Strategic plan

2014/15 – 2015/16

Bracknell & Ascot

BACCG QIPP Triangle

Programme One: Prevention and self care

The focus will be on prevention in line with the priorities in the JSNA(s) and Supported Self-management for people with long terms conditions such as COPD, diabetes and dementia following diagnosis and throughout the course of their condition. Targeted and evidence based programme with an emphasis on reducing NELs and A&E attendancesCurrent year enabling projects•2013/14 Additional resource for joint work with Local Authorities for delivering Call to Action and self-care priorities 2014/15 enabling projects•Establish the preferred methods of communication for local people•Alignment with primary care vision•How technology would support

2014/15 Investment through a joint integrated plan with partnersIntended projects 2014/15 include:•Smoking cessation prior to elective surgery•Reduction of years lost through identifying opportunities to target specific groups of patient from benchmarking national indicators•Healthy Lifestyle education clinics in primary care as part of whole system programme •Talking Health programme•Signposting to services and support•Extensive campaign to promote appropriate use of new UCC and education centre

Programme One: Prevention and self care

Theme 13/14 enabling projects utilising 2% non recurring funds

14/15 QIPP projects 15/16 vision

Self Care Awareness campaigns:•Keep Calm •Self care week•Innovations projects

• Targeted joint campaign to deliver JHWS priorities

• Sign posting and Education on the use of UCC, including young people

• Reduced years of life lost

• Children and Young People support, specifically reducing obesity levels

Supported self-management

Review existing services:•Expert patient programme/Talking Health•Purchase healthy lifestyle tools (Pufell)

• Extended coverage and integration of self management, reviewed support pathways for COPD, Diabetes and Dementia

• All people diagnosed with a long term conditions are enabled to self-manage

Prevention and health improvement

• Flu campaign• Increase capacity at

falls clinic• Condition specific

campaigns i.e. male cancers/heart disease

• New falls pathway• Targeted campaigns• Smoking cessation for

surgical patients

• Risks that local people face are identified and mitigated

Programme Two: Long Term Conditions

This programme will achieve the a QIPP target of 66 (per 1,000 population) for unplanned admissions with a view to reducing to 64 in 15/16. Current year enabling projects:•Long Term Conditions: resources required £40k recurring funds 2014/15 to ensure delivery of benefits•Review of COPD pathway to establish equity of access and outcomes •Review of Diabetes pathway to establish high quality services across primary care•Delivering the joint Dementia Strategy including increasing diagnosis rates•Cancer opportunity being scoped by clinical lead for screening and improve Breast Cancer pathway

Intended projects 2014/16:•Investment in community Mental Health: including medically unexplained symptoms service•Implementation of the Better Care Fund vision, agreed with our partners, with supporting programme of work•Sustainable and effective Integrated Care Teams as part of Better Care Fund and building on evidence and experience to grow caseloads•Review of IT requirements to further integration of key medical information

Theme 13/14 enabling projects utilising 2%

14/15 QIPP projects 15/16 vision

Mental health • Review existing gaps in services i.e. CAMHs

• Talking Health• Dementia • Reviewing liaison

psychiatry provision

• Effective community based services available to all

Diabetes • Review foot health provision

• Education project • Review of pathway

• Best practice pathways for all

• Elimination of unnecessary diabetes related admissions

COPD • Review existing pathways and identify gaps

• Equitable pathways commissioned from best practice sites

• Reducing inhaler waste

• Reduction of unplanned respiratory related admissions

Programme Two: Long Term Conditions

This programme will support the QIPP for unplanned admissions, provide appropriate urgent services for our population and to manage the increasing pressures on accident and emergency services.Current year enabling projects•Urgent Care Centre: resources required £40k recurring funds 2014/15 to ensure delivery of benefits•Scoping of pathways during 2013/14:

– End of Life care planning– Develop the primary care discharge

decision tree– Reducing variation in primary care in

NEL and A&E activity with project support to general practice

– Winter pressures projects including 7 day in-reach nursing to Frimley Park

Intended projects 2014/16:•Deliver the primary care led Bracknell urgent care centre and drive out business case benefits•Integrated frail elderly pathway, with ‘real time’ information across agencies, support through patient journey around Frimley system•Falls Clinic capacity, then redesign local pathway to incorporate prevention and adequate capacity, and aspire to local RACC model•Expand Integrated Care Teams and work with clinicians to achieve more effective patient outcomes•Cellulitis pathway linking to Urgent Care•Nursing and residential homes project delivered jointly with UA

Programme Two: Urgent Care

Theme 13/14 enabling projects utilising 2%

14/15 QIPP projects 15/16 vision

Bracknell UCC • Completion of procurement and mobilisation

• Successful implementation of the new service for April 2014

• Realisation of full UCC benefits

Integrated frail elderly pathway

• Pathway and best practice review and gap analysis

• Clear falls clinic backlog

• Integrated pathway as part of BCF, including falls prevention

• Fully integrated services incorporating new Bridgewell and UCC

Integrated care teams

• Social worker and mental health input to ICTs

• Introduce secondary care clinicians into ICTs

• Review the pilots around sharing essential patient information to improve outcomes

• Support to practices for case identification

• Sustainable cluster teams that meet identified needs

• Review IT needs

• All people with complex needs anticipated and supported by ICTs

Programme Two: Urgent Care

Programme Three: Recovering from Ill Health

This programme includes projects in planned care pathways/services which will maintain the 115 (per 1,000 population) GP referral target, and benchmarked levels of elective care whilst commissioning services closer to home. Current year enabling projects:•Scoping and benchmarking of Gastroenterology pathways •ENT extended scope in the community•Community Cardiology service closer to the patients and acute FPH services•Reduce variation in the use of Pathology and Radiology•Scoping neuro-rehab pathway•Generic rehabilitation pathway scoping linking the stoke reablement

Intended projects 2014/16:•Dermatology commissioning including low risk BCCs in the community •Implementation of MSk service and the new community physiotherapy service•Ophthalmology pathway review with FPH system•Addressing clinical variation via Performance review group – Referral Management, medicines management, pathology etc.•Tongue Ties provision into primary care minor operations service with Area Team•Smoking cessation service prior to surgery•Limiting access to Procedures of Limited Clinical Value

Theme 13/14 enabling projects utilising 2%

14/15 QIPP projects 15/16 vision

MSk and direct access physiotherapy

• Procurement of new service

• Service implementation in Qtr. 1 2014/15

• Improved outcomes for physio patients

• Achievement of top decile performance in MSk elective

Clinical variation in referrals

• PRG escalation framework

• Tier two refresh through referral management

• Review local strategy on C&B/e-referrals

• Additional support to practices to identify and reduce variation

• Include secondary care conversion rate comparison

• Top decile performance = 115 target

Benchmarked variation in elective procedures

• Opportunity locator analysis

• Work within unit of planning to identify opportunities to improve outcomes

• Develop service redesign projects and commissioning intentions, or contract challenge

• Top decile performance

Programme Three: Recovering from Ill Health

Programme Four: Patient Experience &Engagement

This programme is a cross-cutting theme to the strategic plan emphasising the importance of patient and public engagement in all that we doCurrent year enabling projects:•Patient Participation – support and develop the PRG Assembly in conjunction with Healthwatch •Consult and engage around the CCG Communications and Engagement Strategy•Call to Action responses •Response to poor perception of GP access

Intended projects 2014/16:•Work in partnership with Healthwatch to ensure broad engagement across the CCG population•Launch the Communications and Engagement Strategy•Public launch of the CCG website/s and social media (requires recurring investment in post holder)•Gain understanding of the impact of the Personalised Health Budgets•Improve effective public and patient involvement in service redesign

Programme Four: Patient Experience &Engagement

Theme 13/14 enabling projects utilising 2%

14/15 QIPP projects 15/16 vision

PRG engagement

• Development work via Healthwatch

• Programme of engagement

• Fully integrated network with Healthwatch at hub

Communication and Engagement Strategy (C&E)

• Consultation on C&E strategy

• Call to Action

• Implementation of C&E strategy

• Review impact from strategy with partners

Public and patient engagement in service redesign

• UCC, MSk and Physio

• Continuation throughout

• Fully integrated

Programme Five: Quality and Safety

This programme includes quality improvement areas and commissioning intentions for existing provider contracts. All projects have a relationship with quality and safety and with that in mind this programme spans all the three QIPP programmes for the CCG.2013/14 intentions for contracts:•Review of the Community Service specifications to reflect commissioning intentions and integration•Ensure robust quality schedules and monitoring for all new and revised services•Working collaboratively across the Unit of Planning and Frimley System•Support joined up provision of safeguarding across our population in line with Winterbourne

• Continual review all provider contracts and service specifications including unit of planning and Frimley System

• Develop further the collaborative and integrated approach to commissioning with all our partners

• Continue to support our providers to deliver the best high quality services, including CQC, Monitor and assurance around Francis report and Keogh principles

• Maintaining the high quality in general practice

Programme Five: Quality and Safety

Theme 13/14 enabling projects utilising 2%

14/15 QIPP projects 15/16 vision

CQUIN • Appropriate management of unplanned care

• Working across all provider on the shared CQUIN

• 7 day working implementation

• Extension on 13/14 unplanned care CQUIN (three year programme)

Joint (Health) Commissioning

• Ensure robust quality schedules and monitoring for all new and revised services

• Establish robust unit of planning with clear strategic objectives

• Ensure through best practice of commissioning, procurement and contracting we obtain value for money

Ensuring high quality standards

• Continue to reflect on CQC

• Respond to Clinical Concerns, patient and user feedback to improve quality and outcomes

• Service specification review with best practice from Networks

• Deliver quality outcomes indicators i.e. C-diff and MRSA

• Continue the focus on patient safety throughout all services in line with the Berwick review and the Francis report