners in the North East Sector and across Greater Manchester, where it makes sense to do so.
Levels of ambition have been consulted on with the clinical council, based on interventions currently planned, and benchmarking data provided by the public health team. We have designed our interventions and level of ambition based upon:• Current performance• Benchmarking data• Content of clinical programme plans• Commissioning for value packs• Public health outcomes framework• Local health profiles• PHE/NNSE a call to action: commissioning for prevention• JSNA• Areas from 2012 CMO report • New national strategies expected in 2014
The plans for improving outcomes have been aligned to findings from the above data sources, and the intentions of the Oldham Health and Wellbeing Board strategy. The Health and Wellbeing Board have been consulted on with regard to our clinical commissioning priorities and the level of ambition planned in relation to outcomes. The ambitions for national outcomes and local measures for the CCG strategic plan and the Better Care Fund, were the subject of a workshop with the HWBB on the 7 th February 2014.
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Improving health outcomes in alignment with the seven ambitions • Our CCG strategic plan has been based, since its inception, on delivery of the triple aim objectives, with a focus delivery on the NHS
outcomes framework and constitutional rights. This refresh of our 5 year plan describes how we will address through specific interventions, the specific ambitions of :– Securing additional years of life– Improving health related quality for people with long term conditions– Reducing amount of avoidable time spent in hospitals through better integrated care in the community– Increase proportion of older people living independently at home– Increase numbers of people having a positive experience of care within and external to hospitals (GP & Community)– Progress to eliminating deaths in hospitals caused by problems in care
Reducing health inequalities
• Health inequalities in Oldham still remain. The CCG is working with partners (including public health) to take action on the wider determinants of health, and take action with providers (including GP’s) to ensure inequalities are reduced. It is an expectation of Clinical Directors, that as they are developing their programme, that they plan service models that meet the needs of the diverse population and do not just adopt a one size fits all model. There is evidence of this approach already happening in relation to vascular disease, respiratory disease, diabetes and cancer screening.
• The new community service teams currently being designed, will wrap around the Primary Care Medical Home. These teams will be configured to address cluster specific needs based on the JSNA.
• The CCG and OMBC have has committed to producing a delivery plan to reduce health inequalities by the summer, building upon the work which is already taking place, and getting closer alignment between the clusters, district partnerships and the voluntary sector.
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Parity of esteem
• Parity of esteem is defined as making sure that we are just as focused on improving mental as physical health and that patients with mental health problems don’t suffer inequalities, either because of the mental health problem itself or because they then don’t get the best care for their physical health problems. Currently physical and mental health treatments tend to be viewed, and delivered, as separate health services. This means that people with poor mental health are more likely to have poor physical health that goes untreated, or treated too late and vice versa.
• Achieving parity of esteem is not just the role of the health and care services: it has implications for everyone in the local economy, such as local government, police, employers, and schools. In Oldham, we will consider how we can leverage the full range of resources to fund prevention priorities.
• The Parity of Esteem programme has identified three areas as initial priorities for urgent focus. These are IAPT, dementia, and areas within the Mental Health Capacity Act. This has been built into our clinical change programme - we are currently consulting with AQUA with regard to the potential of some tailored support
Delivering the essentials • Essential elements remain: Quality, Access, Innovation, Value For Money. Our approach to these fundamentals is described in detail within the strategic plan. • We recognise the value of minimum standards, and patients constitutional rights, and will work with our providers through contracts and partnerships to ensure that the CCG delivers
the highest standards for our patients. However we also recognise that quality goes beyond the minimum standards, and we will work through our Clinical Directors, to improve patient experience, health outcomes and quality of life of Oldham's diverse population, paying particular attention to under-served and marginalised groups.
• We will also pay specific attention to patient safety, continuing to work with providers to reduce health acquired infections, to ensure serious incidents are investigated and learnt from, and ensuring our safeguarding systems protect children and vulnerable adults.
Partnership working to support the improvement in the wellbeing of the population
• The citizens definition of health, is not always as we imagine it in healthcare. Health is not just about the absence of disease, but about people being able to do what they want to in their lives with joy and fulfilment.
• Asking people their views on health, thoughts include:
- being able to do what they want to do in the absence of pain
- combination of physical , psychological and environmental factors
- growing old without illness
-being able to go to events and participate in social activities they want to
- combination of mental and physical wellbeing ( not being a perfect specimen but being able to cope)
- having a positive mental attitude
• The stresses of life today brought about by factors such as relationships, the economic climate and the different pressures which technological advances have created, means we need to have a focus on personal resilience, to ensure the population can maintain a healthy life. There are clear links between a positive mental attitude and how people perceive their health. As part of 'Healthy Oldham', we are looking to develop a social marketing campaign support this ambition at cluster / district partnership level, working in conjunction with OMBC. The CCG feel this is essential to reduce the burden on health service resources in the future .
2,800
3,081
2,566 2,4662,355
2,249 2,148 2,051 1,959
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012(Baseline)
2014/15 2015/16 2016/17 2017/18 2018/19
Potential Years of Life Lost (PYLL) - Rate per 100,000 population)
PYLL per 100,000 National PYLL per 100,000 North West PYLL per 100,000 Oldham
68.7 70.3 70.6 70.9 71.5 71.9 72.0
0
10
20
30
40
50
60
70
80
2011/12 2012/13 Baseline 2014/15 2015/16 2016/17 2017/18 2018/19
Average EQ-5D score for people reporting having one or more long-term condition
Average EQ-5D score National Average EQ-5D score Oldham
2,685
3,0993,202 3,133
2,7702,583 2,491 2,435 2,416
0
500
1000
1500
2000
2500
3000
3500
2009/10 2010/11 2011/12 2012/13Baseline
2014/15 2015/16 2016/17 2017/18 2018/19
Emergency admissions composite - Rate per 100,000 population
Emergency admissions National Emergency admissions Oldham
124.1 122.0 120.0 118.0 116.0 114.0
0
20
40
60
80
100
120
140
160
2012 Baseline 2014/15 2015/16 2016/17 2017/18 2018/19
Poor inpatient care - negative responses per 100 patients
Negative responses per 100 patients National Negative responses per 100 patients Oldham
5.95.5
5.14.7
4.33.9
0
1
2
3
4
5
6
7
2012 Baseline 2014/15 2015/16 2016/17 2017/18 2018/19
Poor primary care - negative responses per 100 patients
Negative responses per 100 patients National Negative responses per 100 patients Oldham
Local Quality Premium Measure 2014/15
From the indicators below, achieving an increase from 37.5% to 39% of patients dying in their preferred place of death was chosen by the clinical council, though all of the indicators below will be given a focus as part of the Clinical Directors clinical change programmes.
• Patients dying in preferred place - Oldham 37.5 %. National 44.1% -39% trajectory
• Dementia-prescribed anti-psychotic medication – Oldham 13%. National 13%
• Total health gain assessed by Hip replacement patients – Oldham 0.440. National 0.439
• Stroke patients discharged with a joint health and social care plan- No measure yet
• People with diabetes diagnosed less than one year referred to structured education – indicator in development
• Bereaved carers’ views on the quality of care in the last three months of life – indicator in development
3. Priorities for the CCG
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Determining our prioritiesThe CCG has undertaken a formal SWOT analysis as part of the Integrated Care and ACO strategies from an organisational perspective. Whilst many opportunities are afforded through the latest planning framework, our main areas of risk remain:• Financial viability of our local acute provider• Financial landscape for our social care partners With regard to opportunities from a clinical programme perspective, clinical areas of focus remain from 2013/14, with the additions of neurological disease, accident prevention and chronic liver disease, which have been added to the elective and urgent care clinical programme areas. Themes were determined utilising data from:• Commissioning for value packs• Public health outcomes framework• Local health profiles• PHE/NNSE a call to action: commissioning for prevention• Areas from 2012 CMO report • New national strategies expected in 2014• JSNA• Patient views• Performance against national constitutional indicators
With regard to specific interventions, the CCG is now undertaking a process to define what are the specific changes that need to take place over the next 5 years within the broad description of the intervention. The 2-year change programme has been defined. There will be a formal prioritisation process led by our Clinical Directors, involving our membership and the public throughout the spring / summer to determine the 5-year priorities. This programme is built upon in part, the evidence within the commissioning for prevention document produced by NHSE.
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JSNA highlights
Projected change in Oldham’s population by age band, as apercentage of the 2010 Mid Year population estimates (2010-2022)
80%
90%
100%
110%
120%
130%
140%
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
0-15 16-44 45-64 65-84 85+
Forecast changes to the ethnic composition of Oldham’s population 2012-2025
75.4%
78.0%
79.0%
80.6%
10.2%
9.1%
8.7%
8.1%
9.2%
8.0%
7.5%
6.7% 4.6
4.8
4.9
5.3
0% 20% 40% 60% 80% 100%
2022
2017
2015
2012
White Pakistani Bangladeshi Other BME background
IMD rankings from the Indices of Deprivation 2010
Limiting long term illness or disability by ward
20.3%
25.5%
20.0%
19.5%
21.4%
20.8%
19.4%
18.5%
22.6%
23.0%
21.9%
19.1%
19.5%
15.5%
16.5%
18.5%
20.1%
18.1%
21.7%
20.4%
22.0%
0% 5% 10% 15% 20% 25% 30%
Oldham
Alexandra
Chadderton Central
Chadderton North
Chadderton South
Coldhurst
Crompton
Failsworth East
Failsworth West
Hollinwood
Medlock Vale
Royton North
Royton South
Saddleworth North
Saddleworth South
Saddleworth West and Lees
Shaw
St. James'
St. Mary's
Waterhead
Werneth
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Key facts relating to mortality• All age all cause mortality is higher than the England and north west average.
Inequalities remain high
• There has been a reduction in mortality for CVD over the last decade, though rates are still higher than the national average - risk factors in the population for CVD remain high in Oldham
• Stroke mortality rates for the under 75's are 33% higher than expected
• Cancer is the biggest cause of mortality for the under 75's for men and women in Oldham, and has not seen the same trends seen nationally and regionally
• Respiratory diseases are the third main cause of premature deaths.
• Lung cancer is the biggest cause of under 75 mortality from cancer for both men and women in Oldham
• The infant mortality rate is worse than the England average
• Only 34% of Oldham residents who died, died in their usual place of residence, and was the 37th lowest proportion of all PCTS in England in 2010
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Key population indicators
• There are high admission rates for CVD, mental health , COPD and alcohol conditions with differences in wards according to deprivation
• Compared to elsewhere in England , children's admissions are high, and has one of the highest admission rates for diabetes, asthma and epilepsy
• Compared to other areas Oldham has high rates of admission from nursing or residential homes
• Smoking is the single greatest cause of ill health with 27% of adults smoking compared to 20% nationally
• An estimate of 42,000 people aged 16 and over are drinking above levels considered low risk
• In 2011 only 11% of mothers had booked for antenatal care by 11 weeks of pregnancy
• There has been an increase in referrals by 29% for drug and alcohol problems in under 18 year olds
• Rates of teenage conception rates are still below the national target
• The number of people living with dementia is expected to increase by two thirds in 2030
• The CCG spends a high amount on prescribing when benchmarked against national indicators35
Public Health suggestions for Emerging / Refocusing of Priorities
A. Cutting across more than one of the 3 H&WBS themes
1. Long term condition prevention and management: • NHS Mandate priority objective - to ensure the NHS becomes dramatically better at
involving patients and their carers, and empowering them to manage and make decisions about their own care and treatment.
• Stronger emphasis on ‘every contact counts’ re risk factors• Need to move from silo LTC to looking at generic LTC issues and multiple co-
morbidities• Support to practices to get better with personalised care planning and supporting
patients to be true partners in care / self-management including shared decision making – explicit commitments in NHS Mandate regarding this
2. Neurological disease• 10% emergency admissions
• High social care burden• New national neurological strategy expected during 2014 to include emergency
access to specialist neurological opinions, community neuro MDTs, increase use of GPwSPI e.g. headache clinics
3. Mental health and well being• Interrelationship between mental and physical health and learning disabilities and
physical health• NHS Mandate objective is to put mental health on a par with physical health, and
close the health gap between people with mental health problems and the population as a whole.
• Implementation of learning disabilities needs assessment / SAF action plan• Implementation of CAMHS needs assessment • NB:- CMO report 2013 – focus on poor mental health health/wellbeing children• Extension of IAPT esp. for children
• Extending and ensuring more open access to the Improving Access to Psychological Therapies (IAPT) programme, in particular for children and young people, and for those out of work. NHS England has agreed to play its full part in delivering the commitments that at least 15% of adults with relevant disorders will have timely access to services, with a recovery rate of 50%.
• RAID 4. Accident prevention• Oldham has one of highest admission rates for injuries in country 5. Advocacy services• Advocacy services have been cut in recent years • The difficulty that vulnerable groups e.g. mental health, learning disabilities, dementia,
English as second language, have in accessing services contributes to health inequalities
B. Giving every child the best start in life 1. Review of SALT with focus on SLAT provision via play and education settings. 2. Consanguinity• H&WBB paper in Jan to recommend:
• Review genetics services for at risk individuals and families, including identification of affected child(ren), family tracing and proactive offer of counselling and testing. Consider making available a local specialist health visitor or midwife to provide dedicated support and advice to affected families and to encourage community advocacy relating to consanguinity.
• Look to offer training for health professionals, particularly primary care to increase confidence in discussing consanguinity related issues.
• Commission community activities which will raise genetic literacy and encourage uptake of universal and targeted prenatal, antenatal and early childhood services.
• Maximise the impact of prenatal, antenatal care and early years care and services through reviewing specifications relating to these services.
C. Living, Learning and Working Well
1. Fit to work programme• Support for small and medium sized businesses to keep people
with LTC and work related illnesses in work• Rapid access to rehabilitation services e.g. physiotherapy, OT• Rapid access to mental health services 2. Liver disease • Increasing mortality, higher than national average, linked to
alcohol 3. Cancer • Increasingly an outlier in lack of reduction in cancer mortality
D. Ageing Well and Later Life• NHS Mandate - objective is to pursue the long-term aim of the NHS being recognised globally as
having the highest standards of caring, particularly for older people and at the end of people’s lives. 1. Implementation of Vulnerable older adults plan (not yet published)• NHS Mandate priority 2. Malnutrition:• 1 in 10 over 65 malnourished, one of ten high impact changes; NICE identified 6th biggest saving to
NHS by implementing NICE nutritional support guidelines; NICE quality standards recently published • Increase dietetic support
• To provide training, mentoring and support for front line staff in primary, community, social care (social workers, day centres, domiciliary care, reablement services), carer services and voluntary sector organisations and local volunteers (e.g. community champions, peer health mentors) to understand causes of poor nutrition, early identification and management/prevention of malnutrition
• To advise and work with agencies who provide food for the elderly to ensure high nutritional standards are met (e.g. day centres, care homes, community cafes, home delivery services / meals on wheels)
• Clinical assessment and management of elderly who have been screened as malnourished / at high risk of malnutrition
• Support to carers via Carers services NB:- Public health investment plan proposed PH budget investment in luncheon clubs, ‘meals on wheels’, shopping services, peer health mentors
3. Rehabilitation/reablement:• MDT input to Medlock Court, Limecroft, LA reablement services • Community geriatrics• Increased community physio, OT etc.. to provide rehab not just aids and adaptations 4. Preventing Social isolation • Development of peer health and well-being champions for older people - Peer
support and advice regarding healthy living, accident prevention, good nutrition; Signposting and support to access leisure and community activities; Fostering of friendship groups
• Expansion of current befriending services and scheme to put people with like interests in touch with each other
• Intergenerational schemes• Specialist support to help community groups/services to develop their
services/activities to enable continued/enhanced access by frailer older people (e.g. use of libraries)
• Development of volunteer car transport schemes• Voluntary sector ‘hub’ for older people to which older people can be referred by
health and social care professionals for assessment and support to access above
5. Dementia • NHS mandate objectives – The Government’s goal is that the diagnosis,
treatment and care of people with dementia in England should be among the best in Europe. The objective for NHS England is to make measurable progress towards achieving this by March 2015, in particular ensuring timely diagnosis and the best available treatment for everyone who needs it, including support for their carers. NHS England have agreed a national ambition for diagnosis rates that by 2015 two-thirds of the estimated number of people with dementia in England should have a diagnosis, with appropriate post-diagnosis support
• Older person’s RAID,• Dementia friendly communities• Access to intermediate care, Respite care and care at home for inter-current
illnesses• Community mental health teams 6. Carers• Implementation of carers strategy• Carers advocacy services
Key themes from “Call to Action” engagement
• The need to reduce fragmented care for people with long term conditions• The need to make services more responsive and patient-focused• An increased expectation of patients’ involvement, both in their own care and in commissioning• A widespread understanding and acceptance that the NHS needs to change to be sustainable• Concern that key local services are protected • A 24/7 NHS with safe, effective care wherever and whenever I access it.• Timely access to services, especially same day access to primary care• Continuity of care, especially for patients with Long Term Conditions• Integrated, patient-centred health and social care• Shared decision making and good communication - clinicians who listen and tell me what¹s happening• Knowing that my views and experiences will be heard even though people don’t listen to people like me• Easy access, especially car parking/ and transport• Decisions based on my needs, not financial considerations
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NHS Constitution Performance
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CCG Outcomes and Local Priorities
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Oldham CCG has faced challenges in delivering some aspects of core performance in 2013/14, commissioning the majority of care for its population, from a large multi-site provider.
Performance at the end of quarter 4 2013/14 indicates that our main areas of focus need to be:
• Cancer waiting times• Patient experience• Mental health – IAPT intervention and recovery rates• Unplanned admissions• A&E 4 hour waits• Healthcare associated infections
Our approach to commissioning sets out our commitment to:• Deliver as a minimum, the national performance targets required through continuous quality improvement• Maintain excellent performance where this already exists
Addressing the improvement in performance of these indicators and others from the Operating Framework and the NHS outcomes framework, have formed a critical part of programme plans for our Clinical Directors.
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4. Strategic transformation
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A. Context
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Our strategic transformation plan for Oldham
We intend to change the balance of healthcare in Oldham so that patients receive care closer to home, where that is the right place for them. We will do this by working with clinicians from all settings, patients and the public , and will encourage innovation and the use of new technologies to trial new ways of working to meet patients needs. We will support clinicians to develop services, making the best use of their skills and expertise. This is also likely to affect the way in which we use our estate, and the way patients travel to healthcare. We will work with providers and patients to ensure changes are well managed and achieve the intended benefits.
Strategic transformation in Oldham will be achieved through it’s QIPP delivery programme, The framework of Quality, Innovation, Productivity and Prevention (QIPP) will ensure a coherent, patient-centred approach to the financial challenges that will be faced. The CCG recognises that improving quality and value for money go hand in hand and that the best performing systems also often have the lowest costs. A key platform to ensure quality continues to improve whilst delivering value for money is to unlock the productivity potential in the NHS. Innovation will be the basis upon which the most appropriate and evidence-based methods to improve quality and productivity will be identified and delivered. And finally, prevention remains a key priority: delivering improved population health alongside a higher quality, more innovative and more productive health care system. This is an important principle to retain as the drive for greater control over resources should not compromise the vision for optimal care systems, including both the need to enable people to retain health status and the need to prevent avoidable exposure to interventions that add little or no health benefit.
Previously demand, control and governance systems have focused on control of entry, throughput and exit. These control programmes were developed in an era dominated by NHS Trust supply systems and a relatively stable economic growth environment, concentrated on balancing demand and capacity. The onus now needs to shift to align with the concept of dynamic flow management, supported client choice, and best value clinical (optimal) decision-making.
The ambition for healthcare described in the new White Paper proposals is clear. A radically new healthcare system which will combine improvements in patient experiences, better health outcomes for these patients from healthcare providers, and better use of the available NHS resources. Our local GPs will be at the centre of this system and will lead the changes necessary to deliver the future aspirations of the public. This new design will come from a shift of commissioning philosophy and practice from one which is geared around aggregated population-based services to one which is more individual, with personalised healthcare services as the norm. In this future scenario, patients will have far more personalised healthcare choices, support to navigate the system, access to 24/7 care at the appropriate level and location, pro-active management of their conditions, with greater support and guidance to self care. There will be ‘no decision about me, without me’ where GPs and their practices will be the main patient advocate supporting and coordinating individualised care. This will build on the things that have been achieved, are of value and most significantly have been clinical led, such as the Core Vortex approach and the Clinical QIPP strategy (incorporating the work on allocative efficiency via Demand Governance) . The full QIPP strategy and tactical implementation plan is included within the System and Market Management Strategy.
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The existing provider landscape is made up of primary, community and intermediate, mental health, clinical assessment and treatment centres, acute and specialist providers, offering a range of health services to the local population of Oldham. The providers of these services are, as expected, predominantly NHS providers, with a small contingent of independent and voluntary sector providers. In relation to our providers’ performance and our strategic priorities, it is clear that the direction of provider and market development strategies need to take a different approach
The main thrust of this strategy is based around the Primary Care Medical Home (PCMH) as part of the Care Vortex model (2006). We believe that in order to deliver year-on-year improvements in health inequalities we need to quicken the pace of change and the flow of investment towards Wider Primary Care at Scale. We wish to see more differentiation in traditional models of care and build on solid platforms of out of hospital services. Consistent with the Healthier Together Programme, the CCG believes that a strong, viable and coherent Primary Care sector will complement an equally strong, viable and sustainable acute and tertiary sector
Supporting personalised commissioning for identified groups of people is a key priority to reduce health inequalities. The need for this is highlighted within the JSNA ward profiles , the service utilisation profiles and associated recommendations listed below• An increasing range of community-based health and wellbeing service options, tailored to local needs, particularly within primary care are
required. • Increased choice of high quality providers of care. Integrated systems supporting long term condition management, intermediate and urgent
care underpinned by a network of public buildings offering access to advanced technologies is required.• A strong and increasing focus on continuous quality improvement for all providers.• An outcome-based approach to commissioning and service delivery.
The latest Everyone Counts guidance describes 6 key features of transformational service models to deliver the 7 ambitions including:• An approach to ensuring citizens are fully included in all aspects of service design, and change, and fully empowered in their own care• Wider primary care, provided at scale• A modern model of integrated care• Access to the highest quality urgent and emergency care• A step change in the productivity of elective care• Specialised services concentrated in centres of excellence
We believe our existing strategies include these key features, are not new areas of development for us in Oldham. Our strategic plan addresses the specific intentions described within the Everyone Counts guidance of• Improving health, reducing health inequalities, move towards parity of esteem• Call To Action - creativity, innovation and transformation over 5 years to improve quality and to manage funding gap of £30 billion by 2020/21• Significant shift in activity and resource from the hospital sector to the community, supported by the Better Care Fund
As has already been described, he Oldham Care Vortex places primary care at the centre of patient care and describes a way of transforming our thinking to move away from institutional care and move towards a managed system of service transformation. This places greater emphasis (including investment) on managing an increasing caseload within communities, closer to the patient. The model recognises international research and world-class managed care modelling and has guided the thinking, service modelling and service investment profiling in Oldham.
Continuous quality improvement applied to core primary care-based condition management will form the platform by which the bar is raised on service quality and patient experience, and by which health inequalities and secondary demand are reduced. Systematic and industrial scale quality improvement will, over time, contribute to delivering the CCG strategy. An assurance framework has been established to manage and improve the performance of primary care teams across the borough. The diagram below demonstrates the new tactical delivery model which the CCG implement through its business processes.
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Whilst the CCG is not yet responsible for commissioning primary care service, the quality of primary care, in particular general practice is critical to success of the CCG. We have therefore:
• Developed an assurance framework which aligns QoF Quality and Productivity objectives through a series of indicators• Put in place a local forum dedicated to reviewing he quality of primary care providers, which has links to the Grater Manchester Area Team• Developed a support package for practices who are having difficulty in achieving their practice based objectives• Developed the role of clusters to support practice priorities such as CQC registration• Developed a Primary Care Market Development strategy which aligns with the Greater Manchester Primary Care Strategy
The role that practice clusters play, will determine the success of the CCG. An organisational development plan has been put in place to develop the role of the clusters for the future.
Cluster agendas have a focus on:
• Developing integrated health and social health care teams supporting the Long Term Conditions agenda. Each cluster will need a different composition of its multidisciplinary team, based on the health needs of the population. The make up of that team needs to be driven by the clusters with the new community service provider
• Service utilisation at ward level with the JSNA highlighting the differing needs of populations within Oldham• A focus on the quality improvement agenda within primary care, using the assurance framework as a tool • Innovation - Generating good ideas to influence the commissioning agenda • Looking at best practice from other clusters and assessing their application locally • Communication – understanding what’s going on within the CCG and wider • Improving data quality within primary care • Hot topics e.g. supporting CQC registration
The clusters have now been incorporated formally within our governance structure through our clinical council. This is forum for developing clinical strategy with our 8 cluster chairs, our clinical Governing Body members, our 10 Clinical Directors, and CCG Management Team.
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The challenge / opportunities Shorter waits and increased public expectation can drive supply-induced demand. Demographic trends relevant to this planning period indicate growth in the elderly population (and younger). Meanwhile, technological advancements enable people of all ages to live longer with severe, complex and multiple conditions than was previously possible. Both factors increase levels of health and social care needs and costs in the population.
Alongside the need to achieve greater value, is the imperative requirement to drive quality improvements in services from all providers, including primary care. The variation, particularly in relation to long-term condition management is a major contributory factor to the health inequality gap.
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B. Our clinical change programmes
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Our clinical change programmesThis strategy for clinical commissioning in Oldham, outlines how the CCG moving forwards, will manage clinical programme areas using a programme budget approach, under the leadership of Clinical Directors.
The CCG feel that the way to approach clinical commissioning is based on a programme budget with clinical leadership, via the Clinical Director role, applied to the programme budget area e.g. cancer, vascular, to ensure that clinical commissioning is established in a way that delivers enhanced clinical services, experiences and costs. There is significant opportunity to reduce unnecessary specialty (tariff based) activity which will lead to reduced cost and better care. A model that focuses on engaging clinicians, taking account of differing needs of the population, shared decision making, care coordination and improving the processes of care, will therefore be developed over the coming years.
The CCG has developed its ‘plan on a page’ which defines its priority transformation programmes for the next 5 years. Moving forwards,, the Clinical Director role will be two fold, firstly having a focus on the cross cutting priorities for the CCG including improving the quality of core primary care, and progressing quickly the integrated commissioning and health and wellbeing agenda with OMBC, and secondly, designing the clinical change programme which will harvest maximum value from a programme budget area.
Eleven Clinical Directors have been appointed so far, through a formal recruitment process. The Clinical Directors are held to account by the CCG Governing Body for the delivery of key performance indicators relating to the domains of the outcomes framework and wider, for their own clinical area. For 2 clinical areas, the CCG is also testing the idea that clinical quality and outcomes of a programme budget can be jointly managed by an integrated pathway hub / prime vendor and a Clinical Director (MSK and mental health).
The clinical priorities for 2014-2016 are outlined in this section. Strategic clinical areas for 14-16 were determined based on the JSNA from 2012, benchmarking data and priorities within the previous strategic commissioning plan (which were determined though a formal prioritisation process).
By following a standardized methodology, each Clinical Director has each determined their individual list of priorities for the next 2 years.
The slide overleaf describes the detailed delivery plan for the next 2 years. The programme specific intentions have been defined by the Clinical Directors in the amber boxes. Interventions within the green boxes, represent those which are done as a collective to align with CCG transformation programmes, and business as usual requirements. The lilac pillars of the 2 year platform, describe the enablers that will support the CCG and Clinical Directors in achieving their outcomes. 57
Provider Market Development: Dermatology / Cardiology / Pain
IPHs / Alliance / Healthier Together
Community Services Mobilisation: 6 LotsCore Community Services, Specialist Elective, Enhanced Intermediate Care, Continence
Services, Respiratory, End of Life
Quality Improvement: Assurance of Providers in NHS & Independent Sector
Commissioning for Prevention:
Public Health Investment Stategy
Innovation / Research: Dragons’ Den
Performance & Productivity : 20% Elective, 7 Day Working, Constitutional Targets
Outcome Metrics
Long Term Conditions Platform & Primary Care Development: EQALS, Business Development Strategy & Quality Improvement
Better Care Fund: Integrated Teams, Rehabilitation & Reablement, Carers, Care Home Quality, Dementia, Assistive Technology
Diabetes: 8 Processes of Care and
Children’s Community Service
Medicines Management: Needs
Assessment by February 2015 and
Medicines Optimisation
Urgent Care (inc. EoL): Better Care Fund,
Accident Prevention, EoL, ATT, LTC
Platform, Community Mobilisation, Alliance
Respiratory Mobilisation: Tobacco Control
Strategy, Telehealth, Paediatric Needs
Assessment Implementation, AQ Care
Bundles
Vascular: Anticoag in Primary Care, Stroke
ESD & Reconfiguration, Community
Cardiology Service, CKD, DVT, Evaluation of
Pharma and Dragons’ Den Pilots
Cancer: Early Diagnosis in Primary Care,
MacMillan 1:1 Pilot, Upper GI Pathway,
Acute Oncology, Chemo in Oldham,
Awareness & Signposting Toolkit
Children’s: Community Service – Accident
Prevention, Breastfeeding, Consanguinity
Integrated Teams, Observation Pathways,
SEND
Elective: Pain, Fracture Clinic, Clinic
Relocations, Hip Outcomes, Liver Disease,
Neurology, Dermatology, Advice &
Guidance, EUR
Mental Health: IPH (IAPT) , Dementia, LD,
Alcohol & Drugs, CAMHS, ADHD
Procurement, Substance Misuse
2 Year Delivery Platform
The approach to developing the plan on a page and the outcomes of prioritisation
The majority of these plans have been developed following dialogue with providers along the continuum of care. The 2 year plans for each clinical programme area were consulted on at stakeholder events with members, local providers, the public and a range of other key stakeholders.
Key aspects which the Clinical Directors were asked to address within their ‘Plan on a Page’ were:• Having a clear vision for their clinical area• Patient safety and experience• Quality improvement initiatives to reduce inequalities • Benchmarking data to identify unwarranted variation or health inequalities, including access to or quality of primary care• Innovation• Having an in-depth understanding of providers and having effective communication in place to build bridges in gaps in service within their
clinical area• Transparent metrics to measure improvement aligned to objectives and outcomes • Delivering rapid change and performance improvement..
We believe we are already implementing a large proportion of interventions recommended within the commissioning for prevention report, particularly from a secondary prevention perspective- the public health team have undertaken a gap analysis for us against this report.
The Dragons Den Innovations which started in April 2014 begins to address a number of elements of the primary prevention agenda.
Appendices 1 and 2 details the interventions that have been recommended by the Clinical Directors, and the interventions which are being implemented as part of the Dragons Den programme. Appendix 3 details the methodology by which the CD’s have chosen their interventions to implement.
The following slide demonstrates where investment has been prioritised against strategic priorities within the financial plan.
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C. Delivering our Integrated Care Strategy
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Integration within OldhamAs has already been described, a new relationship with Oldham Council is emerging, building on the strengths within the borough and the significant capabilities and altruism that exists between professionals from both social and health environments. There is a ‘One Borough’ movement building across Oldham and the CCG wish to see this develop further, with the re-engineering of the Health and Wellbeing Board and the integrated commissioning function. This gives an ideal platform on which to develop the Better Care Fund agenda.
Within Oldham we have invested a significant time in developing the integration agenda across commissioners and providers, which provides us an ideal platform on which to develop the intentions of the Better Care Fund. A model of commissioning has been developed to take account of both organisations key strategies, and to ensure commissioning decisions taken consider the perspectives of both organisations. Our community services have been respecified and retendered to wrap around the Primary Care Medical Home, as our platform for integration.
To make it visible to staff, patients and the public, what we are trying to do in Oldham, the Oldham family have been developed who represent a variety of population demographics and tell the story about what we are trying to achieve from the integration perspective, which has been consulted on widely with the citizens of Oldham
Our definition of integration is as follows:
• The approach by which by total patients needs are coordinated , the interventions are connected, the pathway of care is seamless and the contributions of professionals, services and organisations are regulated for quality, performance and adherence to optimal customer quality standards
• Properly structured care, delivered by professionals who care and are motivated to work to the highest standards
Our programme for integration has been benchmarked against the latest Kings Fund evidence for implementation of integration at scale and pace, and making best use of the Better Care Fund. On top of the money already invested through the increased commercial value of the community contract, a further £1m will be invested.
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62
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What are we trying to achieve?• Positive impact on the experience of the Oldham family
• Making an impact on population health through the CCG contribution of delivery to the HWBB strategy
• Whole system collaboration not competition – via the urgent care alliance for Urgent Care and Long Term Condition Management
• Services wrapped around the individual in the community – Specified primary Care and Community services will be the vehicle by which we do this
• Challenge quality across the whole system
• “Every non –elective admission is a failure of the whole system”
• Patients know who to turn to at 3am in the morning
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Health and Wellbeing strategy
The Health and Wellbeing Strategy subthemes
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Giving every child the best start in life
Living, learning and working well
Ageing well and later life care
Maternal health Health in the workplace Maintaining healthy lifestyles – signposting and creating opportunities
Positive parenting Sickness in the workplace Carers
Improving nutrition in childhood
Engagement in health Tackling social isolation and loneliness
Readiness for school Reduce smoking Maintaining independence
Reducing risk to health in childhood
Promote healthy eating End of life
Children and young people adopting healthier behaviours
Reduce alcohol consumption Dementia
Children and young people with complex needs or disabilities
Increase physical activity Preventing falls
Long term conditions
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The links to the Oldham familyThe actions described within each of the clinical programme plans will deliver the outcomes described for the Oldham family. Each of the clinical programme areas have a contribution to make to improving the outcomes for families in Oldham.
It is an objective for all programme areas , to reduce health inequalities across Oldham.
Family member Health and Wellbeing Strategy link CCG clinical programme link
Jack - 2 Giving every child the best start in life Children, respiratory, urgent care, prescribing
Steve - 24 Living, learning and working well Mental health, urgent care, prescribing
Sarah - 32Living, learning and working well, giving every child the best start in life Cancer, elective care, children's
Lisa - 40 Living, learning and working well Cancer, mental health
Zubaida -56 Living, learning and working well Elective care, MSK, prescribing
Susan - 64 Ageing well and later life careDiabetes, vascular, ophthalmology, urgent care, prescribing
Ethel - 70 Ageing well and later life careVascular, respiratory, urgent care, mental health, prescribing
Mohammed - 78 Ageing well and later life careEnd of life, vascular, respiratory, urgent care, prescribing
Core assumptions of integration
• High quality primary care is the cornerstone to integration- CCG's also have the responsibility for improving the quality of primary care.
• Community services will need to be re-specified to wrap around the primary care medical home (IC Platform model). This will involve PCMH as a core partner in the deployment of community nursing skills and capacity. The new model will go live on the 1st April 2014
• Integration does not start with cost reduction, it's about doing the right things in the right places, at the right cost - The balanced managed care model
• Resource shifts will be required, with providers of new delivery models to be selected through appropriate (section 75 compliant) routes
• Shared decision making needs to form the basis of all consultations. No decisions for me, without me principles
• Wider links need to be made with social care to address issues such as social isolation , employment and housing, which affect the ability of patients to manage their own conditions
• Assumptions made relating to activity and cost will be estimates based on national and international evidence. Contracting
vehicles need to be geared up to support whole system integration and risk management across providers e.g. alliance contracting/ prime vendor models. This is not marginal change.
The following slides demonstrate the delivery model of the community services we have recently reprocured through our recent community tender exercise, to support the integration agenda.
Extract from new community service tender specification
Extract from new community service tender specification
Apex Managed Care Model - A New Service Paradigm 2007Does this model have currency in todays Integrated Care System we are Designing?
PBC Linked Medical Cover
Direct Link to Medical Consultants
• HAH interventions• Virtual ward rounds
IHSCT for each cluster• Trusted assessor• TAPS
Provision of home based technologies
Direct access & referral for diagnostics
Transport contract in place
Ward budget for aids & adaptations
Direct rights to intermediate care beds
Defined set of condition protocols
Prescribing rights
Defined LOS & Entry Criteria
Managed hospital at home schemes
Defined set of metrics & analytical support to Ward Manager
Rapid & Consistent Clinical Assessment
Ow
nership of Intermediate Care Capacity (step & D
own)
Ref: Original Model from Croydon PCT
The role for the ‘Medical & Social Care’ Home? Just using a different language for a different time?
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Process Control for Apex Model 2007
Coherence with Rapid Responses with our Current IC Thinking?
Apex control is a term to describe the system of clinical management when a patient (either known LTC / Frail Elderly or unknown) suffers an exacerbation and requires immediate assistance in order to be stabilised and return to independence. It is the point of the system whereby coordination is most critical
Control of Entry
Via LTC citizen / carer / advocate referral
Via GP referral
Via acute physician / HAH team referral
• Professionally Led
• Protocol Driven
• Common Methodology & approach
• Agreed set of condition pathways
• Single entry point for assessment
• Clear communication protocols
• Direct referral into Intermediate bed
• Easily understood by patients and carers
Control of Throughput
• Control of assessment
• Control of apex management plan
• Control of anticipated LOS (incl. Intermediate Care)
• Control over diagnostic package
• Identified ‘ward’ controller
• Liaison with partners
• Mobilise equipment & skills for HAH interventions
Control of exit
• LOS set at date of acute admission
• Protocol Driven
• Intermediate Care (step down) re-defined
• Virtual ward & Social partners agree process
• Agreed processes for NH selection & timings
• Clear communication protocols
• Direct referral into AHP services
Via hospital medical teamVia hospital based discharge teams
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Delivering integrated care in Oldham• Strategy developed in partnership with members - Integrated Care and
Wider Primary Care At Scale• Primary care EQALS scheme (Enhancing Quality and Access Local Supply)
is a building block for integration – additional money has already been invested in 13/14 – more will be invested in 14/15, and will be invested recurrently to support the model of the accountable GP
• Re-specified community services located around the Primary Care Medical Home are critical to delivery –mobilised 1st April 2014
• Assessment of additional services suitable for service shift currently underway
• Urgent care and LTC alliance– financial and performance framework– OD /IT/communication and engagement platforms
• Disease specific clinical change programmes led by Clinical Directors• Implementation of Dragons Den bids• Economic and activity shift quantified at programme level • 100 day plan refreshed every 100 day to ensure traction on generic
integration platform and clinical change programmes
Clinical change programme progressRespecified services currently in
place13/14 clinical change programmes 14/15
Ophthalmology EQALS – phase 1 Integrated respiratory service
Pennine MSK Integrated Health and Social Care Teams –phase 1
Integrated end of life service
Urology ICAT Implementation of falls service (partial year effect)
Re-tendered community services
GM CATS Consultant support to Nursing Homes Re – tendered wellbeing services (LA)
Anticoagulant service Cancer 1:1 Macmillan pilot Respecified rehabilitation / Reablement services
Weight Management service Mental health – memory service mobiilsation / IAPT / ASD procurement / CMHT review / Birchwood
IAPT – full year impact, alongside respecified CMHT’s
Fuel poverty Alcohol liaison service Early supported discharge - FYE
HINC ICC cluster pilot relating to social isolation Outcome of pain service review
Oral surgery ICAT (LAT) Planning with OOH and NWAS to reduce OOH admissions
Outcome of fracture clinic review and out-posting of MSK clinics
Integrated sexual health service (LA) Mobilisation of integrated diabetes service Mental health – dementia diagnosis / IAPT / ASD procurement / CMHT review / Birchwood
Dermatology Implementation of ESD (partial year effect) Integrated cardiology service (part year effect)
Total skin service
12.9
12.4
2.9
6.4
1.0
PAHT A&E attendances, Non elective ad-missions, Non elective excess bed days, crit-ical care, Nursing home outreach, Alcohol li-aison
PCFT Integrated Health Teams, Children's community nursing, Enhanced Intermediate care, End of life Care, Occupational Therapy, Physiotherapy, Community Stroke, Neuro Rehad Nurse
GTD GP OOH Service, Walk in Service
OMBC Hospital Social Work Team, Reable-ment and recovery, Limecroft, Medlock Court, OMBC response service
Primary Care EQALS
Urgent Care and Long Term Conditions Alliance Budget Proposal 14/15 Total £35.7M
Vision:The Oldham family – to improve their outcomes and experience by utilising
resources more effectively
Patient experience:· LTC indicator (EQ 5D Score)· A&E Friends and Family Test
End of Life:· Increase in deaths in preferred place of
care
Social care:· Reduction in medically fit patients in
acute beds· Reduction in placements in long term
rescheduled care
Hospital Admissions:· Reducing LTC admissions in and out of
hours for patients with ACS condition· Reducing unplanned children’s
admissions· Reducing NEL admissions from care
homes· Reducing emergency readmissions
Urgent care performance
Alternate to transfer (£440k)
Care home outreach (£53k)
ESD (£63k)
LTC management (£363k)
Management of children in the
community (£500k)
EoL Care(£390k)
Alcohol liaison team (£25k)
Urgent Care Alliance
Performance
Key Results Areas
Priority Schemes &Planned Non-Elective Deflections in 14/15
D. Wider Primary Care at Scale
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Introduction
• The continuous evolution of Primary Care in Oldham is the central mechanism for the pursuit of clinical excellence and clinical service delivery within our ‘out of hospital’ sector
• Integration of service delivery and coordinated patient care management is central to our Integrated Care Strategy (the Oldham Care Vortex)
• We (CCG) believe premium Primary Care is the fulcrum from which most clinical innovations will emerge and thereafter be equally delivered and regulated
• The Oldham Primary Care (patient centred) Medical Home Model is a preferred investable proposition* to pursue the long term reduction in health inequalities
• Our strategy for investment, development and regulation specifically correlates and complies with the expectations within NHSE ‘Everyone Counts Planning for Patients 2014/15 – 2018/19 (ref pages 13-14 & 30)
• The details and proposals contained should be read in conjunction with the broader compendium of CCG strategic planning documentation
• EQALS investment programme + Better Care Fund will be the prime enabling vehicles
80* Preferred based on list centric services, however it is not the only option for differentiated delivery at scale
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Strategic risks connected to the development of Wider Primary Care at Scale in Oldham
1: acute2: social care3: commercial sector4: 3rd sector
CCG Allocations & Potential Growth?
Acute Sector reconfiguration (HT)
Social Care Services
Welfare Benefit System
Commercial Health Care Sector
It means we can't just increase the scale and volume of Primary Care market without a clear and credible rationale and supporting business logic. We also have to factor into the mix the issue of membership system conflicts. Badly managed it will create a perfect storm of controversy. The CCG (i.e. all of us) can not take a flimsy approach to the WPCAS system and investment ROI (return on investment) case.
Hence the need for a robust, thoroughly examined strategy, carefully prepared and well explained. A simple 'let's just do this' approach will bring the CCG and its member practices into disrepute.
The dynamics, challenges and strategic thinking will be described In summarised models & paradigms – these will be supported by simplified explanation notes, therefore no need for bulky written strategy documents.
Wider Primary Care delivered at scale in Oldham, we (CCG) believe is the key and central platform to take our health system into the next 20 years. We will build a cohesive strategic logic to support at scale investments. We will endeavour to build public and professional consensus, that will see an escalation in local accessible services.
Understanding Strategic Risks and Potential Challenges
Facing reductions and significant economic limitations within their market sectors
Flat allocations in real economic terms – no growth expected to 2020
Potential reduction in services & therefore income at Trust / FT level (service changes &
impact of more Out of Hospital shifts)
Real terms economic reductions in Local Authority allocations – mitigated by Better Care
Fund?
Real terms personal / family changes in welfare income (impact on demand for Primary Care?)
Perceived and/or real market shrinkage as a result of commissioner driven changes will result
in EU competition challenges
So What does this mean for the CCG and what do we need to do?
The Views from NHS Leaders
Summary of the Scale of Challenge
facing us
83
Why the Need to Develop Primary Care into a Broader System of Health Delivery?
Current State 2014
Our Citizens
Our Primary Care
Future State via PCMH 2014
• Improved Care Quality• Improved Care Outcomes• Improved Care Experiences• Improved Satisfaction
• Material Increase in PCMH Revenue• Realistic Increase in Fees for Services• Validated total system economic benefits • Sustainable commercial delivery (1,2,3 M)
• PCMH processes and workflow improvements
• Material improvements in care coordination and management of high risk patients
• Meaningful reduction in unwarranted utilisation
• Significant total cost of care savings
• Time to Value Improvements
The (1 page) Context For Extended at scale Primary Care
PC Performance & Quality Improvement: Our CCG
It is one of the prime duties for CCGs and thereforeIt is one of our most important membership system functions. It is not an option for us, it is mandatory. We will invest in continuous quality
improvement and differentiated services (EQALS)
PC Performance & Quality Improvement: Our CCG
It is one of the prime duties for CCGs and thereforeIt is one of our most important membership system functions. It is not an option for us, it is mandatory. We will invest in continuous quality
improvement and differentiated services (EQALS)
Performance & Quality Regulation: NHSE
As it’s one of the prime functions for NSHE at Local Area Team Level, NHSE via the Local Area Teams (LAT) will review and monitor PC as part of ongoing and annual contracting arrangements. CCG need to
develop co-commissioning with the LAT.
WPCAS: The Connection with GM Transformation (HT)
GM CCGs collectively lead and govern transformation at macro (GM) level. In order for this to take place effectively, a distinct connection with Integrated Care and Out of Hospital care will need to be made.
WPCAS is central to this.
WPCAS: The Connection with GM Transformation (HT)
GM CCGs collectively lead and govern transformation at macro (GM) level. In order for this to take place effectively, a distinct connection with Integrated Care and Out of Hospital care will need to be made.
WPCAS is central to this.
Primary Care, Differentiation & Standards: Monitor & CQC & OSCs
The way in which OCCG forms strategy, engages suppliers and selects delivery methods will be subject to public and regulatory
scrutiny. Conflict management systems will be key, as will a focused and transparent selection and regulation system.
Primary Care, Differentiation & Standards: Monitor & CQC & OSCs
The way in which OCCG forms strategy, engages suppliers and selects delivery methods will be subject to public and regulatory
scrutiny. Conflict management systems will be key, as will a focused and transparent selection and regulation system.
WPCAS: Health & Social Care Reform (GM)
WPCAS also requires us to work at collective level across Greater Manchester as some aspects require ‘at scale’ solutions and common
standards. The connection with the Better Care Fund in order to ensure viable investable propositions (at scale) will key, as will ensure
effective deployment within the BCF system with OMBC
National Policy Direction
One of our key aims is to enable general practice, community pharmacy and other primary care services to play a much stronger role, at the heart of a more integrated system of community-based services, in improving
health outcomes. It is clear from the Call to Action that there is a widespread appetite for developing new models of primary care that
provide more proactive, holistic and responsive services for local communities, particularly for frail older people and those with complex
health needs; play a stronger role in preventing ill-health; involve patients and carers more fully in managing their health; and ensure
consistently high quality of care (Page 13)
Planning Our WPCAS Strategy
● understanding of the potential contribution of primary care to the delivery of our local ambitions
● working with partners and the public to develop an integrated approach to primary and community services, with joint commissioning as appropriate
● enable primary care to operate at greater scale to improve access and continuity of care and to enable our urgent and emergency care system to function effectively
Avoidance Of
- Fear- Restricted Access- Confusion- Disorganisation- Apathy- Disrespect
Pursuit Of
- Quality- Enhanced Offers- Connectivity- Contribution- Value (ROI)- Certainty
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85
Executive Summary
Primary care exists to contribute to preventing ill health, providing early diagnosis and treatment, managing on going mental and physical health conditions and helping recovery from episodes of ill health and injury (Ref; NHS Mandate 2013). The Greater Manchester Area Team of NHS England, is fully committed to the principles of the NHS and sees our core function as commissioning quality health services delivered as close to home as possible and in the most cost effective way. Our aim over the next 5 years is to work with our co-commissioning partners to deliver transformed out of hospital care for all people of Greater Manchester.
The case for improving out of hospital services
Population changes create additional demands on health care services and the resources available are not increasing at the same rate. As the population ages and the number of people with chronic conditions rises, the way we currently use our hospitals is becoming unsustainable Improving our out of hospital services will improve patient care and will cost less. Better care, closer to home is the only way to maintain quality of care in the face of increasing demand and limited resources
Access to care and quality of care is variable across Greater Manchester. Improving primary and community services will require new and innovative ways of coordinating services, more investment and greater accountability.
Alignments with GM Wide Primary Care Strategy (Local Area Team)
Our vision for how care will be different
Too often our residents do not receive the care and support they need to prevent ill health, maintain their health and to stay independent for as long as possible. Frequently, when ill, our patients do not know how to access the most appropriate care easily and report that they find care to be fragmented. Our vision is to empower communities in Greater Manchester to adopt healthy living practices, deliver care at the right time through integrated care pathways that coordinate input from the health, social, community and voluntary sectors.Our five key primary care commitments focus on:
Quality and safetyPrimary care providers will consistently provide high quality and safe care as evidenced by appropriatequality assurance systems and the production of transparent, publicly available benchmarking data. All providers will be expected to participate in incident reporting and peer review.
Involvement in careWe will provide clear evidence-informed preventative advice and understandable care pathways with thepatient always at the centre. Patients will have choice, access to their own care records and be provided with accessible information in order to work as partners with professionals to manage their health.
Multidisciplinary CarePatients with long term conditions including those with more than one chronic condition, will have access to an integrated care team designed around their own needs to ensure their conditions are managed effectively.
Access and responsivenessThere will be easy access to high quality, responsive, preventative primary care including a rapid responseto urgent needs so that fewer patients reach crisis and need to access hospital emergency care.
Increased out of hospital servicesWe will ensure patients can access a greater range of local health services easily within their communitiesand those services will work well together to ensure care remains out of hospital wherever clinically appropriate and safe.
The Key is Absolute Alignment Between Oldham CCG Vision for Extended Primary Care and NHS England (via
GM LAT) Strategy for primary Care
We have the same common purpose
The Strategy Model for Sustainable Primary Care at ScaleModified from NHS Sustainable Development Unit Consultation Jan-May 2013
CONTRIBUTIONCONTRIBUTION STANDARDSSTANDARDS INNOVATIONINNOVATION
PatientPatient ProfessionalsProfessionals OrganisationsOrganisations
Engage & Coordinate
Involve & Understand
Engage & Insights
Regulated Professional Contribution
Engage & Specify
Federated Delivery at 3m
System Governance
System Governance
Quality Assurance
Quality Assurance RegulationRegulation
Accountable Commissioning+
Accountable Provision+
Accountable Investments
Via Locally Developed BSCBenchmarked Regionally &
Nationally
System of Incentives &
Conflict Management
Designed care
Designed care TechnologiesTechnologies Federation
ContractingFederation Contracting
Person Based Care Design
Technical + Enabling
Hard & Soft InnovationHarvest AHSN OpportunitiesCreate Industry Partnerships
(e.g. ABPI)
Mutual System Partnerships (MSP) via Federated Primary Care
Accountable Care Commissioning (CCG, NHSE & LA)Accountable Care Commissioning (CCG, NHSE & LA) Accountable Care Provision (MSPs) at 3m levelAccountable Care Provision (MSPs) at 3m level
86
The New System, New Relationships, New Service Opportunities
Core Primary Care(GP Practice Contracts)
Core Primary Care(GP Practice Contracts)
Contract Negotiation & SettingContract Negotiation & Setting
Contract Regulation & MonitoringContract Regulation & Monitoring
Performance ScrutinyPerformance Scrutiny
Market & System ManagementMarket & System Management
Individual Practitioner PerformanceIndividual Practitioner Performance
NHS ENGLAND(via Local Area Team in Greater Manchester)
NHS ENGLAND(via Local Area Team in Greater Manchester)
Structured, Commercial, Regulation Based Quality
Assurance
Structured, Commercial, Regulation Based Quality
Assurance
Opportunities for New Primary Care Systems, New
Commercial Modes for Integration?
Opportunities for New Primary Care Systems, New
Commercial Modes for Integration?
Continuous Quality ImprovementContinuous Quality Improvement
Growth Through EQALS +/- ShiftsGrowth Through EQALS +/- Shifts
‘Community’ Services Integration
Membership Service Offer Collaborations (3m)
Membership Service Offer Collaborations (3m)
Commissioning System LeadershipCommissioning System Leadership
NHS Oldham CCGNHS Oldham CCG
Partnership Models, Extended Delivery
Opportunities, Education, Business Coaching,
Design Based
Partnership Models, Extended Delivery
Opportunities, Education, Business Coaching,
Design Based
Agreed Priorities, Managed Markets, Connected Care Models, Opportunities for
Health & Social Integration, Growth in ‘out of hospital’
market
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88
Constructing our (Oldham) Proposition – Built on Local Insights and researched National & International Models
Oldham National International
• Generations of experience
• Vast knowledge of population
• Significant track record of innovations
• A clear & credible set of plans
• Sound economic stewardship
• An accountable care ethos adopted
• A recognition of need for change
• A good grip on sustainable delivery
• Kings Fund (compendium)
• Nuffield Reports
• RCGP and other Royal Colleges
• Gov.com / NHSE publications
• BMJ
• NHS Alliance & NHS Confederation
• KPMG & other consultancies
• Jankopping (Sweden) Experience
• IHI (Institute for Health Improvement)
• Horizon Healthcare Innovation
• Netherlands Institute for Health Research
• WHO (World Health Organisation)
• National Health Service" (in Italian: Servizio Sanitario Nazionale),
• Danish Healthcare System
Caveats:
This strategy is not intended to be a full empirically researched proposition. Benchmarks and comparisons have been used, however there is an overwhelming weight of national and international opinion, backed by research, as the value of a thriving Primary Care system in relation to Triple Aims. Many citations could be used, however this one below summarises the points very well:
‘The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
US National Institute For Health (Milbank Q. Sep 2005; 83(3): 457–502)
Interesting Fact: Nations that have remodelled their Health Care system, based on the UK NHS Primary Care model, are obtaining better outcomes than the originator (ref WHO ranking of Health Care Systems)
Clear & Robust AccountabilityClear & Robust Accountability
Openness & Transparency Openness & Transparency
Effective Regulation of StandardsEffective Regulation of Standards
- Systems- Method- Behaviour- Contribution- Applied Clinical Logic
= Accountable Commissioning (ACCO)Members Holding Members to Account
So Why is Wider Primary Care Delivered at Scale in Oldham so Important for Integrated Care?
It’s the backbone of the care system & USP in Healthcare Delivery
It’s the preferred (& best) investable proposition to achieve year on year triple aim improvements
It’s what patients need and most value
- Optimal Care Delivery- Harvest Skills & Capacity- Plan the Future- Seize Opportunities- ROI best fit
= Accountable Provision (ACPO)Service Partners Holding Each Other to Account
Integrated & Differentiated Primary Care Delivered at Scale A focus on Continuous Quality Improvement
The Integrated Care Model – The PCMH Delivery Requirement for WPCAS Investment
Core Extended Offers (EQALS) Differentiated Offers (Shift)
• Segment Clients in Risk Cohorts
• Define their support needs
• Allocate resources via care needs
• Wrap-around assurance & care co-ordination
• Form prevention alliances with partners
• Invest assets (incl. BCF) into prevention & demand validation
• Enable rapid access to Core PC service
• Customer satisfaction measured routinely
• Assurance of core quality & accessibility
• Re-engineer Contract + offers (EQALS)
• Re-define ‘control of entry & exit’
• Entry based on core standards delivery & evidence)
• Align care quality systems at Cluster & Oldham Levels
• Connect EQALS system to GM LAT PC offers
• Specify Care maps, contributions & standards
• Defined outcome objectives
• Define ROI in context of BCF principles
• Review PB Markets (SMMS) using ROI logic
• Tailor “Out of Hospital’ care to population needs (3m level)
• Execute WPCAS offers via due diligent systems
• Regulate via commercial contracts
• Create sustainable workforce capability
• Create social capital via commercial coaching
• Strategic & Tactical Management of service segments, incl. Cluster Diagnostic Hubs
• Pursue Prime Vendor, MSP & IPH delivery methods
The Vortex (PCMH) Care Model
1st Contact Care
Accessibility & Continuity of Care
Coordination of Year of Care
Enhanced Contribution & Service Offers
PCMH Cornerstone for Great Primary & Community Care
at Industrial Scale
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The Development of Family Practice into A Wider Model of Differentiated Primary, Community, Social & Acute Care Management
Managed CareManaged Care
Coordinated Care& Shared Decision
Making
Coordinated Care& Shared Decision
Making
GMS / PMS/ DESGMS / PMS/ DES
EQALSEQALS
Acute & Shift Services1&2 m level
Acute & Shift Services1&2 m level
Community Professional Capacity
Community Professional Capacity
AQP based additionsAQP based additions
Out of Hours Urgent Care
Out of Hours Urgent Care
Integrated Health & Social Care (LTC) Teams
Integrated Health & Social Care (LTC) Teams
MSP / ACPO services
Regulating Supplied Delivery under
auspices of ACCO Membership
Regulating Supplied Delivery under
auspices of ACCO Membership
Acute & Tertiary Contracted services
Acute & Tertiary Contracted services
Would be subject to standard NHS contract processes and terms.
Organised at collective level via federations of Practices and/or PCMH
(Cluster and/or Borough)Contracted delivery via a ‘federated / mutual’ PC
organisation
Directly Contracted Delivery
Directly Contracted Delivery
91
Out of Hospital (office based medical) services at 3m level
Wider, at Scale PC Access & Diagnostic Services
Wider, at Scale PC Access & Diagnostic Services
Delivering Wider PC Services
Commissioning & Regulating Contracted Services as a member
of CCG
Connected units of WPCAS specialised
delivery
Acute and Tertiary Sector Reforms
Acute and Tertiary Sector Reforms
Transformed Care Delivery & Pathways
Transformed Care Delivery & Pathways
Large Scale Change Programmes
(PAHT & Healthier Together)
Large Scale Change Programmes
(PAHT & Healthier Together)
Core Primary Care In Oldham(GMS, PMS, APMS)
Core Primary Care In Oldham(GMS, PMS, APMS)
Enhanced Quality & Access Local Supply(EQALS)
Enhanced Quality & Access Local Supply(EQALS)
Enhanced & Integrated Community Services(Collaboratively provided enhanced access &
Community Services)
Enhanced & Integrated Community Services(Collaboratively provided enhanced access &
Community Services)
Local Transformed Out of Hospital Provision(redesigned local acute care services offered at scale)
Local Transformed Out of Hospital Provision(redesigned local acute care services offered at scale)
Pra
ctic
e L
eve
l1
mC
lust
er
Le
vel
2m
Sys
tem
Le
vel
3m
Integrated Health & Social Care Services(redesigned care coordination services via BCF)Integrated Health & Social Care Services
(redesigned care coordination services via BCF)
Integrated Care – Integrated Commissioning & Public Sector
Reform (AGMA & CCG AGG)
Large Scale Public Sector Programmes
(PSR, IC)
Large Scale Public Sector Programmes
(PSR, IC)
Key Drivers For Change for WPCASGearing for DeliveryThe Core Investable Platforms
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The CCG 3M Model Explained The CCG ACCO strategy 2011 forms the source code from which all other strategies and tactics emerge. One of the central themes is regulated contribution. Its not a universally popular term, partly due to the rather Teutonic and instructive perception it creates. However it’s a largely misunderstood concept. Basically explained, the bedrock of Primary Care is based on total family care, for life. It requires consistent quality based approaches to common care needs across populations. Therefore in essence, Primary Care has always been a regulated system, i.e. standards are set by policy such as QOF and 48 hour access, and require regulated delivery. The issue we have in connection with broader investments in a largely membership based supply system, is that the public will correctly wish to see that further £1s invested will ensure regulated access and quality. Unwarranted variability in services will not be tolerated by our public, therefore we have to ensure that great standards are delivered routinely, i.e. they require regulated contributions and consistent and equitable access.
So where does 3m fit into this & what does it mean?
3m = Service Accessibility & Practice Contribution at 3 different levels
1m (micro) = singular level (e.g. a single, stand alone GP Practice)
2m (meso) = partner level (e.g. groups of geographically consistent practices working together)
3m (macro) = federation level (e.g. a single unit of organisational delivery, comprising of many / all GP Practices)
1 m List Based Contract (GMS,PMS,APMS)EQALS at 1m level, DES (NHSE)
2 tier contract1: NHSE (core + DES)
2: EQALS (CCG & BCF)
2 m
Shift (acute) services & diagnostics at Cluster LevelEQALS at 2m level (enhanced access offers)
AQP (shift services) at Grouped Delivery LevelPSR services with OMBC (BCF)
Collaborative (JV) Contract1: EQALS (enhanced access at group level)
2: AQP services at group delivery level3: PSR / BCF services at group level
3 m
Shift (acute) services & diagnostics at Federated Level
EQALS at 3m level (enhanced access offers)WPCAS supply co-ordination at Borough Level
PSR / BCF coordinated supply at Borough Level
Federated Contract1: EQALS (enhanced access at collective entity level)2: AQP services delivered as common choice / access3: PSR / BCF services with single collective contract
Integrated & Enhanced Services
The Citizen Wrap around Service
Market
Strategic ‘whole LTC & Frail Elderly’ urgent care contribution
services Investment in PC coordinated Care patients at risk
management services
(Frail Elderly & LTC)
Demand Governance & Regulation via Gateway
Allocation of total integrated clinical capacity in community
services into PCMH
Define structured self care / support packages & delivery
agents
Bespoke clinical coaching support to Nursing & Residential
Homes
Organising assistive technology deployment and measurement
Establish early warning and rapid intervention systems via
PCMH & ISCATS
commission innovation enabling ideas at 2m Communities –
Reducing Inequalities
Support self referral processes (into apex services)
‘make it clear and fast’ requirement
Liaison & tailored partnering with Carers via Investments
Extended provision via Extra Care & Social Care Housing
Partners
Enable continuous medication review system – named
pharmacist / pharmacy supplier
Shared knowledge systems across BCF partnership
community
Office Based (OOH) Medical & Diagnostic Services delivered at
3m levels
Creating the Landscape for Wider (at Scale) Primary Care Solutions in Oldham
94
Underpinned via Planning & Commissioning & Market Strategy – Delivered via Annual Change Cycles
95
Oldham CCG PCHM based WPCAS system – The Five Incremental Investment Streams to Support Improvement in Population Care
1Revenue from Core Primary Care
Service• Core contract relating to GMS, PMS, APMS list based provision• Any further enhancements connected to core (e.g. DES services)
2 + Care Coordination Revenue
• Additional up-front revenue investment for PCMH activity (EQALS)• Patient care coordination, care planning, compliance to clinical protocols• Management of practice population care BSC & budgets (e.g. prescribing)• Increased efforts to quality improve general care & specific LTC care
3+ Population Care Coordination
Revenue
• Year of Care & horizon support to achieve step change improvements in care by coordinating care for higher risk patients
• Connecting practice workforce with commissioned supplier workforce• Regulating contributions within practice and provided by community teams
4+ Continuous Quality Improvement, Patient Experience and Utilisation
Management (incentive)
• Enhanced revenue for validated improvements in patient care• Enhanced revenue for extensions in core access (above core contract)• Enhanced revenue for improvements in PROMS (specific to practice)• Gain Share arrangements relating to sound financial governance
5+ Differentiated Service and Patient
Access Services (revenue)
• Enhanced revenue for delivery of ‘additional’ fee for service offers to patients• Active delivery of ‘out of hospital’ care delivered at 1/2/3m levels• Enhanced diagnostic provision at 1/2/3m levels• Delivery of enhanced ‘system based’ professional services (e.g. education,
coaching, referral governance)
Underpinned by a set of guiding principles (for PCHM & WPCAS)
• Patient & Quality Focus – substitutions in service and location offers, must not compromise quality, it must enhance it• Emphasis on Downstream Outcomes & ROI for Total Cost of Care – reward PCMH for premium quality decision making and care delivery• Stakeholder Materiality – i.e. the proposal must match market conditions & be a viable delivery proposition• Reliability – requires at scale delivery in order to ensure statistical reliability and coherence• Scalability – Models and propositions should encourage widespread adoption by practices• Setting High but Fair Expectations – recognising differences in sub-populations and practice starting points (Minimum Conditions)• Provide Sensible Incentives for Developing PCMH Infrastructure – Reward practices for implementing best practice processes & innovating
96
Funding WPCAS via PCMH – Economic Models and Challenges Payout for CCG Member Practices (PCHM) – 2 Options
Option 1: An Example (below) Based on Efficiency and Contribution Option 2: Continue with a flat payment structure, undifferentiated for performance Option3: Segment EQALS into 2 sections (1: delivery 2: quality outcomes) & apply Option 1 to part 2 only
£+1
£+0.5
£+0.5
£+3
£+2
£+1.5
£+5
£+3.5
£+2.5
£+6
£+4.5
£+3
LEVEL 3
Level 2 + 90th Percentile on BSC
quality metrics
LEVEL 2
Level 1 + 75th Percentile on BSC
quality metrics
LEVEL 1
50th Percentile on BSC quality
metrics
Qua
lity
Lev
el (
BS
C)
Weighted Utilisation Improvement (BSC)
3-6% 6-9% 9-12% 12%
Key: BSC – CCG Primary Care Balanced Scorecard£+ - refers to share system financial gain share
Shaping the Future Service Market for Out of Hospital Care & WPCAS
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Encourage and Coach in order to continue to innovate, develop new ways to meet patient
need and build collaborations at 2M level
Support the development of a leadership cadre. Invest in personal and team
development in order to harness leadership potential into the future
Continue to offer support to meet the minimum conditions of service (MCOS)
Provide dedicated support and coaching in order to attain higher standards and harvest
the potential value of professional competition
A Common Purpose Federated (PCHM)
Delivery PartnerPCHM
Performance
PCHM Ambition
LOW HIGH
HIGH
Commissioner
P3
P1
P4 P5
P6 (etc..)P2
Commissioner
• Separate contracts with each practice
• Separate objectives for each practice
• Commissioner is the co-ordinator & regulator
• Expectation of dispute & conflict ethos
• Change not easily accommodated (limited incentives)
• Scope for services are constrained & finite
• Practices are islands of contracted service
• Single contract, single performance framework
• Shared risk and reward framework
• Aligned objectives, collective accountability
• Expectation of trust – no fault, no blame
• Change and innovation in delivery are expected
• Engagement & opportunity at 3 commissioning levels
• Enables WPCAS for differentiated communities
Traditional Contracte.g. LES / EQALS
Alliance ContractSingle Unit (1m) Joint Venture (2m) Federated (3m)
Ref: Robert Breedon Wragg & Co (Alliance Contracting)
Drivers for Changing How We Commissioning & Contract For Wider Primary Care ServicesWithin a Membership System
Building Sustainable Partnership Economics
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P1
P2P6
P4
1M
2MSingle Federated Contract
Holder (3m)
Governance of the Procurement & Contracting System
Wider (commissioned) Integrated Team(operates under licence to PCMH)
Cluster (2m) Provider Joint Venture (JV)led by JV Manager
Federated Body & Contract Holder(holds contract & regulated 3m level services)
Commissioner (CCG & LAT)Alliance Leadership Team- senior members (including commissioner) with authority to
commit on behalf of their organisations; includes owner representative
- ensures delivery of the PB outcomes sought- agrees governance of the service or project- sets up roles and accountabilities- ensures data collection is in place for performance
monitoring and agrees reporting cycles
2m Joint Venture Team- key people with subject expertise from each of the
participating (PCMH) organisations- devises implementation plan for specified services- identifies target costs and ensures actual costs are equal
or less than these (i.e. ensures surplus is generated)- Implements & oversees the delivery for the desired
outcomes across the JV- regularly reviews activities and performance to find
improvements & regulates across JV- reviews risks and mitigating actions
1M Managerruns the practice level (PCMH) contract (‘go to’ person)
Ref: Robert Breedon Wragg & Co (Alliance Contracting)
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Practice (1m) Provider Firmled by Principle Partner & Practice Manager
WPCAS System Management
NP
LP
EP
NP
Key: NP = National Procurement LP: Local Procurement EP: EQALS Procurement
ACO Compared to Other Payment Reforms - Fisher et al. 2009
WPCAS & Economics – Do new models of care and new models of PC supplier
collaboration stack up?
We can’t just Drag & Drop models from elsewhere into our system – but we can
learn from research and adapt a solution
Surely that’s part of our innovation task?
One of our key tasks when commissioning viable & sustainable WPCAS is to find the best combination of benefits V risks from the table
opposite
The represent a view on the features of payment reforms that offer (arguably) the best
combination of benefits for us.
They are doable and therefore present the CCG and our BCF partners the opportunity to explore
along term viable investable proposition.
ACPO on their own will fail to deliver triple aims; we have to connect accountable commissioning
with accountable provision…..and stop competing on economic management…its not in
the patient and taxpayer interests. We have to engineer a collaborative model to succeed
100
Drivers for Changing How We Commission For Differentiated Primary Care (at Scale)
Integration Could do it anyway? (true, but not assured & definitely not easy) WPCAS 3m investment aligns strategy, delivery, improvement with an ability to set new contracting forms
Value for money Great results compared with other sectors – can we replicate value from core PC into Wider Access (PC) Health?
Role of commissioner
Can achieve greater access consistency and value penetration through prime contractor (3m), joint venture (2m), and PCMH (1m) Leadership roles
Transformation of delivery
Cluster Delivery Alliances & Federated Prime Vendor contracting techniques drive innovation and outstanding performance (if done well). They also provide a valid mechanism for CCG Member practices to build sustainable and viable provider services at cluster level.
Ref: Modified from Robert Breedon Wragg & Co (Alliance Contracting)101
Regulating Performance of 3m WPCAS Investments
+100 +60 +30
-30 -60 -100
MCOS
Performance Measure
If linear
Stretch
Above MCOS
Game-breaking
PoorBelow MCOS
Failure
What is the definition (one line) of:
– Game-breaking (100)
– Stretch (50 or 75)
– Minimum Conditions of Satisfaction (0)
– Failure (-100)
Ref: Robert Breedon Wragg & Co (Alliance Contracting)
102
Based on Triple Aim Stretch Targets
Based on Triple Aim Minimum Targets
Commissioned by CCG / LAT
Regulated by
1m 2m 3m
A new system of ACPO self regulation (using an IPH contractual framework)
Are we aiming for a community of regulated practice?If so, what is the consequence of failure?
What are the minimum entry requirements, if any?
Based on Defaulted Minimum Triple Aim Targets
An Example WPCAS Commercial framework for 2m & 3m Service Providers
Reimbursement for meeting “Acceptable” Targets
(Minimum Conditions of Satisfaction (MCOS) against
all KPIs MCOSProfit
Corp O/head
Direct Costs
Painshare for poor performance in EQALS program KPIs
Gainshare
Painshare
Gainshare for outstanding performance in EQALS program KPIs
All “MCOS Profit” at risk and some Corporate Overhead
Guaranteed Reimbursement of all Direct Cost (open book)
and some Corporate Overhead multiplier /
percentage
Actual Costs managed and controlled against SCOPE OF WORK on Open Book
basis
Incentives based on program level performance - assessed annually on completed activities against
EQALS Implementation Plan (based on PB methods)
In order for WPCAS providers to sustainably deliver patient value, we (system leaders) need to acknowledge the risks that our PC providers, coming together under new Joint Venture (2m & 3m) arrangements face.
There has to be an engineered system of incentives and if need be penalties, however in order to break away from segmented, micro cultures into a new collaborative mutual delivery partnership the system has to create effective deal flow / gain share arrangements.
This system will underpin quality, safeguard essential services and enable continuous investment in Primary Care quality improvement.
Ref: Modified from Robert Breedon Wragg & Co (Alliance Contracting)
Standard NHS 3 year rolling contracts?
For 2m & 3m Contractors demonstrating consistent enhancement
over and over above MCOS it is recommended that 5 year longitudinal
contacts be offered.
This would support sustainability, innovation and employment prospects
at local level
Standard NHS 3 year rolling contracts?
For 2m & 3m Contractors demonstrating consistent enhancement
over and over above MCOS it is recommended that 5 year longitudinal
contacts be offered.
This would support sustainability, innovation and employment prospects
at local level103
104
EQALS Development Model – Taking an Innovative Idea through to Execution
Ideation
- Research- Challenge- Insights- Prioritisation- Doability (incl.
financials)- Buy-In- Customer Fit- Membership View
Go-Ahead
Adopt & Diffuse
Commercial Offer
Regulation & Calibration
Generating Innovations & PropositionsGoverning, Process Control &
Delivery
Prototyping Test Phase
Test PhaseEvaluation
Modifications Completed -
Fit for Purpose
Via EQALS group + CDs and
others
8 week turnaroundVia Clusters
(varied according to complexity)
Via EQALS Working Group (1) Via Clinical Council (2)
Via ERFPQ (3)
Service Offer + Rules of Engagement (+ re-offers)
Not accepted Accepted
105
EQALS Development – Segmenting Investments into Phases
Phase 1 (£822,561 13/14, £1096,748 14/15)
• LTC• EOL• Dementia• Prescribing Efficiency
Phase 2 (a) £500,000 (b) TBC
• Medical Planning for Nursing Homes• Falls Prevention
Phase 3 (£ TBD)
Enhanced access services, spanning wider primary care offered at scale (2m levels)
Phase 4 (£TBD)
Acute service shifts & substitutions – Enhancing the offers to local people built on PCHM model
Requires Value Proposition & Impact Assessments
Existing Funding Stream via Prioritised Investments(2012-14)
Targeted at care coordination and high risk client group services
New Funding Streams via Prioritisation Process
(2014-16)
Targeted at those services amenable to PCMH delivery and provision within office based medical environments
The Potential Benefits of Integrated (cluster) Partnership For WPCAS
Coherence with todays Primary Care Medical Home Care Model?
The Joint Venture System Manager (2m / 3m)
• Assures Optimal Performance
• Assures VFM & reduces variability
• Assures Clinical Governance
• Assures Quality & manages risk
• Provided with Quality Incentives
• Continuous Improvement of Clinical Pathways & Maps & Service Innovations
• Provides Membership Clusters with an opportunity to develop and deliver niche
services to specifically meet local population needs
The Commissioners
• Oversee outputs & standards • Focus on priorities and quality
• Assured that product design is delivered
• Design & oversee financial assurance
• Focus on patient insights & experience
• Continued relationships with Members
The WPCAS Care Supply Chain
• Advice & support for productivity & efficiency
• Maximises skill mix
• Focus on optimal clinical care
• Can accrue quality based P4QI
• Re-investment in continuous quality improvement
• Sustainable growth in Practice income based on innovations in service offer & quality delivery
P4QI = Payment for Quality Incentives
The Inter-Practice Mutual System Partnership
System BenefitsSystem Benefits
106
107
Common Platform (CP1)GP IT Infrastructure
Common Platform (CP3)Space to Deliver
Shared Common Enabling Platforms (Invested Enablers)
Common Platform (CP2)Service IT Infrastructure
Common Platform (CP4)Technologies & Kit
General Contentions:
- CP1 : is co-commissioned with NHSE, with dedicated local delivery via CSU (regulated by CCG with Members)- CP2 : is developed to disable barriers to effective service delivery (it is a free of charge technical platform for 3m services)- CP3 : is the use of current void space & capacity within NHS community estate (i.e. LIFT centres)- CP4 : is the adoption of technical innovations to enable great care delivery (e.g. diagnostic kit)
Specific Contention:CP1-CP4 are investable platforms at CCG level. They are considered to be enablers for service and thus not charged to 1,2,3m providers
Demand for capable & efficient IM&T
Demand for capable & efficient treatment rooms and tools
Some Additional Early Enabling Ideas (investable propositions)
Review available ‘enabling common platforms’ quantify and attribute resources to 2m partnerships (IT, CSU, Estate) via close
partnerships with NHS Propco & Community Partnerships
Establish a Market Segment Plan (+ PB) for WPCAS. Developed via Clinical Council and regulated via ERFPQ
Establish a Market Segment Plan (+ PB) for WPCAS. Developed via Clinical Council and regulated via ERFPQ
Explore the creation of an Oldham Medical Locum Service, Harvesting experience from retired local Clinical / Medical
professionals
Explore the creation of an Oldham Medical Locum Service, Harvesting experience from retired local Clinical / Medical
professionals
Create a future proofing ‘next generation leadership system’ – Invest in OD programme for younger GPs in Oldham
Take into Clinical Council & ERFPQ as early stage investable propositions
Take into Clinical Council & ERFPQ as early stage investable propositions
Seed Funding to Enable 2m & 3m Federated Partners to Develop their Commercial & Delivery Capabilities
Seed Funding to Enable 2m & 3m Federated Partners to Develop their Commercial & Delivery Capabilities
Explore the possibility / opportunity to form a long term partnership with an academic research partner (brokered via AHSN)
Explore the possibility / opportunity to form a long term partnership with an academic research partner (brokered via AHSN)
108
Include OD based enablers within the total system of sustainable investment in WPCAS (e.g. appraisal systems such as Clarity, +
professional fees for innovation activities)
Include OD based enablers within the total system of sustainable investment in WPCAS (e.g. appraisal systems such as Clarity, +
professional fees for innovation activities)
Create Closer Partnerships with Big Pharma in Order to Explore Triple Aim Opportunities
Create Closer Partnerships with Big Pharma in Order to Explore Triple Aim Opportunities
Explore the creation of an Oldham Medical Locum Service, Harvesting experience from retired local Clinical / Medical
professionals
Explore the creation of an Oldham Medical Locum Service, Harvesting experience from retired local Clinical / Medical
professionals
109
Tackling Health Inequalities through Improved Primary Care at Scale
- Single Contract
- Generic Service offer
- Unregulated Performance
- Undifferentiated Service
- Culturally Neutral
- Little Community Leadership
- Multiple Contract Options
- Service Aligned to Clients
- Performance via 2m System
- Differentiated to Locality
- Culturally Aligned
- Community Capitalised
Tra
diti
on
al (
1 s
ize
) M
od
el o
f P
rima
ry C
are
Cu
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nsitive
& P
op
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Gro
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Alig
nm
en
tHigher
LowerHigher
Patient Benefit & Value
He
alt
h I
ne
qu
ali
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s O
ve
r T
ime
The Formula
Core Standards Delivered Consistently + Differentiated & Flexible Services to Match Meso Population + Connected Meso Leadership + Community
Assets = Impact on Health Inequalities over time
WPCAS Next Steps: Starting to Deliver a Sustainable Reality
Continue Shaping by Engaging with Member Practices & LMC
Continue Shaping by Engaging with Member Practices & LMC
Connect our Thinking with GM LATConnect our Thinking with GM LAT
Form a Consensus Oldham View & Share with OMBC, HWB,AGMA, LAT, HT
Form a Consensus Oldham View & Share with OMBC, HWB,AGMA, LAT, HT
Engage our Key Providers (impact of strategy)Engage our Key Providers (impact of strategy)
Continue to Drive EQALS (1&2) Components +
Build up the 3&4 components for 2014/15
Continue to Drive EQALS (1&2) Components +
Build up the 3&4 components for 2014/15
Internal CCG Programme Hosting via Clinical CouncilInternal CCG Programme
Hosting via Clinical Council
CCG Membership Ownership and OD at Cluster (2m) LevelCCG Membership Ownership and OD at Cluster (2m) Level
Leadership for Delivery with OMBC (Board to Board & HWB &ICP)
Leadership for Delivery with OMBC (Board to Board & HWB &ICP)
Create an Oldham Primary Care ‘next generation’ Group
Harvest Development Resources into a single Programme Budget & PMO
(EQALS, BCF, QIPP, CP1 – CP41 enablers)
Harvest Development Resources into a single Programme Budget & PMO
(EQALS, BCF, QIPP, CP1 – CP41 enablers)
Consulting on WPCAS Model (sharing and learning across GM)
Consulting on WPCAS Model (sharing and learning across GM)
Engage Monitor / LATon Section 75 Health & Social Care Act
Engage Monitor / LATon Section 75 Health & Social Care Act Section 75 & Conflict management
(common GM Association Model?)Section 75 & Conflict management(common GM Association Model?)
Strategy Alignment with Healthier Together & PAHT
Strategy Alignment with Healthier Together & PAHT
110Undertake full HMA (health market assessment) for Out of Hospital / Wider Primary Care at Scale
Undertake full HMA (health market assessment) for Out of Hospital / Wider Primary Care at Scale
WPCAS – Existing State
111
ACUTE Services
• Pennine Acute NHS Trust
• Central Manchester FT
• Tameside FT• Salford Royal FT
• BMI Highfield• Spire Oaklands
• etc.
Subject to NHS choice promise
GP family list based care
Some EQUALS services such as Nursing Home +
LTC Care
OOH Primary Care
CCG:£3m NHSE:£21m
Diabetes
MSK
OphthalmologyUrology
Dermatology
Respiratory
Anti-coag
Gynae
ENT
General Surgery
£15m
DA Diagnostics• NOUS• MRI
Significantly differentiated when benchmarked with other CCGs (i.e. higher number of interface
services incl. CATS)
£142m
TERTIARY Services
• Christie FT• Central
Manchester FT• Salford Royal FT
Fixed viability thresholds
CORE Primary CareENHANCED Community Based
Medicine & Diagnostics
A map of existing Oldham healthcare services
increasing resource intensity
Limited inter-practice referral services• Minor Surgery• Pessary £600k
Nb. OCCG incurs additional expenses to direct service delivery, including prescribing (£40m) and other elements (£33m)
CCG: £0NHSE:£?
CCG TOTAL£300m
Community Services;PCMH model & GM level
AQP services £24m
MENTAL HEALTH Services• Pennine Care
• OOB Independent Sector£27m
Continuing Healthcare
£15m
Financial data is illustrative only (i.e. order of magnitude)
WPCAS – Future State (possible)
112
ACUTE Services
• Pennine Acute NHS Trust• Central
Manchester FT• Tameside FT
• Salford Royal FT• BMI Highfield
• Spire Oaklands• etc.
Subject to NHS choice promise
GP family list based care
EQUALS Level 1 e.g.- Nursing home support
- LTC care- Risk stratification- Insulin initiation- INR monitoring- Minor surgery
OOH Primary Care
Interface Services (Diabetes, MSK,
Urology, Gynae, ENT, Dermatology, Respiratory,
Ophthalmology, Gen Sur, Anti-coag)
Community Services;PCMH model & GM level
AQP services £24m £15m
DA Diagnostics• NOUS• MRI
£129m
TERTIARY Services
• Christie FT• Central
Manchester FT• Salford Royal
FT
CORE Primary Care & EQUALS Level 1
ENHANCED Community Based Medicine &
Diagnostics
A map of future Oldham healthcare services
increasing resource intensity
EQUALS Level 2
(Practice JVs incl. cluster level inter practice referrals)
examples:- Extended evening &
weekend clinics - Urgent care & walk in
appointments- LTC extended case
management- Consultant led diagnostics- Consultant education and
training programmes- Extended medical services
- Extended scope diagnostics
- Phlebotomy - Anti-coag
- Pessary
£10m
Systematic choice and direct listing when onward referring for surgery
Future CATS• Cardiology
• Total Skin Service• Pain
management?• Child
allergy/asthma?
CCG TOTAL£296m
Nb. OCCG incurs additional expenses to direct service delivery, including prescribing (£40m) and other elements (£33m)
CCG:£3m NHSE:£21m
CCG:£0m NHSE:£?
MENTAL HEALTH Services
Continuing Healthcare £15m
£27m
Financial data is illustrative only (i.e. order of magnitude)
CORE Primary Care
Limited inter-prac-tice referral services
Community Services
ENHANCED Com-munity Based
Medicine & Diagnos-tics
ACUTE Services; 63%
MENTAL HEALTH Services
Continuing Healthcare
Current State
CORE Primary Care
EQUALS Level 2
Community Services
ENHANCED Community Based Medicine & Di-
agnostics
ACUTE Services; 58%
MENTAL HEALTH Services
Continuing Healthcare
Future State
WPCAS – Resource Alignment (CCG Budget)
113
Acute spend will reduce to fund investment in extended primary care (i.e. EQUALS Level 2) and to support CCG efficiency savings.
Financial data is illustrative only (i.e. order of magnitude)
E. Better Care Fund
114
The ambition for health and social care services in Oldham for 2018/19
People in Oldham will be independent, resilient and self-caring so fewer people reach crisis point. For those that need it, we want to develop an integrated health and care system that enables people to proactively manage their own care with the support of their family, community and the right professionals at the right time in a properly joined up system. In a crisis, people in Oldham will know exactly what to do, who to contact, receive a rapid response and have their needs met in a completely organised, systematic and careful way.
As has already been described, the integration of services across Primary Care, Community Care and Social Care is a major priority for partners in Oldham. A significant amount of integration work has already commenced within the urgent care partnership, and the opportunities presented by the Better Care Fund to further work already underway is very much welcomed.
Our collective aims are simple: The Commissioning Partners (NHS Oldham CCG & Oldham Metropolitan Borough Council) wish to harvest our collective skills, talents and resources in order that we improve: 1: the macro (LTC Urgent Care Population) health status of a given population segment2: the experience of LTC & Urgent Care for the individual (provided & self-managed)3: to achieve this in a manner that demonstrates optimal resource management
This requirement spans the whole of the patient’s pathway experience from daily self-care, through core Primary Care into Community and Social Services, and subsequently into the Acute and Mental Health sector.
Oldham has established an Urgent Care Alliance, which is a partnership arrangement between the Clinical Commissioning Group, Local Authority, Pennine Acute, Pennine Care Foundation Trust and Go to Doc. All these organisations provide urgent care services in Oldham. The Alliance aims to change the balance of care with increased community based solutions and has an outcome based approach to commissioning and service delivery. The group has a ‘Memorandum of Understanding’, which outlines key result areas, performance frameworks and investment models. The deflections planned as part of the Better Care Fund have been negotiated out of contracts, and are in the sight of the Alliance, who are working together to determine their respective contributions to this ambition.
Consultation and engagement with providers will continue over the coming months as the detail within the schemes associated with the Better Care Fund is developed. The Council currently holds regular (every other month) meetings with residential and domiciliary care providers, and these meetings will also be used to consult on the development of plans.
In addition to this, consultation and engagement will take place with wider partners and other initiatives in the borough in order to ensure wider linkages with other reform activity such as Healthier Together. Bespoke consultation and engagement will also take place with housing providers in Oldham, as they are particularly strong with regards to their work supporting health and social care activity in the Borough.
• The Oldham Family will benefit from staying healthier longer within their own homes with the support of their family and community.
• Partners will work together to help people to stay well and remain independent.
• There will be improved access to the right services at the right time.• There will be holistic management of long term conditions with the person in
control of their care.• When people become unwell, health and social care will be co-ordinated to
ensure they receive continuity of care• People will feel in control of their conditions and circumstances and regain
confidence
What difference will this make to patient and service user outcomes?
Principles of the Better Care Fund
This fund is intended to provide a catalyst to improve services and value for money, by creating a shared plan in the form of a five year strategy for health and social care, overseen by the HWBB.
Based on national guidance, the principles are that the fund must:• Demonstrate clear health benefit• Manage risk • Demonstrate impact• Improve quality• Improve value for money and guarantee £1 spend on social care is mitigated by £1 saved from urgent care in
the whole• Build on the existing integration plan• Be evidence/intelligence based (but not afraid to try something new)• Support demand management and reducing overall levels of need• Support improved outcomes for citizens by intervening at the earliest point• Be organised around a Primary Medical Home Model• Be cognisant of/work in tandem with other key initiatives (such as Healthier Together/PSR)
The Council and the CCG will, therefore, have to redirect funds from existing activities to shared programmes that deliver better outcomes for individuals by adopting a shared approach to delivering services and setting priorities, through the HWBB, in order to shape sustainable health and care for the future. These programmes will be developed taking account of local commissioning challenges and budget pressures.
Schemes within the Better Care Fund
The key schemes covered by the Better Care Fund programme include;
1. Healthy, independent and active citizens• Full Integrated Health and Social Care Teams to offer joined up assessment and care management across all adult
care areas• Integration of Intermediate Care and Reablement to provide a fully joined up and efficient rehab offer for Oldham• Developing a quality care home offer with appropriate clinical and social support• Further integration of Continuing Healthcare, to provide a fully joined up approach2. Development of an integrated support offer for carers that supports and sustains them in their caring role3. Developing an Integrated Support Offer for people with dementia that promotes community options aimed at maintaining independence
In addition to the schemes outlined above, there are additional key cross cutting programmes of work which will support the overall aims of the integration work.
Our work on Falls is one of these key areas. Falls and osteoporosis are significant public health problems for older people, being associated with significant morbidity and mortality. If we can ensure that the risk factors associated with falls are addressed more effectively, it should have a significant impact on long-term impacts on people’s quality of life and the ability to remain living independently.
Our pilot scheme on alternative to transfer will also be a key cross cutting area of work important to the success of the aims set out in this submission. A joint pilot with Tameside & Glossop CCG of the Alternative to Transfer pilot which has run successfully in central Manchester. Alternative to Transfer (ATT) is a process where North West Ambulance Service (NWAS), using the pathfinder tool, identify patients who are safe to be left at home if a clinical assessment can be made within two hours.
Schemes within the Better Care FundAnother cross cutting piece of work relates to the experiences of children in the integrated system. Further work to understand the impact of the integration of health and care on children is also being developed for the purposes of this fund. Specific areas include;
• Integrated teams across H&SC• CAMHS• Re-specification of children's services in relation to the rapid response service and enabling GP's to reduce admissions to PAU by 50%• Troubled families• Paediatric consultants attached to clusters
The two capital elements of the Better Care Fund are the Disabled Facilities Grants and a Social Care Capital Allocation. These capital elements will be used to support the aims and objectives of our key schemes, as an important, cross cutting element of our approach.
The current impact on acute service non-elective activity, as a result of the integration agenda is as follows:
• 2014/15 - £2.2m (£1m children and £1.2m adults)• 2015/16 - £500k (100k children and 400k adults) The reduction in adult admissions will be contributed to significantly, by the actions, which have been described as part of this plan. These deflections have been negotiated out of the contract with acute providers, with a clear capacity reduction profile in place.
Delivery of these reductions should not compromise service performance; however commissioners will need robust systems in place to ensure on a monthly basis, that deflection schemes are delivering to plan. This will be a key focus for the urgent care alliance in 2014/15, to ensure that all organisations are contributing effectively to achieve the required deflections.
With regard to elective care, a number of community based integrated services will be established, however these will remain out the scope of the Better Care Fund, and remain within the Clinical Programme area plans.
Applying measures of health gain to our population
National measures;1.Number of unavoidable emergency admissions2.Delayed transfer of care3.Effectiveness of reablement (% still at home 90 days after reablement)4.Reductions in admissions to residential care•Local indicator proposed to be –dementia diagnosis rate•Dementia diagnosis rate – Oldham 55.1%. National 44.2%. 12/13 – 57.8%•Supplementary indicator - falls•User / patient experience of care will be measured, however this will not be linked to payment
Oversight and Governance of Better Care Fund
H&WBBOverall ownership
ICPManages delivery,
process and outcomes
Council CabinetAdditional approvalsCCG Governing
BodyAdditional approvals
Transformational Change Programme
Urgent care alliance
F. Access to the highest quality urgent and emergency care
Access to the highest quality urgent and emergency care
The CCG has established an Urgent care alliance to deliver the Managed care model previously described ( see integration section). The Alliance is underpinned by a memorandum of understanding, signed by partner organisations. It is anticipated that the Urgent care partners will work in shadow form in 2014/15 with agreed elements of budgets pooled and operating a combined performance framework. The CCG has a defined set of interventions to be implemented through 2014/15, developed by the CCG membership, the Clinical Directors and the Alliance. These interventions have been informed by the Urgent and Emergency Care review and its associated design principles.
Regulation of urgent care performance is undertaken locally through the urgent care the Alliance (see Governance and Terms of reference diagram). However the CCG effectively contributes the North East Sector Urgent Care Board for Pennine Acute Hospital Trust, supported by the Greater Manchester Commissioning Support Unit Utilisation Management team.
Urgent care performance and emergency /winter planning is currently managed through the following forums•Daily tactical conference call (Urgent care providers). •A CCG level via a weekly teleconference with all urgent care providers (CCG coordinated in times of sustained pressure)•A weekly North East Sector Tactical Group (Urgent Care Working group).•Monthly Urgent care Alliance Leadership and Management team meetings•Monthly North East Sector Urgent Care Network Board ( our Urgent Care Working Group)•Quarterly HERG
The CCG continues to work with Go to Doc Ltd and NWAS as current providers of elements of the 111 service. The CCG will continue to work collaboratively with Greater Manchester on the development of the new 111 service, and ambulance commissioning.
The CCG will continue to participate in the Healthier Together programme which may impact on the type of provision of urgent care services across Greater Manchester. We will continue to progress our integration agenda at pace to support the 7% and 8% attendance and admission reductions seen recently.
Urgent Care & Long Term Conditions Governance Arrangements
Alliance Leadership Team
Alliance Management Team
Governing Body
Executive Regulation of Finance, Performance
& Quality
CPAG (assurance of Primary Care)
MembershipCCG: Ian Wilkinson/Dave McMaster/Denis Gizzi/Julie Daines/ Kath Wynne-JonesGo to Doc: David Beckett/Brian LewisLA: Alan Higgins/Maggie Kufeldt/Steven Mair/Michael JamesonPAHT: Hugh Mullen/Brian Steven/Nick GiliPCFT: Martin Roe/Michael McCourt/Judith Crosby/Ian Watson
Terms of Reference1. To develop and own the implementation plan for integration for UC & LTC across Oldham, focusing on the domains within the aqua integration framework2. To ensure the alliance is effective in delivering outcomes in line with the success criteria and the performance framework3. To regularly review the performance of the alliance and risks arising from the implementation plan4. To ensure that integrated working is successfully embedded within partner organisations
Integrated Health & Social Care
Teams delivery group
Nursing home delivery group
EOL delivery group
Carers delivery group
Dementia Alliance
Response/Reablement review group
Falls implementation
group
Children’s Programme
Board
MembershipCCG: Dave McMaster/Kath Wynne-Jones/Julie Flanagan/Ian MilnesGo to Doc: David Beckett/Jane PughLA: Maggie Kufeldt/Paul CassidyPAHT: Nick Gili/Steve TaylorPCFT: Ian Watson/Marie Forshaw
Terms of Reference1. To determine the strategic direction of the health economy in relation to integration, considering the financial stability of all organisations. The initial focus will be urgent care and long term conditions in the first phase, with a view to expansion to other clinical areas in the future.2. To agree and regularly review success criteria and outcomes of the partnership and progress against the performance framework.3. To ensure the organisational infrastructure and associated development plans are in place to support the integration agenda across all partners. This will include the establishment of a dedicated programme team.4. To ensure the vision for integration is successfully cascaded through partner organisations. 5. To monitor delivery of the integration plan by the alliance management team. 6. To resolve issues that cannot be addressed by the alliance management team.
Performance & financial framework & IMT task & finish
groups
J:CCG/UC & LTC gov arrange.ppt(ak june13)
G. A step change in the productivity of elective care
Achieving 20% productivity improvement
within 5 years •Elective care productivity improvements will be realised by the CCG through the three efficiency domains; Allocative, Technical and Market Efficiency. •The CCG has a track record of effective elective care demand management systems, including Referral Governance systems and pioneering Clinical Assessment & Treatment Services (CATS). The challenge now exists to integrate pathways involving multiple providers to fully realise efficiencies and improve patient experiences. Also, innovations such as Advice & Guidance and Referral Decisions Support systems that intend to reduce unnecessary utilisation of high-cost specialist services must become embedded standard practice. •NHS Oldham CCG’s commissioning approach includes clinically led programmes, with assigned Clinical Directors and Programme Managers, with activities tracked through the Programme Management Office. The Elective Care programme is progressing a number of systematic schemes that intend to drive large-scale efficiency in high volume elective care pathways - these include:•Integrated Pathway Hubs (IPH)
– An IPH (i.e. prime vendor) has been assigned to coordinate activities across musculoskeletal (MSK) pathways. This provider will hold other providers to account for delivery on pathway reform. Schemes include fracture clinics, direct listing from primary care and pain management.
– This model will be adopted for other specialities to empower providers to integrate whilst realising resources to meet the productivity challenge.
•Referral Management Protocols– Application of evidence based clinical thresholds.– Referral triage systems.– Peer review of referral decisions (GP & Consultant).– Onward referral and direct listing monitoring (i.e. measure integration)– Patients receive a choice of Provider in good faith and on an objective basis without any prejudicial bias.
•Advice & Guidance– Innovative systems to enable GPs to access specialist advice to enable rapid diagnosis and treatment in primary care.
Acute service reconfiguration as part of the Healthier Together programme, and Trust provider CIP plans will also drive this productivity improvement.
127
5. The Enablers
128
A. Communication, engagement and citizen participation
129
130130
Communication and engagement– listening to patients views
The Everyone Counts guidance sets out the expectation of a “new approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care” and a requirement that our Strategic Plan will demonstrate “how you will include authentic citizen participation in the design of your plans”. Our Strategy is also mindful of the requirements of:
• Sections 14Z2 and 13Q of the Health and Social Care Act 2012• Best practice in this area including the recent guidance from NHS England - Transforming Participation in Health and Care and the
Smart Guides to Engagement series produced for NHS Networks.• The expectation of local patients and groups that they will be involved in all aspects of our work
Our approach to citizen engagement reflects our wider approach as an organisation - accountable, accessible, transparent and honest about our strengths and the areas we strive to improve and the challenges we face.
After consulting the public, we adopted three key principles to guide our engagement work:
• Accessibility, equitability and supporting involvement• Honesty, accountability and transparency• Responsive engagement with clear outcomes
Together, these set out an ethical framework against which the CCG invites the public to judge our engagement activity.
The stakeholders we will communicate and engage with have been informed by our stakeholder mapping. The key mechanisms used to interact with these various groups are illustrated in the table overleaf where the audiences have been segmented.
Our approach is to engage for breadth and depth:
• Breadth – reaching as many people as possible to gather their views and experiences, for example social media interaction, and the listening and responding patient experience tool
• Depth – reaching those who are least likely to otherwise have a voice using bespoke proactive, often face-to-face work, for example working with asylum seekers and people with learning disabilities or chaotic lifestyles.
Our Communications and Engagement Strategy is closely linked to our EDHR Strategy and specifically references the 9 Protected Characteristic Groups with the aim of ensuring no one is left out of the CCG conversation.
Our biggest citizen involvement assets are our clinical leadership and wider membership. We will work to develop new ways to systematically harvest patient insights through their clinical interactions.
We will undertake specific work to encourage all our member practices to have a Patient Participation Group and to develop existing Groups to become a powerful resource both at practice level and for the wider health economy.
The following slide shows our approach in relation to communication and engagement for all stakeholders.
The CCG has held Board to Board meetings with its major health providers, and OMBC to consult on the integrated care strategy, and its implications for the local economy. The HWBB have also been involved in development and have received key strategies, which are aligned to the Health and Wellbeing Strategy for Oldham.
We have also recently consulted with all our key stakeholders to understand how we can our engagement approaches more effective
We will continue to understand the impact we are having for our population, through the use of patient stories at our Governing Body.
Stakeholder Group Mechanisms to reach and interact1 Public •the wider public and communities of place and interest (including protected groups)
• Information via the local and regional press and media• Via Practice Reference Groups (PFGs)• Via specialist media i.e. Asian News • Via community events and outreach work• CCG website • Appropriate social media platforms • Public events, presentations etc..• Via targeted work to reach protected characteristic groups • Through local voluntary sector groups
2 Patients•all users of NHS services including mental health service users, carers etc.., including Practice Reference Groups.
All the above in ‘Public’ plus:• Via contact through the Patient Advice and Liaison Service and the Complaints
Service• Clinical interactions with patients • Specific engagement and involvement work with user groups
3 Members•Oldham GPs and primary care practitioners, practice nurses, practice managers etc.. including LMC, LOC, LPC and LDC.
All the above in ‘Public’ plus:•Via monthly cluster meetings attended by a CCG representative•Monthly ‘Cluster Cascade’ PowerPoint briefing •Fortnightly ‘Oldham CCG Matters’ e-newsletter •Individual letters and contact•Clinical involvement events and networking•Educational events•Engagement events
4 Oldham strategic partners•Health and Wellbeing Board, Oldham Council social care directorate, Overview & Scrutiny Committee, Public Health team, Healthwatch, and the voluntary, community and faith sector.
All the above in ‘Public’ plus:•Formal partnership meetings and forums•External CCG newsletter•Formal reports and events e.g.: Annual Report and AGM
5 Providers•Acute, Community, Out of Hours, and other providers including those not commissioned by the CCG (i.e. Primary and Specialist)
All the above in ‘Public’ plus:•Formal business and contract meetings•Networking and stakeholder meetings•External CCG newsletter
6 Opinion formers•Three local MPs, MEPs, local councillors, local and regional media, staff side reps
All the above in ‘Public’ plus:•Formal communications e.g. letters and reports•Personal face to face briefings•Press conferences, briefings, meetings and press releases
7 NHS stakeholders•Commissioning Support Service, Other North East Sector/ Greater Manchester CCGs, , NHS England (Local Area Team) , NHS North, DH, Public Health England, regulators.
All the above in ‘Public’ plus:•Formal communications e.g. letters and reports•External CCG newsletter•Assessments
8 Staff •NHS Oldham staff, Clinical Directors, own assigned staff, off-site and co-located commissioning support unit staff, staff side reps
All the above in ‘Public’ plus:•Monthly ‘Cluster Cascade’ PowerPoint briefing •Fortnightly ‘Oldham CCG Matters’ e-newsletter •Formal staff letters•Internal email communication•Face to face team briefs•Staff meetings and informal drop ins
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Our engagement so farKey themes arising from our ‘A Call to Action’ engagement, and have shaped our vision have been:• The need to reduce fragmented care for people with long term conditions• The need to make services more responsive and patient-focused• An increased expectation of patients’ involvement, both in their own care and in commissioning• A widespread understanding and acceptance that the NHS needs to change to be sustainable• Concern that key local services are protected
Since its beginnings as an aspirant GP Commissioning Consortium, and before that a PBC Consortium, the CCG has developed an ongoing dialogue with patients, service users, carers and the wider public to understand their needs, opinions, priorities and concerns. This ongoing work has created a body of knowledge which has shaped the Plan. Our population have co-created with us the concept of the ‘Oldham family ‘The ultimate key success factor will be for our people (our Oldham family) to tell us that they have seen a positive difference to the way in which contributors to their care are more organised, systematic and appreciative of their individual care requirements. More recent work undertaken includes the Wrapping Care Around You public events held in June 2013. These clinically-led events gathered experiences of people who had accessed both health and social care services and went on to shape local thinking about how the two could be brought closer together. Arising from this, a series of story videos were produced, highlighting the experiences of people living with long term conditions and who had both good and poor experiences of joined up care. Local conversations on the Healthier Together hospital reconfiguration programme and the out of hospital care element of this have also been held. Further consultation and engagement on this related programme of work will also continue in Oldham as the programme develops. Other recent work which has fed into the development of this plan includes an all-day Patient Summit held in December 2013; the establishment of an Equalities Panel comprising patients representing the protective characteristics; the use of social media to engage the wider public, particularly younger people; and ongoing engagement and dialogue with Oldham Healthwatch and the wider local voluntary sector. Other significant engagement and consultation exercises with citizens have also been undertaken on specific and associated areas of work relating, including;• Provision of specialist dementia services• Falls• Extra care housing• Care at home• Events and forums with carers Themes running through the public conversations have centred on key issues concerning independence, self-reliance and integration. As part of the CCG communication and engagement platform, we regularly review the ‘you said, we did’ framework.
“Wrapping care around you”
Joining up care for people with long-term conditions
• The CCG held Clinically-led events in June 2013 focusing on joining up care for people with long-term conditions.
• The CCG set out the key issues: People are living longer, often managing one or more long-term conditions and experiencing care is generally good but often un-coordinated, leading to fragmented care, duplication and avoidable admissions to hospital.
• It was explained that the end of the current contracts for community services presents an opportunity to rethink how community services are managed and delivered.
• Gathered patient experiences of health and social care and developed ideas for joining up care more effectively.
• Key insights gained:• Lack of co-ordination means patients can lack confidence that their conditions are being
managed properly.• Patients aren't sure who to call when they are worried or their condition exacerbates.• It is not clear who is ultimately responsible for patients’ health and wellbeing.• Communication between care organisations and providers is sometimes poor or non-
existent leading to patients repeating their personal details and medical history over and over again.
The CCG then set out its ideas, including GP-led locality teams to test these with the patients present. These were well received. The role and modus operandi of the teams was discussed at length.
Key patient priorities for the new community services were:• A joined up patient experience, bringing together the different kinds of care and
support that patients need from various providers.• Planned, timely care especially for patients with a long term condition.• Reducing repetition and duplication, preventing the need to explain your needs and
experiences to numerous health and social care professionals.• Genuine continuity of care.• A personal, tailored service wherever possible.• Shared decision making between patients and the people who look after them
Arising from the events, we commissioned a series of video ‘patient stories’ with some of those attending to capture their experiences of joined-up and fragmented care and bring it to the attention of a wider audience.
Further patient stories can be found here:
http://www.youtube.com/channel/UC2LY1vn3wdfS-GNmZKcD4Bw
• Patients were involved on the selection panels for each of the 6 ‘lots’ of community services.
• For the core community services lot, the scoring for patient experience was delegated entirely to a team of patients, supported by CCG staff.
• The patient team reviewed and score each bid for the written answers, presentations and oral questions.
• This proved very successful for the CCG as well as rewarding for the patients involved who gave a considerable amount of their time to this task.
The CCG engages the public in a series of ongoing dialogues with the aims of:
• Gaining a constant stream of intelligence about patients’ experiences and views, including those who are hardest to reach.
• Providing an ongoing narrative to ensure the CCG’s work is understood and misconceptions or surprises are avoided.
Key ways we have this dialogue are through regular public events, through our Equalities Panel, through our close relationships with local voluntary sector organisations, through our members’ Patient Participation Groups and through the use of social media.
The CCG is planning to hold four public events in March 2014 to feed back on progress on local integration, including one in Urdu.
You Said We didYoung men told us they wouldn’t attend CCG events but they would engage through social media.
The CCG has developed a social media strategy to reach out to people who don’t want to engage in traditional ways.
Patients with COPD told us they couldn’t afford to heat their homes, leading to their conditions exacerbating
The CCG, with Oldham Council, has invested in a winter warmth programme to provide new boilers and insulation to patients on low incomes.
Local south Asian patients told us they didn’t know who to turn to when things go wrong with their care.
The CCG is developing a project with community groups to develop new approaches to signposting available support
People with long term conditions told us their services were fragmented and not responsive to their needs.
The CCG developed a new model of local integrated health and social teams led by clusters of GP practices
People with dementia and their carers told us they lacked support and found it hard to access services.
The CCG and partners set up Oldham Dementia Partnership and is holding a Conference to make Oldham a Dementia Friendly Community
Shared Decision Making and Self-Management Support
Shared decision-Making is a process through which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and patients’ informed preferences. It involves the provision of evidence-based information about options, outcomes and uncertainties, together with decision support counselling and systems for recording and implementing patients’ treatment preferences’ (The Health Foundation).
Shared Decision Making and Self-Management Support share many characteristics. They are both ways of working that are characterised by clinicians valuing and respecting the unique perspectives and preferences of individual patients, and working in partnership with them to support them to make decisions and take daily actions that are right for them.
Where they differ is that the purpose of Shared Decision Making is to ensure that patients make an informed, confident discrete episodic decision and they become daily ‘activated problem solvers’. In essence, Shared Decision Making supports patients to make a single decision with the clinician, whilst Self-Management Support enables them to become confident daily decision makers and problem solvers in managing the day to day effects of living with a Long Term Condition.
Evaluation of the LTC6 Questionnaire (measures motivation and confidence) and the Collaborate Tool (Advancing Quality Alliance) in Oldham, revealed that although patients were reasonably satisfied with the care they received they did not feel confident to manage their long term conditions without additional self-management support.
The EQALS scheme includes implementation of Shared Decision Making within primary care. Training is currently being provided for primary care and community staff to support implementation, which will enable the change in culture and behaviour required to improve patient confidence and self management of their conditions.
A Directory of Services of local support and community assets has been developed which will help facilitate access to self care support. This is available for staff to utilise during consultations with patients. This will also be available electronically on the Local Authority and CCG websites. A Business Case is currently being developed to embed Shared Decision Making and Motivational Interviewing across the CCG, as part of the long term condition management platform.
Motivational Interviewing is based on three key elements: collaboration between the clinician and the patient, drawing out the client‘s ideas and beliefs about change and building from where the patient is and emphasising the autonomy of the client so they develop and decide what they are going to do and take ownership.
The expected outcomes of embedding these changes will include :
• Increased knowledge and understanding of their condition and treatment;• An increase in patients feeling they have been actively engaged in their care and treatment ;• Improved Patient Confidence, motivation, skills, resourcefulness and resilience in self-management of their
condition(s);• An increase in individuals taking responsibility for their own health and wellbeing;• A reduction in DNA and demand on health and social care services;• A reduction in hospital readmissions and unplanned service use where lifestyle behaviours and symptom
management are key factors;• Improved clinical outcomes and indicators such as HbA1c, incidence of emergency admissions; • Improved patient satisfaction- family and friends test;• Improved lifestyle - changes to smoking, weight and exercise;• Improved medication compliance;• Improved communication between clinicians and their patients, and amongst peers and colleagues.
B. IM&T
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Delivering better care through digital revolution
The aim of embedding Shared Decision Making, Self-Management Support and Motivational Interviewing across the health economy will facilitate staff to support patients to become more confident in managing their conditions in their home environment.
These techniques can be underpinned by the use of assistive technology for certain patients with long term conditions, enabling self-monitoring of their own condition(s) and resulting in a reduction in hospital admissions. These technologies include Telehealth, Telecare and Mylinqs. All patients who are referred to the Integrated Team have a personal care plan, specific to their needs, which is established within 5 working days. This at present can include Telehealth for respiratory conditions.
The care plan includes contact information and an escalation plan which is accessible in the patients home and in the GP health record. This ensures that patients receive safer care and avoids duplication of information. Work is in progress to inform NWAS and the Out of Hours provider that a Care Plan is in place.
Greater access to web tools and the creation of a digital ‘front door’ will help transform the way patients, their families and carers access information about NHS services and will provide self-management materials and information to further empower them to manage their own condition.
The Clinical Digital Maturity Index has been developed by EHI Intelligence in partnership with NHS England, and is currently being applied within Oldham. This is a unique benchmarking tool that enables NHS Trusts to better understand how investing and effectively using, information technology can achieve better patient outcomes, reduce bureaucracy, improve patient safety and deliver efficiencies.
Oldham CCG procures it IM&T services from our local CSU (Greater Manchester Commissioning Support Unit). In collaboration we are working to develop an Integrated Care Record that combines all aspects of a patients care and is stored securely in a single repository. This will support ease of access and transparency of information across the care providers.
Oldham CCGs IM&T strategy will describe our intentions and timescales for delivery.
Within our local data warehouse we already combine primary and secondary care data from 100% of our practices for commissioning purposes, and we aim to maintain these systems going forward.
Delivering the Operating Model – Securing Excellence in GP IT Services
WHAT WE NEED TO DO:1. Support delivery of high quality care to patients by
general practice.2. Support innovation in the provision of patient care.3. Provide a solid IT platform on which to build future
service improvements.
WHY WE NEED TO DO IT:1. Changing Patient Needs2. GP Centred Care Vortex3. Efficient and Responsive Integrated Services4. Restrictive Financial Environment
WHAT DOES THAT MEAN LOCALLY?This will be achieved through the continuation of national programmes combined with locally defined projects to achieve world class digital systems that support high quality provision whilst empowering patients to have greater control over their health and care.
WHAT ARE THE WORK PROGRAMMES?• Centrally Hosted Clinical Systems• ECC - Electronic Clinical Correspondence• GP2GP - Electronic Records Transfer• Upgraded Hardware & Networks• APR - Access to Patient Records• EPS - Electronic Prescribing• SCR - Summary Care Record• Integrated Care Record• Mobile Working / Virtual Clinics
How do these projects support our organisational goals?
GP IT Systems – Work Programmes 1
EPS - Electronic Prescribing
EPS enables prescribers – such as GPs and practice nurses – to send prescriptions electronically to a dispenser (such
as a pharmacy) of the patients choice. This makes the prescribing and dispensing process more efficient and
convenient for patients and staff.
GP practices are contractually required to promote and offer the facility for patients who wish to order online,
view and print a list of their repeat prescriptions for necessary drugs, medicines or appliances.
This will be facilitated through the hosted clinical system and the EPS project for 32 practices in Oldham within the
financial year 2014/2015
SCR - Summary Care Record
The Summary Care Record is an electronic record which contains information about the medicines a patient takes,
allergies they suffer from and any bad reactions to medicines that they have.
Having this information stored in one place makes it easier for healthcare staff to treat patients in an emergency, or
when their practice is closed.
Within Oldham there are 7 practices that still need to input into the summary care record. This project is planned to be completed within the financial year
2014/2015.
Integrated Care Record
Good records are at the heart of professional practice. Moreover, good healthcare delivery, best use of healthcare resources, and delivery of a cohesive service that satisfies an
increasingly demanding population can be achieved only with good communications and a shared clinical perception of a patient's problems and needs—seamless care is difficult to
achieve without seamless information.
Oldham CCG are part of The North East Sector Integrated Patient Care Project. The project’s aim is to deliver a single best patient view of fragmented patient information spread across multiple organisations through an IT solution. The solution will support direct patient care and contribute to the improvement of patient outcomes. Subject to consent and privacy
rules anyone involved in the delivery of care for an individual will have a view of the patient record tailored to their role irrespective of where they are in the patient journey.
The project is currently at tender stage.
Upgraded Hardware & Networks
Further investment in networks is planned to strengthen the already robust fibre links across Oldham. Possible options are to join the Greater Manchester COIN or alternatively
continue to develop the local COIN.
Higher bandwidth networks will offer major benefits in delivering better healthcare for patients by allowing GP’s to securely access and share vital information across multiple
sites. Such as viewing x-rays and medical notes in their surgeries when meeting patients, rather than waiting for them to arrive in the post.
Improved networks is also a critical precursor to enabling integrated care effectively.
Several options for progression are available locally that are being discussed at present.
GP IT Systems – Work Programmes 2EMIS Mobile / Virtual Clinics
Through the increased use of wireless connectivity and 4G technology, alongside innovative technological developments by clinical systems providers, it is the vision to be able to provide
access to healthcare for patients in the comfort of their own home, office or even on the move through the use of mobile working and virtual clinics.
Virtual clinics can be carried out over the phone or via video conference at a pre arranged time to suit the patient. This may support access outside of traditional opening hours or at
weekends.
Developments in clinical systems can now allow clinicians to carry vital patient records on their tablets/pc’s.
This project is currently in the concept phase.
Centrally Hosted Clinical Systems
GP systems will need to integrate with the wider community in order to support the future service delivery requirements across Primary, Community and Social Care settings. Therefore, future investment in GP system supplier ‘Next Generation’ clinical systems (that are hosted, web-based, patient centric systems) must deliver the functional capability and flexibility to
respond to these changing requirements as and when appropriate.
Within Oldham, for the most part this will be delivered through the migration away from older clinical systems onto EMIS Web for 13 remaining practices within the financial year 2014/2015.
GP2GP - Electronic Records Transfer
GP@GP enables patient’s electronic health records to be transferred directly and securely between GP
practices. It improves patient care as GPs will usually have full and detailed medical records available to
them for a new patients first consultation.
GP2GP starts when a practice accepts a patient onto their list of patients for primary health care and ends when the EHR (electronic health record) is transferred
from the previous practice into the new GP clinical system.
Within Oldham all practices require GP2GP facilitation within the financial year 2014/2015.
APR - Access to Patient Records
A number of IT related changes have become part of the GP contract from April 2014. GP practices are required to promote and offer the facility for patients to view online, export or
print any summary information from their records, i.e. medications, allergies, adverse reactions and any additional information agreed between the GP and the patient.
We will need to publicise plans by 30th September 2014 outlining how we will achieve this requirement. Within Oldham this will be facilitated through he hosted clinical systems for all
practices within the financial year 2014/2015.
ECC - Electronic Clinical Correspondence
The EDT Hub solution enables NHS provider organisations to send all of their patient clinical
correspondence electronically to their respective GP practices. GP practices will receive their patient letter
electronically into the heart of their electronic document management system. This is the work
flowed around the practice using Docman.
Sending clinical correspondence electronically supports patient safety, improves efficiency and staff
processing time and saves money.
Within Oldham there are 8 practices remaining that will join the project within the financial year
2014/2015.
EMIS Mobile / Virtual Clinics.
Through the increased use of wireless connectivity and 4G technology, alongside innovative technological developments by clinical systems providers, it is the vision to be able to provide access to healthcare for patients in the comfort of their own home, office or even on the move through the use of mobile working and virtual clinics.
Virtual clinics can be carried out over the phone or via video conference at a pre arranged time to suit the patient. This may support access outside of traditional opening hours or at weekends.
Developments in clinical systems can now allow clinicians to carry vital patient records on their tablets/pc’s.
This project is currently in the concept phase.
C. Workforce
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WorkforceHaving a robustly skilled workforce in the local economy , is obviously key to delivery of this strategy, and we have considered this within the staff and skills sections of our developing OD plan.
We are working with local academic institutes to discuss the establishment of more generic career paths, to support integration across health and social care , and are engaged with national strategic bodies with regard to highly demanded skills, essential to support the integration agenda, such as General Practitioners.
As Commissioners we are not responsible for determining the workforce our local economy requires, however fully recognise our responsibilities when commissioning services, to ensure that the provider has the appropriate workforce in place to deliver our required outcomes through an effectively mobilised service. We are also mindful of the effect that our commissioning decisions may have on employment within the town of Oldham and the potential effects of this within the wider determinants of health. Within any procurement (which has been our preferred approach to stimulate the market), a significant weighting is given to how robustly the service provider can articulate and mobilise their workforce intentions and we have commissioned panel representatives with specialist skills to inform our decisions. Our processes have fully considered the ability of the provider to be able to support the development of new types of worker (for example with acute and community skills in diabetes management) but also relating to their ongoing education and development. We also recognise that our triple aim strategy that aims to provide care closer to home is to some degree reliant on having the right staff with the right skills in the right place at the right time and to this end we have supported our clinical programme leaders to develop an educational programme that enables knowledge and skills development within key clinical programmes across our primary care workforce. To date we have held development events in Shared Decision Making, Long Term Conditions Management, Cancer Care, Respiratory Care, Vascular Care, Children and Young People, Dementia Awareness and Supporting Care Homes. These events have been held in conjunction with clinicians in acute and community services and have also seen public engagement. We are also currently working with AQuA to support development of Shared Decision Making. We have supported general practice based staff to access e-learning programmes through sponsorship of the Bluestream Academy practice based e-learning programme and are also supporting Practice Nurse Forum that looks to help this staff group to explore future knowledge and skills. A learning forum for new GPs is also under development.
Our innovative Dragons Den programme has a number of schemes where we will be able to gain new knowledge and we will be undertaking a full evaluation of this alongside a funded OD programme to share lessons and good practice that may enable more speedy development of skills and new ways of working.
We fully recognise that patients and the public are some of our greatest assets to reduce demand on healthcare, and are working closely with OMBC, to develop an approach to effectively mobilise community assets, to support improvement of health and wellbeing in Oldham.
D. Collaborative commissioning
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We will work collaboratively with our partners in OMBC, the North East Sector, and Greater Manchester through our collaborative commissioning arrangements where it makes sense to do so.
The Better Care Fund will be the main vehicle by which we progress our joint commissioning agenda with OMBC.
The stability of PAHT will remain a key concern for all of the North East Sector CCG’s across the duration of this plan. We will adopt a collaborative approach to the contract management of our main providers across the North East Sector (PAHT and PCFT) to ensure delivery of performance, quality and financial requirements, supported by individual CCG contract schedules. We will also take a collaborative approach to the quality assurance of CIP schemes across these providers.
Healthier Together will transform the way in which health services are provided across Greater Manchester in the future. This is being led by CCG’s across the footprint. This strategy and future iterations, will be developed in the context of this strategic landscape. The Healthier Together programme is intended to deliver a better way of providing high quality, safe, accessible healthcare services by thriving, viable organisations within the future funding envelope. The CCG will continue to contribute effectively to this agenda.
North East sector CCG’s / AGG
OMBCOldham NHS CCG – UNIT OF PLANNING
Commissioning Support Unit
Contract interface / Provider
Sustainability / Healthier Together
strategy
CCG commissioning arrangements
ICH
Oldham integrated commissioning hub: A joint strategy for Oldham / Joint
Commissioning - the Better Care Fund 153
North East Sector
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The North East Sector Approach to Commissioning - 1The CCGs in the North East Sector of Greater Manchester include:
• Bury• Heywood, Middleton and Rochdale• North Manchester, and• Oldham
Together, the North East Sector CCGs have established a partnership, underpinned by a formal agreement. This formal agreement builds on the previously established arrangements in the North East Sector, with the aim of implementing a partnership approach to the commissioning of secondary care (hospital) services where this makes sense. A joint Commissioning Board has been established, which has authority to make decisions in the best interests of CCGs across the North East Sector - staff are working collaboratively across the sector to cover collective agendas e.g. performance improvement.
• The North East Sector Commissioning Board has the responsibility to: • Review, plan, procure and performance monitor agreed services to meet the health needs of Members’ populations as
follows:
1. Acute (hospital) services, (particularly the contract with Pennine Acute Hospitals NHS Trust)
2. Mental health services
3. Community services
4. Cancer services• To undertake reviews of services, manage the introduction of new services, drugs and technologies and oversee the
implementation of NICE (National Institute for Health and Clinical Excellence) and/or other National guidance or standards relating to the services being collaboratively commissioned.
• To coordinate a common approach to the commissioning of services from the defined providers, with a particular focus on the financial viability.
• To manage the budget for commissioning the agreed services, be held accountable for its use, and develop financial risk sharing arrangements.
• To develop, negotiate, agree, maintain and monitor service level agreements/contracts for collaboratively commissioned providers.
• To work in partnership with other commissioners across Greater Manchester and the North West, and act as lead commissioner where agreed.
The North East Sector Approach to Commissioning - 2
Principles upon which the Commissioning Board is based include:
• The Commissioning Board will support member CCGs in working to achieve financial stability by effective collaborative commissioning of major contracts
• The Commissioning Board will support Member CCGs in striving to reduce the inequalities in access to and delivery of services for the populations the Member CCGs served through the effective negotiation of borough level schedules
• Commitments made by the Commissioning Board will be binding on all Members.• In commissioning and procuring services, the Commissioning Board will support member organisations to comply with all
applicable statutory duties.• The Commissioning Board will review, plan, develop and monitor the agreed services in partnership with clinicians, providers
and service users.• The Commissioning Board will maintain close working links with service providers, clinical networks and other commissioners
or commissioning groups, fora and partnerships.• A standard facilitation/arbitration procedure will apply should disputes between Members arise.
The North East Sector Commissioning Board (CB) is the body mandated by the four North East Sector CCGs as set out in the North East Sector Partnership Agreement. Delivery at a North East Sector Level is underpinned by two work streams
• Programme Level Development Boards (DB) with a focus on the development and implementation of new projects and work streams to improve health outcomes and/or the efficiency of delivering those outcomes.
• Operations and contracting with a focus on contract, quality and performance monitoring and taking action to address performance issues will become the responsibility of these groups.
The North East Sector Approach to Commissioning - 3Strategic Transformation• The priority work stream for 2013/14 has been the management of the economic challenges across the North East Sector
Health and Social care economy over the next 5 years. To this end, a North East Sector Health and Social Care Board has been established, accountable to the North East Sector Commissioning Board.
• The shift away from hospital based care, and the development of primary, community and social care will lead to a reduction in bed utilisation by avoided admissions and a reduced length of stay for some patients. We recognise that whilst activity will decrease, the average length of stay for some patients may possibly increase, as the acute sector deals with a more complex patient spectrum. This will need careful modelling to determine appropriate bed configuration and income / expenditure analysis for the PAHT in particular, linked also to the plans the Trust has for service reconfiguration to ensure financial viability. Pennine Acute Hospital Trust is developing its 5-year Business Plan to move to Foundation Trust Status. For the past 12 months the North East Sector CCGs have been working together with PAHT and the Trust Development Agency to ensure all known activity assumptions around the Healthier Together, Integrated Care, Primary Care and QIPP schemes are reflected in this plan. To this end, the CCG’s have jointly funded 2 roles to support a joint modelling of impact across the sector.
• A series of strategic financial planning assumptions have been agreed with key partners across Health and Social Care. These reflect the activity shift assumptions expected to be delivered through the above programmes over the 5-year period. The plans acknowledge that reinvestment will be required in the community and other services to secure reductions in hospital capacity. The timing and level of investments required (recurrent, non-recurrent and transition costs) will be driven by the pace of change of the Greater Manchester and Borough wide programmes.
• The reduction in activity PAHT will expect to see across the North East Sector of Greater Manchester is significant, and will not be realised without a significant change in the way their services are delivered. Options for change are currently being considered by PAHT and the CCGs that support the out of hospital agenda, whilst ensuring that PAHT is economically viable.
• The financial plans and business cases for the Better Care Fund have been developed at Borough level in the context of the anticipated financial position for the 4 Councils and the Clinical Commissioning Groups over the next five years. The health and care sector challenges have been widely communicated across the North East Sector and the significant task of reducing and managing the CCGs and Councils financial pressures together with delivery of Pennine Acute and Pennine Care Cost Improvement Programme, is being addressed through a variety of inter-dependent programmes, including monthly business meeting with PCFT and PAHT at a Director level
• Plans for year one reduction have been built into the PAHT contract for 2014/15 - the Trust has plans to reduce its capacity accordingly. The CCGs and PAHT are developing a programme of shared monitoring to ensure any risk to delivering activity reductions is identified immediately and can be acted upon.
Performance improvement• The diagram below represents how performance is managed at a North East Sector and Borough level.
Greater Manchester - Healthier Together
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The Healthier Together programme is part of the Greater Manchester (GM) Programme for Health and Social Care (H&SC) Reform, which aims to provide the best health and care for Greater Manchester. It is the largest and most ambitious health and care reconfiguration programme in the country.
The programme is responsible to the 12 Clinical Commissioning Groups across Greater Manchester, with the CCGs exercising our statutory responsibility for commissioning through a shared decision-making body, the Healthier Together Committees in Common (formally a sub-committee of each CCG).
It is widely recognised that the different parts of the health and social care system are inter-dependent, and that major changes to services in the community are required before significant hospital changes can take place. The wider Healthier Together programme brings together the locality programmes developing Community-based Care (Integrated Care and Primary care) with the reform of “In Hospital” care across Greater Manchester for the “in-scope” services (these are: Urgent, Acute and Emergency Medicine; General Surgery; and Women and Children’s services).
The way hospital services in Greater Manchester have evolved and are currently organised, with a hospital in each borough providing a similar broad range of services, was designed to meet the needs of the last century. It is clear that this is not suited to the way in which a broad range of individuals require care. Many of the excellent developments we have seen have arisen from local interest rather than from strategic planning.
This has led to variations in the range and quality of services available in different areas, resulting in inequality of access to services in different areas. For example, the mortality of patients who undergo Emergency General Surgery varies from 23.1 to 51.7 per 1,000 spells across Greater Manchester, depending on where people are treated. This needs to change, with everyone entitled to the best outcome wherever they live, and yet we have a limited number of specialist clinicians, rising demand and serious financial pressures.
An analysis by Mott McDonald has forecast the financial gap between expected activity in acute trusts and available funding across Greater Manchester over the next 5 years at £742 million, with a further £333 million gap in social care funding – a total system-wide pressure of over £1 billion. Doing nothing is not an option. Work on determining the figures for each locality will be completed in February 2014.
As more people receive appropriate treatment at home or in the community, those patients that do need to be admitted into hospital, especially in an emergency, are likely to have more complex needs. They are most in need of very specialist care and being assessed by a senior doctor will improve their chances of recovery. Senior doctors are not available in all specialities on site 24 hours a day, 7 days a week due to the large spread of services across Greater Manchester. This means that Greater Manchester has an inequity of provision out of hours and at weekends often leading to poorer outcomes for patients.
Over the last 24 months, over twenty clinical congresses involving hundreds of clinicians have considered the issues facing our health system. They have explored the potential solutions to ensure services remain high quality, safe and cost effective for future generations. This work, which has been based on evidence and best practice from around the world has developed and contributed to this case for change.
The proposals arising from these congresses are for services to be shared across a number of defined hospital sites, with clinicians working across those sites to provide seamless care, with the teams delivering the “once-in-a-lifetime” specialist care on a designated site. These “single services” are shared across the geographical footprint, and the clinical teams benefit from being part of a wider, sustainable and better supervised team, raising standards in the “routine” work in the District General Hospital as well as meeting the clinical standards at the specialist site, a “win-win” for patients. This should also significantly improve efficiency at all the sites (as routine activity would no longer be interrupted by emergencies), and it is expected that that the Trusts would share the financial risk to avoid the perception of “winners and losers”.
The proposals to change hospital services will be subject to statutory public consultation, and must pass the requirements of the NHS Assurance process. Clinical assurance has already been secured for the model via the National Clinical Advisory Team (NCAT) – “We unanimously support the Programme to proceed to Consultation. This is the most ambitious and well thought out work we have come across. We are highly impressed”.
Following extensive pre-consultation engagement, including with key partners such as the Association of Greater Manchester Authorities (AGMA) the
Committees in Common of the CCGs will decide to proceed to consultation in April 2014. Subject to NHS Assurance, it is planned that formal consultation will
take place in the summer of 2014, with a final decision at the end of 2014. There are considerable risks in a programme of this size and complexity, and given the proximity of a general election there is a possibility that the formal consultation and decision will need to be postponed until 2015 – this would clearly delay the programme and the delivery of the benefits expected to be
realised.
E. Specialised services concentrated in centres of excellence
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Specialised services concentrated in centres of excellence
Healthier Together will transform the way in which health services are provided across Greater Manchester in the future. This is being led by CCG’s across the footprint. This strategy and future iterations, will be developed in the context of this strategic landscape. The Healthier Together programme is intended to deliver a better way of providing high quality, safe, accessible healthcare services by thriving, viable organisations within the future funding envelope. Strategic Clinical Networks will also inform the shape of specialist services in the future. These networks provide the vehicle through which significant and lasting change can be achieved, working across organisational boundaries where either a whole system approach or a collective improvement endeavour is required to improvement
The SCNs have a fundamental role in supporting members (predominantly NHS England Area Teams and Clinical Commissioning Groups) in improving quality and outcomes as well as responding to the Call to Action.
From 2014/16 the SCNs in each geographical area will focus on a small number (3-4) of large scale strategic improvement projects, delivering tangible improvements and ensuring maximum impact to the health economy.
Each of the 3-4 large scale changes will have a plan on a minimum of a page. The plan will confirm the transformational project to be progressed in each geographical area together with the high level context (rationale), aims and success factors for each project. In developing a plan on each page, each geographical area will follow a consistent approach including:
• Engaging a core group of patients/public, clinicians, member organisations (esp. NHS England Area Teams and CCGs) and key partners (e.g. Public Health and Academic Health Science Networks, HWBs) in the co-production of a long list of potential improvement projects, and the assessment and initial prioritisation of the long list of potential improvement projects based on the criteria outlined in ‘The Way Forward’ for Strategic Clinical Networks
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Specialised services concentrated in centres of excellence
• Sharing and gaining feedback on a short-list of emerging priorities from a wider stakeholder group including patients, providers, partners (e.g. Local Education and Training Boards), Health and Wellbeing Boards, National Outcome Framework Domain Leads, National Clinical Directors and the third sector;
• Further shaping and finalising the proposed priorities for inclusion in the plan on each page taking into account:o Expected improvement impact (quality/outcomes and the Call to Action) of each emerging priority based on the intended aims and success factors of each project;o Opportunities to align improvement priorities across England and / or with other partners (e.g.
Academic Health Science Networks) maximising resources and impact.
As the SCNs have been established for five years, in the first instance, recognising the time required to deliver transformational change, the two year business plans will provide a longer-term view and can be aligned to CCG operational plans, but will be refreshed on an annual basis. A common approach will be taken to the development of these plans with stakeholders engaged in the process across the region. It is expected that the SCN Accountability and Governance Framework will be refreshed early in 2014.
The SCNs cover 4 prescribed groupings of conditions (cancer; cardiovascular; maternity and children; mental health, dementia and neurological conditions) which account for over 70% of NHS activity and spend. It is assumed that the improvement projects will be drawn from:
· The specific SCN conditions covered e.g. dementia; or· Cross cutting themes e.g. rehabilitation; or· Areas of collective focus with the Senates e.g. population healthcare.
6. Maintaining the Essentials
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We recognise the value of minimum standards, and patients constitutional rights, and will work with our providers through contracts and partnerships to ensure that the CCG delivers the highest standards for our patients. However we also recognise that quality goes beyond the minimum standards, and we will work through our Clinical Directors, to improve patient experience, health outcomes and quality of life of Oldham's diverse population, paying particular attention to under-served and marginalised groups.
We will also pay specific attention to patient safety, continuing to work with providers to reduce health acquired infections, to ensure serious incidents are investigated and learnt from, and ensuring our safeguarding systems protect children and vulnerable adults.
Following the success of our Dragons Den last year, we will continue with this approach to drive out innovative ideas from our partners
We will ensure that the CCG continues to delivers all of its statutory financial responsibilities
A. Quality
172
QualityOur ambition to achieve our
Triple Aim provides the momentum for all our
Commissioning decisions. The pursuit of quality; effective, safe
care that exceeds the expectations of the population
we serve, is fundamental to our Triple Aim, and therefore
fundamental to what we do.
Our foundational elements
Our strategic frameworks for quality and safeguarding
Our constant and consistent internal challenge to our commissioning plans and external challenge to our providers
Our internal systems and governance structures
Our partnerships with stakeholders, relationships with our practices and our external networking
Our expectation that quality is the way we do business, not a discreet by product of what we do
Designing services
Shaping structure of
delivery
Planning and capacity
managing demand
Supporting patient choice
Managing performance
and measuring
impact
Seeking public and
patient views
Assessing needs
Reviewing service
provision
Deciding priorities
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Quality: Our Foundational elements
1• focusing
2• listening
3• responding
4• engaging
5• co-ordinating
6• improving
7• learning
8• transparency
9• responsibility
10
• accountability
Our quality strategy provides the basis for our relentless focus on the quality and safety of the services that we design and commission. We believe that it will serve to strengthen our assertion that quality is our organizing principle and to provide the basis for the way we do business; our organisational culture.
The concept of the ’Oldham Family’ propels the work that we do at NHS Oldham CCG. A fictional Oldham family was created to support our public engagement, which encompassed a series of examples of typical patients whose experience of care and whose clinical outcomes we are working to improve. Therefore our quality strategy is fundamentally about people, about ensuring that every person receives healthcare that clinically best addresses their need, illness or injury, is provided without doing them any further harm, in way that is convenient, reliable and protects their dignity and respect and about enabling their voice and their experiences to be heard and acted upon. We believe this commitment to quality is explicit within our vision and the reason for our existence - to improve health and healthcare for the people of Oldham, by commissioning the highest quality healthcare in services near to the patient, in an integrated fashion and at the best value for money. In the engagement that we had with patients and the public and with our member practices as we prepared for authorization and our integrated commissioning plan, quality was often the currency of conversation, issues such as safety, timeliness, communication and ‘the human touch’ were raised time and time again. NHS Oldham CCG understands that quality is so much more than
achievement of quality and performance indicators.
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Quality: embedding quality into our business1
• focusing
2• listening
3• responding
4• engaging
5• co-ordinating
6• improving
7• learning
8• transparency
9• responsibility
10
• accountability
We believe that by delivering our strategic objectives as defined in our strategy we are ensuring that we have established a shared understanding of quality within our organization and across our partner organizations and Providers and demonstrate our focus and commitment. We are committed to actively listening to what people, clinicians and groups have to say about the quality and safety of the services they have received or want to receive. We promise to respond to what we are being told by those using the services. We want to better engage with local people who are using the services we commission to help us redesign services and understand what underpins their confidence in those services. We are already developing new approaches to the seamless co-ordination of care for people who need the support and care of multiple services. Continuous improvement in the quality of the services that we commission is a clear aspiration, and we have clear undertaking to support our provider’s desire to deliver higher quality care.We are also committed to learning, not just when things do not happen as they should, but also from best practice from across all health systems, we are actively engaging ourselves in established networks and collaborative to make sure that we secure maximum benefit for the people of Oldham in this horizon scanning. Transparency and our duty to communicate with openness and honesty with the public and our regulators is key to the review of our Communication and Engagement Strategy. We are clear about our responsibilities to the people of Oldham, and we want to develop their confidence in what we do and how we do it, and we are clear about our accountabilities to our regulators and will ensure that we regularly test ourselves against our statutory duties to ensure that we justify the trust placed in us
Quality: Responding to national learning
The final report of the public inquiry, chaired by Robert Francis QC, into the catastrophic failings in care at Mid Staffordshire NHS Foundation Trust (14)
We see the identification of the failing of all elements (provision, commissioning, supervision and regulation) of the health care system in Mid-Staffordshire in the final report produced by Robert France QC (2013) as fundamentally defining for us as a CCG. As a result we have ensured that we have iteratively reviewed our strategic approach to quality since March 2013 , by considering • our strengths as an organization, • our weaknesses, • the threats that could have a latent or active impact on the work we need to do, • the opportunities that we are afforded. The reviews that we have undertaken are cognisant of the recommendations made by Francis, and those recommendations by those subsequently charged with undertaking independent reports , reviews and responses to the findings of the Francis Inquiry and the learning from the unacceptable events at Winterbourne View. It is important to note, however, that we believe that a listening, learning and responding approach should be taken in relation to findings from learning from all relevant national inquiries, regional collaboratives, local serious case reviews all of which should be embedded in our strategic approach to quality, and indeed we see the testing of our response to such learning as a useful assessment of our performance. We understand that patient safety and quality assurance are disciplines in the health care sector that apply patient safety methodology towards the goal of achieving a trustworthy system of health care delivery. Patient safety and quality are also attributes of those systems, minimising the incidence and impact of adverse events and ensuring patience centred outcomes are achieved through seeking high reliability under conditions of risk. We understand that risk is inherent in health care. We also understand that patient safety and quality are irreducibly a matter of systems. Nonetheless, as the setting where the patient receives health care, the microsystem is the locus where the successes or failures of all systems to ensure safety converge. At the same time, quality assurance and patient safety must be concerned with the entire system.
177
Quality: Understanding and profiling whole system quality
We recognise that treating and caring for people in a safe environment and protecting them from avoidable harm requires strong collaboration with partner agencies and local statutory governance structures including, but not exclusive to, the Health and Wellbeing Board and the Local Safeguarding Boards. This is reflected in our established governance mechanisms.
When assuring the quality of a system we believe it is important to understand its elements (for us, that of our providers) and assure ourselves in relation to the cultural infrastructure of the organisations including: organisation and management, work environment, task factors and technology and tools. In addition, in order to understand the impact of the culture of the organisation, framed by the infrastructure above it is vitally important to understand the experience of those working within the system. It is, of course, equally important to understand the experience of those people receiving care from each of the elements and from the system itself, looking at harm but also at reported outcome measures, to make sense of the impact of the way the system has geared itself to deliver optimum care.
The CCG has identified a number of data sources that together essentially begin to provide a cultural proxy, allowing a profile of a provider, or of system to be generated. This enables specific quality concerns to be highlighted and provides a horizon scanning tool for areas where change and improvement would benefit, for instance service redesign. In Oldham we have begun to capture and manage the data using our new soft intelligence system “listening and responding” and our newly developed exception profiling tool, “QuEST”.
Whole system quality: underpinning priorities
Compassion in practice
NHS Oldham CCG believes that in order to make sure it has the evidence, intelligence and insight to ensure that the Compassion in Practice Standards and the application of the 6 C’s are implemented across all services, it is essential that assurance is obtained into how these are implemented within the CCG infrastructure and within the member practices. The Integrated Health and Social Care team at the CCG has already reported to the Governing Body how they are planning to integrate the 6 C’s into their work through their revised philosophy of care and monitoring through internal KPIs and supervision. The CCG has a defined plan of work to ensure that the delivery of services for all our residents in care homes is in accordance with the establishment and maintenance of provider cultures, which support individuals directly providing care to embrace the behaviours identified within the 6 C’s, with particular attention to those deemed at risk.An accreditation scheme will be developed and implemented for its nursing homes, refining ‘Meaningful Moments’ with the intention of rolling out across residential care. There are established processes within the CCG’s contracts to support provider walkarounds and this has been further enhanced strategically in light of the publication of the second Francis report and ward based quality indicator assurance in relation to the application of the 6 C’s and the Compassion in Practice Standards.The CCG has established processes in place, to ensure that information from patient and staff surveys, complaints, incidents and Rule 43 letters is triangulated in order to identify where care may not have been delivered as per the principles of the Compassion in Practice Standards.There is a commitment by the CCG in ensuring on-going improvement in the quality of service provision and an acknowledgement of the significant difference the contribution to service quality of the 6 C’s ‘A Vision and Strategy for Nursing’ makes.
Whole system quality: underpinning priorities
SafeguardingNHS Oldham CCG is committed to ensuring that safeguarding vulnerability is everybody’s business, through the delivery of our safeguarding strategies and statutory responsibilities. Our vision is to ensure that safeguarding children and vulnerable adults is everybody’s business. To achieve this we are committed to commissioning services that promote and protect the human rights of each individual, their independence and their well-being. And we will secure assurance, from all service providers that we commission from on behalf of the population of Oldham, that any child or adult identified as being at risk is effectively safeguarded against abuse, neglect, discrimination, embarrassment or poor treatment, and is treated with dignity and respect. The CCG recognises that long term conditions can introduce vulnerability and is committed to ensuring that all people at risk are protected through our approaches to commissioning and contract monitoring, but also how we handle and incorporate learning from patient stories, soft intelligence and incident reporting. The CCG has produced a safeguarding dashboard to ensure that there is an understanding of current performance across the health economy, and also to understand how partner organisations respond and address vulnerability. The CCG demonstrates full compliance with its statutory requirements.
Whole system quality: underpinning priorities
Listening to patients: Our insightThe Patient Experience aspect of our Communications and Engagement Strategy aims to support the CCG Quality Strategy, in:• Providing assurance to the Governing Body that providers are able to meaningfully measure and
report on the experience of their patients• The proactive specification, capture, analysis, triangulation and interpretation of information about
the experience of patients and carers in using specific services, to inform assessments about the quality or the future planning, or commissioning of services
• Ensure the provision of an effective commissioner-led PALS and Complaints service• Identify issues arising from patient experience measurement and work with providers to ensure they
have plans in place to deal with those issue• Triangulating intelligence from a range of sources, including commissioner PALS and Complaints,
provider reports, local Healthwatch, engagement events etc.. to gain a rounded view of the patient experience and identify early warning signs of provider failure
• Leading Patient Experience improvement initiatives to proactively generate primary data• Managing of routine Patient Experience reporting to provide Governing Body assurance• Implementing systems and processes for monitoring and acting on patient feedback, and particularly
in identifying quality including safety issues• Making arrangements for handling concerns and complaints raised with the CCG, and actions taken
as a result, are clearly communicated to the public.• Bringing together and analysing views of patients and the public about their health, their overall
experiences of services, their expectations, views, beliefs, motivations and preferences, through a range of evidence based methodology
• Ensuring systems are in place to convert insights about patient choices/s are fed into planning and decision making
Quality: Understanding and profiling whole system quality
People who receive care
from the system
System for therapeutic
action: Organisation
and management
People who work in the
system
System For therapeutic
action: Work
environment
Provider contractual governance (including specialist and direct
commissioning)
Commissioner walkarounds
Regulator reports
Complaints (weekly), PALS, Patient stories
Nationally produced data/surveys
Intelligence from member practices
Intelligence from educational
establishments
Regional surveillance groups
Healthwatch
Safeguarding Boards
Serious Untoward Incidents
Patient net promoter scores
Staff net promoter scores
A monthly quality profile including the above domains for all our main providers, is currently in development
Executive walkaroundsOrganisational change• Cost Improvement Plan assurance• Achievement with high impact actions• Achievement with CQUIN schemes• Assurance of action plans designed to support the Compassion in Practice StrategySelf assessment and lessons learnt• Corrective action plans in place exceeding deadlinesInfrastructure• NHSLA compliance• Serious untoward incidents (SUIs) where the Duty of Candour is not evident• SUIs exceeding deadline for sign off• NRLS reporting• QRP estimateSystematic decision making• SUIs where the investigation concludes that a root cause is non clinical managementPrevention of future death reports
System for therapeutic
action: Organisation
and management
Facilities and equipment• Health and Safety Executive and Fire improvement notices• Disability Discrimination Act complianceSafe Staffing• Actual nursing staff in post as a proportion of total establishment• Proportion of registered nurses as a percentage of total nursing staff• Nursing staff in relation to population services (e.g. per bed/population)• Ratio of patients per registered nurse (day and night)• Stability index• Patient to doctor ration• Out of hours consultant coverTask factors• Key performance indicator breaches• Quality indicator breaches• Service delivery performance concern• NICE/best practice guidanceTechnology and tools• Management of CAS alerts• NICE TA implementation• SUI/Complaint where root cause involves technology and tools
System For therapeutic
action: Work environment
Mortality• HSMR/SHMISafeguarding AlertsSerious Untoward IncidentsNever EventsHarm Free CareHealth Care Acquired InfectionsPatient reported Experience measuresPatient reported outcome measuresFriends and Family TestMixed sex Accommodation breachesComplaints• Number of complaints per 1000 contacts• Number of complaints responded to within the
timescale agreed• Number of complaints notified by the ombudsman
where further recommendations are made• Number of complaints where equality, diversity and
human rights have been identified as an issue
People who receive
care from the system
Mandatory/Statutory Training• Compliance with overall mandatory training• Compliance with safeguarding adults andchildren trainingPersonal Development• Personal development review completionWillingness to raise concerns• Near miss to SUI ratio• Use of alternate reporting processesReported incidents of bullying and harassmentSickness absence rateContinuous learning environment• Compliance with organisational development strategy milestones• Number of complaints/incidents where learning is demonstrated• Percentage of staff receiving job-relevant trainingStaff net promoter scoreCompassion in Practice indicatorsActon plans associated with the strategic approach of providers to caring for patients with a learning disabilityStudent/trainee and agency feedback
People who work in the
system
Quality: Formal governance
• Review of all data sources to support whole system exception profiling and identification of strategies to mitigate risk
Quality assurance and clinical governance
group
• Identification of areas of key risk and agreement of/internal challenge to actions proposed
Executive regulation of Finance Performance
and Quality • Challenge provided in
relation to high level risks and their mitigation strategies
Governing BodyPeople who receive care
from the system
System for therapeutic
action: Organisatio
n and manageme
nt
People who work in the
system
System For therapeutic
action: Work
environment
• Identification of latent and actual risk in relation to safeguarding children and vulnerable adults
Child and adult safeguarding
boards
•Challenge provided in relation to high level risks and their mitigation strategies
Health and Well Being Board • Identification and
profiling of risk associated with joint commissioning
Integrated Care Partnership Board
•Whole health economy challenge and risk identification
Quality Surveillance Group
CCG Internal Governance
NHS England
Partner agencies
•Challenge provided in relation to high level risks and and their mitigation strategies for multilateral contracts
NE Sector Commissioning Board
Quality: progressing quality in Member Practices
1• focusing
2• listening
3• responding
4• engaging
5• co-ordinating
6• improving
7• learning
8• transparency
9• responsibility
10
• accountability
Our role in supporting quality improvement in our member practices is clearly cited in our quality strategy
6.1 We will embrace our commitment and our responsibility to work with and help member GP practices and wider primary care to quality assure current standards of care, working closely with NHS England, and to continually improve the range and quality of services we offer in primary care.6.2 We will have a clear pragmatic approach to working with practices where opportunities for improvement in quality or performance have been identified6.3 We will strengthen our relationship with our member practices, our clusters and the Local Medical Committee through collaborative working and regular meaningful engagement to enable us to underpin and incentivise quality improvement and innovation within the core elements of the general practice contracts using the EQALS scheme6.4 We will strengthen our relationship with our member practices, our clusters and the Local Medical Committee through collaborative working and regular meaningful engagement to support core and complementary governance (for instance clinical supervision and safeguarding) in general practice through our ProGrESS initiative
We will demonstrate a clear focus on improving the quality of primary care
Shared intelligence from NHS England to include complaints and incidents
National Primary Care Performance Dashboard
CCG generated performance and quality data
Enhancing Quality Local Supply Scheme (EQALS)
Local soft intelligence
ProGrESS is based on the principles of formative interventions with practices to support sustainable and meaningful quality assurance and quality improvement
Quality in member practices: Formal governance
• Review of all data sources ( including local primary care dashboard)to support practice profiling and identification of formative strategies to mitigate risk
Commissioning performance and advisory group
• Identification of areas of key risk and agreement of/internal challenge to actions proposed by CPAG
Executive Regulation of Finance Performance
and Quality • Challenge provided in
relation to high level risks and their mitigation strategies, escalation to the area team to NHS England where appropriate
Governing Body
•Management of high level performance , quality and safety risk in general practice
Area Team Contract managers
•Management of high level performance, quality and safety risk in General Practice
Direct Commissioning
Board •Management concerns about individual Performers
Responsible Officer
•Whole health economy challenge and risk identification
Primary Care Quality Surveillance Group
CCG Internal Governance
NHS England
•Challenge provided in relation to high level risks and and their mitigation strategies
Local Medical Committee
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B. Our approach to access and convenience
188
• In the latest NHS National Choice Survey (June, 2010), Oldham was second in the country in terms of the percentage of patients that recall being offered a choice of provider, and first for patients responding that they were able to ‘go where they wanted.’ The CCG will retain a focus on ensuring patients receive a choice of secondary care provider and promote the use of national resources such as NHS Choices to support informed choice. The CCG will also work will it’s member practices to ensure choice is offered via the Choose & Book system where referrals are subject to AQP.
• The CCG’s referral management system allows intervention to ensure patients are able to make an informed choice where RTT pressures exist through the support of the Oldham Appointment Centre. This includes signposting to national sources of information including NHS Choices.
• In 2012/13, the CCGs across GM extended choice in community services of adult hearing, core podiatry and direct access diagnostics through AQP. They also continued the offer of choice through AQP for acute elective services and intend to continue this offer. The GM Commissioning Support Unit supports the CCG with the procurement and contracting of AQP providers.
• The CCG plans to explore an AQP framework that incorporates multiple primary care based services, which may include diagnostics in response to policy guidance to extend direct access to accelerate cancer diagnosis. This will expand choice for primary care services.
• Community Services were retendered in 2013/14 and service specifications include requirements for faster response & waiting times, and extended opening hours. Each of Oldham’s practice clusters will have Integrated Health Teams (IHTs) and MDT’s with the community nursing and AHP expertise specially required for the neighbourhood/s they serve (including minority groups). Through the cluster MDT meetings and additional CCG investment in general practice, patients will benefit from additional primary care resources and joined up, responsive services.
• The CCG is undergoing a review of Community Mental Health teams which includes the specific aims of targeting BME groups and improving access to psychological therapies generally, and in line with national indicators. Senior clinicians are about to commence triaging referrals to direct patients more appropriately to effectively meet patient need and make use of voluntary and third sector services. A training program is ongoing to educate a wide range of local health professionals to ensure patients with mental health problems are treated holistically.
• A referral management protocol to ensure choice is appropriately offered to onward referred patients (and evidenced) has been developed and is being included in all CATS and secondary care contracts. This includes leveraging providers to work towards integrating pathways via direct listing wherever possible.
Convenient access for everyone
189
Summary• Promotion of information to support choice (building on sound record of offering choice) • Proactive intervention to ensure informed choice where required• Choice support and signposting by Oldham Appointment Centre• Choice of community AQP services (adult hearing, core podiatry and DA diagnostics)• Additional Primary Care AQP services being explored• Community Services have been re-procured to deliver cluster IHTs and MDTs with practices to
join up primary/community services• A review of Community Mental Health teams to target BME population and improve access• Referral protocol to ensure choice when onward referred by a provider and integrating pathways
Convenient access for everyone
190
• The CCG requires its providers to make patients aware of their rights with regards to RTT times in all written correspondence regarding appointments. Compliance with patient communication guidance will be reviewed via contract review meetings.
• Working with our local acute trust, Pennine Acute, we have established a weekly monitoring system for patients waiting in excess of 18 weeks from RTT. This acts as an early warning system where the level of excess waits (the “backlog”) indicates a significant risk to the achievement of referral to treatment waiting times. The North East Sector (NES) Elective Care Development Board, with senior Commissioner and Provider level representation takes decisions regarding action to manage RTT performance.
• Oldham CCG is currently achieving RTT standards at the aggregate level and for each treatment function (January 2014). Our main acute provider, Pennine Acute does face some current challenges in relation to RTT delivery. Aggregate performance for Admitted and Non-Admitted patients has been above the respective 90% and 95% standards for the two years to November 2013. The proportion of patients waiting more than 18 weeks for treatment at each month end (Incomplete pathways) has reduced significantly over the last 12 months and has been above the 92% standard for the five months to December 2012.
• The CCG is also conscious of the ethical requirement to treat patients in respect of clinical urgency which, to also ensure achievement of minimum RTT times, requires robust demand management arrangements, capacity plans and empowering front line staff. The continuous improvement of demand management systems and regulation of procedures of limited clinical value are central priorities to achieving this aim. For example, the CCG plans to pilot a Consultant led GP Advice & Guidance service to support GPs to manage patients in Primary Care where appropriate and make lasting improvements to the quality of primary care services.
Meeting the NHS Constitution standards
191
• Oldham has a record of commissioning innovative CATS to meet long-term capacity issues and will continue to apply this approach where appropriate to meet clinical need. Effective working relationships with responsive CATS providers has proved valuable in resolving demand pressures and reforming pathways to ensure their long-term sustainability (see plans relating to IPH’s in previous section).
• An in-depth understanding of the underlying causes of long waits is required to make systematic improvements. For primary care based CATS, the CCG currently receive individual breach reports. This allows commissioners to support providers to continuously improve, be it through improving communication with the patient at the point of booking or engaging third party diagnostic providers to improve reporting standards, for example. The principle of individual root cause analysis reports has recently been applied to our main providers.
• Quality concerns (e.g. mixed sex accommodation and infection control breeches) when they arise are addressed with our main acute provider through the Contracting Board
• Oldham CCG considers A&E performance to be an indicator of performance across the urgent care system. The CCG has brought together all the urgent care providers and is seeking to create an alliance of those partners in order to increase the incentives for providers to work together to improve the urgent care system. For the regulation of urgent care performance, the CCG works with the Alliance of provider partners, the North East Sector of Greater Manchester and also with the Greater Manchester Commissioning Support Unit Utilisation Management team. Planning for seasonal variation, emergency situations and times of varying demand are currently conducted at the following forums:– Daily tactical conference call (Urgent care providers).– A CCG level via a weekly teleconference with all urgent care providers (CCG coordinated in times of sustained pressure)– A weekly North East Sector Tactical Group (Urgent Care Working group)..– Monthly Urgent care Alliance Leadership and Management team meetings.– Monthly North East Sector Urgent Care Network Board
Winter funds have been utilised to support the system to meet the expected increases in demand with a focus on supporting discharge processes.
Meeting the NHS Constitution standards
192
• Ambulance hand over times are monitored by the CCG via reports from NWAS and the Utilisation management team. Performance on turnaround forms part of the daily reporting in the North East Sector conference calls. A&E departments are regularly reminded to support turnaround times. This is also part of the North East Sector Urgent Care Board agenda where NWAS are in attendance. The Greater Manchester Urgent Care Leads now hold meetings jointly with NWAS to address ambulance performance for Greater Manchester. Performance against category A standards has historically been lower in the North East Sector of Greater Manchester than for Manchester CCGs as a whole. The above measures are intended to provide a focus to enable improvement in performance across Oldham, Bury and Heywood Middleton and Rochdale. The CCG is also working collaboratively with NWAS and Go-to-Doc ltd on a pilot of the Alternative to Transfer scheme. This initiative enables crews to access a GP who will visit a patient within 2 hours where NWAS deem this is safe and appropriate. This enables ambulance crews to be available for calls and reduces conveyances to hospital.
• This target focuses on the number of people under adult mental illness specialties on Care Programme Approach receiving follow-up (by phone or face to face contact) within seven days of discharge from psychiatric in-patient care. – Our main provider of mental health services, Pennine Care NHS Foundation Trust (PCFT), are committed to
achieving the CPA target and contractually the provider is monitored against this target as part of the joint CCG’s Contract and Monitoring Performance Meeting. In addition, PCFT also monitor this target through their Service Quality Performance Report; quarterly submissions are also made to Monitor and performance is monitored internally as part of their Board Assurance report.
– In quarter 2 of 2013/14, a contract query was raised as CPA performance for the Trust was below target. To rectify this, PCFT undertook a full review of the indicator to provide assurance to commissioners, their own Board and to Monitor. During the review it was identified that some of the breaches occurred due to follow-ups being carried out on the same day as discharge, which is not accepted within the construction of the target. This has been highlighted to services and processes have been put in place to ensure future follow-ups do not take place on the same day as discharge.
– Additional assurance processes have also been put in place to monitor CPA performance more closely, including a review off all future breaches by the Acute Care Forum to fully understand the reasons for breaches and the development of an online tool to support data collection. A report and action plan has been presented to their own Board who have now confirmed that they are assured by the review and subsequent actions that have been put in place. Contract & Monitoring Performance meeting will continue to monitor this closely over the coming months and the CCG will continue to report by exception to the Board until the situation has stabilised over the next quarter. It is worthy to note that since the review the target has been surpassed with performance for November 2013 increasing to 98%.
Meeting the NHS Constitution standards
193
• Working with our local acute trust, Pennine Acute in accordance with National Targets Oldham CCG receive monthly monitoring reports for Cancer patients. Until very recently , Oldham CCG has been compliant for both the two week wait for first outpatient appointment for patient referred urgently with suspected Cancer by a GP and for first outpatient appointment for patients referred urgently with breast symptoms (where Cancer was not initially suspected) . Recent deterioration has been as a result of internal operational issues, which are being addressed by PAHT internally.
• There is a NE Sector Cancer Board which meets quarterly -part of the TOR is to review all on-going Cancer targets. The Board consists of Commissioners and both Acute and Community providers from across the NE Sector. In addition there is the Pennine Acute Contract Board which meets monthly; any underperformance within the Cancer KPI’s are highlighted to the board and if underperformance is identified an action plan is required on how any underperformance will be mitigated.
• Exception reports which identify 31 and 62 day Cancer breaches are received monthly by TPM on behalf of Oldham CCG; if breaches occur TPM (Greater Manchester Commissioning Support Unit; Total Provider Management) request further explanation and if the response is unsatisfactory then the breaches are flagged up to the Pennine Acute Contract Board for a more formal response to the Notice of Performance issued. In addition Pennine Acute have an internal weekly operational performance meeting which highlights any breaches. This meeting is mandatory and requires both Heads of Department and Acute Lead Clinicians to attend, discuss breaches and associated causes and implement a mitigation plan.
• As a result of performance concerns over the past quarter, an elective tactical group has been established to address dipping performance in relation to 18 weeks and cancer targets, to agree health economy wide solutions for performance improvement.
Meeting the NHS Constitution standards )
194
Summary• Compliance with patient communication guidance monitored through contract management process• Early warning system (Pennine Acute “backlog”)• Current and recent performance has met all RTT standards, though PAHT are facing challenges• Advanced demand management system to ensure patients treated in line with clinical urgency• Innovative CATS as required to meet clinical need• Individual patient breach reports to understand root causes of long waits• MSA breaches and cancelled operations are investigated and monitored via Contracting Boards• An urgent care alliance has been established which is monitoring urgent care performance• Ambulance performance addressed via daily conference calls• Mental Health CPA performance addressed through contract performance groups• Cancer performance addressed via Contracting Boards
Meeting the NHS Constitution standards
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C. Our approach to innovation
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A culture focused on health adds more value than one focused solely on health care.
There are many valid approaches to achieving superior health outcomes; we will ruthlessly explore them
We believe in the capabilities of individuals to manage their own health
We believe that communities, correctly supported can innovate their own environments 196
As new Clinical Commissioning leaders, Oldham CCG will ensure we adopt an innovation based commissioning ethos into everything we do. We respect the following key aspects of
innovation:
That business intelligence, used effectively will assist in translating ideas into action and outcomes
The we will have an ‘open book’ transparent culture
We will have trust and respect among CCG members, we will value all ideas and contributions
The collective wisdom of experienced leaders (clinical and non-clinical)
Innovation is part of the fabric of who and what we are, continuous challenge and idea generation will drive triple aim delivery over time
Innovation - Our CCG Ethos
Innovation - Our CCG Beliefs
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Embed ‘bake-in’ the adoption of innovation platforms in each CCG
Clinical Programme Area and leadership PDPs 197
Based on Triple Aim Principles:
• To improve population health in total and via care group• To improve care provided, and the health experience of
individuals• To achieve optimal value from our available resources
Our Accountable Care Commissioning Organisational (ACCO) Vision
The CCG’s vision is to improve health and healthcare for the people of Oldham, by commissioning the highest quality healthcare in services near to the patient,
in an integrated fashion and at the best value for money
Our Accountable Care Commissioning Organisational (ACCO) Vision
The CCG’s vision is to improve health and healthcare for the people of Oldham, by commissioning the highest quality healthcare in services near to the patient,
in an integrated fashion and at the best value for money
I
• INVENTION• Insights, origins, nucleus of ideas and the means by which we will improve value to our patients
A
•ADOPTION•The means by which we will execute the proof of concept into reality. Testing, refining, measuring and quality assuring the change for our stakeholders
D
•DIFFUSION•Systemising effectively throughout our service systems. Industirialising good ideas for macro benefit.
CCG Legal duty to Promote Innovation
The Principles that Guide us (CCG)- Design Driven: End user experience drive & challenge
assumption - Patient Centred: Diversity of individuals voice in every
project
- Open Book: Build partnerships, share intellectual property, learn
- Quantify & Manage: Innovation can be taught, measured, valued
- Swift Execution: Implement continuously & safely, learn & modify
- Cross-Cutting: Focus time on multipoint innovations
- Remove Barriers: Can do, will do attitudes + technical platforms
6 High Impact
Innovations
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Apply a consistent (and if need be) dogmatic approach to innovation within each segment of the CCG Clinical programmes, led by its Clinical Directors, delivered via CSS and assured through the enabling system Governing Body. The application and diffusion of well-
grounded innovation (technical and system based) is a core platform within everything we do. 198
KEY FEATURES
Commissioning for Innovation
Innovation is a pervasive agenda and an enabler of quality and productivity. Embedding innovation tools within the commissioning cycle, the CCG working with its strategic partners and suppliers, allows for significantly better results
in terms of outcomes and optimal Triple Aim commissioning results.
BENEFITS DELIVERED
• Free up scarce resources to invest in innovation (new world solutions)
• Focus resources on our strategic priorities
• Ensure a balanced portfolio of risk and reward
• Embed innovation within a lean commissioning & deployment process
• Enhance performance in relation to CCG ability to continuously harness talents from its members
• Generate returns – improve outcomes and raise productivity
Lead innovation
Create space for
innovation
Build a culture of innovation
Improve idea
generation
Assess progress &
results
Appraise, capture &
diffuse
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• Dragons Den – 23 innovations selected with involvement from business and the public (see appendix 1)
• Hothousing of critical challenges
• QIPP approach
• QIPP delivery (£31m in 2 years) via clinical leadership
• Referral Governance Programme
• Referral Gateway
• Care Vortex Model & Application
• Integrated Commissioning Hub with Local Authority
• Patient led procurements
• Integrated Community applied to Urgent Care, Diabetes Care
• Integrated Pathway Hubs for MSK & Mental Health
• Community based integrated technical solutions (N3 connections, common diagnostics)
• Patients council
The CCG & Innovation – Some Examples
199
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D. Our approach to value
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ContextNHS organisations across the country continue to explore at how they can innovate, be more productive, prevent NHS resources being used in appropriately and ensure services are still of the highest quality.
NHS Oldham, has had its own financial challenges over recent years, largely due to ever increasing demand for an expanding range of services, and QIPP not going far enough or fast enough, to get ahead of the curve. A local financial recovery plan was launched in summer 2010, clinically led by the Practice-Based Commissioning consortia.
Since 2010 then Oldham has delivered in excess of £45m of cash-releasing savings by doing things more efficiently, effectively, productively and differently, whilst still making sure our local patients receive the quality health services they deserve. The financial recovery plan ensured that the CCG on establishment was in a sound financial footing with a underlying recurrent surplus in excess of £20m.
Despite the underlying financial position, the national financial environment along with anticipated changes to CCG allocations and the impact of Better Care Fund requiring pooling of NHS monies, will mean that NHS Oldham’s ability to maintain financial stability will be made increasingly difficult.
The CCG has robust plans in place to do this, but there will still be difficult decisions to take, to ensure that we are providing value for money. Every time a patient contacts the NHS in any way it costs money, Value for money is not about reducing the number of contacts, but making every contact count. For example, sharing test results so that they don’t have to be done again, seeing the right person the first time, ensuring patients can see their GP so that they don’t have to go to A&E, checking repeat prescriptions are still required and so on.
Delivery of the £45million to date has relied up a huge amount of innovative thinking from clinicians, patients and commissioning support staff. This will continue to be built upon to meet the needs of local people in years to come.
We will need to continue to secure full engagement with all providers, whether in the acute, community or primary care setting, to fulfil our commitments to the Oldham population. Further delivery will only be possible as a result of collaborative working with providers across all sectors, the North East Sector commissioners and joint working with the Local Authority. Co-commissioner relationships with NHS England in both a Direct Commissioning and Specialist Commissioning capacity will also be instrumental in ensuring successful delivery in Oldham
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How our money has been spent in Oldham in 2013-14
2% 9%
50%
4%
14%
4%
11%
6% 2%Running Costs
Mental health and learning disabil-ities
Acute
Primary care
Prescribing
Continuing Care & Funded Nurs-ing Care
Community Services
Other Services
Recharges for NHS Property
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Where our money was spent in Oldham during 2013-14
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The financial planning process within the CCG is underpinned by the impact of activity growth assumptions, planned service changes and locally and nationally agreed investments. The starting point in the financial planning process is to estimate the resource limit of the CCG for the forthcoming year, and anticipated allocations for future years based on available national guidance Baseline activity plans for future years are calculated using a combination of forecast outturn and adjustments for national priorities and local and cluster based initiatives, this means that any pressures realised during 2013-14are built in, and only adjusted if of a one-off nature. Contract negotiations held with providers to ascertain whether these assumptions are in line with their planning have in the main concluded satisfactorily.
The following planning assumptions have been made for 2014-2018:• The CCG will hold a minimum 2.5% recurrent surplus in 2014-15 and at least 1% in future years which will enable deployment non-
recurrently to lever service transformation• The CCG will have to deliver as a minimum a 1% operating surplus• The CCG will operate within a running cost allocation.
The opening recurrent costs which are committed against this resource are identified before factoring in the impact of nationally mandated investments, such tariff adjustments and inflationary uplifts.
Baseline activity plans for future years are calculated using a combination of forecast outturn and a linear forecast model to take account of historic trends and predicted activity growth. The commissioner intentions for deflection of activity out of hospital and demand reduction as a result of Healthier Together and Better Care Fund have been incorporated in the 5-year planning assumptions. Contract negotiations are held with providers to agree these assumptions are in line with their planning. Financial activity plans for acute contracts are reconciled to signed CCG contracts and further anticipated deflections. Capacity reduction plans are agreed with providers as a result of QIPP plans, ensuring that they continue to deliver health care in a safe, effective and high quality way.
The financial planning process
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Surplus Strategy and Financial Control
NHS England has adopted a revised funding formula recommended by the advisory committee on Resource Allocation, this has resulted in NHS Oldham CCG being identified as over-funded compared to its ‘fair-share’ of national resource. It has therefore been determined that NHS Oldham allocation growth will be capped at 2.14% for 2014-15 and assumed as 1.7% for future planning years.
The introduction of the Better Care Fund also contributes to CCGs facing a significant efficiency challenge. The Better Care Fund will result in circa £34.2m of CCG money being pooled by 2015/16 (Minimum requirement £16.0m). The majority of this is comprises commitments of a joint commissioning nature. Associated costs will then be met from the pooled fund. However, the pooling also includes additional funding of £4.11m, as a contribution to the protection of social services, in accordance with national guidance.
NHS England have determined that in order to help manage this Health efficiency challenge over a two-year period that access to drawdown surpluses be prioritised to specialist commissioning in the first year and CCGs in the second year.
Longer term Financial stability will require service reconfiguration both within hospitals Primary Care and in the community through Healthier Together and Integrated Care.
Statutory Duties and Financial Business Rules
NHS Oldham CCG has an obligation under statutory law to deliver a number of financial duties:–To ensure that expenditure remains within the ‘programme’ allocation –To ensure running costs remain within the ‘admin’ allocation (running costs)–To ensure that cash remains within cash limits
In accordance with the statutory duties and number of financial ‘ground rules’ have been described in the Everyone Counts guidance:–Every Commissioner must deliver a surplus of at least 1% of its recurrent programme allocation–Every Commissioner must retain 2.5% of its allocation to be used for non-recurrent purposes–Every Commissioner must set aside 0.5% contingency
Finance and business rules
Financial SummaryFor 2014-15 the CCG has received a recurrent allocation (Resource Limit) of £303.6m including £5.75m of Running Costs and anticipated previous year surplus of £6.825m. A further allocation resource for GPIT is anticipated, but not yet confirmed.
The CCG is planning to achieve a net surplus of £6.825m in 2014-15 in excess of the minimum requirement 1% due to the limitation on drawdown of previous years surpluses. In future years a surplus of 1.5% is planned. No Quality Premium payment to the CCG has been assumed as this will not be received until 2015-16, should it be payable.
The CCG Plan exceeds the minimum required 2.5% underlying recurrent surplus (£6.2m), with local recurrent surplus at £15m.
The minimum nationally mandated Contingency has been built in at the required level of 0.5% of revenue (£1.5m).
CQUIN payments have been assumed, which are in line with national planning assumptions, these will only be payable if core/minimum standards within the contract are achieved by the provider. Within the financial plan it is assumed that CQUIN will be fully payable.
Financial Summary (2)
Other Assumptions
• Growth assumptions ranging from 0.5% to 5% reflect both national and local guidance.
• Nationally mandated planning assumptions for inflation and efficiency savings have been included. There is an assumption that all trusts, including mental health and community, will have to respond to the Francis Report. This has been reflected by way of an additional 0.3% recurrent tariff investment for Mental health and Community, along with contingent qualitative requirements, whilst the nationally mandated tariff deflator has also been applied.
• 2.5% Non-Recurrent requirement is planned to be • 0.3% to be used for GM CCGs to collaborate on issues of a pan-GM Strategic
nature, • 1% for local Call to Action response through investment in integrated care, and• 1.2% for other local non-recurrent purposes. These will be subject to NHSE(GM)
scrutiny and assurance process.
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Financial risks
• There are some additional risks identified, not included in the Plan, particularly in 2014/15 (£3.5m reducing to £2.1m from 2015/16 onwards, which are reflected in the Risk analysis in the financial planning submission.
• For 2014/15 these reflect potential levels of over performance on non-block acute contracts (£0.5m) and GP prescribing (£125k), together with a further £1.4m non-recurrent transitional support to our local hospital Trust should in-year finances allow (in addition to the £3m included within the Plan).
• Also, an issue remains with property as a result of baseline allocation assumptions during 2013-14. Should Property charges be administered on an actual basis rather than allocation basis from 1st April 2014, this risk will be avoided. The Plan reflects that these can be otherwise be fully mitigated through contingencies and slippage in investment plans.
• For the purposes of the Plan it has been assumed that running cost expenditure is in line with allocations in future years. 2014-15 negotiations with Greater Manchester CCG are in the majority completed, and indicates that expenditure is contained within the allocated resource when combined with in-house and other external running costs. For planning purposes it is assumed that future years running costs will be affordable within admin allocations reduced by 10% from 2015-16. Greater Manchester CSU is working towards formal merger with Cheshire & Mersey CSU, this is anticipated to derive financial efficiencies to commissioners to meet the running cost efficiency requirements.
• There remains a degree of uncertainty with GPIT, accounted for outside of running costs, due to no formal communication with regard GPIT allocations, based on available information it is anticipated that expenditure will exceed resource allocation by up to £350k in 2014-15, this pressure has been built into the plan. For 2015-16 onwards there is an assumption that GPIT expenditure will be right sized to be affordable with resource allocation.
• NHS Oldham remains a fully committed commissioner of CSU services with the exception of service redesign offering, that has not met our requirements during 2013-14. From 2014-15 this will be in-housed to some extent with niche expertise bought-in as required. Local infrastructure is to bolstered further to manage any further skills and expertise gap remaining from the combination of CSU and CCG infrastructure.
• The CCG has not identified any significant capital investment plans, but has identified £50k of IT and business intelligence system spend to bolster and enhance
the offering from GM CSU. Cash and working capital is anticipated to be managed within the financial limits set nationally.
• GP prescribing costs have historically been a pressure area of expenditure for the CCG and there is a continuing risk that costs will increase if demand is not appropriately managed. The CCG has ensured that a realistic growth assumption is built into financial plan assumptions. GP Prescribing forms a key part of the cash releasing element of QIPP and a key priority for the CCG to manage.
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Financial StrategyThe activity and financial projections provided within the specific operational and financial templates, demonstrate how our ambitions triangulate into activity and financial intentions. The 5 year financial plan demonstrates that our ambitions and intentions are affordable to meet the trajectories described within the outcomes template . We will support clinicians to develop services, making the best use of their skills and expertise. This is also likely to affect the way in which we use our estate, and the way patients travel to healthcare. We will work with providers and patients to ensure changes are well managed and achieve the intended benefits.
At present, we feel the outcomes are affordable within sustainability calculation, however this dependent upon capacity being reduced within the acute sector, and new operating plan requirements released on an annual basis, which may result in additional unplanned investment for the CCG. E.g. introduction of the IAPT target this year
Assumptions made within the health economy are consistent with the challenges identified within a Call to Action
The impact of interventions is described in detail from activity and financial perspectives, within individual templates.
See appendix 8 which provides the detailed description of schemes worked up so far over the next 3 years. This is an evolving piece of work. A number of the interventions described, will all contribute to the reduction in non-elective activity, which have been aggregated up for the purposes of activity and contractual negotiations.
The following slides show where we plan to target our investment
Intervention Outcomes(quality / finance /activity)
Additional investment
Start date Current schemes
Next stage work up
Enablers Barriers
Delivery of integrated care
All
£1m ( recurrent) July 13April 14
Community service retender - £1m additional (ESD and AHP support )
Identify non recurrent solutions to support OOH delivery
EQALSBetter Care FundHealthier TogetherCommunity Service mobilisation
Reducing non-elective capacity in tandemSpeed of gear up of community providers
Wider Primary Care at Scale
All £1.3m (recurrent) £734k (recurrent - named GP)£3m in 2014/15 – to be targeted at WPCAS interventions
July 13 EQALS - £2m Agree content of specification to support primary care kite mark
EQALSCD leadership modelCo-commissioning arrangements
Co-commissioning arrangements
Clinical programme changes
All Interventions to be funded through WPCASAlliance – 0.5m gear up Mental health IPH – 0.5m gear up
TBC £3m in 2014/15, within 2 year delivery plan -– to be targeted at WPCAS interventions
Determine costs per clinical programme and ideas from clusters to be included within clinical change plan
Investment opportunityCD leadership model
Speed of mobilisationDemands placed on monies linked to new strategies
Better Care Fund All £3m top up of established joint commissioning budgets
Dec 13April 13April 13Oct 13Oct 13
Falls service - £300kDementia service - £500kFuel poverty - £250kAlternative to transfer - £130kConsultant outreach scheme to care homes - £150kEnd of life facilitators - £150k
Confirm cots associated with reablement / rehabilitation review - £500k
Integrated Commissioning arrangements already in place
Financial position of OMBCTrust between organisations
Intervention Outcomes Additional investment
Start date Current schemes
Next stage work up
Enablers Barriers
Research and innovation – dragons den
All £600k Y2( non – recurrent)£300k (successful bids from Y1£0k – pharma dragons den – some efficiencies
April 14 23 schemes – majority are public health focused
Y2 - rerun scheme
Non – recurrent fund to test new ides
Ability to evaluate individual interventions
Healthier Together All Non recurrent contribution to HT infrastructure costs
April 13 Not yet defined Start of public conversation to scope options
Dedicated infrastructureGM approach
Speed of implementation linked to PAHT financial position
Red = high risk Yellow= medium risk Green=low risk
Assumption: £3m available for clinical programmes assuming £3m cash releasing QIPP per annum14/15 fully identified15/16 and onwards partially identified
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System and Market Management StrategyThe current financial context demands increased efficiency and more integrated approaches to reduce points of handover, duplication and delay in both service delivery and administration of the system.
The commissioning of new services demands that providers are given clear, pathway-focussed specifications based around the needs of the local population which aspire to best practice services. To realise this ambitious set of aspirations, clear segmented and pathway-centred intelligence is needed to understand the present, define the future and map out both the amount and nature of transformation required to get there.
A system and market management strategy has been developed, which should be read alongside this plan, which will be fully implemented through our commissioning support model, and describes the factors that influence market and system behaviour and examines the strategy and tactical steps that the CCG should put in place, to ensure the population needs of Oldham are best served, now and in the future.
The absolute central theme is the patient’s experience; the role for CCG is therefore to drive maximum quality, efficiency and value with the tools and methodologies at its disposal. It is for this prime reason that strategy and tactical plan for system management has been developed. The aim is to enable people to benefit from increased health gain from the available resources, i.e. increase return on the annual investment.
Integral to this approach are deliberate aspirations at both local and national level to promote the three essential ‘Es’ – efficiency, effectiveness and economy. It is also envisaged that a market-based approach will simultaneously improve the quality of service provision, extend patient choice and reform the strategic group of providers that have traditionally dominated the health market.
The challenge faced is to fully embed this strategy and tactical plan within CCG and deliver the series of actions outlined to support our ambition. The main objectives of the strategy are to outline:
•The delivery model for QIPP which is already being implemented, facilitated strongly by the introduction of the referral gateway•The approach to managing the market from a health market analysis, procurement and contestability perspective•The process to embed supply chain management•The adoption of methods for modelling, forecasting and scenario planning•The approach with regard to managing major strategic programmes, already described above in relation to the internal consultancy model•The framework for prioritisation, investment and undertaking strategic reviews.
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Striving to provide quality care (closer to home) in a timely manner, with respect and a concern for an individual’s dignity will require stimulation of both current and new market entrants in providing innovative, accessible, local, modern and improved quality health improvement interventions and health care solutions. Implementation of this strategy will create a competitive tension that levers up performance, but at the same time strikes a sensible balance between collaboration and competition to secure the best outcomes and maintain a stable health care delivery system, without detriment to patient care. The role of CCG and primary / community care provision within this complex set of scenarios needs to be clear, particularly if faced with potential external challenge, concerning the provision of new innovative services.
It is in the interests of all stakeholders, but particularly local population groups and service users, that all appointed suppliers are correctly regulated and that continuous quality improvement is a business norm, not an exception based on sub-optimal contractual outcomes. To further emphasise this point, the need is recognised to have differentiated engagement processes for each segment of the total health community. These tactical relationship management plans are described in more detail within the System and Market Management Strategy (SMMS).
In addition to this, the SMMS contains the detail of how we have considered all aspects of our system management enterprise in Oldham to date including features such as:
•Collaboration with our commissioning partners across Greater Manchester to manage health market assessment and system management platforms.•A full review of the relative strengths and weaknesses of the supply system (via Health Market Analysis) and a direct alignment within the QIPP (Quality, Innovation, Productivity and Prevention) strategy.•A detailed description of the strategic and tactical plans to stimulate and regulate optimal competition versus collaboration (via market segmentation methods). This has been conducted alongside our local authority partners (Oldham Council), examples of which are the total system of urgent care provision and the emerging ‘Care in the Home – Virtual Ward’ service.•A description of the pilot of health market analysis which has been undertaken within the Oldham health economy already. The system and market management strategy describes this. Working together with Oldham Council this work has (and will continue to) informed strategic planning and potential priorities for market interventions.•A review of the strategic and tactical implications of our provider arm separation, through the Transforming Community Services Programme.•There is a clear description of the methodologies employed to convert market, system and procurement processes into the clinical and technical systems (e.g. choice & booking) to support and enable patient choice.•The Tactical Implementation Plan details how the main implications of adopting systems and market processes convert into a framework for delivery that aligns with the strategic vision, priorities, goals and initiatives, and is described further within the implementation plan associated with this business plan.
Effective execution of this strategy is key to QIPP delivery.
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7. Delivering Our Outcomes
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A. Good governance
The context for the strategic commissioning planDetailed operational planning has to connect our Governing Body Clinical (ACCO) strategy, our Clinical Programme Plans and our financial, contracting, governance, economic and execution plans. These then need to mesh with the operations of the
enterprise at the initiative level and below that at the project level, some of which will be internally handled, a lot of which will be externally delivered through our CSS
arrangements.
Initiatives must be identified that support plan goals, then the projects within initiatives must then be carved out and planned. Operational planning drives the creation of
programme based budgets, because we deep dive into the initiatives and lower-level projects at a level that includes: timeframes, human capital, technology requirements and
in many cases, dependencies on other projects or programs (groups of projects).
Careful attention to detail at this level can help avoid collisions with other projects down the line, ensuring there isn’t a disconnect between clinical vision and economic planning.
Even then, there may be inter-dependencies between these groupings of initiatives and shortages of resources where overlaps exist. Tactical planning must delineate to the
maximum extent possible the timelines, dependency relationships, resource allocations and costs relative to the allocated budgets across operational areas to avoid as many
collisions and conflicts as possible.
If that wasn’t complex enough, we (CCG) also need to factor in the dependencies and delegation of operational delivery to supporting agencies such as CSS and regulate
delivery.
Detailed operational planning has to connect our Governing Body Clinical (ACCO) strategy, our Clinical Programme Plans and our financial, contracting, governance, economic and execution plans. These then need to mesh with the operations of the
enterprise at the initiative level and below that at the project level, some of which will be internally handled, a lot of which will be externally delivered through our CSS
arrangements.
Initiatives must be identified that support plan goals, then the projects within initiatives must then be carved out and planned. Operational planning drives the creation of
programme based budgets, because we deep dive into the initiatives and lower-level projects at a level that includes: timeframes, human capital, technology requirements and
in many cases, dependencies on other projects or programs (groups of projects).
Careful attention to detail at this level can help avoid collisions with other projects down the line, ensuring there isn’t a disconnect between clinical vision and economic planning.
Even then, there may be inter-dependencies between these groupings of initiatives and shortages of resources where overlaps exist. Tactical planning must delineate to the
maximum extent possible the timelines, dependency relationships, resource allocations and costs relative to the allocated budgets across operational areas to avoid as many
collisions and conflicts as possible.
If that wasn’t complex enough, we (CCG) also need to factor in the dependencies and delegation of operational delivery to supporting agencies such as CSS and regulate
delivery.216
How do we avoid disconnects in strategy interpretation?
Our CCG strategy is formulated from clinical discussion and consensus through our practice membership. At the top of the CCG we have a accountable clinical leader / officer
heading up the governing body made up from CCG membership. The COO (Chief Operating officer) and the CFO (Chief Financial Officer) are directly accountable to him
and the Governing body for ensuring the direction and credibility for strategic, operational planning and financial stewardship unfolds effectively. This then connects into our
commissioning business delivery system, headed up by the CCG Business Manager.
Communication of the plan goals is a very important part of that process and another huge factor in accomplishing the creation of meaningful operational plans. Our approach
we have considered in the overall communications strategy, is to translate clinically based plan goals into strategy statements that the CCG can embrace and enact.
The intent is to effectively disseminate the executive vision throughout the organisational membership so that empowered clinical leaders will be energised and capable of helping
their clinical organisation achieve the outcomes set out to meet the needs of our population. As with the business strategy, the communication of the business goals must
be carefully planned and well orchestrated to achieve the intended results. Communications must target the right messages to the right people in the organisation at
the time that they need to receive the message.
Our favoured way of doing this is to align our ACCO strategy, through Clinical Directors Programme Budgets, via a Plan on a Page methodology. The detail delivery plans (the
Integrated Commissioning Plan) will fall under that core headline feature.
Our CCG strategy is formulated from clinical discussion and consensus through our practice membership. At the top of the CCG we have a accountable clinical leader / officer
heading up the governing body made up from CCG membership. The COO (Chief Operating officer) and the CFO (Chief Financial Officer) are directly accountable to him
and the Governing body for ensuring the direction and credibility for strategic, operational planning and financial stewardship unfolds effectively. This then connects into our
commissioning business delivery system, headed up by the CCG Business Manager.
Communication of the plan goals is a very important part of that process and another huge factor in accomplishing the creation of meaningful operational plans. Our approach
we have considered in the overall communications strategy, is to translate clinically based plan goals into strategy statements that the CCG can embrace and enact.
The intent is to effectively disseminate the executive vision throughout the organisational membership so that empowered clinical leaders will be energised and capable of helping
their clinical organisation achieve the outcomes set out to meet the needs of our population. As with the business strategy, the communication of the business goals must
be carefully planned and well orchestrated to achieve the intended results. Communications must target the right messages to the right people in the organisation at
the time that they need to receive the message.
Our favoured way of doing this is to align our ACCO strategy, through Clinical Directors Programme Budgets, via a Plan on a Page methodology. The detail delivery plans (the
Integrated Commissioning Plan) will fall under that core headline feature. 217
218
Good governance is important to patients, the public and clinicians. There are a number of elements to governance including corporate, clinical, financial, information and research
governance. There are multiple connections within the CCG assurance, performance and strategic delivery system. The CCG is a mutual organisation, not a bureaucratic structure
that exists merely to serve a technical process.
The reason why we have engineered this system of control is based around the principle of mutual contribution to population health management and the ceaseless desire to deliver on our Triple Aim (ACCO based) pledges. Our (practice) members are equal stakeholders, as
are every one of our local residents.
Our stakeholders expect the Governing Body to manage the commissioning system effectively and for us to take a careful and diligent attitude to clinical commissioning and
economic stewardship.
The connections described in the Golden Thread will change over time as the CCG evolves, however the core platforms described are ones that regardless of the passage of
time and gained experience will remain the cornerstones for good governance.
We will make it work for us as it makes sense and connects our system components together and will provide assurance to local stakeholders and external regulators.
The CCG has invested significant time and energy in developing a robust assurance framework that effectively measures progress against the outcomes described within our
strategy
Good governance is important to patients, the public and clinicians. There are a number of elements to governance including corporate, clinical, financial, information and research
governance. There are multiple connections within the CCG assurance, performance and strategic delivery system. The CCG is a mutual organisation, not a bureaucratic structure
that exists merely to serve a technical process.
The reason why we have engineered this system of control is based around the principle of mutual contribution to population health management and the ceaseless desire to deliver on our Triple Aim (ACCO based) pledges. Our (practice) members are equal stakeholders, as
are every one of our local residents.
Our stakeholders expect the Governing Body to manage the commissioning system effectively and for us to take a careful and diligent attitude to clinical commissioning and
economic stewardship.
The connections described in the Golden Thread will change over time as the CCG evolves, however the core platforms described are ones that regardless of the passage of
time and gained experience will remain the cornerstones for good governance.
We will make it work for us as it makes sense and connects our system components together and will provide assurance to local stakeholders and external regulators.
The CCG has invested significant time and energy in developing a robust assurance framework that effectively measures progress against the outcomes described within our
strategy218
Commercially Regulated Commissioning Support SystemCommercially Regulated Commissioning Support System
219
The Golden Thread - Delivering & Assuring Though Connected Systems
220
221221
• Commissioning outcomes framework KPI’s• National Statutory Performance KPI’s
• Legal duties – (Economic Stewardship and Innovation)• Statutory duties – core purpose objectives (Triple Aim)
• Covered (KPI’s) within Primary Care Quality Assurance Framework
• Clinical Programme (PB) (H&WB) Management Segmented Objectives + QIPP
• Key 5 Commissioning & System Management risks (see Figure 1)
• Alignment of Personal objectives/PDPs into macro and Programme based goals + Defining CSS support based outcomes required (at people level)
• Alignment of Commercial SLAs with Core Programme requirements and deliverables (at supplier level & in total)
• Corporate Macro ObjectivesKey theme 1
• CCG Membership – Practice Assurance KPIsKey theme 2
• Programme Based goals & Objectives• (at CCG & HWB level)
Key theme 3
•Strategic Commissioning RisksKey theme 4
•People Based work plans & Objectives• (CCG + Integrated Hub Internal) + (CSS contracted
outcomes)Key theme 5
•Delivery specifications for All Contracted Suppliers, Including CSSKey theme 6
Assurance thread 1 (BAF)
Assurance thread 2
(PAF)Assurance thread 3
(FQMS)Assurance thread 4
(PMBS)
Connecting Assurance (Golden) Threads Together
BAF: Board Assurance Framework FQMS: Finance & Quality Management System
PAF: Performance Assurance Framework PMBS: People Management & Business Support Processes
CCG governance arrangements
NHS EnglandHealth & Wellbeing Board
Integrated Commissioning
Partnership (OMBC)
North East Sector Commissioning
Board
Clinical Council Executive Regulation of Finance,
Performance and Quality Remuneration
Committee
Audit Committee
Commissioning Performance
Advisory Group
Planning Forum
IPRPQuality
Assurance Group
Clinical Programme
Review Group
Urgent Care Alliance
Association Governing Group
(GM)
CCG Governing Body
Management Executive
Team
Practice Based Clusters
Practices
Integrated Governance Committee
Assurance Infrastructure
Governing Body
ERFPQ
Clinical Programme Review Group (including
QIPP)
Quality assurance group
Commissioning Performance
Advisory GroupPlanning forum
• CD updates and patient stories (monthly)
• Finance report (monthly)• Corporate performance report
(monthly/quarterly / annual indicators)
• Board Assurance Framework (quarterly/monthly)
• Highlight report from ERFPQ (monthly)
• Finance report (monthly)• Provider performance exceptions (quality
exception profiles and provider performance - monthly)
• Formal reporting - PALS/complaints / SUI’s (quarterly)
• Primary care quality exception reporting (monthly)
• Programme area exceptions (monthly)• Quality assurance exceptions (monthly)• Corporate performance report exceptions
(monthly/quarterly / annual indicators) CCG OF / strategic objectives
• 100 day plan exceptions (monthly)• CCG owners – KWJ/RF
• Driver diagram• Highlight report• Risk register• Balanced scorecard
(Kaplan Norton) - incl. activity /performance
• GB links – AV/ DS• CCG owner – NB
(KWJ – dep)
• Exception profiles• Contract reports• Pt complaints / pt
experience / SUI’s• Clinical audit• Research governance• NICE guidelines• Quality strategy
assurance• Risk register• GB links – IM/ MW/ lay
member• CCG owner – TR (WN –
dep)
• Practice assurance frameworks
• Cluster development and highlights
• Education• EQUALS• Risk register• GB links – IM/ GF• CCG owner – DF (JS
– dep)
• 5 year technical business planning
• Contract negotiation
• 100 day delivery plan
• Risk register• GB lead – KWJ• CCG owner – RF
Performance Management Architecture
North East Sector Commissioning BoardChair: Chris Duffy
Urgent Care Network Board
Chair: Martin Whiting(rep – NB)
Elective Care Board
Chair: Kiran Patel(reps –
KWJ/ZA/MD)
PAHT Contract BoardChair: Andy Lowe(reps: KWJ/JD)
Weekly local performance monitoring forumChair: Kath Wynne-Jones
Urgent Care tactical Group (prospective
view – Urgent Care)
performanceChair: Ian
Mello (reps – CSU)
Elective tactical group to be established
(prospective view – cancer and 18
weeks)Chair: Kath Wynne-Jones (reps – CSU)
Local PCFT contract
performance and delivery
groupChair: Kath
Wynne-Jones
Oldham Urgent Care
Tactical Group
Chair: Nadia Baig
Clinical Programme
Review GroupChair:
Andrew Vance
Governing Body
(corporate performance
meeting)
Final 15.1.14AK
Urgent Care Alliance
Management Team
Chair: Dave McMaster
Urgent Care
Alliance Leadership
TeamChair: Ian Wilkinson
PCFT contract BoardChair: Ian Wilkinson(reps – KWJ/DG/JD)
PAHT Contract
performance and delivery
group Chair: Julie
Daines
Local PCFT mental health
IPH boardChair: Keith
Jeffery
Quality surveillance
Tanya Roberts
Local MSK IPH board
Chair: Zuber
Ahmed
225225
Key areas of responsibility
Responsibility Clinical Leadership Internal Managerial support
Clinical governance and quality Ian Milnes DPD
Membership engagement Ian Wilkinson DPD
Authorisation / Continuous Annual Assessment
Dave McMaster MD
Finance Bilal Butt CFO
Performance Andrew Vance DPD
IMT and information governance – Senior Information Risk Owner (SIRO) / Caldicott Guardian
Zuber Ahmed CFO
Collaborative commissioning – Oldham Council & NE Sector
Ian Wilkinson MD
Health and Wellbeing Board Ian Wilkinson / Zuber Ahmed / Keith Jeffrey
MD
Children's and Young People Ian Milnes - interim DPD
Safeguarding (Children's) Ian Milnes / Maxine Lomax DN
Responsible office for controlled drugs Nick Dawes MD
Safeguarding (Adults) Ian Milnes / Maxine Lomax DN
Organisation development/succession planning
Ian Wilkinson MD
Reducing Inequalities Zuber Ahmed MD
Strategic estates TBC CFOCSU contract Ian Wilkinson MD
The table above outlines corporate areas of responsibility which have now been taken forward by clinician supported by an internal management leadMD – Managing Director / CFO – Chief Financial Officer / DPD – Director of Performance and Delivery / DN – Designated Nurse
226226
B. Our delivery model
The delivery planThe business plan should be read in conjunction with this document, which describes in detail our approach to:
• Communication and engagement• Organisational development• Our collaborative commissioning arrangements• Our approach to establishing an internal infrastructure and a relationship with the Greater Manchester commissioning support service• Governance arrangements and the constitution• Informatics• Contracting• Equality and Diversity
Through this document, the business plan and the associated documents, the CCG has fully described how it will undertake its duties and responsibilities outlined in the “Functions of Clinical Commissioning Groups”, updated to reflect the Health and Social Care Act 2012
The CCG has recently refreshed its governance arrangements to ensure they are fit for purpose, moving forwards with the implementation of this strategy.
This section outlines at a high level the approach to delivery the CCG will take towards:• Implementing the strategy• Programme management• Strategic and delivery risks• Measuring our success – our approach to scorecard development• The operational plan for the next 2 years
227
Implementing the strategy
Technical delivery platformDefining our actions
• Content of clinical programme plans (incl. BCF) – plans on a page / new OF indicators / commissioning for prevention interventions outlined by PH
• Programme methodology• Prioritisation (circa 180 interventions)• Cross cutting schemes : EQALS / community services mobilisation / inequalities / single
assessment processes and care plans• Embedding statutory responsibilities - safeguarding / engagement / E&D • What development do people need?
Governance • Forum to manage performance / quality / QIPP effectively • Process to identify and manage strategic and operational risks• Determine annual business cycle • Standard documentation suite • Contract review infrastructure • Alliance / IPH / BCF frameworks and arrangements• Enact MSB decisions
Measurement • Clinical programme dashboards• Refresh corporate assurance framework• IC dashboard (BCF indicators)• Evaluation of Dragons Den bids• Year of care costs• Patient experience
IM&T • CCG IM&T strategy• Shared information systems• Healthcare technology strategy
230
CCGs that develop a mature response to their planning process have taken governance to another level and have implemented Plan Management Offices (PMO). Plan governance, whether implemented as a formal PMO or administered through a less formalised committee structure, should be responsible for the functions of selecting, managing and measuring of everything entering or within the ‘Clear & Credible Plan’ portfolio. The plan portfolio is the overall macroscopic view of all programs (related groupings of initiatives) and projects within initiatives
that are involved with clinical commissioning strategy implementation.
As a function of the ongoing management of the plan portfolio, plan governance also involves refreshing the strategic and supporting operational plans to reflect changes as a result of completing plan goals and taking on new ones, in addition to resilience matters such as the maintenance of high levels of corporate performance. This structure allows for strategic and operational planning to become much more actively managed and based on shorter time horizons. Shorter time horizons for plans lead to more focus on execution and results in better outcomes. As we have
discussed in several CCG development sessions, a rolling 12-month plan on a page (PoP) that is refreshed quarterly is best suited for achieving optimal results in execution. There are several reasons why this approach yields better planning outcomes. Here are a few:
First, is the tendency of shorter plan horizons to have fewer goals per cycle and therefore are more focused on tactical execution. Rolling 12-month (PoP) plans allows the CCG and the lead CD to be more responsive to change with goal setting, especially in the operational aspect of
planning. Likewise, plans that are refreshed quarterly are easier to manage and keep the CCG sharper and focused on achievement due to the shorter cycles to accomplish chunks of work. It also aligns with the absolute need for forensic scrutiny of KPIs and those engaged to support
delivery of them (e.g. internal CCG partners + external CSS partners).
Second, in our experience, 12-month rolling plans tend to be better at addressing the pressing needs of the business, while maintaining the long-term focus of the CCG Governing Body and Clinical Strategy team (i.e. our CDs). Add refreshed quarterly plans to the mix and we will have
instilled into the organisation a laser-beam focus on results. Plan governance administered on a quarter-by-quarter basis affords management the opportunity to review the initiatives underway and assess any backlog that exists. Management can also assess the CCG capacity to move
an item from the backlog into the active plan – furthering progress towards completion of the plan’s goals.Third, 12-month rolling plans tend to be more realistic. This is attributed to the higher quality data driving the
process, such as: capacity to change, historical achievement, resource availability and current environmental constraints.Within this system new actors will need new roles. The term management is used to describe the function and purpose, not the people. The governing actors are the
CDs with the CCG internal team, the executing and resilience actors will come from CSS.
Plan governance manages alignment of clear and credible plan goals and supporting initiatives through effective oversight at the corporate and operational levels. A Plan Management Office benefits the CCG by having better visualisation into all efforts supporting strategic
implementation. The Plan Management Office also positions the CCG to better manage the interrelationships of all the underlying initiatives, considering dependency relationships and constraints on resources. It aligns our strategy, through business plans into operational execution via internal and external support. Lastly, a plan governance model will harvest metrics and status reporting from across the portfolio of all programs
and their underlying projects. Metrics are harvested from the tactical layer to provide historical acceleration data to offer continual improvement to the planning cycle. In the end, planning governance diligently helps the CCG filter through the minutia of everyday tasks to focus on
accomplishing key outcomes sought by executive leadership.
CCGs that develop a mature response to their planning process have taken governance to another level and have implemented Plan Management Offices (PMO). Plan governance, whether implemented as a formal PMO or administered through a less formalised committee structure, should be responsible for the functions of selecting, managing and measuring of everything entering or within the ‘Clear & Credible Plan’ portfolio. The plan portfolio is the overall macroscopic view of all programs (related groupings of initiatives) and projects within initiatives
that are involved with clinical commissioning strategy implementation.
As a function of the ongoing management of the plan portfolio, plan governance also involves refreshing the strategic and supporting operational plans to reflect changes as a result of completing plan goals and taking on new ones, in addition to resilience matters such as the maintenance of high levels of corporate performance. This structure allows for strategic and operational planning to become much more actively managed and based on shorter time horizons. Shorter time horizons for plans lead to more focus on execution and results in better outcomes. As we have
discussed in several CCG development sessions, a rolling 12-month plan on a page (PoP) that is refreshed quarterly is best suited for achieving optimal results in execution. There are several reasons why this approach yields better planning outcomes. Here are a few:
First, is the tendency of shorter plan horizons to have fewer goals per cycle and therefore are more focused on tactical execution. Rolling 12-month (PoP) plans allows the CCG and the lead CD to be more responsive to change with goal setting, especially in the operational aspect of
planning. Likewise, plans that are refreshed quarterly are easier to manage and keep the CCG sharper and focused on achievement due to the shorter cycles to accomplish chunks of work. It also aligns with the absolute need for forensic scrutiny of KPIs and those engaged to support
delivery of them (e.g. internal CCG partners + external CSS partners).
Second, in our experience, 12-month rolling plans tend to be better at addressing the pressing needs of the business, while maintaining the long-term focus of the CCG Governing Body and Clinical Strategy team (i.e. our CDs). Add refreshed quarterly plans to the mix and we will have
instilled into the organisation a laser-beam focus on results. Plan governance administered on a quarter-by-quarter basis affords management the opportunity to review the initiatives underway and assess any backlog that exists. Management can also assess the CCG capacity to move
an item from the backlog into the active plan – furthering progress towards completion of the plan’s goals.Third, 12-month rolling plans tend to be more realistic. This is attributed to the higher quality data driving the
process, such as: capacity to change, historical achievement, resource availability and current environmental constraints.Within this system new actors will need new roles. The term management is used to describe the function and purpose, not the people. The governing actors are the
CDs with the CCG internal team, the executing and resilience actors will come from CSS.
Plan governance manages alignment of clear and credible plan goals and supporting initiatives through effective oversight at the corporate and operational levels. A Plan Management Office benefits the CCG by having better visualisation into all efforts supporting strategic
implementation. The Plan Management Office also positions the CCG to better manage the interrelationships of all the underlying initiatives, considering dependency relationships and constraints on resources. It aligns our strategy, through business plans into operational execution via internal and external support. Lastly, a plan governance model will harvest metrics and status reporting from across the portfolio of all programs
and their underlying projects. Metrics are harvested from the tactical layer to provide historical acceleration data to offer continual improvement to the planning cycle. In the end, planning governance diligently helps the CCG filter through the minutia of everyday tasks to focus on
accomplishing key outcomes sought by executive leadership. 230
Programme management
Implementation : Controlling our Priority Programmes via Programme office
Via Clinical Directors &
Internal CCG Control Systems
Via Clinical Directors &
Internal CCG Control Systems
Via carefully crafted process delivery, highly
regulated & standardised
platforms
Via carefully crafted process delivery, highly
regulated & standardised
platforms
CSS (SLA)CSS
(SLA)
Clinical Director Driven Programme Budget Leadership
Clinical Director Driven Programme Budget Leadership
QualityInnovationPrevention
Productivity
QualityInnovationPrevention
Productivity
CSS (SLA
)
CSS (SLA
)
106
Delivering our clinical programmes
Clinical Director (CCG)
• Setting the strategy ( in the context of health and social care integration)
• Defining the key outcomes ( including national priorities)
• Defining the plan on a page – what are the key actions to take to deliver the strategy
• Informing the integration strategy - CPDG
• Presenting outcomes and patient stories to the GB
• Defining the clinical content of service specifications
Programme lead (CCG)
• Documenting programme components (strategy, plan on a page, driver diagram, PID, programme plan)
• Defining content of the balanced scorecard• Regulating the plan on a page with the CSU –
what are the key actions to take to deliver the strategy by when.
• Presenting highlights, performance, risk and mitigating actions to CPRG
• Assuring reporting through internal arrangements
• Relationship management with CSU project managers
• Documenting clinical aspects of service specifications
Performance Manager (CCG)
• Population of balanced scorecard indicators with programme leads
• Relationship management with CSU for population of indicators and robust performance reports for ERFPQ/GB
• Identification of opportunities from benchmarking data – linking with CSU
• Delivering weekly reporting to MET
PMO (CCG)
• Converts project actions into time units for CSU and agrees the plan
• Ensuring project actions/external returns are on track
• Distributes and monitors urgent actions in the system e.g. A&E return
• Managing issues with CSU at corporate level• Escalating concerns to DPD
CSU
• Delivering project actions allocated by the CCG programme lead
• Presenting highlights, performance, risk and mitigating actions to the CCG programme lead through formal programme reporting arrangements in relation to specific deliverables
• Performance management with providers of high risk areas
• Performance reporting for CCG internal assurance purposes and external requirements
• Population of specifications in line with national contract requirements
• Clinical audit requirements generated from clinical programmes
233233
Commissioning supportThroughout the transition period and beyond, the retention of crucial skills and talent to take forward the reform agenda will be foremost in our thoughts
The CCG in Oldham is progressing at a pace that requires a more commercially focused support infrastructure, with a core of expert internal partners to ensure that programmes are professionally executed, and clinicians feel assured that premium technical and people resource solutions match their ambitions and requirements.
The CCG will operate within a complex and ever changing political, organisational, societal and clinical landscape. Decisions regarding initiatives, deployed financial efficiencies, shifts of service environment and reformed corporate delivery models require new style relationships between clinical and managerial disciplines. This becomes even more critical with the continued development of the CCG Clinical Commissioning Model (ACCO model: see CCG strategy).
Clinical commissioning will operate at its optimum when clinicians can focus on the broad service reform initiatives, quality of care, clinical contribution management, determine clinical and service based strategies, and provide population based leadership in partnership with Public Health colleagues, thereby enabling NHS Management to engineer the delivery systems to execute local strategic and operational objectives. Therefore, it stands to reason that senior primary and community clinicians and practitioners (operating within a CCG framework) will require a management support system that feels, reacts and delivers value using a differentiated approach to traditional NHS clinician / manager relationships. The approach proposed owes more to the style of ‘internal consultancy’ than typical ‘service improvement support’.
In addition to the obvious and mandatory requirement to be responsive, the ‘internal consultancy style’ will support the following benefits and drive success via mutual partnership:•Controlled management costs•Responsive client based service•Robust client co-ordination role (a particular focus on the Commissioning Support Service)•Centralised management and product control planning.
234234
The CCG is very clear on the issue of CSU. The CCG recognises the critically important requirement to have viable and capable management support to fit alongside its clinical leadership model. It is also very clear on the need to have an internal (albeit relatively small) management system in order to support its clinical leaders to ensure we deliver our accountabilities to our public. CCG cannot (we feel) delegate its core accountabilities and governance responsibilities to an external business support provider. Furthermore, we cannot, and should not, convert clinical leaders into commissioning and corporate managers.
With this in mind we have developed an emergent business model that meets the twin requirements of optimal internal system management with external business support, within a viable operating cost limit. This is based on the Greater Manchester CCG Minimum System Requirements model developed through the Community of Regulated Practice system.
We aim to also connect our internal management system properly and appropriately with partners at a Borough level (Oldham Council) and across the North East of Manchester (Bury and HMR CCGs). The Public Health Team were successfully relocated into OMBC in February 2012.
Front end support from the CSU, will be subject to constant review as both the GM CSU develops its offer in relation to front end commissioning support, and the CCG embeds its operational commissioning delivery business systems throughout this year. It is an accepted principle however within the CCG that roles directly associated with effective, prudent and accountable stewardship of the CCG will be in-house employed roles, whereas the supporting functions such as front and back end professional services will be sought from a capable and viable CSS.
The CSU consideration is based on a premise that the CSU is an industry-leading supplier of commissioning support and could therefore operationally deliver (under contract) the management support for the CCGs’ business and commissioning plan, whilst at the same time providing hands on delivery support for performance and resilience purposes.
235
Another major factor in executing our operational plans begins with creating delivery structures that empower informed employees (whether CCG internal or CSU External) with the latitude to make broader line-level
decisions. This recommendation goes hand-in-hand with CCG leadership having already installed the enabling management support below them with the organisational core competencies that are needed for accomplishing strategic goals. If strong management support (internal & external) is slow to operationalise, CCG leadership should take great care not to over-empower lower-level managers that are ill-equipped to handle increased
responsibilities (decision-making authority).
Stronger line-level management support benefits the entire organisation by improving upon the execution within the business operations while being a major part of the many strategic “goal-supporting” initiatives the CCG
business relies upon for fuelling the future vision. Empowerment of CSU support and internal CCG employees also gets executive management (i.e. CCG Governing Body) out of the minutia by trusting well-informed and
competent staff below them on the organisation chart instead of trying to shoulder too much operational responsibility themselves. This is accomplished with well-constructed strategic plans that concisely relate to the
operational budgets controlling the tactics of implementation.
Organisational performance indicators and metrics help provide the ability to control and manage, as they signal the need for evaluation and analysis early when corrections to implementation tactics can be made more easily
with fewer cost implications. With proper management controls in place, this approach allows those closest to the action to respond quickly and appropriately when it is needed , always operating within predefined spheres of control and in concert with the CCG strategic goals. The goals are well known and understood by empowered
business partners, as their direct relationship manager (i.e. CCG VSMs) will have effectively communicated these goals to them, accompanied by the expectations for how they should directly contribute, allowing them to embrace
the vision and fully participate in the tactical execution.
With empowerment comes accountability, and accountability requires clarity. Clarity regarding roles and responsibilities relative to plan goals requires people who have sufficient incentive and understanding to execute to
that plan. Employees (at CCG and CSU level) that understand what is being done, the reasons why, when to do what, and how they can contribute become empowered team players.
It is important for us (CCG) to note that we do not discriminate or differentiate the value of players within our team on the basis of their employment status (i.e. CCG or CSU). We are concerned with the ability to execute effective
objectives.
Another major factor in executing our operational plans begins with creating delivery structures that empower informed employees (whether CCG internal or CSU External) with the latitude to make broader line-level
decisions. This recommendation goes hand-in-hand with CCG leadership having already installed the enabling management support below them with the organisational core competencies that are needed for accomplishing strategic goals. If strong management support (internal & external) is slow to operationalise, CCG leadership should take great care not to over-empower lower-level managers that are ill-equipped to handle increased
responsibilities (decision-making authority).
Stronger line-level management support benefits the entire organisation by improving upon the execution within the business operations while being a major part of the many strategic “goal-supporting” initiatives the CCG
business relies upon for fuelling the future vision. Empowerment of CSU support and internal CCG employees also gets executive management (i.e. CCG Governing Body) out of the minutia by trusting well-informed and
competent staff below them on the organisation chart instead of trying to shoulder too much operational responsibility themselves. This is accomplished with well-constructed strategic plans that concisely relate to the
operational budgets controlling the tactics of implementation.
Organisational performance indicators and metrics help provide the ability to control and manage, as they signal the need for evaluation and analysis early when corrections to implementation tactics can be made more easily
with fewer cost implications. With proper management controls in place, this approach allows those closest to the action to respond quickly and appropriately when it is needed , always operating within predefined spheres of control and in concert with the CCG strategic goals. The goals are well known and understood by empowered
business partners, as their direct relationship manager (i.e. CCG VSMs) will have effectively communicated these goals to them, accompanied by the expectations for how they should directly contribute, allowing them to embrace
the vision and fully participate in the tactical execution.
With empowerment comes accountability, and accountability requires clarity. Clarity regarding roles and responsibilities relative to plan goals requires people who have sufficient incentive and understanding to execute to
that plan. Employees (at CCG and CSU level) that understand what is being done, the reasons why, when to do what, and how they can contribute become empowered team players.
It is important for us (CCG) to note that we do not discriminate or differentiate the value of players within our team on the basis of their employment status (i.e. CCG or CSU). We are concerned with the ability to execute effective
objectives. 235
Delivering via human resource assets?
236236
CCGCCG
CCGCCG
Harvesting Maximum Value from Investments in People
237237
Risk managementRisk management is the process of identifying and assessing risks, and then responding to them. Any response to risk which is initiated will involve one or more of the following:
• Tolerating the risk• Treating the risk in an appropriate way to constrain the risk to an acceptable level or actively taking advantage, regarding the
uncertainty as an opportunity to gain a benefit• Transferring the risk• Terminating the activity that has given risk to the risk.
Good risk management by the CCG will enable it to:
• Have increased confidence in achieving its outcomes;• Constrain business threats effectively to acceptable levels; and• Take informed decisions about exploiting opportunities.
Each clinical programme area will be responsible for reviewing its risk of delivery , and putting in place the associated mitigating actions to manage risk, which will be reviewed through the Board Assurance Framework by the Governing Body. Key delivery risks are highlighted in this section.
At a more strategic level, the CCG has a number of risk factors it will need to monitor and manage through its assurance processes which are detailed in the following page.
238
Strategic Risk
Effects (limited control / regulation)
Effects (optimal control / regulation)
1.Uncontrolled / Unregulated
Demand
· Demand increases annually· Costs escalate· Suppliers dominate relationships· Risks of overtreatment· Health inequalities prevail· Total system failure· Clinical effectiveness suffers
· Demand = defined need· Cost & investment control possible· Mutuality relationships prevail· Evidenced based treatments· Health inequalities narrow (year on year)· Total system equilibrium· Clinical effectiveness is measurable
2Uncontrolled / Unregulated
Suppliers
· Sub optimal clinical pathways· Supplier induced demand· Increased activity profiles (FUs etc..)· Inferior clinical outcomes· Duplication & poor consumer experience
· Evidence based clinical pathways· Public Health influenced demand· Activity profiles in line with contracts · Clinical outcomes in line with industry best· Patient surveys in top quartile (benchmarked)
3Uncontrolled / Unregulated
Market Entry & Exit
· Monopolies & Cartels dominate· Insufficient consumer choice· Insufficient supplier mix· Barriers to entry restrict enterprise· Risks of legal challenge & litigation· Ineffective contracting / performance
· Differentiated supplier landscape· Extensive consumer choice + enablement· Commissioner leads the system· Smaller niche supplies play a part· Rules apply & market controls mitigate· KPIs are routine: Quality incentives offered
4.Application of Rules: Legal challenge &
litigation
· Legal costs escalate· Stagnation & limited innovation· Management overheads escalate· Shift in strategic relationships· Public perception of PCT suffers
· Disputes & legal costs kept to minimum· Service strategy is delivered as planned· Management overheads are controlled· Strategic power rests with PCT· Public is confident in our leadership
5Sub optimal
patient & public
experience
· Loss of public confidence in local NHS· Public Health inequalities prevail· Increased political & regulatory scrutiny· Complaints & overhead costs increase
· Total public confidence in local NHS· Health equality is the norm · Retain high political & regulatory profile· Limited complaints & overhead costs
238
Our strategic risk factors to manage
Delivery risks
• Financial and performance challenges within the health economy – health and social care
• Workforce availability• Mobilising community assets effectively – community
services and the population• Commissioning support infrastructure• Implementation of deflection schemes• Stakeholder engagement – partners and patients• Relationships between providers - Alliance• IAPT
Elective Care: £2m
Continuing Care: £0.5m
Non-Elective Care: £2m
The approach to delivery our CCG outcomes
Mental HealthRespiratory
Canc
erVa
scul
arIntegration
PlanBSC
Standardised methodology to drive
improvement from clinical programme
budget areas (22 point plan)
To include:
· Driver diagram· Plan on a Page· Clinical change plan· Risk register· Balanced scorecard
Programme budget spend and outcomes
Return of investment from new investment
Process measures to evaluate new investment
Service line reporting for commissioned providers (incl. LES/EQALS)
QP QOF indicators
National & local outcome measures (including public health indicators)
Impro
ving p
opulation healt
h
Corporate Assurance Framework
Practice Assurance
Framework (indicators assigned to
CDs
Improving patient experience
Improving Value for Money
Provider profiles (quality/finance/performance)
Clinical programme budget area balanced scorecards
Elective Care Prescribing
Urgent care and LTC Diabetes
Respiratory Vascular
Children End of Life
Mental health and LD CHC
Cancer
NICE Quality Standards
Operating plan trajectories
242242
8. Key references
243
Local documents• CCG strategy to become an Accountable Care Organisation• CCG Integrated Care Strategy• Health and Wellbeing Strategy • CCG Business Plan • CCG Constitution and Membership Agreement • CCG Organisational Development plan • CCG Equality and Diversity strategy • CCG Quality Strategy • CCG Long Term Condition Strategy • CCG System Reform Strategy • CCG innovation strategy • CCG Communication and Engagement strategy • CCG System and Market Management Strategy • CCG Elective Care Strategy• CCG Managed Care Model• JSNA • CCG Clinical Commissioning plan 2012-2015• Oldham CCG Healthier together submission July 2013• Healthier Together standards of care• Greater Manchester Primary Care strategy
243
KEY GUIDANCE & DOCUMENTS
• Everyone Counts: Planning for Patients 2014/15 to 2018/19• 5 Templates re above• NHS Outcomes Framework• NHS England – A Call to Action • Oldham Health & Wellbeing Board Strategy• Compassion in Practice – the 6 Cs• The NHS Constitution• Transforming Participation in Health and Care• 2014/15 GMS Contract• The Francis Report & Hard Truths• Transforming Care: a national response to Winterbourne View Hospital• The Berwick Review into Patient Safety• Safeguarding Vulnerable People in the Reformed NHS; Accountability
and Assurance Framework• National Quality Board – How to ensure the right people, with the right
skills, are in the right place at the right time• Better Care Fund – Rules/Criteria
245245
9. Appendices
246246
Appendices
Page
Appendix 1 - Innovation Approach – Dragons Den 3
Appendix 2 – Clinical Change & Delivery Programme 11
Appendix 3 – The Clinical Programme Approach 47
Appendix 4 – Wider Primary Care at Scale - Backstory, Data & Statistics - Supporting Logic