1 cumbria cluster and cumbria ccg integrated strategic and operational plan 2012/13 to 2014/15 april...

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Cumbria Clusterand

Cumbria CCG

Integrated Strategic and Operational Plan

2012/13 TO 2014/15

April 2012v 5.2

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CONTENTS

Pages

Executive Summary 3 – 4

1 Strategic Vision 5 – 9

2 Transformation Programme 10 – 17

3 Programme Delivery 18 – 19

4 Resources 20 – 24

5 QIPP 25 – 37

6 Engagement 38 – 39

7 Performance and Quality 40 – 63

8 Workforce 64 – 66

9 Informatics 67 – 69

10 Transition and Reform 70 – 79

APPENDICES Pages

A Integrated Performance Measures – Cumbria trajectories

80 – 82

B Locality Service Initiatives 83 – 89

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EXECUTIVE SUMMARY

During 2012/13 the health economy in Cumbria must keep a grip on finance and performance and improve quality and outcomes against a backdrop of transition to a new commissioning architecture.

The 2012/13 Integrated Strategic and Operational Plan (ISOP) for Cumbria has three main objective:

• To keep a grip on performance and finance during a year of significant changes required by the Health Bill;

• To deliver improved quality and patient outcomes; and• To facilitate transition to the new commissioning

architecture.

PERFORMANCE

Performance has improved in Cumbria over recent years alongside demand management and reductions in unplanned care.

However there are a number of performance issues still to be addressed and these include:

• Stroke and RTT at NCUHT; and• A&E, Stroke and MSA at UHMBFT.

NCUHT has been clearing a backlog in Ophthalmology and Gynaecology cases since January 2012. A recovery plan has been agreed with the Trust and is being performance managed weekly by the CCG. From June 2012 the Trust will achieve all RTT indicators. NCUHT has improved in year against the stroke performance indicator and will be fully compliant by April 2012.

UHMBFT

UHMBFT has consistently failed the A&E and MSA indicators since late 2011. A series of operational changes have been implemented from 12th March 2012 and these will improve the emergency flow through the system. Early analysis shows improved performance and a trajectory will be agreed with the Trust to achieve the 95% target by early 2012/13. It is expected that EMSA will be compliant by April 2012. A fundamental overhaul of Stroke services at UHMBFT may mean that this indicator continues to be variable during 2012/13.

The CCG and NHS North have been working with UHMBFT to develop an action plan to eliminate clinically unjustified MSA. The plan has yet to identify timescales and outcome measures however these will all be agreed and embedded into the Programme Office at UHMBFT. The plan will be signed off by the end of March 2012 and weekly monitoring will be in place between UHMBFT and the CCG.

FINANCE

Commissioners have moved to a position of recurrent balance following problems in 2010/11. The CCG has also agreed realistic activity plans with acute providers which should minimise risk during the year. Contracts were agreed in March, which is a significant step forward from previous years.

However, there is a significant challenge in terms of non recurrent funding due to:

• The ambitious transformational plan for primary care and long term conditions management being developed by the CCG. The GPs have agreed that their main development priority will be improving primary care, particularly increasing capacity and reorganising urgent day time care in Barrow to improve health outcomes and reduce health inequalities;

• The need for funding to support acquisition of NCUHT by Northumbria Healthcare NHS Foundation Trust;

• The need to fund stabilisation of UHMBFT as part of the improvement response to recent quality issues and support the development of a clinical strategy for South Cumbria; and

• Investment in health improvement initiatives (linked to primary care and long term conditions strategies) to tackle the health inequalities that are prevalent in Barrow, Carlisle and parts of West Cumbria.

EXECUTIVE

SUM

MARY

4

EXECUTIVE SUMMARY (cont.)

QIPP & TRANSFORMATIONAL CHANGE

Commissioners have a QIPP gap of £58m, which is in line with other similar health economies. Half of this will be met through transformational change, with 6 key programmes of change identified by the CCG:

• Planned care• Unplanned care• Children and Young People• Long Term Condition Management• Primary care• Secondary care transformation & reconfiguration

The first 4 of these programmes have clear milestones and outcomes and reflect the activity plans set out in the plan and 2012/13 contracts. Primary care and reconfiguration at UHMBFT are in the planning stage and will result in further transformational change. The detailed outcome measures for these programmes are currently being determined. The QIPP gap for Cumbria as a whole is £105m but in addition there is a non recurrent issue associated with the NCUHT underlying deficit which will be addressed through the acquisition process.

BUILDING ON SUCCESS

Delivery of this plan builds upon the success of recent years. Good progress has been made during 2011/12 in delivering reductions in elective referrals through the Evidence Based Referral programme. The initial focus was on 10 procedures of limited clinical value and implemented through a robust referral management system. For 2012/13 the programme has been expanded to 60 procedures.

TRANSITION

Plans are in place to ensure effective transition to the new commissioning architecture. There is a strong CCG with good clinical leadership and involvement. The CCG has been instrumental in the planning process for this ISOP. The CCG is actively managing 100% of the delegated budget and has agreed the year end financial position with providers as well as leading the negotiation of the 12/13 contracts. The CCG is also instrumental in the reconfiguration work in both North and South Cumbria.

There has always been close working relationships between the PCT and local authority which has facilitated speedy development of health and wellbeing shadow board and will ensure smooth transition of the public health function to Cumbria County Council.

Prescribing costs have been reduced through QOF Medicine Management targets, QOF QP indicators, Specials Order Products, Scriptswitch and focusing on clinical systems and processes. Localities will continue to focus on practice outliers to further reduce prescribing costs and achieve the cost avoidance targets.

Use of the national contract has driven down Continuing Care costs and this will continue into 2012/12.

Each locality has been developing its Community Services base with CPFT to deliver the new clinical pathways for people with long term conditions and these will now be expanded to include the new paediatric pathways.

There has been a 9% reduction in unscheduled admissions since the first phase of the Closer to Home plan started in 2007. For this final phase the CCG will focus its efforts for adult admissions on the localities with most to achieve and the delivery of the targets include paediatric admissions across all localities.

EXECUTIVE

SUM

MARY

5

SECTION 1: STRATEGIC VISION - OVERVIEW

xxxxxxThis Integrated Strategic and Operational Plan for Cumbria PCT Cluster builds on the progress to date in transforming the NHS in Cumbria. It sets out a delivery plan for the key initiatives that will be required to meet the Quality, Innovation, Productivity and Prevention (QIPP) challenge over a four year period. It identifies how the financial, performance and activity priorities will be met in 2012/13. It identifies the key milestones for the delivery of the transformational change which will free resources in the system to address the health inequalities that exist across Cumbria.

This Integrated Strategic and Operational plan sets out a vision and delivery plan to transform the NHS in Cumbria in line with national requirements and local need. It will deliver a fully functioning Clinical Commissioning Group (CCG) prepared and ready for authorisation and accreditation. The Plan has been developed jointly between the PCT Cluster and Cumbria CCG.

The CCG will be:• Engaging locally with populations and communities;• Undertaking effective commissioning and redesign of

services to meet local need as identified in the Joint Strategic Needs Assessment (JSNA);

• Working effectively in partnership with the local authority partners; and

• Maintaining good relationships with local providers.

This will result in: • Improved health outcomes and reduced health

inequalities across Cumbria as outlined in the CCG 5 Year Strategic Plan and Clear and Credible Plan for 2012/13;

• A financially resilient health economy that provides real choice to patients; and

• A high performing health economy that consistently achieves the national performance requirements and reflects what is important to patients.

Patients will see a different kind of national health service that:• Builds on the principles of Closer to Home (C2H) set out

in earlier Strategic and Operational Plans;• Is much more integrated between primary care, acute

hospital care, community services and social care provision; and

• Supports them to manage their Long Term Conditions (LTC) better.

This updated integrated plan outlines the key activities that will build on the achievements made in 2011/12 and deliver the vision through to 2014/15 and beyond.

Planning for this year has been adjusted to reflect the achievement of the strategic objectives for Cumbria Cluster in 2011/12.

Achievements in meeting the QIPP challenge during 2011/12 have focused on transactional delivery. However, ongoing delivery of a clinical strategy and associated key initiatives will create the building blocks to underpin the transformational change in 2012/13 and beyond.

The Cluster has maintained strong oversight of the key strategic initiatives throughout 2011/12 and will continue to work with the CCG and local providers during 2012/13 to deliver whole system transformation.

1. STRATEGIC

VISION

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SECTION 1: STRATEGIC VISION – TRANSFORMATION 1. STRATEG

IC VISIO

N

Cumbria has been championing clinically led commissioning for some years as part of the Closer to Home (C2H) Clinical Strategy. Critical to this model of care is a joined up approach which sees greater integration between Primary Care, Secondary Care, Community Services, Social Services and the third sector. Over the last three years the health economy we has gone some way to transforming Community Services and reduced overreliance on secondary care. Clinicians across Cumbria have been involved in the development of this Clinical Strategy and reconfiguration plans to transform how services are delivered.

As a result of this over the last 3 years non elective admissions have fallen by 9% as shown opposite.

The CCG wants to deliver the remaining elements of the Clinical Strategy systematically across Cumbria through a service model whereby:

Individuals are supported to take responsibility for their own health;

Local health services are responsive to local need; Local communities support the health needs of their local

population; Admission to acute secondary care only happens when it is

in the best interest of the patient; and Services are safe and of the quality they would wish for

themselves and their families.

Delivery of this model of care will require whole system transformation to Primary Care, Community Services and Secondary Care.

Pathways are being redesigned and some of the clinical care currently delivered to patients in a hospital bed or outpatient department will be delivered in a different way in a community setting. Staff will be equipped with the appropriate skills and competencies to deliver high quality healthcare services. Our clinical services will always be driven by clinical outcomes.

This approach requires systematic and consistent information and education programmes for individuals living with a long term condition as well as programmes for professionals to ensure they have the skills to deliver services that are more responsive to individual patient need.

Thirty per cent of the population in Cumbria live with a LTC. Modern health services are still organised around a medical model with clinicians taking control away from the individual. Individuals living with a LTC meet with a clinician on only a few occasions within a year however they live with their condition every day of their lives. The new service model will ensure that individuals are equipped to manage their condition every day of their lives.

Primary Care will be the coordinator of services for individuals in their practice populations. Each practice will risk stratify its population, coordinate integrated clinical teams based on clinical need and develop the infrastructure to support self management.

Clinically led commissioning and better integration between Primary Care, Secondary Care, Community Care, Social Care and the Third Sector has resulted in a 9% reduction in unscheduled admissions during a period when other health economies have seen significant increases in admissions.

Unscheduled Admissions

9% reduction in the last three years, contra to the national and regional trend of year on year increases9% reduction in the last three years, contra to the national and regional trend of year on year increases

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1. STRATEGIC

VISION

The CCG has a clear evidence base behind its decision making through the Joint Strategic Needs Assessment (JSNA) and real time patient experience and quality information.

The JSNA draws attention to the higher than average proportion of older residents resulting in more people living with a LTC such as diabetes and dementia. There are also significant inequalities for health outcomes for children alongside a higher than national average rate for suicides. The main causes of premature mortality in Cumbria are cancer and circulatory disease with significant variation in life expectancy across the county. Equally the health economy has the challenges of clinical and financial sustainability caused in part by geography but also by how primary and secondary care services are configured. Over the next three years the QIPP gap for Cumbria amounts to £105 million therefore whole system transformation is required to address these challenges.

The CCG five year strategic commissioning plan sets out key priorities to address these needs. Delivery against the priorities are supported by six initiatives.

The six initiatives are outlined in pages 11 to 17 and include:

• Planned care• Unplanned care• Children and Young People• Long Term Condition Management• Primary care• Reconfiguring Secondary Care in North Cumbria and South

Cumbria

Priority Initiative

Improving care to respond to the challenges of an ageing population

LTC Management

Improving the health of children and young people and the quality and integration of care services

Children and Young People

Improving mental wellbeing and reducing alcohol misuse

Primary Care, LTC Management

Reducing health inequalities and premature mortality from cancer and cardiovascular disease

Primary Care, Children and Young People, LTC Management

Reconfiguring and modernising health services to provide more sustainable and higher quality care

Planned Care Unplanned Care Primary Care

SECTION 1: STRATEGIC VISION – TRANSFORMATION (cont.)

In addition to the initiatives are cross cutting themes which are key enablers to delivery of the strategy and these include:

• A refreshed approach to commissioning for quality;• A new approach to improving patient engagement and

experience;• Aligning the workforce;• Developing the availability and use of patient

information; and• Modernising the estate.

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In line with the strategic vision and the JSNA priorities the health and social care system in Cumbria in five years time will have the following characteristics:

Improved outcomes and performance; Improved safety and quality; Greater integration of care across pathways breaking

down traditional barriers between primary, community, secondary and social care;

Clinical leadership at all levels; Financial stability for all organisations; Individuals supported to take responsibility for their own

health care; Meaningful engagement of patients and communities in

decision making and active use of patient experience to improve care;

Greater innovation and use of technology to drive improved outcomes and transformation;

Earlier intervention through better identification of patients at risk and targeted support; and

Innovative forms of contracting which incentivise integration and joint delivery of better outcomes and quality.

In five years time there will be a higher level of engaged patients and engaged communities, with more patients taking responsibility for their own health and wellbeing. There will be better education for patients to help them co produce their care plan and manage their long term conditions.

There will also be greater support through decision aid tools to enable patients to take informed decisions on secondary care procedures, such as orthopaedic operations. Patients will have access to their care records and summary information will be available to all clinicians to provide better care.

There will be integrated working with the local authority public health team to help improve lifestyles and stay healthier for longer and actively mobilising the many community assets. There will be greater consistency in the quality of Primary Care with an expansion of capacity in Barrow to address the health inequalities.

There will be better management of long term conditions and frail older people to improve quality of life, keep people healthier for longer and reduce unnecessary admissions. Delivery of the strategy will result in shifting activity and the diagram below sets out how services will be configured.

SECTION 1: STRATEGIC VISION – TRANSFORMATION (cont)

1. STRATEGIC

VISION

Primary and community care

Disease registersCase finding

Care planning Annual review (YoC)

DiagnosisBio medical treatmentEducation programmes

Support for self managementMinor elective surgery

Minor injuriesEnd of life care

Primary and community care

Disease registersCase finding

Care planning Annual review (YoC)

DiagnosisBio medical treatmentEducation programmes

Support for self managementMinor elective surgery

Minor injuriesEnd of life care

Specialist support

Identifies best clinical practice for care pathways

Identifies skills gaps for primary care

Delivers programmes to address skills gaps

Delivers complex clinical advice and guidance

Specialist support

Identifies best clinical practice for care pathways

Identifies skills gaps for primary care

Delivers programmes to address skills gaps

Delivers complex clinical advice and guidance

Secondary care

Complex emergency clinical interventions

Complex elective clinical interventions

Complex diagnostic interventions

Secondary care

Complex emergency clinical interventions

Complex elective clinical interventions

Complex diagnostic interventions

CardiologyCardiology Palliative carePalliative care

Etc, etcEtc, etcRespiratoryRespiratory T&OT&O SurgerySurgery

Elderly careElderly carePaediatricsPaediatrics

For primary care to have overall responsibility for health outcomes of practice populations and integrated services they will

secure some enhanced skills

Specialist support will enable primary care to deliver enhanced

integrated services

Secondary care case mix becomes more complex and specialised as primary and community care practitioners become

more skilled

Clinical interventions

Clinical pathways

Specific clinical pathways require specific clinical

interventions

Most interventions will be delivered by multi disciplinary

teams in practices or community based teams

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1. STRATEGIC

VISION

SECTION 1: STRATEGIC VISION - TRANSFORMATION (cont)

A significant shift will take place across the health and social care system based on clinical pathways. Primary Care and Community Services will focus on case finding, care planning, education programmes, minor surgery and end of life care. Cumbria Partnership Foundation Trust will be a key player will be a key player in delivering community services to support LTC management and providing more community alternatives to acute secondary care. They will also provide an improved interface with North Cumbria University Hospitals Trust and University Hospital of Morecambe Bay Foundation Trust to speed up and ensure appropriate admissions and discharge. These will be co ordinated through a Single Point of Access and supported by integrated health and social care teams.

There will be enhanced integration between Community Services, Mental Health Services and Social Care particularly for dementia. There will be an increased move to more community mental health services rather than inpatient care and more effective drug and alcohol services. Over the next five years there will be continued move to higher quality acute units with mortality rates in line with national averages. Provision will be from larger, more sustainable Foundation Trusts with financial stability and provision within tariff.

Acute hospital services will deliver care which cannot be delivered in Primary Care or community settings and there will be more effective networking across the north of England to improve skills in Cumbria and provide specialist skills where they cannot be sustained within Cumbria.

There will be full integration between Primary and Secondary Care to deliver the Emergency Floor Model and for consultant support for better long term condition management and care for frail older people in community settings.

Non elective admission rates per 1,000 population will be maintained despite demographic change although there will be a particular focus on reducing the high levels of unnecessary emergency admissions in Barrow. Paediatric emergency admissions will be reduced through the implementation of a Short Stay Paediatric Assessment Unit linked to the Emergency Floor.

Reductions in elective procedures of limited clinical value will create capacity in acute hospitals to repatriate routine procedures that are currently carried out outside Cumbria alongside the development of new services such as PCI which will be available during 2012/13. Integration with Social Care will focus on priority areas such as dementia and frail older people)and children and young people. There will be more integrated nursing and social care to support discharge from hospital and reduce delayed transfers of care.

There will be more joint commissioning to ensure value for money and more joint deployment of technology such as telehealth.

SECTION 2:TRANSFORMATION PROGRAMME Context Priorities Outcomes/outputs QIPP Programmes & deliverables Cross Cutting Initiatives

Long term conditions management• Deliver C2H Pathways for diabetes, respiratory, heart

failure and service models for older people in care homes and end of life care

• Develop a holistic strategy for long term conditions and integrated primary and community delivery models

Long term conditions management• Deliver C2H Pathways for diabetes, respiratory, heart

failure and service models for older people in care homes and end of life care

• Develop a holistic strategy for long term conditions and integrated primary and community delivery models

Children and young people • Implement short stay paediatric assessment services

integrated with Emergency Floor model • Improve outcomes across 6 key pathways• Improve access to and quality of CAMHS• Improve quality of maternity and paediatrics (see

Morecambe Bay programme)

Children and young people • Implement short stay paediatric assessment services

integrated with Emergency Floor model • Improve outcomes across 6 key pathways• Improve access to and quality of CAMHS• Improve quality of maternity and paediatrics (see

Morecambe Bay programme)

Primary Care• Reduce unacceptable variation• Implement long term conditions strategy• Deliver more focused health improvement work such as

health checks and smoking cessation• Increase primary care capacity in Barrow, and reconfigure

urgent day time primary care • Provide more straight forward planned care • Develop a strategy for managing the changing age and skill

profile of the general practice workforce

Primary Care• Reduce unacceptable variation• Implement long term conditions strategy• Deliver more focused health improvement work such as

health checks and smoking cessation• Increase primary care capacity in Barrow, and reconfigure

urgent day time primary care • Provide more straight forward planned care • Develop a strategy for managing the changing age and skill

profile of the general practice workforce

• 35% reduction in the overall number of paediatric non elective admissions across three years

• Reduction in unplanned hospitalisation for under 19s for asthma, diabetes, and epilepsy*

• 35% reduction in the overall number of paediatric non elective admissions across three years

• Reduction in unplanned hospitalisation for under 19s for asthma, diabetes, and epilepsy*

• 13.5% of people with depression receiving psychological therapy

• 48.5% of people who complete psychological therapy moving to recovery

• 95% of people under adult mental illness specialties on CPA followed up within 7 days of discharge from psychiatric inpatient care

• Reduction in number of alcohol related hospital admissions**

• 13.5% of people with depression receiving psychological therapy

• 48.5% of people who complete psychological therapy moving to recovery

• 95% of people under adult mental illness specialties on CPA followed up within 7 days of discharge from psychiatric inpatient care

• Reduction in number of alcohol related hospital admissions**

• 83% of people with a long term condition to feel independent and in control of their own condition

• Reduction in unplanned hospitalisation for adults with chronic ambulatory care sensitive conditions*

• 15% reduction in patients using anti-psychotics (on primary care dementia registers)

• 10% reduction in unscheduled admissions from residential care homes to acute trusts

• Net 2.3% reduction in adult non elective admissions• Net 5% reduction in number of elective admissions

• 83% of people with a long term condition to feel independent and in control of their own condition

• Reduction in unplanned hospitalisation for adults with chronic ambulatory care sensitive conditions*

• 15% reduction in patients using anti-psychotics (on primary care dementia registers)

• 10% reduction in unscheduled admissions from residential care homes to acute trusts

• Net 2.3% reduction in adult non elective admissions• Net 5% reduction in number of elective admissions

Unplanned care • Implement integrated emergency floor• Implement single point of access for urgent care• Implement new care pathways

Unplanned care • Implement integrated emergency floor• Implement single point of access for urgent care• Implement new care pathways

Planned care • Implement referral protocols and guidelines for clinically

agreed EBR procedures and increase repatriation of out of county activity

• Transfer ophthalmology & MSK into community setting• Repatriate out of county activity

Planned care • Implement referral protocols and guidelines for clinically

agreed EBR procedures and increase repatriation of out of county activity

• Transfer ophthalmology & MSK into community setting• Repatriate out of county activity

Improve care to respond to the

challenges of an ageing population

Improve the health of children and young

people and the quality and integration of care

services

Improve mental wellbeing and reduce

alcohol misuse

Reduce health inequalities and

premature mortality from cancer and

cardiovascular disease

Reconfigure and modernising health services to provide

more sustainable and higher quality care

• Reduction under 75 mortality rate from cancer**• Reduction under 75 mortality rate from CVD**• Reduction in mortality within 30 days of hospital

admission for stroke**• 85% of patients receive first treatment for cancer

within 62 days of an urgent GP referral• 98% of patients receive subsequent treatment for

cancer within 31 days for surgery, anti-cancer drug regime or radiotherapy treatment course (94%)

• 3,807 four week smoking quitters• 20% of people aged 40-74 have been offered an

NHS health check

• Reduction under 75 mortality rate from cancer**• Reduction under 75 mortality rate from CVD**• Reduction in mortality within 30 days of hospital

admission for stroke**• 85% of patients receive first treatment for cancer

within 62 days of an urgent GP referral• 98% of patients receive subsequent treatment for

cancer within 31 days for surgery, anti-cancer drug regime or radiotherapy treatment course (94%)

• 3,807 four week smoking quitters• 20% of people aged 40-74 have been offered an

NHS health check

• 95% of patients seen in A&E in 4 hours or less• 90% of patients referred for treatment admitted

within 18 weeks• 95% ambulances respond to category A calls within

19 minutes• Reduce hospital acquired infections etc.

• 95% of patients seen in A&E in 4 hours or less• 90% of patients referred for treatment admitted

within 18 weeks• 95% ambulances respond to category A calls within

19 minutes• Reduce hospital acquired infections etc.

Secondary care transformation & reconfiguration • Deliver the North Cumbria Clinical Strategy in line with the

recent NCAT review and support the acquisition of NCUHT by Northumbria Healthcare

• Develop and deliver a clinical strategy for the Morecambe Bay area and ensure rapid improvement in the quality of services for: maternity; paediatrics; A&E; stroke; and outpatients

Secondary care transformation & reconfiguration • Deliver the North Cumbria Clinical Strategy in line with the

recent NCAT review and support the acquisition of NCUHT by Northumbria Healthcare

• Develop and deliver a clinical strategy for the Morecambe Bay area and ensure rapid improvement in the quality of services for: maternity; paediatrics; A&E; stroke; and outpatients

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*New indicator – awaiting guidance on target setting

2. TRANSFO

RMATIO

N

PROG

RAMM

E

10

Excess cancer &

CVD deaths

Excess cancer &

CVD deaths

Healthinequalities

Healthinequalities

Prematuremortality

Prematuremortality

Ageingpopulation

Ageingpopulation

Limitedresources

Limitedresources

** Targets for these indicators are currently being developed with Public Health as part of transition planning to ensure future clarity on responsibilities for delivery.

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SECTION 2: TRANSFORMATION PROGRAMME – PLANNED CARE2. TRAN

SFORM

ATION

PRO

GRAM

ME

WHY IS CHANGE NEEDED? WHY IS CHANGE NEEDED?

OBJECTIVEOBJECTIVE

DESCRIPTIONDESCRIPTION

Levels of planned care have not reduced in Cumbria in the same way unplanned admissions have. NHS Cumbria has agreed a strategy with NCUHT to reconfigure acute services internally and address its underlying deficit in year. This requires a reduction in the cost of service delivery, achieving efficiency in service utilisation and creating opportunities to refocus activity towards repatriation of out of area activity.

Levels of planned care have not reduced in Cumbria in the same way unplanned admissions have. NHS Cumbria has agreed a strategy with NCUHT to reconfigure acute services internally and address its underlying deficit in year. This requires a reduction in the cost of service delivery, achieving efficiency in service utilisation and creating opportunities to refocus activity towards repatriation of out of area activity.

To improve planned care quality, efficiency and access and repatriate care back to Cumbria.To improve planned care quality, efficiency and access and repatriate care back to Cumbria.

1. Reduce activity in areas of service with limited clinical value (evidence based referrals-EBR) by implementing referral protocols and guidelines for clinically agreed EBR procedures, supported by ICT tools for procedures to be online on GP desk tops;

2. Increase internal efficiency to repatriate activity (Orthopaedics and PCI) currently undertaken out of Cumbria; implement theatre efficiency programme in NCUHT to increase capacity to repatriate out of area activity; and improve access to services using the Choose and Book system;

3. Reduce out patient activity in line with clinical models and agreed good practice targets;

4. Reduce length of stay and improve early discharge in Orthopaedics;5. Transfer services as appropriate into community settings – Ophthalmology in

North Cumbria and MSK in South Cumbria.

1. Reduce activity in areas of service with limited clinical value (evidence based referrals-EBR) by implementing referral protocols and guidelines for clinically agreed EBR procedures, supported by ICT tools for procedures to be online on GP desk tops;

2. Increase internal efficiency to repatriate activity (Orthopaedics and PCI) currently undertaken out of Cumbria; implement theatre efficiency programme in NCUHT to increase capacity to repatriate out of area activity; and improve access to services using the Choose and Book system;

3. Reduce out patient activity in line with clinical models and agreed good practice targets;

4. Reduce length of stay and improve early discharge in Orthopaedics;5. Transfer services as appropriate into community settings – Ophthalmology in

North Cumbria and MSK in South Cumbria.

KEY MILESTONES FOR 2012/13 Q1 Q2 Q3 Q4

Implementation of EBR protocol & IT referral tool for first 15 procedures

Implementation of EBR protocol & IT referral tool for next 15 procedures

Additional acute capacity available for repatriation

Marketing of services & slot availability by NCUHT

Ophthalmology & MSK transferred to community

Discharge procedures aligned across CPFT/NCUHT

RESOURCE IMPLICATIONSRESOURCE IMPLICATIONS

RISKS MITIGATING ACTIONS

Ability to identify additional capacity in NCUHT for repatriation

NCUHT elective flow programme in place and identified this action

Current Tariff payment stifles change System wide discussions underway to review a financial model and unbundled tariffs

Engagement of GPs in utilising the IT solutions to aid good referral

Integration into core system processes. Validation of content and proactive ‘marketing’ of benefits.

Lack of capacity in community and primary care to support early discharge

Business case to assess cost benefit of any required investment

PERFORMANCE INDICATOR Target 2012/13 2013/14 2014/15

Reduction in admissions (incl EBR) -1,431 -1,964 -1,964

Reduction in out of area activity

Number of community Ophthalmology procedures

Investment£’000

Savings£’000

2012/13 1,052

2013/14 2,897

2014/15 2,898

Total 6,847

WORKFORCE IMPLICATIONSWORKFORCE IMPLICATIONS

None expected. None expected.

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SECTION 2:TRANSFORMATION PROGRAMME – UNPLANNED CARE


OBJECTIVEOBJECTIVE




Achieving an integrated model whilst challenged with medical recruitment in NCUHT

• Recruitment underway for medical consultants

• Alternate clinical roles being explored

Option appraisal and system wide financial model developing

PERFORMANCE INDICATOR Target 2012/13 2013/14

2014/15

Reduction in unplanned adult hospital admissions

-2,282

National and regional trends for urgent care admissions are rising; in Cumbria admissions were down by 8% in the last two years but concerns remain over continued high levels of urgent care admissions, particularly in Barrow. Acute trusts In Cumbria have substantial resource and demand management challenges resulting in a need for alternative solutions to hospital based care.

National and regional trends for urgent care admissions are rising; in Cumbria admissions were down by 8% in the last two years but concerns remain over continued high levels of urgent care admissions, particularly in Barrow. Acute trusts In Cumbria have substantial resource and demand management challenges resulting in a need for alternative solutions to hospital based care.

To redesign integrated urgent care services to reduce hospital attendances & manage care more effectively in community settingsTo redesign integrated urgent care services to reduce hospital attendances & manage care more effectively in community settings

Implement the new integrated model for unplanned care (as agreed in North Cumbria at the Systems Board), with the following key components:

• Implement the integrated emergency floor, with an improved medical assessment & observation model in urgent care services and co-location of urgent care services (A&E and PCAS) on acute sites;

• Implement single point of access into urgent care;• Implement new pathways of care – see long term condition

management and paediatric programs;• Provide specialist clinical out-reach support into communities;• Maximise ‘step up & down’ care in community hospital beds and

ensure effective discharge/admission liaison arrangements with acute beds; and

• Increase care in community settings, particularly capacity for community based short term intervention services.

Implement the new integrated model for unplanned care (as agreed in North Cumbria at the Systems Board), with the following key components:

• Implement the integrated emergency floor, with an improved medical assessment & observation model in urgent care services and co-location of urgent care services (A&E and PCAS) on acute sites;

• Implement single point of access into urgent care;• Implement new pathways of care – see long term condition

management and paediatric programs;• Provide specialist clinical out-reach support into communities;• Maximise ‘step up & down’ care in community hospital beds and

ensure effective discharge/admission liaison arrangements with acute beds; and

• Increase care in community settings, particularly capacity for community based short term intervention services.

Investment£’000

Savings£’000

2012/13 2,245

2013/14 245

2014/15 245

Total 2,735


Detailed workforce plans for Integrated emergency floor in production- expected April 2012Detailed workforce plans for Integrated emergency floor in production- expected April 2012


Operational and workforce model for Integrated Emergency floor

Co-location of urgent care services commenced

Integrated emergency floor fully operational in north Cumbria

Single point of access fully operational in north

2. TRANSFO

RMATIO

N

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RAMM

E

13

SECTION 2:TRANSFORMATION PROGRAMME - CHILDREN AND YOUNG PEOPLE


OBJECTIVEOBJECTIVE




Workforce will need adjusting and recruitment of skills challenging

• Develop innovative/integrated roles to support better recruitment

• Phase implementation to meet staff capacity

PERFORMANCE INDICATOR Target 2012/13 2013/14 2014/15

Reduction in paediatric emergency admissions

-1,604 -1,604

Reduction in length of stay

Cumbria’s acute hospitals have a high rate of admission for paediatric care and there is a focus towards ‘admission to assess’ which results in a longer length of stay and unnecessary admission for the child. An expert review undertaken in 2010 recommended services become more integrated, with more care delivered in the community and the overall delivery model for children integrated across organisational boundaries. There are concerns around maternity and paediatrics in the South of the County. There is also concern around access to CAMHS.

Cumbria’s acute hospitals have a high rate of admission for paediatric care and there is a focus towards ‘admission to assess’ which results in a longer length of stay and unnecessary admission for the child. An expert review undertaken in 2010 recommended services become more integrated, with more care delivered in the community and the overall delivery model for children integrated across organisational boundaries. There are concerns around maternity and paediatrics in the South of the County. There is also concern around access to CAMHS.

To improve the health of and care services for children and young people.To improve the health of and care services for children and young people.

1. Improved pathways for Children, young people and families and promote greater range and use of community based and self managed care: key pathways include: Constipation; Fever; Acute respiratory; Emotional Wellbeing; Attention Deficit Hyperactivity Disorder (ADHD); Autistic Spectrum Disorder (ASD)

2. Deliver an integrated response to urgent care needs including development of short stay assessment services and integration of care within an Emergency Floor model and maximise range of clinical skills

3. Review of CAMHS service4. Design a new model for working collaboratively across organisations and to

deliver seamless services through the Health Builders partnership.5. Improve quality of maternity and paediatrics (see Appendix 6 Morecambe

Bay programme)

1. Improved pathways for Children, young people and families and promote greater range and use of community based and self managed care: key pathways include: Constipation; Fever; Acute respiratory; Emotional Wellbeing; Attention Deficit Hyperactivity Disorder (ADHD); Autistic Spectrum Disorder (ASD)

2. Deliver an integrated response to urgent care needs including development of short stay assessment services and integration of care within an Emergency Floor model and maximise range of clinical skills

3. Review of CAMHS service4. Design a new model for working collaboratively across organisations and to

deliver seamless services through the Health Builders partnership.5. Improve quality of maternity and paediatrics (see Appendix 6 Morecambe

Bay programme)

Investment£’000

Savings£’000

2012/13 0

2013/14 1,326

2014/15 1,326

Total 2,652


• Workforce modelling underway as part of redesign of urgent care services• Integration and co-location of staff expected in a phased approach• Staff skills training will be required and as yet unknown • Recruitment expected for some specialist clinical skills• Resource implication to be identified

• Workforce modelling underway as part of redesign of urgent care services• Integration and co-location of staff expected in a phased approach• Staff skills training will be required and as yet unknown • Recruitment expected for some specialist clinical skills• Resource implication to be identified


Operational & workforce models for Short stay paediatric assessment unit

Co-location of urgent care services commenced

Implementation of short stay paediatric assessment unit (link to emergency floor A2)

Pathways developed and commissioned

Pathway delivery (1 pathway in at least 1 locality)

Review of CAMHS

2. TRANSFO

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N

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14

SECTION 2: TRANSFORMATION PROGRAMME – LONG TERM CONDITIONS MANAGEMENT2. TRAN

SFORM

ATION

PRO

GRAM

ME


OBJECTIVEOBJECTIVE


The number of people, in Cumbria, with one or more Long Term Condition (LTC) is set to increase significantly over the next 20 years in line with a rapidly ageing population. Premature mortality and morbidity from LTCs and Cancer are the main drivers of health inequalities across Cumbria and LTCs currently account for 70% of overall health and social care spend with a projected increase. The current system for managing LTCs will not meet this challenge and does not equip individuals to make informed decisions about their own health needs or to be confident about managing their own health (only one third of diabetes patients currently feel very confident about managing their own health). Whilst we have developed individual LTC pathways (eg for diabetes, COPD and heart failure) there is currently no overall strategy for managing LTCs and reconfiguring the relevant services in Cumbria.

The number of people, in Cumbria, with one or more Long Term Condition (LTC) is set to increase significantly over the next 20 years in line with a rapidly ageing population. Premature mortality and morbidity from LTCs and Cancer are the main drivers of health inequalities across Cumbria and LTCs currently account for 70% of overall health and social care spend with a projected increase. The current system for managing LTCs will not meet this challenge and does not equip individuals to make informed decisions about their own health needs or to be confident about managing their own health (only one third of diabetes patients currently feel very confident about managing their own health). Whilst we have developed individual LTC pathways (eg for diabetes, COPD and heart failure) there is currently no overall strategy for managing LTCs and reconfiguring the relevant services in Cumbria.

To build on previous long term condition pathways and the work of Cumbria diabetes to develop a holistic Long Term Conditions Strategy which encompasses a preventative, anticipatory and whole person approach to managing care, based on self-management by confident patients.

To build on previous long term condition pathways and the work of Cumbria diabetes to develop a holistic Long Term Conditions Strategy which encompasses a preventative, anticipatory and whole person approach to managing care, based on self-management by confident patients.

This programme is in two phases:Phase 1: this is based on continued delivery of existing Closer to Home Pathways for diabetes, COPD/respiratory, heart failure and the service models for care for older people in care homes and end of life care. We have already provided resources for additional community capacity during 2011/12 which will ensure delivery of non elective admissions avoidance targets.

Phase 2: We are developing a holistic strategy for long term conditions which will continue in 2012/13 to ensure CCG member practices and other partners are involved in design and delivery. The service model starts by identifying what common resources are required across Cumbria to support practices in delivering care to their registered population. This will be care directed both at those at risk of developing a long term condition as well as those with established problems.

The core principles underpinning the model are: Know your population; Know your team; Know your community’s resources; Know how to help people become confident self-managers; Know how you are doing.

There will also be a ‘common platform’ approach (drawn from the modern production line found in car manufacturing) to ensure consistency of service delivery across Cumbria, based on a common infrastructure with: integrated electronic records;

This programme is in two phases:Phase 1: this is based on continued delivery of existing Closer to Home Pathways for diabetes, COPD/respiratory, heart failure and the service models for care for older people in care homes and end of life care. We have already provided resources for additional community capacity during 2011/12 which will ensure delivery of non elective admissions avoidance targets.

Phase 2: We are developing a holistic strategy for long term conditions which will continue in 2012/13 to ensure CCG member practices and other partners are involved in design and delivery. The service model starts by identifying what common resources are required across Cumbria to support practices in delivering care to their registered population. This will be care directed both at those at risk of developing a long term condition as well as those with established problems.

The core principles underpinning the model are: Know your population; Know your team; Know your community’s resources; Know how to help people become confident self-managers; Know how you are doing.

There will also be a ‘common platform’ approach (drawn from the modern production line found in car manufacturing) to ensure consistency of service delivery across Cumbria, based on a common infrastructure with: integrated electronic records;

PERFORMANCE INDICATORS: PHASE 1

Target 2012/13 2013/14 2014/15

Reduction in emergency admissions


Continued delivery of phase 1 pathways/models

Overall LTC strategy developed

Continued roll out patient education programmes


The outcomes for the Phase 2 Strategy will be determined in detail as part of the of the strategy development, but the broad outcomes are to:•Reduce premature mortality and health inequalities;•Reduce the rate of increase in the number of people developing a long term condition (we know rates will increase given the aging population; but we want this rate of increase to be significantly reduced compared to ‘doing nothing’);•Improve the number of patients feeling in control of their own self management;•Further reduce the number of unnecessary acute admissions through more effective care planning; and•Increase value for money by better integration of health and social care and more patients being confident self managers.

The outcomes for the Phase 2 Strategy will be determined in detail as part of the of the strategy development, but the broad outcomes are to:•Reduce premature mortality and health inequalities;•Reduce the rate of increase in the number of people developing a long term condition (we know rates will increase given the aging population; but we want this rate of increase to be significantly reduced compared to ‘doing nothing’);•Improve the number of patients feeling in control of their own self management;•Further reduce the number of unnecessary acute admissions through more effective care planning; and•Increase value for money by better integration of health and social care and more patients being confident self managers.

PERFORMANCE INDICATORS PHASE 2PERFORMANCE INDICATORS PHASE 2

Resources for phase 1 were put in place in 2011/12.Resource implications for phase 2 will be determined as part of the Strategy development process.

Resources for phase 1 were put in place in 2011/12.Resource implications for phase 2 will be determined as part of the Strategy development process.

common menu of services from which to create packages of care for patients; a common approach to care planning and clinical teams with the right skills. These are all underpinned by a common set of outcome measures.

In order to deliver appropriate care to people with complex physical and mental health care needs and also for people who have reached the end of their lives, it is necessary to deliver care through integrated practice, community and social care, across a population base of 15,000 - 40,000, in a natural community wherever possible – i.e. bigger than most general practices. These groupings would be known as Accountable Care Partnerships (ACPs).

common menu of services from which to create packages of care for patients; a common approach to care planning and clinical teams with the right skills. These are all underpinned by a common set of outcome measures.

In order to deliver appropriate care to people with complex physical and mental health care needs and also for people who have reached the end of their lives, it is necessary to deliver care through integrated practice, community and social care, across a population base of 15,000 - 40,000, in a natural community wherever possible – i.e. bigger than most general practices. These groupings would be known as Accountable Care Partnerships (ACPs).

15

SECTION 2: TRANSFORMATION PROGRAMME – PRIMARY CARE


OBJECTIVEOBJECTIVE


The quality of primary care in Cumbria is generally good but this masks variation, with unacceptably low standards of care in some practices (often caused by capacity, poor infrastructure or a need for improved skills) leading to unacceptable variation. There is a need to support other strategic change areas such as long term condition management and unplanned care and the age profile and increasing demand on practices means we need a new strategy to attract, retain and skill-up new entrants within the approach outlined above; and consider the skill mix of primary care .

We are developing a strategy to address these issues and this work will continue in 2012/13 to ensure CCG member practices are involved in design and delivery. Hence this plan is indicative of the issues and outcomes the Strategy is likely to address.

The quality of primary care in Cumbria is generally good but this masks variation, with unacceptably low standards of care in some practices (often caused by capacity, poor infrastructure or a need for improved skills) leading to unacceptable variation. There is a need to support other strategic change areas such as long term condition management and unplanned care and the age profile and increasing demand on practices means we need a new strategy to attract, retain and skill-up new entrants within the approach outlined above; and consider the skill mix of primary care .

We are developing a strategy to address these issues and this work will continue in 2012/13 to ensure CCG member practices are involved in design and delivery. Hence this plan is indicative of the issues and outcomes the Strategy is likely to address.

Develop and deliver a strategy for transforming primary care to move from a group of individual practices and community services, into community-aligned federations within an integrated system necessary to deliver sustainable health care

Develop and deliver a strategy for transforming primary care to move from a group of individual practices and community services, into community-aligned federations within an integrated system necessary to deliver sustainable health care

The emerging Primary Care Strategy is likely to focus on:1. Reducing unacceptable variation (e.g. in referrals, prescribing, the level of

exceptions etc.) caused by capacity, poor infrastructure or a need for improved skills;

2. Implementation of the Long Term Conditions Strategy (appendix B4) in primary care, with greater integration with community and secondary services;

3. More focused health improvement work such as increasing delivery of CVD health checks, smoking cessation and brief interventions on alcohol and exercise: there will be increased targeting in deprived areas such as Barrow, Carlisle and the West Coast to help reduce health inequalities;

4. Increasing primary care capacity in Barrow, and the reconfiguration of urgent day time primary care to reduce unnecessary admissions, provide a greater focus on the management of long term conditions targeted to improve health outcomes and reduce health inequalities;

5. Providing local service alternatives in straight forward planned care; and6. Producing a strategy for managing the changing age and skill profile of the

general practice workforce.

The emerging Primary Care Strategy is likely to focus on:1. Reducing unacceptable variation (e.g. in referrals, prescribing, the level of

exceptions etc.) caused by capacity, poor infrastructure or a need for improved skills;

2. Implementation of the Long Term Conditions Strategy (appendix B4) in primary care, with greater integration with community and secondary services;

3. More focused health improvement work such as increasing delivery of CVD health checks, smoking cessation and brief interventions on alcohol and exercise: there will be increased targeting in deprived areas such as Barrow, Carlisle and the West Coast to help reduce health inequalities;

4. Increasing primary care capacity in Barrow, and the reconfiguration of urgent day time primary care to reduce unnecessary admissions, provide a greater focus on the management of long term conditions targeted to improve health outcomes and reduce health inequalities;

5. Providing local service alternatives in straight forward planned care; and6. Producing a strategy for managing the changing age and skill profile of the

general practice workforce.

Investment£’000

Savings£’000

2012/13 4,800 Incl in other programmes

2013/14 3,000 e.g. Long Term Conditions

2014/15 2,000 & urgent care

Total 9,800


Cumbria Primary care strategy developed

Primary care education and workforce plan developed

Additional capacity input to Barrow alongside delivery of day time urgent care initiative

Ongoing peer review and improvement of performance and delivery health checks

Business cases developed for planned care (in line with Strategy)


Performance indicators will be developed in detail as part of the Strategy development, but will focus on improving the following outcomes and outputs, many of which link to other programmes:

•Reductions in premature mortality and health inequality rates •Reduction in unnecessary non elective admissions, especially in Barrow• Increased levels of smoking cessation and health checks • Improvements in the quality of prescribing, with further reductions in outliers for prescribing per 1,000 population and BCBV PIs (both high and low)•Maintenance of high levels of patients satisfaction with primary care• Increase in the percentage of LTC patients feeling confidently managing condition

Performance indicators will be developed in detail as part of the Strategy development, but will focus on improving the following outcomes and outputs, many of which link to other programmes:

•Reductions in premature mortality and health inequality rates •Reduction in unnecessary non elective admissions, especially in Barrow• Increased levels of smoking cessation and health checks • Improvements in the quality of prescribing, with further reductions in outliers for prescribing per 1,000 population and BCBV PIs (both high and low)•Maintenance of high levels of patients satisfaction with primary care• Increase in the percentage of LTC patients feeling confidently managing condition

PERFORMANCE INDICATORSPERFORMANCE INDICATORS

2. TRANSFO

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16

SECTION 2: TRANSFORMATION PROGRAMME – SECONDARY CARE TRANSFORMATION & RECONFIGURATION 3. PRO

GRAM

ME

DELIVERY

The Strategic Vision for North Cumbria was first set out in the Closer to Home (C2H) Public Consultation in early 2008. C2H was embraced within all six localities in Cumbria and underpinned their commissioning intentions year on year.

A series of care streams developed clinical pathways for Planned Care, Unplanned Care, Long Term Conditions, Children’s Services and Mental Health. The membership of each care stream included clinicians from both secondary and primary care and Social Services.

A Locality Board exists in each locality and has representation from each GP practice and other local stakeholders. Each Locality Board is responsible for ensuring their commissioning intentions reflect the needs of their local populations.

Rapid response nursing and social care teams have been created to help people get the care and support they need in their own homes and GPs are working with hospital consultants in emergency departments.

A refreshed Clinical Strategy for North Cumbria was agreed by the PCT and NCUHT in 2011, building on C2H Strategy. As part of the implementation of the Clinical Strategy, a number of key building blocks have been identified, including delivery of an Emergency Floor, Short Stay Paediatric Assessment Unit and Single Point of Access in addition to community based specialist teams.

Milestones and perfromance indicators are included in the Unplanned and Childrens’ Transformational Workstreams.

A System Board has been established in North Cumbria to support delivery of these key building blocks. The diagram below outlines the relationships between the System Board and stakeholders in North Cumbria.

CPFTCPFT

CCGCCG

Primary carePrimary care

CHoCCHoC

Other providers

Other providers

Integrated System BoardIntegrated System Board

Operational and Clinical Delivery Group

Operational and Clinical Delivery Group

Unplanned care

Unplanned care Planned carePlanned care

LTCLTCWorkforceWorkforce ITIT

PaediatricsPaediatrics

Workstream Groups

PCT ClusterPCT Cluster

NCUHTNCUHT

Operational Delivery Group

Operational Delivery Group

5. Governance arrangements

Clinical Leaders Forum

Clinical Leaders Forum

West CAG

West CAG

East CAGEast CAG

DELIVERY OF THE CLINCIAL STRATEGY AND TRUST ACQUISITION IN NORTH CUMBRIA

The other important element of secondary care improvement in North Cumbria is the acquisition of NCUHT by Northumbria Healthcare FT. This will facilitate and accelerate secondary care reconfiguration and ensure greater clinical and financial sustainability of services in the north of the County and better patient outcomes and experience (e.g. through more service delivery within the area). The milestone plan for the acquisition process is set out in Section 10 on Transition and Reform.


To develop and deliver a clinical strategy for North Cumbria alongside an acquisition process which:•Improves health outcomes and reduces health inequalities; and •Ensures the provision of safe, high quality and clinically and financially sustainable services.

To develop and deliver a clinical strategy for North Cumbria alongside an acquisition process which:•Improves health outcomes and reduces health inequalities; and •Ensures the provision of safe, high quality and clinically and financially sustainable services.

OBJECTIVEOBJECTIVE

17

There have been a number of quality issues at UHMBFT over the last 6 months, some of which have been highlighted through major reports from regulators, covering maternity, paediatric, outpatients, A&E and stroke care. These quality issues link directly to poor performance on the Operating Framework indicators in Section 7.

At the same time there is an emerging strategy for improving primary care that will increase capacity in Barrow and improve the quality of care for people living with a Long Term Condition.

The Cumbria CCG, supported by the Cluster and NHS North of England, are beginning the process to develop a strategy to address these issues in partnership with the Lancashire Cluster, UHMBFT and CPFT. Emerging principles include:•Having a clear approach to health improvement, tackling inequalities and using a needs assessment, data driven plan; and•Being driven by quality including Clinical Effectiveness, Patient Safety and Patient experience.

Patients and communities will be reassured that much of this isn’t new; however, there are some “big issues” to tackle and articulate a better vision for services such as maternity services at Barrow.

3. PROG

RAMM

E D

ELIVERY

To develop and deliver a clinical strategy for the Morecambe Bay area which:•Improves health outcomes and reduces health inequalities; and •Ensures the provision of safe, high quality and clinically and financially sustainable services.

To develop and deliver a clinical strategy for the Morecambe Bay area which:•Improves health outcomes and reduces health inequalities; and •Ensures the provision of safe, high quality and clinically and financially sustainable services.

OBJECTIVEOBJECTIVE

SECTION 2: TRANSFORMATION PROGRAMME – SECONDARY CARE TRANSFORMATION & RECONFIGURATION

DEVELOPMENT OF A CLINICAL STRATEGY FOR THE MORECAMBE BAY AREA


Work to develop the Strategy will continue in 2012/13. The key next steps are to:•Bring partners together to recognise the issues, challenges and opportunities and create a consistent and owned impetus for change;•Develop an integrated Clinical Strategy for the Morecambe Bay area (which links to other transformational programmes such as Primary Care and Long Term Conditions) bringing in experts and good practice to address stroke care, paediatrics, maternity etc.;•Engage communities, patients and stakeholders in the process to understand and champion the need for change and consult if appropriate, on new models of care; and•Develop effective programme management and operational arrangements to ensure effective and timely delivery of the strategy across the health and social care system.

Performance indicators will be developed as part of the Strategy formulation and will focus on the following :

•Reductions in premature mortality and health inequality rates; •Reduction in unnecessary non elective admissions, especially in Barrow;•Improvements in the quality of care and achievement of core standards in services such as stroke, paediatrics and maternity; and•Improvements in the level of confidence of the local communities and stakeholders in health services and improvements in patient experience.

Effective programme management and arrangements for operational delivery will be put in place across the health and social care system. Whole system governance arrangements will be put in place with similar arrangements to the System Board in North Cumbria.

18

SECTION 3: PROGRAMME DELIVERY – MANAGING RISK

The approach to programme delivery is based on a cycle of planning and implementation followed by benefits realisation.

During 2011/12 each of the six localities in Cumbria has implemented a series of community based initiatives that will deliver the planned reductions for 2012/13. Appendix B contains the detail by locality however a summary is contained on the next page. Alongside this planning has been underway to deliver an Emergency Floor Model and SSPAU both of which will be fully implemented by late 2012. The key aim of the Emergency Floor and SSPAU is to direct patients to the appropriate service through a Single Point of Access and to provide senior clinical assessment to prevent admission. There will be some in-year benefit from the models during 2012/13 however the full year benefits will be realised during 2013/14.

Also during 2012/13 the CCG will focus on developing a Primary Care Strategy to deliver the infrastructure to support risk stratification, integrated clinical teams and self management using a Year of Care approach. This programme is less well developed however during 2012/13 the CCG will be working though a programme of engagement with Primary Care, Secondary Care and Community Services to identify outcome measures and implementation timelines for 2013/14 and beyond. In addition the PCT Cluster and CCG will be working with secondary care clinicians to implement the Clinical Strategy in North Cumbria and develop a Clinical Strategy in South Cumbria.

For 2012/13 the PCT Cluster is assured that there is a sound and realistic plan through conservative activity reductions and increased community based activity. The emerging plan for 2013/14 will focus on the localities in Cumbria with the furthest to travel in achieving top quartile admission rates.

Cumbria has had some serious financial and quality issues although through Closer to Home the Cluster and CCG collectively are in financial balance. CPFT which provides Mental Health and Community Services is also in financial balance.

NCUHT has yet to achieve financial balance and this will only be achieved through the impending acquisition by Northumbria Healthcare NHS Trust and subsequent reconfiguration of clinical services. This will be a two or three year programme of work and will require significant resources to support the acquisition.

UHMBFT has until recently had recurrent financial balance however significant quality issues means that the CIP programmes may not be achieved. In addition significant stabilisation resources will be needed to reconfigure service models and improve quality.

The PCT Cluster and CCG can therefore expect non recurring resource pressures from four key areas:

• The need to pump prime transformation in Primary Care;

• The need to invest in Public Health initiatives that will address the health inequalities challenge;

• The need for resources to support the acquisition of NCUHT; and

• The need to support service reconfiguration at UHMBFT.

The resource impacts in each of these four areas are currently being determined but in total are likely to be in excess of the resources available from the 2% top slice. This issue is currently being considered with NHS North of England and a resolution to the funding issue is expected early in 2012/13.

3. PROG

RAMM

E D

ELIVERY

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity Reductions

ReductionNo.

Reduction£’000

Summary of Service Initiatives Across Cumbria

Respiratory 182 283 • Increase in number of pulmonary rehabilitation patients• LES for case finding, coding severity, assessment, ensuring appropriate pathway and medication• Re-evaluation of patients using oxygen therapy to optimise treatment• Increase in pulmonary rehabilitation services• Skilled respiratory nurses linking with community based services• Local version of Met office Scheme• Asthma reviews linked to community pharmacist, roll out of asthma prescribing pathway

Cardiac 626 509 • Specialist heart failure service, improved education for primary care teams• LES for identification and management of heart failure patients, optimisation of medication and heart failure scoring• Increase in pulmonary rehabilitation services• 24 hour access to ECHO and ECG diagnostics• Protected learning time for upskilling in primary care• Use of Qrisk tool• Psychological therapies for patients with multiple chronic disease• Exercise on Referral service (lower acuity patients)• Post discharge support for heart failure

Diabetes 49 51 • Practice nurses engaged in diabetes care training courses• Year of care initiative

Elderly Care 478 555 • Established Integrated Care Services for Older People (nursing, physio and pharmacy) improving continuity of care and management of LTCs for residential and nursing homes and extra care housing

• Care plans for all care home residents lodged with CHOC• Availability of interim care home beds for frail elderly and EMI patients including district nurse and GP admission rights• Geriatrician of the week

Alcohol and Drugs 100 65 • Provision of liaison psychiatry services to support people with mental health issues in A&E and on hospital wards. • Brief interventions LES in primary care for patients with harmful drinking

Infrastructure 872 782 • Redesign of community based STINT team to provide rapid response services• Primary Care Medical Assessment Service managing GP referrals for diagnostics and intermediate care services• Joint working with NCUHT to deliver Single Point of Access (Gateway into Services) and Emergency Floor projects

Elective 1,430 1,052 • Use of 30 new referral templates and embedded decision tools• Focus on reduction in unnecessary referrals for orthopaedic procedures, MSK (traigerd through physiotherapy), minor

skin lesions, varicose veins, grommets and tonsillectomies• Expected reduction in day case activity resulting from achievement of 18 week target during 2011/12

TOTAL 3,297

SECTION 3: PROGRAMME DELIVERY – MANAGING RISK (cont)3. PRO

GRAM

ME

DELIVERY

19

20

xxxxxxThe NHS Cumbria financial plan is consistent with the NHS North financial planning guidance. A planned surplus is delivered in each year of the plan. Contracts have been agreed and signed for 2012/13. A limited amount of additional resources are being provided to build capacity in primary and community care settings to support the delivery of the CCG commissioning intentions. The funding requirements and funding sources to support transformation change in NCUHT and UHMBFT are still being considered with NHS North of England.

SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN

KEY RESOURCE ISSUES AND ASSUMPTIONS

The Operating Framework investments planned reflect the need to address key target areas such as dementia, health visiting, health checks and implementation of the summary care record, along with specific investment in re-ablement.

Local investment priorities include the expansion of breast screening, the further expansion of PCI in Cumbria along with the re-instatement of deferred investments from 2011/12 (e.g. EMIS web).

The financial plans include, for each year, a contingency for demographic growth to cover secondary care activity, non-PBR drug costs and continuing care.

Details of the planned cost improvements across the three years of the plan are shown in Section 4.

The PCT currently has a significant number of equal value claims outstanding for which it is not possible to make a reliable estimate of the costs, although should this change then provision would have to be made.

A key assumption is that the transfer of resources relating to changes in organisational responsibilities for managing resources (i.e. public health & specialist commissioning) will be revenue neutral.

4. RESO

URCES

The NHS Cumbria plan is based upon maintaining the 2011/12 planned surplus of £4.1 million as identified in NHS North financial planning guidance. In addition, the plan reflects the requirement to utilise 2% of the recurring revenue resource limit non-recurrently each year.

The secondary care activity plans reflect NHS Cumbria CCG’s commissioning intentions to secure further reductions in secondary care activity. These plans are phased realistically across the plan period, reflecting the need to implement new service models at a time when major reform is taking place in the local acute sector. Similarly transformation is required in primary and community care (notably in the Furness locality) to ensure appropriate capacity and capability is in place to deliver the expansion in local, community based services.

At this stage no specific assumptions are included in respect of the costs relating to the planned acquisition of NCUHT or any long-term transitional requirements of the on-going major incident at UHMBFT. Discussions on resource requirements in these two Trusts during the plan period are being held with NHS North of England. The next discussions on funding requirements and the availablility of resources within NHS Cumbria is set for mid April.

21

xxxxxxThe resource plan includes resources for the assessed impacts of demographic change, the requirements of the Operating Framework and new service investments. These investments are essential for securing the delivery of agreed clinical strategies and for tackling health inequality. The allocation of the £17 million non recurring resource in each year is being reviewed.

SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN (cont.)

SUMMARY 3 YEAR KEY RESOURCE CHANGES FOR NHS CUMBRIA

2012/13£’000

2013/14£’000

2014/15£’000

B/fwd recurring position -14,555 -32,384 -36,632

Surplus returned -4,146 -4,080 -4,088

Less 2% top slice 17,080 17,080 17,421

Growth funding -24,684 -17,080 -8,711

Social Care Funding -6,934 0 0

FUNDS AVAILABLE -33,240 -36,464 -32,010

Demographic change 9,189 9,749 11,240

Inflation 5,302 4,457 4,541

CQUIN (2.5%) 15,342 15,495 16,095

Full year effect 2011/12 investments 3,518 0 0

Operating Framework 1,600 6,000 4,000

Social Care Funding 6,677 6,000 0

Planned Commissioner Intentions 0 1,813 1,813

New service investments 3,117 2,850 4,750

TOTAL NEW SPENDING 44,745 46,364 42,439

RESOURCE GAP 11,505 9,900 10,429

Tariff savings -8,091 -5,500 -5,505

Planned CIPs -4,197 -3,406 -3,923

Commissioning Intentions -3,297 -5,083 -5,083

TOTAL SAVINGS AVAILABLE -15,585 -13,988 -14,511

SURPLUS -4,080 -4,088 -4,082

USE OF 2% TOP SLICE

4. RESO

URCES

The use of the 2% top slice non recurrent allocation across the plan period is currently being considered. The key demands for funding from this source are:

• Pump priming service transformation in Primary Care across Cumbria particularly in Barrow;

• Investing in Public Health initiatives that will help to address health inequalities;

• Underpinning transitional resources for the NCUHT acquisition; and

• Service reconfiguration at UHMBFT.

COM

MIS

SIO

NER

RED

UCT

ION

S

B/FW

D U

NAL

LOCA

TED

FU

ND

S 20

12/1

3

NEW

GRO

WTH

FU

ND

ING

INFL

ATIO

N

NO

N R

ECU

RREN

T SP

END

ING

(AN

NU

ALIS

ED)

DEM

OG

RAPH

IC C

HAN

GE

CQU

IN

OPE

RATI

NG

FRA

MEW

ORK

INVE

STM

ENTS

OTH

ER IN

VEST

MEN

TS

SOCI

AL C

ARE

FUN

DIN

G

TARI

FF R

EDU

CTIO

N COST

IMPR

OVE

MEN

T

SURPLUS 2014/15£4.1M

SURPLUS 2011/12£4.1M

£25.6m

£50.5m £14.3m

£17.4m

£30.2m

£16.1m

£11.6m

£17.9m

£12.7m

£19.1m

£13.5m

£11.5m

RESOURCE MOVEMENTS BETWEEN 2012/13 AND 2014/15

SECTION 4: RESOURCES: NHS CUMBRIA FINANCIAL PLAN (cont.) 4. RESO

URCES

22

23

xxxxxxAll three provider Trusts are expected to have a minimum 4% cost improvement programme in place in each of the plan years. CPFT is expected to retain its annual surplus position. NCUHT is taking action to remove its underlying deficit position and will require further external financial support during the plan period as identified within the Trust acquisition process. UHMBFT is now the subject of a transformation project to deliver improved service quality and stability and it is anticipated that it will similarly require external financial support during the three year plan period.

SECTION 4: RESOURCES: NHS TRUST FINANCIAL PLANS

UNIVERSITY HOSPITALS OF MORECAMBE BAY FOUNDATION TRUST

CUMBRIA PARTNERSHIP FOUNDATION TRUST

4. RESO

URCES

UHMBFT currently has a financial risk rating of 3 and in 2011/12 received agreed financial support from both NHS Cumbria and NHS North Lancashire to ensure the short-term financial consequences of the major incident while maintaining the current financial risk rating.

The expectation is that UHMBFT will continue to deliver the nationally mandated efficiency targets over the planning period but it will require external financial support during the three year plan period. The extent of this support is currently being determined.

The contract for 2012/13 has been agreed and signed with the Trust.

In 2011/12 Cumbria Partnership FT successfully took over the management of the PCT’s provider arm under TCS without any adverse impact on the Monitor Financial risk rating of 5. The expectation is that CPFT will continue to deliver the nationally mandated efficiency targets over the planning period.

The contract for 2012/13 has been agreed and signed with the Trust.

NORTH CUMBRIA UNIVERSITY HOSPITALS TRUST

In 2011/12 NCUHT received strategic support funding of £28 million to address an identified underlying deficit, slippage in its in-year cost improvement programme and the excess costs of its PFI Hospital.

NCUHT has developed a Long Term Financial Model to demonstrate how the historic recurring deficit and future mandated efficiency targets can be addressed. This information has been provided to bidders as part of the acquisition process.

In conjunction with this NCUHT has produced hospital based trading accounts (which again demonstrate how the Trust anticipates getting back into financial balance) and these have been used to support the decision to progress with the redevelopment of the West Cumberland Hospital in Whitehaven.

The Trust, and its preferred bidder, have both identified that further underpinning transitional financial support will be required and this is being considered with NHS North as part of the Trust acquisition process.

24

xxxxxxA £40 million Capital Programme has been identified across the 3 year planning period, which includes the Cockermouth and Cleator Moor projects.

SECTION 4: RESOURCES: NHS CUMBRIA CAPITAL PLAN

3 YEAR CAPITAL PLAN FOR NHS CUMBRIA

KEY PROJECTS

2011/12£’000

2012/13£’000

2013/14£’000

2014/15£’000

Capital to maintain existing infrastructure

3,000 3,000 3,000 3,000

Refurbishment of UHMBFT premises for relocation of GP services

1,000

Cockermouth & Cleator Moor 12,352

New Primary Care Development in Barrow

17,500

Total Plan 3,000 4,000 15,352 20,500

2011/12£’000

2012/13£’000

2013/14£’000

2014/15£’000

Anticipated Capital Resources 3,000 4,000 15,352 20,500

The Capital Resource Limit for NHS Cumbria is set out below.

The associated Capital Programme across the plan period is as follows:

An annual commitment of £3 million is assumed to maintain the existing estate in line with current underlying expenditure patterns;

The ‘on balance sheet’ treatment of the Cockermouth & Cleator Moor projects is shown when the buildings become operational in 2013/14 based on the Stage 2 business case approval and financial close during March 2012. These schemes are developed by ELIFT Cumbria (eLC), NHS Cumbria’s LIFT partner;

Negotiations are currently in place with UHMBFT to refurbish redundant premises on the Furness General Hospital site in Barrow to provide GP premises, with an outline cost estimate of £1 million;

A provisional sum of £17.5 million has been included as the necessary capital investment to address the infrastructure requirements for the modernisation and optimisation of primary care premises in Barrow. Currently feasibility work is being undertaken in conjunction with eLC and it is anticipated that the final scheme will be ‘on balance sheet’;

The capital expenditure profile has been shown based on the current asset base of NHS Cumbria, and therefore for planning purposes potential asset transfers have been excluded;

In addition to the above projects the financial plans include the recurring revenue costs of new Primary Care premises developments in Kendal (Captain French), Grange and Carlisle (Stanwix).

4. RESO

URCES

NHS Cumbria cluster is working with the Cumbria Partnership FT to identify the priorities for estate renewal. The programme below includes funding of a rolling programme to maintain existing infrastructure and the two projects for which the Cluster has now received Stage2 Business Case approval – the Cockermouth Hospital and GP practices project and the Cleator Moor Health Centre.

The programme also includes provisional funding to address the infrastructure requirements for the modernisation of primary care premises in Barrow.

SECTION 5: QIPP: OVERALL APPROACH

25

5. Q

IPP

The short term QIPP Plan centres on the completion of the Closer to Home initiatives, including providing a single point of access to emergency services, implementing integrated emergency floors and providing improved short stay paediatric assessment services. These key initiatives will improve clinical quality and sustainability, integrate care for better patient experience and help to secure reductions in admission rates.

The three year strategy is to maintain non elective admission rates in most localities, despite the increases in demand which we are expecting from an ageing population, but look for significant improvement in Furness. The CCG will seek to reduce paediatric non elective admission rates across all of Cumbria by providing more accessible and child friendly, community based services. There will also be a reduction in elective referral rates which will be achieved through addressing procedures of limited clinical value and making available to GPs more effective decision tools and providing referral management support.

Delivery of Phase 1 of the long term condition strategy, which delivers pathway improvements in diabetes, respiratory and cardiac care, will also allow the CCG to achieve improved admission rates.

It is highly likely, given the substantial change agenda experienced by the two main providers, that the service changes outlined will only be implemented and embedded during the course of 2012/13. For this reason the CCG has planned to achieve its key activity changes across the full three years of the plan period.

An overall 4% efficiency target has also been built into contracts with all providers.

Approximately 58% of the QIPP programme across the three years can be classified as transformational.

In addition to these plans there are transactional QIPP initiatives, such as continuing changes in GP prescribing practices which will deliver cost savings and management cost reductions.

NHS Cumbria has a confirmed plan to achieve change and increased efficiency across all clinical services. However there are four key demands on non recurring resources and these are likely to outstrip the level of non-recurring resources available within the community during the next three years.

PROGRAMME CONTENT RESOURCE PRESSURESWe have had serious financial and quality issues in Cumbria. However, through implementing the Closer to Home programme, which was consulted on in 2007, commissioners have achieved recurrent financial balance and have begun to change the way patients are managed across Cumbria.

The Cumbria-wide community and mental health provider, the Cumbria Partnership FT, is in recurrent financial balance and has a significant agenda for service change across community and mental health services.

NCUHT has a significant deficit which requires a large and sustained cost reduction programme and will need significant underpinning resources to support the acquisition of the Trust.

UHMBFT has until recently had recurrent balance but significant quality problems means there is a risk that CIP programmes will not be achieved and that significant stabilisation resources will be needed to help deliver new service models to secure quality improvement and reconfiguration across sites to deliver long term clinical sustainability.

Commissioners can therefore expect to have a significant call on non recurrent resources from four key areas:

• The need for non recurrent investment to pump prime change in the transformation of primary care;

• The need to find resources to address the significant challenges of health inequalities across Cumbria;

• The need for resources to support the acquisition and transformation of NCUHT by Northumbria Healthcare FT; and

• The need for transformation and stabilisation funding for service change to improve service quality in UHMBFT.

The source of funding which is available to deal with these four key areas is the 2% top slice which is to be applied for non-recurring purposes.

26

xxxxxxThe combined commissioner and provider gap amounts to £105 million for the three year period 2012/13 to 2014/15. Of this, £9.5 million relates to service providers outside of Cumbria. In addition there is a £28 million underlying deficit at NCUHT which will be managed through the Trust acquisition process.

SECTION 5: QIPP: THE COMBINED GAP ACROSS CUMBRIA

The QIPP gaps which have been estimated for the three Cumbria provider Trusts, based on the 4% efficiency requirement, are as follows:

2012/13£’000

2013/14£’000

2014/15£’000

TOTAL£’000

NCUHT (Cluster estimate) 6,549 6,383 6,478 19,410

UHMBFT (Cluster estimate) 4,693 4,543 4,570 13,806

CPFT (Cluster estimate) 6,183 6,247 6,463 18,893

CUMBRIA PROVIDER QIPP GAP

17,425 17,173 17,511 52,109

Less tariff deflator -6,228 -4,359 -4,362 -14,949

11,197 12,814 13,149 37,160

The expectation is that the QIPP gaps identified for UHMBFT and CPFT will be delivered through the internal CIP programmes in those Foundation Trusts.

As a result of the acquisition process, NCUHT is expected to deliver a significant CIP programme as a contribution to the gap identified. However, closure of the gap will require external support during the plan period.

PROVIDER QIPP GAPSOVERALL QIPP GAP

The overall QIPP gap for NHS Cumbria is identified at £105 million. In addition there is a £28 million underlying deficit at NCUHT whichIs being managed as part of the Trust acquisition process.

This is set out in the table below.

2012/13£’000

2013/14£’000

2014/15£’000

TOTAL£’000

Commissioning QIPP gap 15,585 13,988 14,511 44,084

Cost avoidance target 4,669 4,702 4,833 14,204

20,254 18,690 19,344 58,288

Cumbria provider efficiency target*

11,197 12,814 13,149 37,160

Cumbria QIPP gap 31,451 31,504 32,493 95,448

Other providers efficiency target* 2,716 3,345 3,414 9,475

Total QIPP Gap (FIMS QIPP) 34,167 34,849 35,907 104,923

Add NCUHT underlying deficit 28,000 0 0 28,000

62,167 34,849 35,907 132,923

• The provider efficiency targets exclude the value of the tariff deflator which is included in the figures for the Commissioning QIPP gap.

5. Q

IPP

27

xxxxxxA commissioner QIPP gap of £58 million (including the targets for cost avoidance) has been identified across the three year plan. NHS Cumbria Cluster and CCG has identified a robust plan to close this gap so that the required revenue surplus can be delivered in each year.

SECTION 5: QIPP GAP: COMMISSIONER GAP

2012/13£’000

2013/14£’000

2014/15£’000

TOTAL£’000

Changes in Income 33,240 36,464 32,010 101,714

Changes in Expenditure 44,745 46,364 42,439 133,548

Resource Gap 11,505 9,900 10,429 31,834

Surplus Required 4,080 4,088 4,082 12,250

QIPP RESOURCES GAP 15,585 13,988 14,511 44,084

Cost avoidance 4,669 4,702 4,833 14,204

QIPP TOTAL GAP 20,254 18,690 19,344 58,288

IDENTIFICATION OF THE QIPP COMMISSIONING GAPNHS Cumbria has a QIPP gap of £58 million across the three years of the plan. This is constructed as follows:

2012/13£’000

2013/14£’000

2014/15£’000

Total£’000

Unplanned Care 2,245 2,157 2,158 6,560

Planned Care 1,052 2,897 2,898 6,847

Mental health 378 750 750 1,878

Primary care 1,560 1,560 1,560 4,680

Provider tariff deflator 8,091 5,500 5,505 19,096

Other local services 699 508 1,025 2,232

Other transactional projects 1,907 529 490 2,926

TOTAL QIPP PROGRAMME 15,932 13,901 14,386 44,219

PLAN TO DELIVER THE NHS CUMBRIA QIPP RESOURCES TARGETThe savings plan which has been identified is set out in summary below. Delivery of this programme will ensure the closure of the identified £44 million QIPP resources gap.

Identified QIPP Gap

2011/12 Submission

£m*

2012/13Plan£m

2011/12 28.1 28.1

2012/13 23.3 15.6

2013/14 9.3 14.0

2014/15 5.1 14.5

TOTAL 65.8 72.2

• Per QIPP plan dated May 2011 as submitted to NWSHA and which forms the baseline for monitoring in 2011/12

The key issues which have been taken into account in this reassessment are:

• Amended PCT funding levels;• The CCG decision to rephase the commissioner plan following

discussions with NHS North, where 2012/13 becomes a year for consolidation and a lower level of commissioner savings;

• Reconsideration of service investment requirements; and• Reassessment of committed funding requirements.

The QIPP resources gap (which excludes the cost avoidance targets) can be compared to the four year QIPP gap which was identified in May 2011, as shown in the table below.

5. Q

IPP

The PCT has completed the triangulation analysis utilising the SHA template.

28

SECTION 5: QIPP (cont.)

In addition, the following can also be cited as further contractual mechanisms to mitigate risk:

•It is expected that funding for transition/stabilisation with NCUHT and UHMB will be conditional on this being used as the first call on any additional activity;•A risk sharing arrangement for controlling the cost of high cost mental health patients and incentivising repatriating patients to lower cost local alternatives has been established with CPFT;•The NWAS contract provides marginal relief for over activity; and•NHS Cumbria supports the proposal of collective risk sharing for specialised commissioning.

In addition:•The net impact of growth/tariff deflator identified in 2012/13 is quantified at approximately £33 million (circa 3.5% of total RRL); considerably more prudent assumptions have been used for 2013/14 (2.5%) and 2014/15 (1.55%); and•In addition to the prudent assumptions on growth further planning contingencies have been established of circa £15 million for both 2013/14 and 2014/15. 5.

QIPP

Approximately 58% of the QIPP target will be delivered through transformational change (see table opposite).

NCUHT has a dual challenge of delivering the 4% efficiency target, amounting to £19.4 million across the three years of the plan and eradicating the £28 million underlying recurring deficit. This will require transformational change to provide sustainable clinical services. This will be achieved through delivery of the clinical strategy for north Cumbria and the acquisition process with Northumbria Healthcare FT. The North Cumbria System Board will oversee delivery of the transformational change. The QIPP efficiency gap will be delivered through a combination of transactional and transformational change.

The Cumbria three year QIPP efficiency target for UHMBFT is £13.8 million. In view of the deep rooted clinical quality issues there is a need to consider reconfiguration of services across the three hospital sites into primary, secondary and tertiary services. This transformation will be achieved through the emerging system wide Clinical strategy.

The three year QIPP efficiency target for CPFT is £18.9 million. In line with the clinical strategies for both North and South Cumbria, CPFT is planning to deliver more activity for less income. This will result in better integration and more effective services. There are two key priorities. The first is the further integration of community and mental health services following the TCS transfer in April 2011 alongside the integration. The second is securing integration between primary and secondary care in the delivery of a transformed emergency flow pathway including Single Point of Access, Integrated Emergency Floor and Short Stay Paediatric Assessment Service.

TRANSFORMATIONAL CHANGE

Transformational

£’m (est)

Transactional£’m (est)

NCUHT underlying deficit 28.0

NCUHT efficiency target 9.7 9.7

UHMBFT efficiency target 6.9 6.9

CPFT efficiency target 9.4 9.5

Commissioning savings 15.3 9.8

Cost avoidance 0 14.2

TOTAL £m 69.3 50.1

TOTAL % 58% 42%

HEADROOM IN THE NHS CUMBRIA QIPP PLAN

Significant headroom exists in the 2012/13 plan with over £9 million allocated for demographic growth (i.e. activity over and above 2011/12 levels). In some instance this has been encapsulated in contracts with specific providers, and in other areas retained as a generic contingency to manage costs. The prescribing budget also contains a CCG contingency of £900,000 (1%) over and above planned growth.

29

SECTION 5: QIPP SAVINGS ANALYSED BY PROGRAMME AREA 5. Q

IPPANALYSIS OF SAVINGS BY PROGRAMME AREA

The £105 million savings plan across Cumbria has been analysed by service area and this is shown in the table below. This analysis is consistent with the content of the FIMS QIPP return for 2012/13.

2012/13£’000

2013/14£’000

2014/15£’000

TOTAL£’000

Acute elective 4,301 6,212 6,245 16,758

Acute non-elective 8,465 7,729 7,882 24,076

Acute outpatients 2,057 2,562 2,636 7,255

Acute direct access 607 598 622 1,827

Acute other 2,336 1,996 2,234 6,566

Mental health and learning difficulties 2,593 3,336 2,658 8,587

Community services 3,590 3,660 3,805 11,055

Ambulance services 953 906 932 2,791

Specialist commissioning 1,577 1,592 1,637 4,806

Non-NHS contracts 1,075 0 750 1,825

Continuing healthcare 0 508 508 1,016

Primary care prescribing 3,926 3,980 4,085 11,991

Excluded drugs and devices 866 922 1,065 2,853

Primary care, dental, pharmacy, ophthalmology 823 848 848 2,519

PCT running costs 1,000 0 0 1,000

TOTAL 34,169 34,849 35,907 104,925

30

SECTION 5: QIPP: PLANS TO CLOSE THE QIPP GAP

The £28.1 million commissioning QIPP gap for 2011/12 and the reductions to contracts for provider efficiency targets have been delivered, reducing the NHS Cumbria cost base by £50.1 million.

The majority of the gap for the next three years will be managed by Cumbria CCG. The CCG has cost reduction and cost avoidance plans which are fully developed for delivery in 2012/13.

Plans to close the gap in the following two years are currently being reviewed. These plans are a combination of:

• Reductions in hospital based activity in line with the CCG’s clinical and commissioning strategies;

• The impact in each year of the PbR tariff deflator;• Continuous improvements in efficiency which lead to cost

reduction, for example in primary care prescribing;• Securing the benefits from the national contract for

continuing care; and• Standard housekeeping projects.

The activity reduction plans were set out in a Commissioning Framework which was produced in November 2011. These cover unscheduled and elective activity for both adult and children’s services.

Overall, Cumbria has the lowest rate of unscheduled admissions in either the North West or North East and therefore the opportunities to secure further reductions need to take this into account. However, the position varies across the six localities and the strategy therefore is to deliver the agreed patient pathways and to set target admission rates for each locality which reflect the opportunities available to secure reductions in hospital admissions.

Paediatric admission rates are high for all localities and action will be taken to reduce these through the Children and Young People work programmes.

NHS Cumbria has well developed plans to deliver the cost reduction measures necessary to close the £58 million QIPP gap. These are a combination of transformational and transactional changes.

Four of the six localities are at or below the national average rate for elective admissions, although there is scope for improvement to upper quartile rates. The Audit Commission benchmark tool for procedures of limited clinical value confirms that there is scope for significant improvement.

The detail for each of these three programmes for reducing hospital admissions and referrals is set out later in this section. The CCG will seek to ensure provider commitment to achieving the target activity shifts in the interest of our patients as a condition of stabilisation support.

5. Q

IPP

The cash releasing QIPP savings have been embedded into the PCT budget that is approved by the Board with formal delegation to the CCG through an accountability agreement. The financial reporting systems of the PCT have been developed to provide information at PCT, CCG and, where appropriate locality level. Financial performance is monitored through the following formal mechanisms:•The PCT Board, through the Resources Committee, monitors in-year financial performance of the whole NHS Cumbria resources; this process includes scrutiny of year-to-date position (and hence progress on targets), forecast position and the impact of any recovery measures required and implemented to manage variances from plan;•The CCG is in addition monitored on financial performance through monthly performance meeting on delivering its financial targets; and•The CCG has implemented a formal system of “peer review” to review financial performance and corrective action at a locality level. In addition, this approach is supplemented by weekly reporting of key “informal” activity indicators to highlight trends in localities and with individual providers to identify potential risks (e.g. out-patient referrals, admission rates, OOH activity) in advance of receiving formal contractual information. This information, coupled with use of benchmarking tools, is also used to provide assurance of “costs avoided” in addition to planned cash releasing savings.

ASSURANCE PROCESSES FOR DELIVERY

31

SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – ADULT EMERGENCY ADMISSIONS

Overall, Cumbria has the lowest rate of admissions in either the North West or North East. Three out of the six localities are at or below upper quartile levels; two are at or below national average. Only one, Furness, has high levels of admissions. The strategy, therefore, is to maintain rates in South Lakes, Eden and Allerdale; work to improve rates in Carlisle and Copeland (accepting the relatively high levels of deprivation there); and to significantly improve rates in Furness.

Considerable investment in Furness will be necessary to achieve admissions reduction. There is a particular need to address primary care capacity which impacts on the ability to manage urgent day time patient care effectively. This is in line with the CCG primary care strategy.

xxxxxxCumbria has a good track record of reducing hospital based activity over the last three years, particularly in non elective patient care. However, the track record on delivering against plan has not always been consistent and a more rigorous approach is being taken to the activity plans for 2012/13 which reflects the relative position of each of the Cumbria localities.

Emergency Admissions; Q3 2010/11 Annual Rate; Source: NHS Comparators

0

20

40

60

80

100

120

140

160

Primary Care TrustS

tan

dar

ised

Rat

e p

er 1

000

po

p

Cumbria NW & NE SHA PCT Other PCTs Allerdale Carlisle

Copeland Eden Furness South Lakes National Average

Maintain top quartile position

Target for Copeland &

Carlisle

Target for Furness

*NB Overall emergency reductions are the net position excluding paediatric reductions (shown on the next page) to avoid double count.

Locality Policy across the three year period Reduction in admissions

No.*

Reduction in commissioning

cost£’000*

Allerdale Maintain current position within top quartile

0 0

Carlisle Move to top quartile position 33 129

Copeland Move to top quartile position 413 1,004

Eden Maintain current position within top quartile

0 0

Furness Move half way between current position and top quartile

508 1,600

South Lakes Maintain current position within top quartile

0 0

TOTAL 953 2,733

5. Q

IPP

Locality Policy for three year periodReduction in admissions

No.


cost£’000

Allerdale Move to mid point between the average and top quartile position

574 475

Carlisle Move to national average position 492 407

Copeland Move to national average position 364 301

Eden Move to top quartile position 358 296

Furness Move to national average position 873 722

South Lakes Move to top quartile position 547 452

TOTAL 3,208 2,653

SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – PAEDIATRIC EMERGENCY ADMISSIONS

32

Paediatric admission rates are high for all localities and action will be taken to reduce these through the Children and Young People work programmes, particularly implementation of the paediatric assessment unit in each of our main hospitals linked to the emergency floor and single point of access; alongside implementation of new children’s pathways (e.g. for the acutely ill child).

During the plan period, three of the six localities will move to the current national average position, Allerdale will move to the mid point between the average and top quartile position and the Eden and South Lakes localities have an opportunity to deliver top quartile performance.

Paediatric admission rates remain high across Cumbria and the strategy is to reduce the level of admissions in each locality by providing more accessible community based assessment facilities.

Paediatric Emergency Admissions; Q3 2010/11 Annual Rate; Source: NHS Comparators

0

5

10

15

20

25

Primary Care Trust

Sta

nd

aris

ed R

ate

per

100

0 p

op

Cumbria NW & NE SHA PCT Other PCTs Allerdale Carlisle


Target for Eden and South Lakes

Target for Carlisle, Copeland & FurnessTarget for

Allerdale

5. Q

IPP

33

SECTION 5: QIPP: CLEAR & CREDIBLE ACTIVITY PLANS – ALL ELECTIVE ACTIVITY

Four out of the six localities (South Lakes, Eden, Allerdale and Carlisle) are at or below the national average rate for elective admissions, although there is scope for improvement to upper quartile rates. Copeland and Furness are above average (3rd quartile).

Comparisons through the Audit Commission benchmark tool for procedures of limited clinical value indicate there is scope for significant improvement.

The strategy for elective admissions is to move four of the six localities to the current top quartile position and to target performance improvement in Copeland and Furness localities to the level currently achieved in the Allerdale locality.

Locality Policy across the three year period Reduction in admissions

No.


cost£’000

Allerdale Move to top quartile position 1,080 1,178

Carlisle Move to top quartile position 1,322 1,442

Copeland Move to current Allerdale position 811 885

Eden Move to top quartile position 375 409

Furness Move to current Allerdale position 1,054 1,149

South Lakes Move to top quartile position 717 783

TOTAL 5,359 5,846

Elective (Day Case & Ordinary) Admissions; Q3 2010/11 Annual Rate; Source: NHS Comparators

0

20

40

60

80

100

120

140

160

180

Primary Care Trust

Sta

nd

aris

ed R

ate

per

100

0 p

op

Cumbria NW & NE SHA PCT Other PCT Allerdale Carlisle


Target for Allerdale, Carlisle, Eden, and South Lakes

Target for Copeland & Furness

There is scope to improve referral practices in each locality and during the next three years the focus will be on reducing referrals for procedures of limited clinical value.

5. Q

IPP

34

SECTION 5: QIPP: SUMMARY OF COMMISSIONING PLANS

Change on previous year

2011/12 2012/13 2013/14 2014/15 2012/13 2013/14 2014/15

No. No. No. No. % % %

Unscheduled 53,469 50,154 49,611 49,222 -6.2% -1.1% -0.8%

Elective 65,835 65,014 63,692 62,531 -1.2% -2.0% -1.8%

Excess Beddays 30,755 30,725 29,226 27,994 -0.1% -4.9% -4.2%

All outpatients 445,573 399,245 400,513 400,812 -10.4% +0.3% +0.1%

A&E 109,821 110,129 109,458 108,973 +0.2% -0.6% -0.4%

The commissioning plans are brought together in the next two pages to demonstrate the impact of the commissioning policies on overall hospital activity and PbR payments.

These tables also show the anticipated impact on hospital activity of demographic change over the three years of the plan. The CCG has reviewed the way in which it assesses the impact which its ageing population will have on clinical services. This will ensure there is a more accurate assessment of the likely impact of demographic change on elective and non elective admissions.

The summary table below shows the net activity changes that are anticipated over the next three years in the level of hospital based activity.

5. Q

IPPSUMMARY OF THE COMMISSIONING PLANS

35

SECTION 5: QIPP: CHANGES IN PATIENT ACTIVITY LEVELS

Plan 2011/12

No.

Outturn2011/12

No.

Plan2012/13

No.

Plan2013/14

No.

Plan2014/15

No.

Unscheduled

Baseline 53,320 53,469 50,154 49,611

Commissioning intentions -2,378 -2,282 -927 -927

Demographic impact 114 524 384 538

Other net changes -1,293 -1,557

Total 49,763 53,469 50,154 49,611 49,222

Elective

Baseline 66,027 65,835 65,014 63,692

Commissioning intentions -934 -1,431 -1,964 -1,964

Demographic impact 340 642 803

Other net changes 270

Total 65,093 65,835 65,014 63,692 62,531

Excess Beddays

Baseline 33,939 30,755 30,725 29,226

Commissioning intentions -2,718 -2,119 -2,119

Demographic impact 620 887

Other net changes -30

Total 31,221 30,755 30,725 29,226 27,994

Plan 2011/12

No.

Outturn2011/12

No.

Plan2012/13

No.

Plan2013/14

No.

Plan2014/15

No.

Outpatients - First

Baseline 119,011 120,135 120,725 118,630

Commissioning intentions -2,818 -3,020 -3,020



Total 116,193 120,135 120,725 118,630 116,314

Outpatients- Follow up

Baseline 257,148 249,261 201,627 204,397

Commissioning intentions -53,950

Demographic impact 2,770 2,152

Other net changes -47,634

Total 203,198 249,261 201,627 204,397 206,549

Outpatients - Procedures

Baseline 62,213 76,177 76,907 77,486




Total 60,915 76,177 76,907 77,486 77,949

A&E

Baseline 110,055 109,821 110,129 109,458

Commissioning intentions -903 -903


Total 110,055 109,821 110,129 109,458 108,973

5. Q

IPP

The figures shown for outturn 2011/12 and 2012/13 are consistent with contracts for 2012/13

36

SECTION 5: QIPP: CHANGES IN PATIENT ACTIVITY LEVELS – RESOURCE IMPLICATIONS

Plan 2011/12

£’000

Outturn2011/12

£’000

Plan2012/13

£’000

Plan2013/14

£’000

Plan2014/15

£’000

Unscheduled

Baseline 95,651 95,114 90,929 90,584

Commissioning intentions -3,725 -2,245 -1,571 -1,571

Demographic impact 155 1,142 1,226 1,645

Other net changes -2,831 -3,082

Total 89,250 95,114 90,929 90,584 90,658

Elective

Baseline 75,978 81,683 81,220 79,683

Commissioning intentions -924 -1,052 -2,397 -2,397

Demographic impact 400 860 1,020


Total 75,054 81,683 81,220 79,683 78,306

Excess Beddays

Baseline 7,900 7,129 7,135 6,757

Commissioning intentions -660 -514 -514


Other net changes 6

Total 7,240 7,129 7,135 6,757 6,438

Plan 2011/12

£’000

Outturn2011/12

£’000

Plan2012/13

£’000

Plan2013/14

£’000

Plan2014/15

£’000

Outpatients - First

Baseline 19,654 20,125 20,211 19,870

Commissioning intentions -449 -500 -501



Total 19,205 20,125 20,211 19,870 19,489

Outpatients- Follow up

Baseline 23,176 18,961 14,796 15,050



Other net changes -4165

Total 18,084 18,961 14,796 15,050 15,244

Outpatients - Procedures

Baseline 9,559 11,733 11,821 11,911

Commissioning intentions -179



Total 9,380 11,733 11,821 11,911 11,984

A&E

Baseline 10,062 10,201 10,201 10,333 10,291

Commissioning intentions -72 -73



Total 10,062 10,201 10,333 10,291 10,269

5. Q

IPP

The figures shown for outturn 2011/12 and 2012/13 are consistent with contracts for 2012/13

37

SECTION 5: QIPP: ESTATES

NHS Cumbria and its associated provider services are working on a number of estates projects which will assist in closing the QIPP efficiency gap. The eight key projects are listed below.

DRIVING EFFICIENCY FROM ESTATES RATIONALISATION

NHS Cumbria is working with its associated provider organisations to secure efficiencies from new capital projects or through the rationalisation of the existing Cumbria estate. The eight key initiatives are listed below.

NHS Cumbria has signalled its support for the new West Cumberland Hospital. This will deliver an operating surplus of £3 million per annum through more efficient buildings infrastructure and space layout, improved clinical adjacencies and new ways of working facilitated by the new hospital.

The DoH has identified the Cumberland Infirmary, Carlisle as one of a small number of first stage PFI hospitals where excess operating costs can be identified as a result of the contractual conditions which exist. A national funding stream has been identified from which these excess costs will be met. NCUHT anticipates that this will make a significant contribution to its underlying deficit position.

The new estate projects in Cockermouth and Cleator Moor will deliver annual savings of £528,000 per annum (of which £226,000 has been identified from estates services). Both these projects consolidate four existing buildings into one location in each town.

NHS Cumbria is considering the refurbishment of a building on the Furness General hospital site (owned by UHMBFT) to provide new GMS accommodation. This will be a cost effective solution when compared to a new building on an acquired site.

The new GMS development in Stanwix is being built on land owned by Cumbria County Council at less than open market value. This avoids potential costs estimated at around £25,000 per annum.

NHS Cumbria is working with UHMBFT to investigate the feasibility of relocating staff from the Tenterfield site in Kendal to the Westmorland General Hospital site.

The 111 proposals are likely to consolidate the infrastructure in Cumbria, improving utilisation of space & technology.

NHS Cumbria is working jointly with NCUHT and CPFT to review the scope for vacating peripheral buildings on hospital sites to improve the space utilisation of the main buildings and release costs.

5. Q

IPP

38

xxxxxxThe CCG has always set great store on the engagement of patients in decision making and service re-design and will introduce a ‘Listening to Cumbria’ campaign and other initiatives as an early priority.

SECTION 6: ENGAGEMENT : Patients and Communities 6. EN

GAG

EMEN

T

Clinicians in Cumbria have always set great store on the engagement of patients in decision making and service re-design. For example, engagement of patients is at the heart of the diabetes pathway re-design, with a focus on patient education and co-production of the care plan. In line with the ‘promise to patients and communities’ the CCG is keen to make a quantum leap in the development of its engagement arrangements, and like quality, embed them at the heart of all the commissioning arrangements. Members of CCG will work with the emerging Healthwatch organisation to ensure efforts are joined up and there is no duplication. An early priority for the CCG will be to carry out an extensive ‘Listening to Cumbria’ campaign throughout the spring of 2012. This will involve health roadshows, ‘meet your GP’ surgeries and other public facing events in every locality in the county. It will be led by the elected GPs from each locality and seek the views, aspirations and needs of patients. It will also be an introduction to the new world of GP commissioning. There will also be programmed meetings with key stakeholders such as the Overview and Scrutiny Committee, emergent Health and Wellbeing Board, MPs, League of Friends, LMC and social care and local authority representatives. We will also actively seek patient views about how they can be more closely involved with decision-making on both individual and collective levels.

Key Milestone Plan for 2012/13

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Listening exercise

Patient experience metrics dashboard developed/targets included 2013/14 contracts

Systematic approach to engaging patient representation

Third party contract to gather, analyse, report experience metrics: specification & contract

The outcome of the listening campaign will be an evaluation which will lead to a new and dynamic ‘multi-channel’ methodology for capturing and acting upon patient experience on an ‘industrial scale’.

This ‘multi-channel’ methodology will focus include:1. Near time, post treatment, out-bound telephone follow-up interviews;2.On-line opportunities to comment on-line with moderated feedback and publication;3.Structured attitudinal surveys;4.Patient experience sampling across service lines and provider geography;5.Proactive mobilisation of community and voluntary groups to monitor;6.Primary care satisfaction surveys;7.Comments and notes boxes in every GP surgery;8.Requirements of providers to carry out satisfaction surveys in situ;9.Deliberative patient groups in every locality; and10.Feedback loops to patients to demonstrate how their experience has been taken into organisational and contractual learning to make service changes.

It is expected that the CCG will commission these services from an external agency to provide a regular and systematic monitoring of patient experience. This data will be reviewed by clinicians at monthly locality and CCG Executive Boards as a core metric in the quality dashboard and for contract monitoring and service development.

39

xxxxxxThe PCT Cluster has met the first part of the PSED and is engaging across the whole system to develop equality objectives. The Cluster and CCG are working together to develop an implementation plan.

SECTION 6: ENGAGEMENT : Public Sector Equality Duty

The PCT Cluster met the 1st part of the PSED by publishing information of the effects of policies on people protected by the Act on 31st Jan 2012.

In addition the Cluster is reviewing EDS evidence with self assessment due mid March 2012 alongside providing training to enable grading of self assessment by wider Stakeholders 6th March.

A Joint accreditation event where wider stakeholders will verify self assessments leading to a Cumbria wide assessment proving a baseline for EDS will be held on 26 March 2012.

From the event Equality Objectives will be drafted for verification by the Board and publication by 6th April.

The Cluster and CCG will work together to develop performance measures to show how Equality Objectives will be met over the next 4 years.

6. EN

GAG

EMEN

T

40

SECTION 7: PERFORMANCE AND QUALITY – KEY PERFORMANCE INDICATORS7. PERFO

RMAN

CE &

QU

ALITYGood progress has been made in achieving the 2010/11 Operating Framework performance however there are still some key issues that need to be resolved.

Good progress has been made in achieving the 2011/12 Operating Framework performance however there are still some key issues that need to be resolved. The table below sets out the most recent position alongside the year end forecast.

Cum

bria

NCU

HT

UH

MBF

T

Cum

bria

NCU

HT

UH

MBT

Referral to Treatment

A&E 4 hour wait

Cancer - 62 day

Stroke

Mixed Sex Accommodation

HCAI

Ambulance Cat A

RAG - YTD RAG - Forecast

In summary NCUHT will achieve 5 of the 6 key performance indicators from April 2012 and all 6 indicators from June 2012.

However NCUHT remains an outlier in relation to Delayed Transfers of Care (DToC). A series of operational changes have recently been implemented and a whole system event is to take place early May. This will result in a whole system action plan and trajectory and will be performance managed through the current System Board arrangements.

UHMBFT

UHMBFT has consistently been failing the A&E and Mixed Sex Accommodation (MSA) indicators since late 2011. A series of operational changes have been implemented from 12th March 2012 and these will improve the emergency flow through the system. Early analysis shows improved performance and a trajectory will be agreed with the Trust to achieve the 95% target early in 2012/13. A weekly review meeting takes place between UHMBFT, the Cluster, the CCG and the Cluster and CCG in Lancashire.

The CCG and NHS North have been working with the Trust to develop an action plan to eliminate clinically unjustified MSA. The plan has yet to identify timescales and outcome measures however it is expected that MSA will be eliminated from April 2012. The plan will be signed off by the end of March 2012 and weekly monitoring will be in place between UHMBFT and the CCG.

A fundamental overhaul of Stroke Services at UHMBFT may mean that this indicator continues to be variable during 2012/13. In summary, UHMBFT will achieve 4 of the 6 indicators by end March 2012 and will have agreed plans in place to achieve all 6 indicators early in 2012/13.

NCUHT

NCUHT has been clearing a backlog of Ophthalmology and Gynaecology cases since January 2012. The anticipated additional capacity was not fully realised in early 2012 therefore the backlog will not be cleared until May 2012. A recovery plan has been agreed with the Trust and is being performance managed weekly. From June 2012 the Trust will achieve all RTT indicators. NCUHT has improved in year against the stroke performance indicator and will be fully compliant by April 2012.

SECTION 7: PERFORMANCE AND QUALITY: CLUSTER APPROACH

41

Pathways redesignClinical Strategies

Energising for Excellence

High Impact ActionsSafety Express and

Safety Thermometer

Pathways redesignClinical Strategies

Energising for Excellence

High Impact ActionsSafety Express and

Safety Thermometer

External regulation PC performance

CQIN/ContractingManagement of SUIs

Gold CommandSafeguarding

External regulation PC performance

CQIN/ContractingManagement of SUIs

Gold CommandSafeguarding

Primary Care/CHOCCPFT

NCUHTUHMB

NHS Funded Care

Primary Care/CHOCCPFT

NCUHTUHMB

NHS Funded Care

Whole system innovation Service Delivery Performance

Management

5 Outcome measures

1.Helping people recover from episodes of ill health and injury;2.Preventing people dying prematurely;3.Enhancing the quality of life for people with Long Term Conditions;4.Treating and caring for people in a safe environment and protecting from avoidable harm;5.Ensuring people have a positive experience.

5 Outcome measures

1.Helping people recover from episodes of ill health and injury;2.Preventing people dying prematurely;3.Enhancing the quality of life for people with Long Term Conditions;4.Treating and caring for people in a safe environment and protecting from avoidable harm;5.Ensuring people have a positive experience.

Every effort is made to ensure quality and safety is firmly embedded in all commissioned services. This function has remained the responsibility of the Cluster for 2011/12 however the CCG constructed and performance managed the CQIN contracts. During 2012/13 CCG will have full accountability for the quality agenda.

CLUSTER APPROACH

7. PERFORM

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We aspire to deliver high quality safe services whilst improving efficiency, performance and productivity. This vision will be supported by clear leadership for quality in the new NHS arrangement with patients at the heart of what we do and robust methods for delivering innovative solutions.

Patient and public experience is a key driver and will help shape commissioning and service provision. New techniques will be used to understand and act of patient wishes.

A whole system approach will be taken to make quality everyone’s business and there will be a “Quality Alliance” for Cumbria. Clear expectations will be outlines for al providers of healthcare.

Integrated governance arrangements will be in place and will underpin good quality outcomes.

“Scaling up” and “spread” techniques will be promoted and facilitated where necessary.

Workforce changes will be made explicit to ensure that individual clinicians have the right skills and competencies to deliver care outside hospital as well as supporting individuals to manage their LTC.

Systems will be in place to prevent harm, learn lessons and ensure clear board reporting. The Cluster is developing an assurance framework taking a 360 view. This allows safety programmes to be viewed alongside increasing efficiency by “scaling up” areas of innovation.

A proposal is currently being developed to support Cumbria Health Watch to become a strong body for surveillance of our health and care facilities. This work is complemented by ‘deep dives’ in to specific areas such as the care of older people.

The Quality Framework will focus on the five NHS outcomes and the CCG will embed this approach into their commissioning arrangements. Organisations will be held to account through robust contracts and performance measures for quality, safety and outcomes and financial incentives or penalties will be applied through CQIN.

42

SECTION 7: PERFORMANCE AND QUALITY: THE APPROACH OF THE CLINICAL COMMISSIONING GROUP

The CCG recognises the importance of ensuring quality and is developing its approach to quality, with a focus on clinical leadership and embedding quality in the commissioning and contracting process.

The CCG has committed to ensuring that its approach to contracting and quality concentrates on the following major areas:

Patient experience: both more effectively acting upon what patients tell them and strengthening their voice in service improvement and in targeting specific aspects of patients experience, such as personal dignity and communication;

Safety of clinical services: targeting areas of concern raised by external or local intelligence including proactive assurance of performance against national standards and ensuring that action from lessons learnt is taken effectively;

Good clinical practice: Ensuring that clinicians and services are systematically working to accepted good practice guidelines, and that there are good systems of clinical communication that are timely, accurate, relevant and systematic;

Agreed pathways of care: ensuring the effective adoption by primary, community and secondary care services of agreed care pathways in Cumbria, with care indicators that measure the quality of a whole pathway of care;

Commissioning intentions and implementing new models of service delivery.

In each area there will be a strong emphasis on integration of care between providers, primary, community and secondary, with the CCG recognising its responsibility as a partner to ensure that primary care works effectively as part of the health system. The CCG understands integration to mean the effective management of care for a patient between providers, requiring collaboration and communication.

From the patients perspective the CCG will ensure that the service they receive is coherent and of high quality across the health system. That requires individual NHS providers to provide good quality care, but it also requires collaboration between organisations and clinicians to make sure that the patient is the focus of how care is provided. Promoting and supporting that collaboration will be a key feature of the contracts with providers.

The approach will centre on:

Incorporating common indicators across individual Trusts, to support integrated working and improved communication;

Being actively led by clinicians;

Motivating staff and focusing on direct patient care, at team or ward level;

Including specific quality measures for children’s services in all contracts. During the next few years the CCG will develop alternative approaches to contracting that better support integrated working between primary, community and secondary care and place quality at the heart of the contracting process. In agreeing contracts for 2012/13 the CCG will to anticipate those developments by laying foundations for this changed approach. It will maximise the potential in existing contracting arrangements towards supporting its aims for quality.

The CCG regards contracting as a major lever, for both commissioners and providers, in driving attention to and improved performance in the quality of health and health care in Cumbria. It will use contracting as an integrated part of its commissioning processes to support the focus on quality. CQIN will be agreed in 2012/13 and beyond as an incentive to improve performance. This may be performance beyond that nationally mandated or in areas of specific local concern. CQIN will not be used to incentivise practice or performance which would normally be expected to be delivered as part of the national NHS contract. In line with national guidance, targets previously incorporated within local CQIN schemes will be incorporated within the main contract, with CQIN focusing on new areas of improvement or higher levels of performance in areas that remain a priority.

The Clinical Commissioning Group is developing its approach to delivering quality with a key focus on clinical leadership, embedding quality in the commissioning and contracting process and the integration of care between providers across the primary, community and secondary care sectors.

7. PERFORM

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SECTION 7: PERFORMANCE AND QUALITY: THE APPROACH OF THE CLINICAL COMMISSIONING GROUP (cont.)

The CCG will work supportively with its NHS provider partners to ensure that they have a small number of high priority areas that remain at the top of their agenda, and drive the overall approach to quality care. These will be common to all contracts.

Service Reviews: • Each Trust will be required to undertake two service reviews per

year. These reviews will be in areas highlighted through shared understanding of Hospital Mortality data (SHMI) and the NHS Atlas of Variation. The reviews will be against NICE or best practice guidelines with the review scope jointly agreed with Commissioners. Improvement plans, where required, will be jointly agreed between commissioners and providers and progress monitored through the Quality Contract Meetings.

• Each Trust will be required to report regularly on the outcome of lessons learnt from complaints, serious incidents and external service reviews, providing evidence of the effective implementation of lessons learnt or agreed action plans.

• Each Trust will participate, with primary care, in two shared clinical audits per annum. These will be across jointly agreed patient pathways and have jointly agreed development plans monitored through implementation.

• Each Trust will demonstrate effective collaboration across provider Trusts for the implementation of agreed models of care for Children’s Services.

In addition the contract is being used to incentivise the CCG’s commissioning intentions, as set out in the following section on developing services, by ensuring that performance measures and incentives are used effectively in each contract.

The CCG will ensure that the care that it pays for through its contracts is of good quality. Therefore the CCG will:

• Not pay a Trust for care carried out that is agreed locally or nationally as a ‘never’ event;

• Reduce the total contract payment to a Trust should the Trust be in receipt of an improvement notice from the CQC.

Clear expectations for performance and quality are embedded in the CCG’s relationship with its providers, with all quality and performance standards mapped against the NHS Outcome Framework, developed in collaboration wit the Cluster.

The CCG is developing its governance arrangements and its intelligence systems with clinical leadership, through forums such as Clinical Advisory Groups where clinical leaders from all Trusts address outcome, service quality and development issues in open discussion and work projects across Trusts.

The CCG’s six localities ensure clinician and patient feedback are as close to the patient as possible, with delegated authority to address local issues. This local intelligence, is brought together with information from a broad range of data sources ( lessons learnt, public health mortality and trend data, etc) to proactively identify quality issues for action at local, or countywide level.

Quality contracting meetings will be appropriately supported at Director level with clear communication between and within organisations.

Each quality component of the contract, individual targets and major areas of focus, will have a named clinical lead from the CCG and from the NHS Provider Trust. It is expected that this lead will be a Consultant, GP or Senior Clinical Professional at an equivalent level

7. PERFORM

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CONTRACTING FOR QUALITY IMPROVEMENT IN 2012/13

There are a significant number of improvement areas in the CQIN and other contract schedules which will drive quality improvements in our providers. Examples linked to other elements of the Plan are shown in the tables below. These cover delivery of transformational initiatives, targets for improving quality in under performing areas and delivery of operating framework priorities.

Transformational Priority Target

Delivery of emergency floor model

Q1 integrated governance systems in place; Q2: improved performance in LOS, length of stay, A&E lodging; Q3.&4 reduction of admissions, targeted against individual pathways against 11/12 performance (as set out in detailed business case)

Frail older people model for elderly care

10% reduction in unscheduled admissions from residential care homes to acute trusts during the day, Monday to Friday

Evidence based referrals Compliance with evidence based referrals thresholds and clinical criteria (assessed through clinical audit)

Performance and quality issues Target

Clinical communication: discharge letters

Discharge Letters to be sent 24 hours post discharge & of appropriate quality The provider will be penalised £50k Q1, £100k Q2, £250k Q3&4 if the quality of the discharge letters is not up to standard

Quality issues in UHMBFT CQIN payments dependant upon detailed improvement and action plans implemented and CQC assurance achieved as per agreed programme plans

HCAIs Stretch targets for MRSA/CdIff

Operating Framework area Target

Reduce anti-psychotic prescribing

Reduction of 15% (609) patients in use of anti-pyschotics by patients on primary care dementia registers

Dementia Dementia screening for all patients aged 75 and overall inpatient services ( acute, mental health, community)

Care of the elderly During 2012/13 there will be no more than 365 falls which cause harm in community settings across Cumbria. (This is a further stretch of 15% against 2011/12)

SECTION 7: PERFORMANCE AND QUALITY – CQIN TARGETS

44

7. PERFORM

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45

SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES

CANCER SERVICES LONG TERM CONDITIONSCancer is the second greatest cause of death in Cumbria and although overall incidence rates are lower than the national average, mortality rates are higher. The five-year survival rate is 46.9%, which is considerably lower than the regional and national average.

The Cumbria Cancer strategy, produced in 2010 aims to reduce the number of deaths from cancer, the number of premature deaths and the variation in death rates across the county.

In 2011, an external review of cancer services was undertaken, which built on the strategy and enabled the identification of key priority areas for Cumbria:

• Improve early presentation with cancer symptoms, by educating the public, public health campaigns, exploration of incentives in primary care and engaging GPs in the early diagnosis agenda;

• Improve early diagnosis by improved GP response and consistent access across the county to diagnostics to exclude possibility of cancer e.g. ultrasound, CT, MRI;

• Improved screening, increased ownership in primary care of the take up of breast & bowel screening, follow up of patients who do not attend and use of incentives e.g. through a LES;

• Primary care education e.g. by practices undertaking the RCGP audit, develop education programme with secondary care colleagues;

• Information and data at practice level e.g. on screening targets, use of 2 week waits, routes to cancer diagnosis;

• Appoint clinical leads in each locality;• Develop world class oncology for Furness; and• Follow up support with community/practice nurse for

cancer survivors and palliative care patients.The Cluster can confirm that there is sufficient capacity available to manage the anticipated increased demand resulting from the national Bowel Screening Programme.The CCG is refreshing the strategy for 2012/13 to ensure it is focused on the right areas and to invigorate these services for patients.

The number of people, in Cumbria, with one or more Long Term Conditions (LTC) is set to increase rapidly over the next 20 years in line with a rapidly ageing population. The current system for managing LTCs does not equip individuals to make informed decisions about their own health needs and be in control of their lives.

The vision for LTCs in Cumbria is of a whole system approach that improves the lives of people with one or more long term condition. The patient will be the key decision maker and will be equipped to take control of their own healthcare. The vision addresses the health care needs of the population alongside the individual needs of all patients living with or at risk of a LTC. Service delivery will be centred on GP led care that is wrapped around the needs of individual patients and population.

The emerging model describes multi-disciplinary teams that will be organised to reflect local needs and local characteristics. The multi-disciplinary teams will be organised to deliver care based on the needs of those patients who can walk in to receive their care and those who can’t. Care will be supported by specialist teams mapped to areas of need. Use of telehealth and telecare will be considered to enhance the model.

NHS Cumbria recognises that whilst Primary Care and Community Services have a key role to play in the delivery of an effective system all providers, including Social Care and the 3rd sector, will need to work in a different way. We are therefore working with partners to develop a framework and model that makes things better for both patients and staff who deliver care to everyone with a LTC. When agreed, the implementation of the model and performance monitoring will be overseen by the existing North and imminent South Cumbria Integrated Systems Boards.

7. PERFORM

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SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)

MENTAL WELLBEING SERVICES

In line with England’s Mental Health Strategy, No Health without Mental Health, Cumbria launched in October 2011 its own Strategic Framework, Working Together for Wellbeing and Mental health 2011-14. Informed by the national strategy and a mental health joint strategic needs assessment (JSNA), and co-produced through a programme of engagement, it sets out both to improve mental health and wellbeing of people in Cumbria and to improve outcomes for people with mental health problems through high quality, community oriented, services that are equally accessible for all. It identifies the following key outcomes to ensure more people recover sooner from mental health problems:

• More mental health problems are identified and treated early in the community;

• People with mental health problems have better physical health and live longer;

• High quality, recovery focused specialist services are available to all when needed; and

• Citizens, service users and carers are fully engaged and empowered and more people have a positive experience of care and support.

The JSNA has highlighted concerns about the high levels of alcohol related hospital admissions and suicides in Cumbria, and about the quality and capacity of the CAMHS service. A multi agency Cumbria Mental Health Partnership Board, co chaired by adult social care and a person who has personal experience of mental illness, has been set up to assure delivery of the Strategic Framework. This Board reports to the Mental Health Commissioning Steering Group and the Cumbria Joint Commissioning Group, then through these into the Health and Wellbeing Board.

Within this context, priorities for 2012-13 for NHS Cumbria are:

• Continued focus on improving access to psychological therapies, particularly for people with long term conditions;

• Continued improvements in physical healthcare of people with mental health problems, supported through CQUIN targets;

• Development of mental health PbR in a shadow year, for implementation in 2013/14, linked to domains and improved pathways of care; this will also allow the development of more and better community service alternatives alongside preventative models of care;

• Whole system reviews of:o Rehabilitation and recovery pathway;o The effective use of the Psychiatric Intensive Care Unit

to ensure all PICU activity is managed within county;o Child and Adolescent Mental Health Services, to

include review of targeted support for children and young people at particular risk of developing mental health problems, such as looked after children;

• Continued repatriation of out of county placements for treatment in Cumbria;

• Improved substance and alcohol misuse services through a market testing exercise undertaken in collaboration with the Cumbria DAAT; and

• Support to deliver the Cumbria suicide prevention strategy.

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ELECTIVE CARE

NHS Cumbria has delivered significant change in recent years in the commissioning of planned care and is now in the top quartile of performance in the North. However the CCG believes that there are further opportunities both to deliver care in non secondary care settings and to ensure the appropriateness of referrals.

Service TransfersFollowing a procurement process, optometrist-led ophthalmic follow ups will be available, together with Low Vision triage services. Both of these will contribute to easing the significant capacity issues in this specialty in the north of the County.

Evidence Based ReferralsAlthough NHS Cumbria already has an EBR policy in place, this is being extended and strengthened for 2012/13 with IT led decision support through GP clinical systems to aid effective referral management. In addition compliance with EBR protocols is being negotiated into acute contracts.

Repatriation of ServicesCommissioners will be working with providers to ensure that patient choice is available locally for all secondary care services which can be safely and appropriately provided in local hospitals and that these are correctly applied through Choose and Book and associated service directories.

Earlier Discharge Commissioners and providers are developing business cases to determine the viability of earlier discharge into the community for selected procedures (e.g. Joints).

Any Qualified ProviderNHS Cumbria is committed to offering three services to AQP from the national directory. These will be community continence, community diagnostics and primary care psychological therapies.

The CCG is commissioning a new model of emergency care in north Cumbria which is outcomes focused and performs against a set of measurable service aims. All providers of health care are integrating emergency and urgent care services to improve the experience for patients whilst achieving greater efficiency and use of resources.

Adopting a whole systems approach to managing urgent care demand has become a priority as the trend for urgent care is rising at national level and within Cumbria there are pockets of patients who are more likely to experience an admission to hospital than others.

The new ‘Integrated Emergency Floor’ based on each acute hospital site will:• Be clinically led and collaborative;• Deliver a single point of access into urgent care services, including

‘out of hours’ services;• Clinically triage patients into a primary care & community minor

illness/injury pathway and a more serious acute pathway of care;• Case manage patients through emergency care and improve

discharge; and • Divert inappropriate admissions from secondary care.

Whilst the model for emergency and urgent care changes, ambulatory pathways of care are being implemented for a range of conditions with the intention to manage patients with chronic conditions or acute exacerbation in a more efficient and effective way.

A systematic high quality Integrated Emergency care service will be in place by April 2013 with the aim of reducing admission to hospital for some conditions, focussing resources on the most effective treatment for patients and removing organisational boundaries that cause patients to experience a higher rate of admission than may be acceptable.

EMERGENCY CARE

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Cumbria is below trajectory for both MRSA Bacteraemias andClostridium difficile infections. There is a Cumbria wide approach to dealing with these infections with close cooperation between primary care, secondary care and commissioners. We have worked with providers and the Health Protection Agency to comply with the mandatory reporting for meticillin sensitive staphylococcus aureus (MSSA) and E.coIi bloodstream infections.

Preventive activity will continue to focus on high impact interventions of known efficacy, such as hygiene and appropriate use and care of lines and catheters. We will be assured of sustained, reduced rates of Clostridium Difficile associated diarrhoea and MRSA bacteraemias across the health economy via the Provider Assurance Framework. Specific initiatives that we plan to progress in the Cluster this year include:

• Ribotype initiative;• Clostridium difficile testing flowchart; and• Root cause analysis review

The above initiatives will be progressed through the Cumbria Infection Prevention Steering Group. There are already effective County wide networks which will be used to implement the protection and prevention initiatives outlined above. MRSA targets will be included in contracts and the framework outline above will deal with underperformance.

We will continue to use the HCAI assurance frameworks as evidence that all relevant actions are being taken and that compliance with the Health and Social Care Act and national guidance is delivering significant improvements for patients.

48


HEALTHCARE ASSOCIATED INFECTIONSNHS 111

The CCG has played an active part in the development of the 111 project in the North West and is committed to the regional procurement process.

The CCG has elected to seek a ‘sub-regional’ footprint for provision of 111 telephony as it believes local knowledge and content are vital to the success of the project. A full and functioning directory of services has been compiled for the county.

The CCG has made clear that 111 is an integral part of improving primary care and community services. The CCG’s expressed wish is to create a single point of access (SPoA) for Cumbria with 111 as the front end public number for a range of non urgent clinical services.

A specification is being drawn up to supplement the regional procurement process. This specification will require providers to demonstrate that they will deliver not only non urgent call handling but also develop services such as:

• Out of Hours services;• Long term condition advice; • Specialist nurse services; • Social services advice and contact; and • Booking services for patient transport, dentistry etc.

This list is not exclusive and the CCG will be seeking partners who can add the greatest value to enriching primary care and community services.

This service will be fully functional by the start of the 2013/14 financial year.

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STROKE SERVICES

The Cluster has highlighted difficulties associated with the delivery of stroke targets in 2011/12 predominantly as a result of the issues faced by UHMBFT. Whilst performance at NCUHT is close to achieving the 80% on a consistent basis, the variable performance at UHMBFT means that the Cluster will struggle to attain the target across Cumbria by 31st March 2012. This is despite recent improvement in Q3 where the 80% target was achieved by UHMBFT in two months out of the three.

Overall, there is still concern about the ability of UHMBFT to achieve longer term sustainable performance. This is a view shared by North Lancashire Cluster.

To address the current issues, the Royal College of Physicians was invited by the Lancashire Stroke and Cardiac Network to undertake a peer review.

The informal outcome of the peer review highlights significant concerns:

• Lack of ownership across the whole pathway; • Lack of responsibility across the organisation at all levels; • Key relationships are not working;• Pathways are haphazard and fragmented;• Lack of co-ordinated approach;• No proper setting of targets or effective action planning; and• Multiple disconnections in the layers of the organisation.

The review concluded that current stroke unit cannot provide safe and effective care for neurological emergencies and is probably 15-20 years behind current best practice for Stroke care. There needs to be:

• Rigorous, robust ownership and accountability at all levels;• Review of Clinical leadership with support for development of

key roles;• A full review of what can be delivered on the RLI site;• Revision of the whole pathway - thinking about the whole

service differently; and• A Stroke champion at Board level.

Recommendations from the review:

• Thrombolysis: The Coronary Care Unit does not have the facets required for hyper acute stroke care. A process mapping exercise needs to be undertaken once again. In the interim the organisation needs to decide on where to locate circa 6 beds where it will be possible to deliver appropriate hyper-acute stroke care on a 24/7 basis. For thrombolysed patients there will be a requirement for monitoring; other patients with more severe strokes will be sicker and need to be properly and safely managed and this would help to reduce current mortality rates.

• Early Supported Discharge: pursue plans to develop this.

• Commit to engage positively with the Cardiac & Stroke Network.

The above recommendations will be built into the 2012/13 contract with the Trust, along with a requirement for a recovery plan that addresses the Peer Review concerns.

It is apparent that there is a need for a fundamental overhaul of stroke services, which may mean that achievement of performance targets continues to be variable in the south of Cumbria in the coming year.

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HEALTH CHECKS

The Stop Smoking Service (SSS) was transferred to the Cumbria Partnership NHS Foundation Trust in April 2011. Important developments have resulted in improved patient experience:

• The introduction of a central telephone booking system has enable patients to be offered immediate appointments;

• Patients can access immediate support via a telephone consultation called ‘Direct Quit’; and

• The development of an online database via EMIS web, which allows for immediate access to patient notes and also paperless working.

Some difficulties have been experienced in producing documentation for the Department of Health return, which is being addressed.

Advocacy work and campaigns have been delivered addressing the accessibility and visibility of tobacco products by children:

• The removal of vending machines and point of sale displays;• Smoke free environments for children – in homes and cars; and• Raising awareness of illicit tobacco.

There is growing support amongst Authorities in Cumbria to introduce a voluntary ban on smoking in children’s play areas. Women who smoke during pregnancy are being rewarded for not smoking as part of a North West program to reduce the Smoking at Time of Delivery (SATOD) target. Evaluation by Stirling Universityshows that the program results in fewer women smoking throughout their pregnancy.

A program to identify those at risk of undiagnosed COPD targets customers at two pharmacies and the local Stop Smoking Services. Customers are offered the chance to be tested, with results being forwarded to their GP.

SMOKING QUITTERS

Between 2010 and 2012 NHS Cumbria piloted a primary care based Health Check programme within one locality in Cumbria. This targeted hard to reach individuals. Clinical audit within one participating practice suggested that the programme has been successful in identifying and engaging patients with previously undiagnosed vascular conditions. A specification for a primary care Local Enhanced Serviced (LES) has been developed which will roll out within all localitiesduring 2012/13. The specification meets the full requirements of theNHS Health Check programme and will use the national dataset to record findings. Practices will be encouraged to prioritise hard to reach and high risk individuals and will be supported by the Department of PublicHealth and primary care information systems to enable them to do this. Once the primary care programme is established, the Department of Public Health will also commission social marketing activity to promote further uptake in more deprived communities. This will build upon the lessons learned from the recent successful‘cough, cough’ Lung Cancer campaign which utilised a mix of professional engagement, media and community partnership approaches to increase patient ‘push’ factors as well as service ‘pull’ factors. The department of Public Health is also currently developing a Health at Work programme with major employers in the county and will be exploring the potential for implementing NHS Health Checks in workplace settings.

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DEMENTIA SERVICESFRAIL ELDERLY SERVICESThe CCG is developing a new service model for frail older people. Frailty is difficult to define with specificity, and is experienced by different people at different ages. Key features of the service model include:

• Clinical leadership from a lead Consultant Geriatrician;• Assessment and Care Planning around the individual and

their family, rather than around a presenting condition; and• Integrated Care, across physical and mental health needs,

across Primary and Secondary Care, and as far as possible across health, social care and the third sector.

The model will:

• Support the pro-active management of the frail elderly including those resident in nursing and residential homes;

• Provide rapid assessment for those experiencing acute illness or deterioration;

• Radically change hospital discharge and continuity of care;• Improve the end of life pathway, using GSF / Liverpool care

standards; and• Provide a specific focus on dementia co-morbidities.

The model will enable improved outcomes including:• Reduce avoidable hospital admissions, including from

residential/nursing homes and from patients at high risk of admission;

• Reduce hospital LOS, including a reduction in LOS for patients with a dementia co-morbidity;

• Reduce inappropriate medication; and• Reduce morbidity (specific metrics, e.g. reduction in

fractured neck of femur). The patient stories collected by each of Cumbria’s three NHS Trusts will heavily inform the development of the service.

NHS Cumbria is working with Cumbria County Council Adult and Community Services and other partners to deliver the Cumbria Dementia Strategy. Implementation of the dementia strategy and improvement of care environments have been identified as priorities for the investment of resources transferred to the local authority. NHS Cumbria is leading the following work streams of the action plan:

• Prevention and public health; • Integrated care pathways, including early diagnosis, reducing

prescribing of antipsychotics, end of life care, and care in care homes; and

• Inpatient care. Antipsychotic prescribing has been audited in primary care and in specialist dementia services. Findings of the primary care audit and advice and information on alternatives to prescribing have been sent to all Cumbria practices. Findings of the specialist audit are also being implemented. Repeat audits are to take place later in 2012. A CQUIN target for reduced antipsychotic prescribing has been set. The Acute Trusts in Cumbria are implementing the findings of the national audit of dementia care in hospitals and will be compliant with relevant NICE quality standards, with information published in quality accounts. The new mental health liaison service will support delivery of the national CQUIN to improve diagnosis of dementia in hospitals. A specification for dementia advisors has been developed jointly by health and social care, and is to be piloted across Cumbria. Cumbria CCG is reviewing care pathways and service specifications for dementia with a strong locality focus.

Cumbria CC will invest £1.9 million in the dementia strategy over the next 2 years from NHS funds, with the CCG investing a further £0.6m in 2012/13 in dementia services. The CCG funding of £0.9 million for demographic issues in 2011/12 in CPFT has been mainly focused on dementia services.

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CHILDREN’S SERVICES

We aim to commission integrated (acute, community and mental health) children’s services fit for purpose in the 21st century in partnership with Cumbria County Council’s children’s services. The strategy is aligned to Cumbria Children’s Trust Board’s vision:

• No avoidable child deaths;• No children living in poverty;• All children to be ready for school at five years of age; and • Young people ready to be proactive and productive citizens.

To deliver this, we have embarked on a programme of change in conjunction with our service providers. This includes an integrated pathway development for key conditions in childhood e.g. urgent care, constipation, fever, acute respiratory, emotional wellbeing, ADHD, ASD and reflects services being delivered Closer to Home for children and their families. This will also address and improve the health outcomes for children and young people in Cumbria. At present, these outcomes are described as ‘average’ but they hide large inequalities which exist across the county. The urgent care pathway will streamline care for children so the right care is available to children at the right time and in the right place by a workforce with the right skills. This should reduce the number of children admitted to hospital and facilitate children being treated Closer to Home. The constipation pathway which was implemented in August 2011 in Furness has had an impact on reducing admissions to hospital and is now being implemented in all Localities with support from the Locality Boards.

In the West, in conjunction with the plans for a new West Cumberland Hospital, the implementation of the urgent care pathway provides an opportunity to ensure that an appropriate model of care will be developed to meet the needs of children and to avoid unnecessary admissions to the hospital. We have agreed with our providers the principle of an integrated emergency floor model with paediatrics which will provide timely senior paediatric assessment and opinion. This will undoubtedly improve the safety and the quality of service including safeguarding. This approach will streamline resources which would be more appropriately used in the community.

In addition, the paediatric consultant workforce will undertake more outreach clinical work and will also provide education, training, and support to primary care and multidisciplinary teams. Health Builders for Children and Young People- an approach to delivering innovative healthcare- was formed in 2010 as a consortium of health care providers in Cumbria, led by a senior paediatrician. This in initiative is supported by a group called The Village Elders, which includes parents, members of the Children’s Trust Board, the Local Authority, representatives from the voluntary sector, General Practice, Lancaster University, a Public Engagement Lead and our four Health Trusts (NHS Cumbria PCT, UHMBFT, NCUHT, CPFT. This has paved the way for the development of a new children and young people’s service in Cumbria. This approach will support families and their communities to become the healthiest children, adults and parents of the future. This initiative is a response to concerns and feedback from the users and the staff about current services (and confirmed in Dr Andy Mitchell’s report, Review of Children’s Services, Cumbria PCT, Feb 2009 and the publication of the National Child Health Strategy- Healthier Lives, Brighter Futures). The National Strategy outlines a vision of continuous improvement in the quality of children’s services and an ambition of making England the best place for children to grow up. The Health Builder foundation stones- equity, access, prevention (includes early intervention and prevention and health promotion) and experience of service form the basis of their pathway development.

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SECTION 7: PERFORMANCE AND QUALITY: DEVELOPING SERVICES (CONT.)CARERS

Budget 2011/12

£’000

Recurrent Budget£’000

North Cumbria 214 305

South Cumbria 136 195

TOTAL 350 500

During 2011/12 NHS Cumbria agreed recurrent funding for carerorganisations in each local authority area, in consultation with CumbriaCounty Council. Carer organisations submitted plans for how the money would be used in each area in line with the Carers Strategy. The recurrent funding levels which will be provided are set out below.

The detail of services that are being developed are:• Carer support workers being funded with a focus on

supporting primary care to identify carers and refer for assessment of needs;

• Increase in services available to support carers through the carer organisations; and

• Funds in each locality to support short break opportunities.

Some localities have supported this work with a LES for Primary Care to encourage GPs to identify carers and assess health needs in light of their caring roles. Further money has been requested through the transfer of money to ASC to support awareness raising training to be delivered in each practice across the county. A decision about these funds is awaited.

Roll out of Personal Health Budget work has begun already in conjunction with Adult Social Care to support those moving from joint packages of care to fully funded healthcare to continue in packages they have established. Where direct payments have been used from ASC, brokerage arrangements are put in place to ensure continuity of packages. These have been in place for some time.

Learning from the ASC In Control programme is being shared and a funded post to support development of personalisation in healthcare is in place through the ASC money for health outcomes. This post will focus on all health funded packages including CHC, mental health and children’s packages. Locally we are linking with work across the North West to share learning and develop systems to support personalisation.

Performance is led by localities via their contracts with the carers organisation. Quarterly reports to the localities include:

• Overall number of new referrals during the month from a Primary care source;

• Breakdown of number of referrals in the three months from individual GP Practices; and

• Number of:o referrals that have led to a full carers assessment;o support groups provided for young carers across the

range of intervention;o young Carers receiving trips and number of Young

Carers attending support groups;o carers receiving relaxation treatments and number

of treatments delivered;o carers receiving a sit and number of sits delivered;o carers receiving domestic support or other break

and number delivered; o moving and handling training sessions delivered.

Developments in South Lakeland, which operates the same broad agreement as in the rest of the county, include an additional 500 individual short breaks per year for carers, including up to 5 relaxation treatments for 80 different carers and up to 4 sits for 50 different carers; a sitting service to provide a volunteer for up to 3 hours; a requirement to complete 100 carers’ assessments per year; moving and handling training for 50 carers on a one to one basis. Carers will have access to flexible grants which will allow them to spend up to £300 on a break.

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HEALTH VISITORS AND FAMILY NURSE PARTNERSHIPS

The Cumbria target for Health Visitor establishment is 98 and the Cluster is on track to deliver against the trajectory.

The 2011/12 target is to have 78 Health Visitors in post by 31 March 12. The actual position in January 2012 is 74 Health Visitors in post. The projected year end position is 76.

The target for 2012/13 is an additional 7.8 Health Visitors. There are currently 8 Health Visitors undergoing training with a total of 41 by 2014. It is expected that the target will be met for 2012/13.

The Health Visiting Project Board oversees and monitors the implementation of the new service model, quality of provision and future workforce configuration. Members of the group include NHS Cumbria Cluster and CCG, Public Health, Safeguarding, Workforce Development, GP provider and commissioner.

Health Visitor Trajectories

11/12 12/13 13/14 14/15 15/16

Establishment target 76.1 78.4 86.2 92.9 98.5

Additional posts needed in year 2.3 7.8 6.7 5.6 0

END OF LIFE SERVICES

The population of older people in Cumbria is predicted to rise significantly over the next 20 years and by 2029 over 28% of the population will be over 65. By 2031 it is estimated that over 5% will be aged 85 or over, therefore the CCG is is cognisant of the impact this will have on end of life care services.

The vision for end of life care in Cumbria is one that supports people with advanced or progressive incurable illness to live as well as possible until they die. This means providing people and their carers with an opportunity to make choices about their priorities for care and ensure that as far as possible they are treated with dignity, respect and the appropriate levels of care in all care settings.

The Cumbria End of life multi-agency workstream is developing the ‘Cumbria Deciding Right’whole system approach to the delivery of end of life care that supports:

• Early identification of patients and coding in line with the North West End of Life care model;

• Advanced Care Planning using the end of life planning tools – Gold Standards Framework Preferred Priorities of Care and Liverpool Care Pathway;

• Delivery of information to support the patient and their family/carers;

• Timely and appropriate use of ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNA CPR); and

• Support through bereavement.

This will deliver greater quality for patients and carers as well as improved performance for all providers. To achieve this we need to complete the programmes of county wide DNA CPR; achieve electronic connectivity across all palliative care settings; design an education framework to identify the core competencies required across health and social care settings and manage providers to make the change.

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PRIMARY CARE SERVICES

Primary Care services have significant importance in ensuring that the Cumbria health system achieves its commissioning intentions. Its development as an integral and integrated part of the health system in Cumbria is regarded as a key enabler to achieve the performance and quality objectives of the CCG. A strategy is being put together which covers how primary care will continue to develop as part of the healthcare system and this will address health improvement, patient experience and new models of care delivery. That strategy will need to address capacity issues, in particular in the urban areas and west coast localities, particularly in Barrow. These are the communities which have the poorest health of all Cumbrians.

The development of the strategy is an important objective for the CCG during the first quarter of 2012/13. It is important that primary care increases its effective capacity, works consistently to high standards, ensures the efficient use of resources and develops new models of integrated working across the primary, community and secondary care sectors. During 2012/13 the CCG will focus on the following key issues:

• Increasing primary care capacity in Barrow;• Supporting the primary care workforce: increase in capacity,

skills development and mentoring;• A primary care led approach to CVD healthchecks;• Increasing efficiency and developing shared support systems

across GP practices through the Productive Primary Care programme;

• Development of the Year of Care model for Long Term Conditions; and

• Locality based primary and community care teams, with local area services e.g. for frail elderly care, and care of the elderly physicians working as part of multi disciplinary teams with primary care practitioners.

IMPLEMENTING THE INNOVATION REVIEW

The Cluster is currently working towards implementation of the Innovation Review and the six High Impact Innovations. Many innovations have already been adopted across Cumbria through delivery of evidence based clinical pathways.

GPs have been using Map of Medicine to ensure referrals are made at the right time and to the right clinician.

Safer care programmes have been implemented in all provider organisations.

The Year of Care Programme is about to be launched by the CCG and builds on the national pilots.

We want to ensure all patients receive the best possible clinical care and aim to systematically ensure that all providers deliver care in line with the Right Care Atlas of Variation.

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SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Preventing people from dying prematurely

xxxxxxxxx xxxxxxIn January the Cluster underachieved on one cancer target however there has been overall performance improvement and full compliance should be achieved by year end with ongoing delivery against targets during 2012/13.

Measure Definition 12/13 T’hold

Jan 11(YTD)

11/12 Year End

April 2012

12/13 Year end

Operational Plans to secure performance

PHQ 01 Ambulance quality - Cat A response times

Cat A response within 8 mins 75% 76.5% >75% >75% >75%

PHQ 02 Cat A response within 19 mins 95% 95.8% >95% >95% >95%

PHQ 03

Cancer 62 day waits

Percentage of patients receiving first definitive treatment for cancer within 62-days of an urgent GP referral for suspected cancer

85% 84.7% >85% >85% >85%Improved performance and anticipate full achievement by year end

PHQ 04

Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service

90% 96.7% >90% >90% >90%

PHQ 05

Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status

85% 93.8% >85% >85% >85%

PHQ 06

Cancer 31 day waits

Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis

96% 96.7% >96% >96% >96%Improved performance and anticipate full achievement by year end

PHQ 07Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is Surgery

94% 96.8% >94% >94% >94%

PHQ 08

Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is an Anti-Cancer Drug Regime

98% 98.6% >98% >98% >98%

PHQ 09

Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is a Radiotherapy Treatment Course

94% 95.6% >94% >94% >94%

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SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Enhancing quality of life for people with long-term conditions7. PERFO

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Measure Definition 12/13 T’hold

Dec 11 (YTD)

11/12 Year End

12/13 Year End


PHQ 10 Mental health measures - EIThe number of new cases of psychosis served by early intervention teams year to date

- 95126

(target: 195)

195

PHQ 11 Mental health measures - CR/HT

Commissioner measure is number of episodes, provider measure is % of inpatient admissions that have been gate kept by CR/HT

- 165 169 169

PHQ 12 Mental health measures - CPA

The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the quarter (QA).

95% 96.1% >95% >95%

PHQ 13 Mental health measures - IAPT

Proportion of people with depression who receive psychological therapy

- 10.8% 13.5% 13.5%

Proportion of people who complete therapy who are moving to recovery - 43.4% 45% 48.5%

PHQ 14

People with Long Term Conditions feeling independent and in control of their condition

% of people with LTCs who said they had had enough support from local services/orgs

- 87.4%* >82% >82.7%

* Sep 11 data only

PHQ 15Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

Proportion of unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) per 100,000 population

- TBC TBC TBC

It is expected that there should be a reduction in admission rates. This is a new indicator for 12/13 and no guidance on specific targets has yet been issued.

PHQ 16Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Proportion of unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s per 100,000 population

- TBC TBC TBC

It is expected that there should be a reduction in admission rates. This is a new indicator for 12/13 and no guidance on specific targets has yet been issued.

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SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Helping people to recover from episodes of ill health or following injury

Measure Definition T’hold Latest data

Mar2012

April 2012

Mar2013


PHQ 17 Emergency Admissions Emergency admissions for acute conditions that should not usually require hospital admission

TBC TBC TBC TBC This target is aligned with commissioning intentions and contract values. It is expected that there should be a reduction in admission rates. This is a new indicator for 12/13 and no guidance on specific targets has yet been issued.

There has been a year on year reduction in acute emergency admissions. Although the trajectory has yet to be defined delivery of the indicators is aligned with commissioning intentions.

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SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Ensuring that people have a positive experience of care

Measure Definition T’hold Jan 11 YTD

11/12 Year End

April 2012

12/13 Year End


PHQ 18 Patient experience survey

Outliers identified using NHS PF approach + narrative & results of local surveys

PHQ 19

RTT waits

RTT - admitted % within 18 weeks 90% 87.5% <90% >90% >90%Resolution of incomplete pathways will result in underachievement of admitted pathway at NCUHT until May 2012. However there will be full compliance from June 2012.PHQ 20 RTT - non-admitted % within 18

weeks95% 96.3% <95% >95% >95%

PHQ 21 RTT - incomplete % within 18 weeks 92% 89.8% <92% >92% >92%

PHQ 22 Diagnostic Waits % waiting 6 weeks or more <1% 0%* <1% <1% <1%

PHQ 23 A&E% of patients who spent 4 hours or less in A&E

95% 96.7%* >95% >95% >95%

PHQ 24

Cancer 2 week waits

Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer

93% 94.7% >93% >93% >93%

PHQ 25Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer is not initially suspected

93% 93.9% >93% >93% >93%

PHQ 26MSA breaches Numbers of unjustified breaches minimal 74* 99 Minimal Minimal

There will be a dip in RTT performance during Q4 2011/12 however full compliance will be achieved from April 2012 onwards.

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SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Treating and caring for people in a safe environment and protecting them from avoidable harm

Measure Definition T’hold Jan 11 YTD

11/12 Year End

12/13 Year End


PHQ 27HCAI measure(MRSA & CDI)

MRSA bacteraemia-

8 <12 7

PHQ 28 CDI 200 <243 190

PHQ 29 VTE Risk assessment% of all adult inpatients who have had a VTE risk assessment

- 92.5*% >90% TBC

Although no plans are required and no specific standards have been set nationally, it is expected that performance against this indicator improves.

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SECTION 7: PERFORMANCE AND QUALITY: PERFORMANCE MEASURES - Public Health

Measure Definition T’hold Dec 11 YTD

11/12 Year End

12/13 Year End


PHQ 30 Smoking QuittersNumber of 4 week smoking quitters that have attended NHS Stop Smoking Services

- 2083* 3520 3807

PHQ 31 Coverage of NHS Health Checks

% people ages 40-74 who have been offered an NHS health check

- 0.34% 0.5% 20%Resource constraints has precluded delivery in 2011/12. Resources are in place for 2012/13 and commissioning arrangements with primary care for the following two years are being finalised. % people ages 40-74 who have received an

NHS health check - 0.34% 0.5% 13%

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SECTION 7: PERFORMANCE AND QUALITY: INEQUALITIES AND MORTALITY

Life expectancy varies across Cumbria., and on average is slightly below the national average rate. Mortality rates in Cumbria are high and action is being taken to improve health outcomes across a range of high prevalence clinical conditions.

Causes of deaths in major disease categories in Cumbria, January 2010 to December 2010

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Cumbria is a county of contrasts with major differences in health outcomes across the county. As a whole, Cumbria outcomes are similar to the national average across a range of health measures. However, there are marked differences between good health outcomes in South Lakeland, Eden and much of Allerdale compared to poor health outcomes across the board in Barrow, Copeland and Carlisle.

Health inequalities is linked to deprivation. There are significant levels of deprivation in Barrow (which is the second most deprived shire district in England), parts of Carlisle and West Cumbria, as well as pockets of deprivation in rural parts of the County (Carlisle and Barrow were designated Spearhead areas i.e. in the fifth of areas nationally with the worst health and deprivation indicators). Around 16% of our population (95,000 people) live in the bottom fifth of the most deprived wards in England. Around 55,000 people in Cumbria live in wards which are ranked amongst the most affluent 20% of wards nationally.

The main causes of mortality in Cumbria are cancer and circulatory disease, with 34.7% all of deaths being associated with cancer and 22.4% with circulatory disease. Overall, average life expectancy in Cumbria for both males and females is slightly less than the national figure. But the average raises issues in particular areas and four out of the six districts in Cumbria have a lower life expectancy than the England and Wales average, with only Eden and South Lakeland having a higher life expectancy. The most recent life expectancy data shows that female life expectancy has decreased in Cumbria, acting to widen the gap between Cumbria and the national average, but the average masks issues in particular areas.

Male life expectancy varies by 2.4 years between people living in Barrow-in-Furness (77.1) and Eden (79.5). This contrast is even starker at ward level where there is nearly a 20-year gap in life expectancy between people living in Moss Bay in Workington and Greystoke in Eden.

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The standardised mortality figures demonstrate high mortality rates in both UHMBFT and NCUHT. The areas of concern reside in the high prevalence conditions including stroke, ischaemic heart disease, upper gastrointestinal bleed, and respiratory conditions. Cancer survivals are also poor, especially for respiratory and colorectal tumours.

The CCG and Cluster is actively working with both Trusts to improve performance. Examples are enabling service redesign to ensure consultant led acute services 7 days a week to counter the increased risk at weekends and overnight. Improved clinical pathways will ensure prompt assessment of acute illness within Trusts and the community.

Life expectancy at birth gap between the England and Wales average and local authorities in Cumbria. (2007-2009)

SHMI HSMRDeaths in Low-Risk

Conditions

Deaths after

Surgery

UHMBFT 114 124 1.01 127

NCUHT 112 118 0.53 163

Stroke care in north Cumbria has improved but changes are necessary in south Cumbria to establish an effective stroke unit. This work is underway.

The mortality data will form an important part of the discussions within the commissioning and contracting processes, especially around 'contracting for quality', both through the CQUIN process and in shaping the commissioning intentions of the CCG. It will also be a fundamental feature of the development of a clinical strategy for Morecambe Bay (P17)

Particular emphasis will be placed on the necessary expertise being in the right place at the right time, so that experienced clinicians are positioned to effect the best outcomes. Both trusts will need to reduce their reliance on locum clinicians and junior medical staff.

IMPACT ON HEALTH INEQUALITIES FROM THIS PLAN

There are a number of areas in this plan which will have a direct impact on reducing health inequalities, such as:

•Delivery of health checks and smoking cessation targets (page 50);

•Delivery of the Cumbria Cancer Strategy (page 45) and the cancer access to treatment targets (page 56);

•Action in response to SHMI/HSMR data (as described on this page);

•The new approach to long term conditions management (page 14);

•The transformation of primary care programme (page 15);

•Delivery of the Cumbria Suicide Prevention Strategy (page 46); and

•Improvements in the quality of Stroke services (page 49).

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SECTION 8: WORKFORCE 8. W

ORKFO

RCExxxxxxDelivery of the Strategic Vision alongside the system reform requires workforce planning across the whole system. A joint venture is in place with Lancashire Cluster to develop and deliver a whole system workforce strategy.

All healthcare organisations across Cumbria aspire to provide high quality, safe and integrated services and improve productivity and performance. A well trained, committed and flexible workforce who feel empowered to initiate change is an essential element in achieving this overall objective.

NHS Cumbria Cluster has sought assurance from Providers around the Key Lines of Enquiry and narrative questions in the Planning guidance and the themes in the safety and quality assurance framework. It is evident from the QIPP programme that the integration of health and social care staff alongside redesigned care pathways and the realignment of staff in line with service change will underpin the future success of the Cumbrian health economy.

Delivery of the Clinical Strategy requires an integrated approach with relatively fewer staff providing care for more people with more complex needs in changing healthcare settings. Community and primary care staff will be more skilled in the management of long term conditions and the prevention of ill health. Elements of the workforce strategy have already been implemented with the development of community provider teams and it is not expected that further investment will be required. Ongoing priority includes the reshaping of the workforce across care pathways and the education and development of the workforce.

For the past three years there has been an increase in staff costs and numbers across the health economy however this trend is reducing with a 1% reduction in FTE against a 0.22% increase in cost during 2011/12. Work is underway to reassess the numbers and skills of staff to ensure that services are affordable yet deliver high quality and safe patient care.

New ways of working has resulted in an increase in the number of highly competent support staff and more efficient use of expert clinical staff. Cumbria has received recognition within the northwest for having successfully introduced the roles of cadets, apprentices and assistant practitioners across a range of care pathways. The introduction of these new support roles has had an impact on service models and has led to change in the way student numbers are commissioned for pre and postgraduate education programmes. The changes in workforce configuration in Allerdale locality last year resulted in a decrease in acute admissions and lengths of stay across acute and community in-patient services. The positive outcomes resulted in community teams winning seven national awards.

Competency based workforce planning is driving workforce changes by putting multi professional teams at the heart of the service improvement and redesign. This is enabling rapid change and transformation within community services resulting in better management and reduced hospital admissions. In addition to reshaping the workforce around care pathways there has also been a focus on building sustainable capacity across the six localities in Cumbria. New service models with increased workforce numbers and skills and competencies are required on the west coast particularly in Furness. Workforce strategies have required a reduction in the workforce in some localities with increases in others. In order to increase Health Visitor provision commissioners have agreed targeted budget increases to localities such as Furness. Clinicians and workforce teams have held roadshows and recruitment events to attract candidates for the current and future workforce models and expect to be amber for the March 2012 target, although further recruitment is taking place. The target for March 2012 is 78.4 FTE, currently the shortfall is 2.8 FTE.

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SECTION 8: WORKFORCE (cont) 8. W

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RCE

The key workstreams supporting the changing workforce include:

• Completion of the transition of PCT staff to new organisations complemented by a programme of voluntary redundancy to achieve necessary reductions in workforce numbers;

• Regular dialogue and planning with HEIs to ensure that education and development programmes keep pace with changing skill mix requirements;

• Collaborative workforce planning and deployment to ensure that staff are retained within the NHS wherever possible thereby retaining skills and minimising the effect on local communities of job losses;

• Closer integration between CPFT Community Staff and Adult Social Care; and

• Integrated back office functions with Lancashire through a joint venture Commissioning Support Service.

The collaboration between Human Resources Directors will be extended to include:

• Benchmarking of workforce metrics including sickness absence, turnover and workforce numbers alongside staff surveys and staff forums;

• Working across the North West to explore how eWin functionality can be improved to interrogate data and enable planning and performance management discussions across pathways;

• Working with Directors of Nursing in relation to working with care homes, education strategy groups and competency based education programmes for long term conditions;

• Training needs analysis and identification of workforce competencies across care pathways and the establishment of local education networks that can deliver tailored and flexible programmes to the health care workforce in Cumbria; and

• Review of learning and Development activities to promote eLearning and developmental toolkits, generate reduced costs through more effective procurement and greater portability of pre-existing learning between organisations. The assurance work undertaken indicates a need to improve participation in appraisal and mandatory training to sustain staff morale and the overall safety and quality of services.

Succession planning and talent management to retain and develop the most talented staff is underway. This is a piece of collaborative working across Cumbria and Lancashire which seeks to retain a highly skilled and inspirational set of clinicians and managers to drive and sustain service reconfiguration and redesign. It is even more important to retain and develop these staff at a time of change and the assurance work demonstrates the need for a more systematic approach to leadership development at all levels.

Health care organisations in Cumbria are seeking to maximise opportunities for staff. This has included a review of the use of agency staff, locums and overtime. All organisations have agreed a target to reduce costs through the development of flexible employment contracts and flexible staffing models.

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SECTION 8: WORKFORCE (cont) 8. W

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RCE

Whole system reform across Cumbria means changes and uncertainty for all staff.

A joint Transition Team has been established with NHS Lancashire to ensure a smooth transition of all PCT functions and staff to successor organisations during 2012/13. Work programmes supporting transition are in place and staff are actively engaged in managing themselves through this process positively and constructively.

Where service reconfiguration or major clinical changes are proposed the Communications and Engagement teams across Cumbria and Lancashire are increasingly working together to ensure that a robust strategy for Stakeholder and staff engagement compliment the service redesign proposals. Existing communication systems work well but the assurance work indicates the need to improve the engagement and involvement of staff representatives in services changes particularly in the PCT.



HR Strategy Forums established

Education and workforce plans agreed

Cohort 1 HV trainees commenced

Education and workforce strategy in place

It is recognised that more development work needs to take place to plan more accurately and at an earlier stage for the workforce implications arising from pathway redesign and a methodology for examining the workforce plans of local providers needs to be developed. There is evidence of clinical involvement at all levels in workforce planning (including Nurse and Medical Directors) arising from service redesign but this needs to be more strongly integrated with performance management systems generally and for regular audits of actions to be undertaken.

The major incident at UHMBFT has highlighted the need for a more robust approach to examining workforce metrics against quality and safety considerations and for identifying more robust mechanisms to provide ‘early warning’ of workforce difficulties impacting on service quality and safety. These pieces of work are underway.

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SECTION 9: INFORMATICS 9. IN

FORM

ATICSCumbria has recognised that ICT can be a key enabler for improved patient care. To this end we embarked 12 months ago on an ambitious programme of interoperability and electronic patient record deployment. Directed by good clinical leadership, this is already improving outcomes for patients and care delivery as well as delivering efficiencies. The CCG plan is to build on this strong foundation of local interoperability and blend this with national strategic initiatives, such as the summary care record (SCR), in order to further enhance patient care.

CAPABILITY AND CAPACITYThe Cluster and CCG are working with Cumbria Partnership Foundation Trust (CPFT) to implement a deeper collaborative approach to informatics delivery. Building on existing jointly delivered ePR and network projects, it makes sense for us to define a common set of requirements for informatics provision in Cumbria. Future informatics service provision will be shaped by these requirements.

Recognising the common objective of moving this programme forward, we have already agreed to establish a jointly funded Programme Office in 2012/13 to drive delivery and achieve the outcomes defined below.



Deployment of Summary Care Records

Deployment of Community Electronic Care Records (ePR)

Deployment of Children & Young People Service ePR

Telemonitoring/Telehealth

Patient Access to electronic records

Pilot Intelligence led choice for patients (outcome led)

Information Sharing/Interoperability Programme across organisations

Majority of Primary Care on hosted application

Business Intelligence to support commissioning

Review of Informatics Service

The Information Strategy for the NHS, defined in the operating framework 2012/13 outlines the need for improved patient access, better information on outcomes to inform patient choice and supported by information sharing across organisations to ensure the right information is provided at the right time to improve patient care. In Cumbria we are already on this journey and now have 75% of our community services fully operating in a ePR, a growing programme of information sharing across primary, secondary and community settings as well as innovative interoperability work underway to join up information provision with non NHS providers to support care pathways.

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SECTION 9: INFORMATICS (cont.)

INFORMATION SHARING & INTEROPERABILITY

9. IN

FORM

ATICS

NHS Cumbria will be deploying the Summary Care Record (SCR) in conjunction with the existing local detailed care record development underway. We will have fully implemented the SCR by March 2013.

SUMMARY CARE RECORD

.

COMMUNITY & MENTAL HEALTH ELECTRONIC PATIENT RECORDS (ePR)

In the next 7 months we will have completed the deployment of a community based ePR. We will also be establishing a ePR for Children and Young People services, including Child Health, by March 2013 in conjunction with Cumbria Partnership Foundation Trust (CPFT) as provider. We already have over 1600 community users operating in clinically rich electronic patient records with information sharing supporting clinical care across services as appropriate.

In parallel, we are working with CPFT to define and explore the requirements for a Mental Health ePR and a deployment plan thereafter. PATIENT ACCESS

We already have the technical capability to provide direct access for patients electronically (EMIS) within primary care with our other major primary care supplier (INPS) undertaking to provide the same functionality in the next 12 months. However, there is still a programme of work to ensure this is being universally activated and promoted to patients so that it isproperly utilised. Wider access to records outwith primary care will be supported by the implementation of electronic patient records elsewhere in the programme.

There is an ever increasing need for interoperability – the ability to share information between multiple systems and service providers - to facilitate and enable new and improved patient pathways. In addition, the need to achieve more efficient working practices through the QIPP agenda is driving healthcare providers to look for opportunities to improve processes, reduce administration and the ‘paper chase’.

With this in mind, NHS Cumbria has embarked on a dynamic interoperability programme that is already having far reaching benefits for patients and the wider health economy in Cumbria. Through the sharing of clinical views from detailed care records and associated clinical documentation via a secure data exchange, clinicians have ready access to accurate, timely information that supports patient care and joins up health provision in an unprecedented way. Indeed, NHS Cumbria is leading the way in the utilisation of the Medical Interoperability Gateway (MIG), a joint system development by INPS and EMIS clinical systems.

We have a continuing programme of work to further enable information sharing across care settings including:

• Sharing of clinical views between primary care and community services;

• Sharing of clinical views and discharge summaries between acute and primary care services;

• Sharing of electronic discharge summaries between Acute(s) and Mental health trusts through to primary care; and

• Sharing notifications and support plans from adult social care to primary and community services.

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SECTION 9: INFORMATICS (cont.)

TELEHEALTH AND TELECARE

With the geography of Cumbria the CCG recognises that telehealth and telecare would bring significant patient and service benefits. The CCG is in a pilot phase with Cumbria County Council to deploy assistive and monitoring technology across the Allerdale locality led by a locality GP. Subject to suitable justifications the CCG will assess further roll out.

The CCG has commissioned Wide Area Network upgrades which will be able to support many to many High Definition video consultation and case conferencing.

NHS NUMBER COMPLIANCE AND USEAGE

In the NHS Spine compliant systems in Cumbria NHS Number compliance is complete. Some systems in Cumbria are not compliant but these are in the process of being decommissioned as a result of our ePR programme. Any new systems are required to be NHS number compliant.

9. IN

FORM

ATICS

SUPPORTING PATIENT CHOICE

One element of the CCG commissioning plan is to require that more ‘slots’ are published through Choose and Book to enable improved referral processes, greater choice for the patient. We will also be deploying mediated (system to system) referrals locally to enhance choice and improve the quality of referral information supported by detailed care record sharing.

The CCG is pushing CfH to enable Choose and Book compliance testing from our Community EPR.

Planned enhancements to our ePR to support electronic care planning will enable the capture and recording of outcomes for current patients. This in turn will enable new patients to have better information of outcomes by service in Cumbria. We intend to pilot outcome based choice following the successful deployment of care planning in our ePR.

Information governance is seen as a key enabler for pragmatic sharing of clinical information with informed patient consent and legitimate relationships. We have embedded IG support within our informatics programme to ensure we have the best advice and guidance in all aspects of our delivery.

Realistic plans are in place for all Provider organisations, including GPs and the GP Out of Hours provider, to have achieved IG Toolkit compliance in year.

INFORMATION GOVERNANCE

BUSINESS INTELLIGENCE TO SUPPORT COMMISSIONING

Business intelligence is a by product of high quality clinical data capture as well as good administrative practices. Our ePR programme has allowed us to design, build and implement a full data extract which, when blended with other administrative information, supports more effective analysis of this aggregated information.

In addition, CPFT is currently (March 2012) completing the roll-out of additional functionality in the community ePR system to support the data capture for RTT and CIDS datasets with our support. High quality information is crucial to support patient choice and intelligent commissioning.

PRIMARY CARE HOSTED APPLICATIONS

We have an on-going programme of migration of primary care systems to hosted environments. This is to improve business resilience and continuity as well as supporting information sharing at the detailed care record level. As a by product this will also achieve efficiency savings in the longer term through improved support arrangements and the decommissioning of on site clinical servers.

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: TRANSITION PROGRAMME , CONTRACTS & NCB LOCAL OFFICE10. TRAN

SITION

&

REFORM

A comprehensive Transition Programme and programme control process has been established , covering all aspects of transition to the new commissioning landscape. The programme encompasses links to joint programmes with other agencies, including receiving bodies.

NHS COMMISSIONING BOARD

Following release of the design guidance for NCB there has been initial scoping of the work required for transition to NCB local office arrangements. Further discussions are required regarding the shape and scope of a local office to cover Cumbria. However, planning and activities for transition of Primary Care , Specialist Commissioning, Prison & Military Health commissioning are well developed (see Direct Commissioning section).

STAFF TRANSITION PLANNING

A joint Transition Team has been established with NHS Lancashire to ensure a smooth transition of all PCT functions and staff to successor organisations during 2012/13. Work programmes supporting transition are in place and staff are actively engaged in managing themselves through this process positively and constructively.

CONTRACTS TRANSITION

The Cluster is fully engaged in the ongoing DH exercise to support the transition of healthcare contracts.

The stocktake phase detailing all existing NHS and non-NHS healthcare contracts will be completed and submitted to NHS NoE by end March 2012. The stocktake phase will provide two valuable outcomes:

• A list detailing every existing healthcare contract held by the PCT, which will support the mapping of all existing services to successor bodie;s and

• Any clinical, legal, contractual or financial risks related to existing healthcare contracts will be identified.

The PCT will then embark on a period of stabilisation in which measures will be taken to mitigate and eliminate those risks identified in the stocktake phase. By 1 October 2012 the PCT will be in a position to start the shift of healthcare contracts to future contracting authorities, including NCB.

TRANSITION PLANNING

A comprehensive Transition Programme has been established within the Cluster to plan and oversee the activities needed to ensure effective transition to the new Commissioning architecture . It includes workstreams covering routes to all receiving organisations/functions:

CCG; Commissioning Support Services; NHS Commissioning Board (NCB) local office; & national scale services; NCB Primary Care; NCB Specialised Commissioning; NCB Prison/Military; Public Health; Health & Wellbeing Boards, PropCo; CT dissolution.

It also includes workstreams for cross-cutting functions that enable the receiving routes:

Estates management; Emergency Planning & resilience; managing performance; Quality/Governance/Legacy; Contracts transition; Finance; Information management /IT/Information Governance; Communications & Engagement ; HR/Workforce transition; workforce development.

Programmes incorporate all relevant national and NHS North of England milestones and every programme workstream has an identified executive level lead.

The Programme Steering Group regularly reports to the Cluster Board and Management Executive. Progress reporting includes risk management and linkage between workstreams.

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: CLINICAL COMMISSIONING GROUPS10. TRAN

SITION

&

REFORM

Cumbria has always had a high level of clinical involvement, especially GPs and the past 12 months have been characterised by GPs taking further leadership and responsibility for 100% of CCG resources. They have made good progress in establishing the CCG, with an interim structure and decisions on ‘do’, ‘share’, buy. They also have a clear development for the organisation and are producing a ‘clear and credible’ strategic commissioning plan, key elements of which are reflected in this operating plan, both in terms of strategic vision and operational plan delivery.

There is a strong CCG emerging which has been established in the interim as a sub-committee of the PCT Board. It has 100% of relevant CCG budget delegated through a formal Accountability Agreement and the CCG is exercising responsibility, agreeing recovery plans, year end closure and so forth.

The lead GPs in the CCG led the 2011/12 contract negotiation in South Cumbria with UHMBFT and supported the negotiation of the other two major contracts with CPFT and NCUHT. They have also lead in-year contract monitoring and management .

The CCG developed commissioning intentions documents for acute, mental health, community and childrens’ services and are actively leading the negotiation of all relevant contracts for the 2012/13 contract round in line with these intentions.

The CCG are heavily involved in system transformation, such as the commissioning input to the acquisition process for NCUHT, the approval process for the West Cumberland Hospital Full Business Case and support to the UHMBFT Gold Response.

There is an interim structure in place to get the CCG under way, with resources seconded to the CCG localities (for commissioning, service redesign and relationship management) and corporate functions (strategic, finance and contract support). Work on decisions for ‘do/share/buy’ and organisational development (using the self assessment tool) has been undertaken with support from the Cluster and the Region through external consulting.

The CCG Executive is developing the strategic narrative for the CCG – focused on a ‘closer to patients’ theme and illustrating the added value of clinical commissioning. Alongside a clear view on the shape of the health economy over the next 5 years, this will be embedded at the heart the CCG’s clear and credible Strategic Commissioning Plan. This is currently being developed in parallel with this Operating Plan to ensure CCG leadership. The CCG is also working with Cumbria CC to produce the new JSNA so that there is a firm evidence base to the key priorities in the Plan.

Although there are generally good primary care results (e.g. low prescribing costs; high patient satisfaction) the CCG is developing a primary care transformation strategy, which will focus on long term condition management & year of care, improved education and training and greater primary care capacity in Barrow particularly for day time urgent primary care.

The CCG is also setting out its vision for putting quality at the heart of the contracting process, with a focus on doing the right things for patients, with robust and measurable metrics, including an increased emphasis on patient experience and engagement.

The CCG is leading service change, particularly through the System Board in North Cumbria – specifying the models for emergency floor, Single Point of Access, paediatric assessment units and so forth. There is also an ambition to develop new forms of contracting (eg Alliance and AQC) once the key providers are in a more stable position following quality improvement in the South and Trust acquisition in the North.

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: CLINICAL COMMISSIONING GROUPS (cont.)

Aspect MilestoneProgress

Position

Configuration ✔ All Cumbrian practices signed up to a single viable CCG

Phase 1 Risk Assessment ✔ Assessed green except amber for LA Boundary (Bentham membership)

CCG Budget allocation ✔ 100% of approved budgets have been delegated

Build a track record✔

Engagement & leadership in key areas: planning & service development; strategic planning; response to Operating Framework; formulation of commissioning intentions & contract negotiation; quality issues across all domains; QIPP workstream including System Board and all clinical relationships across organisations; HAWB interaction increasing.

Organisational Development ✔ Diagnostic undertaken jointly by CCG and Cluster including clinician inputs; development areas identified for joint development planning. External OD expertise enlisted. Locality offices established & phase 1 assignment of support staff completed; MD and senior staff in place. CCG internal functions/operating model established & draft structure developing.

Authorisation ✔ Regular joint CCG Authorisation/Development group; evidence bank established; Cluster management resource provided to support DCD and CCG leadership.

CCG User Requirements ✔ Do/share/buy considerations undertaken and affordability tested; CSU specification being developed.

Commissioner Support Business Process

✔ Initial stocktake completed and function/people mappings submitted; working to create robust ‘client’ specification of requirements to support development of Cumbria/Lancashire joint venture CSS.



Do/share/buy decisions and CSS agreement in place

2012/13 Contracts negotiated by CCG

Development Plan and Clear & Credible Commissioning Plan approved

Budgets agreed (100% delegation) and staff in place to manage and continue to develop CCG

Lead the local health system, actively reviewing finance, performance, quality and activity

Confirm senior leadership

Prepare authorisation application & complete process

Be operating and prepared full statutory responsibilities with contracts & SLAs for 2013/14 in place

10. TRANSITIO

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: COMMISSIONING SUPPORT

xxxxxxSignificant progress is being made by Cumbria Cluster and CCG in determining and implementing the model for commissioning support, including the delivery of a stand-alone integrated Cumbria and Lancashire Commissioning Support Service (CLaSS).



Set up & design phase & Checkpoints 1 & 2 - Prospectus and OBC submittedCCG do/share/buy requirements/specification clarified, CSS response agreed , HoAs for 12-13 agreed with CCGsInterim Managing Director & leadership team in placeExit option appraisal completed, exit strategy developed, staff consultation in progress, FBC produced, NHSCB hosting approvedCLaSS operating at arms length (prior to NHS CB hosting), 13/14 CCG contracts agreed, exit route agreed

Cumbria Cluster has entered into a joint venture with Lancashire Cluster to develop an integrated Commissioning Support Service (CSS) and to manage workforce into the new commissioning architecture.

The CSS has successfully undertaken the set up and design phase of the national CS review process and passed checkpoint 1 with the production of a service offer prospectus and technical appendix. The offer arose from early planning and development work, and provided early assurance that a viable, appropriately focussed service could be developed as well as an initial discussion document for much more in depth engagement with CCGs.

Since then the CSS has undertaken significant 1:1 work with all of the Cumbria and Lancashire CCGs, jointly exploring CCG do/share/buy perspectives and CSS responses. As a result the CSS has developed its planning on a flexible & tailored service offer that will meet customer needs and wants, and further defined its pricing and organisational design. Cumbria CCG, supported by the Cluster with external facilitation, developed , in February, a detailed specification for the service elements and approach it requires from a CSS. A high level memorandum of agreement has been signed off, to be followed by a fuller HOA in April and a contract in July – following iterative co-production of the service offer with CCGs and agreement on running cost implications.

The shadow year 2012/13, will be a transition year for both CLaSS and CCGs, whilst new ways of working and business like relationships are established.

Significant steps have been taken to fully integrate the Lancashire and Cumbria dimensions into a unified model , Cumbria and Lancashire Support Service (CLaSS) , to be taken forward at arms-length from the Clusters from April 2012. An interim Managing Director and dedicated interim senior team have been appointed March 2012, mirroring a more substantive leadership structure for the shadow year 12/13 and a future externalised service. Governance arrangements have been put in place to provide accountability to both Clusters during the shadow year.

CLaSS is progressing a wide-ranging programme to develop as a customer focussed, commercially viable service. This includes active consideration of partnerships (with LAs, other NHS agencies, independent sector) and outsourcing/brokerage, based on an assessment of where services could be practicably sourced externally or in partnership to provide better quality or value for money. Appropriate scale of provision is being considered as the organisational structure is developed further , including appropriate linkages with national at scale services. An Outline Business Plan, describing progress so far, has been submitted for checkpoint 2 and a Full Business Case will be developed by September 2012. Early in 12/13 CLASS will undertake an options appraisal of exit route options, followed by staff consultation.

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74

SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: DIRECT COMMISSIONING, PRIMARY CARE

xxxxxxA primary care development plan has been developed between NHS Cumbria Cluster and CCG and the baseline assessment of primary care contracts has been completed.

Following publication of the draft operating model for primary care a draft primary care development plan has been discussed with the CCG. It will be agreed by 30th June to enable implementation to commence 1st July 2012. An implementation lead for primary care commissioning has been appointed to oversee the transition period and the field force configuration.

The baseline assessment of the primary care contracts that will need to pass to the NHS Commissioning Board was completed at the end of January 2012. That stocktake has informed the contract transition programme which is progressing, to ensure effective handover. All general medical contracts to be re-issued to ensure all providers have complete signed documentation by June 2012. Standard PMS contracts will be issued and agreed with PMS providers by June 2012. There are no PCTMS contracts in Cumbria.

Dental and optometrical contracts will be reissued by exception only. Discussions with all LRCs are taking place in relation to contract stabilisation and these will be completed by April 2012.Contracts will be available in electronic format by December 2012. Work to facilitate standardised payment system will be taken forward pending further guidance.

Local professional network pilots for Dentistry and Pharmacy have been established. The Dental LPN met and agreed terms of reference in December 2011. A dental Clinical Engagement event is planned for March 2012 and the agenda for next year, to include refresh of Oral Health Strategy, will be agreed in April 2012. A meeting planned with LOC April 2012 to begin scoping exercise around Optometry. Further work is required in next months to align LPNs with the aims and objectives of the HWBB. A discussion with Cumbria LMC is planned for April 2012 to agree the process for review of general medical practice lists. This process will be undertaken with LaSCA and Registration team during summer 2012 with an aim to complete by December 2012. An implementation lead for primary care commissioning has been appointed to oversee the transition period and the field force configuration. Scoping is underway to map out the field force configuration. This work will be informed by national guidance as it becomes available. We await the publication of “Towards Excellence in Primary Care” (Spring 2012) which will set out the vision for the single operating model and provide clarity around configuration and functions.

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Primary Care development plan agreed with CCG

Contract transition baseline assessment completed

LPNs for dentistry & pharmacy established

Practice review framework agreed & standard performance review completed with all practices

Initial scoping re capacity & capability, and plans developed to map field force configuration

Standard Operating model in operation

Primary care commissioning staff transferred

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: DIRECT COMMISSIONING, SPECIALISED SERVICES

xxxxxxThe stepped implementation of the transfer of specialised service commissioning is well underway and transitional governance arrangements were agreed in December 2011.



Formally agree transitional governance arrangements

Facilitate the contract activity & price work needed for minimum take service contract transfer to SCG for 2012/13

Agree the support arrangements at CCG/CSS level to facilitate the operation of direct commissioning functions for specialised commissioning

Operate the shared operating model

Facilitate the transition of the full specialised services commissioning list

NHS Cumbria is working closely with the North West and North East Specialised Commissioning teams and service providers on the stepped implementation of the transfer of specialised service commissioning.

The PCT Board agreed to transitional governance arrangements in December 2011, following the clustering of the existing Specialised Commissioning Groups.

The first phase of transfer, a minimum take of services to be commissioned by all Specialised Commissioning Groups (SCGs) for 2012/13, is progressing to completion. This involves providers identifying and splitting out activity and prices from existing contracts and validation by commissioners in preparation for revised contract sign off for 2012/13.

In Cumbria’s case, the minimum take for 2012/13 includes a number of services previously commissioned by NHS Cumbria:

Some services which are provided locally such as radiotherapy, vascular surgery and interventional radiology; and

A number of services which are provided outside of Cumbria e.g. Cardiac electrophysiology, major trauma, HIV inpatient services at identified centres, specialised mental health services including disorders, Tier 4 CAMHs.

The operation of direct commissioning functions inline with agreed operating model is being considered as part of transition planning and the CCG/Commissioning Support Service do/share/buy analysis. 10. TRAN

SITION

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: DIRECT COMMISSIONING, PRISON & MILITARY HEALTH SERVICES

xxxxxxProgress is being made in the delivery against the key milestones for the commissioning of Prison and Military health services.

Aspect MilestoneProgress

Position

Prison HNA completed Possible provider identified and working with NE PCT to establish appropriate methodology

Prison Health Service Specifications Service specifications being updated and KPIs and quality monitoring put in place for 2012/13 contract year

Prison secondary care activity and costs Currently identifying activity and costs associated with prisoners accessing local health services (elective and emergency – acute and MH)

Cluster lead for military health identified ✔ Lead identified – to attend regional military health network meetings; lead GP and Non Exec lead also identified; HWBB work due to start in April

Military Health - SHAs should maintain and develop their Armed Forces networks

✔ Cluster has place on SHA AF Network and regular correspondence and quarterly meetings.

The MOD NHS Transition protocol for those who have been seriously injured in the course of duty to be implemented

✔ SHA has links with Military PRU to manage the transition of the seriously injured on a case by case basis. Procedures for referral for accessing care and prosthetic devices to be understood locally and will depend on nature of needs and location



Cluster lead identified

Cumbria mental health mapping JSNA (July) and AQ event with key stakeholders (April)

Engagement with Disability Service Centre in relation to meeting needs of veteran amputees

NSC completed to ensure reservists released for service as required

Service specs, KPIs and quality monitoring agreed

Engagement with Shadow HWBB

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77

xxxxxxThe shadow Health and Well Being Board will be operational from April 2012 and will contain all of the statutory partners.

SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: HEALTH & WELLBEING BOARDS



Shadow HWB operational

JSNA published

Health and Wellbeing Strategy Published

Cumbria is part of the National Early Implementers Network for the Health and Wellbeing Board.

An interim Health and Wellbeing Board (HWB) was established in June 2011 and has met regularly supported by senior managers from Cumbria Cluster and Cumbria County Council.

The CCG has had a member on the board for some months with a mandate to represent the CCG and the localities.

The CCG is supporting the JSNA refresh and will be involved in the development of the Health & Well Being Strategy, which will be reflected in its commissioning intentions.

The shadow board will offer a place to the Director of Commissioning as an interim position as links with NHSCB are considered.

The shadow Health and Wellbeing Board will be operational from April 2012 and will contain all the statutory partners. Previous work has meant that there will also be agreed representation from the district councils and one member representing parish councils.

Officers from the PCT Cluster and from the local authority are supporting the development of Healthwatch focusing on wide stakeholder involvement.

A programme to support the H&WB members has been agreed and commissioned.

A JSNA will be published in April 2012 and will result in a Health and Wellbeing Strategy which will be published in June 2012.

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SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: PUBLIC HEALTH

xxxxxxDelivery of the JSNA has already facilitated the establishment of close working relationships between stakeholder organisations and Cumbria County Council. Building on these relationships the reconstituted Health and Wellbeing Board will ensure delivery of the Public Health agenda.



Business plan and Workforce Plan agreed

Scheme of delegation in place

Integrated Plan submitted to DH

Most Public Health duties transferred to CCC

All Public Health duties transferred to CCC

Complete formal handover to CCC

Public Health Transition Executive and Operational Groups have been established to ensure that all national and local milestones are met.

A transition programme board co-chaired by the DASS and the PCT CE has been established to oversee the transfer, maintain performance and mitigate against any risks. The board is accountable to the loc auth CE.

A senior member from the public health team has been identified to manage the programme, with support from both the PCT and the council.

Each work-stream will have a project plan which will be monitored by the board.

An overarching action plan has been developed with workstreams to include:

HR and workforce;

Embedding the health responsibilities into the local authority.

Commissioning, contracting and finance;

Delivery of Public Health functions prior to transition;

Milestones against migration;

Core offer of Public Health support to CCG;

Governance, risk, infrastructure and quality assurance;

Access to shared functions; and

Communications and engagement.

10. TRANSITIO

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xxxxxxThe Tripartite Formal Agreement identified that NCUHT would achieve Foundation Trust status through a merger or acquisition with another Foundation Trust. This process is well advanced with the identification of a preferred bidder and the expectation is that new Trust status will be achieved by October 2012.

SECTION 10: TRANSITION AND REFORM – COMMISSIONING DEVELOPMENT: NCUHT ACQUISITION



Preferred bidder identified

Management contract agreed

Due diligence completed

Monitor and CCP approvals received

Business Case construction and approval

Secretary of State approval

New Trust in place and fully operational

Engage in delivery of key objectives

The acquisition process is being conducted by NCUHT with support from NHS North. NHS Cumbria Cluster and CCG are engaged in providingCommissioner support to the negotiation process following the identification of the preferred bidder.

At the end of January 2012 Northumbria Healthcare Foundation Trust was identified as the preferred bidder. It is expected that a Management Contract will be in place by April 2012.

It is anticipated that, subject to due diligence process and confirmation by Monitor and the Co-operation and Competition Panel, a new Trust will be formed and operating in October 2012.

The Cluster and CCG key objectives for working with a new enlarged Foundation Trust are:

Delivery of the agreed clinical strategy for north Cumbria; Securing the opportunities that exist to repatriate patient

activity and enhance the portfolio of services available within Cumbria;

Implementation of a robust plan to deliver financial stability in north Cumbria within the period of this plan;

Implementation of enhanced management processes; Delivery of economies of scale across a larger

organisation including improved efficiency in back office and support functions; and

Confirmation of support for the West Cumberland Hospital development.

10. TRANSITIO

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APPENDIX A

INTEGRATED PERFORMANCE MEASURES – CUMBRIA TRAJECTORIES

APPEND

IX A

81

APPENDIX A: INTEGRATED PERFORMANCE MEASURES – CUMBRIA TRAJECTORIESAPPEN

DIX

A

2012/13

ACTUALS - 2011/12

2012/13 Trajectories 13.5%

ACTUALS - 2011/12

2012/13 Trajectories 48.5%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2012/13

ACTUALS - 2011/12 2 1 0 1 1 0 1 1 0 1

2012/13 Trajectories 1 1 0 1 1 0 1 1 0 1 0 0 7

ACTUALS - 2011/12 19 23 31 17 18 19 11 25 16 21

2012/13 Trajectories 18 18 17 17 16 16 16 15 15 14 14 14 190

2012/13

ACTUALS - 2011/12

2012/13 Trajectories 3,807

ACTUALS - 2011/12

2012/13 Trajectories 20%0

ACTUALS - 2011/12

2012/13 Trajectories 13%4.3%1.6% 3.0% 4.1%

PHQ31_05 Percentage of eligible people that have received an NHS Health Check in 2012/13

0.1% 0.2% 0.3%

2% 4% 6% 8%

Q4

PHQ31_04 Percentage of eligible people who have been offered an NHS Health Check in 2012/13

0.1% 0.2% 0.3%

PHQ28 Number of C. Difficile infections

PHQ27 Number of MRSA bacteraemia

Q3

3.5% 3.3% 3.8%

PHQ13_06 The proportion of people who complete treatment who are moving to recovery

PHQ13_06 The proportion of people who complete treatment who are moving to recovery

Q1 Q2

3.3% 3.3% 3.4% 3.5%

842 898 710 1357

PHQ30 Number of 4-week smoking quitters that have attended NHS Stop Smoking Services

768 687 590

3.5% 3.3% 3.8%

47.0% 48.0% 48.9% 50.0%

Q1 Q2 Q3 Q4

1 YEAR TRAJECTORIES

82

APPENDIX A: INTEGRATED PERFORMANCE MEASURES – CUMBRIA TRAJECTORIESAPPEN

DIX

A

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 12/13 13/14 14/15

ACTUALS - 11/12 4399 4389 4448 4352 4395 4385 4560 4353 4621 4471 4286

12/13 Trajectories 4246.9 4332.3 4159.5 4203.2 3886.7 4073.8 4267.9 4143.3 4500.9 4201.4 3836.3 4348.7 50201 49666 49269

ACTUALS - 11/12 8845 9915 10061 9700 9714 9549 9406 9607 7750 8982 9492

12/13 Trajectories 8690.7 10063 8690.7 10063 10063 9148.1 10520 10063 8690.7 10063 9148.1 9148.1 114351 113036 111556

ACTUALS - 11/12 2804 3306 3177 3078 3099 3144 3100 3135 2896 3317 3151

12/13 Trajectories 2864.2 3316.5 2864.2 3316.5 3316.5 3015 3467.2 3316.5 2864.2 3316.5 3015 3015 37687 37025 36280

ACTUALS - 11/12 6968 7832 8299 8099 7873 8656 8006 8438 7147 7775 7501

12/13 Trajectories 7390.6 8557.6 7390.6 8557.6 8557.6 7779.6 8946.6 8557.6 7390.6 8557.6 7779.6 7779.6 97245 95930 94451

ACTUALS - 11/12 10728 11841 12566 11939 11730 12642 12091 12622 10777 12118 11736

12/13 Trajectories 11112 12866 11112 12866 12866 11697 13451 12866 11112 12866 11697 11697 146208 144230 142006

ACTUALS - 11/12 1392 1423 1542 1520 1422 1625 1542 1620 1444 1494 1582

12/13 Trajectories 1389.1 1606.9 1388.9 1607.7 1603.9 1461.3 1678.7 1606.4 1389.2 1603.8 1459.7 1462.2 18258 17955 17694

ACTUALS - 11/12 4415 4776 5161 4884 4684 5032 4873 5164 4565 5261 4882

12/13 Trajectories 4425.3 5124.1 4425.3 5124.1 5124.1 4658.2 5357 5124.1 4425.3 5124.1 4658.2 4658.2 58228 57210 56312

ACTUALS - 11/12 5807 6199 6703 6404 6106 6657 6415 6784 6009 6755 6464

12/13 Trajectories 5814.4 6731 5814.2 6731.7 6728 6119.6 7035.6 6730.4 5814.5 6727.9 6118 6120.5 76486 75165 74006

ACTUALS - 11/12 1440 1542 1528 1451 1398 1482 1366 1558 1303 1493 1449

12/13 Trajectories 1391.3 1489.9 1476.4 1401.9 1350.7 1431.9 1319.7 1505.4 1545 1543.1 1554.7 1406.8 17417 17417 17417

ACTUALS - 11/12 11524 12688 13266 12939 13549 13266 12671 13743 12601 13586 13513

12/13 Trajectories 11749 12935 13525 13191 13814 13525 12918 14011 12631 12354 12695 11209 154555 154555 154555

ACTUALS - 11/12 23031 25099 24058 25400 25486 24903 24849 24785 24749 23845 25279

12/13 Trajectories 25000 24900 24800 24700 24700 24700 24700 24700 24700 24700 24700 24700 24700 24700 24700

PHS06 - Non-elective FFCEs

PHS07 - No of GP written referrals

PHS09 - No 1st outpatient attendances after GP referral

PHS11 - No of elective FFCEs - Daycase Adms

PHS11 - No of elective FFCEs - Total

PHS15 - Diagnostic Activity - non-Endoscopy based tests

PHS14 - Diagnostic Activity - Endoscopy based tests

3 YEAR TRAJECTORIES

PHS16 - Total numbers waiting on an incomplete RTT pathway

PHS08 - No of other (non-GP) referrals

PHS10 - No of first outpatient attendances

PHS11 - No of elective FFCEs - Ordinary adms

83

APPENDIX B

Locality Service Initiatives

APPEND

IX B

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity ReductionsAllerdale Locality

ReductionNo.

Reduction£’000

Service Initiatives Timeframe

Respiratory 60 94 LES for identifying , coding severity, assessment, ensuring appropriate pathway and medication of all patients with respiratory diseaseFully skilled respiratory nurse in each of the five sub localities linking with the community based servicesAll patients using oxygen therapy re-evaluated to optimise treatment Increase in pulmonary rehabilitation services

In place

Expanded from April 2012In placeIn place

Cardiac 49 41 Direct access to ECHO diagnostics and 24 hour access to ECG.Heart failure nurses managed by CHOC to improve focus and direction

In placeIn place

Diabetes 17 19 Practice nurses engaged in diabetes care training courses In place

Elderly Care 39 52 Elderly care team recruited to ensure basic levels of care and end of life care in place in care homesCare plans for all care home residents lodged with CHOC

In place

In place

Alcohol and Drugs

0 0

Infrastructure 131 121 Joint working with NCUHT to deliver the Single Point of Access (Gateway into Services) and Emergency Floor projects

Partial implementation from September 2012

Elective 268 215 Use of 30 new referral templates and embedded decision toolsFocus on reduction in unnecessary referrals for orthopaedic procedures and minor skin lesions

From June 2012Continuing from 2011/12

TOTAL 542

APPEND

IX B

84

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity ReductionsCarlisle Locality

ReductionNo.

Reduction£’000


Respiratory 50 80 Chronic Disease Management Network reviewing COPD servicesExpansion to COPD specialist team (includes expansion of pulmonary rehabilitation services)Local version of Met Office schemeAsthma patient reviews linked to community pharmacist, roll out of asthma prescribing pathway

In place

In placeIn place

Cardiac 131 107 Community cardiology service

Heart failure team Protected learning time used for upskilling in primary carePsychological therapies for patients with multiple chronic diseaseUse of Qrisk tool

In place, referrals expandingIn placeIn placeIn placeIn place

Diabetes 0 0

Elderly Care 80 98 Development of Integrated Care Model

Warmer Home and flu vaccines projectsCare homes work (medication reviews, falls, pressure sores, nutrition) long established and being extended to house bound patients

Increasing impact during 2012/13In placeIn place and being extended

Alcohol and Drugs

41 25 Mental health liaison support within CICSupport to DAAT to support those people most at risk of admission

April 2012April 2012

Infrastructure 46 41 Joint working with NCUHT to deliver the Single Point of Access (Gateway into Services) and emergency Floor projects




TOTAL 555

APPEND

IX B

85

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity ReductionsCopeland Locality

ReductionNo.

Reduction£’000


Respiratory 54 81 New breathlessness pathway, CPFT deliver new breathlessness serviceDrug reviews and case management for asthma and COPD patientsIncrease in uptake of pulmonary rehabilitation service

Q2 2012/13In placeIn place

Cardiac 36 28 CPFT deliver new breathlessness serviceHeart failure management workshops for practice nurses, community staffRelaunch of Exercise on Referral service (lower acuity patients)Enhanced case management, part of LESExtended hours for community based serviceReview of oxygen service

Q2 2012/13In placeIn placeIn placeIn place

Diabetes 32 32 Upskilling community service staff to raise the level of clinical support In place

Elderly Care 32 37 Implementation of Care Home 6 Steps Programme – full sign upAvailability of interim care home beds for frail elderly and EMI patients including district nurse and GP admission rightsGeriatrician of the week

In placeIn place

Alcohol and Drugs

0 0





TOTAL 550

APPEND

IX B

86

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity ReductionsEden Locality

ReductionNo.

Reduction£’000


Respiratory 2 3 Increased referrals to community support servicesImplement ambulatory care pathways for children with respiratory diseaseImplementation of adult pathways for COPD and asthma

In placeIn placeFully developed by July 2012

Cardiac 28 24 CHOC led community cardiology servicesIncreased referrals to pulmonary rehabilitation servicesReview of oxygen therapy servicesOn call stroke physician out of hour cover

In placeIn placeApril 2012In place

Diabetes 0 0

Elderly Care 98 116 LES for Care Home engagement and production of assessment and care plans, prescription reviews

April 2012

Alcohol and Drugs

0 0



Elective 127 102 Use of 30 new referral templates and embedded decision toolsFocus on reduction in unnecessary referrals for orthopaedic and MSK procedures (triaged through physiotherapy) and minor skin lesions


TOTAL 290

APPEND

IX B

87

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity ReductionsFurness Locality

ReductionNo.

Reduction£’000


Respiratory 0 0 Systematic review of COPD pathway undertaken with increase in number of pulmonary rehabilitation patients

In place

Cardiac 187 150 Increasing caseload for specialist heart failure service, improved education for primary care teamsLES in place to improve identification and management of heart failure patients, optimisation of medication and heart failure scoring

In place

April 2012

Diabetes 0 0

Elderly Care 112 127 Established Integrated Care Services for Older People (nursing, physio and pharmacy) improving continuity of care and management of LTCs for residential and nursing homes and extra care housing

In place and increasing care home coverage

Alcohol and Drugs

0 0 Provision of liaison psychiatry services within Furness Gh to support people with mental health issues in A&E and on wards. Brief interventions LES in primary care for patients with harmful drinking

June/July 2012

Infrastructure 370 330 Redesign of community based STINT team to provide rapid response servicesPrimary Care Medical Assessment Service managing GP referrals for diagnostics and intermediate care services

April 2012, fully function Q3 2012/13April 2012/13



TOTAL 799

APPEND

IX B

88

Service Initiatives in Place to deliver the 2012/13 Commissioned Activity ReductionsSouth Lakes Locality

ReductionNo.

Reduction£’000


Respiratory 16 25 Specialist respiratory nursing service for patient diagnosis, case finding and identification of sub optimal drug regime

In place

Cardiac 195 159 Specialist heart failure nursing service with consultant oversight and prescribing supportEducation programme for primary carePost discharge follow up for heart failureLES for primary care upskillingCase finding for patients with atrial fibrillation, improved prescribing

In place

In placeIn placeIn placeIn place

Diabetes 0 0

Elderly Care 117 125 Recruitment of elderly care physicianCare Home engagement of district nurses and dietitians and production of assessment and care plans, prescription reviewsPrimary and community care programme for patients with co-morbid dementia

October 2012In place

In place

Alcohol and Drugs

59 40 Improve extended brief interventions in primary care for patients with harmful drinkingBuild psychiatric liaison service to provide A&E and ward support at WGH and RLI

In place

Infrastructure 7 6

Elective 318 206 Use of 30 new referral templates and embedded decision toolsFocus on reduction in unnecessary referrals for orthopaedic procedures minor skin lesions, varicose veins and grommets and tonsillectomiesExpected reduction in day case activity resulting from achievement of 18 week target in 2011/12

From June 2012Continuing from 2011/12Anticipated in 2012/13

TOTAL 561

APPEND

IX B

89

90

APPENDIX C

Public Health Transition Plan

APPEND

IX C

1 cumbria cluster and cumbria ccg integrated strategic and operational plan 2012/13 to 2014/15 april...

Documents

performance performance

improved performance

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cumbria ccg

stroke performance indicator

performance managed

number of performance

action plan